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... 1 Title: Implementation of a Home Exercise Program Inventory: Shared Decision Making Approach to Aging Macy Pohl May, 2023 A capstone project submitted in partial fulfillment for the requirements of the Doctor of Occupational Therapy degree from the University of Indianapolis, School of Occupational Therapy. Under the direction of the faculty capstone advisor: Dr. Lori Breeden, EdD, OTR Associate Professor 2 Abstract This study examined a home exercise program (HEP) inventory's impact on occupational therapy (OT) practice at Hoosier Village. The purpose of this project is 1) Determining the impact of HEP inventory on OT practice at Hoosier Village and 2) Evaluating how a HEP inventory can facilitate a shared decision making (SDM) approach to OT practice within Hoosier Villages therapy department. In partnership with Healthcare Therapy Services (HTS), I developed the HEP inventory and conducted a pre-and post-test on current HEP processes and a single case study design to investigate the HEP inventory impact. The pre-and post-test and case study resulted in themes in which the HEP inventory promotes an SDM approach to care, assists with maintaining therapy progress, and increases the motivation and value of HEP. Due to the limited sample size, further research is recommended to seek the relationship between a HEP inventory and an SDM approach to therapy. 3 Introduction Situated in Zionsville, Indiana, is a Baptist Homes of Indiana (BHI) Senior Living Community called Hoosier Village, which spans over 300 acres (Hoosier Village, 2023). With the continuum of care framework, Hoosier Village provides individuals 62 years and older with a maintenance-free lifestyle, wellness programming, various housing options, and therapy services offered by Healthcare Therapy Services (HTS). HTS, ...serves communities by providing comprehensive physical, occupational, speech therapy and wellness programs (HTS, 2023, p.1). Within Hoosier Village specifically, HTS serves residents throughout the continuum of care to facilitate positive health outcomes for residents aging in place. For the doctoral capstone experience (DCE), I will pair HTSs services with the wellness emphasis of the community in the shared decision-making (SDM) approach. The SDM approach ... provides a framework for the challenging process of integrating the clients perspectives with knowledge gained from research to assist consumers in making well-informed health care decisions (Albarqouni et al., 2020; Moleman et al., 2021 cited Cahill & Richardson, 2022, p.1). This will be accomplished by developing a home exercise inventory in which therapy professionals present home exercises that pair with the clients interests, emphasizing an SDM approach. Throughout this paper, I will outline the research behind why this DCE project is needed, discuss implementation, and outline the outcomes of the DCE project. The outcomes will come from case study analysis and questionnaire data for a comprehensive approach. The primary objective of this DCE is to utilize an SDM approach to enhance the therapy experience by having home exercises that clients are more likely to engage in and have increased access to for increased client satisfaction. 4 Background Since the communitys conception in 1952, Hoosier Village, a BHI Senior Living community, has developed a community with on-site healthcare providers, therapy services, a wellness center, and varying dining options to be the ideal community for individuals to retire (Hoosier Village, 2023). HTS has roles at Hoosier Village that range from a consultation for home modifications to direct patient care. This directly relates to the occupational therapist's scope of practice, where therapy professionals can be experts at the table to enact change and positively influence health outcomes for older adults aging in place. Based on the needs assessment with Katie Grissom, Vice President of Operations at HTS, one of the primary areas of need is continuing the positive health outcomes once discharged from therapy (K. Grissom, personal communication, February 25, 2022). Katie reported that their residents frequently remain home after therapy services, and those in assisted living will often struggle with daily living activities and struggle to maintain the progress they had made in therapy. There is great potential for continuing health outcomes after discharge as Hoosier Village offers a range of wellness-based programming onsite, offers personal training, and onsite equipment where residents have the potential to continue their therapy progress. To address this need, the collaborative decision to develop a home exercise program inventory for residents was made for increased motivation and adherence to home exercise programming by using a shareddecision making approach tailoring the inventory to interests and commonly treated conditions. The literature for community-dwelling older adults in the world of wellness supports and further enhances the home exercise inventory for Hoosier Village residents. There is no direct research to be found on the direct impact a home exercise program inventory has in a population consistent with Hoosier Village. With that in mind, Hunter and Kearney (2018) confirm and 5 support occupational therapys role in preventing and maintaining instrumental activities of daily living (IADLs) for older adults. Building upon this, evidence by McMahon (2016) supports that there is a need for interventions focused on health education and physical interventions within community-dwelling older adults. There is also an additional need to offer this type of programming both in-person and on a virtual platform to facilitate the best outcomes. Tam et al. (2021) showed digital wellness programming was feasible for older adults and had reasonable satisfaction among this population. By providing a home exercise inventory on a digital platform, therapy professionals can utilize a SDM approach to pairing client's interests with an inventory of exercises that can continue positive health outcomes. Extensive evidence supports programming and intervention approaches within the older adult population that allow older adults to live independently for as long as possible and more successfully. Noh et al. (2021) discusses interventional approaches to older adults living independently within their homes, which directly relates to the Hoosier Village population. Katie discussed that individuals within Hoosier Village live in a continuum of care, which is why it is crucial to understand each population. Noh et al. (2021) outlined that interventional approaches can successfully aid loneliness and fragility by utilizing a community-based integrated intervention approach consistent with how to approach the inventory on a digital platform. Understanding that evidence supports interventions that can address all areas of health, such as physical, emotional, and intellectual, only further accredits my approach. With research evidence supporting the need for a health and wellness website for older adults, it is essential to highlight the emphasis on research supporting the effectiveness of project implementation as it relates to this. Cahill & Richardson (2022) discuss shared decision making and one of the recommendations is, Dont initiate occupational therapy interventions without 6 completion of the clients occupational profile and setting collaborative goals (p.1). It is just as important to frame home exercise programming and discharge planning in the same context of shared decision making as this is an emerging healthcare priority (Cahill & Richardson, 2022). Building upon this, Levasseur et al. (2019) outline in detail the positive impact of wellness-based programming and resources on older adults as it relates to the ability of individuals to age in place for longer and participate in their occupations for as long as possible. To further support the feasibility of health and wellness programs among older adults, Cassidy et al. (2017) found that older adults found that the type of program I intend to facilitate is feasible, specifically when facilitated by occupational therapists. These research-based articles supported both the impact of my project design on older adults and the feasibility of wellnessbased programs being implemented by occupational therapists. There have been approaches to enhance home exercise compliance. However, the SDM approach is unique in that, "Client gains associated with SDM include increased knowledge, understanding, satisfaction, trust, and adherence to recommendations (Cahill & Richardson, 2022, p.1). This approach has the potential to yield positive outcomes with an SDM approach to HEP inventory for increased HEP motivation and compliance. This is completed by implementing an inventory with client interests and motivation in mind with accessibility ranging on both digital and printed platforms for increased accessibility and client choice. Theory and Model to Guide Doctoral Capstone For my doctoral capstone experience (DCE), I will utilize the occupational therapy-based model Person-Environment-Occupation-Performance (PEOP). My doctoral capstone is at Hoosier Village, an older adult living community that integrates on-site occupational therapy services and other supports to enhance the aging experience. Through utilizing PEOPs top-down 7 approach, this model focuses the client (residents of Hoosier Village) at the center and encompasses several systems to enhance occupational performance further. My project will use my expertise as an occupational therapy consultant to assess the person, environment, occupation, and performance of residents at Hoosier Village to further encourage and educate residents on occupational therapy services available within the community (Cole & Tufano, 2020). The frame of reference (FOR) I plan to utilize within my DCE site is rehabilitative FOR. This FOR focuses on remediation, adaptation, and compensation, enabling occupational performance for all individuals (Cole & Tufano, 2020, p.227). At Hoosier Village, older adults are the primary population of focus. These individuals have made the specific plan to live in a community and environment that enhances aging in place. The rehabilitative FOR will examine extrinsic and intrinsic client factors within Hoosier Village to facilitate occupational participation and enhance occupational therapy involvement. PEOP model and rehabilitative FOR work symbiotically to enhance occupational performance by looking at client factors and how Hoosier Villages occupational therapy services support occupational performance. The goal of using the PEOP model and the rehabilitative FOR is to increase Hoosier Villages occupational therapy scope to enhance the lives of the residents and increase their occupational performance. Project Design By completing a needs assessment and consulting with stakeholders, the Hoosier Village staff and I produced a project design to improve adherence and motivation for completing home exercise programs. This project design is carried out by increasing the inventory of home exercises at Hoosier Village, varying in condition focus and exercise intensity and type. By presenting more options, therapists can offer options through an SDM approach, improving 8 adherence and motivation for completing the home exercises. It is essential to complete the inventory in an SDM approach as it focuses on the client and therapist to, ...take steps to actively participate in the process of decision making, share information and personal values, and together arrive at a treatment decision with shared responsibility (Doherr, 2017, p.2). The increase in the inventory of home exercises for individuals receiving therapy services is both needed and beneficial for therapy clients at Hoosier Village and therapy professionals. The project design was structured to measure inventory success through an SDM approach. For the occupational therapy practitioner, a pre-survey was administered utilizing a 5Point Likert Scale from strongly disagree to strongly agree, addressing the accessibility to home exercise materials in the current inventory provided by Hoosier Village. Post-implementation, this same survey is implemented to understand how the inventory impacts the therapy practice and SDM approach to home exercise recommendations. Implementation The project implementation occurs in phases: educating the occupational therapist on SDM, inventory presentation with adaptation, and then directly implementing the inventory shown in Appendix B with clients. With Hoosier Village clients specifically, the focus on the implementation will be clients in the process of discharging from therapy and receiving home exercises to continue progress. Nevertheless, therapy professionals can pull from the inventory home exercises at any point during the treatment as the SDM approach ... is associated with feelings of autonomy, control, and individual competence (Doherr et al. 2017, p.2). The lack of discharging clients has impacted the case study approach and ability to analyze the previous discharge protocol with home exercises. Nevertheless, stakeholders and clients have supported 9 the project design and implementation from the start, producing great insights, recommendations, and compliance. Project Outcomes To evaluate the home exercise program (HEP) inventory in an SDM approach, the researcher completed a descriptive case study design incorporating an unstructured interview of the occupational therapist (OT) and the client to assess the effectiveness of the HEP inventory at Hoosier Village. Data collection consisted of one case study, incorporating an unstructured interview of the OT and client where themes surrounding the HEP inventory could naturally arise. The interview questions were informally asked to begin the conversation and further understand the inventory impact. The two formal questions asked to the client are stated below. 1. Do you find this inventory helpful when choosing your preferred HEP? 2. How do you feel about having more than one HEP presented in an inventory? The case study occurred during the discharge session of a 74-year-old client with the chief complaint of neck and back stiffness treated by the lead OT, who has worked at Hoosier Village for nine years. The OT verified the content of the unstructured interview. In addition, the OT completed a pre-and post-test utilizing a 5-point Likert scale to evaluate the impact of the inventory, shown in Appendix A. The pre-and post-test assists with evaluating the sustainability and impact this inventory has on clients served at Hoosier Village from the OT perspective. Two primary themes were developed based on the case study, unstructured interview, and survey results. Maintaining Therapy Progress Through the unstructured interview and case study analysis, one theme that directly correlated with the HEP inventory was maintaining therapy progress. The OT examined the 10 importance of HEP to her practice to maintain therapy progress for her clients, which can assist with maintaining occupational therapy positive outcomes and deferring decline. The client was agreeable that having an inventory was a good idea to have more options for individual interests post-discharge to maintain the therapy progress and evade digression. Therefore, the client took the three HEPs post-discharge to determine which works best for her schedule and interests. Motivation and Value Throughout the discharge session case study, the OT educated the client on the importance of HEP compliance and that the clients progress can be significantly impacted by HEP compliance. When reviewing the inventory, three HEPs were identified which would benefit the client based on condition, interest, and motivation. The client expressed interest in all three and was interested in completing the three HEP at home to see which one she enjoys and wants to move forward with, emphasizing an SDM approach. The HEP inventory allows the OT to present more than one HEP program for increased motivation to complete a HEP, directly correlating to compliance. There was an increase in the level of agreement in the following questions when comparing pre- to post-implementation showing the inventorys impact from the OT perspective. 1. The current HEP inventory fits 50% or more of clients conditions. 2. 50% or more of the clients are confident in the HEP after reviewing the plan at discharge. The increased level of agreement in Appendix A indicates the increased understanding the inventory provides clients and how the inventory is more comprehensive in addressing clients conditions. Summary Healthcare Therapy Services (HTS) serves residents at Hoosier Village in a 11 continuum of care model, where individuals can reside in independent living, assisted living, skilled nursing, or memory care. Hoosier Village is a wellness-minded community, having onsite wellness facilities and health-based education opportunities to facilitate positive health outcomes for Hoosier Village residents. I developed a HEP inventory with residents interests in mind in partnership with HTS to facilitate a shared decision making (SDM) approach to occupational therapy practice at Hoosier Village. It is important for OT practitioners to practice in an SDM framework as it, ...allows for flexibility in decision-making styles to accommodate patient's unique preferences and needs and to expand the maneuvering space for decision making (Moleman et al., 2021, p.926). The HEP inventory was developed to be accessible to HTS clients virtually or in a printed format for individual preferences. The inventory is aimed to assist in continuing the positive health outcomes gained from therapy and provide options for an SDM approach to HEP implementation. Before implementation, a pretest was administered to the OT practitioner to understand the HEP process and areas of improvement regarding the current HEP process. Throughout the inventory development, there was continuous feedback from HTS, wellness professionals, and residents at Hoosier Village. After inventory development, a single case study was designed to investigate the HEP inventory impact on the therapy professional's approach to care and to receive client feedback. After the case study, the post-survey was administered to the OT practitioner for further understanding of the inventory's impact and to investigate further how the inventory can be applied to the clients conditions and interests. Through the case study and post-test results, themes were pulled out to understand further the impact a HEP inventory has in the therapeutic process and how a HEP inventory can facilitate an SDM approach to therapy. Conclusion 12 When evaluating the home exercise program (HEP) inventory in an SDM approach, the researcher conducted a re-and post-test and a descriptive case study design incorporating an unstructured interview of the occupational therapist (OT) and the client. By implementing a more comprehensive HEP inventory, the descriptive case study resulted in two primary themes 1) Maintaining Progress and 2) Motivation and Value. With more options in the HEP inventory, individuals are more likely to engage in the HEP, which assists with continuing and maintaining therapy progress. Building upon this, the more HEP options in the inventory increase the motivation to engage in HEP, and clients value the options and accessibility of the inventory. The re-and post-test results found that the inventory is more comprehensive in addressing clients conditions, and the inventory contents allow clients to be more confident in their HEP. The entire site, from the HTS professionals to Hoosier Village residents, values the project and will continue to benefit from the HEP inventory. The inventory was developed to provide more HEP options to residents and facilitate a more client-centered approach to discharge planning represented by the SDM approach to care. Residents will be able to choose their HEP and have the ability to have both printed and digital access to the exercises for future use and benefit. From an occupational therapy perspective, the occupational therapy professional at Hoosier Village can have a foundation of HEPs to pull and match with the clients interests and conditions. Providing a HEP inventory promotes an SDM approach to care, assists with maintaining therapy progress, and increases the motivation and value of HEP for clients. With a limited sample size for the case study approach, further research is recommended to seek the relationship between a HEP inventory and an SDM approach to therapy care. 13 References Albarqouni, L., Glasziou, P., Bakhit, M., Del Mar, C., & Hoffmann, T. C. (2020). Development of a contemporary evidence-based practice workshop for health professionals with a focus on pre-appraised evidence and shared decision-making: A before-after pilot study. BMJ Evidence-Based Medicine, 25, 12. https://doi.org/10.1136/bmjebm-2019-111220 Berman, J., Pardasani, M., & Powell, M. (2020). The impact of age-tastic! on health literacy about depression among older adults: a pilot study. Educational Gerontology, 46(3), 117 128. https://doi.org/10.1080/03601277.2020.1714832 Cahill, S., & Richardson, H. (2022). Shared decision making and reducing the use of low-value occupational therapy interventions. The American journal of occupational therapy, 76(3), 7603090010. https://doi.org/10.5014/ajot.2022.050065 Cassidy, T. B., Richards, L. G., & Eakman, A. M. (2017). Feasibility of a lifestyle redesigninspired intervention for well older adults. The American Journal of occupational therapy, 71(4), 7104190050p17104190050p6. https://doi.org/10.5014/ajot.2017.024430 Cole, M. & Tufano, R. (2020). Applied theories in occupational therapy: A practical approach (2nd Ed.). SLACK Incorporated. Doherr, H., Christalle, E., Kriston, L., Hrter, M., & Scholl, I. (2017). Use of the 9-item shared decision making questionnaire (SDM-Q-9 and SDM-Q-Doc) in intervention studies-A systematic review. PloS one, 12(3), e0173904. https://doi.org/10.1371/journal.pone.0173904 Healthcare Therapy Services. (2022). Drive quality. reduce risk. Healthcare therapy services, inc. https://www.htstherapy.com/compliance/ Hoosier Village. (2022). Our mission. Hoosier village. https://www.hoosiervillage.com/about/ 14 Hunter, E. G., & Kearney, P. J. (2018). Occupational therapy interventions to improve performance of instrumental activities of daily living for community-dwelling older adults: A systematic review. The American journal of occupational therapy, 72(4), 7204190050p17204190050p9. https://doi.org/10.5014/ajot.2018.031062 Levasseur, M., Filiatrault, J., Larivire, N., Trpanier, J., Lvesque, M. H., Beaudry, M., Parisien, M., Provencher, V., Couturier, Y., Champoux, N., Corriveau, H., Carbonneau, H., & Sirois, F. (2019). Influence of lifestyle redesign on health, social participation, leisure, and mobility of older French-Canadians. American Occupational Therapy Journal, 73(5), 7305205030p17305205030p18. https://doi.org/10.5014/ajot.2019.031732 McMahon, S. K., Wyman, J. F., Belyea, M. J., Shearer, N., Hekler, E. B., & Fleury, J. (2016). Combining motivational and physical intervention components to promote fall-reducing physical activity among community-dwelling older adults: A feasibility study. American Journal of Health Promotion, 30(8), 638644. https://doi.org/10.4278/ajhp.130522-ARB265 Noh, E.-Y., Park, Y.-H., Cho, B., Huh, I., Lim, K.-C., Ryu, S. I., Han, A.-R., & Lee, S. (2021). Effectiveness of a community-based integrated service model for older adults living alone: A nonrandomized prospective study. Geriatric Nursing, 42(6), 14881496. https://doi.org/10.1016/j.gerinurse.2021.10.006 Saravanakumar, P., Higgins, I. J., Van Der Riet, P. J., & Sibbritt, D. (2018). Tai chi and yoga in residential aged care: Perspectives of participants: A qualitative study. Journal of Clinical Nursing, 27(2324), 43904399. https://doi.org/10.1111/jocn.14590 15 Tam, E., Boas, P., Ruaro, F., Flesch, J., Wu, J., Thomas, A., Li, J., & Lopes, F. (2021). Feasibility and adoption of a focused digital wellness program in older adults. Geriatrics (Basel, Switzerland), 6(2), 54. https://doi.org/10.3390/geriatrics6020054 Turner, J., Greenawalt, K., Goodwin, S., Rathie, E., & Orsega-Smith, E. (2017). The development and implementation of the art of happiness intervention for communitydwelling older adults. Educational Gerontology, 43(12), 630640. http://dx.doi.org/10.1080/03601277.2017.1380894 Ward, K., Pousette, A., & Pelletier, C. A. (2020). Not everybodys an athlete, but they Certainly can move: Facilitators of physical activity maintenance in older adults in a northern and rural setting. Journal of Aging & Physical Activity, 28(6), 854863. https://doi.org/10 16 Appendix A Table 1 Pre-and Post-Test Results Question Pre-Test Result Post-Test Result The current HEP inventory fits 50% or more of clients conditions. Agree Strongly Agree The current HEP inventory fits 50% or more of clients interests Agree Agree 50% or more of the clients are confident in the HEP after reviewing the plan at discharge. Neutral Agree 17 Appendix B Landing Page for Inventory https://sites.google.com/view/htsinventory/inventory?authuser=0 18 Appendix C Capstone Weekly Log Wee DCE Stage k Objectives Tasks Goals and Objectives Status Completed 1 Orientation 1. Orient to the capstone company and site. 2. Learn policy and procedures to enhance the capstone experience further. 1. Online In progress orientation 2. Reading and reviewing policies, population statistics, and staff organization. 3. Participate in training and education. 2 Evaluation 1. Participate in further training and education. 2. Evaluate priorities for website inventory. 1. Met staff and residents onsite to ask about role, scope, and need. 2. Participated in wellness classes and continuing education. Achieved: By week 2, I will develop priorities for website content, build main themes share with staff. 01/22/2023 3 Evaluation 1. Meet with stakeholders at Hoosier Village. 2. Develop a survey for increased evaluation and validity. 1. Arrange meetings and stakeholder interviews. 2. Complete survey research and development. In progress 01/29/2023 4 Development 1. Develop inventory structure and organization. 1. Development of inventory and design In progress 02/05/2023 01/15/2023 19 2. Participate in wellness courses for increased knowledge of wellness programming available. through the feedback I received from stakeholders. 2. Making a wellness course list based on energy consumption by receiving feedback and completing wellness classes. 5 Development 1. Develop clear categories and begin combining previously used home exercise plans with newly developed ones. 1. Working on the inventory from design to function and importing home exercise programs developed personally and pulled from professional inventories. 6 Development 1. Develop new exercises for the inventory. 2. Complete a clear organization based on sustainability and userfriendly features. 1. Developed and completed pages of new exercises and programs that were requested. 2. Worked on the design for the continuation of editing and developing. 02/12/2023 Achieved: By the end of week 6, there will be Healthcare Therapy Services marketing materials formed for distribution among Hoosier Village Residents on outpatient occupational therapy 02/19/2023 20 services. Achieved: By the end of week 6, Hoosier Villages residents will obtain discharge information and occupational therapys primary role in wellness and prevention through outreach. 7 Implementation 1. Unveil the inventory to stakeholders and get the first round of feedback to adjust and alter areas. 1. Presenting the inventory to stakeholders and completing a comprehensive edit of different components and notations of areas that needed more home exercise programs. Achieved: By week 4, have website materials finalized and prepared for the case study. 02/26/2023 8 Implementation 1. Identify case study client and begin the process of case study planning and training for the occupational therapist onsite. 1. Discussed and met with the occupational therapy practitioner onsite to develop an approach to the case study and identify a best-fit case study client based on the In progress 03/05/2023 21 parameters. 9 Implementation 1. Make final adjustments and present to stakeholders, occupational therapy practitioners, and residents for final feedback. 1. Completing last round of edits by sweeping the entire inventory and ensuring there were equal exercise options for the categories and adding any further requested materials. In progress 03/12/2023 10 Implementation 1. The case study was completed with data pulled and post-survey administered. 1. Prepared and completed the case study process and arranged a data analysis day where the case study, observation, and postsurvey were administered. Achieved: By week 6, there will be a case study analysis completed with at least 3 individuals receiving occupational therapy services. Achieved: By the end of week 8, 3 priorities will be developed from the case study and data analysis to increase residents knowledge and skills of prevention and wellness and make further adjustments to the website. 03/19/2023 22 11 Data Analysis 1. Begin data analysis and finding themes and survey results. 1. Complete In progress data analysis by finding themes and finding areas where the survey showed progress. 03/26/2023 12 Data Analysis 1. Finalize data analysis and work on dissemination presentation and approach. 1. Finalized In progress the data I disseminated and developed an approach to present the data and results in a comprehensive format and approach to disseminate. 04/02/2023 13 Finalization 1. Finalize dissemination plan and work on consolidating and sharing materials. 1. Completed dissemination presentation and script to be clear and concise about research results and implementatio n process Achieved: 04/09/2023 By the end of week 6, there will be a resource developed with instructions on how to adapt the website and edit. Achieved: By the end of week 10, there will be at least 3 inperson meetings regarding how to edit and implement the website to develop the best outcomes for patients. 23 14 Dissemination 1. Disseminate research to all stakeholders and ensure stakeholders have all resources available for longevity and sustainability. 1. Disseminated the results to stakeholders which included the VP of Operations at HTS, the therapy department, and with key residents. All goals were achieved. 04/16/2023  ...

... IMPLEMENTATION OF INDIVIDUAL LIFE SKILLS SESSIONS AT AN INPATIENT PSYCHIATRIC HOSPITAL Implementation of Individual Life Skills Sessions at an Inpatient Psychiatric Hospital Claire Petersen May 1, 2023 A capstone project submitted in partial fulfillment for the requirements of the Doctor of Occupational Therapy degree from the University of Indianapolis, School of Occupational Therapy. Under the direction of the faculty capstone advisor: Christine Kroll, OTD, MS, OTR, FAOTA 1 IMPLEMENTATION OF INDIVIDUAL LIFE SKILLS SESSIONS AT AN INPATIENT PSYCHIATRIC HOSPITAL Abstract My doctoral capstone aimed to develop a trial program for individual life skills sessions to expand and improve patient-centered care at an inpatient psychiatric hospital. Using resources and research evidence along with feedback from the occupational therapists (OTs) and rehabilitation director, I created a life skills resource binder and assisted in scheduling OTs for trial individual life skills sessions. By implementing this trial program, OTs comfort, confidence, and perceived benefit of this type of treatment increased. Furthermore, the trial sessions advocated for the professions ability to positively impact a psychiatric setting. The project met the sites need, gained optimistic responses from the OTs and rehabilitation director, and began the conversation regarding future rehabilitation scheduling and structure. There is a high likelihood that the program will continue to develop and expand. Keywords: individual, life skills, patient-centered, psychiatric 2 IMPLEMENTATION OF INDIVIDUAL LIFE SKILLS SESSIONS AT AN INPATIENT PSYCHIATRIC HOSPITAL 3 New Hampshire Hospital (NHH) is an inpatient psychiatric hospital in Concord, NH whose mission is to provide comprehensive compassionate inpatient psychiatric services to the people of NH (New Hampshire Department of Health and Human Services, 2016). All patients suffer from a mental illness and are admitted due to a variety of distressful mental health events. Disposition and recidivism are large issues at NHH (M. Grayston, personal communication, March 9, 2022) due to this populations decreased living skills, making it harder to successfully transition out of the hospital and reintegrate into the community (Dsormeaux-Moreau, Larivire, & Aubin, 2018). The rehabilitation structure of NHH consists of mainly group sessions led equally by occupational therapists, recreational therapists, and activity leaders (M. Hasey, personal communication, January 10, 2023). Although these are beneficial, and the hospital has begun group life skills sessions, there is a need to incorporate individual life skills sessions to improve patient-centered care and take greater advantage of the clinical skill set of occupational therapists (OTs). However, some OTs at NHH have decreased confidence and comfort in conducting these sessions and have a lower perceived benefit of this type of treatment (M. Grayston, personal communication, March 9, 2022; M. Hasey, personal communication, January 10, 2023). The goal of my project was to create a resource binder that outlines individual life skills sessions for OTs to follow in trial sessions, leading to increased confidence, comfort, and perceived benefit. Furthermore, the dissemination of this data to the occupational therapy department and administration should encourage future integration of more individual life skills therapy sessions into the rehabilitation schedule. The following sections of the paper explain the importance of the project, its development, and its outcomes. Appendices A and B shows the projects timeline and the projects weekly planning guide. IMPLEMENTATION OF INDIVIDUAL LIFE SKILLS SESSIONS AT AN INPATIENT PSYCHIATRIC HOSPITAL 4 Background Various life skills are challenging for individuals with mental illness. Many inpatient psychiatric patients have poor self-care, leading to unhealthy eating habits, decreased personal hygiene, and limited physical activity (Gill et al., 2021). Most individuals with a psychiatric disorder have difficulty adhering to medications (Buchman-Wildbaum et al., 2020), exacerbating their symptoms and decreasing their ability to live independently. Additional life skills this population struggles with, but desires more assistance in, include understanding services available to them in the community, establishing a meaningful daily routine, preventing loneliness, developing coping strategies, taking care of their physical and mental health, becoming part of a community, and establishing more peer support (dnanes et al., 2020). It is important for these patients to receive help in these areas while in the hospital because research indicates that the period immediately following discharge is critical for psychiatric patients due to the high risk of self-harm (Hengartner et al., 2017). Many individuals with mental illness have poor social functioning and unstable relationships, causing them to lack accountability in attending appointments and taking medications (Hengartner et al., 2017). Overall, they have difficulty living in the community, participating in everyday activities, and living independently (Jun & Choi, 2020; Moummourtty et al., 2020). These life skills can be difficult to address solely through group therapy sessions. Individual therapy sessions are more patient-centered and have resulted in increased benefits to patients at psychiatric facilities (Kearns & Shiel, 2021; Pratt et al., 2017). These patients reintegrated more successfully into their community and family life, experienced increased quality of life and decreased re-hospitalizations, and continued their engagement in community programs post-discharge (Fontaine et al., 2019; Saha et al., 2020). Unfortunately, therapy IMPLEMENTATION OF INDIVIDUAL LIFE SKILLS SESSIONS AT AN INPATIENT PSYCHIATRIC HOSPITAL 5 sessions personalized to patients unique needs are lacking in psychiatric settings (Moummourtty et al., 2020), creating a need for my project at NHH. At NHH and many inpatient psychiatric hospitals, group therapy sessions are the main form of therapy offered. Through my needs assessments with NHH, I learned about the potential benefits and desire of incorporating individual life skills sessions into the rehabilitation structure. I learned that there is decreased confidence, comfort, and perceived benefit in conducting these sessions and concern about having the time to plan these sessions (M. Grayston, personal communication, March 9, 2022; M. Hasey, personal communication, January 10, 2023). Previous studies also found limited confidence in this setting, which informed me that there was a need to develop resources that give the OTs ideas for sessions and decrease the time they need for planning (Whiteford et al., 2020). The director of rehabilitation and my OT mentor were particularly excited and in favor of this project. This OT mentor believed there was an opportunity for OTs to use their skills more in this setting (M. Hasey, personal communication, January 11, 2023). After introducing my project in an OT meeting, the other OTs were excited and on board, stating that it would be nice to meet patients individual needs. It was important to gain buy-in from all OTs because OTs bring a unique approach to patient care that can benefit psychiatric patients. Occupational therapists ability to use a holistic approach and create patient-centered goals and interventions enables them to make large contributions in this field, especially with the increased awareness and discussions about mental health in society in the last few years (Huri, 2017; Thompson et al., 2021). Many studies have indicated the importance and benefits of patient-centered and occupation-based interventions allowed through individual sessions (Lai et al., 2021; Skaltsi et al., 2021; Syed, 2020; Whiteford et al., 2020). IMPLEMENTATION OF INDIVIDUAL LIFE SKILLS SESSIONS AT AN INPATIENT PSYCHIATRIC HOSPITAL 6 Several studies have integrated similar projects of educating healthcare staff to improve their confidence and competence, resulting in better patient care and outcomes. In Sharp et al.s (2018) study, individuals created a workbook with interventions for the nursing staff that helped them structure their conversations and interventions with patients and increase nurses confidence. The authors of this study found it critical to evaluate the staffs view of the resource, which I implemented in my project. Jones et al. (2018) wrote a systematic review containing studies about the effectiveness of stroke education for healthcare workers. The educational sessions consisted of lectures, workbooks, and discussions. Most studies in this review indicated improvements in the quality of care and patient outcomes after staff participated in the sessions. Hill (2022) assessed nurses knowledge and confidence in self-harm patients before and after the educational videos and discussion. Most nurses experienced increased knowledge and confidence, and all felt more empathic toward the patients after participating in the educational sessions. Results from these studies indicate the potential for a project of similar ideas and structure to impact therapists and patient care at NHH positively. Although these studies ended in improvements to healthcare staff and patient care, there were shortcomings. Participants in Sharp et al.s (2018) study found it difficult to integrate the workbook in the correct situations as not all patients were appropriate due to their physical or mental status. Several studies in Jones et al.s (2018) systematic review lacked a quality outcome measure. Studies from this review and Hills (2022) article did not state whether the educational sessions became an ongoing implementation and if the projects created overall change within the hospitals. I considered these issues and limitations during the development and implementation of my project to improve outcomes. IMPLEMENTATION OF INDIVIDUAL LIFE SKILLS SESSIONS AT AN INPATIENT PSYCHIATRIC HOSPITAL 7 Theory The model I used for my DCE is the Person-Environment-Occupation-Performance model (PEOP) (Cole & Tufano, 2020). This model helped organize the current personal and environmental challenges at NHH and highlighted the projects performance goals. The person aspect of this model was the OTs and how they had decreased confidence and comfort in conducting individual life skills therapy sessions and did not have a high perceived benefit of this treatment. The environment aspect included the complexity of patients with mental illness, the lack of screening to determine appropriate patients, the lack of scheduling individual sessions, and the decreased time for planning these sessions. The occupation within this model was the conduction of effective individual life skills sessions. Finally, the performance aspect was how the OTs felt conducting sessions when using the resource binder and what changes the project made to the administrations thoughts regarding incorporating this treatment into NHHs schedule in the future. The frame of reference I used for my DCE is the lifespan theory. This frame focuses on understanding an individuals missing skills and current stage of development and life due to illness (Cole & Tufano, 2020). Therefore, it is essential during individual sessions to assess and understand the patients current stage of development compared to others at their age. Using this frame of reference, therapists should design evidence-based resources that include activities and environments that match patients current level of functioning and abilities, creating a just-right challenge. According to this theory, its helpful for therapy sessions to be centered around increasing patients self-identity, independence, engagement in meaningful occupations, and performance in life skills required to succeed in their life roles and environments (Cole & Tufano, 2020). IMPLEMENTATION OF INDIVIDUAL LIFE SKILLS SESSIONS AT AN INPATIENT PSYCHIATRIC HOSPITAL 8 Project: Design and Implementation