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... Developing Small Group Lessons and Sensory Regulation Strategies in a Head Start Program Bridget Downs 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: Laura Aust, OTD, MS, OTR Abstract This Doctoral Capstone Project took place at a community center containing a Head Start Early learning program in a low income area of South Bend, Indiana. The focus of the project was developing occupational therapy based small group lessons to promote developmental and school readiness skills, implementing school-wide sensory regulation strategies, and collaborating with staff on individual student recommendations. I based my program on a Response to Intervention (RTI) model that consists of a multi-tiered approach to providing interventions. The project is important for the site to improve classroom performance for the kids, increase awareness of the scope of OT, and increase teachers confidence in using these strategies to ensure sustainability. In the results, teachers reported their students classroom performance improved, teachers gained new knowledge from the resources I developed, and teachers feel confident they will be able to continue using these strategies in the future. Introduction This Doctoral capstone took place at a newly constructed neighborhood center in South Bend, Indiana. The entire center will contain Head Start learning programs, youth and senior programs, pharmacy services, community services such as WIC and mental health resources, and leisure spaces for all neighborhood members (Neighborhood Center-UWSJC.org, n.d). The Capstone focused on the Head Start and Early Head Start programs. This site was built to meet the needs of neighborhood members in a low income area of South Bend, IN. The poverty rate is around 42% and the neighborhood was previously deemed a childcare desert (Neighborhood Center-UWSJC.org, n.d. ; Early Learning Indiana.org, n.d.). This Head Start program addresses early childhood education needs by providing increased access to high-quality childcare that is close to home and affordable. The vision of Head Start includes supporting every child, family, and community to create change and meet the needs of children to ensure success (National Head Start Association.org, n.d.). There are eight classrooms ranging from infant, toddler, and preschool ages and around 120 kids total. The project included developing occupational therapy based small group lessons to promote developmental and school readiness skills and implementing school-wide sensory education and strategies to increase children's self regulation abilities. The program was based on a Response to Intervention (RTI) model that consists of a multi-tiered approach to providing strategies for students and teachers. This project is important for the site to improve classroom performance for the kids, increase awareness of the scope of OT, and increase teachers confidence in those areas. The rest of this report on the Doctoral Capstone Project & Experience will include background information, theory and model that guide the project, project development and implementation, outcomes, summary, and conclusions. Background There are often significant barriers to receiving high quality childcare in low income urban neighborhoods, due to limited accessibility and affordability (Moran, 2019). This Head Start center hopes to have a significant impact on the community by providing access to a high quality early education program, which is found to close almost half of the later achievement gap in school (Moran, 2019). In addition, children ages 0-5 are at a time when they are experiencing critical developmental milestones and living in poverty can affect the development of these skills (Corr et al., 2020). Head Start is helpful to work on school preparedness during this time. A needs assessment was conducted by interviewing the site mentor and the teachers and conducting a search of relevant literature. The site mentor identified needs of collaborating with teachers when a student needs more support and increased knowledge of the scope of OT. Teachers identified the need for assistance with ideas for after school dismissal transitions. OTs in Head Start may address childrens participation in self care, play, pre-handwriting, fine motor skills, sensory integration, social skills, cognition, and more (Jasmin et al., 2018). Although OT services were viewed as beneficial by teachers, there can be a discrepancy between perceptions of each others professional scopes (Benson et al., 2016). Bowyer et al., (2016) found that Head Start teachers often addressed issues within OT domains. For example, teachers are likely to include sensory related activities in early childhood classrooms but there was a gap in teachers' understanding of sensory avoidant or sensory seeking behaviors (Wilburn et al., 2020). The development of a program of sensory interventions with educational resources increased teachers knowledge and effective use of sensory tools. To determine the best interventions for individuals and adaptations to the entire classroom, one first needed to develop a better understanding of the teachers style, routines, and constraints of the classroom environment (Stancliff & Baist, 2021; Wilburn et al., 2020). When creating changes in a site, structured collaboration needs to be addressed among interdisciplinary teams. As collaboration increases between teachers and OTs through assessment, intervention development, and progress monitoring, student skill development increases resulting in improved educational outcomes (Benson et al., 2016; Sisti & Robledo, 2021). Using an RTI structure was the most effective in this setting due to a larger number of children having access to services within the consultative model, and a proactive approach results in fewer number of future referrals for traditional occupational therapy services (Jasmin et al., 2018). There is not an OT here currently so the student addressed Tier 1 and Tier 2 approaches, along with creating a foundation for an easy transition in the future when an OT is on site by increasing awareness of OT scope. In RTI, Tier one interventions are classroom and school wide universal instructions, and preventative/ health promotion activities. Tier two interventions are more targeted individualized or small group activities to promote the development of age appropriate skills (Reeder et al., 2011). Tier three is traditional one on one therapy services (Jasmin et al., 2018). See Figure 1 below. Tier one of the program included creating school wide sensory regulation strategies. OT focuses on sensory because a mismatch in sensory integration can affect a person's ability to participate in their daily occupations (Pfeiffer et al., 2018). In one urban Head Start Program, 1735% of kids had a sensory modulation disorder which is higher than other populations (Reynolds et al., 2008). In a school type setting, sensory dysregulation can cause disruptions in the classroom, difficulty with transitions, and more off task behaviors (Miller- Kuhaneck & Watling, 2018). When addressing sensory needs on a larger scale through environmental changes, occupational therapists can support teachers' independent use of sensory concepts (Wilburn et al., 2020). Occupational therapy provides a unique perspective to coach and collaborate with teachers and parents to help them understand sensory difficulties and enable them to devise their own strategies (Miller- Kuhaneck & Watling, 2018). There were multiple methods developed to improve student regulation including a sensory path in the hallway, after school dismissal transition activities, sensory centers in classrooms, and a reference guide of a sensory toolbox. Tier two of the program included the creation of small group activities with an OT focus on developmental skills such as fine motor, writing, executive functioning, visual motor skills, motor planning, posture/ core strength, and others (Stancliff & Baist, 2021; Reeder et al., 2011; Gibb et al., 2021). OT small groups have been found to improve skills of preschool age children and better prepare them for kindergarten (Buzzell et al., 2021; Marr et al., 2003; Martino & Lape, 2021). The small groups focused on a different topic each week and the student created an educational resource packet that explains the skill, why its important, activities to work on it, and developmental milestones. Along with the implementation of small groups, Tier 2 interventions included individualized consultations when a teacher notices specific difficulties. They would be provided 2-3 strategies to try over a short period and then check in and adjust as needed (Reeder et al., 2011). If the strategies are not successful for the child, they may move up to Tier 3 which wasnt provided by capstone student. There have been previous authors conduct studies or projects related to my project. Robyn Scarlett (2020) conducted a capstone using an RTI structure in kindergarten classrooms and found the structure effective for OT and improved school performance. Lust and Donica (2011) found that when Head Start centers use a handwriting program, it increased the students prewriting skills and fine motor skills. My program combined sensory, fine motor, and more topics into an RTI structure to improve teacher confidence and student performance. Model and Frame of Reference I used the Person, Occupation, Environment, Performance (PEOP) model to guide my capstone. PEOP is applicable to organizations with the goal of achieving occupational engagement. This model looks at occupation in a top down manner and breaks it down further into components (Cole & Tufano, 2020). This guided the evaluation of the current processes and how to adapt them to increase performance. The groups of people involved in the model are currently the teachers, students, and the parents and in the future will include therapists. The environmental aspects include the physical structure of the community center, cultural values, social support, and economical means. Occupations for my project include play, sensory regulation, work, education, and social participation with the goal of achieving increased performance of students and teachers through collaboration with small group activities. I used the sensory motor and processing frame of reference to guide my Capstone. This frame focuses on the client factor of body functions in the areas of sensory integration, sensory modulation, self regulation, sensory responsiveness, sensory discrimination, and praxis (Cole and Tufano, 2020). Functioning includes being able to self regulate and perform daily occupations without being overly distracted by extraneous sensations. Dysfunction occurs when sensations create barriers due to not being able to regulate internal systems. Interventions require understanding of the duration, intensity, and type of sensory input that individuals need, or the types they need to avoid, to normalize their sensory system and develop functional responses to complete daily occupations (Cole and Tufano, 2020). Interventions can be done in groups or individualized to help students be more regulated. This frame guided the creation of my sensory strategy interventions and creation of educational materials for the teachers to use as a resource to assist them with sensory regulation of their students. Project Design I designed this project in a way to be sustainable and impactful even after the Capstone is finished. I developed weekly lessons with topics of fine motor skills, sensory, executive functioning, visual skills, gross motor/ posture, and motor planning/ bilateral coordination that fit within the Head Start curriculum requirements. Each week I created an informational packet for the teachers with what the skill is, why its important, relevance to the scope of OT, related developmental milestones for the skill, and multiple small group activities to address the skill. I separated the activities and milestones by age groups of the classrooms from 0-1, 1-2, and 3-5 year olds. I designed the lessons with this format so the teachers had an informational resource to look back on and be able to implement the activities in a way that fits best with their class schedule and routine. The goal of these lessons was to promote the developmental skills of toddlers and developmental/school readiness skills of preschoolers, the early identification of specific needs of students, and increase the teachers knowledge of OT and ability to implement their own strategies with this knowledge. Along with weekly lessons, I developed a sensory path in the hallway, a sensory toolbox to assist teachers with promoting optimal sensory input and regulation for their students, and implement changes to the after school dismissal process. To measure this project, I conducted a pre and post opinion survey of the teachers relevant to their knowledge and skills of the areas in my project. The survey included multiple choice and open ended questions. The design of my project focused on how the teachers can promote students skills in the weekly topics and use sensory strategies. The method of measuring teacher opinions on ability to implement small groups and strategies will be most effective due to wanting the effects of my project to continue after I am finished and to gauge teachers confidence in their responses. Project Implementation I decided to send the weekly packets with the teachers leading the small groups rather than leading the groups myself. I determined this because there are eight classrooms so I wouldnt be able to make it to each one during small group time weekly. In addition, I wanted the teachers to be able to continue the groups after I finished with my capstone. I decided to model my program more like an RTI consultative model (see figure 1 below) and I would check in each week to spend time in the classroom, answer any questions, and assist with any students who needed more help during small groups. Some challenges with this method include potential misunderstandings of the information in the packets and working within constraints of the existing curriculum. To overcome this, I tried to be informative but concise in my wording, provide check in times to answer any questions, and check with my site mentor on all activities. Some successes include teachers being excited to receive the packet each week, asking for more activities in certain topics, and on multiple occasions noting improvement in skills such as pencil grasp, scissor skills, and sensory regulation and teachers ability to intervene in these areas. My project also included parental involvement by providing a summary of the skills children were working on and developing a summer activity packet for parents to do with their kids. Project Outcomes I evaluated the results of my project using a pre and post survey of the teachers at my site. This survey is relevant to their knowledge of OT, skills of the students in their class, knowledge of sensory regulation, the efficacy of the small group activities, and their ability to implement recommended strategies. I decided to use an opinion survey method to gauge the impact of my program based on the opinions of the teachers because I was focused on professional collaboration and ease of use for teachers to use the recommended interventions as my intended outcome. With the design of my project, I wanted to increase the teachers ability to promote interventions related to the weekly lesson topics and sensory regulating strategies. Some outcomes I have observed from my project include teachers being able to correct a students pencil grasp according to their age, use the sensory path in the hallway to assist students with regulation, implement heavy work activities in the classroom, and feel confident using things recommended for individual students such as a PECS Board, transition strategies, and visual schedules. Post Survey questions for the teachers, with the option to leave comments, included: Did teachers learn something new from the resource packets with the lessons; Did kids improve the related skills with the activities; Did teachers increase knowledge of scope of OT; Do teachers feel more confident in addressing sensory regulation; and Do teachers see themselves continuing to use these resources in the future. The results indicated positive outcomes from my project. The survey had a 58% response rate overall, but not every teacher answered every question. Teachers reported new knowledge of developmental milestones for writing, how to help kids dexterity and fine motor, large body movements can be calming, if kids sensory systems are dysregulated it is harder for them to focus, kids respond differently to various forms of sensory input, how to implement sensory objects in the classroom to help students regulate, and they had new ideas to try for small groups. 100% of respondents indicated the small group activities improved their students age appropriate skill levels. Teachers increased their knowledge of OT scope by providing examples of OT helps children with sensory issues get through normal daily activities, OT emphasizes developing and maintaining the skills people need to perform daily activities, and OT could consult on classroom design and assist with behaviors. 100% of respondents indicated they were going to continue to use these resources in the future. Overall, these results depict successful outcomes of increasing teachers knowledge and confidence for them to implement these small group activities and sensory strategies to assist with improving students classroom performance and engagement. Summary Head Start Programs provides a context where children who are more at risk for later school delays can have access to high quality early learning, and a service delivery context for therapy services. The specific location where my capstone took place has a speech therapist and behavior therapist, with OT and PT to come in the future. While Head Start Programs have a well structured curriculum, therapists can provide a different insight into childhood development and skills but it is most effective when all the different professional teams are working together (Benson et al., 2016). There was not an occupational therapist onsite at this location yet, so as a capstone student I focused on building that connection of what is in the scope of OT and how it can help in the classroom while I provided more universal interventions from an OT perspective in an RTI based model. I developed strong rapport with the students and teachers, focused on the evolving needs of the site while I was there, and used evidence based interventions to increase the likeliness the results of my project would be successful. Conclusion Throughout the fourteen week Doctoral Capstone Project and Experience, I learned valuable lessons and accomplished my goals. The deliverables to the site included six small group lessons with informational resources including relevant developmental milestones, why the skill is important, and activities to work on it. These topics were fine motor, executive functioning, visual perceptual/ motor skills, motor planning/bilateral coordination, body awareness, and tactile sensory. I developed a sensory toolbox with information on what dysregulation looks like, helpful activities to try to regulate it, and how to create sensory area in the classroom. I put a sensory pathway in the hall to assist with transitions and increase student engagement. Lastly, I assisted with the dismissal transition and collaborated with the teachers, the behavior specialist, and the speech therapist on individual student recommendations. Overall, my project depicted the effectiveness of occupational therapy in Head start to play a role in universal student performance, collaboration with teachers, and provision of resources. I learned about the role of OT in not only Head Start Programs but also generalizable skills working with kids ages 0-5. I strengthened my intervention planning by determining what to include in the lessons and developing multiple activities to work on those skills. The site benefitted from the project in various ways such as new lessons to include in their curriculum development, increased teacher knowledge, and sensory strategies. I planned the project to be sustainable so the teachers could continue to implement their new knowledge. While my project was conducted only at one site, implications for the overall profession can be inferred. OTs can have a large role in Head Start centers as a natural treatment area to help decrease the disparities often seen later in school settings with kids from low income neighborhoods. In this setting, occupational therapists could work with the general population from a preventative perspective. Occupational therapists are uniquely prepared to address the childs skills, family involvement, psychosocial aspects, and community based resources necessary for this type of setting. This project also depicted the efficacy of a consultative based OT service delivery model and how it may be helpful in other settings. I will use this evidence throughout my future career as an occupational therapist. References About National Head Start Association. NHSA (n.d.). Retrieved January 17, 2023 from https://nhsa.org/about-nhsa/ Benson, J. D., Szucs, K. A., & Mejasic, J. J. (2016). Teachers perceptions of the role of occupational therapist in schools. Journal of Occupational Therapy, Schools, & Early Intervention, 9(3), 290301. https://doi.org/10.1080/19411243.2016.1183158 Bowyer, P., Moore, C. C., & Thom, C. (2016). Occupational therapy in the context of head start: A preliminary survey study. Journal of Occupational Therapy, Schools, & Early Intervention, 9(4), 332339. https://doi.org/10.1080/19411243.2016.1245169 Brock, L. L., Kim, H., & Grissmer, D. W. (2018). Longitudinal associations among executive function, visuomotor integration, and achievement in a high-risk sample. Mind, Brain, and Education, 12(1), 2327. https://doi.org/10.1111/mbe.12164 Buzzell, K., Feeney, J., Gentile, L., Morris, S., Webster, S., & Herlache-Pretzer, E. (2021). Effects of occupational therapy-led fine motor centers on fine motor skills of preschoolaged children: An evidence-based program evaluation. Journal of Occupational Therapy, Schools & Early Intervention, 14(3), 248256. Cole, M. & Tufano, R. (2020). Applied theories in occupational therapy: A practical approach (2nd Ed.). SLACK Incorporated. Corr, C., Milagros Santos, R., Fowler, S. A., Spence, C., & Skubel, A. (2020). Early interventionists perceptions of supporting families experiencing poverty. Early Child Development and Care, 190(13), 20932105. https://doi.org/10.1080/03004430.2018.1560276 Earlylearningin. (2022, February 17). Early learning Indiana announces winners of $1 million statewide child care deserts competition. Early Learning Indiana. Retrieved March 18, 2023, from https://earlylearningin.org/early-learning-indiana-announces-winners-of-1million-statewide-child-care-deserts-competition/ Gibb R., Coelho L., Van Rootselaar NA., Halliwell C., MacKinnon M., Plomp I., & Gonzalez CLR. (2021). Promoting executive function skills in preschoolers using a play-based program. Frontiers in Psychology. (12) 720225. Doi: 10.3389/fpsyg.2021.720225 Jasmin, E., Gauthier, A., Julien, M., & Hui, C. (2018). Occupational therapy in preschools: A synthesis of current knowledge. Early Childhood Education Journal, 46(1), 7382. https://doi.org/10.1007/s10643-017-0840-3 Lust, C. A., & Donica, D. K. (2011). Research Scholars InitiativeEffectiveness of a handwriting readiness program in Head Start: A two-group controlled trial. American Journal of Occupational Therapy, 65, 560568. Doi: 10.5014/ajot.2011.000612 Marr, D., Cermak, S., Cohn, E. S., & Henderson, A. (2003). Fine motor activities in head start and kindergarten classrooms. The American Journal of Occupational Therapy, 57(5), 550 557. https://doi.org/10.5014/ajot.57.5.550 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. American Journal of Occupational Therapy, 72, 7201190030. https://doi.org/10.5014/ajot.2018.029017 Martino, E. M., & Lape, J. E. (2020). Occupational therapy in the preschool classroom promoting fine motor and visual motor skills for Kindergarten Readiness. Journal of Occupational Therapy, Schools, & Early Intervention, 14(2), 134152. https://doi.org/10.1080/19411243.2020.1822261 Moran, K. K. (2019). Perspectives on the child care search process in low-income, urban neighbourhoods in the United States. Early Child Development and Care, 191(5), 655 669. https://doi.org/10.1080/03004430.2019.1641703 Pfeiffer, B., May-Benson, T. A., & Bodison, S. C. (2018). Guest EditorialState of the science of sensory integration research with children and youth. American Journal of Occupational Therapy, 72, 7201170010. https://doi.org/10.5014/ajot.2018.721003 Reeder, D. L., Arnold, S. H., Jeffries, L. M., & McEwen, I. R. (2011). The role of occupational therapists and physical therapists in elementary school system early intervening services and response to intervention: A case report. Physical & Occupational Therapy in Pediatrics, 31(1), 4457. Reynolds, S., Shepherd, J., & Lane, S. (2008) Sensory modulation disorders in a minority head start population: preliminary prevalence and characterization. Journal of Occupational Therapy, Schools, & Early Intervention (1) :3-4, 186-198. https://doi.org/10.1080/19411240802589031 Scarlett, Robyn R., (2020) Occupational therapy support in the kindergarten classroom through rti tier I interventions: kindergarten teachers perceptions of need. Occupational Therapy Doctorate Capstone Projects. 