In order to develop a new program and protocol for individual treatment sessions, I had to create an evidence-based resource binder containing individual life skills therapy sessions for the OTs. The resource binder provides clear examples and structure of sessions and largely decreases the amount of time the OTs would need to plan sessions on these topics. Before creating the resource binder, I introduced the project at an OT meeting to the rehabilitation department and administered a pre-survey to the OTs (See Appendix C). Data from this quick assessment of OTs perceptions indicated initial scores on comfort, confidence, and perceived benefit; which life skills to focus on in my resource binder; and what I needed to consider when creating it so that it was understandable to patients and addressed the OTs main barriers. This assessment was effective in that it showed me how OTs currently felt and indicated necessary information for the design of my resource binder. I cross-referenced the OTs ideas and needs with the Occupational Therapy Practice Framework (American Occupational Therapy Association, 2020) when creating subsections on each topic. I did this to ensure occupation-based topics and language. I spent six weeks using resources from NHH and further research to create and edit the binder, as well as develop a quick screening tool to help determine which patients are appropriate and interested in individual life skills sessions and which topics they want to work on throughout these sessions. I developed these screening questions with reference to assessment tools in Ashers (2007) occupational therapy textbook, a PROMIS life satisfaction tool (General life satisfaction, 2022), and the Occupational Therapy Practice Framework (American Occupational Therapy Association, 2020). After five weeks, I led an educational session at an OT meeting over the binder and its layout and gathered feedback through discussion on the first draft of the binder. Then, I IMPLEMENTATION OF INDIVIDUAL LIFE SKILLS SESSIONS AT AN INPATIENT PSYCHIATRIC HOSPITAL 9 completed six screenings and three trial individual life skills therapy sessions to test the binder myself. These trial sessions, along with the OTs feedback, indicated adjustments to make to the binder. After finalizing the binder, I discussed with the administration how best to schedule at least one individual life skills session for each OT in the next three weeks. I administered a postsurvey to the OTs following their session and a post-implementation survey regarding overall thoughts of the binder (See Appendix D and E respectively). The OTs briefly shared their experiences in an OT meeting. After gathering all data, I created a dissemination plan and presented my project to the OT department and administration during my last week at NHH. I experienced challenges and successes during my project design and implementation. Successes included positive buy-in from all staff, helpful information from surveys, a wellorganized timeline, and successful trial sessions with the binder. Challenges included the initial design of the binder and some patients low desire to try participating due to their decreased insight into deficits, motivation to improve, and knowledge of the sessions benefits. Also, many patients during this time were very acutely ill, unsafe, and not appropriate for sessions. Project: Outcomes I analyzed data from the pre- and post-surveys (See Appendices C and D) to discover outcomes that my program resulted in regarding OTs comfort, confidence, and perceived benefit in conducting individual life skills sessions. Eight OTs conducted one session with patients. Refer to Table 1 for detailed results of this pre-survey. Along with these results, this survey also showed that the primary barrier to having an individual life skills session for patients was mental stability, and for the OTs it was finding time to plan and implement the session (six OTs) and how to start a session (three OTs). Two OTs also wrote that a lack of knowledge or awareness of IMPLEMENTATION OF INDIVIDUAL LIFE SKILLS SESSIONS AT AN INPATIENT PSYCHIATRIC HOSPITAL 10 available community resources was a barrier. I designed my program and resource binder to address and decrease these barriers. After implementation, the OTs completed a post-survey with the same questions (See Table 2). Data from pre- to post-survey found that 38% of OTs experienced increased comfort with selecting appropriate patients for individual life skills sessions. Data found that 50% of OTs experienced increased comfort in conducting an individual life skills session. Twenty five percent of OTs experienced increased confidence that their session would be very beneficial. Confidence in the session being patient-centered also increased for 25% of the OTs. Lastly, 50% of OTs had increased scores for how beneficial they believe individual life skills sessions would be to their patients. At the end of the survey, OTs identified barriers that continue to exist for conducting these sessions. These include time in OTs schedules and patients decreased motivation, large number of difficulties to work on with the patient, and cognitive deficits. Table 3 represents data from the post-implementation survey. Seven of the eight OTs said the resource binder was very user-friendly, all eight said it was very helpful and they are very likely to use it again, and all except for one OT reported it would be at least somewhat beneficial to have more time for these sessions (three OTs said very beneficial). The OT that chose neutral reported that her schedule already allows time for this. When OTs provided a briefing of their session, they had many positive comments such as it gave a lot of information to the treatment team, it opened up conversations that wouldnt have occurred otherwise, the screening made it very efficient, it was nice to use stuff I never have before, this will be beneficial in group sessions too, and it was really helpful to just grab sheets. In addition, many OTs were planning to continue working with their patient on other skills. IMPLEMENTATION OF INDIVIDUAL LIFE SKILLS SESSIONS AT AN INPATIENT PSYCHIATRIC HOSPITAL 11 Summary As discussed earlier, individuals with psychiatric conditions have decreased living skills which makes it harder to successfully transition out of the hospital, reintegrate into the community, effectively perform daily activities, and live independently (Dsormeaux-Moreau, Larivire, & Aubin, 2018; Jun & Choi, 2020; Moummourtty et al., 2020). Individual life skills sessions, which are not the standard at NHH, can successfully address these difficulties and in a much more patient-centered manner (Fontaine et al., 2019; Kearns & Shiel, 2021; Saha et al., 2020). The trial program that I implemented at NHH addressed this issue through the creation of a resource binder for OTs to use in trial individual life skills sessions. The goal was to increase OTs comfort, confidence, and perceived benefit of the sessions. The main findings include (1) a 38% increase in comfort selecting appropriate patients (2) a 50% increase in comfort conducting a session, (3) all OTs felt very confident that their sessions would be patient-centered, (4) a 50% increase regarding how beneficial OTs believe individual life skills sessions would be to their patients, and (5) 88% of OTs believe it would be at least somewhat beneficial to have more time in their schedules to implement these sessions. Continued difficulties in planning and implementing included time in OTs schedule and patients decreased motivation and cognition. It is important to note that two of the OTs work on a unit (I/J geriatric unit) that is different than the others. Most of these patients are waiting to be discharged to an assisted living or skilled nursing facility and likely wont utilize many community resources. Many of them have cognitive deficits which limit the effectiveness of life skills sessions. This unit also has more OTs. These factors decreased the scores of these two OTs for the questions regarding how beneficial individual life skills sessions would be to their patients and how beneficial it would be to have more time in their schedule for these sessions. IMPLEMENTATION OF INDIVIDUAL LIFE SKILLS SESSIONS AT AN INPATIENT PSYCHIATRIC HOSPITAL 12 Conclusion Implementing this project at NHH accomplished the goal of increasing the thoughts and conversations surrounding future changes in the rehabilitation structure at this hospital. The project also indicated the need for OTs and their clinical skills in an inpatient psychiatric setting. The OTs benefitted from using the resource binder as it saved them a lot of time and gave them intervention ideas that they had never used before. Many of the OTs reported that they planned to use the resource binder again to address more life skills with their patients. OTs also believed that the resource binder would not only be helpful for individual sessions, but also for group sessions. Having OTs conduct trial individual life skills sessions allowed the rest of the treatment team including the provider, nurses, social worker, etc. to witness the positive impact that OTs can have on psychiatric patients. Apart from increasing OTs comfort, confidence, and perceived benefit in conducting these sessions, the project advocated for the importance of OTs clinical skills and knowledge at NHH to improve patients life skills and ability to reintegrate into the community after discharge. The OTs and rehabilitation department director very positively viewed this project and the usefulness of the resource binder. The increased discussion surrounding future integration of individual life skills sessions will hopefully lead to more opportunities for OTs to use their clinical skills at this site, resulting in improved patient care. IMPLEMENTATION OF INDIVIDUAL LIFE SKILLS SESSIONS AT AN INPATIENT PSYCHIATRIC HOSPITAL 13 References dnanes, M., Cresswell-Smith, J., Melby, L., Westerlund, H., prah, L., Sfetcu, R., Stramayr, C., & Donisi, V. (2020). Discharge planning, self-management, and community support: Strategies to avoid psychiatric re-hospitalization from a service user perspective. Patient Education and Counseling, 103(5), 10331040. https://doi.org/10.1016/j.pec.2019.12.002 American Occupational Therapy Association. (2020). Occupational therapy practice framework: Domain and process (4th ed.). American journal of occupational therapy, 74 (Supplement 2). Advance online publication. Asher, I. E. (Ed.). (2007). Occupational therapy assessment tools: An annotated index (3rd ed.). AOTA Press. Buchman-Wildbaum, T., Vradi, E., Schmelowszky, ., Griffiths, Mark. D., Demetrovics, Z., & Urbn, R. (2020). Targeting the problem of treatment non-adherence among mentally ill patients: The impact of loss, grief and stigma. Psychiatry Research, 290, 113140. https://doi.org/10.1016/j.psychres.2020.113140 Cole, M. & Tufano, R. (2020). Applied theories in occupational therapy: A practical approach (2nd Ed.). SLACK Incorporated. Dsormeaux-Moreau, M., Larivire, N., & Aubin, G. (2018). Modelizing home safety as experienced by people with mental illness. Scandinavian Journal of Occupational Therapy, 25(3), 190202. https://doi.org/10.1080/11038128.2017.1335343 Fontaine, B. N., Puttaert, C. M., Stewart, T. L., Struthers, A. M., & Bapuji, S. B. (2019). Bridging the gap between hospital and community-based mental health services. Occupational Therapy in Mental Health, 35(2), 157178. https://doi.org/10.1080/0164212X.2018.1539367 IMPLEMENTATION OF INDIVIDUAL LIFE SKILLS SESSIONS AT AN INPATIENT PSYCHIATRIC HOSPITAL 14 General life satisfaction. (2022, November 9). Health Measures. Retrieved January 11, 2023, from https://www.healthmeasures.net/index.php?option=com_instruments&task=Search. pagination&Itemid=992 Gill, R., Tyndall, S. F., Vora, D., Hasan, R., Megna, J. L., & Leontieva, L. (2021). Diet quality and mental health amongst acute inpatient psychiatric patients. Cureus, 13(1), 1-9. https://doi.org/10.7759/cureus.12434 Hengartner, M. P., Klauser, M., Heim, G., Passalacqua, S., Andreae, A., Rssler, W., & Wyl, A. (2017). Introduction of a psychosocial postdischarge intervention program aimed at reducing psychiatric re-hospitalization rates and at improving mental health and functioning. Perspectives in Psychiatric Care, 53(1), 1015. https://doi.org/10.1111/ppc.12131 Hill, R. (2022). Nursing staff confidence and knowledge when caring for people with self-harm injuries: a service improvement study. British Journal of Nursing, 31(4), S42S50. https://doi.org/10.12968/bjon.2022.31.4.S42 Huri, M. (Ed.). (2017). Occupational therapy - Occupation focused holistic practice in rehabilitation. IntechOpen. https://doi.org/10.5772/65138 Jones, S. P., Miller, C., Gibson, J. M. E., Cook, J., Price, C., & Watkins, C. L. (2018). The impact of education and training interventions for nurses and other health care staff involved in the delivery of stroke care: An integrative review. Nurse Education Today, 61, 249257. https://doi.org/10.1016/j.nedt.2017.11.024 Jun, W. H., & Choi, E. J. (2020). The relationship between community integration and mental health recovery in people with mental health issues living in the community: A IMPLEMENTATION OF INDIVIDUAL LIFE SKILLS SESSIONS AT AN INPATIENT PSYCHIATRIC HOSPITAL 15 quantitative study. Journal of Psychiatric and Mental Health Nursing, 27(3), 296307. https://doi.org/10.1111/jpm.12578 Kearns Murphy, C., & Shiel, A. (2021). Evaluation of an intensive occupational therapy intervention to facilitate independent living and improve occupational performance and participation. results of a longitudinal case study design. Occupational Therapy in Mental Health, 37(1), 1537. https://doi.org/10.1080/0164212X.2020.1852149 Lai, D. W. L., Chan, K. C., Daoust, G. D., & Xie, X. J. (2021). Hopes and wishes of clients with mentally illness in Hong Kong. Community Mental Health Journal, 57(8), 1556 1565. https://doi.org/10.1007/s10597-021-00779-9 Moummourtty, P., Nagarajan, P., Rajkumar, R. P., & Kaliamoorthy, C. (2020). Rehabilitation needs of patients with schizophrenia attending the general hospital psychiatric unit of a tertiary care hospital in South India. Industrial Psychiatry Journal, 29(2), 329-334. https://doi.org/10.4103/ipj.ipj_180_20 New Hampshire Department of Health and Human Services. (2016). New Hampshire Hospital. dhhs. https://www.dhhs.nh.gov/dcbcs/nhh/ Pratt, S. I., Mueser, K. T., Wolfe, R., Santos, M. M., & Bartels, S. J. (2017). One size doesnt fit all: A trial of individually tailored skills training. Psychiatric Rehabilitation Journal, 40(4), 380386. https://doi.org/10.1037/prj0000261 Saha, S., Chauhan, A., Buch, B., Makwana, S., Vikar, S., Kotwani, P., & Pandya, A. (2020). Psychosocial rehabilitation of people living with mental illness: Lessons learned from community-based psychiatric rehabilitation centres in Gujarat. Journal of Family Medicine and Primary Care, 9(2), 892897. https://doi.org/10.4103/jfmpc.jfmpc_991_19 IMPLEMENTATION OF INDIVIDUAL LIFE SKILLS SESSIONS AT AN INPATIENT PSYCHIATRIC HOSPITAL 16 Sharp, M., Gulati, A., Barker, C., & Barnicot, K. (2018). Developing an emotional coping skills workbook for inpatient psychiatric settings: a focus group investigation. BMC Psychiatry, 18(1), N.PAG-N.PAG. https://doi.org/10.1186/s12888-018-1790-z Skaltsi, P., Konstantinou, G., Papagathangelou, M., Angelopoulos, E., & Papageorgiou, C. C. (2021). The role of occupational therapy within an acute mental health setting: A naturalistic cohort study. Psychiatric Annals, 51(3), 131139. https://doi.org/10.3928/00485713-20210207-01 Syed, Z. (2020). Occupational therapy: The process in acute psychiatry. African Journal of Health Professions Education, 12(1), 911. https://doi.org/10.7196/AJHPE.2020.v12i1.1185 Thompson, A. N., Fugard, M. I., & Kirsh, B. (2021). Organizational workplace mental health: An emerging role for occupational therapy. Occupational Therapy in Mental Health, 37(3), 240263. https://doi.org/10.1080/0164212X.2021.1908925 Whiteford, G., Jones, K., Weekes, G., Ndlovu, N., Long, C., Perkes, D., & Brindle, S. (2020). Combatting occupational deprivation and advancing occupational justice in institutional settings: Using a practice-based enquiry approach for service transformation. British Journal of Occupational Therapy, 83(1), 5261. https://doi.org/10.1177/0308022619865223 IMPLEMENTATION OF INDIVIDUAL LIFE SKILLS SESSIONS AT AN INPATIENT PSYCHIATRIC HOSPITAL 17 Table 1 Results of Pre-Survey to OTs Question Number of OTs out of Eight in Each Category Very Somewhat Comfortable Comfortable 3 5 4 3 How comfortable do you feel selecting patients who are appropriate and would benefit from individual life skills sessions? How comfortable would you feel conducting an individual life skills session with a patient today? How confident do you feel that your individual session would be very Very Somewhat Confident Confident 1 6 Neutral Somewhat Very Uncomfortable Uncomfortable 0 0 0 0 1 0 Neutral 0 Somewhat Very Unconfident Unconfident 1 0 IMPLEMENTATION OF INDIVIDUAL LIFE SKILLS SESSIONS AT AN INPATIENT PSYCHIATRIC HOSPITAL beneficial to the patient? How confident do you feel that your individual session would be patientcentered? How beneficial do you think individual life skills sessions would be to your patients? 6 2 Very Somewhat Beneficial Beneficial 2 4 0 Neutral 2 0 0 Somewhat Very Unbeneficial Unbeneficial 0 0 18 IMPLEMENTATION OF INDIVIDUAL LIFE SKILLS SESSIONS AT AN INPATIENT PSYCHIATRIC HOSPITAL Table 2 Results of Post-Survey to OTs Question Number of OTs out of Eight in Each Category Very Somewhat Comfortable Comfortable 6 2 0 0 0 7 1 0 0 0 How comfortable do you feel selecting patients who are appropriate and would benefit from individual life skills sessions? How comfortable would you feel conducting an individual life skills session with a patient today? How confident do you feel that your individual session would be very Very Somewhat Confident Confident 2 6 Neutral Neutral 0 Somewhat Very Uncomfortable Comfortable Somewhat Very Unconfident Unconfident 0 0 19 IMPLEMENTATION OF INDIVIDUAL LIFE SKILLS SESSIONS AT AN INPATIENT PSYCHIATRIC HOSPITAL beneficial to the patient? How confident do you feel that your individual session would be patientcentered? How beneficial do you think individual life skills sessions would be to your patients? 8 0 Very Somewhat Beneficial Beneficial 4 4 0 Neutral 0 0 0 Somewhat Very Unbeneficial Unbeneficial 0 0 20 IMPLEMENTATION OF INDIVIDUAL LIFE SKILLS SESSIONS AT AN INPATIENT PSYCHIATRIC HOSPITAL Table 3 Post-Implementation Survey to OTs Question Number of OTs out of Eight in Each Category Very User- Somewhat User- Friendly Friendly Neutral Not UserFriendly How userfriendly was the 7 1 0 0 resource binder? Very Helpful Somewhat Neutral Not Helpful Helpful How helpful was the resource binder in 8 0 0 0 planning sessions? Very Likely Somewhat Neutral Not Likely Likely How likely is it that you would use the resource 8 0 0 0 binder again? Very Beneficial Somewhat Neutral Not Beneficial Beneficial How beneficial do you believe it would be if you had more time in your schedule 3 4 1 0 21 IMPLEMENTATION OF INDIVIDUAL LIFE SKILLS SESSIONS AT AN INPATIENT PSYCHIATRIC HOSPITAL for individual life skills sessions? 22 IMPLEMENTATION OF INDIVIDUAL LIFE SKILLS SESSIONS AT AN INPATIENT PSYCHIATRIC HOSPITAL 23 Appendix A DCE Timeline Week 1 (January 9-13) o Update needs assessment and MOU o Create pre-survey to gather data on OTs confidence and comfort with individual therapy sessions and thoughts about life skills topics o Write up summary of project and introduce to therapists at OT meeting; administer pre-survey o Work through orientation checklist o Research more recent literature o Begin looking through hospitals resources on assessment/screening tools, research articles, etc. o Summarize info learned from surveys with supervisor on Friday Week 2 (January 16-20) o Required orientation classes scheduled for most days of the week o Work on introduction and background sections of paper o Decide on 4-6 life skills to focus my resource binder on o Gather materials from hospitals library and staffs books to help in creating my life skills resource binder o Develop or find a screening tool or quick assessment tool for determining appropriate patients for individual sessions o Submit updated MOU by 20th o Finish Introduction for submission on Monday week 3 Week 3 (January 23-27) o Continue to gather resources to help with my binder o Finish screening tool if not done o Decide on a structure for my binder and get feedback from supervisor o Begin creating life skills individual sessions to put in binder o Finish Background for submission on Monday week 4 Week 4 (January 30 - February 3) o Continue to work on creating life skills individual sessions o Finish Project: Design & Implementation for submission on Monday week 5 Week 5 (February 6-10) o Finish rough draft of resource binder to show at OT meeting on Thursday o Brief education to OTs about binder and layout o Gather feedback from OTs during meeting and begin making adjustments Week 6 (February 13-17) o Begin engaging in at least 2 trial individual life skills therapy sessions with patients using the resource binder IMPLEMENTATION OF INDIVIDUAL LIFE SKILLS SESSIONS AT AN INPATIENT PSYCHIATRIC HOSPITAL 24 o Make changes to binder as needed after trial sessions Week 7 (February 20-24) o Continue engaging in trial individual sessions and making adjustments to binder o Begin working with administration to schedule time in OTs schedule during weeks 9-11 for at least one individual session per OT Week 8 (February 27 March 3) o Complete scheduling with administration o Finalize resource binder for the OTs to use the following three weeks Week 9 (March 6-10) o Oversee communication of individual sessions that OTs do with the resource binder during weeks 9-11 o Receive post-surveys after these sessions for data on comfort and confidence. Receive post-implementation surveys about using the resource binder and having time to conduct more of these sessions o Participate in group therapy sessions to gain more experience Week 10 (March 13-17) o Oversee communication of individual sessions that OTs do with the resource binder o Receive post-surveys after these sessions for data on comfort and confidence. Receive post-implementation surveys about using the resource binder and having time to conduct more of these sessions o Begin analyzing data and writing up results o Communicate with rehabilitation director about scheduling time for dissemination presentation during week 14 o Finish Dissemination Plan for submission Monday week 11 o Participate in group therapy sessions to gain more experience Week 11 (March 20-24) o Oversee communication of individual sessions that OTs do with the resource binder o Receive post-surveys after these sessions for data on comfort and confidence Receive post-implementation surveys about using the resource binder and having time to conduct more of these sessions o Finish analyzing data and writing up results o Participate in OT meeting where each OT briefly shares their experience from their session o Finish Project: Outcomes for submission Monday week 12 o Participate in group therapy sessions to gain more experience Week 12 (March 27-31) o Continue to work on dissemination presentations with feedback from site mentor IMPLEMENTATION OF INDIVIDUAL LIFE SKILLS SESSIONS AT AN INPATIENT PSYCHIATRIC HOSPITAL Week 13 (April 3-7) o Continue to work on dissemination presentations with feedback from site o Finish Abstract, Summary, & Conclusion for submission Monday week 14 Week 14 (April 10-14) o Dissemination to OTs and rehabilitation department administration 25 IMPLEMENTATION OF INDIVIDUAL LIFE SKILLS SESSIONS AT AN INPATIENT PSYCHIATRIC HOSPITAL 26 Appendix B Doctoral Capstone Experience and Project Weekly Planning Guide Week 1 DCE Stage (orientation, screening/evaluatio n, implementation, discontinuation, dissemination) Orientation, Screening/Evaluatio n Weekly Goal 1) I will develop an evidencebased resource binder with assessments and interventions for OTs at NHH to use in individual therapy sessions by the end of week 6. Objectives 1) In the first few weeks, I will gain administrative support for scheduling more OT individual sessions, gain buy in from OTs to try the resources, and give the OTs a pre-survey to determine level of comfort and confidence with individual sessions. 2) Within the first two weeks, I will ascertain life skills topics from OTs that are believed to be the most beneficial to focus on during individual sessions. Tasks I met with administration to gain buy-in for scheduling individual sessions. I introduced the project to OTs through an introduction write up that was emailed to staff. I created a pre-survey and administered this to collect data on OTs comfort and confidence with and perceived benefit of individual life skills sessions. Using the survey and conversing with my site mentor, I decided on the life skills Date complete Objectives 1, 2, and 3 completed 1/13/23. IMPLEMENTATION OF INDIVIDUAL LIFE SKILLS SESSIONS AT AN INPATIENT PSYCHIATRIC HOSPITAL 3) I will help determine which patients are appropriate for individual therapy sessions by creating or finding an assessment or screening tool to include in the binder by the end of week 5. 2 Orientation, Screening/Evaluatio n 1) I will develop an evidencebased resource binder with assessments and interventions for OTs at NHH to use in individual therapy sessions by the end of week 6. 1) The resource binder will include 4-6 individual sessions that correlate with these life skills by end of week 6. 2) I will have increased knowledge about life skills interventions to use with individuals with mental illnesses after creation of the binder by to focus on in my resource binder. I created a quick screening tool to determine appropriate patients for sessions. I updated my needs assessment, MOU, literature review, and timeline. I completed many orientation tasks required by the site. I participated in many inperson orientation training courses required by the site. I looked through life skills books and resources that my mentor and site had. I explained my project and what I would be doing the next few weeks to OTs at the OT meeting and 27 IMPLEMENTATION OF INDIVIDUAL LIFE SKILLS SESSIONS AT AN INPATIENT PSYCHIATRIC HOSPITAL the end of week 6. 3 4 Evaluation Evaluation 1) I will develop an evidencebased resource binder with assessments and interventions for OTs at NHH to use in individual therapy sessions by the end of week 6. 1) I will develop an evidencebased resource binder with assessments and interventions for OTs at NHH to use in individual therapy 1) The resource binder will include 4-6 individual sessions that correlate with these life skills by end of week 6. 2) I will have increased knowledge about life skills interventions to use with individuals with mental illnesses after creation of the binder by the end of week 6. 1) The resource binder will include 4-6 individual sessions that correlate with these life skills by end of week 6. 2) I will have increased sought feedback. I began designing and creating my resource binder. I finished completing my orientation tasks/classes. I worked on creating the resource binder of four life skills with subsections within each skill. I looked through resources that the hospital has as well as my own research. I made good progress on the design of the binder and shared this with my site mentor. I worked on creating the resource binder of four life skills with subsections within each skill. I emailed a draft of this binder to the OTs for them to give me 28 IMPLEMENTATION OF INDIVIDUAL LIFE SKILLS SESSIONS AT AN INPATIENT PSYCHIATRIC HOSPITAL sessions by the end of week 6. 5 Evaluation knowledge about life skills interventions to use with individuals with mental illnesses after creation of the binder by the end of week 6. 1) I will 1) The develop an resource evidencebinder will based include 4-6 resource individual binder with sessions that assessments correlate with and these life interventions skills by end for OTs at of week 6. NHH to use in individual 2) I will have therapy increased sessions by knowledge the end of about life week 6. skills interventions 2) I will to use with receive individuals feedback with mental about the illnesses after resource creation of binder and the binder by make the end of changes to it week 6. as needed by the end of 2-1) I will week 8. conduct educational session(s) about the binder with the OTs at NHH during feedback next week at the OT meeting. I worked on creating the resource binder of four life skills with subsections within each skill. I completed a first draft of the resource binder, sought feedback from the OTs at the OT meeting after explaining the layout and sections, and began making adjustments to the binder. 29 IMPLEMENTATION OF INDIVIDUAL LIFE SKILLS SESSIONS AT AN INPATIENT PSYCHIATRIC HOSPITAL 6 Evaluation, Implementation weeks 5-7 and make changes to the resource binder based on the feedback that I receive. 1) I will 1) The develop an resource evidencebinder will based include 4-6 resource individual binder with sessions that assessments correlate with and these life interventions skills by end for OTs at of week 6. NHH to use in individual 2) I will have therapy increased sessions by knowledge the end of about life week 6. skills interventions 2) I will to use with receive individuals feedback with mental about the illnesses after resource creation of binder and the binder by make the end of changes to it week 6. as needed by the end of 2-1) I will week 8. engage in at least 2 trial 3) I will individual learn clinical sessions using practice the resource skills at binder to NHH determine through further engaging in adjustments at least two during weeks one-on-one 6 and 7. I finished creating the resource binder, but I will continue to make changes in the next two weeks if I receive additional feedback. I started screening patients and completing trial individual life skills sessions with patients which involved getting OT orders, having to add some resources to the binder, scheduling the sessions, and planning the sessions. 30 Goal 1 met 2/14/23. Objective 1 met 2/14/23. Objective 2 met 2/17/23. IMPLEMENTATION OF INDIVIDUAL LIFE SKILLS SESSIONS AT AN INPATIENT PSYCHIATRIC HOSPITAL 31 therapy sessions using the binder throughout my DCE as measured by site mentor feedback. 7 Evaluation, Implementation 3-1) I will debrief with my site mentor about the quality and effectiveness of my one-onone therapy sessions after these are completed. 1) I will 1) I will receive conduct feedback educational about the session(s) resource about the binder and binder with make the OTs at changes to it NHH during as needed by weeks 5-7 the end of and make week 8. changes to the resource 2) I will binder based learn clinical on the practice feedback that skills at I receive. NHH through 2) I will engaging in engage in at at least two least 2 trial one-on-one individual therapy sessions using sessions the resource using the binder to binder determine throughout further my DCE as adjustments measured by during weeks site mentor 6 and 7. feedback. 2-1) I will 3) I will debrief with learn my site I continued to screen patients and finished completing 2 trial individual sessions and debriefed with my supervisor on all sessions. I gathered more feedback from OTs through email and in-person discussions for adjustments to the resource binder. I met with the rehab manager to start determining how to approach making time in each OTs Objective 1 met 2/24/23. Objective 2 met 2/24/23. Goal 2 met 2/24/23. Objective 2-1 met 2/24/23. IMPLEMENTATION OF INDIVIDUAL LIFE SKILLS SESSIONS AT AN INPATIENT PSYCHIATRIC HOSPITAL 8 9 Evaluation Implementation managing services through assisting in the scheduling of individual therapy sessions with the management staff at NHH during weeks 7-11. 1) I will receive feedback about the resource binder and make changes to it as needed by the end of week 8. 2) I will learn managing services through assisting in the scheduling of individual therapy sessions with the management staff at NHH during weeks 7-11. 1) I will assess confidence and comfort mentor about the quality and effectiveness of my one-on- one therapy sessions after these are completed. 1) I will get OTs that participated in the educational session to try using the binder in at least one individual session during weeks 8-11. 2) I will make changes based on OTs feedback as needed throughout weeks 8-11. 1) I will get OTs that participated in the schedule for an individual session in the next 3 weeks. I participated in group therapy sessions and team meetings. Goal 1 I made all final changes met 3/3/23. to the resource binder and put together the final electronic and hard copy. I continued to work with the rehab director to schedule individual sessions for all OTs. I emailed the final electronic copy of the resource binder to the OTs. I participated in group therapy sessions to 32 IMPLEMENTATION OF INDIVIDUAL LIFE SKILLS SESSIONS AT AN INPATIENT PSYCHIATRIC HOSPITAL in conducting individual sessions with OTs that used the binder in at least one intervention session by the end of week 11. 2) I will learn managing services through assisting in the scheduling of individual therapy sessions with the management staff at NHH during weeks 7-11. educational session to try using the binder in at least one individual session during weeks 8-11. 2) I will assess the OTs confidence and comfort with these sessions through a post-survey by the end of week 11. 3) I will make changes based on OTs feedback as needed throughout weeks 8-11. 2-1) I will oversee the individual sessions that OTs complete with the resource binder and receive immediate feedback, further practicing managing skills by the obtain more experience interacting with patients and to seek out more patients who may be appropriate for and interested in individual life skills sessions. I answered any questions that OTs may have had about the individual sessions they had to start trying to do this week. I participated in an OT meeting and learned about how to approach advocating for higher salaries for the OTs at this site. I began making plans for dissemination at my site. 33 IMPLEMENTATION OF INDIVIDUAL LIFE SKILLS SESSIONS AT AN INPATIENT PSYCHIATRIC HOSPITAL 10 Implementation 1) I will assess confidence and comfort in conducting individual sessions with OTs that used the binder in at least one intervention session by the end of week 11. 2) I will learn managing services through assisting in the scheduling of individual therapy sessions with the management staff at NHH during weeks 7-11. end of week 11. 1) I will get OTs that participated in the educational session to try using the binder in at least one individual session during weeks 8-11. 2) I will assess the OTs confidence and comfort with these sessions through a post-survey by the end of week 11. 3) I will make changes based on OTs feedback as needed throughout weeks 8-11. 2-1) I will oversee the individual sessions that OTs complete with the resource binder and receive I participated in group therapy sessions to obtain more experience interacting with patients and to seek out more patients who may be appropriate for and interested in individual life skills sessions. I began writing up outcome results from the pre-survey to be prepared for the postsurvey. I had conversations with my site mentor about my dissemination plan and began working on this. I discussed with the rehabilitation director times for my final presentation. I also got her help in 34 IMPLEMENTATION OF INDIVIDUAL LIFE SKILLS SESSIONS AT AN INPATIENT PSYCHIATRIC HOSPITAL 11 Implementation 1) I will assess confidence and comfort in conducting individual sessions with OTs that used the binder in at least one intervention session by the end of week 11. 2) I will learn managing services through assisting in the scheduling of individual therapy sessions with the management staff at NHH during weeks 7-11. immediate feedback, further practicing managing skills by the end of week 11. 1) I will get OTs that participated in the educational session to try using the binder in at least one individual session during weeks 8-11. 2) I will assess the OTs confidence and comfort with these sessions through a post-survey by the end of week 11. 3) I will make changes based on OTs feedback as needed throughout weeks 8-11. 2-1) I will oversee the individual 35 reiterating to the OTs when I need the completed surveys by. I participated in group therapy sessions to obtain more experience interacting with patients and to seek out more patients who may be appropriate for and interested in individual life skills sessions. I answered any questions that OTs may have had about the individual sessions they had to start trying to do this week. I collected the post-surveys from the OTs and began analyzing this data. I had conversations with my site mentor about Goals 1 and 2 met 3/24/23. Objectives 1, 2, 3, and 2-1 met 3/24/23. IMPLEMENTATION OF INDIVIDUAL LIFE SKILLS SESSIONS AT AN INPATIENT PSYCHIATRIC HOSPITAL sessions that OTs complete with the resource binder and receive immediate feedback, further practicing managing skills by the end of week 11. 12 Discontinuation the results from the surveys I received from each OT. 13 Dissemination I studied the results of my project and began creating my dissemination presentation for the site to show the usefulness of my project and advocate for OT. I communicate d with and received feedback from my site mentor about my presentation to the site. I completed the draft of my scholarly report. I continued working on my dissemination presentations 36 IMPLEMENTATION OF INDIVIDUAL LIFE SKILLS SESSIONS AT AN INPATIENT PSYCHIATRIC HOSPITAL 14 Dissemination for NHH and UIndy. I communicate d with and received feedback from my site mentor about my presentation to the site. I edited my scholarly report after receiving feedback. I made final adjustments to my presentation and disseminated to NHH. 37 IMPLEMENTATION OF INDIVIDUAL LIFE SKILLS SESSIONS AT AN INPATIENT PSYCHIATRIC HOSPITAL 38 Appendix C Pre-Survey to OTs: Please circle and/or write in Name: __________________________________________ Unit: _____________ 1. How comfortable do you feel selecting patients who are appropriate and would benefit from individual life skills sessions? Very Comfortable Somewhat Comfortable Neutral Somewhat Uncomfortable Very Uncomfortable 2. How comfortable would you feel conducting an individual life skills session with a patient today? Very Comfortable Somewhat Comfortable Neutral Somewhat Uncomfortable Very Uncomfortable 3. How confident do you feel that your individual session would be very beneficial to the patient? Very Confident Somewhat Confident Neutral Somewhat Unconfident Very Unconfident 4. How confident do you feel that your individual session would be patient-centered? Very Confident Somewhat Confident Neutral Somewhat Unconfident Very Unconfident 5. How beneficial do you think individual life skills sessions would be to your patients? Very Beneficial Somewhat Beneficial Neutral Somewhat Unbeneficial Very Unbeneficial 6. On average, how often do you conduct individual life skills treatment sessions (not to include portions of an evaluation) with patients per month? 0 times 1-2 times 3-4 times 5+ times IMPLEMENTATION OF INDIVIDUAL LIFE SKILLS SESSIONS AT AN INPATIENT PSYCHIATRIC HOSPITAL 39 Which life skills did these OT sessions address: ______________________________________________________ 7. What do you believe are the patients largest barriers in individual life skills sessions? Health Literacy Attention Span Lack of Interest Safety Concern Mental Stability Other: _________________________________________________________________ 8. What do you believe are your largest barriers to increased comfort and confidence in conducting individual life skills sessions? How to Start 1:1 Experience Building Rapport Safety Choosing the Topic Finding Time for Planning & Implementation Documenting an Individual Note/SOAP Note Other: _______________________________________________________________________________________ 9. Which life skills topics do you believe would be most beneficial to your patients? Community Resources Health Management Financial Management Home Management Daily Routines/Time Management Medication Management/Adherence Apply to College Beneficial Leisure Stress Management & Coping Apply to Jobs Community Mobility Establishing Peer Support Integrating into the Community Other: _______________________________________________________________________________________ IMPLEMENTATION OF INDIVIDUAL LIFE SKILLS SESSIONS AT AN INPATIENT PSYCHIATRIC HOSPITAL 40 Appendix D Post-Survey to OTs: Please circle your answer. Name: __________________________________________ Unit: _____________ 1. How comfortable do you feel selecting patients who are appropriate and would benefit from individual life skills sessions? Very Comfortable Somewhat Comfortable Neutral Somewhat Uncomfortable Very Uncomfortable 2. How comfortable would you feel conducting an individual life skills session with a patient today? Very Comfortable Somewhat Comfortable Neutral Somewhat Uncomfortable Very Uncomfortable 3. How confident do you feel that your individual session would be very beneficial to the patient? Very Confident Somewhat Confident Neutral Somewhat Unconfident Very Unconfident 4. How confident do you feel that your individual session would be patient-centered? Very Confident Somewhat Confident Neutral Somewhat Unconfident Very Unconfident 5. How beneficial do you think individual life skills sessions would be to your patients? Very Beneficial Somewhat Beneficial Neutral Not Beneficial 6. What do you still find difficult about implementing and conducting individual life skills sessions at NHH? IMPLEMENTATION OF INDIVIDUAL LIFE SKILLS SESSIONS AT AN INPATIENT PSYCHIATRIC HOSPITAL 41 Appendix E Post-Implementation Survey 1. How user-friendly was the resource binder? Very User-Friendly Somewhat User-Friendly Neutral Not User-Friendly 2. How helpful was the resource binder in planning sessions? Very Helpful Somewhat Helpful Neutral Not Helpful 3. How likely is it that you would use the resource binder again? Very Likely Somewhat Likely Neutral Not Likely 4. How beneficial do you believe it would be if you had more time in your schedule for individual life skills sessions? Very Beneficial Somewhat Beneficial Neutral Not Beneficial  ...

... 1 Promoting Safe Aging in Place by Implementing Assistive Technology Sara Maria Panczyk May 2023 A capstone project submitted in partial fulfillment of the requirements of the Doctor of Occupational Therapy degree from the University of Indianapolis, School of Occupational Therapy. Under the direction of the faculty capstone advisor: Dr. Lucinda Dale EdD, OTR, CHT, FAOTA 2 Abstract Aging adults underutilized MonTECH services, an assistive technology loan program, and were at risk of diminished well-being and quality of life in their homes. The capstone student developed a program that enhanced aging in place by incorporating assistive technology (AT) to expand MonTECH services to the older adult population who live in an assisted living facility. A total of eight (n = 8) residents from a local assisted living facility volunteered to complete three sessions with an occupational therapy (OT) student to address barriers to occupational performance and borrow AT. Each participant completed a pre and post-survey to assess AT perceptions and utilization. Most participants had positive perceptions and frequently used AT. Survey outcomes demonstrated comfort levels with AT increased by approximately 12%. Furthermore, older adults used and recommended MonTECH services to others. Keywords: aging in place, older adults, assistive technology 3 Promoting Safe Aging in Place by Implementing Assistive Technology Older adults who preferred to live in their homes had more opportunities to gain independence when they used AT (Song, 2019; Chen, 2020). The World Health Organization (WHO) defined AT as tools that enable[d] and promote[d] inclusion and participation, especially of persons with disability, aging populations, and people with non-communicable diseases. The primary purpose[was] to maintain or improve an individuals functioning and independence, thereby promoting their well-being (2022, para. 1). AT could be a permanent addition to ones life and used in the community and the home (Pendleton & Schultz-Krohn, 2017). Medicare, Medicaid, private insurance, organizations, state vocational rehabilitation centers, schools, and federal and state programs often funded or provided AT (Assistive Technology Industry Association [ATIA], 2022). MonTECH is a statewide organization funded under the Assistive Technology Act of 1998 that ensures access to AT for residents of Montana with disabilities (The University of Montana Rural Institute, 2022a). The primary goal of MonTECH is to improve the quality of life among individuals with disabilities. MonTECH offices are located in Missoula and Billings, Montana. The staff offers in-person and virtual services such as AT demonstrations and evaluations. Also, they have an online community buy-sell page for people to purchase used assistive devices from individuals in the area (The University of Montana Rural Institute, 2022b). Demonstrations are free, and a client can loan an assistive device to improve informed decision-making when purchasing AT (The University of Montana Rural Institute, 2022b). The MonTECH team serves individuals across the lifespan and expressed interest in increasing their older adult clientele. 4 The goal of the doctoral capstone project was to promote safe aging in place among older adults by implementing AT. This project further expanded MonTECHs statewide services to the underserved aging population in Montana. The author aimed to synthesize the needs assessment data acquired from MonTECH employees and existing literature to support the project's purpose. The occupational adaptation (OA) model and rehabilitative frame of reference (FOR) guide the project design and implementation. Lastly, this paper summarized project outcomes and future implications for OT professionals serving the geriatric community. Background An increased prevalence of disabilities and chronic illnesses among the United States older citizens was concerning (Orellano-Coln et al., 2017). Approximately 30% of adults in Montana have a disability (Centers for Disease Control and Prevention [CDC], 2021). Among the types of disabilities, mobility and cognition disabilities were the most prevalent. A significant proportion of the older adult population lived independently in their homes even if they could not age in place safely due to a disability, illness, or functional decline (Chen, 2020; Orellano-Coln et al., 2017). Often, these individuals did not have the means to perform daily activities independently and required assistance (Chen, 2020; Orellano-Coln et al., 2017). It was possible to promote adaptations and increase the quality of life among aging individuals who chose to reside in their homes with AT (Chen, 2020; Orellano-Coln et al., 2017). Thus, the project's mission promoted the acceptability and adoption of AT among older adults in Montana which preserved independence, protected their dignity, and fostered safe aging in place. Older adults felt compelled or reluctant to try assistive devices and services related to AT. Peterson & Adams-Price (2021) suggested that the predictors of AT utilization included the extent of physical mobility and emotion. Older adults with more significant physical mobility 5 and fear appearing dependent[were] more likely to endorse positive attitudes toward assistive device use (p. 9). Also, older adults considered AT if it met their satisfaction (Chen, 2020). On the contrary, dependency and age-related stereotypes dissuaded AT use and fostered isolation (Orellano-Coln et al., 2017; Polku et al., 2018). The cost and maintenance of these devices deterred both the caregiver and the older adult (Beaudoin et al., 2020; Thilo et al., 2021). Lastly, some caregivers pressured an older client to adopt AT which inadvertently discouraged AT use (Thilo et al., 2021). With this knowledge, the capstone student anticipated the potential challenges and attributes of acceptability and adoption of AT among older participants. A thorough needs assessment of MonTECH formed the Doctoral Capstone & Experience (DCE) project idea. Molly Kimmel, OTR/L and director of MonTECH, disclosed challenges in serving the older adult population. She remarked, We serve more kids than adults. However, we are hoping to expand our services since we help people across their lifespan (personal communication, February 8, 2022). Maddy Musson, the program coordinator, shared possible factors contributing to the underutilization of MonTECH services among the aging population, If the care provider is aware of MonTECH, the utilization of services is happening more frequently. Folks that are socially isolated or not in routine care are less likely to admit difficulty and ask for help (personal communication, March 2, 2022). Other staff members of MonTECH noted they needed partnerships with aging services and rural communities. The MonTECH team expressed hardships reaching the older adult population, as many aging individuals could not come into the office to participate in demonstrations. Furthermore, the team hoped to expand operations to include off-site demonstrations; however, they did not have a full-time employee who could lead this project. The DCE project expanded MonTECH services to the senior 6 community and incorporated research from a literature review that maximized program effectiveness. A comprehensive literature review served to inform the DCE project development. Larsen et al. (2019) conducted a study with OTs and older adults that promoted the adoption of AT. These authors suggested an occupation-based approach effectively promoted AT use among older adults. However, the researchers data collection varied among participants posing a risk of bias because data collection ceased subjectively when a researcher noticed a pattern. Next, Holthe et al. (2020) studied the feasibility of program evaluation and implementation of assistive devices. A strength of this study was the incorporation of a tailored, client-centered, and collaborative approach when implementing an assistive device, specifically sensor technology, among older individuals. Consequently, these findings could not be generalizable regarding the feasibility of AT and adaptive equipment because the researchers studied only sensory technology. Overall, these two studies had significant results and limitations that influenced the capstone project design. The student enhanced the project design by considering the limitations and strengths of the Holthe et al. (2020) and Larsen et al. (2019) studies. Contrary to the study led by Holthe et al. (2020), the students project included an assortment of AT and adaptive equipment to increase the generalizability of findings. Similarly to the study conducted by Larsen et al. (2019), the student utilized an occupation-based and client-centered approach that promoted AT use during desirable activities. However, the student created a more systematic approach to survey administration that was also influenced by standardized assessments to facilitate reliable data collection. Therefore, the Canadian Occupational Performance Model (COPM) and the Rapid Assistive Technology Assessment (rATA) influenced the pre-survey (Appendix B) and post- 7 survey (Appendix C) design which enabled the participants to prioritize their functional activities. The student and client problem-solved together and identified participation levels in meaningful tasks using a COPM structure (Canadian Occupational Performance Measure [COPM], 2020). Lastly, the student implemented an occupational therapy theory to further strengthen the project design. It was essential to encompass theoretical groundwork for the DCE project at MonTECH. The occupation-based model and FOR chosen to guide the DCE project were the OA model and rehabilitative FOR (see Figure A1). The student explored a persons capacity to alter their life to participate in occupations using the OA model (Cole & Tufano, 2020). The OA model included processes that helped the student educate caregivers, older adults, and community members to anticipate AT needs and promote safe aging in place. Furthermore, it guided the student to educate Montanans on how to recognize the demands of occupations that were meaningful to them. Rehabilitative FOR blended well with the OA model because adaptation was a significant component of this FOR (Cole & Tufano, 2020). Compensatory devices and adaptive equipment facilitated older individuals to preserve independence for as long as possible (Cole & Tufano, 2020; Song, 2019). Using this FOR, the student encouraged individuals to assess their occupational behavior and environment and determined their abilities to perform skills and roles (Cole & Tufano, 2020). The OA model and rehabilitative FOR guided the formation and implementation of the DCE project. Project Design and Implementation The primary focus of this capstone project was program development. The program consisted of three one-to-one sessions with older adults in an assisted living facility, The Village: 1) evaluation, 2) intervention with AT training, and 3) re-evaluation. Residents of The Village 8 volunteered to participate in this program. The capstone student actively recruited older adults who participated in activities hosted by staff at The Village. One participant (n = 1) was between the ages of 70-79, two (n = 2) participants were between the ages of 80-89, and five (n = 5) participants were between the ages of 90-99. Participants included six (n = 6) females and four (n = 4) males. The evaluation consisted of a pre-survey and screening. The pre-survey included 18 questions with follow-up questions and client goal setting. The re-evaluation consisted of a postsurvey and providing alternative AT if needed. The post-survey included eight (n = 8) questions with follow-up questions with client goal evaluation. The COPM and the rATA influenced the pre-survey (Appendix B) and post-survey (Appendix C) design, enabling participants to prioritize their functional activities. The student and client identified participation levels in meaningful tasks using a COPM structure (COPM, 2020). Additionally, this design facilitated the capstone student to determine optimal AT that promoted participation in meaningful activities. During the initial evaluation, the student screened each participant for cognition using the Short Blessed Test and visual impairments utilizing a functional approach. Furthermore, the student completed an informal home assessment and made recommendations when appropriate. Throughout the session, the student used strategies to build rapport with the participant and provided education when appropriate. After the evaluation, the student analyzed the evaluation results and consulted with the assistive technology professional (ATP) to select an assistive device from the MonTECH inventory. The student planned an intervention session to include an occupation-based activity and education. Then, the student scheduled an intervention session with the participant. During the intervention session, the student trained the participant to use the recommended device or equipment. Most borrowed items included low-tech magnifiers and 9 adaptive kitchenware. After the training, the student checked the participant's understanding when the individual explained and demonstrated how to use the device. Then, the participant performed a functional activity using the assistive device or equipment. The participant loaned the recommended AT for up to 30 days. The student completed a re-evaluation using the postsurvey approximately halfway into each participants loan period to determine the frequency of use and participant satisfaction. Outcomes Both surveys consisted of three to five-point Likert-scale questions to gather quantitative data. A Likert-scale format enabled participants to measure their familiarity, frequency of use, satisfaction, participation level, and comfort level with AT (Vagias, 2006). Additional information on both surveys included feedback and goals. The student administered the pre and post-survey to reduce barriers to participation, such as reading and writing skills. Each older adult (n = 8) completed a pre-survey during the initial session and a postsurvey during the final session. The pre-survey consisted of 5-point Likert-scale questions which gathered information about perceived satisfaction and confidence with AT. All the participants responded that they use or have used AT and adaptive equipment. When asked how comfortable older adults were using AT and adaptive equipment, approximately 75% of participants responded that they felt comfortable or very comfortable. This was not a surprising response because the same percentage of participants found AT helpful. However, when asked to rate their comfort level with smartphone use, 40% of the participants felt uncomfortable. Only three participants used MonTECH services in the past. Nevertheless, seven out of eight participants considered obtaining AT, and all participants felt satisfied with the program service thus far. Furthermore, 5 out of 8 participants felt the AT device or services would meet their needs. 10 The post-survey consisted of 5-point Likert-scale questions on perceived satisfaction and comfort with AT after borrowing a device. Approximately 75% of the respondents felt somewhat or extremely satisfied with the AT they borrowed. Only one person was somewhat dissatisfied due to the magnification strength and the lack of light emitted from the magnifier. Even though this participant was dissatisfied, the participant was receptive to trialing more AT in the future. When asked to rate their comfort level with AT, seven out of eight participants responded that they felt somewhat or extremely comfortable. One participant responded with neither uncomfortable nor comfortable. After the older adults completed a trial with an assistive device for at least five days, approximately 62% responded that they used the device often or always. One older adult stated he never used the device because he was unable to recall how to operate the device. Approximately 88% of the participants stated yes they considered obtaining AT and the remaining participant responded with might or might not. Six out of eight participants felt they met their occupation-related goals of using the AT they loaned. However, half of the participants felt the AT device or services would meet their needs. Nonetheless, all participants are either somewhat satisfied or extremely satisfied with the MonTECH services through this program. Lastly, all participants are either likely or very likely to recommend MonTECH services to others. Summary The capstone student promoted AT use among older adults to preserve independence, protect their dignity, and promote safe aging in place. Aging individuals increasingly resided in their homes even if they were not safe or unable to preserve the physical ability to do so independently. Furthermore, this population underutilized AT. Thus, the students primary goals 11 and objectives were to integrate appropriate AT that enhanced or compensated for performance skills that facilitated meaningful daily living. The pre and post-survey results indicated that all participants used AT and were comfortable using it. Most survey respondents were satisfied with program services and reported they would continue using AT. A participant who expressed dissatisfaction with a specific assistive device still reported that she considered exploring other device options. Results indicated that older adults were receptive to AT training and were willing to incorporate it into their daily occupations. Conclusion The student gained extensive knowledge of AT during this Doctoral Capstone Experience (DCE). The student learned valuable skills to appropriately match devices to an individuals needs and successfully integrated AT into treatment plans. When working with older adults, many experienced vision and memory loss. The student supported individuals with these conditions and provided holistic intervention, including AT, to maximize functional independence. The capstone project benefitted MonTECH as it informed how feasible and indemand at-home services are among older adults. The MonTECH staff understood the findings of this pilot program and how they can execute this program with more participants. Additionally, this project demonstrated the value of OT in enabling aging individuals to participate in important tasks that increased their well-being and safety when they chose to reside in their homes. There were added challenges to integrating AT among aging adults, such as cognition, vision, and hearing. The student had a limited sample size of 8 people consisting of mostly females who were in the 90-99 age group. The varying cognitive levels of individuals impacted the usability of AT as some participants required more training time and cueing than others. Moreover, the student was limited by the time to conduct the project and the number of 12 sessions allotted per participant. Nevertheless, this project demonstrated the possibility of promoting AT use, especially when it simulated the OT process of evaluation, intervention, and outcomes. OTs have a unique skill to assess supports and barriers to occupational performance and discover methods to incorporate AT into daily living. Thus, OTs can integrate AT recommendations and training when working with an older adult population. 13 References Assistive Technology Industry Association [ATIA]. (2022). AT resources funding guide. https://www.atia.org/home/at-resources/what-is-at/resources-funding-guide/ Beaudoin, M., Oladele, A., Mortenson, B.W., Claudine, A., Demers, L., Wister, A., Plante, M., & Routhier, F. (2020). Interviews with family caregivers of older adults: Their experiences of care and the integration of assistive technology in care. Technology and Disability, 32(3), 1-11. http://dx.doi.org/10.3233/TAD-190253 Canadian Occupational Performance Measure [COPM]. (2020). About the COPM. https://www.thecopm.ca/about/ Centers for Disease Control and Prevention [CDC]. (2021, June 28). Disability & health U.S. state profile data: Montana. https://www.cdc.gov/ncbddd/disabilityandhealth/impacts/montana.html Chen, K. (2020). Why do older people love and hate assistive technology? An emotional experience perspective. Ergonomics, 60(12), 1463-1474. Cole, M. & Tufano, R. (2020). Applied theories in occupational therapy: A practical approach (2nd ed). SLACK Inc. Holthe, T., Casagrande, F. D., Halvorsrud, L., & Lund, A. (2020). The assisted living project: A process evaluation of implementation of sensor technology in community assisted living. A feasibility study. Disability and Rehabilitation: Assistive Technology, 15(1), 2936. https://doi.org/10.1080/17483107.2018.1513572 Larsen, S. M., Hounsgaard, L., Brandt, ., & Kristensen, H. K. (2019). Becoming acquainted: The process of incorporating assistive technology into occupations. Journal of Occupational Science, 26(1), 77-86. 14 Orellano-Coln, E. M., Morales, F. M., Sotelo, Z., Picado, N., Castro, E. J., Torres, M., Rivero, M., Varas, N., & Jutai, J. (2017). Development of an assistive technology intervention for community older adults. Physical & occupational therapy in geriatrics, 35(2), 49-66. Pendleton, H. M. & Schultz-Krohn, W. (Ed.) (2017). Pedrettis occupational therapy: Practice skills for physical dysfunction (8th ed.). Elsevier Mosby. Peterson, K. F., & Adams-Price, C. (2021). Fear of dependency and life-space mobility as predictors of attitudes toward assistive devices in older adults. The International Journal of Aging and Human Development, 94(3), 273-279. https://doi.org/10.1177/00914150211027599 Polku, H., Mikkola, T. M., Gagn, J. P., Rantakokko, M., Portegijs, E., Rantanen, T., & Viljanen, A. (2018). Perceived benefit from hearing aid use and life-space mobility among community-dwelling older adults. Journal of Aging and Health, 30(3), 408-420. https://doi.org/10.1177/0898264316680435 Song, Y. (2019). Electronic assistive technology for community-dwelling solo-living older adults: A systematic review. Maturitas, 125, 50-56. The University of Montana Rural Institute. (2022a, September 7). About/mission. MonTECH. Retrieved January 23, 2023, from https://montech.ruralinstitute.umt.edu/who-weare/about/ The University of Montana Rural Institute. (2022b, September 7). Evaluations. MonTECH. Retrieved January 23, 2023, from https://montech.ruralinstitute.umt.edu/evaluations/ The World Health Organization [WHO]. (2022). Assistive technologies. https://www.who.int/health-topics/assistive-technology#tab=tab_1 Thilo, F. J., Hahn, S., Halfens, R. J., Heckemann, B., & Schols, J. M. (2021). Facilitating the use 15 of personal safety alerting device with older adults: The views, experiences and roles of relatives and health care professionals. Geriatric Nursing, 42(4), 935-942. Vagias, W. M. (2006). Likert-type scale response anchors. Clemson International Institute for Tourism & Research Development, Department of Parks, Recreation and Tourism Management. Clemson University. 16 Appendix A Figure A1: Professional Reasoning Visual Diagram of Occupational Adaptation OBM and Rehabilitative FOR Appendix B: Pre-Survey Questions 1. Do you use or have used assistive technology? (yes, maybe, no) 17 . What do/did you use? a. How often do you use AT? (Always, often, sometimes, rarely, never) . If no longer using the product: Why are you not using the product now? 2. Did you find AT helpful? (Extremely helpful, very helpful, Somewhat helpful, Slightly helpful, Not at all helpful) 3. How comfortable are you with assistive technology? (Very uncomfortable, uncomfortable, neutral, comfortable, or very comfortable) 4. How comfortable are you with using a smartphone? (Very uncomfortable, uncomfortable, neutral, comfortable, or very comfortable) 5. Would you consider obtaining assistive technology? (Yes, maybe, no) 6. Have you ever loaned a device from MonTECH or used MonTECH services before? (Yes, maybe, no) 7. How satisfied are you with MonTECH services? (Very dissatisfied, dissatisfied, neutral, satisfied, very satisfied) 8. What kind of decision about AT devices or services were you able to make after your device demonstration? (AT device will meet my needs, AT device will NOT meet my needs, Have not decided) 9. What are some goals you have to use AT in your daily life? 18 Appendix C: Post-Survey Questions 1. How satisfied are you with _______(assistive technology provided)? (very dissatisfied, dissatisfied, neutral, satisfied, very satisfied) a. If dissatisfied, what are the reasons? (Fit/size/shape, pain/discomfort, weight, appearance, safety, durability, other) b. Would you like to try something else? 2. Did you find the device you loaned helpful? (Extremely helpful, Very helpful, Somewhat helpful, Slightly helpful, Not at all helpful) 3. How comfortable are you with assistive technology? (very uncomfortable, uncomfortable, neutral, comfortable, or very comfortable) 4. In the past two weeks, how often did you use ______(provided AT)? (Almost every day, half of the time, rarely, none at all) 5. Would you consider obtaining AT? 6. How satisfied are you with MonTECH services? (very dissatisfied, dissatisfied, neutral, satisfied, very satisfied) 7. What kind of decision about AT devices or services were you able to make after your device demonstration? (AT device will meet my needs, AT device will NOT meet my needs, Have not decided) 8. How likely are you to recommend MonTECH services to others? (very unlikely, somewhat likely, neither, likely, very likely) 9. Are your goal(s) met or unmet? 19 Appendix D: DCE Weekly Planning Guide Week 1 Orientation to site 1.09.23 - 1.13.23 Begin Literature Search Draft Timeline Met staff Scheduled meeting with staff member Madi Reviewed Memorandum of Understanding (MOU) with site mentor and made changes Reviewed AT on website and in the office Co-led and observed AT demonstrations Attend the following virtual meetings: RTC: Rural Research and Practice Summit - Personal Assistance Services; Rural Digital Access Week 2 Re-write Introduction 1.16.23 - 1.20.23 Continue Literature Search Begin project design Weekly Forum and responses Finalize Timeline Made changes to this timeline as needed Attended Montana Occupational Therapy Association (MOTA) meeting Updated needs assessment and goals and objectives as needed Co-led and observed AT demonstrations Gathered materials for project Scheduled meeting with site mentor Week 3 Turn in Introduction draft on Monday 1.23.23 -1.27.23 Write background Continue project design Weekly Forum and responses Coordinated meeting with assisted living to discuss project implementation Attended meeting with The Village Senior Living staff, Rhonda McCarthy Toured Assisted Living facility Met with the University of Montana OT Program Director candidate Met with my site mentor, Molly Kimmel Met with North Dakota AT program staff Finalized project dates Assessment tool development Co-led and observed AT demonstrations Monthly Check-In: Review February Goals and Timeline Week 4 Turn in Background draft 1.30.23 - 2.03.23 Start Project design section Weekly Forum and responses Created participant recruitment flyers Scheduled meeting with site mentor MOTA Meeting ATIA Virtual Conference (2 days) Co-led and observed AT demonstrations Brainstormed AT resource guide Week 5 Turn in project design draft 2.06.23 - 2.10.23 Weekly Forum and responses Project presentation at assisted living facility Recruited 4 participants for project Created appointments to conduct evaluation (pre- 20 survey) and AT demos with each participant (sessions 1 and 2) Co-led AT demonstration Loaned out AT to participants Attended OT/PT Hill Day in Helena Week 6 Catch up on readings and literature 2.13.23 - 2.17.23 search Weekly Forum and responses Continued sessions for evaluations and interventions with participants (session 1 and 2) Began to administer post-surveys to participants who trialed AT for at least 5 days (session 3) Scheduled meeting with site mentor Worked on AT resource guide Attended MonTECH event at the student center on campus Week 7 MIDTERM evaluation with site 2.20.23 - 2.24.23 mentor Read articles Weekly Forum and responses Continued AT intervention sessions (sessions 2) Continued to administer post-surveys to participants who trialed AT for at least 5 days (session 3) Recruited one additional participant and began sessions 1 and 2. Home Health visit with OT Discussed midterm evaluation with site mentor Filmed video about my project for the MonTECH social media pages Week 8 Begin writing outcomes section 2.27.23 - 3.03.23 Begin writing methods section Weekly Forum and responses Led AT demonstration with MyNotifi Met with OT student, John Continued to administer post-surveys to participants who trialed AT for at least 5 days Scheduled meeting with site mentor Presented at the assisted living facility - Physical and Mental Wellness with AT Set a date to present at Missoula Aging Services (MAS) - Reducing Carepartner Burden with AT Attended staff meeting Monthly Check-In: Review March Goals and Timeline Week 9 Continue writing outcomes section 3.06.23 - 3.10.23 Finalize methods section Weekly Forum and responses Continued to administer post-surveys as needed Worked on presentation for MAS Participated in daily office tasks Led an AT demonstration Week 10 Turn in outcomes draft and get 3.13.23 - 3.17.23 faculty mentor feedback Participated in AT demos with AT professional Led AT demonstration 21 Start dissemination plan Weekly Forum and responses Attended staff meeting Finished presentation for MAS Participated in daily tasks in office Met with site mentor Assisted with The Village presentation Wrapped up my program sessions with clients Worked on resource guide to hand out to MAS staff Week 11 Turn in dissemination plan 3.20.23 - 3.24.23 Make edits to outcomes draft if needed Weekly Forum and responses Participated in daily tasks in office Attended MonTECH presentation in Hamilton Presented to MAS Analyzed data from pre and post survey Revised surveys for future use Week 12 Begin abstract, Summary, and 3.27.23 - 3.31.23 Conclusion section Weekly Forum and responses Began making plans for sustainability/translation to site Assisted with an assisted living facility (Grizzly Peak) presentation Participated in daily tasks in office Led an AT demonstration Networked with community members Met with site mentor Attended staff meeting Week 13 Turn in draft of Abstract, Summary, 4.03.23 - 4.07.23 and Conclusion section Weekly Forum and responses Participate in AT demos with AT professional Participate in daily tasks in office Observe Director to obtain administration skills Created project outcomes infographic to handout to The Village Staff Send thank you note to assisted living facility and participants Attended IEP seminar on campus Week 14 FINAL evaluation with site mentor 4.10.23 - 4.14.23 Weekly Forum and responses Project Dissemination to MonTECH staff and The MonTECH Advisory Council Project dissemination assisted living facility Rhonda and handing out infographics to staff Created a program sustainability document Picked up AT from a participant Completed office tasks (answering phone calls, cleaning equipment)  ...

... Expansion of the Dancers with Disabilities Program at Kids Dance Outreach Lauren Ober May 6, 2023 A capstone project submitted in partial fulfillment for the requirements of the Doctor of Occupational Therapy degree from the University of Indianapolis, School of Occupational Therapy. Under the direction of the faculty capstone advisor: Dr. Jennifer Fogo, PhD, OTR Abstract Kids Dance Outreach (KDO) is a non-profit organization that provides free dance programming to the Indianapolis community. KDO is partnering with Skills on Wheels at IUPUI to provide dance programming to children who use manual wheelchairs. This doctoral capstone experience aimed to improve the perceptions of the KDO teaching artists regarding their ability to adapt the pedagogy for children who use manual wheelchairs. The teaching artists engaged in professional development. Pre- and post-surveys collected the teaching artists' confidence and comfortability to adapt the KDO pedagogy for children who use manual wheelchairs. The doctoral capstone experience revealed that through continued education of staff, Kids Dance Outreach could expand its Dancers with Disabilities program to serve more children in their community. Kids Dance Outreach (KDO) is a non-profit organization that provides free in-school and extracurricular dance programs to children across central Indiana. KDOs mission is to positively impact the lives of all children through joyful dance programs that inspire excellence, instill confidence, encourage teamwork, and applaud persistence (Kids Dance Outreach, n.d.). KDO utilizes a pedagogy created by Jacques dAmboise at National Dance Institute and is the only dance outreach program in Indiana. KDO staff includes teaching artists who engage students through accessible movement and musicians who enhance the flow of the class through live music. Kids Dance Outreach embodies diversity, equity, accessibility, and inclusion throughout its business model. KDO intentionally partners with Indianapolis public schools to serve students from diverse backgrounds. KDO proactively hires teaching artists and musicians of various cultural backgrounds to foster a sense of safety and inclusion in the spaces of their programs. KDO is committed to being inclusive for all students, and their Dancers with Disabilities program provides an opportunity to dance in a supportive environment. The Dancers with Disabilities program only consists of the Adaptive Dance program. The Adaptive Dance program teaches children aged 7-12 with Down Syndrome to dance while building a community. Kids Dance Outreach administrators want to grow their Dancers with Disabilities program by partnering with other local pediatric programs in Indiana. KDO wants to be sure they can fully support all children, despite their various needs and abilities. During this capstone experience, the KDOs teaching artists' will evaluate their confidence and comfortability regarding teaching children with disabilities, learn how to adapt their pedagogy to meet children's needs, and the organization will advocate for inclusive movement within the Indianapolis community. Background Kids Dance Outreach offers programs to school-age children in Indianapolis public schools and charter schools for free. The schools KDO partners with consist of children who are 70% minorities, with more than 80% on the free/reduced meal program. There is an even 50/50 split between boys and girls in the schools. Since Kids Dance Outreach opened in 2012, the organization has served over 14,000 children. Every year more than 2,000 kids participate in Kids Dance Outreach programs. KDO has community partnerships with 17 Indianapolis elementary schools (Kids Dance Outreach, n.d.). For Kids Dance Outreach to continue being fully funded by donations and grants as they grow their programs, the community must understand the benefits of inclusive dance. Inclusive dance movement can improve physical, psychological, and social skills. As seen in the study by Anjos and Ferraro in 2018, typically developing children who participated in dance classes saw an increase in motor development faster than their peers who did not dance. Children with disabilities saw similar motor development growth trends after participating in dance classes. Children with disabilities can improve their balance, coordination, flexibility, agility, perceptual motor, and rhythm skills by participating in inclusive dance classes (May et al., 2021). Children with disabilities tend to have difficulty with independence in occupations due to delayed motor development. Inclusive dance programs for children with Down syndrome, like Kids Dance Outreach, can help provide a source to reach motor skills goals set by parents, such as gross motor skills and endurance (McGuire et al., 2019). Regarding children with cerebral palsy, posture can improve and reduce skeletal deformities (Tow et al., 2020). Dance movements can be focused on locomotion and mobility for functional skills that translate into greater independence in daily tasks (Adorno et al., 2021). Dance also promotes positive mental health in children with disabilities. Dance as an art form can improve internal drive, cognition, and mindfulness (Prieto & Haegele, 2020). Peer acceptance is a big part of dancing alongside peers, as everyone in the group is participating in the same moves. This sense of inclusion while participating in accessible movement is an excellent way for children with disabilities to feel like they belong with their classmates (Zitomer, 2016). After participating in a dance class, students and caregivers raved about their experience and how they thoroughly enjoyed the class (Aujla, 2020). A safe space where children can feel included is vital to their growth as they develop their sense of self. Movement for children with disabilities can improve social skills by fostering interactions with others. The systematic review by Prieto and Haegele (2020) noted that most articles reviewed had increased social benefits through dancing. Parents also notice improvements in social participation (Cherriere et al., 2020). Dance is a social activity that is a source of communication with others through bodily movement. Children can engage with and accept others. Dance class can also be a great source to learn from other students and how to behave with others. Dance can improve the quality of life for all children participating in an inclusive program. In-school and extracurricular dance programming can help children grow alongside their peers and learn fundamental life skills that enable them to succeed. The needs assessment at KDO revealed that the organization wants to expand its Dancers with Disabilities program, but there is a concern for financial, environmental, and staff resources. KDO does not have a budget just for its Dancers with Disabilities programs. Poor budgeting can lead to economic tension as their adaptive programming requires more support. KDO values providing accessible movement for all people in a safe environment, but currently, KDO only has the resources to support an Adaptive class for children with Down Syndrome. The Adaptive program occurs in the JCC, which does not have the proper equipment to accommodate different disabilities and is not in a central location for families. KDO needs highly trained staff to lead Dancers with Disabilities classes in a safe and supportive environment. KDO is experiencing a three hundred percent increase in inquiries about the Adaptive program from the prior semester and is adding class time to meet the high demands. The organization wants to continue this trend and build its Dancers with Disabilities program for children with many disabilities. KDO is building a partnership with Skills on Wheels at IUPUI to bring dance movement to pediatric participants in their camp and provide a unique opportunity to build confidence in their mobility. Skills on Wheels programming borrows occupational therapists from Riley Hospital for Children and IUPUI's occupational therapy students to deliver safe manual wheelchair training. Skills on Wheels teaches children aged eight to seventeen who use a manual wheelchair to navigate their environment (IUPUI, n.d.). In preparation for Skills on Wheels upcoming events, Kids Dance Outreach would like more education regarding adapting their pedagogy for children who use manual wheelchairs. Most KDO teaching artists have experience teaching in-school programming to a class that may happen to have a student with a disability. Still, many teaching artists have minimal experience teaching children who use a wheelchair. The focus of my capstone project is to assess the teaching artists' current perceptions regarding teaching children who use wheelchairs, educate them about wheelchairs, and give ideas on how to adapt their pedagogy for the upcoming fall break camp. The opportunity for KDO to partner with Skills on Wheels would provide access to a new audience with adequate support. To continue growing and funding the Dancers with Disabilities program, spreading awareness about the benefits of inclusive dance in the community will help market KDO in the Indianapolis area. The best way to advocate is through understanding what is going on in policy, communication with the community, and awareness through resources (Milling, 2018). The marketing environment theory will be used as a planning source to help develop KDO effectively within the confines of their environment (Professional Academy, n.d.). The internal environment is KDO's staff, policies, and mission. The micro-environment is the families they reach, the stakeholders that provide funding, and the community partners that provide resources to the organization. The macro-environment is outside of KDO's control that impacts the organization, such as the economy and policy. This theory will help guide the capstone project to navigate Kids Dance Outreach's relationships in a way that helps to build upon their Dancers with Disabilities program. The PEOP occupation-based model focuses on the client functionally performing and is perceived as valuable (Cole & Tufano, 2020). PEOP uses a similar structure to the marketing environment theory, but with this model, factors must fit into each other to make a balance. The intrinsic factors are the staff, families, stakeholders, and values. At the same time, the extrinsic factors are the community partners, schools, and donors. The performance is how these factors play into each other to provide free dance programs to the children of Indianapolis. Kids Dance Outreach can advocate for the organization by utilizing the marketing environment theory and PEOP occupation-based model to provide inclusive dance movement to their community, spread awareness about the benefits for dancers with disabilities, and create partnerships to reach underserved pediatric populations. Project Design After completion of a needs assessment and a SWOT analysis, the site mentor and I decided that to expand the Dancers with Disabilities program at KDO, it is vital that the KDO staff feel confident and competent in their ability to adapt the pedagogy for children who use a manual wheelchair for mobility (see Appendix). The upcoming partnership with Skills on Wheels requires the KDO staff to prepare a dance class for approximately thirty children who use wheelchairs during their big celebration at the end of camp. The Scale of Teacher's Attitudes Towards Inclusive Classrooms (STATIC) questionnaire was utilized to inspire the evaluation of the KDO staffs perception surrounding teaching inclusive dance to children who use wheelchairs (Cochran, 1998). The original STATIC questionnaire (see Table 1) consisted of twenty questions using a 5-point Likert scale. The pre-test utilized six questions from the original STATIC questionnaire that were modified. Then the post-test used four of those modified questions to measure growth. The participants rated their confidence and comfort from 1 being equal to no confidence or uncomfortable to 5 being very confident or comfortable. The pre-test was twelve questions, including demographic survey questions to reveal the participants' experience with teaching and their comfort with modifying the KDO pedagogy (see Table 2). The pre-test also included a qualitative question for participants to note any specific questions or concerns they would like addressed during the professional development. The posttest consisted of seven questions with space for participants to ask any lingering questions or comments after the professional development (see Table 3). Pre- and post-test questions were discussed and approved by the site mentor. All teaching artists were emailed the pre-test Google survey a week before the professional development. A follow-up reminder with a link to the presurvey was given through the KDO direct messaging app, Connecteam, the day prior to the professional development. At the end of the professional development, participants quickly filled out the post-test in person using a QR code. Implementation The professional development took place at the Atheneum for an hour and a half, and five teaching artists attended. The professional development consisted of a thirty-minute presentation about the parts of a manual wheelchair, skills that would be important to master for community mobility, and how to dance while seated in a wheelchair. Participants used three wheelchairs to explore what it is like to use a manual wheelchair and dance while seated for the next hour. The participants practiced wheelchair-specific language while teaching and adapted their established pedagogy. The participants were given three possible adaptations to each letter (movement sequence), and all the teaching artists found new ways to move. The KDO staff trialed their warm-up and letters with ample space to move. The teaching artists also practiced the language they should use when teaching children who use wheelchairs and how their language can create an engaging environment. As the KDO teaching artists practiced teaching and dancing from a seated position, they quickly realized straightforward adaptations to their pedagogy and the movements that did not directly translate. The teaching artists had no issues with the upper extremity movement. Directional changes and staying on the beat of the music were different because of how long it can take to control the rolling motion of the wheelchair. The teaching artists found new ways to adapt lower extremity movement, level changes, and formations for proper space to move. An unexpected challenge to teaching from a wheelchair was being visible to the musicians and the timing of music needed to complete movements. The collaboration between teaching artists and musicians affects the overall flow of the class, so everyone must see the teaching artist in the room. Teaching artists were more aware of time as transitions between each dance move took slightly longer. The professional development highlighted areas of direct translation and the necessity of creativity to teach children who use a manual wheelchair effectively. Results Of the nine teaching artists on the KDO team, five filled out the pre-survey. One respondent of the pre-survey did not participate in the professional development. However, to demonstrate overall teaching artist knowledge and confidence regarding teaching children who use manual wheelchairs, their response was included. Three participants responded to the posttest, and one did not complete the pre-survey. "Participant" followed by a number replaced the teaching artists' names to preserve confidentiality. Participants 1, 4, and 5 did not fill out the post-test. Participant 6 did not fill out the pre-test. Participants 2 and 3 were the only teaching artists who completed pre- and post-test surveys. The results included all responses demonstrating the overall understanding of KDO teaching artists. Based on the five teaching artists who completed the pre-survey, the participants had a wide range of teaching experience at KDO, ranging from six months to eleven years. Most teaching artists had no experience teaching children who use manual wheelchairs, with only two participants saying they had experience, although it was minimal. One participant indicated they are working with a student who utilized a wheelchair during their in-school programming at a local Indianapolis public school. When asked if "adaptive materials and equipment can are easily acquired for meeting the needs of students who use a wheelchair in in-school programming on the pre-survey, two participants disagreed, and three participants felt neutral about the statement. All five participants agreed that in-service training should be required for all KDO staff to teach students who use a wheelchair. Participants also agreed that they would benefit from having the time to practice what it feels like dancing in a manual wheelchair and adapting their current "letters (movement sequence). All the participants expressed interest in participating in the Skills on Wheels partnership in some capacity after participating in the professional development. Figures 1-4 show participants' pre-and post-test results for confidence and comfort with teaching children using manual wheelchairs. The confidence when teaching a student who uses a wheelchair during in-school programming increased. The pre-test revealed that the confidence level when teaching a student who uses a wheelchair during in-school programming ranged from "somewhat comfortable" to "comfortable." After the professional development, participant three grew most by two points from "somewhat comfortable" to "comfortable." The participants felt the most comfortable on the pre-test when modifying the KDO pedagogy. After the professional development, all participants felt at least "comfortable" with this aspect. Lastly, participants' confidence to teach a class only for children who use wheelchairs stayed the same or increased. Summary The Kids Dance Outreach Dancers with Disability program is currently only made up of one program, the Adaptive Dance program. The administrative team of KDO has been wanting to expand their Dancers with Disabilities program but has been concerned about creating a supportive environment for their dancers. The Skills on Wheels team at IUPUI is collaborating with KDO and provide the extra space and qualified professionals required to create a supportive environment for an adapted dance program. The adapted dance program through this collaboration would be for children who are new manual wheelchair users. The partnership between Skills on Wheels and KDO will combine the community mobility skills training provided by the Skills on Wheels team with the engaging movement break led by KDO. Many of the KDO teaching artists have little to no experience teaching dance to a child who uses a wheelchair during their in-school programming, so teaching a class only for children who use manual wheelchairs can make teaching artists feel unconfident. The lack of experience teaching children who use manual wheelchairs can cause some hesitancy going forward with the Skills on Wheels partnership. After teaching artists attended the professional development, their confidence and comfort in teaching in an in-school program with a child using a manual wheelchair increased. The opportunity to experiment with dancing in a wheelchair also increased teaching artists' comfortability to modify the pedagogy for children who use a manual wheelchair. The teaching artists' confidence to teach a program only for children who use a manual wheelchair increased, which will help to grow the collaboration with Skills on Wheels going forward. Teaching artists felt more prepared for the Skills on Wheels partnership and were able to modify their pedagogy to meet the needs of children who use manual wheelchairs. Conclusion The Kids Dance Outreach teaching artists learned about manual wheelchairs and the skills needed for mobility in the community. They utilized this information to modify the KDO pedagogy for children who use wheelchairs. The teaching artists can reach an underserved audience of children who use manual wheelchairs with the knowledge gained to uphold the KDO values of instilling confidence and inspiring excellence. The professional development gave teaching artists a starting point for the Skills on Wheels partnership. As the collaboration between the two organizations grows, new ideas of inclusive movement for children who use manual wheelchairs will arise. The partnership between Kids Dance Outreach and Skills on Wheels will open the door for KDO to connect with other Indianapolis community pediatric organizations with similar values. For KDO to continue expanding its Dancers with Disabilities program, they need collaboration with other local organizations and the knowledge of its teaching artists to provide a safe and supportive environment for inclusive dance. Kids Dance Outreach and its Dancers with Disabilities program has the potential to reach children all over Indianapolis and provide equitable, inclusive dance programming for everyone. References Adorno, E. T., Dos Santos, D. C. J., Dejesus, B.M., Passos, A. A., & Teixeira-Machado, L. (2021). Dance, functioning, and quality of life in children with Down syndrome and autism spectrum disorder. Clinical Child Psychology and Psychiatry, 0(0), 1-11. https://doiorg.ezproxy.uindy.edu/10.1177/13591045211061795 Anjos, I. V. C., & Ferraro, A. A. (2018). The influence of educational dance on the motor development of children. Revista paulista de pediatria, 36(3), 337-344. http://dx.doi.org/10.1590/1984 0462/;2018;36;3;00004 Aujla, I. J. (2020). Its my dream come true: Experiences and outcomes of an inclusive dance talent development programme. British Journal of Special Education, 47(1), 4866. https://doi.org/10.1111/1467-8578.12297 Cherriere, C., Robert, M., Fung, K., Racine, F. T., Tallet, J., & Lemay M. (2020). Is there evidence of benefits associated with dancing in children and adults with cerebral palsy?: A scoping review. Disability and Rehabilitation, 42(23), 1-8. https://doi.org/10.1080/09638288.2019.1590866 Cochran, H. K. (1998). Differences in teachers attitudes toward inclusive education as measured by the scale of teachers attitudes toward inclusive classrooms (STATIC). Paper presented at the MidWestern Educational Research Association Annual Meeting, Chicago, IL. Cole, M. & Tufano, R. (2020). Applied theories in occupational therapy: A practical approach (2nd Ed.). SLACK Incorporated. IUPUI. (n.d.). Skills on wheels. School of Health and Human Sciences. https://shhs.iupui.edu/community/skills-on-wheels/index.html Kids Dance Outreach. (n.d.). Kids Dance Outreach. https://kidsdanceoutreach.org/ May, T. Chan, E. S., Lindor, E., McGinley, J., Skouteris, H., Austin, D., McGillivray, J., & Rinehart, N. J. (2021). Physical, cognitive, psychological, and social effects of dance in children with disabilities: Systematic review and meta-analysis. Disability and Rehabilitation, 43(1), 1326. https://doi.org/10.1080/09638288.2019.1615139 McGuire, M., Long, J., Esbensen, A. J., & Bailes, A. F. (2019). Adapted dance improves motor abilities and participation in children with Down syndrome: A pilot study. Pediatric Physical Therapy, 31(1), 7682. https://doi.org/10.1097/PEP.0000000000000559 Milling, S. (2018). A plan for advocacy. Journal of Dance Education, 18(1), 4546. https://doi.org/10.1080/15290824.2017.1413881 Prieto, L. A., & Haegele, J. A. (2020). Dance programs for school-age individuals with disabilities: A systematic review. Adapted Physical Activity Quarterly, 37, 349-376. https://doi.org/10.1123/apaq.2019-0117 Professional Academy. (n.d.). Marketing theories- The marketing environment. https://www.professionalacademy.com/blogs/marketing-theories-the-marketing-environment/ Tow, S., Gober, J., & Nelson, M. R. (2020). Adaptive sports, arts, recreation, and community engagement. Physical Medicine and Rehabilitation Clinics of North America, 31, 143-158. https://doi.org/10.1016/j.pmr.2019.09.003 Zitomer, M. R. (2016). Dance makes me happy: Experiences of children with disabilities in elementary school dance education. Research in Dance Education, 17(3), 218234. http://dx.doi.org/10.1080/14647893.2016.1223028 Table 1 The scale of Teachers' Attitude Towards Inclusive Classrooms (STATIC) 1. I am confident in my ability to teach children with special needs. 2. I have been adequately trained to meet the needs of children with disabilities. 3. I become easily frustrated when teaching students with special needs. 4. I become anxious when I learn that a student with special needs will be in my classroom. 5. Although children differ intellectually, physically, and psychologically, I believe that all children can learn in most environments. 6. I believe that academic progress is possible in children with special needs. 7. I believe that children with special needs should be placed in special education classes. 8. I am comfortable teaching a child that is moderately physically disabled. 9. I have problems teaching a student with cognitive deficits. 10. I can adequately handle students with mild to moderate behavioral problems. 11. Students with special needs learn social skills that are modeled by regular education students. 12. Students with special needs have higher academic achievements when included in the regular education classroom. 13. It is difficult for children with special needs to make strides in academic achievement in the regular education classroom. 14. Self-esteem of children with special needs is increased when included in the regular education classroom. 15. Students with special needs in the regular education classroom hinder the academic progress of the regular education student. 16. Special in-service training in teaching special needs students should be required for all regular education teachers. 17. I dont mind making special physical arrangement in my room to meet the needs of students with special needs. 18. Adaptive materials and equipment are easily acquired for meeting the needs of students with special needs. 19. My principal is supportive in making needed accommodations for teaching children with special needs. 20. Students with special needs should be included in regular education classrooms. Note. From Cochran, H. K. (1998). Differences in teachers attitudes toward inclusive education as measured by the scale of teachers attitudes toward inclusive classrooms (STATIC). Paper presented at the Annual Meeting of the Mid-Western Educational Research Association, Chicago, IL. Table 2 Pre-test for Teaching Artists 1. Name 2. How long have you taught with KDO? 3. Do you have experience teaching children who use a wheelchair? If yes, please explain. 4. Do you currently have a student in your in-school programming who uses a wheelchair? 5. How confident do you feel teaching a child who uses a wheelchair in an in-school program? 6. How comfortable do you feel teaching a child who uses a wheelchair in an in-school program? 7. How comfortable do you feel modifying the KDO pedagogy for a child in a wheelchair? 8. How confident would you feel teaching a class only for children who use a wheelchair? 9. Adaptive materials and equipment are easily acquired for meeting the needs of students who use a wheelchair in in-school programming. 10. In-service training should be required for all KDO staff when teaching students who use a wheelchair. 11. Would you benefit from having the time to practice in a safe space what it feels like dancing in a wheelchair and adapting your current "letters"? 12. Do you have any questions or concerns about teaching a class with a child(ren) who uses a wheelchair that you would like to be addressed during the PD? Table 3 Post-test for Teaching Artists 1. Name 2. How confident would you feel teaching a child who uses a wheelchair in an in-school program after the PD? 3. How comfortable would you feel teaching a child who uses a wheelchair in an in-school program after the PD? 4. How comfortable would you feel modifying the KDO pedagogy for a child in a wheelchair after the PD? 5. How confident would you feel teaching a class only for children who use a wheelchair after the PD? 6. Are you interested in being involved in the Skills on Wheels partnership? 7. Do you have any lingering comments, questions, or concerns? Figure 1 How confident do you feel teaching a child who uses a wheelchair in an in-school program? How confident do you feel teaching a child who uses a wheelchair in an in-school program? 5 Confidence 4 3 2 1 0 Participant Participant Participant Participant Participant Participant 1 2 3 4 5 6 Participant Responses Pre-Test Post-Test Figure 2 How comfortable do you feel teaching a child who uses a wheelchair in an in-school program? How comfortable do you feel teaching a child who uses a wheelchair in an in-school program? Comfortability 5 4 3 2 1 0 Participant 1 Participant 2 Participant 3 Participant 4 Participant 5 Participant 6 Participant Responses Pre-Test Post-Test Figure 3 How comfortable do you feel modifying the KDO pedagogy for a child in a wheelchair? How comfortable do you feel modifying the KDO pedagogy for a child in a wheelchair? Comfortability 5 4 3 2 1 0 Participant 1 Participant 2 Participant 3 Participant 4 Participant 5 Participant 6 Participant Responses Pre-Test Post-Test Figure 4 How confident would you feel teaching a class only for children who use a wheelchair? How confident would you feel teaching a class only for children who use a wheelchair? 5 Confidence 4 3 2 1 0 Participant 1 Participant 2 Participant 3 Participant 4 Participant 5 Participant 6 Participant Responses Pre-Test Post-Test Appendix Doctoral Capstone Experience and Project Weekly Planning Guide Week DCE Stage Weekly Goal Objectives Tasks 1 1/91/15 Orientation 1) Complete orientation by the end of the week Meet with the site mentor and KDO staff to introduce myself and educate them on how I will be advocating for KDO over the next 14 weeks Set up and attend meetings with the administrative team about the Dancers with Disabilities program 1/10 Determine involvement in KDO programs and create a schedule to attend classes 1/12 Understand site environment 2 1/161/22 3 1/231/29 Screening/ Evaluation Screening/ Evaluation Date complete 2) Have a complete understandin g of KDO pedagogy by the end of the week 1) Complete literature search by the end of the week Understand KDO pedagogy and available programs to expand the dancers with disability program Attend weekly classes and understand the pedagogy used in the programs 1/14 Gain a complete understanding of the benefits of adaptive dance Complete literature search 1/21 2) Complete needs assessment by the end of the week 1) Connect with the Skills on Wheels team Complete SWOT analysis Determine what questions to ask and set up a meeting with appropriate staff Reach out to the Skills on Wheels team and set up a 1/16 Finalize questions for needs assessment Build a partnership with the Skills on Wheels 1/27 by the end of this week 2) Establish outcome measures by the end of the week 4 1/302/5 Implementation 5 2/62/12 Implementation 6 2/132/19 Implementation program at IUPUI to plan future events Establish outcome assessment meeting to discuss logistics necessary for future events Review outcome assessments with site mentor and faculty mentor 1/27 1) Connect with one potential community partner by the end of the week 1) Find three potential community partners and their contact information by the end of the week Advocate for KDO in the community to increase participation and funding Reach out to one organization and educate them about KDOs programming 1/31 Advocate for KDO in the community to increase participation and funding Document 2/10 organizations with similar values as KDO on a spreadsheet 2) Provide one adaptation to KDO pedagogy by the end of the week 1) Find three potential community partners and their contact information by the end of the week Increase accessibility of the pedagogy for children who use wheelchairs Think of one adaptation to the pedagogy and receive feedback from admin team Advocate for KDO in the community to increase participation and funding Document 2/17 organizations with similar values as KDO on a spreadsheet 2) Provide one adaptation to KDO pedagogy by Increase accessibility of the pedagogy for children who use wheelchairs Think of one adaptation to the pedagogy and receive feedback from admin team 2/10 2/17 7 2/202/26 8 2/273/5 Implementation Implementation the end of the week 1) Reconnect with Skills on Wheels Meet Skills on Wheels team in-person and discuss needs for upcoming camp Discuss how I can 2/20 help promote Skills on Wheels partnership and educate KDO teaching artists 2) Provide one adaptation to KDO pedagogy by the end of the week Increase accessibility of the pedagogy for children who use wheelchairs Think of one adaptation to the pedagogy and receive feedback from admin team 2/26 3) Plan a professional development draft for the KDO staff by the end of next week 1) Finish PD draft for the KDO staff by the end of the week Increase awareness when working with children who use wheelchairs and create ideas for adapting pedagogy Create information guide (PowerPoint and information outline) 3/3 Increase awareness when Create PD working with children information guide who use wheelchairs and (PowerPoint) create ideas for adapting pedagogy 3/3 2) Discuss with the site mentor date of professional development and plan for needed materials by the end of the week Plan for all aspects required to put on professional development for KDO teaching artists and secure details 3/3 Schedule professional development and plan how to collect materials. Coordinate borrowing wheelchairs, a tv for presentation, and space for presentation 9 3/63/12 Implementation 1) Discuss Skills on Wheels with KDO admin by the end of the week 10 3/133/19 Implementation 1) Finalize all aspects of professional development by the end of the week Confirm KDO admin understand the progress of the Skills on Wheels partnership and advocate for progression of partnership Virtual meeting with KDO admin to discuss the branding of Skills on Wheels, the wheelchair skills that are addressed, and how to move forward with this partnership in the future Prepare for professional Complete and development and finalize receive approval all documents by site mentor of PowerPoint and surveys 3/10 2) Coordinate borrowing wheelchairs for professional development by the end of the week Communicate with UIndy and IUPUI to retrieve wheelchairs for the professional development 3/19 Schedule a time to pick up wheelchairs for the professional development 3/19 11 3/203/26 Implementation 1) Evaluate prior knowledge of KDO staff by professional development Assess confidence and Administer the comfort level of teaching outcome measure artists to adapt the KDO to KDO staff pedagogy through a presurvey 3/27 12 3/274/2 Implementation 1) Present professional development to KDO staff Increase awareness when Present working with children information to who use wheelchairs and KDO staff at PD creating ideas for adapting pedagogy 3/28 2) Evaluate knowledge gained by KDO staff by the end of the week Assess confidence and comfort level to adapt the KDO pedagogy after the professional development 4/2 Administer the outcome measure to KDO staff 13 Discontinuation 4/3-4/9 14 4/104/14 Dissemination 1) Finalize survey results by the end of the week Assess confidence and comfort level to adapt the KDO pedagogy through survey results Assess growth of 4/7 KDO teaching artists to adapt the KDO pedagogy 2) Plan dissemination to Skills on Wheels and KDO admin by the end of the week Inform Skills on Wheels team and KDO admin about the teaching artists ability to adapt pedagogy for the dancers with disabilities program and promote partnership 1) Disseminate capstone project by the end of the week Inform Skills on Wheels team and KDO admin about the teaching artists ability to adapt pedagogy for the dancers with disabilities program and promote partnership Prepare information to share about KDO staff knowledge, advocate for partnership, and promote future events Present information 4/7 4/14  ...