61. https://encompass.eku.edu/otdcapstones/61 Sisti, M., & Robledo, J. (2021). Interdisciplinary collaboration practices between education specialists and related service providers. The Journal of Special Education apprenticeship 10(1) Available at: https://scholarworks.lib.csusb.edu/josea/vol10/iss1/5 Southeast Neighborhood Center. UWSJC. (n.d.). Retrieved March 5, 2022, from https://uwsjc.org/community-impact/southeast-neighborhood-center/ Stancliff, S. R., & Baist, H. (2021). Improving community-based preschool teacher confidence. Journal of Occupational Therapy, Schools, & Early Intervention, 14(1), 5974. https://doi.org/10.1080/19411243.2020.1799905 Wilburn, V. G., Douglas, C. M., Chase, A., Van Antwerp, L., & Stoll, H. (2019). Understanding early childhood educator practices. Journal of Occupational Therapy, Schools, & Early Intervention, 13(2), 126135. https://doi.org/10.1080/19411243.2019.1672605 Tables Post Survey Results 7 Teacher Responses 6 5 4 3 2 1 0 Did your students skills improve with the activities? Do you better understand what Occupational Therapy is? Will you continue to use these resources in the future? Do you feel more confident using Sensory Regulation strategies? Did you gain new knowledge from the weekly lesson packets? No 0 0 0 0 0 Yes 5 4 5 6 6 Left Comments 3 3 6 5 Teacher comments: Did your students skills improve with the activities? 1. Yes drastically 2. Yes, the majority of my class 3. Yes, it helped them in a few different ways Teacher Comments: Do you better understand what occupational therapy is? 1. That it helps children with sensory issues and helps children get through normal daily activities 2. I learned that it emphasizes developing and maintaining the skills people need to perform the activities or occupations of daily life 3. I learned occupational therapy can consult in the classroom on curriculum design, room set up, identify triggers for behaviors, and how to best help a child based on their learning style or other needs Teacher Comments: Do you feel more confident using Sensory Regulation Strategies? 1. Yes, large body movements can help calm the body 2. Yes, I learned that if their sensory system is dysregulated it is harder for them to function/ focus 3. Yes, I learned having different forms of sensory activities available help children self regulate 4. Yes, I put sensory objects in the quiet area such as heavy work and it helped our children calm themselves down 5. Yes, the lessons were a good refresher 6. Yes, it educated me more on sensory and how to use it in the classroom Teacher Comments: Did you gain new knowledge gained from the weekly lesson packets? 1. They gave me more ideas for fine motor to help my kids dexterity 2. I enjoyed the lesson that had the developmental milestones for writing. We did all of the activities. It gave us new things to try instead of doing some of the same activities weve been doing for so long 3. I got new ideas for small groups 4. Gave me the ability to try new things with the children at home and at school 5. Everything was very informative and helpful Figures Tier 3: Traditional Intervention (Not provided by Capstone Student) Tier 2: Targeted Intervention - Developmental skills small group lessons - Individualized recommendations Tier 1: Universal Intervention - Sensory path hallway - Sensory Toolbox resource - Sensory Center in the classroom - Dismissal transition changes Figure 1. Capstone RTI Structure Appendix 1: DCE Weekly Planning Guide Week 1 2 DCE Stage (orientation, screening/evaluation, implementation, discontinuation, dissemination) Orientation 4 Complete Site Orientation Objectives Tasks Introduce myself to each teacher Understand the daily site schedule, expectations, rules, etc. Complete new literature search Screening/ Evaluation Update Needs Assessment Screening/ Evaluation Develop and send out teacher presurvey Continue literature search on updated relevant topics Finalize schedule/topics for weekly small groups Analyze Presurvey results Try one new idea for quieter after school dismissal process per teacher request Briefly meet with each teacher on Friday to discuss structure of 1st packet, see if they recommend any changes Send the teachers the Fine Motor packet Check with site director to ensure all activities fit within the site curriculum standards 3 Weekly Goal Screening/ Evaluation Implementation Implementation Spend time in each classroom to get to know teachers and kids Observe morning and afternoon transitions Discuss with site mentor and teachers of my new plan Finalize MOU Tape circles onto the hallway floor in dismissal location Date Complete 1/13 1/20 1/27 Research topics to make weekly lessons evidence based Attend an on-site training scheduled for the teachers about All School Sings morning transition program Observe Library time with 2/3 multiple classrooms 5 Implementation Send the teachers the small group sensory activities packet and the Sensory Toolbox resource 6 Implementation 7 Implementation Develop and send executive functioning skills packet including activities to work on problem solving, emotional regulation, communication, attention, working memory, and planning. Put in Sensory Path on the hallway floor Check in with teachers on structure of weekly packets so far to ensure efficacy and increased knowledge Meet with each class to check on fine motor packet from previous week. One teacher asked me to observe a childs pencil grasp and make adjustments Observe children on the playground as it was built to be accessible Observed progress in dismissal transition with requiring less redirection from teachers for students to stand or sit on the spots 2/10 Finalize plan for sensory path materials (with no budget)- use of paper materials the site had 2/17 Learned more from teachers about their methods for tracking student progress during parent teacher conference week Recommended change in morning sign-in sheet to add a checkbox for dismissal method (bus or car) to ensure teachers and parents were on the same page and didnt require trying to remember from the morning 2/24 8 Implementation Develop and send motor planning/ bilateral coordination packet Learn more about therapeutic process at this site when speech therapist started two days a week Collaborated with behavior therapist with one classroom on shortening transition times and using heavy work strategies Implement heavy work activities with two students in one classroom 9 Implementation Develop and send sensory in the classroom packet and trial sensory movement center in one room 10 Implementation Develop post survey for teachers. Continue spending time in each classroom to ensure adequate time for teachers to ask questions/ collaborate 11 Discontinuation Send out post survey to teachers Meet with director to go over post survey 12 Discontinuation Send reminder to fill out post survey In-person check in with each teacher to inquire if they needed any more information/ resources The school had lead testing this week due to increased risk of high lead exposure in the neighborhood. 3/3 Observe heavy work activities in classroom. Continue collaboration with SLP and provide recommendations of kids for her to screen from my observations Meet with director and teachers in one room to brainstorm more effective transitions. Recommended visual timer and visual schedule Begin discontinuation process of mentioning I only have a few more weeks Compile all resources in one place and share access with site director and teachers 3/10 3/17 3/24 3/31 13 14 Dissemination Develop summer activities Work on dissemination packet to be sent home presentation with parents for summer break Dissemination Dissemination to Ensure going into each Finish summer activities site. Present results classroom to explain its packet to teachers and my last week and have a director smooth transition after I am gone Appendix 1: Doctoral Capstone Experience and Project Weekly Planning Guide Site Spring Break Analyze post survey results 4/7 4/14  ...

... Sexuality and Intimacy Across the Continuum of Care Courtney Cummings, OTS, PCBIS 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. Beth Ann Walker PhD, MS, OTR, FAOTA Cummings 1 Abstract One challenge occupational therapy practitioners face in practice is addressing sexuality and intimacy. This doctoral capstone project aims to increase practitioners' level of knowledge, comfort, attitudes, and willingness to address sexuality and intimacy across the continuum of care. A needs assessment across six different UC Health network locations found that each site believed occupational therapy practitioners had a role in addressing sexuality and intimacy, however only one site routinely addressed it. This project strives to establish a culture of shared understanding of the importance of sexuality by providing an education module and resources. The paper emphasizes the importance of addressing sexuality and intimacy in occupational therapy practice and highlights the need for further research to continue the development of educational programs and tools to establish a holistic incorporation of sexuality into clinical practice. Keywords: Occupational therapy practitioners, sexuality, intimacy, educational module, continuum of care. Cummings 2 Introduction UC Health Network is a large healthcare organization in the Greater Cincinnati area which provides rehabilitations services (OT, PT, SPL etc - fill in) across a variety of settings including acute care, long-term acute care, skilled nursing facilities, outpatient hand clinic, outpatient lymphedema clinic, and outpatient neuro clinic. UC Health is committed to improving the health of all people regardless of race, ethnicity, geography, or ability to pay (UC Health, n.d.). To be fully committed to improving the health of all people, healthcare workers have to look at clients through a holistic lens and need to be prepared to address all topics with patients, families, and staff. Sexuality and intimacy are important aspects of the human experience regardless of age, injury, illness, or disabilities (Couldrick, 1998; Lynch & Fortune, 2019; WHO, 2006). After completing an introductory interview at the UC outpatient Neuro clinic, it was determined that sexuality and intimacy are rarely addressed due to a gap in the therapists level of comfort and knowledge. If therapists at one location are not discussing sexuality and intimacy with patients, it is reasonable to assume other locations may not be addressing this topic either. The purpose of my capstone project was to increase therapists' levels of comfort, willingness, attitudes, and knowledge of sexuality and intimacy across the continuum of care. This capstone project aimed to create an education module on the topic of addressing sexuality and intimacy across the continuum of care by providing theoretical frameworks, assessment tools, and intervention resources for occupational therapy practitioners. The educational modules were presented across the UC Health Network to ensure therapists throughout the continuity of care are better prepared to address sexuality Cummings 3 and intimacy. Modules included a pre and post-knowledge check and a satisfaction survey to measure knowledge gain, level of comfort, change in attitudes, and willingness to address sexuality and intimacy Background Occupational therapy is a holistic, client-centered profession that aims to assist patients in reaching their optimal levels of performance in their activities of daily living (ADLs). To stay true to our profession and practice in a holistic and client-centered manner occupational therapists are obligated to address sexuality and intimacy with their clients (Fouche, 2014; Gray, 2021). Addressing sexuality and intimacy within occupational therapy practice has been highlighted within the literature for generations (Connie et al., 1979; Couldrick, 1998; Eglseder & Webb, 2018) This topic is not new or emerging, yet continues to be rarely addressed in routine practice (Dyer & Nair, 2013). The American Occupational Therapy Association (AOTA) has recognized and acknowledged sexual activity as an area of occupation within activities of daily living (ADL) (AOTA, 2020). The majority of occupational therapy practitioners recognize and acknowledge the importance of sexuality and that it is within the domain of our practice (Young et al., 2020). Despite this knowledge occupational therapy practitioners continue to be reluctant to address sexuality with their clients (Esmail et al., 2010). Literature suggests the barriers to addressing sexuality an intimacy include lack of knowledge, decreased comfort, attitudes, willingness, and perceived readiness of clients (AreskougJosefsson et al., 2016; Eglseder & Webb, 2017; Hyland & McGrath, 2013; McGrath & Lynch, 2014; Young et al., 2020). Cummings 4 A representative from each of the six UC Health therapy locations was selected to complete a needs assessment addressing sexuality and intimacy in their setting. The representatives from each site, long-term acute care, skilled nursing facilities, outpatient hand clinic, outpatient lymphedema clinic, and two outpatient neuro locations, believe that sexuality and intimacy are within the occupational therapy scope of practice. Out of the six locations, only the lymphedema clinic is routinely addressing the topic. The lymphedema clinic representative believes sexuality and intimacy are more likely to be addressed in this setting due to the nature of the work, being in patients' personal space, and the topic is an item on the Lymphedema Life Impact Scale which is administered during the initial evaluation. Additional barriers noted by representative occupational therapists included: clinician discomfort, lack of screening tools, lack of knowledge, environmental factors such as lack of private space to discuss topics, perceived readiness of clients/wrong setting, lack of resources, and no prior training. The barriers identified at UC Health align with barriers found within the literature, signify a call to action to address these barriers. Many articles highlight the importance of addressing sexuality and intimacy within the scope of occupational therapy (MacRae, 2013), yet there is a gap between professional ideology and practice in occupational therapy (Eglseder & Webb, 2018; McGrath & Lynch, 2014). Throughout the literature, it is repeated that the need for future research is to develop education and programs to establish a holistic incorporation of sexuality into clinical practice (Couldrick, 1999; Eglseder & Webb, 2018; Haag et al., 2016; Mohammed, 2017; OMullan et al., 2021; Young et al., 2020). The barriers to addressing sexuality and intimacy have been established for decades, however, very little Cummings 5 research has been explored regarding the development of educational modules for occupational therapists in practice. This capstone project aimed to create a community at UC Health to establish a culture of shared understanding of the importance of sexuality by providing education modules and resources that can enhance comfort, attitudes, knowledge, and skill set when addressing sexuality and intimacy to enhance the sexual education for our patients (Eglseder & Webb, 2017). This project strived to improve occupational therapy practitioners' level of comfort and willingness to address sexuality and intimacy by increasing their knowledge through educational modules. More recently Fortinsky and Shaham (2020) modified the needs assessment to evaluate the attitudes, knowledge levels, and skill requirements of addressing sexuality for occupational therapists in Israel. They found that due to limitations within occupational therapy education, therapists lack intervention skills for addressing sexuality with patients. They proposed the need to develop a three-part seminar to enhance the learning and skill development necessary to address sexuality with patients. Similarly, Lepage et al., (2020) explored occupational therapists' perceptions of the factors that influence their practice addressing sexuality and identified the need to develop continuing education. Lepage et al., (2020) discussed the need for educational training to address occupational therapists' attitudes to understanding client factors, as well as assessments and interventions. More recently Walker et al., (2023) presented a workshop at the 2023 AOTA conference on Using a positive solution-focused approach to enhance education related to the global practice of OT in addressing sexuality and intimacy, once again illustrating the need for educational changes in addressing sexuality and intimacy. These Cummings 6 articles are just a few of the many that highlight the need for the development of educational resources pertaining to addressing sexuality and intimacy in occupational therapy. There is a lot of literature highlighting the need for educational modules, the need for change, and the need for implication into practice, but very little is known about the success of that education or how it is created. My project aims to capitalize on the followthrough and identify how to make that change by creating an educational module. Guiding Theory Occupational therapy practitioners are uniquely skilled to incorporate the Person, Environment, and Occupation (PEO) model to address the challenges with sexuality and intimacy after injury or illness. The PEO model is dynamic in nature due to the constant transaction between person, environment, and occupation that impacts occupational performance (Cole & Tufano, 2020). The transaction goes beyond interaction, and if one area changes then every area changes and occupational performance is impacted. As these areas change they can either overlap more and maximize the fit or spread a part minimizing the fit; the better the fit the better the occupational performance. In the case of the capstone project, the Person is the individual therapist, the Occupation is addressing sexuality and intimacy and the Environment is UC Health. The aim of the educational module addressing sexuality and intimacy at UC Health was to influence the knowledge of individual therapists, thus the Person and further influence the environment, and occupation and leading to the improvement of occupational performance. Cummings 7 In conjunction with the PEO model, the Occupational Therapy Sexual Assessment Framework (OTSAF) will be utilized to guide the development of educational modules and educational resources. The OTSAF is a theoretical framework that addresses sexuality and intimacy in the context of occupational therapy. The OTSAF is made up of nine constructs; sexual knowledge, sexual response, sexual interest, sexual self-view, sexual expression, sexual activity, intimacy, sexual health, and family planning (Walker et al., 2020). As the educational module is developed, it is important to consider each to understand the occupational nature of sexuality and intimacy construct and how they impact clients at UC Health. Creating educational modules will not only help improve therapists ability to define the occupational nature of sexuality and intimacy but enable them to address sexuality and intimacy in practice, thereby potentially enhancing their clients quality of life. Project Design Educational modules addressing sexuality and intimacy within the scope of occupational therapy were developed due to the discovery of a gap between professional ideology and practice. An introductory needs assessment was conducted across six UC Health therapy locations and it was determined that sexuality and intimacy were not being routinely addressed. Barriers addressing sexuality and intimacy that were reported across the UC Health network included; lack of knowledge, lack of comfort, perceived readiness of clients, lack of assessment upon evaluation, and limited private space to address topics in the clinic. The educational module was developed in evidence-based research with a strong influence from the Occupational Therapy Sexual Assessment Framework (OTSAF). The Cummings 8 55-minute educational module was created on Google Slides and accompanied by a voiceover lecture. The educational module was distributed across the six UC health network locations via email for Occupational Therapy Practitioners to review as their schedule permits. For four weeks, weekly email reminders were sent out to ensure that the maximum number of occupational therapy practitioners were reached. Occupational Therapy Practitioners were also encouraged to participate by word of mouth. Prior to viewing the educational modules occupational therapy practioners completed a semi-structured survey from a modified version of the Knowledge, Comfort, Approach, and Attitudes towards Sexuality Scale (KCAASS) (Kendall et al., 2003) which was developed in reference to the framework - The Occupational Therapy Sexual Assessment Framework (OTSAF) (Walker et al., 2020). The original outcome measure was designed for health professionals working in Spinal Cord Injury rehabilitation to gather information about the topic of sexuality. The outcome measure was modified to suit occupational therapists working with the general physical rehabilitation population across the continuum of care. Approval to modify and use the KCAASS was granted by Kendall (2003) and was distributed across the continuum of care at the UC Health Network. The modified version of the KCAASS consisted of four sections: knowledge, comfort, willingness, and attitudes. The outcome measure was shortened from 47 to 35 questions, with 9 items addressing staff knowledge, 15 items related to staff comfort, 8 items addressing staff willingness, and 3 items addressing attitudes towards sexuality. Alterations were made to the terminology with the purpose of being inclusive and gender-neutral. Nine new items were added in place of staff knowledge to capture the Cummings 9 occupational nature of sexuality and intimacy based on the OTSAF. Five new items were added to staff comfort with the purpose of capturing the levels of comfort regarding sexual minorities. A panel consisting of an expert in the field and an onsite therapist was utilized to provide initial feedback on the modified version of the KCAASS. Suggestions were taken into consideration and the modified version of the KCAASS was refined and revised. See Appendix A for a full copy of the modified KCAASS. Project Outcomes Participants Participants were recruited for this study from the six occupational therapy practice settings at UC Health via email and word of mouth. A total of five participants completed the pre-test measure but only four completed the post-test measure. Of the four participants who completed the module, three identified as female and one identified as male. The participants' years of experience ranged from 1 to 7 years, with an average of 4.5 years. Two participants had a Master's degree in Occupational Therapy, while the other two participants held a Doctorate in Occupational Therapy. Three participants worked full-time and one participant worked PRN. The participants worked in various practice settings, including Outpatient Hands, Skilled Nursing Facility (SNF), and two worked in Outpatient Neuro rehab. Statistical Analysis A statical analysis was conducted to compare the mean scores between the pretest and post-test measures of the modified Knowledge, Comfort, Approach, and Cummings 10 Attitudes Towards Sexuality Scale (KCAASS) following the educational module addressing sexuality and intimacy within the scope of occupational therapy across the continuum of care. The category addressing occupational therapy practitioners' knowledge had 9 items, Comfort had 15 items, willingness had 8 items, and attitudes had 3 items. All together the four categories had 35 items. The total score was calculated for each pre and post test category. The total score for each category was then averaged and the standard deviation was calculated. The pretest and post test score for each category was then compared to determine the percentage of change. Knowledge The pre-test category knowledge of sexuality and intimacy (M = 20.5, SD = 4.43) and post-test (M = 27.25, SD = 7) showed increase in knowledge gained by 18% Discomfort The pretest measuring occupational therapy practitioners' level of discomfort addressing sexuality and intimacy (M = 31.5, SD = 6.08) compared to the post-test (M = 24.25 , SD = 7.68), showed a decrease in discomfort by 13%. Willingness The pre-test measuring occupational therapy practitioners willingness to address sexuality and intimacy (M = 20.3, SD = 2.63) compared to the post-test (M = 26 , SD = 5), showed an increase in willingness to address sexuality and intimacy by 18% Attitudes Cummings 11 The pretest of occupational therapy practitioners attitudes (M = 8.25, SD = 0.5 ) and post-test (M = 9.3, SD = 1.05), showed an increase in positive attitudes toward sexuality and intimacy by 8%. Knowledge, Comfort, Willingness, Attitudes Table 1. Highlights the pretest and post-test scores below. It