... 1 Daily Life Skills for Homeless Veterans Within the Domiciliary Care Program Kayla R. Nowlin May 1st, 2023 A capstone project submitted in partial fulfillment for the requirements of the Doctor of Occupational Therapy degree from the University of Indianapolis, School of Occupational Therapy. Under the direction of the faculty capstone advisor: Dr. Kelsey Peter, OTD 2 Abstract There is an increased need for treatment and recovery for homeless Veterans suffering from mental health and substance use disorders. The Indianapolis Domiciliary Care Program for Homeless Veterans provides such care for these Veterans (Wenzel et al., 1995). Veterans participate in recovery groups, treatment sessions, and eventually discharge and reintegrate back into the community. I identified a need for education on daily occupations (i.e., IADLs, leisure) since there is not an occupational therapist on site. The six-week program, Daily Life Skills, was designed to target everyday tasks an individual may perform and the education to be able to do so independently while focusing on three domains (anxiety, confidence, motivation). A pre/post Likert Scale tool was utilized to capture the results of each group. The results of the program indicated that providing these Veterans with the resources, knowledge, and ability to complete everyday occupations more independently equated to improved levels of anxiety, confidence, and motivation in their respective manners. 3 Introduction The U.S. Department of Veteran Affairs defines the Domiciliary as an active clinical rehabilitation and treatment program for male and female Veterans and Domiciliary programs are now integrated with the Mental Health Residential Rehabilitation and Treatment Programs (MH RRTPs) (Health, n.d.). The Indianapolis Domiciliary Care Program for Homeless Veterans (DCHV) specializes in Veterans suffering from substance abuse and/or mental illnesses who currently do not have permanent housing. The DCHV offers an interdisciplinary team that includes recreational therapists, nurses, psychologists, psychiatrists, social workers, a pharmacist, dietician, and chaplain. The team works to provide a safe, healthy routine for Veterans to experience and encourages them to re-enter the community with a home, job, and the skills to live a sober, safe, and meaningful life. For my Doctoral Capstone Experience project, I analyzed the gaps identified in the existing programs within the DCHV and attempted to address those gaps with a Daily Life Skills program. This program was utilized to increase problem solving, prevent homelessness, and other beneficial tools and resources that would be useful for Veterans making the transition back into their communities. Specific areas targeted include routine building, home management/ environmental modifications, meal preparation/recipe creation, grocery shopping, and social wellbeing as well as additional resources, discussions, and questions a Veteran/s may have. Veterans who reside at the Domiciliary are searching for their next path and the resources required to get them there. Based on the need at this site and the information obtained from both Veterans and employees, the Daily Life Skills program was deemed critical for a Veterans success with community reintegration. The program was designed through the lens of occupational therapy and aligned with the mission and vision of the Domiciliary/VA. 4 Background Each Domiciliary around the United States specializes in specific populations of Veterans. The Indianapolis Domiciliary targets mental illness and substance abuse. To be accepted into the Indianapolis DCHV, there is a process that determines if a Veteran is a good fit for the site. Qualifications that make a Veteran high risk allowing them to be prioritized include where a Veteran currently lives (i.e., streets, car, couch surfing), gender, and comorbidities (i.e., diabetes) (Health, n.d.). Most of the Veterans who are accepted into the DCHV have limited support, are unemployed, and/or struggling with drug withdrawals/mental illness. They are looking for assistance to regain a safe, sober lifestyle within the community. The Daily Life Skills program included tools to assist Veterans with their independence. Based on the data discovered by Campbell (2010), Veterans who were previously homeless recorded better outcomes for reintegration into the community after experiencing basic employability and entry-level technical skills training, along with access to support systems that encouraged meeting the needs of their families while they continued to grow and become more competent in their daily skills. Estrella et al., (2021) discussed the importance of proper housing, such as the DCHV, which has an environment that fits Veterans needs for engagement and social interaction. By attending the Daily Life Skills program, Veterans improved their knowledge for everyday tasks where they had limited experience prior. The sessions included creating a daily routine schedule, grocery lists to successfully shop, healthy support systems, and/or socialization with others to address the skills needed for job interviews and relationships. After examining the Daily Life Skills program, I presented the design of the program to the interdisciplinary team at the DCHV to gather feedback and areas of improvement. All staff agreed that the specific topic areas targeted within the Daily Life Skills program were beneficial 5 for Veterans and their return to the community. One staff member reported that, Many Veterans are fearful when leaving the Domiciliary because they are leaving a structured lifestyle your program will assist them and hopefully reduce those fears they may have to be more successful in the reintegration process. In an article by Stacy et al., (2017) it was identified that the reintegration process into the community, regaining the responsibilities of owning a home, and/or working a new job can be difficult. Newly reintegrated Veterans would report their first job ending primarily due to the use of drugs and/or alcohol (Stacy et al., 2017). The DCHV needs assessment identified that areas of an individuals daily occupations were missing. This was based on what the recreational therapists were stating as areas of growth and evidenced in the literature from other domiciliary sites who assist homeless Veterans. As listed above and included in the Daily Life Skills program, there were some areas deemed more important to target such as grocery shopping and routine creation. Due to the absence of an occupational therapist (OT) at the DCHV, these areas were missing from the current curriculum. Homelessness is a barrier for Veterans and can result in the inhibition of occupational performance. OT is a specialized profession that includes activities of daily living, instrumental activities of daily living, self-management, mental health, and daily skills to target increased independence for an individual (OTPF, 2014). In an article by Allard et al. (2022), Selfmanagement interventions, from an occupational therapy perspective, incorporate broad-based personal and social learning strategies that help build self-efficacy during difficult situations. Allard et al. (2022), also discovered that studies have shown that self-management skills from occupational therapy interventions are effective in promoting and maintaining performance and participation in people with chronic mental health conditions. An OT staffed at the Domiciliary could also target the promotion of mental health, which is understood as a state of well-being in 6 which a person realizes his or her abilities, copes with challenges, and is able to work and contribute to the community through the education of the Daily Life Skills program (Mental Health Promotion, 2017). By shaping a program within the DCHV with an OT perspective for Veterans it allowed for areas of growth for both the OT profession and for Veterans. An existing problem within the DCHV and programs around the world is the lack of knowledge of what OTs do and how they can assist specific populations. In addition, there is limited experience of working with homeless Veteran populations within many health-care professions. An article written by Olenick et al. (2015), targeted towards the importance of health-care personnel awareness of Veterans, determined that successful Veteran reintegration into civilian life rests upon providing Veterans with training that builds on their military knowledge and skill, employment post-separation from service, homelessness prevention, and mental health programs that promote civilian transition. There is a need at the Indianapolis DCHV for the OT role to address these concerns. OTs can provide additional training of skills necessary for a homeless Veteran to improve their overall independence within the community while advocating for the profession within the VA. Many of the programs established at the DCHV target barriers beyond just homelessness. They analyze how those barriers negatively impact a Veteran's success in the community, social participation, and problem solving. The Daily Life Skills program targeted these areas and then broke them down into smaller subcategories to assist Veterans with tasks they may encounter often from an OT perspective. By examining and understanding the daily life of a Veteran from an OT lens, the Daily Life Skills program improved the self-confidence of a Veteran. This lens included a more holistic perspective of daily occupations and skills considered critical for Veterans living independently within the community. 7 Occupation Based Model and Frame of Reference The Person-Environment-Occupation (PEO) occupation-based model (OBM) was utilized to guide the design and implementation of the Daily Life Skills program. This OBM incorporates the person (Veterans), environment (homelessness, transitions within the Domiciliary program, community reintegration), and occupation (educating the Veterans on daily skills to help maintain a job, track financials, maintain housing, etc.). These three components work together to achieve occupational performance. The PEO model is based on balance and the best fit for everyone within their own person, environment, and occupation. It provides a unique approach to accommodate each Veteran to help them reach their specific goals and gain the daily life skills to keep their PEO balanced to prevent returning to homelessness. In support of the PEO OBM is the Cognitive Behavioral frame of reference (Figure 1). This frame of reference is guided by the idea of thinking influences behavior (Cole & Tufano, 2020). Many of the Veterans lack the competence of real-world and self-management skills. Techniques within the Cognitive Behavioral FOR are useful for practicing self-management thoughts that cause barriers to occupational performance. To be considered functioning within the Cognitive Behavioral FOR, Veterans are able to process, reason, and create realistic perceptions of themselves and others in their environment (Cole & Tufano, 2020). Utilizing both the PEO OBM and the Cognitive Behavioral FOR within the design of the Daily Life Skills group session and throughout the capstone experience increased the occupational performance and participation of the Veterans. Based on this new insight, it can carry over into a Veterans routine after leaving the program to allow each Veteran to maintain a healthy, safe, and independent lifestyle. 8 Program Design & Implementation This project was based on the demand discovered from a needs assessment and observation during the first few weeks at the Domiciliary. A six-week program was designed to increase a Veterans independence with everyday living while providing them the motivation and confidence to maintain healthy lifestyles. Prior to the Domiciliary, Veterans struggled to spend their time and resources on safe and sober activities which then progressed to Veterans losing their home, relationships, and decreased satisfaction with their lives. The design of the program was based on learning from other groups already established at the Domiciliary. Each provider (i.e., recreation therapists, social workers, pharmacists, etc.) also led weekly groups based on their specialties. These sessions were held in group rooms and oftentimes had a main topic that correlated with videos, activities, and discussions. I chose to maintain this same structure because many of the Veterans prefer to have a schedule for how their day should look. A key challenge in the design of the group sessions was to find the right balance between education and enjoyment. The absence of an occupational therapist at the Domiciliary added to this challenge causing each group to be created from scratch versus leveraging an existing program. The emphasis to focus on the three domains of anxiety, confidence, and motivation provided guidance towards each group session design. A Likert Scale was used to measure outcomes of each group. The Likert Scale was presented as a pre/post data survey specifically created for each group session. The targeted areas of data being measured included levels of anxiety, confidence, and motivation. Each survey was adapted to the topic of the group to allow for more customized responses to the sessions. The Likert Scale was chosen based on the evidence established by Sullivan and Artino (2013), that it 9 was a valid and common tool used to assess performance after educational interventions to provide quantitative outcomes. The project was broken down into several main topics such as routine building, home/environmental management, grocery shopping, and meal planning. I placed routine building as the first group because once the routine was established, a Veteran could then plan when they wanted to clean/manage their environment or decide which day they wanted to go to the grocery store and schedule it within the routine. The program was designed so that each group session built off the previous week, but it was not necessary for a Veteran to attend each group to benefit from the topic of the day. Project Outcomes Likert Scale surveys were a tool already utilized at the Domiciliary as a measure for other recreation activities; therefore, the Likert Scale was familiar for the Veterans to complete. Three factors (anxiety, confidence, and motivation) were assessed weekly during the Daily Life Skills group. Each Likert Scale survey utilized a pre and post side to complete at the start and end of each group. By utilizing a Likert Scale, it provided a quantitative measure for each factor, was able to be completed easily, and identified quick changes within the factors for each Veteran. The Likert Scale scoring used for the evidence-based group sessions 1 through 5 was 5 = High, 1 = Low to then translate as having high or low anxiety, confidence, and motivation towards the group topic. During the sixth group, the Likert Scale metric was adapted to be 5 = Strongly Agree, 1 = Strongly Disagree, was provided at the end of the session and was utilized as a Daily Life Skills full program evaluation. All post surveys included a Would recommend the group to their peers question. Over the course of six weeks all participants responded yes for recommending the group to their peers. 10 Table 1 indicates the average changes that occurred for group sessions 1 through 5. The average results indicated that at a minimum one of the three factors being analyzed - anxiety, confidence, motivation changed in their respective manner as follows: Group 1 - Routine Building (Brown et al., 2011): anxiety decreased; motivation increased Group 2 - Home Management/Environmental Modifications (AOTA, 2023): anxiety decreased; confidence and motivation increased Group 3 - Meal Planning/Recipe Creation (Sughair et al., 2021): anxiety decreased; confidence increased Group 4 - Grocery Shopping Made Simple (OTPF, 2014): anxiety decreased Group 5 - Exercise Your Social Wellness (Youn et al., 2020; Takagi et al., 2013): anxiety decreased; confidence and motivation increased Group 6 (Table 2) was designed to be a review session for those who had attended prior groups or a new learning opportunity for someone attending the Daily Life Skills group for the first time. The scores within Table 2 are supportive indicators for the Daily Life Skills group being valuable, well led, engaging, and applicable to Veterans and their daily lives. A key takeaway from the program occurred during group 6. Many Veterans had attended this group that had not been to prior groups and were able to verbally describe the benefits of the review group and how they could apply what they learned in one session to improve their own levels of anxiety, confidence, and motivation. This was evident when analyzing the pre/post data and determining that at least one or more domains were improved in their respective manner throughout the six-week program. 11 Summary The Indianapolis DCHV is specialized to provide care for Veterans who are homeless and suffering from mental health and substance use disorders. Each Veteran is educated and enabled with tools, resources, safety, and support while living in the Domiciliary to provide them the opportunity to regain the confidence and independence to reintegrate into the community while remaining sober and maintaining a stable place to live. Even though the Domiciliary is equipped with talented and experienced professionals who assist the Veterans through difficult portions of their lives, I analyzed the Domiciliary treatment options and identified areas where additional care from an OT lens may be necessary for a Veterans success. The Daily Life Skills program, covered the five topics on daily routines, home management/environmental modifications, meal planning, grocery shopping, and social wellness which were all areas Veterans had limited exposure. The program was created to target three domains (anxiety, confidence, motivation). By creating the Daily Life Skills program, it assisted in decreasing anxiety while increasing confidence and motivation to perform the five topics listed above more independently and safely. A Likert Scale was used to collect data for three domains and the results indicated at least one of the three improved in its respective manner and in two of the groups, all three domains improved in their respective manner. During the sixth group, Veterans were provided an overview of the five topics from weeks prior. 100% of the Veterans who attended the Daily Life Skills groups said they would recommend the program to their peers. Overall, this group positively impacted Veterans who attended based on the changes in their levels of anxiety, confidence, and motivation and will potentially create an easier transition for them as they discharge from the Domiciliary and re-integrate within the community. 12 Conclusion Over the course of 14 weeks, connections were built with site mentors, staff, and Veterans. The Daily Life Skills program taught the importance of confidence and knowledge to carry out everyday occupations. Due to the Veterans within the Domiciliary being previously homeless, many of them lacked the knowledge or ability to complete the topics taught within the Daily Life Skills groups. Veterans who were able to attend the Daily Life Skills group sessions exhibited an improvement in at least one domain being measured - anxiety, confidence, and/or motivation towards the five topics educating on occupations. The positive experiences the Veterans had within the Daily Life Skills groups carried over to other Veterans and staff based on the comments received. This validated the importance of the knowledge an occupational therapist can provide in a setting and population such as the Domiciliary. I was able to emphasize the need of an occupational therapist at the site through a dissemination presentation provided to the interdisciplinary treatment team by displaying my outcomes from each group and the feedback received from the Veterans who attended the Daily Life Skills groups. Due to there not being an occupational therapist at the site, all the information I created within the Daily Life Skills group was created from my own experiences and knowledge gained from my graduate program. I created a resource binder of my six-week program for future occupational therapy students to use. It will allow for future students to expand upon my program and cover more areas of occupational therapy while increasing the need for the profession within the Domiciliary. 13 References Allard, J., Leisenheimer, H., & Omotunde, A. (2022). Effectiveness of Occupational Therapy Self-Management Interventions Among Chronically Homeless Veterans with Mental Health and Substance Abuse Disorders. Critically Appraised Topics. https://commons.und.edu/cat-papers/42 Brown C., Stoffel V. & Munoz J. P. (2011). Occupational therapy in mental health: a vision for participation. F.A. Davis. Campbell, K. (2010). An analysis of homeless veterans participating in the homeless veteran reintegration program. Theses and Dissertations. https://scholarsjunction.msstate.edu/td/459 Cole, M. & Tufano, R. (2020). Applied theories in occupational therapy: A practical approach. (2nd Ed.). Thorofare, N.J.: SLACK Inc. Estrella, M. J., Kirsh, B., Kontos, P., Grigorovich, A., Colantonio, A., Chan, V., & Nalder, E. J. (2021). Critical Characteristics of Housing and Housing Supports for Individuals with Concurrent Traumatic Brain Injury and Mental Health and/or Substance Use Challenges: A Qualitative Study. International Journal of Environmental Research and Public Health, 18(22). https://doi.org/10.3390/ijerph182212211 Health, V. O. of M. (n.d.). Domiciliary Care for Homeless Veterans Program - VA Homeless Programs [General Information]. https://www.va.gov/homeless/dchv.asp Mental Health Promotion, Prevention, and Intervention in Occupational Therapy Practice. (2017). The American journal of occupational therapy: official publication of the American Occupational Therapy Association, 71(Supplement_2), 7112410035p1 7112410035p19. https://doi.org/10.5014/ajot.2017.716S03 14 Occupational Therapy Practice Framework: Domain and Process (3rd Edition). (2014). The American Journal of Occupational Therapy, 68(Supplement_1), S1S48. https://doi.org/10.5014/ajot.2014.682006 Olenick, M., Flowers, M., & Diaz, V. (2015). US veterans and their unique issues: enhancing health care professional awareness. Advances in Medical Education and Practice, 635. https://doi.org/10.2147/AMEP.S89479 Stacy, M. A., Stefanovics, E., & Rosenheck, R. (2017). Reasons for job loss among homeless veterans in supported employment. American Journal of Psychiatric Rehabilitation, 20(1), 1633. https://doi.org/10.1080/15487768.2016.1267049 Sughair, A., Park, K., MacDermott, S., & Cohill, B. (2021). Enhancing Eating Routines to Support Occupational Functioning. Summer 2021 Virtual OTD Capstone Symposium. https://soar.usa.edu/otdcapstonessummer2021/13 Sullivan, G. M., & Artino, A. R. (2013). Analyzing and Interpreting Data From Likert-Type Scales. Journal of Graduate Medical Education, 5(4), 541542. https://doi.org/10.4300/JGME-5-4-18 Takagi, D., Kondo, K., & Kawachi, I. (2013). Social participation and mental health: moderating effects of gender, social role and rurality. BMC Public Health, 13(1), 701. https://doi.org/10.1186/1471-2458-13-701 Wenzel, S. L., Bakhtiar, L., Caskey, N. H., Hardie, E., Redford, C., Sadler, N., & Gelberg, L. (1995). Homeless Veterans Utilization of Medical, Psychiatric, and Substance Abuse Services. Medical Care, 33(11), 11321144. http://www.jstor.org/stable/3766410 15 Youn, H. M., Kang, S. H., Jang, S.-I., & Park, E.-C. (2020). Association between social participation and mental health consultation in individuals with suicidal ideation: a crosssectional study. BMC Psychiatry, 20(1), 305. https://doi.org/10.1186/s12888-020-027248 16 Table 1 Averages from Pre/Post Likert Scales for Group Sessions 1 through 5 Groups and Likert Scale Questions Asked Pre Post Group Group Averages Averages Group 1 - Routine Building (n = 6) Negative Stressors Stress Level of Current Routine at Domiciliary 2.33 2 Anxiety Level for Creating a New Routine 3.5 2.5 Anxiety Level for Maintaining a New Routine Positive Stressors 3.33 3.17 Satisfaction Level of Current Routine at Domiciliary 3.33 3.83 Confidence Level for Maintaining a Regular Routine 3.5 3.17 4 4.33 Anxiety Level for Living Outside the Domiciliary Environment Anxiety Level for Creating Ideal Home Environment Outside of Domiciliary Positive Stressors Confidence Level for Creating Comfortable Home Outside of Domiciliary Motivation Level to Sustain Changes made to Home Environment Outside of Domiciliary Group 3 - Meal Planning/Recipe Creation (n = 8) Negative Stressors 3.55 3.45 3.82 3.27 3.18 4 4.09 4.27 Anxiety Level for Planning Meals Outside of Domiciliary Anxiety Level for Making Meals Outside of Domiciliary Positive Stressors Confidence Level for Creating Meals Outside of Domiciliary Motivation Level to Sustain Planning Meals Outside of Domiciliary Motivation Level to Sustain Making/Cooking Meals Outside of Domiciliary 2.13 2.25 1.75 2.13 4.25 4 4.5 4 4.38 4.13 Motivation Level to Maintain a Regular Routine Group 2 - Home Management and Environmental Modifications (n = 11) Negative Stressors 17 Groups and Likert Scale Questions Asked Group 4 - Grocery Shopping Made Simple (n = 8) Negative Stressors Anxiety Level Towards Shopping at the Grocery Store Positive Stressors Confidence Level in Grocery Shopping Habits Motivation Level to Plan for Going Grocery Shopping Group 5 - Exercise Your Social Wellness (n = 6) Negative Stressors Anxiety Level with Attending Social Activities/Events Anxiety Level with Planning your own Social Activities /Events Positive Stressors Confidence Level in Maintaining Social Activities/ Events in Daily Routine Motivation Level to Attend a Social Activity/Event Motivation Level to Plan a Social Activity/Event Pre Post Group Group Averages Averages 2.63 2 3.63 3.38 3.38 3.13 3.33 3 4 3.5 3.33 3.33 2.17 4 3.67 2.83 Table 2 Average Likert Scale scores for overall Daily Life Skills Program Group 6 - Daily Life Skills in Review (n = 7) Post Daily Life Skills Program Averages Groups Were a Valuable Use of my Time 4.57 Groups Were Effectively Led and Facilitated 4.71 Groups were Interactive/Engaging As a Result of Attending Groups, I can Apply What I Learned to my Daily Life 4.86 4.57 18 Figure 1 Person-Environment-Occupation Model and Cognitive Behavioral Frame of Reference. Note. Adapted from Cole & Tufano, 2020. 19 Appendix A Weekly Planning Guide 20 21  ...

... DEVELOPING EDUCATIONAL RESOURCES IN A PEDIATRIC SETTING Developing Caregiver Education Resources for Increased Implementation of Therapeutic Interventions: A Multidisciplinary Approach Name: Megan Newton, OTS May 1st, 2023 A capstone project submitted in partial fulfillment for the requirements of the Doctor of Occupational Therapy degree from the University of Indianapolis, School of Occupational Therapy. Under the direction of the faculty capstone advisor: Dr. Jennifer Fogo, PhD, OTR 1 DEVELOPING EDUCATIONAL RESOURCES IN A PEDIATRIC SETTING 2 Abstract Caregiver involvement is crucial in the success of therapeutic interventions in the pediatric population. One of the roles of an occupational therapist is to provide modifications & adaptations for increased success in daily occupations, which in pediatric populations can include parent education. The purpose of this project was to create caregiver education resources for increased implementation of therapeutic interventions into daily routines. This project consisted of data collection in forms of surveys and Zoom meetings with the result of creating resources based on current familys needs. Based on their discipline, different practitioners reviewed the 49 handouts that were created. The results of this project were increased therapist satisfaction for greater access to resources as well as therapy practitioners stating they were more likely to share these new resources with the families they serve. According to the therapists at this pediatric facility who completed the post-survey, creating easily accessible resources will be effective for improving services they provide for families. Introduction Family-centered care (FCC) is crucial to the success of therapeutic interventions, especially in the pediatric population (American Occupational Therapy Association, 2020). Implementing the FCC approach in practice allows the child to be viewed as a whole and all aspects of the child are examined and treated. The profession of occupational therapy (OT) is known for being client-centered and are educated to treat people across their lifespan (American Occupational Therapy Association, 2020). Occupational therapists are currently implementing FCC into practice by including caregivers in the therapeutic process. This project involves a partnership with PediPlay, an outpatient pediatric clinic and First Steps provider in Indianapolis, Indiana. PediPlay provides developmental, occupational, DEVELOPING EDUCATIONAL RESOURCES IN A PEDIATRIC SETTING 3 physical, and speech therapy services to children from birth to age 12 with a wide range of diagnoses. As a First Steps provider, PediPlay deliver services to children within their homes. The goal of First Steps is to bring families closer together by increasing their childs functioning to meet developmental milestones (First Steps, 2020). This project is intended to increase caregivers self-efficacy with an infusion of therapy activities in daily routines with an outcome of increased caregiver enjoyment in therapy activities and child progress in therapeutic outcomes. Currently, there is a need for this project as there is no consistency and monitoring with healthcare providers regarding the resources they are providing to families. Additionally, the current education resources are disorganized and outdated which is ineffective for providers. One large role of an occupational therapist is education; therefore, this project is directly within their scope of practice. A frame of reference was included for this project. All resources will be posted on PediPlays website which contains topics within the Rehabilitative Frame of Reference (FOR). Background Occupational therapy promotes health, well-being, and quality of life for all persons, populations, and communities by providing practical solutions that enable involvement in daily activities (American Occupational Therapy Association, 2022). Occupational therapists can work in multiple different pediatric settings including acute care, early intervention (EI), home health, outpatient clinics, and schools (Beisbier & Laverdure, 2020). Across these settings, occupational therapists will typically work on an interdisciplinary team with other healthcare professionals including physical therapists and speech-language pathologists. While all three of these disciplines are important in the childs treatment plan, one essential member of the team that is often overlooked is the childs caregiver (Carlson & Schwartz, n.d.). The childs caregiver is DEVELOPING EDUCATIONAL RESOURCES IN A PEDIATRIC SETTING 4 essential in helping determine the childs goals because they see the child the most in their natural environment and observe behaviors a therapist might not see during a therapy session (Beisbier & Cahill, 2021). Oftentimes, especially in EI, caregivers play a large role in the goalplanning process and assist with determining specific goals for their child (Seruya et al., 2022). Typically, the primary goal in pediatrics is to increase the functioning of the family unit, and with occupational therapists' wide range of knowledge in areas such as activities of daily living, social participation, sensory, cognitive, and motor functioning, they can achieve this goal (American Occupational Therapy Association, 2020; Darrah et al., 2010). With, the relationship between an occupational therapist and caregiver is essential due to the crucial information they can provide to best support the success of the child (D'Arrigo et al., 2017). In addition to this partnership, providing education to families is a large part of an occupational therapists role. Parent education is defined as any educational effort to increase the parents knowledge of how to positively impact the childs performance and outcome (Ji et al., 2014; Smith et al., 2002). Due to the positive outcomes of caregiver involvement, this Doctoral Capstone will increase caregivers knowledge and self-efficacy of how to best provide for their child. Self-efficacy is defined as an increase in task-specific confidence or ability to perform a specific task (GafniLachter & Ben-Sasson, 2022). Due to the results of the needs assessment, this project is necessary at PediPlay because currently, this organizations education resources are unorganized and outdated. Due to the lack of unideal resources, therapists are limited in terms of the resources they can give to caregivers and families might be missing out on important information that could benefit their child. Additionally, therapists are currently having to find outside resources to provide to caregivers that might not be evidence-based and accurate. This Capstone project will reduce the need for DEVELOPING EDUCATIONAL RESOURCES IN A PEDIATRIC SETTING 5 therapists to locate outside resources and allow PediPlay to better monitor what educational resources are being given to families. Additionally, these resources will be used to educate caregivers on developmental milestones and age-appropriate characteristics to make them aware of the need to access services when their children are not meeting milestones. This project is unique because the practitioners will be guiding the determination of education topics based on the survey results. The selection of educational topics will be applicable to practice as they will be focused on topics families currently want more information about. Additionally, the evidence supports the effectiveness of parent education and familycentered care when implemented in practice. Evidence supports the use of occupational therapy intervention when involving a familys daily activities and routine which positively increases the parents competence and the childs everyday functioning (Lin et al., 2018). Within a familys daily routine, occupational therapists can support families to address issues with participation and performance in ADLs (Beisbier & Cahill, 2021). ADLs such as sleep, eating, and toileting habits are often primary concerns for families with young children (Gronski & Doherty, 2020). Beisbier & Cahill supports caregiver and family involvement as it allows practitioners to model appropriate strategies to increase a childs participation in specific tasks such as self-care routines (2021). In early childhood, ADLs and play are the main meaningful occupations for a young child. Since occupational therapists are trained to deliver therapy services through meaningful occupations and activities their involvement in play is very appropriate for the pediatric population (Gammer & Donoso Brown, 2022). Occupational therapists can support children in play by educating families on appropriate toys for their age, ways to modify toys and their environment, and suggest toys encourage important skills such as problem-solving and taking DEVELOPING EDUCATIONAL RESOURCES IN A PEDIATRIC SETTING 6 turns (American Occupational Therapy Association, 2012). Other studies suggest that occupational therapists can educate parents on using imitation and modeling during play to support participation in play, especially among children with autism spectrum disorder (ASD) (Kuhaneck et al., 2020). When providing family-centered care, each family is unique, and practitioners need to be prepared to adjust their interventions to best meet the needs of the whole family unit. Additionally, compliance from the family is significant in the childs therapeutic outcome however it is important for the practitioner not to overwhelm the family with suggestions and information. Family engagement in home therapy positively correlates with the childs outcome in the therapeutic process (Case-Smith, 2015). With these positive findings, this project will aid in increasing parents' ability to incorporate therapeutic interventions in their family routine for increased outcomes in their childs therapy. Model & Theory Used for Project The model used to guide this Capstone Project was the Model of Human Occupations (MOHO) model. The MOHO model focuses on how occupations are motivated, patterned, and performed (Cole & Tufano, 2008). This model is intended to understand occupations and how the physical and social environment influence it (Cole & Tufano, 2008). The model has three subsystems: volition, habituation, and performance capacity. The end goal of this model is occupational adaptation, an outcome of occupational performance (Grajo, et al., 2018). This model was chosen because it specifically looks at what influences motivation and the caregivers must be motivated to learn more about their child and promote their success. This model also focuses on how the environment influences occupation and sees if any adaptations need to be DEVELOPING EDUCATIONAL RESOURCES IN A PEDIATRIC SETTING 7 made. For some of these children their environment may need to be adapted to help them be successful in daily occupations. The frame of reference (FOR) chosen to guide this Doctoral Capstone Project was the rehabilitative frame of reference. The rehabilitative FOR is used for clients who have underlying conditions that are unlikely to remediate and will live with deficits for the rest of their lives (Cole & Tufano, 2008). This FOR includes concepts of adaptation, compensation, and environmental modifications (Cole & Tufano, 2008). This FOR is appropriate for this project as it includes a wide range of interventions including education about different topics which will result in an increase in their childs success in daily occupations. Additionally, some children have irreversible diagnoses; therefore, it will be important to adapt their occupations and environment to make them the most successful while living with deficits. Project Design & Implementation This project idea was designed and invented by the director of PediPlay, Barb Blain. Barb is additionally an occupational therapist by trade and saw the value in providing families with educational resources. During the needs assessment, Barb indicated a need for the development of resources as there were very limited resources developed and most of their resources are outdated and not easily accessible. To aid with this issue, this project was developed to create caregiver education resources based on familys needs within practice. Individuals including speech, occupational, physical, and developmental therapists completed a pre-survey at the beginning of this project. The purpose of this survey was to determine if other professionals at PediPlay felt the need to develop new caregiver education and what topics they would like more information about. Additionally, therapists were asked what DEVELOPING EDUCATIONAL RESOURCES IN A PEDIATRIC SETTING 8 resources are currently being given to families and how satisfied they are with access to resources. The survey was sent out to 85 on-staff therapists by email containing a link to the survey. Data was collected from the pre-survey from January 13th through January 24th for therapists to access and complete with a reminder email about when the survey would close, and all responses need to be completed. The pre-survey asked therapists six questions such as what topics are you currently providing caregivers information on? with the option of selecting multiple choices. An optional prompt was provided for therapists to share their personal experience based on familys needs in practice if the main topic was not listed above. The next part of the survey asked therapists to share feedback about their current satisfaction to access of resources using a Likert scale ranging from very dissatisfied to very satisfied. The final part of the survey included an open-ended prompt that allowed therapists to type their answer. This question asked, what topics would you like more information/resources on? The complete pre-survey can be found in Appendix A. 27 therapists completed the pre-survey, with a response rate of 31.7%. Of the 27 therapists who completed the pre-survey, 88.89% indicated that play was common topic families were interested in gathering more information about. Following play as a major area of interest was sensory (85.58%), feeding (62.96%), toilet training (51.85%), speech (51.85%), and eating (51.85%). Additionally, therapists stated that majority of them were satisfied or neither satisfied nor dissatisfied with their current access to resources. Figure 1 shows the pre project satisfaction levels among therapists. Finally, a list of resources therapists wanted more information about was compiled and approved by the director of PediPlay. The list of resources can be created based on therapists request and Barbs requests and can be found in Appendix B. DEVELOPING EDUCATIONAL RESOURCES IN A PEDIATRIC SETTING 9 Additionally, a survey was created for caregivers to complete. This survey was intended to gain information from caregivers that attended the Families United for Support and Engagement (FUSE) fair in Greenfield, IN. This free event is hosted for individuals to attend to gain resources for themselves or their children with or without a disability. At the event, there many different booths for companies to display their information about therapy services, medical equipment, ABA centers, IEP counselors, and many more. This survey consisted of two questions asking, what challenges do you face with your child that you wish you had more information on? looking at two different environments; home and the community. The purpose of this survey was to specifically ask members of the community about what topics they would like more information on and confirm if they felt there was a need for this project. This was intended to broaden the range of education topics and make it more appropriate for members of the community. The complete survey can be found in Appendix C. Approximately 7 parents scanned the QR to access the survey, however, no individuals completed the survey at the FUSE fair. Attempts were made to gather information from families however most people walked away from the booth before completing the survey and did not complete the survey on their own time. However, parents at the FUSE fair verbally showed interest in the project and stated they believed the project would be beneficial for them with having a child who receives services. Lastly, 64 on staff PediPlay therapists were invited to a Zoom call to better understand what families are wanting more information about. The meeting focused on the five main topics practitioners are currently educating families on. Five poll questions were created before the meeting and launched during the meeting. The poll questions consisted of dividing each topic into smaller areas to identify what specifically families were wanting more information on. DEVELOPING EDUCATIONAL RESOURCES IN A PEDIATRIC SETTING 10 During the Zoom meeting, each poll was launched one at a time and therapists were asked to complete the poll. The poll question was open for roughly two minutes or less depending how long it took therapists to respond then an open discussion was conducted to further understand the areas within the main topic. The top five subjects for discussion were play, sensory, feeding/eating, toilet training, and speech. The poll questions can be found in Appendix D. 11 therapists were present for the Zoom call with a variety of different disciplines, which was an attendance rate of 17.2%. Within each subject, eight to ten subtopics were created and used for the poll questions. The therapists were asked to answer the poll questions and were allowed to select multiple answers. The results of the Zoom meeting are presented in Table 1 and were used to guide the determination of future educational topics not already created. Based on the information gathered, my Doctoral Capstone project consisted of creating updated educational resources for caregivers. I created a list of resources which was compiled and organized for easy access to resources for families and practitioners. In total, 49 educational resources were created with a wide range of topics. The final list of educational resources can be found in Appendix E. The links to the resources were all put on one document for therapists to view and sorted into different categories including activities of daily living, motor skills, eating/feeding, play, sensory, speech, and miscellaneous. All resources were created using the online platform Canva in variations of flyers, social media posts, and infographics. Free images were used through Canva, and no identifying images were used for privacy reasons. All resources were moved into PediPlays Drop Box to maintain ownership of resources after the discontinuation of the Capstone Project. Additionally, the PediPlay therapists examined all the resources to ensure accuracy. Also, an outsider was used to examine resources and ensure accurate health literacy. DEVELOPING EDUCATIONAL RESOURCES IN A PEDIATRIC SETTING 11 As part of the dissemination plan with this project, I met with staff at PediPlay to talk about how these resources will be posted and distributed. Barb was given access to edit these resources, so they can change information on them after I leave if needed. Additionally, she said these resources will be posted on PediPlays Facebook for individuals to access and eventually PediPlays website. Additionally, all on staff therapists were sent links to view and download these resources. The hope is that practitioners will utilize these resources and share them with families they provide services to. Project Outcomes Lastly, a final list of resources and post-survey was sent to on staff therapists to gather information of their increased satisfaction levels with their access to resources. The survey was made through Survey Monkey and sent out online via email. The post-survey consisted of three questions such as after accessing the published resources, how satisfied are you now with your access to resources and how likely are you to share these resources with the families you provide services to? The final part of the survey included an open-ended prompt that allowed therapists to type their answer. This question asked, do you have any questions, comments, or concerns? The complete survey can be found in Appendix F. The post-survey was sent to 57 therapists, with a response rate of 17.4%. Data was collected from the post-survey from March 28th through April 3rd for therapists to access and complete with a reminder email about when the survey would close, and all responses need to be completed. The results of the post-survey can be found in Figure 2 and were used to determine the effectiveness of this project. Of the 10 therapists that completed the survey, 30% of therapists stated they were satisfied and 70% of therapists stated they were extremely satisfied with their access to resources after the completion of this project. Additionally, 70% of therapists said they DEVELOPING EDUCATIONAL RESOURCES IN A PEDIATRIC SETTING 12 were very likely and 30% said they were likely to share these with families. One comment from a therapist included Thanks so much for all the time and effort you put in to create the resources. It will be extremely helpful and convenient to be able to provide to families out in the field. They are a great balance of simple, straightforward, and easy-to-digest paired with sufficient detail to be very valuable. Cant thank you enough for those! Additionally, all the therapists who completed the survey stated these resources will be helpful and they appreciated the hard work in creating these resources they dont have the time to find online or create. Also, a few therapists stated they will download these resources and save them on their desktops to be able to easily share them with families. These findings support the objectives for this project which was to increase therapists satisfaction levels to their access to resources. The results were that there was an increase in satisfaction levels from the pre-survey to the post-survey, which will motivate practitioners to share these resources with families and positively impact the childs success in life. Due to the increase in therapist satisfaction, this project was beneficial to update resources for families and the hope for this project is that therapists will share these resources with families they service. Summary This Capstone Project was completed using the OT scope of practice which was appropriate for the pediatric population due to occupational therapists wide range of knowledge in topics such as sensory, play, activities of daily living, and fine motor skills. Additionally, occupational therapists are educated on the importance of caregiver education for improved family involvement and patient outcomes. The purpose of this project was to increase implementation of therapeutic interventions into daily routines of families receiving services. DEVELOPING EDUCATIONAL RESOURCES IN A PEDIATRIC SETTING 13 This 14-week project consisted of determining and creating caregiver education handouts for families in the community. On staff therapists were recruited to determine the specific education topics based on the need in current practice. Data was gathered through surveys and Zoom calls to determine the topics for the caregiver resources. A total of 49 resources were created using the online platform, Canva, consisting of six main topics of feeding/eating, motor skills, play, sensory, speech, activities of daily living, and others. These resources were checked with practitioners based on their scope of practice and sent out to all on staff therapists for suggestions. At the end of the project, a post-survey was sent to all on staff therapists to gather their satisfaction levels after the development of resources. The results were that there was an increase in satisfaction levels from the pre-survey; dissatisfied (12%), neither satisfied nor dissatisfied (42%), satisfied (42%), and extremely satisfied (4%) to the post-survey; satisfied (30%), and extremely satisfied (70%). Additionally, 70% of therapists said they were very likely and 30% said they were likely to share these with families. With the creation of these resources practitioners, will be able to educate caregivers on different strategies to implement in their daily routine outside of therapeutic services. This will be beneficial for members of the community to allow them to access updated and evidence-based resources about various topics related to their childrens functioning. Conclusion The focus of this project was to develop caregiver education resources to provide therapists with evidence-based resources to distribute to families. This was accomplished by creating 49 resources with a variety of main topics. The target population for these resources is families in the community with children with or without a disability. The hope is that DEVELOPING EDUCATIONAL RESOURCES IN A PEDIATRIC SETTING practitioners will utilize these resources and share them with families they provide services to. Prior to this project, PediPlays resources were outdated and unorganized, so this project was beneficial for PediPlay staff so that they can share updated, reliable resources for families. The project demonstrates the necessity for creating updated caregiver education resources for increased therapist satisfaction to access of resources. With the creation of updated resources, therapists stated they were more likely to share these resources with families they serve for improved services to the families they provide. Due to the known benefits of caregiver involvement and PediPlay therapists stating these resources would be effective in improving services to the families they provide; practitioners should continue to be educated on the importance of caregiver education for increased family involvement. 14 DEVELOPING EDUCATIONAL RESOURCES IN A PEDIATRIC SETTING 15 References American Occupational Therapy Association. (2012). Tips for living life to its fullest learning through play. Retrieved January 30, 2023, from https://www.aota.org/~/media/Corporate/Files/AboutOT/consumers/Youth/Play/Learning %20Through%20Play%20tip%20sheet.pdf American Occupational Therapy Association. (2020). Occupational therapy practice framework: Domain and process (4th ed.). American Journal of Occupational Therapy, 74(Suppl. 2), 7412410010. https:// doi.org/10.5014/ajot.2020.74S2001 Beisbier, S., & Cahill, S. (2021). Occupational Therapy Interventions for Children and Youth Ages 5 to 21 Years. The American Journal of Occupational Therapy, 75(4), 7504390010. https://doi.org/10.5014/ajot.2021.754001 Beisbier, S., & Laverdure, P. (2020). Occupation- and Activity-Based Interventions to Improve Performance of Instrumental Activities of Daily Living and Rest and Sleep for Children and Youth Ages 521: A Systematic Review. The American Journal of Occupational Therapy, 74(2), 7402180040p1-7402180040p32. https://doi.org/10.5014/ajot.2020.039636 Carlson, S., & Schwartz, S. (n.d.). Engaging Caregivers in Family-Centered Pediatric Occupation Therapy. 65. Case-Smith, J. (2015). Foundations and practice models for occupational therapy with children. In J. Case-Smith & J. Clifford OBrien. (Eds.), Occupational therapy for children and adolescents (7th ed., pp. 27-64). St. Louis, Missouri: Elsevier Mosby. Cole, M. & Tufano, R. (2008). Applied theories in occupational therapy: A practical approach. DEVELOPING EDUCATIONAL RESOURCES IN A PEDIATRIC SETTING 16 Thorofare, N.J.: SLACK Inc. D'Arrigo, R., Ziviani, J., Poulsen, A. A., Copley, J., & King, G. (2017). Child and parent engagement in therapy: What is the key? Australian Occupational Therapy Journal, 64, 340-343. doi:10.1111/1440-1630.12279 Gafni-Lachter, L., & Ben-Sasson, A. (2022). Promoting Family-Centered Care: A Provider Training Effectiveness Study. The American Journal of Occupational Therapy, 76(3), 7603205120. https://doi.org/10.5014/ajot.2022.044891 Gammer, K., & Donoso Brown, E. V. (2022). Prompting play for preschoolers with intellectual and developmental disability: A pilot investigation of an occupational therapy led virtual workshop series. Journal of Occupational Therapy, Schools, & Early Intervention, 112. https://doi.org/10.1080/19411243.2022.2027837 Grajo, L., Boisselle, A., & DaLomba, E. (2018). Occupational adaptation as a construct: A scoping review of literature. The Open Journal of Occupational Therapy, 6(1), 2. Gronski, M., & Doherty, M. (2020). Interventions Within the Scope of Occupational Therapy Practice to Improve Activities of Daily Living, Rest, and Sleep for Children Ages 05 Years and Their Families: A Systematic Review. The American Journal of Occupational Therapy, 74(2), 7402180010p1-7402180010p33. https://doi.org/10.5014/ajot.2020.039545 Ji, B., Sun, M., Yi, R., & Tang, S. (2014). Multidisciplinary Parent Education for Caregivers of Children with Autism Spectrum Disorders. Archives of Psychiatric Nursing, 28(5), 319 326. https://doi.org/10.1016/j.apnu.2014.06.003 Kuhaneck, H., Spitzer, S. L., & Bodison, S. C. (2020). A Systematic Review of Interventions to DEVELOPING EDUCATIONAL RESOURCES IN A PEDIATRIC SETTING 17 Improve the Occupation of Play in Children with Autism. OTJR: Occupation, Participation and Health, 40(2), 8398. https://doi.org/10.1177/1539449219880531 Lin, C.-L., Lin, C.-K., & Yu, J.-J. (2018). The effectiveness of parent participation in occupational therapy for children with developmental delay. Neuropsychiatric Disease and Treatment, Volume 14, 623630. https://doi.org/10.2147/NDT.S158688 Seruya, F. M., Feit, E., Tirado, A., Ottomanelli, D., & Celio, M. (2022). Caregiver Coaching in Early Intervention: A Scoping Review. The American Journal of Occupational Therapy, 76(4), 7604205070. https://doi.org/10.5014/ajot.2022.049143 Smith, C., Perou, R., & Lesesne, C. (2002). Parent education. In M. H. Bornstein (Ed.), Handbook of parenting. Biology and ecology of parenting, Vol 2. Mahwah, NJ: Erlbaum. DEVELOPING EDUCATIONAL RESOURCES IN A PEDIATRIC SETTING 18 Table 1 Zoom Results #1 #2 #3 Play Sensory Deep pressure activities, Heavy work Feeding/ Eating Feeding therapy, Positioning Toilet Training Establishing a routine Milestones associated with play 9/11 (81.08%) 9/11 (81.08%) 8/11 (72.70%) 8/11 (72.70%) 11/11 (100%) Recommended toys for ageappropriate play 8/11 (72.70%) Picky eaters due to sensory Bottle feeding, Feeding developmental milestones 7/11 (63.36%) Hygiene, Clothing management Recommended shows 7/11 (63.36%) 9/11 (81.08%) Different types of play, Incorporating speech into play, Sensory play 7/11 (63.36%) Establishing a sensory diet Food hierarchy, Thickened liquids, Facial massage 6/11 (54.54%) 5/11 (45.40%) 7/11 (63.36%) Speech Basic signs to teach your child Communicating Recommended the need to use books the restroom 6/11 (54.54%) 6/11 (54.54%) DEVELOPING EDUCATIONAL RESOURCES IN A PEDIATRIC SETTING Figure 1 Pre-Satisfaction Level with Access to Resources 11 # of Participants 11 3 0 Very dissatisfied 1 Dissatisfied Neither satisfied nor dissatisfied Satisfied Very satisfied Figure 2 Post-Satisfaction Level with Access to Resources # of Participants 7 3 0 0 0 Very dissatisfied Dissatisfied Neither satisfied nor dissatisfied Satisfied Very satisfied 19 DEVELOPING EDUCATIONAL RESOURCES IN A PEDIATRIC SETTING 20 Appendix A Pre-Survey 1. Please select your discipline. o Speech Therapy o Occupational Therapy o Physical Therapy o Developmental Therapy 2. What topics are you currently providing caregivers information on? Check all that apply. o Sleep o ADL training o Toilet training o Sensory o Grasp o Feeding o Eating o Speech o Articulation o Breathing o Gait o Positioning o Adaptive Equipment o Range of motion o Stretching/ Exercise o Gross Motor Skills o Fine Motor Skills o Play o Other 3. What types of resources are you providing to caregivers? o Handouts (pdfs, infographics) o Videos o Images o Other 4. What platform do you use when searching for caregiver education resources? ______________________________________ 5. How satisfied are you currently with your access to resources? o Very satisfied o Satisfied o Neither satisfied nor dissatisfied o Dissatisfied o Very dissatisfied 6. What topics would you like more information/resources on? (Within the scope of practice of all disciplines) ______________________________________ DEVELOPING EDUCATIONAL RESOURCES IN A PEDIATRIC SETTING 21 Appendix B List of Resources from Pre-Survey Results What topics would you like more information/resources on? (Within the scope of practice of all disciplines) 1. Parents are always asking us about community resources/group so that could be nice! 2. How to get access to medical equipment, information on how to get the Medicaid waiver 3. Caregivers do seem to have a lot of questions about behaviors. 4. Parent resources in diff languages 5. Reflex Integration 6. Behavior Management and Emotional Regulation 7. Speech and behavior 8. Sensory 9. Strategies for toe walkers. Sensory strategies for children with sensory processing, activities for torticollis, gait training 10. How to apply for Medicaid Waiver and disability. Local resources for housing, food, utilities assistance, diaper and formula assistance, furniture, etc. Local ABA centers. Ways to get an autism diagnosis (Riley takes over a year!) 11. I have many kiddos that have quite a few characteristics of ASD without diagnosis. Perhaps topics on benefits of early assessment 12. I think I'd like more resources for play groups for families, easily accessible handouts for sensory, fine motor, and language activities. 13. Early intervention autism 14. Potty training 15. Behavior issues 16. Sleep 17. Anxiety 18. Social Emotional 19. Examples, videos, of real life play to encourage language, and supporting children with Autism. 20. Behaviors, Sleep, Routines, Technology (i.e., screen time), etc. 21. rare diagnoses (like where to tell caregivers to look for info) / lip/tongue tie / swallow studies explanations (MD offices don't do a very good job with these) 22. Picky eating/sensory 23. Handouts. Waiver info. Free resources. 24. Emotional regulation 25. Developmental ages for children (e.g., what they should be accomplishing @ what age) 26. Parent friendly, single topic upbeat videos DEVELOPING EDUCATIONAL RESOURCES IN A PEDIATRIC SETTING 22 Appendix C FUSE Fair Caregiver Survey 1. What challenges do you face at home with your child that you wish you had more information on? Check all that apply. o Going to sleep o Staying asleep o Frequent tantrums o Inappropriate behaviors (not getting along with others, violence towards others, etc.) o Potty training o Having accidents at night o Daily hygiene (taking a shower, brushing teeth, hair washing, etc.) o Unable to sit still during a movie or other activity o Being bothered when someone touches them o Being bothered by loud noises, strong smells, etc. o Eating habits o Being more interested in technology then other toys o Playing with siblings o Communicating with others o Not listening/obeying you o Other 2. What challenges do you face in the community with your child that you wish you had more information on? Check all that apply. o Paying attention in school o Difficulties in class with crafts (coloring, writing, holding a pencil, cutting, etc.) o Difficulties in PE class (running, jumping, throwing a ball, kicking a ball, etc.) o Getting along with classmates o Unable to remain seated during class o Being bothered when someone touches them o Being bothered by loud noises, strong smells, etc. o Staying in line during transitions o Difficulties with making new friends o Difficulties with transitioning to other activities o Not listening/obeying authority o Difficulties with going through the cafeteria line o Meltdowns in public o Complaining/ whining about activities o Other DEVELOPING EDUCATIONAL RESOURCES IN A PEDIATRIC SETTING 23 Appendix D Zoom Poll Questions 1. Within play, what topics are you currently providing caregivers information on? Check all that apply. o Milestones associated with play o Importance of play o Different types of play o Incorporating speech into play o Sensory play o Importance of play with both genders o Recommended toys for age-appropriate play o Other 2. Within sensory, what topics are you currently providing caregivers information on? Check all that apply. o Compression vests o Weighted lap pads o Fidgets o Establishing a sensory diet o Interoception o Deep pressure activities o Heavy work o Picky eaters due to sensory o Hypersensitivity vs hyposensitivity o Other 3. Within feeding/eating, what topics are you currently providing caregivers information on? Check all that apply. o Disorders associated with feeding and eating o Feeding therapy o Feeding developmental milestones o Food hierarchy o Tongue thrusts o Adaptative equipment o Positioning o Bottle feeding o Thickened liquids o Facial massage o Other 4. Within toilet training, what topics are you currently providing caregivers information on? Check all that apply. o Communicating about the need to use the restroom o Establishing a routine o Awareness o Clothing management o Motor skills (balance, strength, etc.) DEVELOPING EDUCATIONAL RESOURCES IN A PEDIATRIC SETTING 24 o Pericare o Hygiene (washing and drying hands) o Physical adaptations and modifications o Developing a reward system o Other 5. Within speech, what topics are you currently providing caregivers information on? Check all that apply. o Recommended books o Recommended shoes o Disorders associated with speech and language o Milestones associated with speech o How to set up AAC devices o AAC device hygiene o Basic signs to teach your child o Other DEVELOPING EDUCATIONAL RESOURCES IN A PEDIATRIC SETTING Appendix E Final List of Resources 1. Activities for Torticollis 2. Animal Walks 3. ASD & Echolalia 4. Benefits of Early Intervention 5. Benefits of Play 6. Books to Encourage Your Child to Read 7. Community Resources 8. Deep Pressure Activities 9. Difference in Disciplines 10. Early Games to Promote Social Skills 11. Feeding Therapy 12. Fine Motor Activities 13. Games to Improve Executive Functioning 14. Gross Motor Activities 15. Heavy Work Activities to Try at Home 16. Household Chores 17. Is My Child a Picky Eater? 18. Objects to Build an Obstacle Course 19. Picky Eaters- Is it Sensory or Oral Motor? 20. Pre-Crawling and Crawling Activities 21. Play is Therapy! 22. Recommended Show to Promote Speech 23. Recommended Toys for Age-Appropriate Play 24. Red Flags for ASD 25. SLP Screening vs. Evaluation 26. Sensory Play 27. Sensory Activities Before Bed 28. Sensory Garments- What are They? 29. Sensory Terms 30. Setting Your Childs Plate 31. Signs to Teach My Child 32. SLP Disorders 33. SLP Terminology You Need to Know 34. Songs to Encourage Speech 35. Stages of Play 36. Strategies for ADHD 37. Strategies for Picky Eaters 38. Strategies to Prevent Burnout 39. Strategies for Toe Walker 40. Tantrums or Sensory Meltdowns? Whats the difference? 41. Tips to Help Your Child Fall Asleep Faster (Infographic) 42. Tips to Help Your Child Get Dressed Faster 25 DEVELOPING EDUCATIONAL RESOURCES IN A PEDIATRIC SETTING 43. Tips for Potty Training 44. W-Sitting 45. Ways to Incorporate Speech into Play 46. Ways to Promote Family Wellness 47. Weighted Blankets for Kids 48. When is My Child Ready to Potty Train? 49. What is Heavy Work? 26 DEVELOPING EDUCATIONAL RESOURCES IN A PEDIATRIC SETTING Appendix F Post-Survey 1. After accessing the published resources, how satisfied are you now with your access to resources? a. Very satisfied b. Satisfied c. Neither satisfied nor dissatisfied d. Dissatisfied e. Very dissatisfied 2. How likely are you to share these resources with the families you provide services to? a. Very likely b. Likely c. Neither likely nor unlikely d. Unlikely e. Very unlikely 3. Do you have any questions, comments, or concerns? ______________________________________ 27 DEVELOPING EDUCATIONAL RESOURCES IN A PEDIATRIC SETTING 28 Appendix G Weekly Planning Guide Week # 1 DCE Stage (Orientation, screening/evaluation, implementation, discontinuation, dissemination) Orientation Screening/Evaluation Weekly Goal Objectives Tasks Date Complete Determine how to get needs assessment information from therapists Get familiar with the building and staff Create a weekly January schedule with 13th goals and plans for each week Complete SWOT analysis Finish the survey and send to the participants Send email to therapists to set up shadowing Set up meeting with Bri 2 Screening/Evaluation Meet stakeholders and learn publishing guidelines for resources Update MOU with site coordinator Meet all stakeholders involved in the project Finalize MOU January 20th Meet with Bri about publishing guidelines Create a schedule when shadowing sessions/working on the project Begin researching literature based on the results Work on the introduction of paper 3 Screening/Evaluation Develop assessment for project Establish pre/post assessment Start shadowing sessions January 27th DEVELOPING EDUCATIONAL RESOURCES IN A PEDIATRIC SETTING with site coordinator 29 Work on background for paper Start receiving survey responses back Create a master list of caregiver education topics from survey 4 Implementation Research literature for caregiver resources Develop clinical skills in specialized area of scope of practice Continue shadowing sessions February 3rd Gather research articles on topics Begin developing intervention binder Organize and take inventory on current caregiver education resources within the facility 5 Implementation Develop caregiver education resources Develop clinical skills in specialized area of scope of practice Continue shadowing sessions February 10th Determine what platform to use for creating resources Gather research articles on topics 6 Implementation Create caregiver education resources Provide educational resources within OT/PT/ST scope of practice Continue shadowing sessions Create handout resources February 17th DEVELOPING EDUCATIONAL RESOURCES IN A PEDIATRIC SETTING 7 Implementation Create caregiver education resources Build skills in creating resources (part of OTs role) Meet with Bri to approve format and design after completing a few resources Provide educational resources within OT/PT/ST scope of practice Finish shadowing sessions 30 February 24th Gather interventions seen in sessions Create handout Build skills resources in creating resources (part of OTs role) 8 Implementation Create caregiver education resources Provide educational resources within OT/PT/ST scope of practice Research any trainings or opportunities to advance knowledge in feeding/eating March 3rd Develop Build skills intervention binder in creating resources (part of OTs role) 9 Implementation Create caregiver education resources Provide educational resources within OT/PT/ST scope of practice Participate in trainings if available March 10th Work on intervention binder Host Zoom Build skills meeting to better in creating understand topics resources (part of OTs role) 10 Implementation Create caregiver education resources Provide educational Finish editing all resources March 17th DEVELOPING EDUCATIONAL RESOURCES IN A PEDIATRIC SETTING resources within OT/PT/ST scope of practice Build skills in creating resources (part of OTs role) 11 Implementation Checking education resources for publishing Send post assessment Create survey to be sent out to therapists and send out 31 Go over intervention binder with site mentor Send resources out to therapists for feedback Compile resources into accessible location for families and therapists to access March 24th Send out survey again to gather data on therapists satisfaction levels with access to resources 12 Implementation Determine conclusions/benefits of project Create graphs for project on finding within Excel Note significant findings in data collected 13 Discontinuation Finalize analyzation of data collected and draw conclusions Assemble PowerPoint and schedule a time to present Start drawing conclusions Put resources in Dropbox March 31st Determine conclusions from surveys Work with website creator on making sure resources are in correct format and compatible with website preferences Start writing the conclusion of the scholarly report. Create PowerPoint to show findings and present to site mentor April 7th DEVELOPING EDUCATIONAL RESOURCES IN A PEDIATRIC SETTING 32 based on findings 14 Dissemination Disseminate project to site Present findings to site mentor and other staff who are interested Schedule a time to present findings Discuss with site mentor findings and future recommendations on how to keep project sustainable April 13th  ...