is shown that the implementation of the education module leads to an increase in knowledge, a decrease in discomfort, an increase in willingness, and an increase in positive attitudes addressing sexuality and intimacy across the continuum of care. The Pre-test and Post-Test modified KCAASS found that knowledge Pre-test (M = 20.5, SD = 4.43) and post-test (M = 27.25, SD = 7) and willingness, a pre-test (M = 20.5, SD = 4.43) and post-test (M = 27.25, SD = 7) had the highest increase in the mean difference at 18%. This suggests that with an increase in knowledge occupational therapy practitioners may be more willing to address sexuality and intimacy. Discomfort scores, Pre-test (M = 31.5, SD = 6.08) and the posttest (M = 24.25, SD = 7.68) decreased by 13%. Attitudes had the smallest amount of change with an increase in positive attitudes by 8 %, Pre-test (M = 8.25, SD = 0.5 ) and post-test (M = 9.3, SD = 1.05). and post-test (M = 27.25, SD = 7) with an increase in willingness to address sexuality and intimacy by 18%. Table 1 Outcome Measures Mean Pretest Score (M) Pretest Score Std. Deviation (SD) Mean PostTest Score (M) Post-Test Std. Deviation (SD) Mean Difference (MD) Number of Participants (n) Knowledge 20.5 (57%) 4.43 27.2 (76%) 7 + 6.75 (18%) 4 Discomfort 31.5 (56%) 6.08 24.25 (43%) 7.68 - 7.25 (13%) 4 Cummings 12 Willingness 20.3 (63%) 2.63 26 (81%) 5 + 5.8 (18%) 4 Attitudes 8.25 (69%) 0.5 9.3 (77%) 1.05 +1 (8%) 4 Summary Throughout the literature review it was found that many occupational therapist practitioners acknowledge that sexuality and intimacy are within the scope of occupational therapy, however, are reluctant to address the topic due to barriers such as lack of knowledge, comfort, willingness, attitudes, lack of time, and professional support. This capstone project was developed for the six UC Health Network locations in the Greater Cincinnati area for occupational therapy departments across a wide range of settings including acute care, long-term acute care, skilled nursing facilities, outpatient hand clinic, outpatient lymphedema clinic, and an outpatient neuro clinic. A representative from each of the six UC Health therapy locations was selected to complete a needs assessment addressing sexuality and intimacy in their setting. The needs assessment found that each site identified that sexuality and intimacy were within the scope of occupational therapy, however only one out of six sites addresses the topic regularly in practice. The gap between professional ideology and practice in occupational therapy in regard to sexuality and intimacy highlighted the need for an educational module in sexuality and intimacy. This capstone project aimed to increase occupational therapy practitioners' level of comfort, willingness, attitudes, and knowledge of sexuality and intimacy across the continuum of care through an educational module. A dependent sample t-test was conducted to determine if there was a significant difference in scores between the pre-test Cummings 13 and post-test measures of the modified KCAAS. The study found that knowledge, comfort, attitude, and willingness all had an increase in pre and post-test scores. Conclusion As a result of this capstone project an educational module and digital resource binder to address sexuality and intimacy across the continuum of care was created. The educational module provided theoretical frameworks, a screening and assessment tool, intervention strategies, goal writing, billing codes, and a case study for occupational therapy practitioners. The educational module was presented across the UC Health Network at six locations, two outpatient neuro clinics, a skilled nursing facility, a hand clinic, a lymphedema clinic, and a long-term acute care facility. The goal was to ensure occupational therapy practitioners throughout the continuum of care are better prepared to address sexuality and intimacy. In the future, it is suggested to present the information in person to create accountability to increase participation. The initiation of conversation surrounding sexuality and intimacy relies on practitioners' interprofessional collaboration and intrinsic factors. The development of educational modules can improve knowledge, but comfort, willingness and attitudes are intrinsic factors that rely on the development of selfreflection and personal growth. To evolve and expanded our role as occupational therapy practitioners there needs to be a positive change in enhancing education as it relates to addressing sexuality and intimacy (Walker et al., 2023). To truly be a holistic client center profession and uphold our ethical obligations, we must address sexuality and intimacy. Cummings 14 Reference 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 Areskoug-Josefsson, K., Larsson, A., Gard, G., Rolander, B., & Juuso, P. (2016). Health care students attitudes towards working with sexual health in their professional roles: Survey of students at nursing, physiotherapy and occupational therapy programmes. Sexuality and Disability, 34(3), 289302. Cole, M. & Tufano, R. (2020). Applied theories in occupational therapy: A practical approach (2nd Ed.). SLACK Incorporated. Conine, T., Christie, M.,, & Hammond, K. (1979). An assessment of occupational therapists roles and attitudes toward sexual rehabilitation of the disabled. American Journal of Occupational Therapy, 33, 515519. Couldrick, L. (1998). Sexual Issues an Area of Concern for Occupational Therapist. British Journal of Occupational Therapy, 61(11). Dyer, K., & das Nair, R.(2013). Why don't healthcare professionals talk about sex? A systematic review of recent qualitative studies conducted in the United Kingdom. The Journal of Sexual Medicine, 10(11), 26582670. Eglseder, K. & Demchick, B. (2017). Sexuality and spinal cord injury: The lived experiences of intimate partners. OTJR: Occupation, participation and health, 37(3), 125-131. Cummings 15 Eglseder, K., & Webb, S. (2018). Sexual Functioning in Occupational Education: A Survey of Programs. Open Journal of Occupational Therapy (OJOT), 6(3), 1 16 Esmail, S., Darry, K., Walter, A., & Knupp, H. (2010). Attitudes and perceptions towards disability and sexuality. Disability and Rehabilitation, 32, 11481155. http://dx. doi.org/10.3109/09638280903419277 Fortinsky, H., & Shaham, O. (2020). Needs assessment for developing an educational project in the field of sexuality and intimacy in occupational therapy. Israel Journal of Occupational Therapy, 29(2), E28E47. Fouch, L. (2014). An occupational therapists perspective on sexuality and psychosocial sexual rehabilitation. In R. Crouch & V. Alers (Eds.), Occupational therapy in psychiatry and mental health., 5th ed. (pp. 212226). Gravetter, F. J., & Wallnau, L. B. (2014). Essentials of statistics for the Behavioral Sciences (8th ed.). Wadsworth, Cengage Learning. Gray, A. N. (2021). Adolescents with autism and sexual health: Lets tackle the gap! [ProQuest Information & Learning]. In Dissertation Abstracts International: Section B: The Sciences and Engineering, 82 (12B). Haag, H. L., Caringal, M., Sokoloff, S., Kontos, P., Yoshida, K., & Colantonio, A. (2016). Being a woman with acquired brain injury: Challenges and implications for practice. Archives of Physical Medicine and Rehabilitation, 97(2 Suppl), S64S70. https://doi.org/10.1016/j.apmr.2014.12.018 Hyland, A., & McGrath, M. (2013). Sexuality and occupational therapy in IrelandA case of ambivalence? Disability and Rehabilitation: An International, Cummings 16 Multidisciplinary Journal, 35(1), 7380. https://doi.org/10.3109/09638288.2012.688920 Kendall, M., Booth, S., Fronek, P., Miller, D., & Geraghty, T. (2003). The development of a scale to assess the training needs of professionals in providing sexuality rehabilitation following spinal cord injury. Sexuality and Disability, 21(1), 49-64. Kielhofner, G., & Taylor, R. (2017). Research in occupational therapy: Methods of inquiry for enhancing practice. F.A. Davis Company. Lepage, C., Auger, L.-P., & Rochette, A. (2020). Sexuality in the context of physical rehabilitation as perceived by occupational therapists. Disability and Rehabilitation, 43(19), 27392749. Lynch, C., & Fortune, T. (2019). Applying an occupational lens to thinking about and addressing sexuality. sexuality and disability. Sexuality and Disability, 37. MacRae, N. (2013). Sexuality and the role of occupational therapy. American Occupational Therapy Association. Mohammed, A. (2017). Addressing Sexuality in Occupational Therapy. OT Practice, 22(9), CE-1-CE-8. McGrath, M., & Lynch, E. (2014). Occupational therapists perspectives on addressing sexual concerns of older adults in the context of rehabilitation. Disability and Rehabilitation, 36, 651657. National Institute of Standards and Technology (NIST). (n.d.). Student's tDistribution Table. In Engineering Statistics Handbook. Retrieved April 10, 2023 from https://www.itl.nist.gov/div898/handbook/eda/section3/eda3672.htm. Cummings 17 OMullan, C., OReilly, M., & Meredith, P. (2021). Bringing sexuality out of the closet: What can we learn from occupational therapists who successfully address the area of sexuality in everyday practice? Australian Occupational Therapy Journal, 68(3), 272281. https://doi.org/10.1111/1440-1630.12723 UC Health Mission. About UC Health. (n.d.). Retrieved December 12, 2022, from https://www.uchealth.com/about/#:~:text=Our%20Mission,and%20building%20a %20diverse%20workforce. Young, K., Dodington, A., Smith, C., & Heck, C. S. (2020). Addressing clients' sexual health in occupational therapy practice. Canadian Journal of Occupational Therapy, 87(1), 5262. Walker, B. A., Otte, K., LeMond, K., Hess, P., Kaizer, K., Faulkner, T., & Christy, D. (2020). Development of the Occupational Performance Inventory of Sexuality and Intimacy (OPISI): Phase One. The Open Journal of Occupational Therapy, 8(2), 118. https://doi.org/10.15453/2168-6408.1694 Walker, B. A., Soros, J., Reese, K., Ellis, K., Alter, A., Cummings, C., Downs, B., Elstien, K., Greenwell, I., & Luna, K. (2023, April 20-23). Using a positive solution-focused approach to enhance education related to the global practice of OT in addressing sexuality and intimacy [Conference workshop]. American Occupational Therapy Association INSPIRE 2023 Conference, Kansas City, MO. World Health Organization. (2006). Defining sexual health: Report of a technical consultation on sexual health 28-31 January 2002, Geneva. https://www.who.int/reproductivehealth/publications/sexual_health/defining_sexu al_healh.pdf?ua=1 Cummings 18 Appendix A Modified Knowledge, Comfort, Approach and Attitudes Towards Sexuality Scale (KCAASS; M. Kendall, S. Booth, P. Fronek, D. Miller, T. Geraghty) Characteristic of participants: 1. What sex were you assigned at birth, on your original birth certificate? a. Female b. Male c. Dont know d. Prefer not to answer 2. What is your current gender? a. Male b. Female c. Transgender man d. Transgender woman e. Non-Binary f. Other g. Prefer not to answer 3. Years of Experience in Occupational Therapy? 4. Highest Level of Education received within Occupational Therapy? a. Doctorate in Occupational Therapy b. Masters in Occupational Therapy c. Bachelors in Occupational Therapy d. Associates in Occupational Therapy 5. Position a. Full Time b. Part time c. PRN 6. What practice setting do you work in? a. Outpatient Neuro b. Long-term Acute Care (LTAC) c. Skilled Nursing Facility (SNF) d. Outpatient Lymphedema e. Outpatient hands f. Inpatient psychiatric hospital g. other: _____ 7. Do you have any areas of speciality/extra certifications or credentials? Cummings 19 8. Have you received previous education areas of sexuality and Intimacy within the scope of occupational therapy? a. Yes b. No 9. If you replied Yes to the question above, How was that education received? a. Occupational therapy Program b. Self-Selected Continuing Education c. At Work d. Self-Taught (books, videos) e. Social Media f. Other SECTION 1: Knowledge On a scale of 14, please indicate your current level of knowledge in dealing with the following topics as they relate to your patient population 1. Sexual Knowledge: What a person knows, understands, believes, and values regarding sexuality and intimacy. a. No knowledge b. Limited knowledge c. Some knowledge d. Excellent knowledge 2. Sexual Activity: A persons ability to safely engage in sexual and/or intimate activities (alone or with another person). Sexual activities may include hugging, kissing, foreplay, masturbation, oral sex, anal sex, vaginal sex, and use of sexual toys or devices. a. No knowledge b. Limited knowledge c. Some knowledge d. Excellent knowledge 3. Sexual Interest: A persons psychological and physiological drive, motivation, desire, or libido related to participation in sexual activities alone or with another person. a. No knowledge b. Limited knowledge c. Some knowledge Cummings 20 d. Excellent knowledge 4. Sexual Response: The bodys physical sexual response associated with sexual activity including physiological arousal, response to erogenous zones, nipple erection, clitoral excitation, erection, vaginal lubrication, prostate release, ejaculation, and/or orgasm. a. No knowledge b. Limited knowledge c. Some knowledge d. Excellent knowledge 5. Sexual Expression: A persons ability to express themselves as a sexual being. A person may express their sexuality and/or gender identity through behaviors, mannerisms, preferences, appearance, pronouns, political engagement, acquired tendencies, daily routines, symbolic actions, or preferred roles. a. No knowledge b. Limited knowledge c. Some knowledge d. Excellent knowledge 6. Sexual Self-View: How a person views themselves as a sexual being and includes aspects of sexual identity, gender identity (examples among many: man, woman, nonbinary, transman, ciswoman, genderqueer, gender nonconforming), sexual selfesteem (a persons comfort and confidence with how they view themselves as a sexual being), and body image (mental representation of how a person pictures themselves). a. No knowledge b. Limited knowledge c. Some knowledge d. Excellent knowledge 7. Intimacy: A persons ability to initiate and maintain close intimate relationships which includes the ability to give and receive affection needed to successfully interact in the role as intimate partner. a. No knowledge b. Limited knowledge c. Some knowledge d. Excellent knowledge Cummings 21 8. Sexual Health: A persons ability to develop, manage, and maintain routines for sexual health including practicing safe sex and identifying, understanding, selecting, and use of protection a. No knowledge b. Limited knowledge c. Some knowledge d. Excellent knowledge 9. Family Planning: A persons ability to develop, manage, and maintain routines associated with fertility, pregnancy, and/or parenthood. a. No knowledge b. Limited knowledge c. Some knowledge d. Excellent knowledge SECTION 2: Comfort Please rate the following items on a scale from 1 (no discomfort), to 4 (high discomfort) on the amount of comfort/discomfort you would feel in these situations. 1. When you are teaching how to self-catch, the patient gets an erection. a. No Discomfort b. Low Discomfort c. Medium Discomfort d. High Discomfort 2. Patient asks, Will I ever be able to have an erection? a. No Discomfort b. Low Discomfort c. Medium Discomfort d. High Discomfort 3. Patient with tetraplegia asks, Can I still have sex? a. No Discomfort b. Low Discomfort c. Medium Discomfort d. High Discomfort Cummings 22 4. Patient who identifies as a gay man with a spinal cord injury is requesting information about intimacy. a. No Discomfort b. Low Discomfort c. Medium Discomfort d. High Discomfort 5. Patient says I cant feel anything anymore, so whats the point? a. No Discomfort b. Low Discomfort c. Medium Discomfort d. High Discomfort 6. Partner asks Will I hurt my partner(s) during sex? a. No Discomfort b. Low Discomfort c. Medium Discomfort d. High Discomfort 7. Patient who identifies a bisexual female with recent SCI, Do I show my wheelchair on the dating apps or not? a. No Discomfort b. Low Discomfort c. Medium Discomfort d. High Discomfort 8. Patient asks, Will I ever be able to have an orgasm again? a. No Discomfort b. Low Discomfort c. Medium Discomfort d. High Discomfort 9. Patient who identifies as non-binary with a stroke asks, Will I ever be able to have children? a. No Discomfort b. Low Discomfort c. Medium Discomfort d. High Discomfort 10. Patient asks, What will I do with my catheter during sex? Cummings 23 a. No Discomfort b. Low Discomfort c. Medium Discomfort d. High Discomfort 11. Patient who identifies as a heterosexual male with a TBI says I want to have sex but my partner has lost interest. What should I do? a. No Discomfort b. Low Discomfort c. Medium Discomfort d. High Discomfort 12. Patient asks, What if I have a bowel accident during sex? a. No Discomfort b. Low Discomfort c. Medium Discomfort d. High Discomfort 13. Patient says None of my friends would ever go out with someone in a wheelchair. a. No Discomfort b. Low Discomfort c. Medium Discomfort d. High Discomfort 14. Patient bursts into tears stating I have never felt like the sex I was assigned at birth a. No Discomfort b. Low Discomfort c. Medium Discomfort d. High Discomfort 15. Patients ask for adaptive equipment to assist with positioning during sex. a. No Discomfort b. Low Discomfort c. Medium Discomfort d. High Discomfort SECTION 3: Willingness Cummings 24 Please indicate your current level of willingness when dealing with the following topics as they relate to your patient population. Rate the following items on a scale from 1 (Very Unlikely), to 4 (Very likely). 1. How likely are you to include aspects of sexuality and intimacy in elevator speech for what it OT a. Very Likely b. Unlikely c. Likely d. Very Likely 2. How likely are you to include aspects of sexuality and intimacy in your initial evaluation a. No Discomfort b. Low Discomfort c. Medium Discomfort d. High Discomfort 3. How likely are you to officially screen for client concerns related to sexuality and intimacy a. No Discomfort b. Low Discomfort c. Medium Discomfort d. High Discomfort 4. How likely do you think you would be to use a formal assessment sif concerns were identified in the screening process? a. No Discomfort b. Low Discomfort c. Medium Discomfort d. High Discomfort 5. How likely are you to provide interventions for sexuality and intimacy a. No Discomfort b. Low Discomfort c. Medium Discomfort d. High Discomfort 6. How likely are you to write goals to address sexuality and intimacy a. No Discomfort Cummings 25 b. Low Discomfort c. Medium Discomfort d. High Discomfort 7. How likely are you to address adaptive equipment for the use of sexual activity a. No Discomfort b. Low Discomfort c. Medium Discomfort d. High Discomfort 8. How likely are you to refer out for sexuality and intimacy issues a. No Discomfort b. Low Discomfort c. Medium Discomfort d. High Discomfort e. SECTION 4: Attitudes 1. Occupational therapy has a professional role in addressing Sexuality and Intimacy a. Strongly Disagree b. Disagree c. Agree d. Strongly Agree 2. Addressing sexuality and intimacy is a priority in my setting a. Strongly Disagree b. Disagree c. Agree d. Strongly Agree 3. My employer is willing to let me address sexuality and intimacy a. Strongly Disagree b. Disagree c. Agree d. Strongly Agree Cummings 26 Appendix B Sexuality and Intimacy Across the Continuum of Care Project Timeline Orientation Week 1: January 9th-13th: Orientate to the setting and site. Learn about cultural, intervention styles & Patient population Discuss initial project ideas with supervisor - Completed Jan 9th Set up meeting times with BA for the semester - Completed Jan 18th Updates on project Discuss Pre/Post test & Survey questions How to disseminate the OPISI across UC campus Begin setting up meeting times for the six locations to complete individual needs assessments Completed Wednesday Jan 11th, Meeting with Colton for OP Neuro Clinic @ 11 Completed Friday Jan 13th Meeting via Teams with Maureen for Lymphedema Clinic @ 3pm. Completed Thursday Jan 23rd - Jody @ Drake OP Neuro, Rachel and Amanda @ for SNF & LTAC Create an updated literature review Barriers to address S/I Find condition specific articles Screening/ Evaluation Week 2:January 17th-20th - Continue completing needs Assessment while evaluating information already gathered -Completed Jan 23rd Begin developing Outcome measures Completed Jan 19th Find methodology articles to support outcomes measures Cummings 27 Determine how to disseminate pre/post test & Survey; Google survey/qualtrics? Update literature review, research, and MOU - Completed Jan 20th o Begin writing Intro Draft (Due 1/23) Submitted MOU, IRB form & SiteMentor Resume Completed Jan 19th Meeting with Melissa Kendall,@ Hoxworth Hands @ 12:15-45 Completed Thursday 19th Friday 20th, Transgender research @12-1 pm Via teams Completed Friday 20th Capstone Check-in 1-1:30 via Teams Completed Friday 20th Reflection responses due. Completed Friday 20th Week 3 January 23rd-27th: Finalize Pre/Post survey & test, How I will disseminate information, Outline Educational modules Meeting with Sarah @ Drake SNF, Rachel @ Drake LTAC @ 1-2 Completed Jan 23rd Meeting with Jody@ DrakeOP Neuro, 12-12:45 Completed Jan 23rd Send out the Outcome measurement to BA and make sure it is ready to go live and does not need to be revised. Start writing Background Draft Completed Jan 30th Review of best evidence and use of a theory/framework to guide project Begin Outlining lesson plans for educational modules - Completed Jan 30th solidify needs assessment information to structure outline Capstone Check-in 1-1:30 via Teams Completed Jan 27th Reflection responses due. Completed, Jan 27th Implementation: Weeks 4-10: Implement of educational modules, case study examples, Smartphrase template, Intervention Ideas, and patient educational material Week 4 January 30th-February 3rd : Background Draft turned in Completed Jan 30th Begin Developing Educational Moduled Open with trigger warning - Safe space & brave space S/I Within the Domain of OT Sexual Minorities OPISI Case study Cummings 28 Interventions Questions Begin writing Project: Design & Implementation Draft (Due 2/6) Capstone Check-in 1-1:30 via Teams Completed February 3rd Reflection responses due. Completed Febuary3rd Week 5 February 6th-10th: Develop and complete Educational modules Send educational modules out for feedback Completed Feb 17th Site Mentor Capstone Check-in 1-1:30 via Teams Completed Friday 20th Reflection responses due. Completed Friday 20th Week 6 February 13th-17th: Final Version of educational modules Completed Feb 20th Revises Educational modules Record educational modules on VT Completed Feb 20th Can I make people fill out a google form that gives them a link to the educational module to ensure I have all accurate outcome measures? Week 7 February 20th-24th: Midterm Evaluation, Educational Modules goes live Educational Modules goes live - Completed March 10th Mid Term Evaluations o UC Eval - Feb 21, @ 12:30-1 Completed Feb 21th o UIndy Eval -Online Core Completed Feb 20th Week 8 February 27th-March 3rd: Epic SmartPhrase, Send out Post Outcomes Assessment Develop Smartphrase/documentation for addressing sexuality and intimacy Completed March 14th In initial eval, future assessment/OPISI Send out post test/survey Completed March 10th Via google forum Week 9 March 6th-10th:Outcomes Draft, Answer Educational Module Questions, Find resources Begin writing Project: Outcomes Draft (Due 3/13) - Completed April 10th Cummings 29 Send out email about educational module going live and encouragement to complete pre/post test for educational module - Completed March 10th Gather intervention resources Completed April 7th Week 10 March 13th-17th: Dissemination Plan, Answer Educational Module Questions, Find resources Begin writing Dissemination plan Completed March 20th Gather intervention resources Completed April 7th Send out reminder email to complete pre/post test Completed March 15th Discontinuation Week 11 March 20th-24th: Wrap up Module Questions and Outcome measures Analyze all data gathered -Completed April 12th Develop figures accordingly Completed April 12th Week 12 March 27th-31st: Make final reports of data and feedback Completed April 13th What can the presentation include in the future? Dissemination Week 13 April 3rd-7th: Begin writing Abstract, Summary & Conclusion Draft & Thank yous, Begin writing Abstract, Summary & Conclusion Draft -Completed rough draft April 10th Write Thank yous Completed April 7th Week 14 April 10th-14th: Disseminate information, Disseminate info of the project to the site -Completed April 10th Make future recommendations Final Evaluation - Completed April 14th UC @ 1 pm UIndy on Core Evaluation of Doctoral Capstone Experience Completed April 24th Begin writing reflection draft - Completed April 24th Begin Poster Draft Completed April 24th Cummings 30 Begin VT Draft Completed April 24th Week 15 April 17th-21st: Work Remote Begin Doctoral Capstone Project Poster (electronic) (Due 5/1) Week 16 April 24th -28th: On Campus Begin Summary Written Reflection on DCE learning & experience (Due 5/1) Begin Capstone Project Presentation: VoiceThread & PPT (Due 5/1) Week 17 May 1-6th: On campus, half marathon, Graduation! Pinning Ceremony May 5th Half Marathon May 6th GRADUATION May 6th  ...