... Reducing Overdoses within the Aging Population through Policy and Program Implementation Erika Murphy May, 2023 A capstone project submitted in partial fulfillment for the requirements of the Doctor of Occupational Therapy degree from the University of Indianapolis, School of Occupational Therapy. Under the direction of the faculty capstone advisor: Christine Kroll, OTD, MS, OTR, FAOTA REDUCING OVERDOSES WITHIN THE AGING POPULATION 1 Abstract The purpose of this doctoral capstone project was to collaborate with a nursing home facility to implement naloxone education for nursing home staff. Research indicates there continues to be an increase in opioid presence in the Cuyahoga County area. I worked with MetroHealths Office of Opioid Safety, the county hospital in Cleveland, Ohio, and IPRO QINQIO, a federally funded Medicare Quality Innovation Network, to implement the Nursing Home Naloxone Policy and Procedure Toolkit into Eliza Jennings Nursing Home. I created a resource binder, completed four in-services to train and educate nursing staff on the new policy and procedures, and used a pre- and post-survey to assess knowledge gained from the presentation. The in-services yielded a 17% increase in knowledge, and staff reported feeling confident with using naloxone in an overdose situation. The results imply that there is a need for more education in nursing home staff on naloxone. REDUCING OVERDOSES WITHIN THE AGING POPULATION 2 MetroHealth Hospital is in Cleveland, Ohio, the county hospital for Cuyahoga County in the greater Cleveland, Ohio area. For my Doctoral Capstone Experience (DCE), I worked in MetroHealths Office of Opioid Safety with their education coordinators. Our mission is to promote opioid safety throughout the MetroHealth system and in the greater community through education, advocacy, and treatment through increased access to non-opioid pain management modalities, safe opioid prescribing, prevention of opioid use disorder, addressing the stigma of substance use disorders, harm reduction, and access to addiction treatment (Office of Opioid Safety, 2022). This office has a variety of programs, such as a mobile RV unit that serves as a syringe exchange program, offers assistance to individuals in the county jail, and has a Motivational and Engagement Clinic which offers medicated assisted treatment. The education team was looking to grow their platform to bring education to individuals across the lifespan. The team works with high school age children and young adults through local schools and colleges. My research finding is that nursing homes were identified as a high-risk population for being affected by the opioid epidemic that the United States is experiencing (Pruskowski et al., 2019). I collaborated with individuals from IPRO QIN-QIO, a federally funded Medicare Quality Innovation Network to implement their new Nursing Home Naloxone Policy and Procedure Toolkit into Eliza Jennings Nursing Home in Cleveland, Ohio. With an aging population, it is critical to provide education and increase awareness of the opioid epidemic to the 55+ population. This allowed me to gain advanced skills in integration of OT and program development and education. This paper will detail my doctoral capstone project in its entirety. I will focus on relevant background information, occupation-based theory, my project design and implementation, project outcomes, and conclusions. REDUCING OVERDOSES WITHIN THE AGING POPULATION 3 Background According to the Ohio Department of Health (2022), in the first six months of 2021, Ohio had a higher number of unintentional drug overdose deaths than in the first half of 2020. In addition, there has been a 25% increase in overdose deaths since 2019. More specifically, overdose in Cuyahoga County remains the leading cause of injury-related deaths, with heroin and fentanyl being the two main factors, and 75% of prescription drug overdose deaths involve opioid pain relievers (Opioid Use and Misuse, 2022). Opioid use continuously proves to be an area of much-needed help across the entire lifespan. Substance use disorder does not discriminate, and there has been an increasing number of older adults affected by substance use disorder. The Ohio Department of Health reported that there have been 3,628 deaths of people 55-64 and 756 deaths of people 65 and older (2022). The State Operations Manual, Appendix PP highlights the increased risk for older adults with overdoses and the US general surgeon is recommending all nursing facilities have a standing order of naloxone (State Operations Manual Appendix PP, 2023). Hunnicutt et al. (2018) highlighted the fact that older adults are at a higher risk of having dangerous side effects when using opioids due to several factors, including older age, comorbidities, mental health, frailty, and other factors. Nursing homes admit people for a variety of reasons. For example, Surgery has been shown to be an important risk factors for developing new chronic opioid use among previous nonopioid users (Buys et al., 2022). Buys et al. (2022) also discovered that orthopedic surgery patients discharged typically to a nursing home for further rehabilitation. These patients in a nursing facility often used opioids for an average of 22 days versus patients who were discharged home and used opioids for 11 days. Also, fractures of joints are the most common in patients over the age of 65, and Torchia et al. (2019) discovered that opioid use increased significantly after a fracture. Other research reports found that patients with Alzheimer's and REDUCING OVERDOSES WITHIN THE AGING POPULATION 4 Alzheimers related disease were more likely to receive opioids for pain (Wei et al., 2021). A study looking into OTs role on the opioid epidemic revealed that many people did not understand current guidelines which can cause poor treatment (Daniel & Wasmuth, 2020). It is vital that there are more resources available to facilities to better assist those with an opioid addiction. The Office of Opioid Safety has an abundance of resources for all areas of need except for nursing homes. Currently, the education coordinators are providing education to young adults through lecture styled PowerPoint presentations, Zoom calls, resource fairs, and professional presentations to others in the field. By completing my needs assessment and literature review, I identified and targeted the older adult population and their need for resources. I connected with an individual from the Center of Health Affairs, a nonprofit advocacy group in Ohio for hospitals and community engagement. The Center of Health Affairs helped IPRO QIN-QIO, an organization that includes quality assurance and improvement services for local, state, and federal contracts, to roll out their naloxone tool kit. The Nursing Home Naloxone Policy & Procedure Toolkit has information such as an introduction, how to use it, the RIOSORD assessment, naloxone education, and competency policy/procedures, standing order for the use of naloxone for residents, staff, and visitors, and a suspected overdose drill. This resource packet is generalized to nursing homes. For my project, I implemented this resource packet into one nursing home, Eliza Jennings, in the Cleveland area, presented this information to them clearly and concisely, and created a quick reference binder. I assessed how I did as a speaker, how I conveyed this information, had participants complete a pre- and post-knowledge survey, and asked translational questions to my audience. There have been other successful implementations of naloxone and opioid education and overdose education in facilities. Pauly et al. (2018) implemented and evaluated opioid overdose REDUCING OVERDOSES WITHIN THE AGING POPULATION 5 education and naloxone distribution in a VA center. This program aimed to reduce harm and the risk of an overdose. In this study, the research team educated the staff, including primary care providers, care providers, and mental health staff, to consult a patient with a high risk for developing an addiction and how to use a naloxone kit properly. Researchers concluded that a majority of the participants found the education beneficial, easy to understand, and knowledgeable. The limitation of this study in comparison to mine is that it is done with a population who has the ability to leave and return on a day-to-day basis. In a nursing home, there is an increased risk for visitors bringing in supplies to the patients. Patients in a nursing home are also surrounded by staff all day who have busy schedules. In the case of visitors, anyone can visit the facility, which only increases the number of potential overdoses in the home. Naloxone must be present with easy instructions in case of emergency for anyone in the facility. There was another study completed by Perera et al. (2022) where the researchers conducted a needs assessment to determine harm reduction needs. Researchers worked with a community-based organization that supplied harm reduction equipment and training to the Addiction Care Team. This team attended harm reduction, safer injection, and overdose prevention training. The trainings proved successful as the participants reported reduced stigma (Perera et al., 2022). With the rising number of opioid overdoses, more attention must be brought to the importance of this subject. Sullen et al. (2022) found that providing education optimistically and respectfully positively impacts the audience. OTs have a unique role in drug prevention because we have the resources and education to advocate and educate those around us (Aust, 2020). By implementing the Nursing Home Naloxone Policy & Procedure Toolkit into a nursing home, I will be helping one facility be better prepared and confident in its ability to handle an emergency. REDUCING OVERDOSES WITHIN THE AGING POPULATION 6 Occupation-Based Model PEO (Person-Environment-Occupation) Model According to Cole and Tufano (2020), the PEO model focuses on the person, their environment, and their occupation and their interconnectedness. This model is dynamic, meaning all parts are interconnected and change when another part is affected. In the case of my project, I extrapolated out the PEO to the organizational level. The nursing home staff serves as the person, the environment is the nursing home facility, and the occupation is naloxone education (Cole & Tufano, 2020). Because all of these factors are integrated, it was important to me that I showed how they were all moving together. In the case of Eliza Jennings, the occupation was me completing four in-services to the nursing staff, including registered nurses (RN) and certified nursing assistants (CNA). The education or the occupation affects how the environment and the person operate on a day-to-day basis. I chose to use the PEO model because Substance Abuse and Mental Health Services Administrations perspective on health and purpose connects with the PEO person and occupation concepts, and SAMHSA home and community aspects highlight the PEO environment concepts in the occupational therapy literature (Stoffel, 2013). The PEO model helped to guide the implementation of my project. I created a pre- and post-knowledge check for the nursing staff that followed the PEO model. Martin et al. (2015) used the PEO model to develop a survey about occupational dysfunction and substance abuse. I adopted a similar version of their questions to create my assessment presentation questions. I used I statements to address their level of confidence and my presenter abilities on a scale of one to five. Using the PEO model helped me create a wellrounded survey to address both translation of education and presenter abilities. Project Design and Implementation REDUCING OVERDOSES WITHIN THE AGING POPULATION 7 I developed this project by reviewing research articles and talking with individuals from IPRO. Previous research articles have shown that naloxone and overdose education positively impacted individuals confidence and knowledge. These researchers conducted their study in different studies, including acute care settings, a VA center, and substance use disorder treatment centers (Pauly et al., 2018; Perera et al., 2022; Pade et al., 2017). For this project, I focused on implementation of naloxone and overdose education in a nursing home. I broke my project into four steps. The first step was to connect with individuals from IPRO who guided me toward a facility that would be interested in working with me to implement the Nursing Home Naloxone Policy & Procedure Toolkit created by IPRO. I also established a relationship with the director of Eliza Jennings, the nursing director, and the pharmacist. Second, I created a resource binder that included Nursing Home Naloxone Policy & Procedure Toolkit created by IPRO QIN-QIO, a quick reference guide to naloxone administration, Eliza Jennings Policy information, and additional resources for the facility to have. The additional resources included a list of MetroHealths community partners, emergency phone numbers, and contact information. Third, I completed four 2530-minute presentations to Eliza Jenningss RNs and CNAs and other important personnel on a breakdown of the Nursing Home Naloxone Policy & Procedure Toolkit, overdose education, signs of an overdose, and how to use naloxone. At the beginning of my presentation, I had the staff complete a pre-survey with demographic information and five questions on naloxone and the new policy. After the presentation, staff completed the same five questions and a presenter assessment using a Likert scale. I chose to do this to test the knowledge gained throughout my presentation. Knowledge translation is defined as the synthesis, dissemination, and application of knowledge and evidence to improve the health of clients and strengthen the greater health system (Juckett, 2021). Using these questions helped me assess the likelihood that my project will be put into practice. The fourth step was to interpret REDUCING OVERDOSES WITHIN THE AGING POPULATION 8 the results from the pre- and post- knowledge check and create an implementation checklist for IPRO QIN-QIO. The implementation checklist was a step-by-step guide for other nursing facilities to easily establish this new policy into their facility. The largest barrier I faced throughout my project was communication with different individuals throughout the process. I also struggled with nursing home staff engagement and participation. Some successes throughout my project were promoting the education of naloxone and overdose and reducing stigma. Additional successes include advocating for OT in substance use. Project Outcomes To determine the success of my education to the nursing staff at Eliza Jennings, I created a pre and post-survey to analyze the results of knowledge gained and the presenter assessment. My pre-survey consisted of demographic questions, including age and gender and five questions regarding my presentation, refer to Table 1. The post-survey asked the same five questions and had a presenter assessment using a Likert scale. The five questions were multiple choice, with two true/false and one where the staff had to select two answers. The scale was from one to five, one being least effective, five being most effective. There was a total of 27 nursing staff, including RNs and CNAs, for the four presentations. All participants identified as female. Eight participants were in the 20-40 age range, seven were in the 40-50 age range, and eight were in the 50+ age range. The other four participants did not answer. The main findings were that there was a 17% gain in knowledge from the staff overall (table 2). There was also a 31% knowledge gain in understanding the administration of naloxone nasal spray and 35% knowledge gain for the assessment tools (table 3). For the presenter assessment, I analyzed the effectiveness of my presentation, and I received an average of 4.78 out of five (table 4). Five nurses did not complete the presenter assessment and five did not follow directions to REDUCING OVERDOSES WITHIN THE AGING POPULATION 9 select two answers for the fourth question. I encouraged all participants to read directions thoroughly and to take the time to complete the presenter assessment. The nursing staffs overall reaction was positive and optimistic. They felt comfortable asking questions throughout the presentation and after. The most asked question was if an individual can be allergic to naloxone and who was allowed to be administered naloxone. I was able to answer the questions for them and they stated they felt more confident. On the other hand, there were a few nurses who stated they were too busy to be there and expressed annoyance throughout the presentation. I took note in the fact that they were the ones who did not take the time to complete the presenter assessment. Overall, the feedback and results from the four presentations were positive and showed an increase in knowledge. The nursing director and pharmacists spoke positively of the presentation and was present to re-emphasize the importance of the new policy and field any additional questions that I was not able to answer that were specific to the facility. Summary The Ohio Department of Health continues to present statistics about how overdoses continue to be present and affecting our communities (2022). MetroHealths Office of Opioid Safety is committed to making a change throughout the greater Cleveland area through advocacy, education, and stigma reduction through different services throughout the area. The education coordinators provided education to mostly college and high school-aged students via presentations, lectures, and resource fairs. I connected with IPRO QIN-QIO to help implement the new policy for a standing order of naloxone into Eliza Jennings Nursing Facility in Cleveland. Through this, I was able to provide education to nursing staff and collaborate with personnel from Eliza Jennings to bring the new policy into play. I completed four in-services using IPROs presentation and edited it to fit what would be most beneficial to RNs and CNAs. I REDUCING OVERDOSES WITHIN THE AGING POPULATION 10 used pre- and post-surveys to assess the knowledge gained and obtain feedback on the presentation. The in-services highlighted the new policy, assessment tools, signs of an overdose, and how to use both intramuscular injection and nasal spray naloxone in an emergency and provided extra time for questions. My pre- and post-survey yielded a 17% increase in overall knowledge gain, and participants felt confident to administer naloxone. I created an implementation checklist that IPRO will use in the future for other nursing facilities to implement the new policy into their facility easily. For my dissemination, I was invited to help lead a round table discussion with the Ohio Department of Healths Office of Aging and Long-Term Care. The meeting was conducted virtually and had about 40 nursing homes in the Ohio area attend. This presentation consisted of IPRO personnel and me speaking to Ohio nursing homes about the new toolkit, and I spoke about the implementation process. I also presented my implementation checklist, which is now part of the toolkit that is a list for nursing homes as they continue to implement the new policy into their facilities. Conclusions My Doctoral Capstone project gave me the opportunity to learn a variety of skills. I grew professionally through making connections, practicing advocacy skills, communicating with different providers, and educating others on OTs role in this field. Through working with IPRO, I was able to connect MetroHealths Office of Opioid Safety with Eliza Jennings Nursing Home and connect the education coordinators with the other nursing homes in Ohio.I was also able to advocate for OT with education in this role and increase awareness and attention to the opioid epidemic affecting people in the Cleveland area of all ages.I educated the Office of Opioid Safety on the profession of occupational therapy and how occupation therapists could be useful in this setting. REDUCING OVERDOSES WITHIN THE AGING POPULATION 11 In the future, I think OT would benefit in a clinical education role like this because we can bring our clinical, advocacy, and education experience to create a well-rounded piece. As OTs are professionals who treat clients as a whole, it is important to understand all aspects of a persons life. This opportunity has allowed me to understand substance use disorders, how they can affect someone, and how I can carry these skills into everyday practice. REDUCING OVERDOSES WITHIN THE AGING POPULATION 12 References Aust, L. (2020). Exploring the Role of OT in School-Based Drug Prevention...2020 AOTA Annual Conference & Expo. American Journal of Occupational Therapy, 74, 1. https://doi.org/10.5014/ajot.2020.74S1-PO2125 Buys, M. J., Anderson, Z., Bayless, K., Zhang, C., Presson, A. P., Hales, J., & Brooke, B. S. (2023). Postsurgical Opioid Use Among Veterans Discharged to Skilled Care Facilities Compared to Veterans Discharged to Home After Orthopedic Surgery. Journal of the American Medical Directors Association, 24(2), 258. https://doi.org/10.1016/j.jamda.2022.10.016 Cole, M. & Tufano, R. (2020). Applied theories in occupational therapy: A practical approach (2nd Ed.). SLACK Incorporated. Daniel, J., & Wasmuth, S. (2020). The Opioid Crisis: OTs Perceptions and Experiences From the Front Lines...2020 AOTA Annual Conference & Expo. American Journal of Occupational Therapy, 74, 1. https://doi.org/10.5014/ajot.2020.74S1-PO7319 Hunnicutt, J. N., Chrysanthopoulou, S. A., Ulbricht, C. M., Hume, A. L., Tjia, J., & Lapane, K. L. (2018). Prevalence of longterm opioid use in longstay nursing home residents. Journal of the American Geriatrics Society, 66(1), 4855. https://doi.org/10.1111/jgs.15080 Martin, L. M., Triscari, R., Boisvert, R., Hipp, K., Gersten, J., West, R. C., Kisling, E., Donham, A., Kollar, N., & Escobar, P. (2015). Development and evaluation of the Lifestyle History Questionnaire (LHQ) for people entering treatment for substance addictions. American Journal of Occupational Therapy, 69(3), p1p9. https://doi.org/10.5014/ajot.2015.014050 REDUCING OVERDOSES WITHIN THE AGING POPULATION 13 Ohio Department of Health (2022, June). Ohio Monthly Overdose Preliminary Data Summary, June 2022. https://odh.ohio.gov/know-our-programs/violence-injury-preventionprogram/media/ohio-unintentional-drug-overdose-deaths-preliminary-june-2022 Office of Opioid Safety. The MetroHealth System, MetroHealth, 2022, https://www.metrohealth.org/office-of-opioid-safety. Opioid use and misuse. Cuyahoga County Board of Health. (2022, January 24). Retrieved March 11, 2022, from https://www.ccbh.net/opiates/ Pade, P., Fehling, P., Collins, S., & Martin, L. (2017). Opioid overdose prevention in a residential care setting: Naloxone education and distribution. Substance Abuse, 38(1), 113117. https://doi.org/10.1080/08897077.2016.1176978 Juckett, L. A., Robinson, M. L., Malloy, J., & Oliver, H. V. (2021). Translating Knowledge to Optimize Value-Based Occupational Therapy: Strategies for Educators, Practitioners, and Researchers. American Journal of Occupational Therapy, 75(6), 17. https://doi.org/10.5014/ajot.2021.756003 Pauly, J. B., Vartan, C. M., & Brooks, A. T. (2018). Implementation and evaluation of an opioid overdose education and naloxone distribution (OEND) program at a Veterans Affairs Medical Center. Substance Abuse, 39(2), 206210. https://doi.org/10.1080/08897077.2018.1449174 Perera, R., Stephan, L., Appa, A., Giuliano, R., Hoffman, R., Lum, P., & Martin, M. (2022). Meeting people where they are: implementing hospital-based substance use harm reduction. Harm Reduction Journal, 19(1), 17. Pruskowski, J., & Hanlon, J. T. (2019). Is There an Opioid Crisis in Nursing Homes? Journal of the American Medical Directors Association, 20(3), 273274. https://doi.org/10.1016/j.jamda.2018.12.025 REDUCING OVERDOSES WITHIN THE AGING POPULATION 14 Sellen, K., Goso, N., Halleran, L., Mulvale, F. A., Sarmiento, F., Ligabue, F., Handford, C., Klaiman, M., Milos, G., Wright, A., Charles, M., Sniderman, R., Hunt, R., Parsons, J. A., Leece, P., Hopkins, S., Shahin, R., Jni, P., Morrison, L., & Campbell, D. M. (2022). Design details for overdose education and takehome naloxone kits: Codesign with family medicine, emergency department, addictions medicine and community. Health Expectations, 25(5), 24402452. https://doi.org/10.1111/hex.13559 State Operations Manual Appendix PP - Guidance to Surveyors for Long Term Care Facilities. CMS. (2023, February 23). Retrieved April 21, 2023, from https://www.cms.gov/Medicare/Provider-Enrollment-andCertification/GuidanceforLawsAndRegulations/Downloads/Appendix-PP-StateOperations-Manual.pdf Stoffel, V. C. (2013). Opportunities for Occupational Therapy Behavioral Health:A Call to Action. American Journal of Occupational Therapy, 67(2), 140145. https://doi.org/10.5014/ajot.2013.672001 Torchia, M. T., Munson, J., Tosteson, T. D., Tosteson, A. N. A., Wang, Q., McDonough, C. M., Morgan, T. S., Bynum, J. P. W., & Bell, J.-E. (2019). Patterns of Opioid Use in the 12 Months Following Geriatric Fragility Fractures: A Population-Based Cohort Study. Journal of the American Medical Directors Association, 20(3), 298304. https://doi.org/10.1016/j.jamda.2018.09.024 Wei, Y.-J. J., Schmidt, S., Chen, C., Fillingim, R. B., Reid, M. C., DeKosky, S., Solberg, L., Pahor, M., Brumback, B., & Winterstein, A. G. (2021). Quality of opioid prescribing in older adults with or without Alzheimer disease and related dementia. Alzheimers Research & Therapy, 13(1), 114. https://doi.org/10.1186/s13195-021-00818-3 REDUCING OVERDOSES WITHIN THE AGING POPULATION 15 Table 1. Pre/Post Knowledge Check Questions and Answers Question Question Wording Question 1 The Centers for Medicare and Medicaid (CMS) released revisions to the state operations manual that allow naloxone to be administered by a licensed nurse or authorized staff to residents/patients/staff/visitors Question 2 If the individual does not respond in __ to __ minutes, administer additional doses of naloxone solution for intramuscular injection. Question Options A. True B. False A. 4 to 5 B. 2 to 3 C. 6 to 7 D. 3 to 4 Question 3 When using the Opioid Risk Tool-Revised (ORT-R) A. 5 assessment tool, a score of __ or more means that patient is at B. 7 a high risk for opioid use disorder C. 1 D. 3 Question 4 Please select 2 answers: When administering the naloxone A. Stomach solution for intramuscular injection, you inject deeply into B. Deltoid C. Calf D. Anterolateral thigh Question 5 When administering the naloxone Nasal Spray you should A. True spray the naloxone into both nostrils B. False Answer A B D B and D B REDUCING OVERDOSES WITHIN THE AGING POPULATION Table 2. Nursing Home Naloxone Policy and Procedure Toolkit Training pre-test post-test difference 1st presentation 40% 100% 60 3/14 at 2pm 80% 100% 20 100% 80% -20 100% 80% -20 60% 80% 20 80% 100% 20 40% 100% 60 2nd Presentation 60% 100% 40 3/14 at 8pm 80% 80% 0 40% 100% 60 40% 40% 0 60% 80% 20 3rd Presentation 80% 80% 0 3/16 at 2pm 80% 100% 20 80% 80% 0 80% 100% 20 60% 100% 40 80% N/A 0 60% N/A 0 4th Presentation 60% 60% 0 3/16 at 8pm 60% 80% 20 80% 80% 0 80% 100% 20 16 REDUCING OVERDOSES WITHIN THE AGING POPULATION Average 60% 100% 40 60% 80% 20 60% 80% 20 80% 80% 0 17.03703704 17 REDUCING OVERDOSES WITHIN THE AGING POPULATION 18 Table 3. Question Breakdown of Knowledge Gained Question Question 1 Question 2 Question 3 Question 4 Question 5 Pre-Test 100% 80% 45% 64% 53% Post Test 100% 92% 80% 84% 84% Knowledge Gain 0% 12% 35% 20% 31% REDUCING OVERDOSES WITHIN THE AGING POPULATION 19 Table 4. Presenter Assessment Results Question Question wording Average Response Question 1 The training objectives were met 4.7 Question 2 The speaker was well prepared 4.9 Question 3 The trainer was knowledgeable about the training of the topic 4.8 Question 4 The training will be useful in my work 4.8 Question 5 How comfortable do you feel using naloxone after this presentation 4.7 Note: The average response was a scale from 1 to 5, 1= least effective, 5= most effective. REDUCING OVERDOSES WITHIN THE AGING POPULATION 20 Appendix A Doctoral Capstone Experience and Project Weekly Planning Guide Week DCE Stage (orientation, screening/evaluation, implementation, discontinuation, dissemination) Weekly Goal Objectives Tasks 1 Orientation Complete orientation by end of week -Meet with my coordinator and the other staff involved in the office of opioid safety. -Ensure all orientation items are complete -Introduce myself to the team and explain my role/what OT is. -Finalize questions for needs assessment with education coordinators (Libby and Natalie) -Understand the work environment including dress code, parking, workspace. -Complete SWOT analysis -Complete Literature Review -Explain my role 1/13 to education coordinators at the office of opioid safety -Address their needs from me as a student -Finalize MOU -Complete LEAP modules 2 Screening/Evaluation Complete search of literature and finalize details of project after meeting on 1/18 @ 12:30pm with Carrie Lang -Meet with Carrie Lang about finalizing details of project (1/18) -Finalize MOU and update goals depending on project -Attend resource fair on Saturday to better expand my knowledge on the office of opioid safety. -Create ideas and 1/20 bullet point key facts for meeting with Carrie Lang -Finalize MOU after speaking with Carrie and Uindy faculty mentor about new project -Discuss new project with education Date Complete REDUCING OVERDOSES WITHIN THE AGING POPULATION 21 -Start to develop plan for project. coordinators and site supervisor 3 Screening/Evaluation Continue finding articles and recent research on substance use disorders in older adults -Continue to reach out to people in the community regarding my project -Talk to others in the office about my project for ideas -Attend in person presentation at CSU and online -Spend 1 day on mobile unit -Better learn 1/27 professional communication skills -Discuss other project contacts in case my original idea does not go as planned -Learn presentation skills through observing others speak -Better understand grants and funds and how they work for an organization 4 Evaluation Get in contact with IPRO individual regarding my project -Meet with Carrie (Center of Health Affairs) and Anne (IRPO) and colleagues on 2/2 at 1-2pm -Create questions and write down ideas for meeting -Create blank PowerPoint to begin for presentation to nursing home -Send email to rehab director to ask to shadow -make corrections to introduction and background drafts 2/3 5 Evaluation Set up a date and time to meet with selected nursing home to discuss me presenting at an in-service -Meet with nursing director, director, and unit manager at Eliza Jennings (SNF) to discuss IPRO toolkit on 2/9 -Meeting with IPRO and staff on 2/7 to discuss nursing -Create a plan to discuss with nursing home staff -Establish a date for in-service -Continue to make corrections to drafts previously submitted 2/10 REDUCING OVERDOSES WITHIN THE AGING POPULATION 22 homes in area who may be interested -Help office pack up for their move (sorting papers) 6 Evaluation Review finalized PowerPoint sent from IPRO, write down questions for meeting, and gather thoughts on how to tackle in-service -Work from home all week due to office moving -Meet with IPRO staff on Tuesday 2/14 to discuss progress with SNF staff and ask questions -Meet with site mentor to review midterm evaluation and update her due to my mentor being switched in week 5 -Continue to find resources for final paper -Meet with Christine to discuss progress with project -Better refine my professional communication skills -Start scipt for inservice presentation -Prepare for meeting with SNF staff on 2/23 at 1pm -Ask site mentor for advice regarding pre/post knowledge check -Work with Christine to develop questions for in-service 7 Evaluation Review again updated PowerPoint sent by IPRO, collect any ideas for presentation, continue to research. -Meet with IPRO on weekly Tuesday meeting to discuss progress and ask questions -Meet with nursing home and pharmacist on Thursday to confirm in-service dates, standing Naloxone order, and other details for day. -Continue to work 2/24 on questions for survey -Prepare for inservice presentations (March 14th and 16th at 2pm and 8pm) -Gather resources/materials from Metro and IPRO for presentation 8 Evaluation Talk with mentor/IPRO about different resources and key points -Meet with IPRO on weekly Tuesday meeting to discuss progress/ask questions -Prepare for in3/3 services -Gather resources/materials -Talk with IPRO about me 2/17 REDUCING OVERDOSES WITHIN THE AGING POPULATION 23 throughout presentation -Continue to find resources (use AJOT) -Gather resources from Project DAWN, OOS, and IPRO presenting to the Ohio Department of Health and what I must do. 9 Evaluation Practice presentation for nursing home, review and gather resources, complete the resource binder -Create binder with resources -Print out everything for binder -Organize binder -Practice presentation -Meet with nursing home on Wednesday -Discuss nursing home needs for presentation (# of pamphlets, handouts) -See presentation space at nursing home -complete and finalize binder -Shadow IP OT to learn the operations of Metros IP rehab center. 3/10 10 Implementation Present to nursing home 4x total. - March 14th at 2pm and 8pm - March 16th at 2pm and 8pm -Successfully present 4 in-services to Eliza Jennings -Collect pre/post surveys from staff members -Continue to talk with people from IPRO throughout week with questions and challenges I faced during my presentation. -Ask for guidance from educational coordinators at office about presentation skills/tips -successfully engage the staff at Eliza Jennings about the importance of this topic 3/17 REDUCING OVERDOSES WITHIN THE AGING POPULATION 24 11 Interpretation of Results -Interpret the results from the pre/post surveys from my presentations -2 presentation at CSU -Meet with mentors to discuss how to interpret results -Create excel sheet and understand how to create tables to input results to see knowledge gained. -Spend 1 day shadowing the IP OT at Metro -Grade all pre/post 3/24 surveys and input them into excel to average the knowledge gained. -Spend time reviewing SCI/TBI information in preparation for shadowing experience. -Shadow on Friday March 24th (7am3:30). -Participate in informed choices presentation at CSU this week. 12 Dissemination -Prepare for dissemination to ODH -Complete edits to presentation for IPRO -Attend resource fair -Start implementation checklist for IPRO -Submit and meet with individuals from IPRO to discuss presentation and review edits. -Practice education and advocacy at resource fair at Lake Erie College -Review all documents to determine the process of implementation into Eliza Jennings. -Interpret results and better understand what they concluded -Research more into the new FDA approval of naloxone being an OTC drug. 3/31 13 Dissemination -Complete finalized checklist -Prepare for presentation -Visit MEC -Make final edits to checklist -Meet with IPRO individuals to practice presentation -Learn about MECs day to day operations. -Ask mentors for final guidance about presentation -Ensure I was registered for ODH presentation -Better understand how medicated assisted treatment works and 4/7 REDUCING OVERDOSES WITHIN THE AGING POPULATION 25 understand the importance of it. 14 Dissemination -Complete presentation -Practice and review all necessary documents before presentation -Attend informed choices class with mentors -Explain importance of OT in community settings, review my project, explain the steps, review of the results, and overview of what I created to audience. 4/14  ...

... Title: Sensory Pathway to Support a Calm Body Analicia M. Morales May 1, 2023 A capstone project submitted in partial fulfillment for the requirements of the Doctor of Occupational Therapy degree from the University of Indianapolis, School of Occupational Therapy. Under the direction of the faculty capstone advisor: Laura Aust, OTD, MS, OTR SENSORY PATHWAY TO SUPPORT A CALM BODY 2 Abstract The sensory pathway was implemented at Westerhold Early Learning Center (ELC) to support the student's sensory needs. The project aimed to provide more sensory integration opportunities within the school to support self-regulation for all students. The sensory pathway targeted the sense of sight, sound, touch, vestibular input, and proprioceptive input. Alerting and calming activities like animal walks, yoga, and deep breathing helped the students self-regulate. Qualitative data was collected through informal/formal observations, interviews with staff, and a feedback survey. The project revealed that the sensory pathway was beneficial and allowed the students to self-regulate outside their classroom environment. SENSORY PATHWAY TO SUPPORT A CALM BODY 3 Sensory Pathway to Support a Calm Body Westerhold Early Learning Center is a school in Des Plaines, Illinois, where they provide multiple education programs. The education programs offered for students are book time for 2s, mini school, preschool, preschool lunch bunch, preschool plus (full day), jr. kindergarten, jr. kindergarten lunch bunch, jr. kindergarten plus (full day), and extended day kindergarten. The services delivered are social work, psychology, occupational therapy, physical therapy, and speech therapy. The Early Learning Center (ELC) received a grant in 2019 to build a sensory room which was completed during the 2019-2020 school year. The students had few opportunities to utilize the sensory room since COVID-19 and social distancing. The occupational therapist at the site stated, "Students who don't receive services don't get to utilize the sensory room" (M. Molenda, personal communication, January 9, 2023). The ELC has provided three sensory bins in the hallway for students to use when a sensory break is needed, but it only targets sight, sound, and touch, which is three out of eight senses. My project is to incorporate more sensory integration opportunities in the school to help with self-regulation by implementing a sensory pathway. The occupational therapist at the site had mentioned that she wanted to create a sensory pathway and believed it would benefit the students. As I began to develop the sensory pathway, I wanted to provide fun sensory activities that would include our sense of sight, sound, touch, vestibular input, and proprioceptive input. A sensory pathway would benefit the ELC because every student can participate and regulate their body to prepare for class. During my time at the ELC, staff received a pre-test to assess their knowledge of sensory processing, a handout with more information on sensory processing, observing classroom dynamics, and creating a sensory pathway for the students to use. I SENSORY PATHWAY TO SUPPORT A CALM BODY 4 observed staff and students for weeks to see if the sensory pathway had been beneficial or unhelpful to the students in the school environment. School Performance When I began the needs assessment, I interviewed the OT at the ELC. She mentioned she wanted to incorporate more relaxation techniques and body awareness during intervention sessions. (M. Molenda, personal communication, January 12, 2023). She pushes into the classrooms for sessions which helps educate the teachers on how to help students calm their bodies in the classroom. She mentioned how the students were returning to school and having anxiety after attending school online for a year and a half. The school adopted a deep breathing program that helps the students with emotional regulation and mindfulness in the classroom. The students have received help with their emotional regulation but need help with their sensory regulation. After interviewing the OT and gaining more information about her goals and the occasional use of the sensory room, it helped me think about how I can help with sensory regulation by creating a sensory pathway. Students who have sensory processing disorder may have more of a difficult time with their performance in school. The authors in this study found that school systems could benefit from awareness of sensory processing difficulties and interventions to support childrens participation in school activities (Nielsen et al., 2021). If school systems were more aware of sensory processing difficulties, they would be able to accommodate and provide students with sensory breaks to support their occupational performance. The sensory pathway will allow students to have a sensory break outside their classroom environment, which will benefit them. Overall, staff who better understand sensory processing difficulties and utilize sensory breaks in their classroom will help their students with sensory regulation. SENSORY PATHWAY TO SUPPORT A CALM BODY 5 Impact of Sensory Integration Sensory integration can make a difference in a students occupational performance in the classroom. If a child can regulate their body before going to the classroom and sitting for a few hours, they will have more success. One of the studies talks about sensory activity schedule intervention. The study had a control group in which students were receiving usual classroom teaching and a group receiving the sensory activity schedule and usual classroom teaching to compare the performance of both groups. Overall, students who received the Sensory Activity Schedule intervention improved significantly more than the control group students in overall cognitive strategy" (Mills et al., 2021). I collaborated with the classroom staff and created possible schedules to use the sensory pathway so the students are aware, and it's not a surprise to them. Another study compared sensory integration to usual care for children who experience sensory processing difficulties. These sensory processing difficulties are associated with behaviour and socialisation problems and affect education, relationships, and participation in daily life" (Randell et al., 2019). If a child doesn't receive sensory integration, it might affect how they behave and socialize with others in the classroom. I'm in a school with children between the ages of 2-5, so staff may think the students are just misbehaving instead of considering the student may be having difficulty with sensory regulation. The sensory pathway will allow staff to take their students out of the classroom environment and help with sensory regulation. I've had the chance to observe different classrooms and the occupational therapist to understand their schedule better so I can help create a time to use the sensory pathway. When collaborating with the occupational therapist, we talked about how the sensory pathway should start with a couple of body movements like animal walks, SENSORY PATHWAY TO SUPPORT A CALM BODY 6 go to the texture board for a minute, then stretch arms above the head and across midline, and end with deep breathing so their body is calm as they go back into the classroom. Staff Perspectives School-aged children rely on their teachers to give them the support they need in the classroom. In a classroom, you may have the teacher, a teacher assistant, and a paraeducator all in one class to support the student's performance. One study found is based on the paraeducators perspectives on sensory-based intervention within the classroom. The paraeducators stated sensory-based interventions are efficacious and described benefits such as prevention of problematic behaviors, improved behavioral control, and improved readiness to participate in learning (Kaiser et al., 2020). Paraeducators found that sensory-based interventions were beneficial for the students occupational performance. Teachers may not realize or understand how overwhelming the classroom environment can be for their students. The article is about an assessment tool teachers use to assess their classroom environment. The tool used in the study is the Classroom Sensory Environment Assessment (CSEA) to examine the environment. If teachers and staff in the school can be aware of the class environment, they will be able to provide ways to help their students succeed. Occupation Based Model As I began creating my project, the PEO model helped me focus on the students, their environment, and their occupations. The person aspect of the model emphasized the students gross motor, fine motor, and sensory needs. The environment aspect of the model targeted the students physical and social environment. The occupation aspect of the model targeted social interactions through play. The maximum fit is described as having all three categories in the model correlate to maximize occupational performance. The PEO model has been incorporated SENSORY PATHWAY TO SUPPORT A CALM BODY 7 into my DCE project to create the maximum fit for occupational performance in Westerhold Early Learning Center. Frame of Reference Sensory integration frame of reference helped me focus and narrow down the specific items to place in the sensory pathway. I addressed sight, sound, touch, vestibular, and proprioception in the sensory pathway. Sight was addressed by adding pictures on the wall and floor to follow; for sound, the texture board had some items that make noise when you touch it, and for touch, there is a texture board with multiple textures. The sensory pathway integrated vestibular input by adding jumping and balance movements. Proprioception which is body awareness, is incorporated by adding animal walks. Animal walks worked on hand-eye coordination and bilateral movements. Incorporating the sensory integration frame of reference into my DCE project focused on exteroceptors, interceptors, and proprioceptors. Project Design and Implementation The project was developed because the sensory room is occasionally being used, and students not receiving services cannot use the sensory room. I wanted to create a sensory pathway so all students could take a sensory break out of their classroom environment to help with regulation. The pathway has a specific order that the students will need to follow to enhance their experience. They will start with some body movements like animal walks, then pass by the texture board, and end with more body movements like stretching, yoga, and deep breathing to calm their bodies before returning to the classroom. The pathway has an order because I want the students to start with alerting gross motor movements. The alerting activities will lessen as they continue, resulting in a calmer and more regulated body. SENSORY PATHWAY TO SUPPORT A CALM BODY 8 The outcome assessments included interviews with staff and post-surveys. I have chosen those outcomes to know how frequently the staff used the sensory pathway, how prepared the students were for class, and whether it helped with sensory regulation and allowed the staff to give me feedback. I observed some students using the pathway and checked in with their teacher to see if they had noticed a difference in the student. The interviews are more personable to gather more information, whereas the post-survey was briefer. I observed the students to see if the order of the pathway helped with regulation and class readiness. I provided staff with an informational handout to explain the different activities in the pathway with pictures so they have an idea before using the sensory hallway. The handout to staff will also explain why the students have to go through the pathway in a specific order and what the order will be. I also created an instruction sheet for the staff to follow when they are using the pathway with their students so they can follow the order Challenges I faced are the staff not using the sensory pathway, the staff, and students not following the order, and students wanting to stay at the texture board. If the staff does not go through the pathway in the specific order, the child will go into the classroom more alert than with a calm body. The successes were helping the students with sensory regulation, allowing all students to take a sensory break out of their classroom environment, and having the students be more prepared for their classroom activities. Outcomes The assessment tools were qualitative informal/formal observations, interviews, and a feedback survey. Observations are crucial because it's important to ensure that the staff runs through the pathway the way intended and to see students using it. Interviews with staff had been helpful because I better understand what the teacher experienced and their students classroom SENSORY PATHWAY TO SUPPORT A CALM BODY 9 behaviors. The feedback form was beneficial because staff can be very busy and may need more time to sit down and converse with me. The feedback form allowed staff to inform me about their observations with their students and to provide any feedback. I have observed staff taking their students through the pathway, and I have noticed that taking a larger group of students is more difficult because the students are excited and start to become impatient. When a smaller group of students go, it's easier because the staff-to-kid ratio is smaller; the ratio is about ten students to three staff. I have been able to interview three staff, and I asked them the questions from the feedback form. The three staff I interviewed stated that their students are excited to use the sensory pathway and request to go more often. One staff member mentioned they wanted to start taking their class in smaller groups because they become impatient when the students are waiting. I also asked a few students what they enjoyed the most, and the majority stated they liked the texture board, especially the sequin part. The following five questions were asked to gain more insight into the usefulness of the sensory pathway: On average, how many days a week do you take your students to the pathway? What was the student(s) favorite part of the pathway? Did the student(s) appear to be more calm or hyper after going through the sensory pathway? What part(s) of the pathway helped the student(s) calm down? What part(s) of the pathway did the student become more hyper? Did you notice a difference in the student(s) behavior in the classroom? Ex: had a calm body during circle time or really focused on the task given to them. Do you have any additional comments for me? SENSORY PATHWAY TO SUPPORT A CALM BODY 10 Overall, the students and the staff enjoyed the sensory pathway, and students appeared calmer after. I'm noticing more staff are taking their students for a sensory break. The students and staff are becoming more comfortable with the structure of the pathway, leading them to use it more often. Summary Westerhold Early Learning Center (ELC) received a grant to build a sensory room in 2019, and they finished right when COVID-19 happened. When the students returned to school, they were not allowed to use the sensory room due to social distancing, and it became a storage room. As social distancing rules were slowly fading, the students receiving services could start using the sensory room. Many students returned to school with anxiety and had difficulty with selfregulation. All the students would benefit from taking a sensory break outside their classroom environment to help with self-regulation. The needs of the students at the ELC inspired me to create a sensory pathway to support their sensory needs. The classroom environment is overwhelming for many students, and it's important to educate the staff at the ELC about sensory processing and sensory breaks outside of their classroom. If students don't have the opportunity to self-regulate, they may struggle with classroom performance and may have behaviors in the classroom (Randell et al., 2019). The sensory pathway targets the sense of sight, sound, touch, vestibular input, and proprioceptive input. The pathway starts with animal walks to the texture board, then yoga poses with dynamic stretching and ends with deep breathing calming their body after completing alerting movements. The students used the sensory pathway for three weeks, and then the staff completed a feedback survey. Overall, the sensory pathway was successful and provided the students with sensory integration opportunities to support self-regulation. SENSORY PATHWAY TO SUPPORT A CALM BODY 11 Conclusion The goal of the sensory pathway was to provide students with more sensory integration opportunities in their school environment to help with self-regulation. Through observations, feedback surveys, and interviews, I have learned staff felt like it was benefitting their students and have added the sensory pathway into their class schedule. The pathway has been beneficial for the students because they have an area where they can get some of their energy out and then calm their bodies. The students get many sensory breaks within the classroom, but they need an area to have a sensory break outside their classroom environment. I have noticed that once the students reach the end of deep breathing, their bodies are calm and prepared to return to the classroom. Future Work In the future, I would have staff go through the sensory pathway so they can experience it themselves and understand how it can benefit students in their classroom. I would also ask the staff to fill out a feedback survey about their experience with the sensory pathway. It's essential for occupational therapists need to educate others to provide the best care for our patients. SENSORY PATHWAY TO SUPPORT A CALM BODY 12 References Benson, J. D., Breisinger, E., & Roach, M. (2018). Sensory-based intervention in the schools: A survey of occupational therapy practitioners. Journal of Occupational Therapy, Schools, & Early Intervention, 12(1), 115128. https://doi.org/10.1080/19411243.2018.1496872 Butera, C., Ring, P., Sideris, J., Jayashankar, A., Kilroy, E., Harrison, L., Cermak, S., & AzizZadeh, L. (2020). Impact of sensory processing on school performance outcomes in high functioning individuals with autism spectrum disorder. Mind, Brain, and Education, 14(3), 243254. https://doi.org/10.1111/mbe.12242 Kaiser, L., Potvin, M.-C., & Beach, C. (2020). Sensory-based interventions in the school setting: Perspectives of paraeducators. The Open Journal of Occupational Therapy, 8(3), 111. https://doi.org/10.15453/2168-6408.1615 SENSORY PATHWAY TO SUPPORT A CALM BODY 13 Kashefimehr, B., Kayihan, H., & Huri, M. (2018). The effect of sensory integration therapy on occupational performance in children with autism. OTJR: Occupation, Participation and Health, 38(2), 7583. https://doi.org/10.1177/1539449217743456 Kranowitz, C. S. (2005). The out-of-sync child: Recognizing and coping with sensory processing disorder. Penguin Group . Kranowitz, C. S. (2006). The out-of-sync child has fun: Activities for kids with sensory integration dysfunction. Penguin Group. Miller-Kuhaneck, H., & Kelleher, J. (2018). The classroom sensory environment assessment as an educational tool for teachers. Journal of Occupational Therapy, Schools, & Early Intervention, 11(2), 161171. https://doi.org/10.1080/19411243.2018.1432442 Miller-Kuhaneck, H., & Watling, R. (2018). Parental or teacher education and coaching to support function and participation of children and youth with sensory processing and sensory integration challenges: A systematic review. The American Journal of Occupational Therapy, 72(1), 7201190030p1-7201190030p11. https://doi.org/10.5014/ajot.2018.029017 Mills, C., & Chapparo, C. (2018). Listening to teachers: Views on delivery of a classroom based sensory intervention for students with autism. Australian Occupational Therapy Journal, 65(1), 1524. https://doi.org/10.1111/1440-1630.12381 Mills, C. J., Chapparo, C., & Hinitt, J. (2021). Impact of a sensory activity schedule intervention on cognitive strategy use in autistic students: A school-based pilot study. British Journal of Occupational Therapy, 84(12), 775784. https://doi.org/10.1177/0308022620982888 Nielsen, A. N., Brandt, ., & la Cour, K. (2021). Exploration of sensory processing difficulties among children attending primary school in denmark. Occupational Therapy International, 2021, 17. https://doi.org/10.1155/2021/8893345 SENSORY PATHWAY TO SUPPORT A CALM BODY 14 Pfeiffer, B., Clark, G. F., & Arbesman, M. (2018). Effectiveness of cognitive and occupation-based interventions for children with challeges in sensory processing and integration: A systematic review. American Journal of Occupational Therapy, 72(1). https://doi.org/10.5014/ajot.2018.028233 Randell, E., McNamara, R., Delport, S., Busse, M., Hastings, R. P., Gillespie, D., Williams-Thomas, R., Brookes-Howell, L., Romeo, R., Boadu, J., Ahuja, A. S., McKigney, A. M., Knapp, M., Smith, K., Thornton, J., & Warren, G. (2019). Sensory integration therapy versus usual care for sensory processing difficulties in autism spectrum disorder in children: Study protocol for a pragmatic randomised controlled trial. Trials, 20(1), 113. https://doi.org/10.1186/s13063-0193205-y Whiting, C. C., Schoen, S. A., & Niemeyer, L. (2023). A sensory integration intervention in the school setting to support performance and participation: A multiple-baseline study. The American Journal of Occupational Therapy, 77(2). https://doi.org/10.5014/ajot.2023.050135 Ying , T., & Zhagan, M. (2021). Implementation of Sensory Integration Activities to Improve On-task Behaviour for Pupils with Autism Spectrum Disorder. Asian Journal of Behavioural Sciences, Vol. 3(No. 2), 108118. https://myjms.mohe.gov.my/index.php/ajbs/article/view/14530/7507 SENSORY PATHWAY TO SUPPORT A CALM BODY 15 SENSORY PATHWAY TO SUPPORT A CALM BODY Figure 1 Sensory Pathway with Animal Walks 16 SENSORY PATHWAY TO SUPPORT A CALM BODY Figure 2 Sensory Pathway and Texture board 17 SENSORY PATHWAY TO SUPPORT A CALM BODY Figure 3 Sensory Pathway and Alerting Activities 18 SENSORY PATHWAY TO SUPPORT A CALM BODY Figure 4 Sensory Pathway and Deep Breathing 19 SENSORY PATHWAY TO SUPPORT A CALM BODY 20 Appendix A DCE Weekly Planning Guide Week 1 DCE Stage (orientation, screening/evaluation , implementation, discontinuation, dissemination) Orientation 1/91/13 Weekly Goal 1. Orient to site 2. Begin to create a pretest for the staff Objectives Will meet with site mentor and introduce myself to site participants. Observe OT in the classroom/scho ol setting. 2 1/161/20 Screening/Evaluati on 1. Start sensory processing handout 2. Collaborate with site mentor to brainstorm Continue observing school intervention sessions. Print and Tasks Date comple te DUE: Project Plan Timeline (Friday 1/13) 1/10/23 Ensure paperwor k for orientatio n is complete. 1/9/23 Join a team meeting. 1/9/23 Observe an IEP meeting. 1/10/23 and 1/12/23 Complete sensory processing pre-test for staff. Receive feedback from site mentor and revise pre-test. 1/12/23 1/17/23 SENSORY PATHWAY TO SUPPORT A CALM BODY ideas for the sensory pathway. 3 1/231/27 Screening/Evaluati on 1. Observe different classrooms to observe the participants. 21 discuss pre-test with site mentor. Provide staff with the pretest. Provide a list of ideas and narrow down materials needed for my project. Collaborat 1/23/23 e with site mentor to narrow down materials that will be needed. Collect pre-tests and reviewed the data. 1/18/23 1/25/23 Introducti on Draft due 1/23. 4 1/302/3 5 2-6- Screening/Evaluati on Screening/Evaluati on 1. Complete/rev ise sensory processing handout 2. Gather materials needed and begin to create sensory pathway activities. 1. Lead part of group sessions Collect materials that are at the school and order materials that are needed. Educate staff on sensory processing. Find activities for students to do to work on Provide staff with sensory processing handout. 1/31/23 Meet with principal to discuss where I can create the sensory pathway. 2/2/23 Backgrou nd Draft due 1/30. Fine motor activities. 2/6/23 SENSORY PATHWAY TO SUPPORT A CALM BODY 2/10 6 2. Finalize sensory pathway ideas. Implementation 2/132/17 7 2/202/24 Implementation fine motor skills. Research different sensory pathways. 1. Start on the texture board 2. Lead part of group sessions. 3. Start on sensory pathway informational handout Find activities for students to do to work on fine motor skills. 1. Go to an IEP meeting. 2. Complete texture board. 3. Create sensory pathway instruction sheet Obtain all materials for sensory pathway and start creating the pathway. 22 Join a team meeting. 2/8/23 Project: Design and Implement ation due 2/6. Fine 2/13/23 motor activities. Work on texture board 2/14/23 2/17/23 Email the principal to ask when the hallway will be cleared out. Finish texture board. 2/16/23 Observed 2 IEP meetings. 2/23/23 Email principal and custodian to discuss what I can and cant place on the walls. 2/24/23 2/21/23 SENSORY PATHWAY TO SUPPORT A CALM BODY 8 Implementation 2/273/3 9 Implementation 3/63/10 10 Implementation 3/133/17 11 3/203/24 Implementation 1. Complete sensory pathway. 2. Inform staff about the pathway. Revise and review sensory pathway informational handout and instruction sheet. 1. Observe students utilizing sensory pathway. 2. Start creating feedback questions. 1. Continue to observe staff taking students to the pathway. Observe staff using the pathway to ensure they understood the instructions on the sheet. 1. Continue to observe staff taking students to Interview students to ask why they liked or didnt like after going through the pathway. Gather feedback about sensory pathway by interviewing 23 Complete sensory pathway handout. Finish creating sensory pathway. 2/24/23 Email staff informatio n on the sensory pathway and to let them know they can start using it with their students. Observe students when going through the pathway. 3/2/23 Review and revise feedback questions and create form. 3/14/23 Project: Outcomes Draft due 3/13. Interview staff. Collect 3/1/23 3/6/233/8/23 3/22/23 3/23/23 3/23/23 SENSORY PATHWAY TO SUPPORT A CALM BODY the pathway. 12 Discontinuation 3/273/31 13 Discontinuation 4/34/7 14 4/104/14 Dissemination and handing out feedback forms. 1. Analyze Finish results. analyzing data. 2. Start creating PowerPoint to present to the site. 1. Create video Present data for sensory pathway. 2. Present to principal, site mentor, and other site personnel. 1. Finish creating video. 2. Join an IEP meeting. Present video to staff. 24 feedback forms. Dissemina tion Plan due 3/20. Analyze data 3/30/23 Start 3/31/23 creating PowerPoin t Presentati 4/6/23 on Abstract, summary, and conclusion draft due 4/10. IEP reevals Presentati on 4/11/23 4/12/23  ...