... Running Head: FALL PREVENTION TRAINING 1 Fall Prevention and Transfer Training Program for Non-Clinical Adult Day Staff Livia M. Crispen 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: Tricia Holmes, DHSc, MOT, OTR FALL PREVENTION TRAINING 2 Abstract Objectives Falls are common in older adults and the consequences of falls can be serious. The purpose of this program evaluation was to implement and assess the effectiveness of fall prevention and transfer training with the goal of increasing knowledge and attitudes of non-clinical adult day staff. Study Design Mixed methods program evaluation. Methods Training and evaluation methodology included the health belief model and the Person-Environment-Occupation-Performance model. A variety of surveys formed the criteria to determine if the outcomes were met. Results Knowledge scores improved from pre-survey to post-survey for all participants. For the attitudes portion of the survey, there was no difference in attitudes between the pre-survey and post-survey, as the surveys indicated an overall positive attitude. Conclusions The fall prevention and transfer training program is a facilitator for increased client and staff safety. The staff demonstrated increased knowledge and attitudes toward adopting the learned material while working. FALL PREVENTION TRAINING 3 Fall Prevention and Transfer Training Program for Non-Clinical Adult Day Staff Joys House is an adult day organization that provides services to adults with life-altering diagnoses like dementia and their caregivers. Joys House envisions a world where all individuals with life-altering diagnoses and their families are living fulfilled lives of knowledge, choice, and comfort, (Joys House, n.d.). Joys House serves families from all over Indianapolis, Indiana with two locations in Broad Ripple and on the University of Indianapolis campus. Families pay out of pocket, file their insurance, or receive scholarships through Joys House for the daily rate. The clients who attend Joys House during the day are referred to as Guests. The Guest Relations Assistants (GR) are the individuals who work directly with the Guests daily. The GR staff receive general training initially after hire in regard to a typical day at Joys House, food safety, basic fall prevention, helping Guests with toileting, how to redirect a person with dementia and other important training pieces. Falls are very common in older adults age 65 and older and the consequences of falls can be serious (CDC, 2019). Additionally, the rate of falls in community-dwelling older people with dementia is twice that of a cognitively intact population with almost two-thirds of people with dementia falling annually, (Zhang et al., 2019, p. 18). There is a need to intervene and ensure non-clinical caregivers like GR staff are equipped to promote fall prevention in older adults with life-altering diagnoses; therefore, intervention regarding fall prevention and transfers is essential for a population like Joys House to increase the safety of the Guests. The purpose of this program evaluation was to implement and assess the effectiveness of fall prevention and transfer training with the goal of increasing knowledge and attitudes toward fall prevention for increased safety of the Joys House GRs and the Guests they serve. FALL PREVENTION TRAINING 4 Background In the needs assessment conducted with administrative and GR staff, fall prevention and transfer training were found to be both needed and desired. There has been no formal follow-up staff training in the past three years regarding fall prevention and Guest safety after initial hire. Joys House UIndys Family Care Manager, Leah Jones, noted that addressing and updating the initial-hire training regarding fall prevention and client transfers would be helpful, as well as creating and implementing training for current staff as a continuing education piece that can be repeated periodically (L. Jones, personal communication, February 25, 2022). The GR staff were responsive and eager to engage in future fall prevention training, noting that multiple Guests at both Joys House locations require assistance from two or more people for transfers, and are concerned for the safety of the Guests and themselves. Literature Review The purpose of this literature review was to understand how fall prevention training for non-clinical caregivers impacts the safety and quality of client care. Through the literature appraisal process, multiple themes were found regarding fall prevention and effective training for caregivers. The major themes included effectiveness of fall prevention training and the importance of prevention of musculoskeletal disorders with safe client transfers. Effectiveness of Fall Prevention Training Measuring employee attitudes and overall effectiveness of fall prevention training is vital to the encouragement of sustainability and safety for clients. An effective program should encourage empowerment and competence of the employees when caring for the Guests at Joys House. Although there are currently no regulations in many states to ensure proper continuing education on safe patient handling in adult day centers, there is extensive data from researchers FALL PREVENTION TRAINING 5 who found that fall prevention training improved knowledge and attitudes toward safe handling of clients. Gendron et al. (2017) found through their formal evaluation that continued fall prevention education led to increased confidence in the care staff and less frequent falls. Montgomery and Smith (2020) used the Stopping Elderly Accidents, Death, and Injuries (STEADI) toolkit from the Centers for Disease Control and Prevention (CDC) to train non-medical caregivers and found that the participants knowledge and confidence increased. Laing et al. (2011) sought to learn the knowledge and attitudes of employees who serve older adults. They found that most employees recognize that falls are urgent health-related issues; however, most did not perceive themselves as very knowledgeable on proper fall prevention practices (Laing et al., 2011). Additionally, nursing students completed an online fall prevention training and demonstrated increased knowledge and self-efficacy in fall prevention for client safety (Patton, 2017). Each of these studies indicates positive outcomes from implementing safety education regarding fall prevention. Researchers developed a work-based learning program that aimed to improve skills of employees working in assisted living settings (White & Cadiz, 2013). The employees noted that they felt more confident in their abilities to perform their job duties and reflected on increased job satisfaction when they receive effective training (White & Cadiz, 2013). This information is valuable to share with staff administrators to relay that high quality training can increase employee satisfaction, quality of care, and passion for the job. Researchers aimed to evaluate a multidisciplinary team-based patient safety training (Slater et al., 2012). Overall, participants found the program impactful, and the researchers found that the team-based learning style is effective and feasible; however, it can take more time (Slater FALL PREVENTION TRAINING 6 et al., 2012). In contrast, Patton (2017) suggested that a combination of online education and the practice experience is helpful based on their training of nursing students mentioned earlier. Similarly, Wang et al conducted a prospective study on professional caregivers and found that using multimedia education in combination with the teach-back method can improve knowledge, confidence, and behaviors of preventing falls (2022). In addition to understanding the effectiveness and positive attitudes toward fall prevention training, it is also important to recognize barriers to implementing safe fall prevention techniques. Dykeman et al. (2018) conducted interviews with providers and found that common barriers of practicing safe fall prevention techniques included a lack of policy and legislative offers as well as provider education. Education is a large part of providing adequate care to clients; therefore, effective training should include emphasis on ongoing training practices including safe fall prevention measures. Caregiver Safety Fall prevention training is not only important for the clients being cared for, but it is necessary for the safety of the staff members completing the client handling. The United States Department of Labor (n.d.) reported that worker injuries are mainly from overexertion related to repeated manual patient handling activities associated with transferring and repositioning patients and working in extremely awkward postures, (para. 2). They also developed information about the importance of safe body mechanics to prevent musculoskeletal disorders. The writers listed specific solutions for any hazards like repositioning, transferring, and lifting (United States Department of Labor, n.d.). It is important that employees are informed of the risks involved with not using proper body mechanics. Administrators should be encouraged to provide proper training to decrease the risk of injury for their employees. FALL PREVENTION TRAINING 7 Theories to Guide the Program The Person-Environment-Occupation-Performance (PEOP) model uses a top-down approach with an emphasis on values and performance and works well for community populations (Cole & Tufano, 2020). This project included program development and implementation for fall prevention on the staff at Joys House UIndy. This model was used to guide the evaluation process. This included the parts of the staff and work space including the person, environment, occupation, and performance to ensure that the staff members receive and apply the best fall prevention program that fits the Joys House Guests needs. The public health theory, health belief model (HBM), addresses the psychological and behavioral aspects that impact the adoption of health behaviors (LaMorte, 2019). Some of the main components that were focused on included perceived costs, perceived benefits, perceived severity, cues to action, and self efficacy. It was necessary to understand what perceived barriers and benefits each staff member had toward fall prevention training to best understand how likely they are to apply the learned material during their shifts. This also helped improve the understanding of how to tackle any barriers to adoption that the staff are facing. Project Design Participants A sample was formed through the GR staff at both Joys House locations. The sample included 13 GR staff members, ages ranging from 20 to 74 years old, with a mean age of 30 years old. Participants included 11 women, one man, and one nonbinary individual. Design The program evaluation involved a pre and post training survey to measure the GR staffs knowledge and attitudes toward fall prevention and Guest transferring. I developed the following FALL PREVENTION TRAINING 8 objectives for the training. The participants in the training will: (1) demonstrate knowledge of fall prevention and transferring Guests, and (2) describe attitudes supportive of fall prevention and safe transferring at Joys House. For the staff participants, the program design included a pre-training knowledge and attitude survey, the training experience, and a post-training knowledge and attitude survey with supplemental feedback questions regarding the perceived benefit of the training. The training began with a fall prevention presentation that was developed using the STEADI tool (CDC, 2019). This material was used with permission from the CDC and presented using laymans terms and language for the adult day staff. The fall prevention presentation incorporated the burden of falls, why falls can be costly and life-threatening, and common risk factors for falls in older adults. As the primary population at the adult day center includes adults with a dementia diagnosis, additional information was incorporated on how dementia is an independent risk factor for falls (Jensen & Padilla, 2011; Zhang et al., 2019). Following the fall prevention presentation, the participants viewed a video on safe Guest transferring that the writer developed. The video included information regarding proper body mechanics during a transfer, proper donning and use of a gait belt, important things to consider before completing a transfer, how to set up a wheelchair for a transfer, and demonstrations of both a one-person and two-person transfer to and from multiple surfaces. After viewing the video, there was time dedicated to questions and discussion about the information, as well as time to practice demonstrating the skills learned from the video. Before the session ended, the staff received a fall prevention binder to keep at each location, filled with resources from the CDC including a fall risk assessment and handouts for caregivers like a home safety checklist FALL PREVENTION TRAINING 9 (CDC, 2019). The binder also included a printed copy of the fall prevention presentation that the staff could refer back to. Project Outcomes Pre and post survey The pre and post survey included two parts, the first part containing 13 questions that assessed the staffs knowledge. The knowledge portion was an adapted version of Montgomery and Smiths (2020) pre/post knowledge test with permission from the first author. The writer developed the second part of the survey, which contained 7 attitudinal items with a four-option Likert response scale, with one indicating strongly disagree, and four indicating strongly agree. Questions 14, 15, 16, 17, and 20 on the attitude portion of the survey were reverse scored due to the more favorable response being strongly disagree. The first two sections of the post-survey were identical to the pre-survey, but also included a third section. This third section included seven items that were either open-ended or used a Likert agreement scale. The questions evaluated if the staff found the training useful, a worthwhile use of their time, and if they expected they could successfully apply what they learned while working. The open-ended questions provided space for the participants to make comments or suggestions for training improvement. The knowledge and attitude survey items can be viewed in appendix A. Results Difference in Pre-survey and Post-survey Knowledge and Attitudes Analysis of the survey items involved analyzing the knowledge items and the attitude items separately to determine the participants overall improvement in each category. All 13 participants completed the pre-survey in its entirety; however, only 11 of the participants completed the post-survey following the training. For the knowledge portion of the survey FALL PREVENTION TRAINING 10 (Montgomery & Smith, 2020), there was a difference between the pre and post survey scores, with a pre-survey mean score of 70% correct responses, and post-survey mean score of 87% correct responses (Figure 1). The pre-survey scores ranged from 46% to 92%, and the post-survey scores ranged from 85% to 100%. For the attitudes portion of the survey, there was no difference in attitudes between the pre-survey and post-survey, as the surveys indicated an overall positive attitude. 100% of participants rated each item on the likert scale as a more favorable response, either somewhat agree or strongly agree, or reverse scored to the more favorable response of somewhat disagree or strongly disagree for all attitude questions. All participants also rated each supplemental post-survey likert scale attitudes item as a more favorable response, either somewhat agree or strongly agree. When asked the significant reasons why the staff believes they can successfully apply what they learned, 8 out of 11 participants selected the training itself, and help from my co-workers. Additionally, when asked for suggestions to allow the staff to better apply what they learned, the majority of the participants suggested that the training be accessible in the future and to have future opportunities to refresh their skills. These results indicate that the participants overall reported a favorable attitude toward fall prevention and believed the training program was effective. Summary Falls are common in the older adult population, especially those with dementia (Zhang et al., 2019). Falls lead to expensive hospital stays and loss of independence with activities of daily living and other desirable occupations (CDC, 2019), which are all reasons why it is imperative for staff to receive education regarding fall prevention for Guest safety. Fall prevention education leads to increased confidence in providing safe care and decreasing falls (Gendron et al, 2017). FALL PREVENTION TRAINING 11 Following the development and implementation of the fall prevention and transfer training program for non-clinical care staff at Joys House, the staff demonstrated overall increased knowledge of fall prevention measures and proper safe transfer techniques. The staff also expressed positive attitudes toward adopting the information while working with the Guests at Joys House. Conclusion Throughout this project, I learned a lot about how to approach and teach multiple staff members who all come from different backgrounds regarding their lifestyles, education levels, previous work experience, and current experience at Joys House. I feel accomplished in my ability to recognize Joys Houses needs, develop a program, and implement it successfully for increased safety of both the staff and Guests on a daily basis. The program will be sustained through digital versions of the training that I provided the Adult Day Services Director. This will allow future staff members to receive the same educational content and current employees can refer back to the program as needed. Occupational therapy is much needed in the adult day community setting and can be impactful for the future at Joys House. Occupational therapy should take part in encouraging the establishment of initial and recurring Guest safety screening and level of assistance with activities of daily living, providing recommendations of assistive device and assistive technology usage, and providing caregiver resources like role and routine assistance or stress management intervention to alleviate caregiver burden. These are just a few examples of ways that occupational therapy can be a powerful tool for this community setting, in which Joys House has open arms for the future of OT. FALL PREVENTION TRAINING 12 References Centers for Disease Control and Prevention and National Institute for Occupational Safety and Health. (n.d.). Occupational hazards in health care. Department of Health and Human Services. Retrieved from https://www.cdc.gov/niosh/docs/2010-125/pdfs/2010-125.pdf?id=10.26616/NIOSHPUB2 010125 Centers for Disease Control and Prevention and National Center for Injury Prevention and Control. (2019). STEADI: Older adult fall prevention. https://www.cdc.gov/steadi/index.html Cole, M. & Tufano, R. (2020). Applied theories in occupational therapy: A practical approach. (second edition). Thorofare, N.J.: SLACK Inc. Dykeman, C. S., Markle-Reid, M. F., Boratto, L. J., Bowes, C., Gagn , H., McGugan, J. L., & Orr-Shaw, S. (2018). Community service provider perceptions of implementing older adult fall prevention in Ontario, Canada: A qualitative study. BMC Geriatrics, 18(1), 34. https://doi.org/10.1186/s12877-018-0725-3 Gendron, T. L., Pryor, J. M., & Welleford, E. A. (2017). Lessons Learned From a Program Evaluation of a Statewide Continuing Education Program for Staff Members Working in Assisted Living and Adult Day Care Centers in Virginia. Journal of Applied Gerontology : The Official Journal of the Southern Gerontological Society, 36(5), 610628. https://doi.org/10.1177/0733464816633124 FALL PREVENTION TRAINING 13 Jensen, L. & Padilla, R. (2011). Effectiveness of interventions to prevent falls in people with Alzheimer's disease and related dementias. American Journal of Occupational Therapy, 65,532-540. doi: 10.5014/ajot.2011.002626 Joys House. (2022). Retrieved February 25, 2022 from https://joyshouse.org Laing, S. S., Silver, I. F., York, S., & Phelan, E. A. (2011). Fall prevention knowledge, attitude, and practices of community stakeholders and older adults. Journal of Aging Research, 2011, 19. https://doi.org/10.4061/2011/395357 LaMorte, W. (2019). The health belief model. Boston University School of Public Health. Retrieved March 21, 2022 from https://sphweb.bumc.bu.edu/otlt/mph-modules/sb/behavioralchangetheories/behavioralch angetheories2.html Montgomery, E. E., & Smith, Y. H. (2020). Stall the Fall: Training Non-Clinical Caregivers to Prevent Falls in Community-Dwelling Older Adults. Journal of Community Health Nursing, 37(4), 179188. https://doi.org/10.1080/07370016.2020.1809859 Patton, S. K. (2017). Improving nursing students assessment of fall risk in community-dwelling older adults. Gerontology & Geriatrics Education, 39(4), 507520. https://doi.org/10.1080/02701960.2016.1269007 Shapiro, Z. (2019). Hearing loss and the increased risk of falls. ASHAWIRE. Retrieved from https://leader.pubs.asha.org/do/10.1044/hearing-loss-and-the-increased-risk-of-falls/full/ Slater, B. L., Lawton, R., Armitage, G., Bibby, J., & Wright, J. (2012). Training and action for patient safety: embedding interprofessional education for patient safety within an FALL PREVENTION TRAINING 14 improvement methodology. The Journal of Continuing Education in the Health Professions, 32(2), 809. https://doi.org/10.1002/chp.21130 United States Department of Labor. (n.d.). Safe patient handling. Occupational Safety and Health Administration. Retrieved from https://www.osha.gov/healthcare/safe-patient-handling White, D. L. P. D., & Cadiz, D. M. P. D. (2013). Efficacy of work-based training for direct care workers in assisted living. Journal of Aging & Social Policy, 25(4), 281300. https://doi.org/10.1080/08959420.2013.816124 Zhang, W., Low, L., Schwenk, M., Mills, N., Gwynn, J.D., & Clemson, L. (2019). Review of gait, cognition, and falls risks with implication for fall prevention in older adults with dementia. Dementia and Geriatric Cognitive Disorders, 48, 17-29. doi: 10.1159/000504340 FALL PREVENTION TRAINING 15 Figure 1 Mean Knowledge Survey Scores Note. Comparison of mean knowledge scores between pre and post-knowledge survey items. FALL PREVENTION TRAINING 16 Appendix A Pre/Post Knowledge and Attitude Survey Questions Pre/Post-survey Knowledge Questions Instructions: Complete each statement by selecting the most correct answer for multiple choice questions or selecting the correct answer choice(s) food items that instruct to select all that apply. KEY: correct answers highlighted in yellow 1. Why are falls in older adults a problem? a. If it happens in a facility, employees will get in trouble b. Injuries from falls can lead to serious injuries or even death c. Falls are not a problem d. Falls in older adults do not result in high medical bills 2. What can happen as a result of a fall in an older adult? [select all that are correct]: Serious injury, like brain injury or broken hip Costly medical expenses Improved balance 3. What are some of the most common reasons older adults fall? [select all that are correct]: Vitamin D deficiency Lower body weakness Use of medications (like sedatives and anti-depressants) Good balance and steady walking 4. Charlotte is a 72-year-old woman who is afraid of falling. She hasnt had her eyeglasses prescription checked in a few years and only wears slip-on bedroom shoes when walking around Joys House. She also frequently feels dizzy when she stands up too fast. Select all items that can increase Charlottes risk for falling: Fear of falling Outdated eyeglasses prescription Dizziness upon standing Slip-on bedroom shoes FALL PREVENTION TRAINING 17 5. A caregiver is assisting a Guest in the car and stops to ask a Joys House employee, What can we do to prevent falls in our home? The employee most appropriately responds [select all that are correct]: Increasing lighting, especially at night, would be very helpful Installing grab bars and safety rails can help prevent falls Remove any throw rugs that may move when stepped on Move the Guest to a bedroom upstairs so he/she can practice balancing on the stairs 6. A Guest who has fallen twice in the past year and takes 23 seconds to complete the Timed Up and Go (TUG) Test is considered: a. High risk for falls b. Moderate risk for falls c. Low risk for falls d. Not at risk for falls 7. A Guest is going for a doctor visit today for a physical. Which of the following would be helpful for the caregiver to mention to the doctor in regards to falls? [select all that are correct] Dizziness when standing up too quickly Vitamin D level Medication check Thinning hair 8. An employee is helping an older adult stand up. In order to reduce the risk of injury to the employee, the employee should: a. Stand close to the Guest and use rocking motions to help stand b. Pulling the Guest up by their arms c. Keep knees and feet close together when helping to stand d. Tell the Guest they just need to stay seated 9. An employee is helping move a Guest who is weak and unable to stand by themself. The employee knows the best ways to prevent on the job injuries when moving Guests are [select all that are correct]: Use a gait belt whenever possible Ask another employee for help if needed FALL PREVENTION TRAINING 18 Twist at the waist and lock knees while lifting the Guest 10. Select all of the following correct principles of body mechanics to be aware of when transferring a Guest: Bend the knees; use your legs, not your back Keep a neutral spine (not a bent or arched back) Keep a narrow base of support Stand at least 1 foot away from the Guest 11. Select all appropriate questions to consider before performing a transfer: Can the transfer be performed safely by one person or is assistance required? Is there enough time allotted for this transfer? Are you in a hurry? Does the Guest understand what is going to happen? If not, does the Guest demonstrate fear or confusion? Are you prepared for this limitation? Has all equipment been placed in the correct position? Has all unnecessary equipment (eg, footrests, armrests) been moved out of the way? 12. Select all of the correct steps involved in a one-person transfer from the wheelchair to the toilet: Have the Guest scoot to the edge of the wheelchair and put their feet flat on the floor Make sure the Guests heels are pointed away the surface to which they are transferring The Guest may reach toward the surface to which they are transferring or may push off the surface from which they are transferring Guide the Guest toward the transfer surface and gently help them down to a sitting position 13. True or false: when completing a two-person transfer, it is most effective to have one person in front of the Guest to assist the Guests forward weight shift, and one person in the back to shift the Guests buttocks in the direction of the transfer. This can be done in a few steps, making sure the Guests buttocks land on a safe, solid surface. It is important to reposition yourself and the Guest to maintain safe and proper body mechanics. Be sure to coordinate the time of the transfer by counting to three aloud and to initiate the transfer on three. a. True b. False FALL PREVENTION TRAINING 19 Pre/Post-Survey Attitude Statements Instructions: Complete each item by selecting the answer that best represents your attitude toward fall prevention using the scale with 1 being strongly disagree and 4 being strongly agree. 14. I am not confident in my ability to engage in fall prevention measures 1- Strongly disagree 2- disagree 3- agree 4- strongly agree 15. Fall prevention is not compatible with my role in serving the Guests at Joys House 1- Strongly disagree 2- disagree 3- agree 4- strongly agree 16. Using fall prevention skills takes too much time 1- Strongly disagree 2- disagree 3- agree 4- strongly agree 17. Using fall prevention skills may cause Guests and caregivers to question my skills as a direct care staff member 1- Strongly disagree 2- disagree 3- agree 4- strongly agree 18. Using fall prevention skills will increase my personal safety 1- Strongly disagree 2- disagree 3- agree 4- strongly agree 19. Using fall prevention skills will increase the safety of the Guests 1- Strongly disagree 2- disagree 3- agree 4- strongly agree 20. Fall prevention skills can only be carried out by health care professionals (example: CNA, nurse) 1- Strongly disagree 2- disagree 3- agree 4- strongly agree Post-Survey Attitude Statements and Open-ended Questions 21. I was clear about the purpose of the training 1- Strongly disagree 2- disagree 3- agree 4- strongly agree FALL PREVENTION TRAINING 20 22. I can successfully apply what I learned in the training 1- Strongly disagree 2- disagree 3- agree 4- strongly agree 23. If you answered 3 or 4, Agree or Strongly Agree, to the previous question, what are the significant reasons? (check all that apply) My past experience The training itself Extra help from the session leader Help from my co-workers A good system of accountability My own efforts and discipline to apply what I learned Ability to refer back to the training materials Recognition of my efforts Other _______________________________________________________________ 24. The training session was a worthwhile use of my time 1- Strongly disagree 2- disagree 3- agree 4- strongly agree 25. I am expecting positive results from this training in the future 1- Strongly disagree 2- disagree 3- agree 4- strongly agree 26. Comments: ______________________________________________________________ 27. What suggestions do you have that would make you better able to apply what you learned? _____________________________________________________________________ FALL PREVENTION TRAINING 21 Appendix B Doctoral Capstone Weekly Planning Guide Week 1 2 3 4 DCE Stage Weekly Goals & Objectives Tasks Orientation - Set up times with key staff members 1) Complete orientation - Ensure all orientation paperwork 2) Establish project timeline is signed by the end of the week 3) Observe GR staff at both houses - Schedule observation hours with 4) Review literature review articles Guests and GRs at both houses and identified training programs - Review how to conduct a 5) Review current JH training literature search materials and company policies - Review current JH training materials and company policies Screening/ Evaluation 1) Complete and submit "Introduction Draft" 2) Complete literature search 3) Finalize needs assessment 4) Finalize and submit final MOU 5) Identify current training materials Screening/ Evaluation - Faculty mentor check-in meeting 1) Complete and submit - Begin film and script "Background Draft" development 2) Continue developing training - Schedule film days/times with program "actors" 3) Develop pre/post knowledge and - Receive permission to modify attitude surveys developed knowledge test (Montgomery & Smith, 2020) Screening/ Evaluation 1) Complete and submit "Design & Implementation Draft" 2) Continue filming and script development 3) Finalize pre-training surveys 4) Identify equipment/material need for in-person training - Meet 1:1 with GR staff members to discuss project purpose and ask follow-up needs assessment questions - Send out emails requesting use of survey tool (Montgomery & Smith, 2020) - Spend time with Guests and GR staff to continue to build rapport - Send email to promote training to GR staff - Distribute pre-survey to both houses - Purchase binders and folders for FALL PREVENTION TRAINING 22 fall prevention binder - Identify needed walkers/wheelchairs/gait belts for training 5 1) Collect pre-survey data from Broad Ripple House 2) Roll out training videos Implementatio 3) Finalize in-person training and n materials 4) Identify training day equipment at both houses - Send follow-up email to complete pre-survey - Share training materials with site mentor for review/ final edits - Identified appropriate hands on training tools - Print and organize binder materials 6 1) Collect pre-survey data from UIndy house 2) Implement training at Broad Implementatio Ripple House n 3) Collect post-survey data from Broad Ripple 4) Collect pre-survey data from UIndy - Attend Broad Ripple Staff Meeting for training - Faculty mentor check-in - Email UIndy staff to complete pre-survey - Email Broad Ripple staff to complete post-survey 7 1) Final collection of pre-survey data from UIndy house Implementatio 2) Implement training at UIndy n house 3) Collect post-survey data from both houses - Email follow-ups to both houses to collect data - Review midterm evaluation with site mentor - Discuss intervention days with site mentor for reflection and recommendations 8 9 1) Complete collection of Implementatio post-training surveys n 2) Update fall prevention presentation 1) Complete and submit "Program: Outcomes" Implementatio 2) Update transfer training videos n 3) Begin interpreting results from pre/post surveys - Discuss adding more material regarding vision effects on falls to fall prevention presentation - Film fall prevention presentation for future new hire viewing - Discussed adding information about "assisted fall" to transfer training - Breaking transfer training into 3 videos: introduction to transfers/ body mechanics/ gait belt donning; FALL PREVENTION TRAINING 23 one person transfer/ assisted fall; two person transfer 10 1) Attend Broad Ripple house staff meeting Implementatio 2) Finalize updated fall prevention n presentation 3) Finalize and submit dissemination plan 11 1) Attend UIndy house staff meeting 2) Complete and submit "Summary Implementatio - Film and review transfer training and Conclusion" n videos with site mentor 3) Finalize updated transfer training videos 12 1) Establish sustainability of Discontinuatio program n 2) Begin planning dissemination presentation - Identified location and uploaded all training materials to JH Teams site for access for all administration and GR staff - Discuss with site mentor invitations for dissemination and major talking points 13 1) Complete and submit "Abstract, Summary, & Conclusion Draft" by end of week 13. Dissemination 2) schedule final dissemination presentation 3) Finalize final presentation - Practice dissemination meeting with site mentor - establish meeting time with "Care Team" 14 1) Complete and submit "Final Draft" of DCE Report. Dissemination 2) Complete final dissemination presentation - Meet with Care Team - Present OT recommendations for sustainability and future safety recommendations - Final faculty mentor check-in - Film and review fall prevention presentation with site mentor - Faculty mentor check-in  ...

... MAXIMIZING QUALITY OF LIFE IN RESIDENTIAL CARE 1 Maximizing Quality of Life in Residential Care for Individuals Living with Brain Injury Christina Christenson 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. Beth Ann Walker, PhD, MS, OTR, FAOTA MAXIMIZING QUALITY OF LIFE IN RESIDENTIAL CARE 2 Abstract After sustaining a brain injury, it is often difficult to find age-appropriate residential care for the individual. Hinds Feet Farm was created with the mission to maximize the potential of individuals post-brain injury through the use of integrated, unique, and holistic programs. This doctoral capstone projects aim was to further develop the residential program at Hinds Feet Farm to increase the quality of life for the residential members. Challenges to maximizing quality of life that were identified included decreased member engagement throughout the day, decreased physical exercise, decreased social support, and residents experiencing feelings of decreased effort from the residential staff. These challenges were addressed through the creation of a weekend activity box for the residential homes and by providing education to the residential staff. Keywords: acquired brain injury, age-appropriate care, quality of life, residential, adult, program development MAXIMIZING QUALITY OF LIFE IN RESIDENTIAL CARE 3 Maximizing Quality of Life in Residential Care for Individuals Living With Brain Injury Hinds Feet Farm was founded by Puddin Foil when her youngest son suffered a motor vehicle accident and sustained a traumatic brain injury. Following the accident, she wanted to create a loving environment where individuals can reach their best potential post-brain injury (History, 2020). Hinds Feet Farm was created with the mission to maximize the potential of individuals post-brain injury through the use of integrated, unique, and holistic programs. They want the members to pursue meaningful activities while developing a sense of belonging on the site, at home, and in the surrounding communities (Our Mission, 2022). Hinds Feet Farm provides residential and day programs for individuals who have sustained a brain injury. These programs focus on shifting from the traditional medical model of care to a more holistic approach to care, health, and wellness (B. Turney & C. Willis, personal communication, February 10, 2022). Throughout the process of a needs assessment, it was shared that the site values person-centered programs and having a holistic view of its members (B. Turney & C. Willis, personal communication, February 10, 2022). This doctoral capstone projects aim was to further develop the residential program at Hinds Feet Farm to increase the quality of life for the residential members. Project goals were to increase the reported quality of life through verbal reports from the residential members of Hinds Feet Farm and to address reported barriers in routine with staff and members in the residential program. Further development of the sites residential program helped create an opportunity for adults who have sustained a brain injury to find care that is holistic and client-centered. Background At Hinds Feet Farm, the members of the residential program is under the age of 65 years old. It is important to understand the problems many individuals of this population experience MAXIMIZING QUALITY OF LIFE IN RESIDENTIAL CARE 4 within residential care so that further development of the residential program at Hinds Feet Farm is age-appropriate and holistic to its members. Hinds Feet Farm is a unique site for individuals who have sustained brain injuries. After sustaining a brain injury, it is often difficult to find age-appropriate residential care for the individual. The relationship between a caregiver and the individual who has sustained a TBI is often marked with communication disorders and behavior disorders (Huet et al., 2018, p. 1058). Brain injury residential rehabilitation services are scarce, and as a result, many young adults who have sustained a brain injury are moved into nursing homes to accommodate their care (Dwyer et al., 2019, p. 34). There is a general consensus that moving young adults into nursing homes for residential care is inappropriate. Common experiences that were identified in young adults who reside in aged-care facilities due to their disability include lack of community participation, limited social interactions, lack of choice in their activities, and mental health issues (Oliver et al., 2020, p. 1453). Mental health issues for individuals who have sustained a brain injury are prevalent due to the long-term disability from the injury (Lewis & Horn, 2017, p. 401). Neuropsychiatric symptoms like anxiety, depression, and mood disorders are common in individuals who have acquired a brain injury under the age of 65 years of age (Kohnen et al., 2020, p. 1643). There is an increased number of individuals who survive severe traumatic brain injuries past the acute phase and move into residential care, and the knowledge of neuropsychiatric symptoms in this population is important in providing proper care (Kohnen et al., 2020, p. 1643). Depression is the most common comorbidity reported following a traumatic brain injury (Kohnen et al., 2020, p. 1643; Lewis & Horn, 2017, p. 401). Lewis & Horn (2017) explored the prevalence of depression following a traumatic brain injury, and their research concluded that remediation of depressive MAXIMIZING QUALITY OF LIFE IN RESIDENTIAL CARE 5 symptoms during rehabilitation significantly improved the individuals outcomes in rehabilitation. The effects of depression should be addressed in the further development of the residential program at Hinds Feet Farm so the members can reach their optimal abilities in cognition, physical, social, and communication. Dwyer et al. (2019) interviewed young adults who have sustained a brain injury and reside in nursing homes, and they identified two major themes in the participants experience: the young adults felt like they were in a prison from the results of their injury, and that they are now stagnant in their lives (p. 36). These themes reflect how nursing homes may not be appropriate for many individuals who have sustained a brain injury and being placed in such a facility increases the risk of the individuals experiencing dehumanization (Dwyer et al., 2019, p. 38). The needs assessment for this capstone project was informed by a literature search review and by performing interviews with stakeholders for the project. The stakeholders included the sites Day Program Director, the Allied Health Coordinator who is also an occupational therapy assistant, and four residential members. Additional stakeholders that were identified but I wasnt able to meet with during the initial needs assessment include the family of the residential members and the residential staff. The two predominant themes identified through the needs assessment were that the current programs are there to assist the members in reaching their potential through a holistic approach to care and there is a need for more engagement for the members of the sites residential program. It was continuously mentioned throughout the needs assessment process that the site valued providing its members with the right to have a choice (B. Turney, personal communication, February 10, 2022). While performing my literature search prior to my needs assessment, I identified an article by Oliver et al. (2020) which emphasized that placement of young individuals with disability in an aged-care facility is inappropriate, and MAXIMIZING QUALITY OF LIFE IN RESIDENTIAL CARE 6 an issue was that they experienced a severe lack of choice. While Hinds Feet Farm is not an aged-care facility, this article signifies the value and need for the rare setting this site provides in offering age-appropriate care. Unfortunately, the stakeholders reported they feel like the site is not providing enough engagement for the residents of the residential program over the weekends, when the day program is not available, limiting the residents quality of life (B. Turney & C. Willis, personal communication, February 10, 2022). The sites holistic approach to care helped them identify that the residents quality of life can be improved by providing more engagement and activities. Theory The Model of Human Occupation (MOHO) was used to guide the planning and research for the doctoral capstone