... THE WEIGHTED BALL MASSAGE PROTOCOL AND SENSORY INTEGRATION 1 The Weighted Ball Massage Protocol: A Deep Pressure Modality for Sensory Regulation Emily Moore, OTS May 1st, 2023 A capstone project submitted in partial fulfillment for the requirements of the Doctor of Occupational Therapy degree from the University of Indianapolis, School of Occupational Therapy. Under the direction of the faculty capstone advisor: Laura Aust, OTD, MS, OTR THE WEIGHTED BALL MASSAGE PROTOCOL AND SENSORY INTEGRATION 2 Abstract Sensory integration in the school setting is crucial for students to be successful in the classroom. One role of an occupational therapist (OT) is to implement strategies for sensory regulation so children are able to be independent in their occupation as students. The weighted ball massage protocol (WBMP) is a modality that applies a deep pressure input to promote sensory regulation. There were 25 participants total in the study who received the WBMP with six receiving it once daily, three receiving it once a week and 16 twice daily. The results determined that the WBMP is an effective modality for sensory integration in the school setting. OTs would benefit from incorporating a deep pressure input modality, such as the WBMP, to increase sensory regulation in students. Introduction Sensory integration is the way in which people process sensory stimuli as it reaches the brain (Ayres & Robbins, 2005). Children who have difficulty detecting, modulating, interpreting and responding to sensory experiences may indicate a sensory processing disorder (SPD) condition (Miller, et al., 2007). SPD is in correlation with under or over responsiveness to sensory stimuli such as movement and touch sensations (Alibrandi, et al., 2014). Research shows an increase in children having difficulty with processing sensory stimuli resulting in a difficulty for them participating in their daily occupations (Lang, et al., 2012). School is one of the main occupations children are involved in therefore the more they are dysregulated, the less successful they will be in this environment. Therefore, it is beneficial for OTs to implement sensory interventions to improve sensory processing and integration for children to acquire appropriate adaptive responses to everyday stimuli (Kashefimehr, Kayihan & Huri, 2018). THE WEIGHTED BALL MASSAGE PROTOCOL AND SENSORY INTEGRATION 3 For my doctoral capstone, I was placed at Fairfield Schools to implement a protocol developed by the OT at one of the elementary schools and determine its effectiveness. It is called the weighted ball massage protocol (WBMP) and it provides deep pressure stimulation to the student it is performed on in order to regulate them for participation in the classroom. There are other sensory breaks given to the students who need it, including jumping and crashing, swinging, ball walks etc. The WBMP is only provided to students that the OT believes would benefit from it. Data sheets have been used to track effectiveness but due to inconsistencies between staff implementing it and documenting properly it is unknown how effective this protocol is for sensory regulation. OTs currently implement sensory modalities to students but there is minimal evidence of deep pressure therapies being used in the school setting that prove effective with regulation (Bestbier & Williams, 2017). The goal of my project was to do a program evaluation of the WBMP to determine if it is an effective modality for sensory integration. Surveys were provided to teachers to assess participation in classroom activities along with parents to see how the child was at home. After weeks of myself implementing this protocol and taking data, I compiled my findings with those from the surveys to determine if it was an effective modality. After concluding this project, my findings were indicative of this being an effective modality and I shared my findings with the OT and other staff members during dissemination. Background The population I completed my program evaluation on include students who attend an elementary school in Fairfield Ohio. Students grades range from preschool to fifth grade although there are no fourth graders in my study due to not meeting inclusion criteria. All participants demonstrated difficulties with sensory processing and have either an individualized THE WEIGHTED BALL MASSAGE PROTOCOL AND SENSORY INTEGRATION 4 education plan (IEP) or a 504 plan along with OT services. I implemented the WBMP on these participants five days a week, twice daily. Three participants attended separate pre-schools in the Fairfield area. They only received the WBMP paired with other heavy work modalities, such as brushing and vibrations, once a day, one day a week by the OT. Majority of the participants learn in neurotypical classrooms with SPDs. Some participants have additional diagnoses varying from attention deficit/hyperactivity disorder (ADHD), fetal alcohol syndrome (FAS), oppositional defiant disorder (ODD), a rare chromosomal diagnosis and sensory issues. Five of the participants are a part of the social communication classroom with diagnoses of autism spectrum disorder (ASD). These participants received the WBMP once a day paired with swinging since they all were sensory seeking and required more input. The primary challenge most students are facing in this school setting is overstimulation of their sensory systems which disturbs their daily functioning (Schoen, et al., 2019). Poor sensory processing can contribute to maladaptive behaviors which impacts their ability to participate in household routines, social relationships, and school occupations (Schaaf & Miller, 2005). This same article found that sensorimotor activities can help the nervous system change through interactions between an individual and their environment to shape their brain development (Schaaf & Miller, 2005). Recently, there has been a variety of deep pressure interventions OTs have used in the school to help with sensory processing. The population for one study focused on children diagnosed with Autism and used somatosensory stimulation interventions because the deep pressure input that the children receive is found to be effective for sensory regulation (Hodgetts & Hodgetts, 2007). These somatosensory stimulation interventions incorporated; weighted vests, pressure vests and gloves, arm splints with THE WEIGHTED BALL MASSAGE PROTOCOL AND SENSORY INTEGRATION 5 pressure arm wrappings, and massage therapy (Hodgetts & Hodgetts, 2007). Another study searched databases and found 15 of the articles listed compression garments, massage, sensorimotor interventions and positioning interventions as effective for addressing sensory integration (Paleg, Romness & Livingstone, 2018). Overall, deep pressure input interventions were found to be useful especially for those with sensory needs. Although the WBMP is a modality that applies deep pressure input to the student, similar to the interventions mentioned above, it is not currently represented in the literature due to it being an upcoming intervention. Therefore, the OT requested a program evaluation of the WBMP modality to determine its effectiveness in regulating students with SPDs. In addition, we looked at some factors such as; gender, diagnosis, grade, consistency, combining with another modality and the duration it keeps a child regulated throughout the day to analyze how they impact findings. The main goals the OT wanted to see at this site included; students demonstrating independence across all environments, emotional and sensory regulation, and obtaining the skills needed for school related performance. One article studied massage as an intervention for sensory regulation and concluded that the group that received the deep input massage intervention significantly improved their total motor, gross motor and sensory sensitivity behavior score (Lu, et al., 2019). If proven effective, the WBMP should meet all of the goals regarding students' success in the classroom as the massage intervention did in the study above. Another study looked at Touchpoints which is a device that activates the tactile sensory system through vibrations of the device to help reduce emotional and bodily distress for children with sensory oversensitivity (McGhee, et al., 2021). The main finding from this study concludes that using Touchpoints before bedtime helped increase the childs ability to fall asleep and sleep latency (McGhee, et al., 2021). We paired a similar vibratory device to Touchpoints with the WBMP to the three pre-school THE WEIGHTED BALL MASSAGE PROTOCOL AND SENSORY INTEGRATION 6 children in our study in order to determine if combining the protocol with other heavy work is beneficial for sensory regulation. During the needs assessment, a significant barrier the OT reported is the failure of faculty to follow-through with interventions, specifically the WBMP and implementing it correctly and consistently. Research shows effectiveness of treatment is diminished when there is a lack of treatment integrity (Humphries, Snider & McDougall, 1997) therefore it is vital to have consistency when implementing sensory interventions. One study found that sensory modulation helped with the young children and their parents sleep, relationships, self-care, academic performance, and independence in daily tasks (Williamson & Ennals, 2020). It is notable that somatosensory stimulation interventions, especially those that provide deep pressure input, are not only effective for sensory modulation at school but they also improve childrens sleep and their relationships. If these somatosensory interventions that provide a deep pressure input are effective for sensory regulation, the WBMP should prove to be as well. After reviewing the literature, findings indicate somatosensory interventions are effective. However, there is still limited evidence on how it impacts the students performance in school, their ability to sustain focus, participation in the classroom and their behaviors at home. For my study, I used a pre/post survey for parents to fill out that looks at the students sleep and their behavior after school. I also had teachers fill out a weekly form collecting data on their student(s) participation in class, completing seated work independently, and following directions. Instead of looking at academic performance, I am focusing on other ways to be successful in the classroom. Theories The Occupational Adaptation (OA) model and the Sensory Integrative (SI) frame of reference were utilized to help guide my DCE project. The OA model focuses on the interactive THE WEIGHTED BALL MASSAGE PROTOCOL AND SENSORY INTEGRATION 7 process between a person and their environment along with the internal adaptive process that occurs when engaged in occupations (Cole & Tufano, 2020). My populations occupations consist of playing, learning, self-care, rest, sleep, and social participation. The OA model assisted in guiding my program evaluation by investigating if my population is experiencing dysfunction in any of these areas. This was assessed through surveys completed by teachers who have these students in the classroom, parents from what they experienced at home, and lastly the OT along with other staff members at the school my population frequently interacted with. Sensory integration affects all of the occupations a person is involved in, especially with occupational performance at school with the participants in this study. The purpose of the SI frame of reference from an OT standpoint is to discover activities that involve the type of intense sensory input students need to normalize their sensory processing (Cole & Tufano, 2020). This theory guided the WBMP through data collection sheets that recorded behaviors before and after implementation, zone of regulation from student and teacher perspective, and the time of day it was received. These documents were able to record if participants were able to integrate their sensations by engaging in their age-appropriate occupations, such as classroom expectations. Project Design & Implementation The WBMP was created by the OT at the elementary school (see Appendix A). When her son was little, she noticed him having difficulty sleeping, outbursts when returning home from school and constant sensory dysregulation. She designed the WBMP to apply deep pressure, similar to a massage, that is less invasive through utilizing a ball instead of with hands. She created her own data sheets and listed individualized characteristics of each student when regulated and dysregulated, to be recorded before and after the modality (see Appendix B). She also added a portion about the zones of regulation to see if students are able to correctly identify THE WEIGHTED BALL MASSAGE PROTOCOL AND SENSORY INTEGRATION 8 how they are feeling. She has implemented this for 20 years and requested a program evaluation to determine effectiveness. There were 25 participants total in the study who received the WBMP with six receiving it once daily, three receiving it once a week and 16 twice daily. I implemented the WBMP to the 16 students twice daily, five days a week at the same time for consistency. Then, I filled out the data sheets twice a day per student to document behaviors and feelings before and after implementation. Five of the six students who received the WBMP once a day were a part of the social communication classroom therefore they also received swinging paired with the WBMP. Three students were preschoolers who received the WBMP once a week paired with other heavy work such as brushing and vibration. I also sent out teacher surveys to be filled out weekly to document the students ability to participate in the classroom, sustained attention, remaining seated during classwork and following directions (see Appendix C). Lastly, I sent out a pre and post survey for parents to fill out regarding their child's behavior and sleep at home at the beginning and end of the study (see Appendix D and F). Each week all data sheets were calculated, analyzed then interpreted on a Google Sheets spreadsheet. The data calculated represents how often students were within normal limits, how often the modality was effective, how often it was not effective and the amount of times students were correctly able to identify the zone of regulation. A student in the green zone, meaning they are calm or happy, are considered within normal limits. If a student was sad, bored, excited, mad, silly or demonstrated other offtask behaviors and after their sensory breaks resembled being calm or happy, the modality was effective. All data was converted into percentages and recorded on a graph. There were quite a few challenges I encountered during implementation of my project. The first issue was parent participation in my pre and post survey regarding their childs THE WEIGHTED BALL MASSAGE PROTOCOL AND SENSORY INTEGRATION 9 behaviors at home. I only received a third of them back so it is unclear if the WBMP at school shows long term effectiveness in at home behaviors. Another challenge was having teachers fill out the weekly surveys in a timely manner. It is difficult for me to determine if the WBMP regulates students to be able to participate in the classroom if teachers are unable to report students progress timely. Another huge barrier is being able to see students consistently to implement the ball rolling modality. Student absences, snow days, and two-hour delays are some of the reasons students were not seen consistently. Lastly, I included five students with ASD who are in the social communication classroom and there were many days some of them were extra wiggly or having meltdowns which made implementation difficult. One of the main successes during implementation included students willingness to participate in the WBMP multiple times a day. Another huge success is teachers were very understanding of the importance of sensory breaks therefore allowing me to pull their students out of class for my project. Project Outcomes At the beginning of the study, only two students were within the green zone 100% of the time during their sensory break (see Figure 1). At the end of implementation, six students were within the green zone 100%, and two were within the green zone 76-99% of the time (see Figure 4). When students were not in the green zone at the beginning of the study, the WBMP was effective, meaning they were able to get back to the green zone, with four students 100%, one 83% and three 50-75% of the time out of 19 students (see Table 2) (see Figure 3). At the end of implementation, the WBMP was effective for eight students 100% and four students 60-67% of the time out of 15 students (see Table 4) (see Figure 6). Initially, the WBMP was not effective 025% of the time 12 out of 21 times (see Table 1), which increased to 20 out of 21 times by the end THE WEIGHTED BALL MASSAGE PROTOCOL AND SENSORY INTEGRATION 10 of the study (see Table 3). All of this data indicates that the WBMP is an effective modality for sensory regulation. In addition to measuring the short term effectiveness, my study assessed the ability for students to correctly identify which zone of regulation they are in. At the beginning of the study, nine students identified the correct zone 76-100%, seven 51-75%, and one 26-50% of the time (see Figure 2). By the end of implementation, 13 students identified the correct zone 76-100% and three students 51-75% of the time (see Figure 5). Over the course of eight weeks students demonstrated the ability to correctly identify the zone of regulation they are in, meaning they are able to express how their bodies are feeling and noticing when they need a break. Teachers were encouraged to fill out a survey at the end of each week for the eight weeks I implemented the WBMP. Data was then exported from the Google survey to a Google sheets document. Due to most teachers not consistently filling out the weekly surveys, I decided at the end of my project to discuss students' behaviors and performance in the classroom with their teachers and compare those findings to data collected from week one (see Appendix E). The biggest improvement seen is students ability to remain seated in the classroom. Also, there were some improvements made with students following directions. There were not many improvements with classroom participation, sustained attention to classroom tasks and ability to initiate tasks. Five teachers reported seeing no improvements in their students after receiving the WBMP over the course of eight weeks. On the contrary, five teachers noted less behaviors and their students being more calm in class, two teachers noticed an increase in work production, and two others reported an increase in participation. A few other teachers saw improvements with their students remaining on task, remaining seated and better body control. I included five students from the social communication classroom with diagnosis of ASD and their teacher THE WEIGHTED BALL MASSAGE PROTOCOL AND SENSORY INTEGRATION 11 reported seeing improvements with transitions from preferred to non-preferred activities and less behaviors after consistently receiving the WBMP. Parents were sent a pre and post survey regarding their childs behaviors at home and their ability to sleep. About 54% of caregivers filled out the pre-survey. When analyzing the data collected, 61.5% of caregivers were instructed in the WBMP from the OT with 31% of them implementing it at home with their children. When asked about childrens behaviors at home, 84.6% report their child is full of energy, with 38.5% indicating their child is wiggly. In addition, 69.2% selected their child as happy . A little over half of caregivers report their student refuses to complete homework and a little less than half have outbursts. Caregivers also selected their students to be hyperverbal and whiny 23.1% of the time. Only three caregivers report their child is calm at home. Lastly, only one caregiver reported difficulty getting their child to bed each night with them also demonstrating difficulty sleeping throughout the night. After implementation, only about 33% of parents filled out the post parent survey. When reviewing the findings, 75% of those caregivers checked that their child is full of energy at home with 50% experiencing outbursts and refusal to complete homework. However, 62.5% also checked that their child is happy at home. When asked about bedtime, 88% of caregivers report having minimal to no difficulty with their child going to bed with 50% sleeping completely, 12.5% mostly and 37.5% average throughout the night. Caregivers were asked if any changes were seen in their child at home with 62.5% reporting yes and 37.5% reporting no. For those who selected yes they were encouraged to check the boxes where changes were seen. Majority of improvements were seen with transitions in the home with a handful of caregivers reporting less behaviors, improved sleep and that their child is happier. Summary THE WEIGHTED BALL MASSAGE PROTOCOL AND SENSORY INTEGRATION 12 Sensory integration is essential for children to independently participate in their occupations as students in the classroom. The OT at the school recognizes this and developed the weighted ball massage protocol which is a modality that provides deep pressure input to the student for sensory regulation. In order to determine the effectiveness of the weighted ball massage protocol, 25 students were selected to be a part of the study with 17 receiving the modality at the same time twice daily. Students all had SPD with some diagnosed with other conditions such as ASD, ADHD, FAS, etc. Data sheets were created to document the students zone of regulation before and after receiving the weighted ball massage protocol to measure short term effectiveness. Teacher surveys were sent out weekly and at the end of the study they were interviewed to document their student(s) progress to measure long term effectiveness in the classroom. A parent pre-survey and postsurvey were sent out to determine if consistency with sensory breaks at school carried over to at home. When comparing data from the beginning of the study to the end, results showed an increase in students being in the green zone by the time of their sensory breaks meaning they were more regulated. Another finding showed when students were not in the green zone, they were more likely to return to the green zone after receiving the weighted ball massage protocol. Students also improved in their ability to correctly identify the zone of regulation they are in at the time of their sensory breaks. The main improvements teachers noticed within their classroom included seeing less behaviors and an increase in their students remaining seated during work time. Parents reported noticing their students being more calm at home and improvements in sleep. Conclusion THE WEIGHTED BALL MASSAGE PROTOCOL AND SENSORY INTEGRATION 13 Sensory interventions are vital for students who are dysregulated to be able to focus on their tasks in the classroom. By the end of the study, the majority of students increased their ability to identify the correct zone of regulation they were in before and after receiving their sensory break. Also, students were more regulated, in the green zone, by the time of their sensory breaks. During the times students were dysregulated, the weighted ball massage protocol was effective in regulating students back into the green zone. The main improvements seen within the classroom include less behaviors and an increase in students remaining seated during classwork. Some parents even noted seeing improvements in their childs sleep and report they are happier. Overall, it can be concluded that the WBMP is an effective modality for sensory regulation. The OT at my site has been implementing this modality for many years knowing it was beneficial to the students but wanted to know specifics for effectiveness. Since my data shows the specifics, the OT is using my data to educate teachers and other staff members of the importance of consistent sensory breaks, and incorporating the WBMP more. There is a lot of research proving the importance of sensory interventions to promote regulation in the classroom. However, there are not many deep pressure modalities utilized in the school setting. Since my study shows the WBMP is an effective deep pressure modality for sensory regulation, OTs in any pediatric setting, especially schools, would benefit from implementing this with students with SPD to help assist in their independence with their occupations at school. THE WEIGHTED BALL MASSAGE PROTOCOL AND SENSORY INTEGRATION 14 References Alibrandi, N., Beacock, L., Church, C., Des Moines, S., Goodrich, K., Harris, L., Sprague, C., Vrtovsnik, L., (2014). Perceptions and Awareness of Sensory Processing Disorder Among Head Start Personnel (Masters Thesis). Retrieved from UMI (1558942) http://gradworks.umi.com/15/58/1558942.html Ayres, A. J., & Robbins, J. (2005). Sensory integration and the child: Understanding hidden sensory challenges. Western psychological services. Bestbier, L., & Williams, T. I. (2017). The immediate effects of deep pressure on young people with autism and severe intellectual difficulties: demonstrating individual differences. Occupational therapy international, 2017, 7534972. https://doi.org/10.1155/2017/7534972 Cole, M. & Tufano, R. (2020). Applied Theories in Occupational Therapy: A Practical Approach (2nd Ed.). Slack, Inc. Hodgetts, S., & Hodgetts, W. (2007). Somatosensory stimulation interventions for children with autism: literature review and clinical considerations. Canadian Journal of Occupational Therapy. Revue Canadienne dergotherapie, 74(5), 393400. https://doi.org/10.2182/cjot.07.013 Humphries, T. W., Snider, L., & McDougall, B. (1997). Therapists' consistency in following their treatment plans for sensory integrative and perceptual-motor therapy. The American journal of occupational therapy : official publication of the American Occupational Therapy Association, 51(2), 104112. https://doi.org/10.5014/ajot.51.2.104 Kashefimehr, B., Kayihan, H., & Huri, M. (2018). The Effect of Sensory Integration Therapy on Occupational Performance in Children With Autism. OTJR : occupation, participation and health, 38(2), 7583. https://doi.org/10.1177/1539449217743456 THE WEIGHTED BALL MASSAGE PROTOCOL AND SENSORY INTEGRATION 15 Lang, R., O'Reilly, M., Healy, O., et al. (2012). Sensory integration therapy for autism spectrum disorders: a systematic review. Research in Autism Spectrum Disorders. 2012;6(3):1004 1018. doi: 10.1016/j.rasd.2012.01.006. Lu, W.-P., Tsai, W.-H., Lin, L.-Y., Hong, R.-B., & Hwang, Y.-S. (2019). The beneficial effects of massage on motor development and sensory processing in young children with developmental delay: A Randomized Control Trial Study. Developmental Neurorehabilitation, 22(7), 487495. https://doi.org/10.1080/17518423.2018.1537317 McGhee, K., Kidney, E., Pou, K., Pruyn Bouley, H., & Reynolds, S. (2021). The Effectiveness of Bilateral Alternating Tactile Stimulation for Improving Sleep in Children with Sensory over-Responsivity. Occupational Therapy in Health Care, 35(4), 424441. https://doi.org/10.1080/07380577.2021.1946734 Miller, L. J., Anzalone, M. E., Lane, S. J., Cermak, S. A., & Osten, E. T. (2007). Concept evolution in sensory integration: A proposed nosology for diagnosis. The American Journal of Occupational Therapy, 61(2), 135. Paleg, G., Romness, M., & Livingstone, R. (2018). Interventions to improve sensory and motor outcomes for young children with central hypotonia: A systematic review. Journal of Pediatric Rehabilitation Medicine, 11(1), 5770. https://doi.org/10.3233/PRM-170507 Schaaf, R. C., & Miller, L. J. (2005). Occupational therapy using a sensory integrative approach for children with developmental disabilities. Mental Retardation and Developmental Disabilities Research Reviews, 11(2), 143148. https://doi.org/10.1002/mrdd.20067 Schoen, S. A., Lane, S. J., Mailloux, Z., May-Benson, T., Parham, L. D., Smith Roley, S., & Schaaf, R. C. (2019). A systematic review of ayres sensory integration intervention for THE WEIGHTED BALL MASSAGE PROTOCOL AND SENSORY INTEGRATION 16 children with autism. Autism research : official journal of the International Society for Autism Research, 12(1), 619. https://doi.org/10.1002/aur.2046 Williamson, P., & Ennals, P. (2020). Making sense of it together: Youth & families co-create sensory modulation assessment and intervention in community mental health settings to optimize daily life. Australian Occupational Therapy Journal, 67(5), 458469. https://doi.org/10.1111/1440-1630.12681 THE WEIGHTED BALL MASSAGE PROTOCOL AND SENSORY INTEGRATION 17 Table 1 Week One: Data CollectionData Sheet Findings WNL Effective Not Effective Able to ID 76-100% 7 0 0 76-100% 9 51-75% 5 3 1 51-75% 7 26-50% 6 3 8 26-50% 1 0-25% 3 15 12 0-25% 0 Note. There were 21 students during week one. Numbers indicate how often students were WNL (in the green zone), how often the WBMP was effective (students who were not in the green zone but then were after) and how often it was not effective (students were not in the green zone and still were not) before and after their sensory break. The numbers on the right indicate how often students correctly identified the zone of regulation they were in before and after their sensory break. Table 2 Week One: Effectiveness of WBMP not including those WNL Percentage Effective 76-100% 5 51-75% 3 26-50% 6 0-25% 5 Note. There were 21 students during week one. Two students were in the green zone (WNL) 100% of the time therefore they were not included in this tables data. This data looked at 19 students and assessed how effective the WBMP was at regulating them back to the green zone. THE WEIGHTED BALL MASSAGE PROTOCOL AND SENSORY INTEGRATION 18 Table 3 Week Eight: Data CollectionData Sheets Findings WNL Effective Not Effective Able to ID 76-100% 8 1 0 76-100% 13 51-75% 5 2 0 51-75% 3 26-50% 4 6 1 26-50% 0 0-25% 4 12 20 0-25% 0 Note. There were 21 students during week eight. Numbers indicate how often students were WNL (in the green zone), how often the WBMP was effective (students who were not in the green zone but then were after) and how often it was not effective (students were not in the green zone and still were not) before and after their sensory break. The numbers on the right indicate how often students correctly identified the zone of regulation they were in before and after their sensory break. Table 4 Week Eight: Effectiveness of WBMP not including those WNL Percentage Effective 76-100% 8 51-75% 4 26-50% 2 0-25% 1 Note. There were 21 students during week eight. Six students were in the green zone (WNL) 100% of the time therefore they were not included in this tables data. This data looked at 15 students and assessed how effective the WBMP was at regulating them back to the green zone. THE WEIGHTED BALL MASSAGE PROTOCOL AND SENSORY INTEGRATION 19 Figure 1 Week One: Effectiveness of Weighted Ball Protocol Note. Graph represents data from Table 1, comparing how often the WBMP was effective, not effective and how often students were WNL before and after sensory break during week one. THE WEIGHTED BALL MASSAGE PROTOCOL AND SENSORY INTEGRATION 20 Figure 2 Week One: Ability to Correctly Identify Zone of Regulation Note. Graph represents the percentage of students able to correctly identify the zone of regulation they are in during week one of implementation. THE WEIGHTED BALL MASSAGE PROTOCOL AND SENSORY INTEGRATION 21 Figure 3 Week One: Effectiveness of Weighted Ball Protocol Note. Graph represents data from Table 2, comparing effectiveness of the WBMP after removing those WNL. THE WEIGHTED BALL MASSAGE PROTOCOL AND SENSORY INTEGRATION 22 Figure 4 Week Eight: Effectiveness of Weighted Ball Protocol Note. Graph represents data from Table 3, comparing how often the WBMP was effective, not effective and how often students were WNL before and after sensory break during week eight. THE WEIGHTED BALL MASSAGE PROTOCOL AND SENSORY INTEGRATION 23 Figure 5 Week Eight: Ability to Correctly Identify Zone of Regulation Note. Graph represents the percentage of students able to correctly identify the zone of regulation by the end of implementation. THE WEIGHTED BALL MASSAGE PROTOCOL AND SENSORY INTEGRATION 24 Figure 6 Week Eight: Effectiveness of Weighted Ball Protocol Note. Graph represents data from Table 4, comparing effectiveness of the WBMP after removing those WNL, after implementation. THE WEIGHTED BALL MASSAGE PROTOCOL AND SENSORY INTEGRATION 25 Appendix A Weighted Ball Massage Protocol (WBMP) Use a 3, 4 5, pound ball which is found online. The ball should be close to 5-8% of the childs body weight and pliable. *Important you must be in-service/trained by an Occupational Therapist prior to beginning this technique. Once you begin contact with the ball on the child do not break contact so the input can reach summation in the brain all at once. START: Place the student on their stomach. Start at the childs waistband. Make a v on each side of the spine. Proceed from the middle of the spine to the lower back and up to the base of the neck. Roll the ball up and down the spine 10 times. Do not roll the buttocks area. Next: Roll from the neck area to the shoulder and down the arm, firmly. Then, push 10 times to the back of the hand fast, using firm pushes (like cardiac compression). Come up the arm across the back to the other arm, roll down the arm and push 10 times on the hand. Come back up the arm, and then down the spine. Then: Place your non-dominant hand on the back of the thigh firmly. Pick up the ball and roll down the back of the leg firmly. Then: Push 10 times on the ankle in the resting position. Now: Go down the foot 10 times, from the heel to the toes, slowly and firmly, proceed to the other foot and roll up and down the other foot 10 times. Then: Come up the leg, rolling firmly across the back of the knee. Pick up your hand and place it on the back. Pick up the ball and roll up and down the back 10 times, making a v on each side of the spine. Finally: have the student roll on his or her back. Hold their arm as to not break contact. Place the ball on the forehead and push or roll on the forehead, between and just above the eyebrows, 10 times. Ask the child if they want to repeat if they say yes. Push 10 Times and repeat as necessary up to 60 times. Then: say, all done. It is important not to talk to the child other than counting or asking them how it feels during the protocol. Candace Yates, MS,OTR/L Occupational Therapist. THE WEIGHTED BALL MASSAGE PROTOCOL AND SENSORY INTEGRATION 26 Appendix B Weekly Data Sheets THE WEIGHTED BALL MASSAGE PROTOCOL AND SENSORY INTEGRATION 27 Name of teacher: __________ Name of student: __________ Appendix C Weekly Teacher Surveys How often has your student followed your directions this week? 90-100% of the time 75-89% of the time 50-74% of the time 25-49% of the time 0-24% of the time Student demonstrated ability to sustain attention to classroom tasks 90-100% of the time 75-89% of the time 50-74% of the time 25-49% of the time 0-24% of the time Child was able to initiate task(s) Independently Minimal cues Moderate cues Child never initiated any task(s) Student remained seated during class work All of the time Most of the time Half of the time Less of the time Never Student participated in class 90-100% of the time 75-89% of the time 50-74% of the time 25-49% of the time 0-24% of the time Off task behaviors displayed this week (if applicable): __________ Any other questions/comments/concerns regarding your student this week: __________ THE WEIGHTED BALL MASSAGE PROTOCOL AND SENSORY INTEGRATION 28 Appendix D Pre-Parent Survey Have you been instructed and trained in the ball rolling protocol by the OT? Yes No How often do you implement the ball rolling at home with your child? Every day 4-6 days a week 1-3 days a week A couple times a month Never Other:_____________ Check all that apply regarding your childs behavior at home: Full of energy Hyperverbal Refusal to do homework Whiny Wiggly Angry Outbursts Calm Happy Other:_____________ How does your child respond when it is bedtime? Goes right to bed with no problems Has some resistance but ultimately goes to bed with few problems Demonstrates negative behaviors, overall difficult to get to bed nightly How is your child sleeping at home? Excellent! Sleeps through the night Not bad! Mostly sleeps through the night Average! Sometimes sleeps throughout the night, sometimes unable Not good! Frequently has difficulty sleeping through the night Horrible! Never sleeps through the night Additional comments/concerns about your child at home that you feel may be beneficial to my study: __________________________________________________________________________________ THE WEIGHTED BALL MASSAGE PROTOCOL AND SENSORY INTEGRATION 29 Appendix E End of Implementation Teacher Reflection Interview/Survey How often has your student followed your directions this week? 90-100% of the time 75-89% of the time 50-74% of the time 25-49% of the time 0-24% of the time Student demonstrated ability to sustain attention to classroom tasks 90-100% of the time 75-89% of the time 50-74% of the time 25-49% of the time 0-24% of the time Child was able to initiate task(s) Independently Minimal cues Moderate cues Child never initiated any task(s) Student remained seated during class work All of the time Most of the time Half of the time Less of the time Never Student participated in class 90-100% of the time 75-89% of the time 50-74% of the time 25-49% of the time 0-24% of the time Overall, have you noticed any improvements in your student over the past eight weeks? If so, in regards to what? (i.e, remaining seated increased participation, completing classroom assignments, less behaviors, sustaining attention, etc.) ____________ Any other questions/comments/concerns regarding your student this week: __________ THE WEIGHTED BALL MASSAGE PROTOCOL AND SENSORY INTEGRATION 30 Appendix F Post-Parent Survey Check all that apply regarding your childs behavior at home: Full of energy Hyperverbal Refusal to do homework Whiny Wiggly Angry Outbursts Calm Happy Other:_____________ How does your child respond when it is bedtime? Goes right to bed with no problems Has some resistance but ultimately goes to bed with few problems Demonstrates negative behaviors, overall difficult to get to bed nightly How is your child sleeping at home? Excellent! Sleeps through the night Not bad! Mostly sleeps through the night Average! Sometimes sleeps throughout the night, sometimes unable Not good! Frequently has difficulty sleeping through the night Horrible! Never sleeps through the night I have implemented my project for 8 weeks (Jan 30-March 24). Have you noticed any changes in your child at home during this time? (Examples: behaviors, completing homework, sleeping better, more calm, transitioning betteretc.) Yes No Please select all the changes you have seen (if any): Less behaviors Completing homework Improved sleep Child is more calm/better body control Transitions better Child follows more directions at home Child is happier None of the above, my child has remained the same at home Other:_____________ Additional comments/concerns about your child at home that you feel may be beneficial to my study: __________________________________________________________________________________ THE WEIGHTED BALL MASSAGE PROTOCOL AND SENSORY INTEGRATION 31 Doctoral Capstone Experience and Project Weekly Planning Guide Week 1 1/9-1/13 DCE Stage (orientation, screening/evaluati on, implementation, discontinuation, dissemination) Orientation Weekly Goal Objectives Get accustomed to the site and meet students/develop a potential caseload. 1. Observe OTs caseload and meet/start building rapport with students. 2. Get familiar with the building and staff. 2 Screening/Evalua tion Determine students on caseload, finalize project and get trained in the ball rolling protocol. 1. Continue to build rapport with students and staff 2. Make any final changes to MOU 3. Finalize project and which aspects of the ball rolling protocol we want to study 3 Screening/Evalua tion Finalize entire project details and prepare all documents needed for implementation next week. 1. Continue to build rapport with students and staff 2. Review literature review and edit if needed 1/161/20 1/231/27 Tasks Date comple te 1. Read through 1/13 student files. 2. Communicate with staff members to inform them of my project. 3. Create a weekly schedule with goals and plans for each week. 4. Create surveys for teachers/parents to fill out 1. Create a 1/19 schedule when to see students 2. Edit surveys for teachers/parents to fill out 3. Begin drafting data sheet 4. Continue updated searches of the literature for new findings 5. Get trained in ball roll protocol 6. Review students personal data sheets Submit final MOU due 1/20 1. Finalize schedule 1/26 for when students will be seen. 2. Finalize surveys for parents and staff THE WEIGHTED BALL MASSAGE PROTOCOL AND SENSORY INTEGRATION 32 3. Communicate with staff about their documentation needed weekly during implementation of project 4 Implementation Implement ball roll protocol and recording data 5 Implementation Implement ball roll protocol and recording data 6 Implementation Implement ball roll protocol and recording data 1/30-2/3 2/6-2/10 2/132/17 1. Begin following schedule and implementing ball rolling protocol to students during sensory breaks 2. Continue communication with staff members 3. Continue building rapport with students on caseload 1. Continue following schedule and implementing ball rolling protocol to students during sensory breaks 2. Continue communication with staff members 3. Continue building rapport with students on caseload 1. Continue following schedule and 3. Send out to teachers and caregivers to fill out weekly for 8 weeks 4. Final searches of literature for new findings 5. Finalize data sheet Submit Introduction Draft due 1/23 1. Implement ball roll protocol while following schedule 2. Record data on finalized data sheet 3. Obtain surveys from teachers/staff Submit Background Draft due 1/30 2/3 1. Implement ball roll protocol while following schedule 2. Record data on finalized data sheet 3. Obtain surveys from teachers/staff Submit Project: Design and Implementation Draft due 2/6 2/10 1. Implement ball roll protocol while following schedule 2/17 THE WEIGHTED BALL MASSAGE PROTOCOL AND SENSORY INTEGRATION 33 7 Implementation Implement ball roll protocol and recording data 8 Implementation Implement ball roll protocol and recording data 9 Implementation Implement ball roll protocol and recording data 2/202/24 2/27-3/3 3/6-3/10 implementing ball rolling protocol to students during sensory breaks 2. Continue communication with staff members 3. Continue building rapport with students on caseload 1. Continue following schedule and implementing ball rolling protocol to students during sensory breaks 2. Continue communication with staff members 3. Continue building rapport with students on caseload 1. Continue following schedule and implementing ball rolling protocol to students during sensory breaks 2. Continue communication with staff members 3. Continue building rapport with students on caseload 1. Continue following schedule and implementing ball 2. Record data on finalized data sheet 3. Obtain surveys from teachers/staff 1. Implement ball roll protocol while following schedule 2. Record data on finalized data sheet 3. Obtain surveys from teachers/staff 2/24 1. Implement ball roll protocol while following schedule 2. Record data on finalized data sheet 3. Obtain surveys from teachers/staff 3/3 1. Implement ball roll protocol while following schedule 3/10 THE WEIGHTED BALL MASSAGE PROTOCOL AND SENSORY INTEGRATION 34 10 Implementation Implement ball roll protocol and recording data 11 Implementation Implement ball roll protocol and recording data 12 Discontinuation Review and analyze data collected over the past 8 weeks to find significant findings 3/133/17 3/203/24 3/273/31 rolling protocol to students during sensory breaks 2. Continue communication with staff members 3. Continue building rapport with students on caseload 1. Continue following schedule and implementing ball rolling protocol to students during sensory breaks 2. Continue communication with staff members 3. Continue building rapport with students on caseload 1. Continue following schedule and implementing ball rolling protocol to students during sensory breaks 2. Continue communication with staff members 3. Continue building rapport with students on caseload 1. Found similarities/differe nces in data collected 2. Record data on finalized data sheet 3. Obtain surveys from teachers/staff 1. Implement ball roll protocol while following schedule 2. Record data on finalized data sheet 3. Obtain surveys from teachers/staff Submit Project: Outcomes Draft due 3/13 3/17 1. Implement ball roll protocol while following schedule 2. Record data on finalized data sheet 3. Obtain surveys from teachers/staff Dissemination Plan due 3/20 3/24 1. Compiled all surveys from teachers from the implementation 3/31 THE WEIGHTED BALL MASSAGE PROTOCOL AND SENSORY INTEGRATION 35 2. Noted significant findings in data collected 13 Discontinuation Finalize analyzation of data collected and draw conclusions 1. Continued drawing conclusions based on findings 2. Assembled powerpoint and scheduled a time to present. 14 Dissemination Disseminate project to site 1. Presented findings to site mentor and special education staff members 4/3-4/7 4/104/14 period and took notes 2. Compiled all surveys from parents from the implementation period and took notes 3. Listed all significant findings and similarities/differen ces on a handout for members during dissemination. 1. Took the list of 4/7 findings and drew conclusions. 2. Started writing the conclusion of the scholarly report. 3. Create powerpoint to show findings and present to site mentor 1. Scheduled a time 4/14 to present findings 2. Discussed with site mentor findings and future recommendations for ball rolling protocol Abstract, Summary and Conclusion Draft due 4/10  ...