experience (DCE). This model has a holistic approach to the individual with an emphasis on the individuals volition, habituation, and performance capacity within the person (Cole & Tufano, 2008, p. 95). Simpson et al. (2020) explored the relationship between spirituality, resilience, hope, and caregiver outcomes following a traumatic brain injury or spinal cord injury, and identified that spirituality played a significant role in the well-being of the individual and family. Hinds Feet Farm values the individuals right to choose and the residential program must continue to reflect that. McPherson et al. (2018) indicated that better outcomes of recovery and care occur when it is in response to the individuals context and assumptions are avoided. OReilly (2017) concluded that humor might be effective to use in rehabilitative care to provide compassionate care to young adults who have sustained a brain injury. Further development of Hinds Feet Farms residential program is to be person-centered and engaging for the members. MAXIMIZING QUALITY OF LIFE IN RESIDENTIAL CARE 7 Allens Cognitive Levels Frame guided the experience by encouraging the assessment of task equivalence between the developing program and the residential members. Recovery following a traumatic brain injury is a complex process of recovery and adaptation (McPherson et al., 2018, p. E45). Hart et al. (2018) performed a scoping review of educative literature provided to patients and families that were affected by a traumatic brain injury, and they concluded that even the most basic education could improve the patients recovery and participation (p. 12). Education to the staff at Hinds Feet Farm on the use of assistance, adapting to the environment, and task equivalence is critical in the implementation of the developed residential program. Project Barriers were identified in the residential program that potentially limited maximizing the quality of life of the residential members. This DCE project was designed utilizing observational and qualitative data. The first four weeks of the project were used to complete orientation and collect observational data about the site. This included spending time during the day and residential programs. Data was collected on the residential program on the weekend through observation and semi-structured interviews with the residential staff and the residential members. The Seven Dimensions of Wellness (Green, 2016) was utilized during the interviews with residents to maintain a holistic approach. The seven dimensions are listed in Table 1. See the Appendix for the DCE Weekly Planning Guide. Table 1 Seven Dimensions of Wellness Physical Emotional Spiritual Intellectual Environmental Occupational Social MAXIMIZING QUALITY OF LIFE IN RESIDENTIAL CARE 8 Initial observation days included observation in each residential home. This was beneficial to understand the general routine of the day. Non-structured interviews were conducted over the course of evaluation and implementation. The staff was asked if they have any barriers when it comes to activity engagement with the residents. In both residential homes, staff reported not having enough staff to do community outings. This data guided the interventions of this DCE to be based on-site. Six of the seven residents participated in the interviews, and five residents provided significant data used in the analysis. One resident did not participate in an interview due to the need for a translator. One resident provided inadequate data due to scarce verbalization. It was identified that four of the residents have a desire for more social support and interaction, reporting they want to have someone to talk to on the weekends. Four residents also reported the desire to help around the house more in aspects including cooking, laundry, yard work, and other instrumental activities of daily living (IADLs). Figure 1 illustrates the four most common themes identified in the interviews with the residents. Figure 1 Significant Categories of Weekend Desires and the Number of Residents Reporting the Desire Note. Five residents provided information on weekend desires from being interviewed using the Seven Dimensions of Wellness as a guide. The most reported desire for the weekend by the residents includes participation in IADLs and increased social support. MAXIMIZING QUALITY OF LIFE IN RESIDENTIAL CARE 9 This DCE brought awareness to barriers throughout the day in the residential program that limits the quality of life for the residential members, specifically on days when the day program is not available. The challenges identified were decreased member engagement throughout the day, decreased physical exercise, decreased social support, and residents experiencing feelings of decreased effort from the residential staff. Successes carried out by this DCE include holistic client-centered care, increased staff-to-member engagement, and occupational engagement of the residential members. Outcomes The challenges of decreased residential member engagement and residents expressing the feeling of decreased effort from the residential staff were addressed by creating weekend activity boxes for the residential homes and providing education for the residential staff. The content of the activity box focused on promoting physical movement, cognitive engagement, and socialization. Perez-Rodriguez et. al., (2023) identified exercise programs, regardless of the type of intervention, led to significant changes in functional capacity and quality of life for individuals with an acquired brain injury. Fann et. al., (2009) found that physical exercise was the preferred treatment method for depression over talk, medications, and groups. With this information, I guided the activity boxes to include physical activity to promote exercise. Examples include chair yoga and a variety of outdoor scavenger hunts. Singer (2018) identified strong evidence that loneliness is associated with poor health. With this information, the staff was encouraged to promote group activities and socialization opportunities. Staff education included one-on-one discussions, modeling of residential engagement, and educational handouts. The staffs understanding of the quality of life assists in facilitating an improved quality of life for the residents (Hande et. al., 2020). MAXIMIZING QUALITY OF LIFE IN RESIDENTIAL CARE 10 The outcome evaluation was conducted through an outcome survey with the residents and staff. Residents participated in a non-structured interview to collect qualitative data on their opinion of the activity boxes and weekend engagement. Staff was asked to rate their level of understanding and usability on a 5-point Likert Scale for the weekend activity box, and to rate their understanding and confidence in the educational materials. The Likert Scale is demonstrated in Figure 2. Figure 2 Likert Scale for Outcome Evaluation 1 2 3 4 5 I don't understand it at all I barely understand I think I understand I understand I Strongly Understand Very Unusable Unusable Neutral Usable Very Usable Very Unconfident Unconfident Neutral Confident Very Confident The resident interview results identified good satisfaction with the weekend activity boxes and weekend engagement during the implementation of the project. One resident reported, I feel like we are doing things now and I am motivated to get up to do something. Having the pre-planned option of activities through a rotating weekend activity box provides the opportunity for residential members to engage. The staff rating of the weekend activity boxes averaged the highest rating for understanding its purpose at a five, indicating the strongest understanding. The usability rating of the weekend activity box averaged at a four, indicating understanding. Concerns shared by the residential staff included having enough staff to engage residents and having time in the day. The staff rating for understanding and confidence in using the information from the educational material averages both at a five, indicating the strongest understanding and confidence. Staff reported the material was clear and easy to follow. MAXIMIZING QUALITY OF LIFE IN RESIDENTIAL CARE 11 In the final weeks of the capstone project, the Residential Activity Specialist was educated on the capstone project outcomes and provided with materials to continue the implementation of the weekend activity boxes for increased weekend residential engagement after completion of the DCE. Summary Hinds Feet Farm is a unique site for individuals who have sustained brain injuries to visit. After sustaining a brain injury, it is often difficult finding age-appropriate residential care for the individual. This doctoral capstone projects aim is to further develop the residential program at Hinds Feet Farm to increase the quality of life for the residential members. This DCE project was designed utilizing observational and qualitative data. Challenges to maximizing quality of life that were identified include decreased member engagement throughout the day, decreased physical exercise, decreased social support, and residents experiencing feelings of decreased effort from the residential staff. These challenges were addressed by creating a weekend activity box for the residential homes and providing education for the residential staff. Results from the residential staff outcome surveys indicated a good understanding and usability of the weekend activity boxes and a good understanding and confidence in utilizing the educational materials. The qualitative data collected by the non-structured surveys of the residential members and staff revealed a positive perspective of the weekend activity boxes for increased engagement on the weekends. These results indicate that further development of the sites residential program assists in creating an opportunity for increased engagement on the weekends, to facilitate maximizing the quality of life for the residents. Conclusion MAXIMIZING QUALITY OF LIFE IN RESIDENTIAL CARE 12 The completion of this capstone project has furthered my knowledge and experience in program development. The results of the project provide supporting evidence and format for interventions to assist in improving the quality of life for the residents on the site. The results of the assessment also indicate that occupational therapy has a role in program development to assist in maximizing the quality of life. Occupational therapists have a unique role in developing and implementing meaningful activities to assist in improving ones quality of life. Future studies should further assess the impact of residential staff's perspective and understanding of the quality of life within the population of individuals who have acquired a brain injury. Overall, the projects results indicate that further development of activities and engagement over the weekends in the residential homes increases the quality of life for the residential members. MAXIMIZING QUALITY OF LIFE IN RESIDENTIAL CARE 13 References Cole, M. & Tufano, R. (2008). Applied theories in occupational therapy: A practical approach. Thorofare, N.J.: SLACK Inc. Dwyer, A., Heary, C., Ward, M., & MacNeela, P. (2019). Adding insult to brain injury: young adults experiences of residing in nursing homes following acquired brain injury. Disability and Rehabilitation, 41(1), 33-43. Fann, J. R., Jones, A. L., Dikmen, S. S., Temkin, N. R., Esselman, P. C., & Bombardier, C. H. (2009). Depression treatment preferences after traumatic brain injury. The Journal of head trauma rehabilitation, 24(4), 272-278. Green, A. (2016). Seven Dimensions of Wellness. Alive: Canadas Natural Health & Wellness Magazine, 404, 1523. Hande, M. J., Keefe, J., & Taylor, D. (2021). Long-term residential care policy guidance for staff to support resident quality of life. The Gerontologist, 61(4), 540-551. Hart, T., Driver, S., Sander, A., Pappadis, M., Dams-OConnor, K., Bocage, C., ... & Cai, X. (2018). Traumatic brain injury education for adult patients and families: a scoping review. Brain injury, 32(11), 1295-1306. History. Hinds Feet Farm. (2020, August 25). Retrieved March 1, 2022, from https://hindsfeetfarm.org/history/ Huet, M., Dany, L., & Apostolidis, T. (2018). Explain the unexplainable: A qualitative inquiry of the representations of the caregivers of brain-injured people. Journal of health psychology, 23(8), 1050-1062. Kohnen, R. F., Lavrijsen, J. C., Akkermans, R. P., Gerritsen, D. L., & Koopmans, R. T. (2020). The prevalence and determinants of neuropsychiatric symptoms in people with acquired MAXIMIZING QUALITY OF LIFE IN RESIDENTIAL CARE 14 brain injury in nursing homes. Journal of the American Medical Directors Association, 21(11), 1643-1650. Lewis, F. D., & Horn, G. J. (2017). Depression following traumatic brain injury: Impact on posthospital residential rehabilitation outcomes. NeuroRehabilitation, 40(3), 401-410. McPherson, K., Fadyl, J., Theadom, A., Channon, A., Levack, W., Starkey, N., ... & TBI Experiences Research Group. (2018). Living life after traumatic brain injury: phase 1 of a longitudinal qualitative study. Journal of head trauma rehabilitation, 33(1), E44-E52. Oliver, S., Gosden-Kaye, E. Z., Jarman, H., Winkler, D., & Douglas, J. M. (2020). A scoping review to explore the experiences and outcomes of younger people with disabilities in residential aged care facilities. Brain injury, 34(11), 1446-1460. OReilly, K. (2017). HumorA Rehabilitative Tool in the Post-Intensive Care of Young Adults With Acquired Brain Injury. Rehabilitation Nursing Journal, 42(4), 230-234. Our Mission. Hinds Feet Farm. (2022, February 23). Retrieved March 1, 2022, from https://hindsfeetfarm.org/ Prez-Rodrguez, M., Gutirrez-Surez, A., Arias, J. . R., Andreu-Caravaca, L., & PrezTejero, J. (2023). Effects of exercise programs on functional capacity and quality of life in people with acquired brain injury: a systematic review and meta-analysis. Physical therapy, 103(1), pzac153. Simpson, G. K., Anderson, M. I., Jones, K. F., Genders, M., & Gopinath, B. (2020). Do spirituality, resilience and hope mediate outcomes among family caregivers after traumatic brain injury or spinal cord injury? A structural equation modeling approach. NeuroRehabilitation, 46(1), 3-15. Singer, C. (2018). Health effects of social isolation and loneliness. J. Aging Life Care, 28, 4-8. MAXIMIZING QUALITY OF LIFE IN RESIDENTIAL CARE 15 Appendix Doctoral Capstone Experience and Project Weekly Planning Guide Week 1 2 DCE Stage (orientation, screening/evaluation, implementation, discontinuation, dissemination) Orientation Orientation Weekly Goal Orientation to day program routine Meet and get to know members of the day program. Start on-site orientation coursework. Complete orientation work Need assessment meeting with staff Finalize MOU On-site first-aid training 3 Orientation Objectives Orientation to residential program Understand the site expectations and environment. Meet with site mentor and other stakeholders to complete a needs assessment and review goals. Plan and update MOU with site mentor Plan date with staff and OTAs Orientate with residential program Tasks Introduce yourself to members of the program. Complete on-site coursework Set up a meeting with site mentor and COTA. Create talking points prior to the meeting. Finalize MOU Send MOU for signatures Complete first-aid course on-site Meet with OTA and OTA students about their work Spend time in residential homes Tour Hart cottage Complete Getting It Right Training Complete search for literature on Identify additional research on health and Date complete 1/9/23 1/13/23 1/17/23 1/16/23 1/17/23 1/18/23 1/17/23 1/24/23 1/25/23 1/25/23 1/27/23 1/27/23 MAXIMIZING QUALITY OF LIFE IN RESIDENTIAL CARE 4 Screen/Evaluation residential programs wellness in residential program Background draft Collect information and formulate background draft of final paper Project design meeting Review project design with site stakeholders 16 Research and identify new and relevant articles Write background draft Plan and review talking points prior to meeting. Plan meeting with stakeholders Plan Schedule for the month of February Plan February schedule to include weekends Group Presentation and Activity Create PowerPoint for presentation with Rec therapist Meet with stakeholders. Meet with staff to schedule February Collect information for presentation to day program Create format of presentation Present representation to day program. Teach Microsoft PowerPoint skills to members Select topic Demonstrate and practice PowerPoint skills 1/23/23 1/30/23 1/30/23 1/31/23 1/31/23 1/30/23 1/30/23 2/1/23 2/2/23 Complete preparing presentation Presentation day Choose a topic with the member for PowerPoint presentation Educate PowerPoint formatting Teach advanced skills like embedding videos 1/30/23 2/2/23 2/2/23 MAXIMIZING QUALITY OF LIFE IN RESIDENTIAL CARE 5 Screen/Evaluation 7 Dimensions of Wellness Create 7 Dimensio of Wellness worksheet to use as guide Semi-structured interviews with residents Observation of routine in residential program Spend the day in Puddin Place Spend the day in Hart Cottage 17 Research information on 7 Dimensions of wellness for resident interview 2/8/23 2/9/23 Create 7 Dimension of Wellness table for interview guide 2/10/23 Print worksheet prior to interview 2/11/23 Meet with residents of Puddin Place 2/12/23 Meet with residents of Hart Cottage 2/11/23 Take note of routine throughout weekend day 2/12/23 Take note of routine throughout weekend 6 Implementation Weekend Activity Box planning Discuss opinion from staff on weekend activity boxes Discuss views from residents on weekend activity boxes 7 Implementation Gain understanding of games available in residential homes Gain an understanding of Puddin Place games available Ask the opinion of having the option of weekend activity box in the home. Ask the opinion of having the option of a weekend activity box in the home. Cleanout activity closet Create excel sheet of games in home Organize activity closet Gain an understanding of Hart Cottage games available Engage residents by assisting in the task. 2/18/23 2/19/23 2/18/23 2/19/23 2/25/23 2/25/23 2/25/23 2/25/23 2/26/23 2/26/23 MAXIMIZING QUALITY OF LIFE IN RESIDENTIAL CARE 18 Cleanout activity closet 2/26/23 Create Excel sheet of games in home Organize activity closet 8 Implementation Progress final report Weekend Activity Box Planning Residential I/ADL engagement Identify more research articles for report Brainstorm activity box content Residential staff education Identify articles that may be relevant to the final report 3/1/23 3/2/23 Print articles to review 3/4/23 3/5/23 Review new articles 3/4/23 Brainstorm activity box content with residential staff Brainstorm activity box content with residents 3/3/23 3/4/23 3/4/23 Discuss with weekend residential staff about I/ADL engagement over the weekend. 9 Implementation Progress final report Work on final paper Progress project section of final paper Create figures from interview data Weekend Activity box planning IADL engagement Collect/print activities for weekend activity boxes Create informative poster Start outline for Outcomes section of final paper Print activities for activity boxes Collect information to add 3/10/23 3/12/23 3/10/23 3/11/23 3/12/23 3/12/23 3/12/23 MAXIMIZING QUALITY OF LIFE IN RESIDENTIAL CARE 19 Create informative page 10 Implementation DCE dissemination plan Progress final report DCE Presentation Write dissemination plan Progress outcomes on final paper Create DCE PowerPoint and poster Write dissemination plan for project turn in dissemination project Begin writing outcomes for final paper Identify and create layout for PPT 11 Implementation DCE Presentation IADL Engagement Work on DCE PPT Gardening around the farm Identify layout for poster Create introduction, background, and project goals slides in PowerPoint Collect supplies to fill garden with new soil Identify what is needed Identify location of gardens that require new soil Weekend Activity Boxes Identify weekend activity for boxes Implementation of activity boxes 3/15/23 3/17/23 3/18/23 3/19/23 3/19/23 3/22/23 3/23/23 3/23/23 3/23/23 3/23/23 3/24/23 Engage residents and staff for assistance in filling gardens 3/24/23 Collect supplies for weekend activity 3/24/23 Create instruction sheet for weekend activity Identify location in residential homes to keep activity boxes 3/24/23 3/25/23 3/26/23 MAXIMIZING QUALITY OF LIFE IN RESIDENTIAL CARE 12 Discontinuation Weekend Activity Boxes Activity box material Identify staff members to continue weekend activity boxes 13 Discontinuation Weekend Activity Boxes Staff education Final Paper 14 Dissemination Dissemination of project Final paper DCE PowerPoint DCE Poster DCE VoiceThread 20 Promote use of weekend activity boxes in the residential homes Identify and collect material for weekend activity Organize collected weekend activity box material for Residential Activity Specialist 3/31/23 3/31/23 3/31/23 Meet with Residential Activity Specialist to identify purpose and desire of activity boxes Educate residential staff on weekend activity boxes and continuation of project Observe Resident Activity Specialist implement weekend activity box Progress final paper Complete final paper draft Share final paper with site and stakeholders Complete DCE PowerPoint Complete DCE Poster Complete and film DCE Voice Thread Share DCE VoiceThread with site and stakeholders. 4/8/23 4/9/23 4/7/23 4/8/23 4/9/23 4/10/23 4/15/23 4/11/23 4/11/23 4/11/23 4/13/23 MAXIMIZING QUALITY OF LIFE IN RESIDENTIAL CARE 21  ...

... Implementing Peer-Supported Financial Literacy Workshop Program for Refugees to Address Occupational Deprivation Grace Cho 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: Lucinda Dale, EdD, OTR, CHT, FAOTA Abstract There are few studies on refugees receiving peer-support and even fewer on refugees in peersupported programs that help address occupational deprivation (OD). The Doctoral Capstone (DC) project at Catholic Charities Indianapolis (CCI) implements a peer-supported program that provides financial literacy to refugees to gain practical knowledge, confidence, and social support in order to address OD. A peer mentor facilitated two workshop sessions at each small group of refugee clients. Pre-& post-workshop surveys and assessments were given to two groups of participants to measure their outcomes. All five participants in one group achieved an increase in financial knowledge, overall confidence, and perceived support. Two participants in the second group also showed improvement in financial knowledge and increase in perceived support. Occupational therapy (OT) in resettlement agencies like CCI must assume sociocultural roles by enabling refugees to participate in occupation-based programs supported by fellow peer mentors to address OD. Introduction Catholic Charities of Indianapolis (CCI) is one of the four supporting agencies in Indiana that provides refugee resettlement services (Indiana State Department of Health, n.d.). Currently, the Refugee and Immigrant Services of CCI is serving over 1,300 refugees (Catholic Charities of Indianapolis, 2021) with aid in housing, healthcare, social welfare, and legal assistance (Archdiocese of Indianapolis, 2022). To provide those services, CCI obtains funding from local grants such as the United Way of Central Indiana (CCI, 2021, p. 5), and federal grants such as the Match Grant program and the Targeted Assistance Grant (Archdiocese of Indianapolis, 2022). Among their main services, CCI uses the Match Grant program to aid their refugee clients by enrolling them within the first 30 days of arrival (Archdiocese of Indianapolis, 2022). This program aims to help refugees achieve self-sufficiency through employment services, English Second Language (ESL) classes, and job readiness classes (Archdiocese of Indianapolis, 2022). However, like most resettlement agencies, CCI does not have sufficient support and staff to provide job readiness classes, which ultimately contributes to the ongoing barriers refugees face (Darawsheh et al., 2022). Furthermore, very few research is done on refugees receiving occupation-based interventions, which indicates that refugees may not be meeting occupational needs and there is a strong need to provide such interventions (Darawsheh, 2019; Hugelius et al., 2020; Trimboli & Halliwell, 2018). To address those needs, my Doctoral Capstone (DC) project will provide refugee clients at CCI an occupation-based intervention centered on money management which will allow them to participate in a peer-mentored financial literacy workshop. As a group, these participants will not only gain social support from peer mentors, but also gain necessary skills that promote job readiness and self-sufficiency (Kisiara, 2021; Winlaw, 2017). Background Refugees are considered as people who are targeted or threatened due to political conflicts and flee to another country (U.S. Department of State, n.d.). According to the report of Fiscal Year of 2023, the U.S. admitted 6,750 refugees (Refugee Processing Center, 2023). Of those refugees, the State of Indiana resettled 199 refugees, the majority of which come from countries such as Afghanistan, Burma, and the Democratic Republic of the Congo (Bureau of Population, Refugees and Migration, 2023). As refugees undergo forced displacement and resettlement, all aspects of their lives drastically change: their environments, sociocultural norms, and occupations are impacted by external stressors such as trauma from political crisis and a loss of resources (Dubus, 2018; Utran & Wieling, 2020) Consequently, refugees struggle with occupational deprivation (OD), a state in which one is unable to participate in their usual occupations (Darawsheh, 2019, p. 2). Due to OD, refugees reported having low levels of self-efficacy, self-esteem, and well-being (Darawsheh, 2019, p. 6). Significant factors that contributed to the refugees difficulty of integration and OD include language barrier, cultural differences and shock, social segregation, and social and occupational injustices (Darawsheh et al., 2022; Kisiara, 2021). Refugees also reported that lack of work and financial means is a significant factor (Hugelius et al., 2020); the loss of their livelihood causes them to experience feelings of being dependent [and] in a limbo state (p. 5). Not only do refugees lack resources and support, but they also lack receiving resources and social support from American resettlement policies and agencies, which contribute to OD (Darawsheh et al., 2022). Resettlement policies that promote refugees early employment and self-sufficiency often do not provide social support (Darawsheh et al., 2022, p. 10). This oversight exacerbates their experiences of social isolation which increases dependency on public assistance and decreases their self-efficacy (Darawsheh et al., 2022; Paloma et al., 2020). To meet their sociocultural needs, refugees express the desire to be self-reliant (Skran & EastonCalabria, 2020). This self-reliance is considered as the social and economic ability [] to meet essential needs in a sustainable manner (Easton-Calabria & Omata, 2018, p. 1). Their efforts to receive social support is often found in seeking help from other fellow refugees and reflects their resilience (p. 9). However, very few studies examine refugee resilience, indicating that refugees continue to lack and need social support (Walther et al., 2021). According to existing studies and findings, social support is a key factor to resilience and social networks provide emotional as well as informational support and promote a sense of belonging (Walther et al., 2021, p. 14). Additionally, refugees who had support from social networks and fellow refugee communities were able to have a more successful resettlement transition, more successful employment process, and higher levels of well-being (Badwi et al., 2018; Dubus, 2018). Therefore, it is imperative that resettlement agencies provide the necessary resources and social support by offering opportunities to gain knowledge and skills that helps address OD and enables occupational engagement (Darawsheh, 2022; Winlaw, 2017). Within resettlement agencies and other organizations, occupational therapy (OT) can help address OD by developing programs that equip refugees with practical skills required for meaningful daily activities (Darawsheh et al., 2022). Moreover, OT can address refugees sociocultural needs by assuming the roles as cultural translator, social connector, and collaborative coach while providing the interventions (Blankvoort et al., 2018; Krishnakumaran, 2022). While OT is active within this population, research on refugees and OT are limited and still emerging (Blankvoort et al., 2018; Darawsheh, 2022; Krishnakumaran, 2022; Trimboli & Halliwell, 2018). Within the Refugee and Immigration Services at CCI, my DC project will further contribute with an OT intervention that allows refugees to engage in money management activities and gain necessary skills and knowledge for money management in the States. According to Awidi & Quan-Baffour (2021), providing basic financial literacy improved the refugees livelihood, empowered the refugees, and enhanced their sense of self-efficacy. Unlike this study however, my DC project will also incorporate peer mentorship and peer-supported groups that will help accommodate for the refugees cultural and language barriers (Paloma et al., 2020). Refugees in this project will attend a basic financial literacy program where they will not only receive educational resources but will also gain confidence and self-efficacy from the social support from peer mentors (Gower et al., 2022). Including peer support will help promote refugees social integration and stability (Frster et al., 2022) and increase their levels of selfefficacy and empowerment as they participate in a meaningful activity (Mahon, 2022; Paloma, 2020). With this combination of the practice-based education and peer support in my project, refugees of CCI will be able to experience greater benefits from both of these components. Theory & Frame of Reference The theory that guided my DC project was the theory of Selection, Optimization, and Compensation (SOC) (Baltes, 1997). The SOC theory is a developmental theory that explains that due to the dynamic interactions between the person and environment and the limited resources at certain life stages, the process of selecting, optimizing, and compensating is a necessary strategy to adapt and achieve goals in life (Freund & Baltes, 2000). Because refugees experience complex environmental and social changes and barriers due to their displacement and lack of resources (Utran & Wieling, 2020; Krishnakumaran, 2022), the SOC theory is appropriate to use in helping refugees restore their occupational balance and promote occupational engagement. This theory helped develop and implement my DC project by selecting topics of money management that are essential for the refugees, optimizing on the practicality of the workshop through peer mentoring and interactive learning, and compensating for the limited time and availability of peer mentors and participants. During the workshop sessions, the SOC theory also helped inform my decisions on which content to focus on as each group demonstrated different needs and levels of financial literacy. The surveys and test questions that I created and administered also centered on this theory as the evaluations assessed and reflected the level of knowledge and confidence before and after the workshop. Project Design & Implementation Based on the needs assessment of CCIs Refugee and Immigration Services (RIS), there is a significant need and benefit in providing social support to the refugees as they are overwhelmed from adjusting new lives during their resettlement process (Darawsheh et al., 2022; Mahon, 2022). Staff at CCI also expressed that refugees lack opportunities to learn basic financial literacy due to limited staff and resources. Therefore, my DCE project was developed into a peer-supported workshop program that provided social support and financial literacy to small groups of refugee clients. In each small group, I selected refugees from the Match Grant program at CCI, and peer mentors who were previous clients of CCI that shared the same culture and language as the participants. Peer mentors facilitated the program by translating and helping with the workshop sessions. Because of the groups limited availability and lack of transportation, the program held two 90-minute workshop sessions at a refugees home. To make efficient use of limited time, I developed surveys and assessment tests centered on six basic financial literacy topics: Using banking services, Keeping track of account activity, Setting up online payment, Writing checks, Planning a budget, and Finding ways to save money (see Appendix B). I also created educational handouts and activity sheets based on resources I obtained online and from a financial literacy coach. I then translated these sheets using Google Translate into the refugees languages and corrected any mistranslations (see Appendix C for all handouts). The first workshop session covered content on banking services, credit cards, pay stubs and checks. The second workshop session reviewed past content, then covered budgeting and saving goals. Before and after each session, I verbally administered a 5-point Likert survey and a 10-question assessment with the peer mentors translation to measure the participants level of knowledge, perceived level of confidence, and perceived level of support from CCI and from outside of CCI. The most challenging part of implementing this program was coordinating the session times with the peer-mentored group. I was able to start the program with three groups; however, one of them was unable to finish the program due the entire group being unavailable and busy with their work schedules. Another group had schedule conflicts involving appointments with CCI staff, and needed a new peer mentor because the previous one who became unavailable. The language barrier was also a challenge, and it required extra time to interpret the content to the participants through the peer mentor. However, the most successful part was finishing the program with two of the three groups, with a total of seven participants. All participants also gave positive feedback of the program and were able to read the educational info sheets that I translated in their languages. Project Outcomes For the projects outcomes, the surveys and assessments tallied the scores of each participant before and after the program. The assessment included 10 financial literacy questions that participants circled Yes or No to determine if they knew the answer and scored a point for every Yes. The scores were calculated out of a total of 10 points. This simple and direct method allowed participants to answer without any confusion while the questions were translated by the peer mentor. The total maximum scores in the survey that measured the level of confidence in six financial literacy topics, overall level of confidence, and perceived levels of social support from CCI and from outside of CCI were 30, 10, and 5 respectively. Two groups completed the surveys and assessments: the Afghan group of two participants, and the Congolese group of five participants. At the end of the program, participants rated how helpful the workshop sessions were. When comparing the pre- and post-surveys, there were improvements in the participants level of confidence in all six financial literacy topics and in the overall confidence in their financial literacy (see Appendix A for Figures). As shown in Figure 1, the Afghan groups average confidence scores increased from 22.5 to 26.5 out of 30. The Congolese group increased their average confidence scores from 11.6 to 26.8. In the levels of overall confidence in financial literacy, both groups achieved a score of 8.0 out of 10 score (see Figure 2), with the Congolese participants improving the most from 6.2 to 8.0. Although the Afghan group showed a decrease from 9.0 to 8.0 in the overall confidence, this difference may reflect that they were still familiarizing with new content despite having high levels of overall confidence. Participants also increased in their perceived levels of social support both from CCI and from the community outside of CCI (see Figure 3 and Figure 4). The Afghan group increased their perceived support from CCI from an initial score of four to a five, while their perceived level of support outside of CCI remained at 4.5. However, the Congolese group increased from 4.2 to 4.6 out of five in the level of perceived support from CCI, while their level of support outside of CCI increased from one to two out of five. According to the assessment outcomes, all participants showed an increase of scores (see Figure 5). The Afghan groups initial average score of seven improved by three points to a final average score of 10, while the Congolese groups initial average score of 4.6 improved to an average score of 9.8. The Congolese group showed a greater improvement in their confidence and knowledge in financial literacy, as the participants started with a lower baseline than the Afghan group. All of the participants greatly benefited from the workshop, as shown from their feedback (see Figure 6) and the results reflecting an almost full scores in the assessment of confidence and financial knowledge. Summary Refugees experience OD due to multiple barriers and stressors that impact their ability to adapt and integrate into a new environment and society (Darawsheh et al., 2022; Hugelius et al., 2020; Utran & Wieling, 2020). Studies also showed that resettlement agencies lack in social support, and that it is especially necessary to provide peer support for refugees (Darawsheh et al., 2022; Mahon, 2022). To address OD and the need for social support, my DC project at CCI implemented a basic financial literacy program to a group of refugees supported by a fellow peer mentor. The aspect of peer mentorship and peer-support groups help overcome the language barrier, enhance the refugees learning process, and ultimately promote resilience and selfefficacy (Frster et al., 2022; Gower et al., 2022; Paloma, 2020). During the development and implementation process, the SOC theory guided my project by selecting, optimizing, and compensating in areas of the refugees needs, capabilities, and available resources. Despite the challenges I encountered in carrying out my workshop sessions, I succeeded in completing the program with two different refugee groups. Using the pre-& postsurveys and tests, I gathered each groups data in their knowledge of financial literacy, their confidence in money management, and perceived level of social support from CCI and outside community. Outcomes from the program showed an overall increase in all of the assessed areas for both groups, with the Congolese group showing the most significant improvement from their baselines. These results indicated that the program proved beneficial for the groups. Conclusion Despite the programs short period of two sessions and the refugees limited availability, participants were able to engage in money management activities with fellow peer mentors and demonstrated effective learning and enhanced social support. The Congolese group who arrived recently in the U.S. showed a lower baseline than the Afghan group who had longer time to resettle and socialize. Although there were differences between both groups outcomes, both groups gained knowledge and achieved confidence in their financial literacy, especially among the Congolese group. The outcomes and feedback from both groups indicated that any form of social support supplemented with educational resources can be beneficial for the refugees. In the future, implementing this workshop program with newly arrived refugees such as the Congolese group may be more beneficial because of the greater availability of time new refugees have. To ensure implementation of this program, I created electronic folders and resource binders and stored the content such as worksheets and handouts for the staff at CCI. I also used Google Translate to translate the documents into Dari and Swahili as well as additional languages of other refugee groups such as Burmese and Pashto, which were then compiled into the resource folders for easy access and future opportunities with other incoming refugees. In non-traditional settings such as CCI, it is imperative to pursue further research in expanding the understanding of refugee needs in the sociocultural context as refugees are heavily impacted by the social aspect of their resettlement experiences (Darawsheh, et al., 2022; Utran & Wieling, 2020). Future implications also including in expanding OT roles as social connector and cultural translator (Blankvoort et al., 2018; Krishnakumaran, 2022) in order to provide effective interventions and programs that address OD in this population. References Archdiocese of Indianapolis. (2022). Refugee and Immigrant Services. https://www.archindy.org/cc/refugee/about.html Awidi, S. J., Quan-Baffour, K. (2021). Situating Adult Learning and Education in Refugee Livelihood Adaptation and Progression Toward Self-Reliance: The Case of Refugees in the Kyaka II Settlement in Southwestern Uganda. Adult Education Quarterly, 71(2). 148165. https://doi.org/10.1177/0741713620963575 Badwi, R., Ablo, A. D., & Over, R. (2018). The importance and limitations of social networks and social identities for labour market integration: The case of Ghanaian immigrants in Bergen, Norway. Norsk Geografisk Tidsskrift - Norwegian Journal of Geography, 72(1), 2736. https://doi.org/10.1080/00291951.2017.1406402 Baltes, P. B. (1997). On the incomplete architecture of human ontogeny: Selection, optimization, and compensation as foundation of developmental theory. American Psychologist, 52, 366-380. Blankvoort, N., Arslan, M., Tonoyan, A., Damour, A. Q., & Mpabanzi, L. (2018). A new you: A collaborative exploration of occupational therapys role with refugees. World Federation of Occupational Therapists Bulletin, 74(2), 9298. https://doi.org/10.1080/14473828.2018.1526560 Bureau of Population, Refugees and Migration [PRM]. (2023). Refugee Arrivals by State and Nationality. Refugee Processing Center. https://www.wrapsnet.org/documents/Refugee%20Arrivals%20by%20State%20and%20N ationality%20as%20of%2031%20Dec%202022.pdf Catholic Charities Indianapolis [CCI]. (2021). 2020-2021 Annual Report. http://www.archindy.org/CC/indianapolis/documents/2132_CCI_AnnualReport_202021%20Final.pdf Darawsheh, W. B. (2019). Exploration of Occupational Deprivation Among Syrian Refugees Displaced in Jordan. The American Journal of Occupational Therapy, 73(4). 7304205030p17304205030p9. https://doi.org/10.5014/ajot.2019.030460 Darawsheh, W. B., Bewernitz, M., Tabbaa, S., & Justiss, M. (2022). Factors Shaping Occupational Injustice among Resettled Syrian Refugees in the United States. Occupational Therapy International, 2022, 112. https://doi.org/10.1155/2022/2846896 Dubus, N. (2018). Integration or Building Resilience: What Should the Goal Be in Refugee Resettlement? Journal of Immigrant & Refugee Studies, 16(4), 413429. https://doi.org/10.1080 /15562948.2017.1358409 Frster, M., Klier, J., Klier, M., Schfer-Siebert, K., & Sigler, I. (2022). Leveraging the Power of Peer Groups for Refugee Integration: A Randomized Field Experiment Comparing Online and Offline Peer Groups. Business & Information Systems Engineering, 64(4), 441457. https://doi.org/10.1007 /s12599-021-00725-9 Freund, A. M., & Baltes, P. B. (2000). The orchestration of selection, optimization and compensation: An action-theoretical conceptualization of a theory of developmental regulation. Control of human behavior, mental processes, and consciousness: Essays in honor of the 60th birthday of August Flammer, 35-58. Gower, S., Jeemi, Z., Forbes, D., Kebble, P., & Dantas, J. A. R. (2022). Peer Mentoring Programs for Culturally and Linguistically Diverse Refugee and Migrant Women: An Integrative Review. International Journal of Environmental Research and Public Health, 19(19), 12845. https://doi.org /10.3390/ijerph191912845 Hugelius, K., Semrau, M., & Holmefur, M. (2020). Perceived Needs Among Asylum Seekers in Sweden: A Mixed Methods Study. International Journal of Environmental Research and Public Health, 17(14), 4983. https://doi.org/10.3390/ijerph17144983 Kisiara, O. (2021). Motivations of Refugee-Background Adults in Enrolling in English Language Classes in the United States. Adult Learning, 32(3), 115124. https://doi.org/10.1177 /1045159520969859 Krishnakumaran, T., Bhatt, M., Kiriazis, K., & Giddings, C. E. (2022). Exploring the Role of Occupational Therapy and Forced Migration in Canada. Canadian Journal of Occupational Therapy, 89(3), 238248. https://doi.org/10.1177/00084174221084463 Mahon, D. (2022). A Scoping Review of Interventions Delivered by Peers to Support the Resettlement Process of Refugees and Asylum Seekers. Trauma Care, 2(1), 5162. https://doi.org/10.3390 /traumacare2010005 Paloma, V., Morena, I., Sladkova, J., & LpezTorres, C. (2020). A peer support and peer mentoring approach to enhancing resilience and empowerment among refugees settled in southern Spain. Journal of Community Psychology, 48(5), 1438-1451. https://doi.org/10.1002/jcop.22338 Refugee Processing Center. (2023). Refugee Admissions Report. https://www.wrapsnet.org/documents/PRM%20Refugee%20Admissions%20Report%20a s%20of%2031%20Dec%202022.xlsx Skran, C., & Easton-Calabria, E. (2020). Old Concepts Making New History: Refugee Selfreliance, Livelihoods and the Refugee Entrepreneur. Journal of Refugee Studies, 33(1), 121. https://doi.org/10.1093/jrs/fez061 Trimboli, C., & Halliwell, V. (2018). A survey to explore the interventions used by occupational therapists and occupational therapy students with refugees and asylum seekers. World Federation of Occupational Therapists Bulletin, 74(2), 106113. https://doi.org/10.1080/14473828.2018.1535562 U.S. Department of State. (n.d.). U.S. Refugee Admissions. https://www.state.gov/refugeeadmissions/ Utran, D. S., & Wieling, E. A. (2020). A Phenomenological Study on the Experience of Syrian AsylumSeekers and Refugees in the United States. Family Process, 59(1), 209-228. https://doi.org/10.1111/famp.12408 Walther, L., Amann, J., Flick, U., Ta, T. M. T., Bajbouj, M., & Hahn, E. (2021). A qualitative study on resilience in adult refugees in Germany. BMC Public Health, 21(1), 828. https://doi.org/10.1186 /s12889-021-10817-6 Winlaw, K. (2017). Making the connection: Why refugees and asylum seekers need occupational therapy services. Occupational Therapy NOW, 19(4), 18-19. https://www.caot.ca/document/5748/Making%20the%20connection%20Why%20refugee s%20and%20asylum%20seekers.pdf Appendix A Figure 1 Average Level of Confidence in Six Financial Topics Pre Confidence Scores 30 Post 25 20 15 10 5 0 Congolese Group Afghan Group Participants Note. Scores in each topic were calculated in total. Figure 2 Average Level of Overall Confidence in Financial Literacy Pre Post Confidence Scores 10 8 6 4 2 0 Congolese Group Afghan Group Participants Note. Total scores calculated in practice and knowledge of financial literacy. Figure 3 Average Level of Perceived Support from CCI Pre Post Support Scores 5 4 3 2 1 0 Congolese Group Afghan Group Participants Note. Scores reflect social support from staff at CCI. Figure 4 Average Level of Perceived Support from Outside of CCI 5 Pre Post Support Scores 4 3 2 1 0 Congolese Group Afghan Group Participants Note. Scores reflect social support from community. Figure 5 Average Assessment Scores in Financial Literacy Pre Post Assessment Scores 12 10 8 6 4 2 0 Congolese Group Afghan Group Participants Note. Assessment scores calculated from total of 10 points. Figure 6 Scores Reflecting the Helpfulness of the Workshop Program 5 Scores 4 3 2 1 0 1 2 3 4 Participants 5 Note. Each participant rated a score out of five. 6 7 Appendix B Survey First and Last Name: Please rate your level of confidence for each topic from a scale of 1 to 5. (1 = least confident, 5 = most confident) 1) Using bank services (Taking out or putting money into the account, accessing bank account online). 