... Self-Management of Psychosocial Wellness in Lymphedema Patients Sidney C. Metzger, OTS, PCBIS April 24, 2023 A capstone project submitted in partial fulfillment of the requirements of the Doctor of Occupational Therapy degree from the University of Indianapolis, School of Occupational Therapy. Under the direction of the faculty capstone advisor: Kelsey Peter, OTD, OTR PSYCHOSOCIAL WELLNESS IN LYMPHEDEMA PATIENTS 2 Abstract Patients who suffer from lymphedema may experience psychosocial barriers such as stress, depression, anxiety, frustration, irritability, poor self-esteem, etc. that limit daily functioning and quality of life. The overall goal of this project was to implement individual psychosocial sessions for lymphedema patients and their caregivers to reduce mental health barriers, increase self-management skills, and improve well-being. Mental health and physical health are closely related in that a problem in one area may affect the other. Researchers discovered that individuals with lymphedema are very likely to experience psychosocial barriers during their everyday life. Lymphedema psychosocial sessions occurred over the course of six weeks during each treatment session for nine participants. Eleven interventions, three educational handouts for participants, two educational handouts for caregivers, a lymphedema website resource, a caregiver quiz, and self-reflection questions were provided. Five participants showed improvement on the Lymphedema Life Impact Scale and the Psychosocial Concerns subsection of the assessment. One caregiver participated and did not show improvement on the Caregiver Self-Assessment Questionnaire. Five themes were found that viewed signs/symptoms, coping mechanisms, psychosocial barriers, the importance of self-management, and overall improvement. Lymphedema is a chronic condition that may increase chances of poor psychosocial health and well-being, therefore there is a continued need to increase psychosocial understanding, self-management, and opportunities for individuals diagnosed with lymphedema. I learned the importance of advocating for and discussing mental health barriers with those who suffer from lymphedema. PSYCHOSOCIAL WELLNESS IN LYMPHEDEMA PATIENTS 3 Introduction HSHS St. Elizabeths Hospital offers abundant services to provide patients with the highest quality of care. The comprehensive array of services continues to grow and develop to positively impact all patients (HSHS, 2021). The purpose of this project in the outpatient rehabilitation department is to provide psychosocial health education and advocacy to patients and caregivers to improve self-management, reduce mental health barriers, and increase wellbeing. I worked alongside an OTR/CLT (Certified Lymphedema Therapist), who is also my site mentor, to address a population of patients diagnosed with lymphedema. My site mentor focuses on tracking edema, performing MLD (manual lymph drainage), compression bandaging or recommending compression garments, providing exercises, and educating on proper skin care. Lymphedema causes long-term physical and psychosocial consequences for all individuals diagnosed (Borman, 2018). Psychosocial and mental health barriers should be considered to improve quality of life, daily activities, and overall wellness (Smallfield et al., 2021). The psychosocial wellness project was needed because patients who suffer from lymphedema may experience negative thoughts, behaviors, feelings, and emotions while attempting to manage their chronic disease (NIMH, 2021). I provided education on coping strategies, poor mental health signs, mental health and daily performance, caregiver burnout, and perspectives on mental health in a chronic condition. I provided resources for patients that aimed to target psychosocial factors. An outline was developed to maintain a project timeline throughout the duration of the DCE. See Appendix A for the weekly planning guide. PSYCHOSOCIAL WELLNESS IN LYMPHEDEMA PATIENTS 4 Background Lymphedema Characteristics The major lymphedema causes experienced at this site are chronic venous deficiency, venous stasis, and cancer surgery/treatment. Other relevant causes consist of obesity, cardiovascular problems, kidney disease, and genetics. The severity, location, and cause are dependent on the patient (Med Bridge, 2023). It is important to focus on skincare, compression bandaging or garments, MLD, elevation, and exercises during lymphedema self-management (Schaverien et al., 2018). Per OTR/CLT, lymphedema patients are at risk of infection due to lymphedema being a protein-rich fluid, therefore patients must keep their skin clean and moisturized to prevent any skin openings or wounds. It is recommended patients wear shortstretch compression bandages to reduce edema, then they may wear compression garments once lymphedema has plateaued (Schaverien et al., 2018). Patients are instructed to elevate the affected lower extremities above the inguinal lymph nodes, which is hip level, and to elevate the affected upper extremity above the axillary lymph nodes, which is the heart. MLD and home exercises depend on the client factors of the individual (Medbridge, 2023). Patients with lymphedema may experience other diagnoses that can impact their independence and self-management ability when self-bandaging, performing exercises, and remaining compliant due to reduced independence (Shier, 2016). Supporting Literature: What did others have to say? Mental Wellness Mental and physical health are closely linked together, so a problem in one area can greatly affect the other (Ohrnberger et al., 2017). Therefore, patients suffering from physical conditions may be at risk of poor mental health. Mental wellness aids in a positive, functional PSYCHOSOCIAL WELLNESS IN LYMPHEDEMA PATIENTS 5 lifestyle for patients with lymphedema. Wellness is defined as a conscious and self-directed process (Baum, 2022). Focusing on individuality when it comes to mental health is beneficial, because mental health risks can be found at different scales across a population. (WHO, 2022). Psychosocial Interventions Your emotional health is key to a happy life (Morin, 2022). Morin (2022) discusses that people with greater psychological well-being report better quality of life. Some interventions that target improving psychological well-being consist of finding purpose, positive thinking, acts of kindness, reflecting on positive life events, practicing mindfulness, identifying strengths, expressing gratitude, and fostering relationships or support. Caregiver Burnout It is essential to address the emotional and mental health of patients with lymphedema as well as their caregivers. Psychoeducation, skills training, and therapeutic interventions for caregivers can reduce burnout and improve quality of life. Caregivers should be directed to appropriate resources for support (Swartz & Collins, 2019). Psychosocial Impact of Lymphedema Studies Fu et al. (2013) discovered 23 relevant studies of the psychosocial impact on lymphedema patients. The studies showed significantly poorer social well-being, body image, appearance, and sexuality in individuals with lymphedema. Researchers concluded that lymphedema has a negative psychosocial impact. Dominick et al. (2014) studied 335 women who showed significant distress due to their lymphedema. Results showed that breast cancer survivors who carried lymphedema-related distress had worse mental health when compared to women with no presence of lymphedema. PSYCHOSOCIAL WELLNESS IN LYMPHEDEMA PATIENTS 6 For my project, I addressed individuality in mental health barriers. It is essential to take a holistic approach when identifying mental health's individual, social, and structural determinants (WHO, 2022). A holistic approach is necessary to address mental health barriers within the clinical setting so patients continue maintaining self-management upon discharge. Theory: PEOP and Cognitive Behavioral There is a strong emphasis on occupations, valued roles of the individual, activities, and daily performance in the occupation-based model, PEOP (Cole & Tufano, 2020). For patients who suffer from lymphedema, their relationship with others and within themselves can become affected. Lifes roles may become altered which can in turn impact occupational participation and engagement. Occupations can become difficult to perform for patients with lymphedema, especially dressing. Individuals may experience small or uncomfortable clothing, and shoes may increase falls or safety risks. Also, everyday performance can become impacted by activity tolerance, mental health barriers, and discomfort of the affected body part. Individuals are strongly influenced by support which can be groups, friends, family, or the community. Public access to the community may be constricted due to poor mobility and minimal accessibility. The frame of reference, cognitive behavioral, focuses on how our thinking influences our behavior. Psychosocial self-management is necessary when addressing negative barriers and facilitating positive behavior changes (Cole & Tufano, 2020). Behaviors that may be present in individuals with lymphedema consider social isolation, ignorance of the condition, poor selfmanagement, and altered relationships with food. Emotions to consider focus on denial, frustration, depression, anger, and feeling withdrawn. Thoughts to consider focus on anxiety, financial burden, body part dissociation, and body dysmorphia. PSYCHOSOCIAL WELLNESS IN LYMPHEDEMA PATIENTS 7 Project Design and Implementation Project Design Based on the needs assessment and research, it was determined that including psychosocial wellness interventions and education would be beneficial. Interventions included a support plan, understanding mental health stigma, finding values, identifying strengths, finding purpose, positive self-talk, identifying triggers, acts of kindness, a self-care plan, a weekly selfcare checklist, and a mental health maintenance plan (National Institutes of Health, 2022), (Kirsch et al. 2019), (CDC, 2022), (Morin, 2022). See Appendix B for psychosocial interventions. Educational handouts were provided for participants and caregivers that addressed coping strategies, mental health signs, daily performance barriers, caregiver burnout, and mental health perspectives (Canva, 2022). See Appendix C for educational handouts. Self-reflection questions were addressed during each session to assist in achieving goals and improving participant compliance. See Table 1 for self-reflection questions. A seven-question knowledgebased caregiver quiz was provided to address the understanding of lymphedema and mental health. See Appendix D for the caregiver quiz. Additionally, a lymphedema website resource was provided to participants to discuss financial assistance, advocacy, lymphedema awareness, and building community (NFLF, 2022), (LANA, 2022), (NLN, 2022). See Appendix E for the lymphedema website resource. Outcome Measures Since challenges faced by lymphedema patients include various physical, functional, and psychosocial factors (Togawa et al., 2021), I chose the Lymphedema Life Impact Scale (LLIS). See Appendix F for the LLIS. The LLIS has been validated as an 18-item comprehensive PSYCHOSOCIAL WELLNESS IN LYMPHEDEMA PATIENTS 8 lymphedema-specific instrument to assess various effects of lymphedema in the affected extremity through physical, functional, and psychosocial concerns with 0% being least impaired and 100% being most impaired (Weiss & Daniel, 2018). Psychosocial Concerns on the LLIS consist of 6 items and scores ranging from 0-24, 0 being least impaired and 24 being most impaired. Additionally, I chose the 18-item Caregiver Self-Assessment Questionnaire (CSAQ) to target stress levels, psychosocial health barriers, and well-being in caregivers who help their loved ones (American Psychological Association, 2011). See Appendix G for the CSAQ. Project Implementation Project implementation occurred during each participants scheduled treatment session with the OTR/CLT. Psychosocial Sessions (PS), for each participant, occurred once or twice per week depending on their treatment frequency. The project occurred briefly before, during, or after the session. My role consisted of providing educational handouts to participants and caregivers. Education was followed by explaining the purpose of the weekly intervention, then the participants were asked to engage in the activity in their home environment to aim to improve psychosocial self-management. Caregivers had the opportunity to engage in psychosocial interventions with the participants. See Table 2 regarding the project layout across six weeks for participants without caregivers and Table 3 across seven weeks for participants with caregivers. Project Outcomes Overall findings show improvement in mental health understanding, psychosocial health, and self-management awareness. Nine patients participated in the project with two participants completing all six weeks and seven participants discharging from therapy during the project. See PSYCHOSOCIAL WELLNESS IN LYMPHEDEMA PATIENTS 9 Table 4 regarding the number of sessions per participant and educational handouts and interventions provided. LLIS Pretest vs. Posttest Results show that five participants improved their LLIS scores. Four participants either did not improve or did not participate in the posttest. Of those four participants, one participant had a 1.38% increase on the posttest which could be caused by poor understanding or attention to the assessment, and three participants did not return to therapy after completing the pretest. Five participants showed improvements in the Psychosocial Concerns subsection on the LLIS assessment. One participant scored a 0 in the subsection on both the pretest/posttest. See Figures A and B regarding pretest/posttest scores for the LLIS and Psychosocial Concerns subsection. CSAQ Pretest vs Posttest One caregiver participated in the project and completed the CSAQ pretest/posttest. The caregiver scored a 3-point increase from the pretest to the posttest. The caregiver did not indicate an improvement in scores; however, I believe it was limited due to an increase in falls for his wife or time constraints during the pretest. See Figure C regarding CSAQ pretest/posttest score. Overall Improvement Figures D and E show the overall improvement in the LLIS and Psychosocial Concerns subsection in each participant. PSYCHOSOCIAL WELLNESS IN LYMPHEDEMA PATIENTS 10 Psychosocial Themes Common Symptoms & Signs Experienced Signs and symptoms discussed consisted of frustration, shame, emotional breakdown, embarrassment, depression, loneliness, body image struggles, and social detachment. Common Coping Skills Participants shared coping skills consisting of distraction, increased socialization, leisure task engagement, avoiding problems, participation in new hobbies, meditation, and exercise. Psychosocial Barriers During Tasks Participants expressed that daily performance is limited which may cause frustration, irritation, annoyance, worry, crying spells, and emotional behaviors. Other factors that contribute to psychosocial barriers include lack of familial support and time constraints to manage lymphedema. Other participants found no performance limitations, however, lymphedema contributed to orthopedic pain which did influence participation. Importance of Self-Managing Psychosocial Health Per participant response, psychosocial health leads to an overall healthy mind and body which leads to a productive lifestyle. Mental health helps get us through the day and increases our quality of life. Mental health helps us to feel okay, especially in social situations. Physical and mental health go together, therefore if one is affected, then the other is affected. Improvement Most participants stated an increase in overall understanding regarding mental health and how to self-manage it. It was discussed that it can be difficult to keep up with lifes struggles, PSYCHOSOCIAL WELLNESS IN LYMPHEDEMA PATIENTS 11 although it is important to remember to practice positive psychosocial health. Participants found the educational components and activities helpful, beneficial, and easy to understand. Summary Lymphedema is a chronic condition that may increase the chances of poor psychosocial health and well-being. If wellness and quality of life are impaired, then functional performance and independence are at risk. There is a continued need to increase psychosocial understanding, self-management, and opportunities for individuals diagnosed with lymphedema. It can be difficult for lymphedema patients to reduce and maintain edema at home, both physically and psychosocially. Participants stated that bandaging or donning garments, performing self-MLD, and completing HEP can be time-consuming and stressful. If patients are unable to self-bandage or don garments, then they must have a strong support system to assist. Other participants discussed their frequent cellulitis infections or some DVTs. Lymphedema can cause serious infections which patients must monitor. Participants discussed feelings of worry, anxiety, and frustration with reoccurring infections. Throughout project implementation, the importance of addressing mental health barriers, viewing positive coping mechanisms, increasing ways to improve psychosocial health, and obtaining a strong support system was discussed. It was essential to address individuality in mental health barriers because no participant is the same. Education remained client-centered, and participants were able to reflect on their difficulties whether that is at home, work, or any given environment. Participants expressed great understanding throughout the education components and interventions. PSYCHOSOCIAL WELLNESS IN LYMPHEDEMA PATIENTS 12 Psychosocial health must be addressed in chronic conditions to increase the quality of life. Overall pretest/posttest findings show improvements regarding psychosocial barriers in lymphedema patients. Conclusion Throughout the doctoral capstone experience, I learned the importance of advocating for and discussing mental health barriers with those who suffer from lymphedema. Most participants were uneducated on poor mental health signs, symptoms, feelings, emotions, and behaviors. It was my role to educate on how to reduce negative psychosocial barriers and increase selfmanagement skills. St. Elizabeths Hospital benefited from the project, Self-Management of Psychosocial Wellness in Lymphedema Patients, due to addressing psychosocial issues that are not commonly viewed in patients with lymphedema. Lymphedema patients must learn how to self-manage their physical condition at home through compression, MLD, skin care, HEP, and elevation, however, they lack knowledge on how to manage psychosocial barriers. Due to a lack of knowledge of psychosocial barriers, there must be continued work in this area. OT in mental health must still be advocated for to adequately address psychosocial barriers in physical conditions. OTs should focus on increasing education, awareness, and selfmanagement skills when addressing mental health barriers. An option for future work is for OTs to lead groups while creating safe spaces to share mental health struggles when coping with chronic conditions. This project demonstrated a need to address psychosocial health in lymphedema patients. The participants who received education and interventions strongly benefited from them. PSYCHOSOCIAL WELLNESS IN LYMPHEDEMA PATIENTS 13 References American Psychological Association. (2011). Caregiver Self-Assessment Questionnaire. https://www.apa.org/pi/about/publications/caregivers/practice-settings/assessment/tools/selfassessment Baum, E. (2022, December 16). The 7 Dimensions of Wellness. https://7summitpathways.com/blog/the7-dimensions-of wellness/#:~:text=The%207%20Dimensions%20of%20Wellness%20are%3A%201%20Social,O ccupational%20Wellness%206%20Intellucutaional%20Wellness%207%20Physical%20Wellnes s Borman, P. (2018). Lymphedema diagnosis, treatment, and follow-up from the viewpoint of physical medicine and rehabilitation specialists. Turkish Journal of Physical Medicine and Rehabilitation, 64(3), 179-197. Doi: 10.5606/tftrd.2018.3539. Canva. (2022). https://www.canva.com/your-apps/ CDC. (2022, May 9). Adult Mental Health. Adult Mental Health (cdc.gov) Cole, M. & Tufano, R. 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Doi: 10.1080/0164212X.2019.1588832 Lymphology Association of North America. (2022). https://clt-lana.org/index Medbridge. (2023). Fundamentals of Lymphology and Lymphedema Diagnosis. Fundamentals of Lymphology and Lymphedema Diagnosis | MedBridge (medbridgeeducation.com) Morin, A. (2022, February 10). How to Improve Your Psychosocial Well-being. https://www.verywellmind.com/improve-psychological-well-being-4177330 National Institutes of Health. (2022). Emotional Wellness Checklist. https://www.nih.gov/sites/default/files/health-info/wellness-toolkits/emotional-wellnesschecklist-2022-7.pdf National Lymphedema Network. (2022). https://lymphnet.org/2022 National Institute of Mental Health. (2021). Chronic Illness and Mental Health: Recognizing and Treating Depression. https://www.nimh.nih.gov/health/publications/chronic-illness-mentalhealth. PSYCHOSOCIAL WELLNESS IN LYMPHEDEMA PATIENTS 15 NIH Medline Plus. (2022). Lymphedema: Living with Swelling and Stiffness. Lymphedema: Living with swelling and stiffness | NIH MedlinePlus Magazine. Ninjas Fighting Lymphedema Foundation. (2022). https://www.winourfight.org/ Ohrnberger, J., Fichera, E. & Sutton, M. (2017). The relationship between physical and mental health: A mediation analysis. Social Science & Medicine, 195, 42-49. Doi: 10.1016/j.socscimed.2017.11.008. Schaverien, M. V., Moeller, J. A. & Cleveland, S. D. (2018). Nonoperative treatment of lymphedema. Seminars in Plastic Surgery, 32(1), 17-21. Doi: 10.1055/s-0038-1635119 Shier, B. (2016). The occupational therapists role in lymphedema self-management. Occupational Therapy Now, 14.3, 1-34. https://clrhealth.com/wp-content/uploads/2016/06/OT.Now_.Selfmanagement.FINAL-1.pdf. Smallfield, S., Fang, L., & Kyler, D. (2021). Self-management interventions to improve activities of daily living and rest and sleep for adults with chronic conditions: A systematic review. The American Journal of Occupational Therapy, 75(4), 1-21. https://doi.org/10.5014/ajot.2021.046946. Swartz, K. & Collins, L. G. (2019). Caregiver care. American Family Physician, 99(11), 699-706. p699.pdf (aafp.org) Togawa, K., Ma, H., Smith, A. W., Neuhouser, M. L., George, S. M., Baumgartner, K. B., McTiernan, A., Baumgartner, R., Ballard, R. M & Bernstein, L. (2021). Self-reported symptoms of arm lymphedema and health-related quality of life among female breast cancer survivors. Scientific Reports, 11(1). Doi: 10.1038/s41598-021-89055-0. PSYCHOSOCIAL WELLNESS IN LYMPHEDEMA PATIENTS Weiss, J. & Danial, T. (2018). Validation of the lymphedema life impact scale version 2: A conditionspecific measurement tool for persons with lymphedema. Rehabilitation Oncology, 28-36. WHO. (2022, June 17). Mental Health: Strengthening Our Response. https://www.who.int/newsroom/fact-sheets/detail/mental-health-strengthening-our-response 16 PSYCHOSOCIAL WELLNESS IN LYMPHEDEMA PATIENTS 17 Table 1. Self-Reflection Questions Can you report mental health signs that you experience? What are some mental health barriers that you face when completing daily tasks? Have you found these resources helpful? What are ways that you cope with life difficulties? Can you explain the importance of selfmanaging psychosocial wellness? Have you noticed any improvement through participating in the project? Table 2. Participants without Caregivers Week 1 Intro Introduce the project, purpose, and expected outcomes. Provide recruitment flyers and interest forms to lymphedema patients. Week 2 PS Week 3 PS LLIS Triggers, Life Purpose, Self-Talk Mental Health Barriers Handout Coping Strategies Handout Lymphedema Website Symptom Resources Handout Support Plan, Mental Health Stigma, Strengths, Values Self-Reflection SelfReflection Week 4 PS Acts of Kindness, Self-Care Plan & Checklist SelfReflection Week 5 PS Week 6 PS Participants questions, comments, and concerns LLIS Mental Health Maintenance Plan Address areas of improvement and limitations SelfReflection Table 3. Participants with Caregivers Week 1 Intro Introduce the project, purpose, and expected outcomes. Week 2 PS LLIS Week 3 PS Week 4 PS Coping Strategies Handout Triggers, Life Purpose, Self-Talk Week 5 PS Acts of Kindness, Self-Care Plan & Checklist Week 6 PS Week 7 PS LLIS Participants questions, comments, and concerns PSYCHOSOCIAL WELLNESS IN LYMPHEDEMA PATIENTS Provide recruitment flyers and interest forms to lymphedema patients. Mental Health Barriers Handout CSAQ Caregiver Lymphedema Burnout and Website Perspectives Symptom Resources Handout Handout Support Plan, Mental Strengths, Health Stigma Values SelfReflection 18 SelfSelfReflection Reflection Caregiver Quiz CSAQ Mental Health Maintenance Plan SelfReflection Address areas of improvement and limitations Table 4. Layout of Psychosocial Sessions (PS) and Resources Pt 1 2 3 4 5 6 7 8 9 # Of PS 3 3 1 0 5 3 3 1 5 Education Handouts 10 Coping Strategies- 1, Signs/Symptoms of Poor Mental Health- 2, Mental Health Daily Barriers- 3, Caregiver Burnout- 4, Mental Health Perspectives for Caregivers- 5 Education Handouts Interventions/Activities 1, 2, 3 PS (1-7), D/C (8-11) 1, 2, 3, 4, 5 PS (1-4), D/C (5-11) 1, 2, 3 D/C (1-4) None None 1, 2, 3 PS (1-11) 1, 2, 3 PS (1-7), D/C (8-11) 1, 2, 3 PS (1-7), D/C (8-11) 1, 2, 3 D/C (1-4) 1, 2, 3 PS (1-11) KEY Interventions/Activities Support Plan- 1, Understanding Mental Health Stigma- 2, Identifying Strengths- 3, Finding Values- 4, Reflecting on Triggers- 5, Life Purpose- 6, Self-Talk- 7, Acts of Kindness- 8, Self-Care Plan- 9, Self-Care Checklist- 10, Mental Health Maintenance11 Key: PS (#-#) indicates interventions provided during the session with follow-up on materials next PS. D/C (#-#) indicates interventions provided during the session with no available follow-up on materials. PSYCHOSOCIAL WELLNESS IN LYMPHEDEMA PATIENTS Figure A. LLIS Pre/Posttest Figure B. Psychosocial Pre/Posttest 19 PSYCHOSOCIAL WELLNESS IN LYMPHEDEMA PATIENTS Figure C. CSAQ Pre/Posttest Key: Red= Pretest, Pink=Posttest Figure D. LLIS Improvement 20 PSYCHOSOCIAL WELLNESS IN LYMPHEDEMA PATIENTS Figure E. Psychosocial Concern Improvement 21 Appendix A PATIENTS PSYCHOSOCIAL WELLNESS IN LYMPHEDEMA Week 1 DCE Stage Orientation Weekly Goal 2 Screening/ Evaluation Complete all orientation and review expectations by the end of the week. Observe at least 5 lymphedema patient sessions to gain an understandin g of treatment. Create a project timeline by the end of the week. Review Needs Assessment, research, and lymphedema knowledge by the end of the week. Refine goals and objectives to update the project as needed. Organize and research psychosocial interventions and develop Canva handouts. Finalize recruitment and interest form to utilize the 22 Objectives Tasks Meet with site mentor, patients, and other staff to introduce myself and DCE. Review the completed timeline with the site mentor and make changes if necessary. Email the timeline to the faculty mentor. Familiarize self with goals, objectives, literature review, MOU, and education on lymphedema. Review goals and objectives for adjustments or modifications before the final MOU is due. Meet with the site mentor to introduce forms and edit as needed. Discuss experience goals with the site mentor. Increase hands-on experience during sessions. Find recent and educational Go over the orientation binder with the site mentor and address questions. Submit the implementation timeline to Brightspace for review. Locate new research on lymphedema. Complete Med Bridge educational lymphedema lectures provided by the site mentor. Prepare for project implementation by analyzing goals, researching interventions, and creating educational handouts. Finalize necessary forms and provide them to patients next week. Ensure everything has been reviewed Date complete 1/13/23 1/20/23 PSYCHOSOCIAL WELLNESS IN LYMPHEDEMA PATIENTS 3 Screening/Evaluati on start of Week 3. Practice compression bandaging and measuring patients throughout the week. Start to learn manual lymphatic drainage (MLD) techniques and begin to practice on patients by Friday. Continue to add and organize literature that is relevant to DCE. Turn in MOU by Friday. Increase treatment technique (MLD, compression bandaging, measuring, body mechanics). Begin the recruitment process (provide the flyer and interest form). Finalize at least 10 wellness interventions/ activities. articles that will be beneficial to include in the Scholarly Report. Address and work towards experience goals through lymphedema treatment. Recruit patients/caregivers during treatment sessions. Ensure wellness interventions and handouts are appropriate and effective through research and mentor feedback. Address reliability and validity for outcomes. Begin background draft (4 pages). 23 and discussed by the MOU. Focus on professional growth and skills by participating in patient sessions. Provide purpose, background, and other information to patients regarding the DCE project. Meet with Shana to go over selected interventions based on research. Email handouts to Shana Monday to have final handouts by Friday. 1/27/23 PSYCHOSOCIAL WELLNESS IN LYMPHEDEMA PATIENTS 4 Implementation Finalize all educational handouts. Finalize outcome measures (LLIS & CSAQ). Confirm FOR/OBM (PEOP and CB). Continue to review and add to relevant literature. Conduct 1st and/or 2nd Psychosocial Session (PS) of educating and focusing on selfmanaging psychosocial wellness in lymphedema patients. Provide 1st and/or 2nd PS handouts and interventions to all participants/c aregivers depending on treatment frequency. Continue to recruit additional participants. Complete project design and implementati on draft! Provide pre-test and/or post-test to participants and caregivers (LLIS, CSAQ). Lead ~10-minute educational session before, during, or after the participants treatment time. Provide necessary handouts and interventions based on the Project Implementation Checklist, then discuss the importance of selfmanagement (practicing psychosocial wellness at home). Recruit additional participants and welcome new patients. 24 Email outcome measures to Shana Monday for feedback by Friday. Ensure weekly handouts and interventions are printed and ready to go. Continue to keep project implementation binder organized. Keep track of resources provided to each patient (some may need more/less depending on the frequency of treatment). Utilize recruitment schedule and attendance spreadsheet to track no-shows, cancellations, discharges, or new evaluations. 2/3/23 PSYCHOSOCIAL WELLNESS IN LYMPHEDEMA PATIENTS 5 Implementation 6 Implementation Conduct 1st, 2nd and/or 3rd PS. Provide 1st PS 2nd, and/or 3rd PS handouts and interventions to all participants/c aregivers and continue to recruit additional participants. Provide additional resources depending on patient availability, scheduled discharge, and treatment frequency. Self-check-in questions to address participant compliance, mental health understandin g, and data collection. Work through project problems and identify solutions throughout implementati on. Conduct 2nd, 3rd, or 4th PS. 25 Continue to provide pre-tests to participants (LLIS) if needed (No more caregivers participating). Lead ~ 5-to-10minute educational session Provide all resources and follow up with participants selfmanagement skills. Provide additional resources to those participants discharging. Begin to provide post-test and/or caregiver quiz as some patients discharge. Final recruitment week! 4 more patients to discuss the project with. Lead ~ 5-to-10minute educational session Ensure weekly handouts and interventions are printed and ready to go for each patient. Continue to keep project implementation binder organized and up to date. Continue to keep track of resources provided to each patient in the Patient Tracker folders. Keep track of how long each participant engages in the project by continuously updating the attendance sheet with dates/times. 2/10/23 Ensure weekly handouts and interventions are printed and 2/17/2023 PSYCHOSOCIAL WELLNESS IN LYMPHEDEMA PATIENTS Provide 2nd, 3rd, or 4th interventions/ activities. Self-check-in questions Assess project progress, goal achievement, and changes. 7 Implementation Conduct 1st (due to new Pt), 2nd, 3rd, 4th, or 5th PS. Provide 1st, 2nd, 3rd, or 4th interventions/ activities to participants. Self-check-in questions Midterm with site mentor. Begin to analyze Provide all resources and follow up with participants selfmanagement skills. Provide additional resources to those participants discharging. Begin updating the Project Outcome spreadsheet, as patients exit the project, with pretest/posttest, number of PS participated in, resources provided, and selfreported data (as patients discharge OR finish the selfmanagement project.) Continue to provide post-test as some patients discharge or finish the project. Provide pretests to new participants and continue to provide necessary posttests. Lead ~ 5-to-10minute educational session. Provide all resources and follow up with participants selfmanagement skills. 26 ready to go for each patient. Continue to keep project implementation binder organized and up to date. Continue to keep track of resources provided to each patient in the Patient Tracker folders. Keep track of how long each participant engages in the project by continuously updating the attendance sheet with dates/times. Ensure weekly handouts and interventions are printed and ready to go for each patient. Continue to keep track of resources provided to each patient in the Patient Tracker folders. Continue to keep track of 2/24/2023 PSYCHOSOCIAL WELLNESS IN LYMPHEDEMA PATIENTS project outcomes and address project limitations. 8 Implementation Conduct 2nd, 3rd, 4th, or 5th PS. Provide 2nd, 3rd, or 4th interventions to participants. Self-check-in questions. Continue to analyze project outcomes. 9 Implementation/ Discontinuation Finish providing necessary psychosocial sessions. Provide the rest of the Provide additional resources to those participants discharging or finishing the project. Continue to update the Project Outcome spreadsheet. Work through challenges and changes with both mentors. Lead ~ 5-to-10minute PS. Provide all resources and follow up with participants selfmanagement skills. Provide additional resources to those participants discharging or finishing the project. Continue to provide posttests as needed. Continue to update the Project Outcome spreadsheet. Begin addressing common themes from self-reported data and start the graph. Lead ~ 5-to-10minute PS Provide all resources and follow up with participants self- 27 how long each participant engages in the project by continuously updating the attendance sheet with dates/times. Ensure weekly handouts and interventions are printed and ready to go for each patient. Continue to keep track of resources provided to each patient in the Patient Tracker folders. Continue to keep track of how long each participant engages in the project by continuously updating the attendance sheet with dates/times. 3/3/2023 Ensure weekly handouts and interventions are printed and ready to go for each patient. 3/10/23 PSYCHOSOCIAL WELLNESS IN LYMPHEDEMA PATIENTS interventions to participants who did not get to finish the project. Self-check-in questions. Gather the rest of the project outcomes for analysis. Project Outcomes draft due. management skills. Provide all additional resources due to the project ending. Provide posttests for all remaining patients. Finish updating outcomes on the spreadsheet. Continue to focus on common themes, project success/failures, and limitations. Finalize bar graphs, line graphs, and tables for project outcomes draft 28 10 Discontinuation Submit project outcomes draft. Plan dissemination with the site mentor. Address feedback, comments, and questions from staff and patients regarding the project. Work on PowerPoint for the site. Gather all data to finish graphs and themes. Discuss dissemination options and work on the dissemination draft. Plan a way to gather feedback when disseminating work to the site. Continue to structure PowerPoint and address project outcomes/conclusi ons. Continue to keep track of resources provided to each patient in the Patient Tracker folders. Continue to keep track of how long each participant engages in the project by continuously updating the attendance sheet with dates/times. Engage in closing remarks with the site mentor and remaining participants. Discuss project outcomes with mentors. 3/17/23 Main tasks for the week include submitting the outcomes draft, finalizing the dissemination plan, beginning the virtual poster, working on the site PowerPoint, and focusing on client/staff feedback. PSYCHOSOCIAL WELLNESS IN LYMPHEDEMA PATIENTS 11 Discontinuation 12 and 13 Discontinuation/Di ssemination Finalize dissemination poster for the site. Finalize virtual dissemination poster for lymphedema partners (LANA, NLN, NFLF, ACOLS, Norton, Klose, and LE&RN) Work on Google Form for end users and partners to gather feedback and comments. Submit dissemination plan to Brightspace. Present poster to site 3/28-4/7. Send PowerPoint to site staff via email by 3/30. Send the virtual poster and survey to various lymphedema partners, ILOTA, AOTA, and more. Send the survey to site staff by 4/7. Print off all resources and provide them 29 Create a hard copy of the dissemination poster to display in the common area as an informal presentation/discu ssion. Create PowerPoint to email to site staff. Create a survey with open responses for comments, concerns, questions, and further research, then address responses through a follow-up email. Include intro, goals, methods, findings, and conclusions in the presentation. Encourage staff to fill out the survey to gather feedback. Print poster, intervention activities, educational handouts, and other resources that were given to participants for staff to view. Gather partner contact info to disseminate the presentation. 3/24/23 Hang up the poster in the common area for staff to see in between patients and during lunch; initiate informal discussion about overall project goals and outcomes. Send virtual poster and survey to partners with an intro of self and project. 4/7/23 PSYCHOSOCIAL WELLNESS IN LYMPHEDEMA PATIENTS 14 Dissemination to the site mentor. Complete all sections of the scholarly report. Complete PowerPoint, VT, and Poster for UINDY. Analyze Feedback from Google Survey Work on Summary Written Reflection. Final Evaluation by site mentor. Work on UINDY DCE requirements (virtual poster, scholarly report, VT, and PowerPoint). Closing remarks with site; last day 4/14 30 Rough drafts of 4/14/23 all requirements completed by 4/14. Send to Kelsey to review, final (poster, VT, PPT, reflection) due 5/1. Scholarly Report due 4/24. PSYCHOSOCIAL WELLNESS IN LYMPHEDEMA PATIENTS Appendix B https://tatepublishingnews.com/ https://positivepsychology.com/ 31 PSYCHOSOCIAL WELLNESS IN LYMPHEDEMA PATIENTS https://positivepsychology.com/ https://blog.zencare.co/identifying-personal-strengths/ 32 PSYCHOSOCIAL WELLNESS IN LYMPHEDEMA PATIENTS http://www.thiscache.blogspot.com/ belmontwellness.com https://www.therapistaid.com/ 33 PSYCHOSOCIAL WELLNESS IN LYMPHEDEMA PATIENTS https://mommymoment.ca/99-acts-of-kindness/ https://steemit.com/health/@yogirama/easy-self-care-plan-for-those-who-are-too-busy-to-care-for-self 34 PSYCHOSOCIAL WELLNESS IN LYMPHEDEMA PATIENTS demonsinsidemyhead.com.au https://www.therapistaid.com/ 35 PSYCHOSOCIAL WELLNESS IN LYMPHEDEMA PATIENTS Appendix C 36 PSYCHOSOCIAL WELLNESS IN LYMPHEDEMA PATIENTS 37 PSYCHOSOCIAL WELLNESS IN LYMPHEDEMA PATIENTS 38 PSYCHOSOCIAL WELLNESS IN LYMPHEDEMA PATIENTS Appendix D Caregiver Quiz: Lymphedema & Mental Health True or False. Patients with chronic illnesses are at risk for poor mental health. True or False. Physical health is way more important than psychosocial health. True or False. Effective self-management of lymphedema can help to improve mental health. True or False. It is not important to focus on psychosocial health. True or False. Poor mental health does not impact daily living tasks. True or False. One way to promote positive health is by participating in healthy habits and routines. True or False. Engaging in positive coping strategies can help increase positive feelings and emotions. 39 PSYCHOSOCIAL WELLNESS IN LYMPHEDEMA PATIENTS 40 Appendix E Lymphedema Resources for You: Ninjas Fighting Lymphedema Foundation (NFLF) - Opportunities to apply for financial assistance when managing lymphedema. 21 Day Wellness Challenge focused on self-perception and building relationships. Ensures no one must manage lymphedema alone. Advocates for individuals with lymphedema. Lymphology Association of North America (LANA) - Aims to help individuals manage their lymphedema. Promotes lymphedema awareness. Uses comprehensive knowledge to maximize function and improve quality of life. National Lymphedema Network - Education and guidance regarding lymphedema management to - patients, healthcare workers, and the public. Plenty of information on the prevention and management of lymphedema. World Lymphedema Day! Every year on March 6th the world joins together to support all of those living with lymphedema. In-depth information about your lymphedema is provided. You can even join Facebook groups! By meeting people going through similar life experiences or conditions, you can improve mental/emotional wellness and quality of life. It is amazing what can happen when we discover we are not alone! PSYCHOSOCIAL WELLNESS IN LYMPHEDEMA PATIENTS Appendix F 41 PSYCHOSOCIAL WELLNESS IN LYMPHEDEMA PATIENTS Appendix G 42  ...