1 2 3 4 5 2) Keeping track of the account activity (how much money is spent & earned, fees received, bills paid, etc). 1 2 3 4 5 3) Setting up online payment (adding card information to pay for bills & other expenses). 1 2 3 4 5 1 2 3 4 5 4) Writing checks. 5) Planning a budget for expenses (spending) and for saving. 1 2 3 4 5 2 3 4 5 6) Finding ways to save money. 1 Please rate the level of support you feel for the following from 1 to 5. (1= least supported, 5 = most supported) 1) Receiving support from staff at Catholic Charities (CCI). 1 2 3 4 5 2) Receiving support from people outside of Catholic Charities CCI (ex: fellow refugees/immigrant community, friends, other service agents) 1 2 3 4 5 Please rate your level of confidence from 1 to 5. (1 = least confident, 5 = most confident) 1) Having general financial knowledge 1 2 3 4 5 3 4 5 2) Practicing general financial knowledge 1 2 *Post: How helpful were these workshop sessions to you? Please rate from 1 to 5. (1 = least helpful, 5 = most helpful) 1 Comments/Suggestions: 2 3 4 5 Assessment Questions Name: __________________________ Answer yes or no for the following questions: 1. Do you know how to withdraw and deposit money? Y N 2. Do you know what Direct Deposit is? Y N 3. Do you know what is the difference between debit and credit card? Y N 4. Do you know what is the difference between a paycheck and a pay stub? Y N Y N 6. Do you know what things you need to know to make an online payment? Y N 7. Do you know what a budget is? Y N 8. Do you know what are expenses and what are incomes? Y N 9. Do you know how to keep track of your money? Y N 10. Do you know ways to save money? Y N 5. Do you know what things are on your pay stub? Review Questions 1. How do you withdraw and deposit money? 2. What is Direct Deposit? 3. What is the difference between debit and credit card? 4. What is the difference between a paycheck and a pay stub? 5. What information is written on your pay stub? 6. What information do you need to know to make an online payment? 7. What is a budget and how can it help you? 8. What are expenses and what are incomes? 9. How do you keep track of your money? 10. What are two ways to save money? Appendix C Activity: Identify on Your Pay Stub 1) Identify on Your Pay Stub: Pay Period Tax Deductions Gross Income Net Income 2) Mark and write the definition of the ones you are most unfamiliar with What is the Difference Between Your Pay check and Pay stub? Pay Check: A physical paper that is given to the employee for the amount paid based on the hours worked. Pay Stub: The document that shows a summary of amounts from a paycheck. A record of your salary details and wage information. This is your proof of income. Info in Your Pay Stub Pay Period The calendar of days included in the paycheck. Your employer sets the pay schedule. Some people get paychecks weekly or monthly, but most get paid every two weeks. Tax Deductions The taxes, insurance premiums, and the cost of other programs that are subtracted from your gross income. Gross Income The total pay before taxes and other deductions are taken out. Net Income The amount of money you bring home in your paycheck after taxes and other deductions are taken out; also called take-home pay. Dari . . Paycheck Pay stub  Pay Stub . . * 1) Pay Period 2) Gross Income 8) Tax Deductions 9) Net Income Pashto . . ) (Paycheck Paycheck Pay stub  . . . * Pay stub 1) Pay Period 2) Gross Income 8) Tax Deductions 9) Net Income Appendix D Week DCE Stage Weekly Goal Objectives 1 Orientation -Introduce myself and my DCE project. Meet with site mentor and other staff members. 2 Screening/Eval uation -Finalize Q&As for Needs Assessment -Update Goals & Objectives 3 Screening/Eval uation 4 Screening/Eval uation 5 Implementation -Complete Needs Assessment -Finalize and Submit MOU -Start search for peer mentors and participants -Complete literature search for program development -Finalize workshop schedules -Develop workshop content -Finalize coordinating workshop session 1 schedule -Complete workshop session 1 content -Finalize survey & assessment questions -Complete workshop session 2 content -Schedule workshop session 1 for two Afghan groups -Find & coordinate session times with peer mentors & clients -Contact potential peer mentors -Create outline of the sessions -Confirm workshop schedules with Afghan group clients -Finish 1st session ppt content & activity sheets -Continue search for peer mentors -Schedule 2nd session with Dari group & Pashto group Tasks Set up meetings to determine who to collaborate with for the DCE project. -Meet with case managers for needs assessment -Meet with site mentor for MOU -Meet with MG coordinator on search & workshop plans -Discuss with MG coordinator to find times with clients -Contact Employment team supervisor for possible peer mentors -Create pre & post-workshop surveys & assessments -Contact Afghan group -Print survey & assessments and ask Sana to review/edit the translated ones -Email Burmese American Community Institute for peer mentors -Make edits on workshop content as needed -Confirm session 1 schedules Date complete 1/13 1/19 1/28 2/3 2/8 6 Implementation 7 Implementation 8 Implementation 9 Implementation 10 Implementation 11 Implementation 12 Discontinuation 13 Dissemination 14 Dissemination -Complete 2nd session content (ongoing) -Complete 2nd session content -Complete workshop session 2 with groups -Secure at least 1 new group of clients -Complete outline of 2nd session lesson plan -Finalize activities and worksheets, assessments & surveys -Confirm schedules with clients and peer mentor -Confirm with peer mentors schedule and availability -Schedule with new group -Confirm Congolese -Prepare for workshop session group workshop schedule 1 with Congolese group -Workshop session 1 with Congolese group -Prepare for Congolese -Contact peer mentor and Sana group workshop session for workshop session schedule -Review relevant content for Congolese group -Finish last workshop -Contact peer mentor and session with Congolese group to confirm schedule group -Organize & analyze -Organize survey & gathered data assessment outcomes -Finish project outcomes -Present to primary -Create resource binders & stakeholders electronic folders -Present to primary -Create PowerPoint slides stakeholders -Finalize outline of second session -Make edits & changes on activities/worksheets, assessment & surveys -Call and text clients to remind them of the session -Meet with academic advisor to discuss DCE project -Notify existing workshop group -Request for new peer mentors -Print resource material, worksheets, and content copies -Notify the group and Freddie -Discuss workshop times with Sana for last workshop session -Contact peer mentor for session -Send text reminders -Print any other worksheets as needed -Input and calculate averages -Create graphs as needed -Print out all financial literacy & other materials -Organize & save files into Arch Indy network drive 2/18 2/27 03/02 03/07 03/17 03/22 3/31 4/10 4/13  ...

... Facilitating Healthy Occupations Through Components of Resiliency Carmen Chastain 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. Beth Ann Walker, PhD, MS, OTR, FAOTA Abstract Dove Recovery House is an inpatient substance use recovery house for women which aims to empower women to become substance free, self-sufficient, and healthy, by providing safe housing, quality programming, and above all hope for the future (Dove Recovery House, 2022). Resilience is a key piece to recovery and occupational engagement as it serves as one of the largest contributing factors to preventing relapse. To address these barriers to healthy occupational engagement, I designed a project centered on resilience. Five therapeutic group sessions were held to cover the three main principles of resilience and their relationships to establishing healthy occupational engagement: self-awareness and self-efficacy, realistic views of experiences, and optimism. The project was informed by the Contemporary Trauma Theory and Trauma Informed Care (CORE) model and a thorough needs assessment. Program participants demonstrated an increase in overall understanding of information given in the occupation-based program, apart from the shame category. Group-based occupational therapy interventions designed to address factors of resilience from social skills and budgeting, to understanding life roles as a woman in sobriety may be an effective way to increase occupational engagement and wellness, and further facilitate recovery through discovery of an occupational identity outside of the context of addiction. Introduction DOVE recovery house in Indianapolis, IN serves as one of the largest Womens recovery treatment centers in Indiana. The organization aims to empower women to become substance free, self-sufficient, and healthy, by providing safe housing, quality programming, and above all hope for the future (Dove Recovery House, 2022). DOVE House currently holds 40 beds broken up between one small dorm, one large dorm, ten senior dorms (two-person living), and two independent-living apartments. Residents are required a minimum 90-day commitment to work the inpatient program but can stay up to two years if necessary for a safe and long-term transition into sobriety. In building off the mission statement, I used DOVEs emphasis on hope to guide the basis of my project by exploring the three main components of resilience: self-awareness and self-efficacy, realistic views of experiences, and optimism. With these concepts, five total sessions have been created to highlight each of these areas. The sessions were designed using the visual of traveling down a road. Each session zoomed in on an area of the road. Session one served as an introduction and highlighted a point on the map stating, you are here, or focusing on the component of resilience that is self-awareness and self-efficacy. Sessions two and three highlighted a past portion of the map stating, where youve been, or realistic views of experiences. Sessions four and five focused on where youre headed, or the optimism component of resilience. Using an occupational therapy perspective paired with a trauma informed model of care, I designed this series of programs for the residents at DOVE to increase occupational engagement and wellness, by discovering their occupational identity outside of the context of addiction. The remainder of this scholarly report will provide a background of the population I served and detailed information of the theoretical foundation, project design, and outcomes of the project. Background Resilience Lathan et al. (2020) defined resilience as a characteristic of the 3 Es of trauma, with resilience being an experience-related factor. Resilience can further be defined as either innate or acquired resilience, with acquired resilience factors strongly relating to substance use disorder (SUD) outcomes and drive to recovery, as explained by Yamashita et al. (2021). Boles (2017) remarked that resilience isnt a superhuman trait, but rather a trait that is more common than not in people recovering trauma, a trait that often presents itself with time, and allows one to get back to normalcy in their daily routines. One study used resilience in the context of a coping strategy and an adaptive response (Lathan et al., 2020). Further, the study found that with a measure of the womens subjective feelings such as resilience, the researchers were given a better predictor of PTSD than if given characteristics of the traumatic event themselves, in fact psychological resilience was the strongest predictor of anxiety, depression, and sense of safety. (Lathan et al., 2020). Additionally, women who had high trauma exposure but higher resilience, were measured less likely to have PTSD and postpartum depression (Lathan et al., 2020). Each of the above studies support program implementation for a series of sessions centered on resiliency within this community. The evidence supports resilience as a strong predictive factor in substance use recovery and trauma informed care, which therefore provides a foundation for the basis of my program series. Self-Efficacy Self-efficacy is often a predictor of outcomes in substance use disorder and treatment, as described by Petker et al. (2021), self-efficacy is considered an addiction-specific outcome. Selfefficacy can also be defined as personal beliefs in oneself to have control over situations within their environment, based on certain ques available to them (Taylor et al., 2015). Additionally, Taylor et al. (2015) describes self-efficacy as a key proponent to behavioral change. According to Taylor et al. (2015), implementing curriculum-based programming on self-efficacy is imperative for behavioral change to begin lifestyle changes in women with substance use disorder. In a study designed to implement programming involving self-efficacy awareness and training, the study found that from admission to discharge improvements in self-efficacy perceptions and scores were important predictors of outcomes from treatment (Petker et al., 2021). According to Taylor et al. (2015), lower levels of self-efficacy in situations such as financial problems, familial problems, or social turmoil, increases potential for relapse. The success of the above programs in self-efficacy training for lifestyle development and the continuation of sobriety, provided a strong foundation for the development of this program. Research supports the important role that self-efficacy plays in maintaining sobriety, which additionally supports occupational engagement and facilitation of healthy occupations through increased self-efficacy. Self-Stigma Self-stigma can be defined in many ways, one of which is internalized negative stereotypes upon oneself (Melchoir, 2018). Melchior et al. (2018) reported that self-stigmas relationships to depression are stronger than the relationships between PTSD and depression, noting the negative correlation between self-stigma, self-esteem, hope, and empowerment. Friendships and connectedness have been shown to correlate with a lesser likelihood of selfstigma and furthermore reduce the risk of SUD or relapse (Vatanasin, 2022). Age, SUD severity, and depression as important variables in identifying an increased risk of self-stigma in patients with substance use disorder (Melchoir, 2018). Self-esteem was also found to be a predictor of self-stigma and therefore of relapse, SUD, and other negative coping mechanisms (Vatanasin, 2022). While research is limited, studies support the use of programming to support self-esteem and therefore reduce self-stigma. Being proactive in programming and interventions is the best way to reduce the likelihood of self-stigma and therefore of further negative consequences with SUD. The literature that exists on resilience and other coping mechanisms, largely support my project idea at DOVE Recovery House. By focusing on resilience as a component of recovery, the designed programs aimed to foster healthy occupational engagement and lifestyle changes necessary for the residents at DOVE house. Theory/Model/FOR I chose to add to a currently existing model of trauma informed care to guide my doctoral capstone experience (DCE). The Contemporary Trauma Theory and Trauma Informed Care model (CORE) views substance use disorders through the lens of trauma history and childhood trauma (Goodman, 2017). This model theorizes three pathways that typically branch from a history of childhood trauma: resilience, coping, and current trauma symptoms. This theory proposes that substance use is a coping mechanism from experiencing childhood trauma. The focus of this DCE was to develop a program series focusing on building characteristics that are related to resilience to understand occupational identity outside of the context of addiction. The residents of DOVE Recovery House are already facing substance use as a coping mechanism, focusing on the trait of resiliency and its components can help develop healthy coping mechanisms for their past trauma, their current substance abuse, and for other present symptoms of their trauma. The CORE model was created using the frames of reference of contemporary trauma theory and trauma informed care. These frames each provide an understanding of the biopsychosocial view of trauma on children and its impact into adulthood (Goodman, 2017). In addition to using this model for my programs, using a trauma informed care frame of reference to guide my everyday tasks at my DCE was imperative. This outlook provided the basis for which all programmed sessions were developed, keeping childhood trauma and adverse experiences in mind as the source of substance use disorders, rather than substance use as an illness or ailment. As depicted in Appendix A, the following components of resiliency were addressed in programming: self-awareness and self-efficacy, realistic views of experiences, and optimism. Each of these components were further explored through the lens of trauma informed care to create a holistic and meaningful series of programs for the population at DOVE Recovery House. Project Design This project was developed based on each piece of information gathered within the needs assessment in addition to evidence-based research. Although the original needs assessment did provide a foundation for the rest of the project to come, the original needs assessment meeting more so provided foundational knowledge of the organization, rather than what specific needs they were looking to meet. To fill in these gaps, I provided two questionnaires after the initial needs assessment regarding the presence or absence of coping skills within this population. I provided both the Guilt and Shame Experience Scale and the Brief-COPE. The Guilt and Shame Experience Scale is a self-report measure that addresses the distinct feelings of both shame and guilt, being sure to pay close attention to the varying emotions and experiences associated with each (Malinakova, K., et al., 2020). Additionally, I chose to use the Brief-COPE inventory, another self-reported measure to assess both effective and ineffective use of coping mechanisms (Buchanan, D. B., 2023). Specifically, I chose this measure to assess the prevalence of unhealthy coping mechanisms within this population, under the assumption of substance use already occurring as one of multiple unhealthy coping mechanisms. After compiling each of the questionnaires, information gathered from the needs assessment, researching the literature, and having deeper conversations with the staff and residents, it became apparent that the major lacking component of women in recovery was a sense of self, an identity of who they are outside of addiction. Both pieces of information concluded a foundational needs assessment in which I began exploring barriers and facilitators to creating a sense of self and identity outside of the context of addiction. Each of these components led to my final project design of creating a 5-session groupbased educational program centered around the above information. The basis of each session was centered around the three components of resilience: self-awareness and self-efficacy, realistic view of past experiences, and optimism. I chose to design my outcome measure to capture knowledge, comfort, and attitudes associated with each topic covered in the sessions. This was developed uniformly throughout by taking each subject and using the same question stem for knowledge, comfort, and attitude on each subject. Because the goal was to assess information gained after educational sessions, a likert scale of knowledge, comfort, and attitudes was the best way to do this (Sullivan, G. M., & Artino, A. R., 2013). Needs Assessment Two main interviews were conducted to gather pertinent information on DOVE Recovery House, each with the organizations chief operating officer Lara Chandler. The information gathered was aimed toward understanding how the lens of occupational therapy can benefit DOVE Recovery House to create sustainable change at best. I found it important to identify gaps within programming in order to find a space for sustainable change that could be filled through a capstone project. The chief operating officer expressed that it was most important that the residents receive training on life skills, time management, and scheduling skills within their programming at DOVE. Furthermore, Lara expanded on these areas to say that self-sufficiency is the goal of the residents and any programming geared toward this can always be used. Any intervention given at DOVE, whether it be through programming or simply conversation, is to follow principles of trauma-informed care. The organization uses traumainformed care as the foundation for all that it does. Keeping this service delivery model in mind has been of utmost importance to provide sustainable and meaningful occupational engagement for the residents. The pairing of information from Lara, the models of care used at DOVE, and a general assessment of the population through volunteer work and two brief questionnaires as a needs assessment prior to the project, the overall delivery of my project was developed. Project Implementation The project was carried out through holding a one-hour educational and interactive group session every week. Any free program offered to the residents from the community is required if a resident is in-house at that time. Because of this, I had consistent attendance every week averaging 10 residents at each session. I spent weeks 1-4 at DOVE Recovery House immersed in the lives of the residents while designing educational, occupation-based, and group-based content for each group session. I used Group dynamics in occupational therapy: the theoretical basis and practice application of group intervention (Cole, M., 2018) to create a streamline group protocol that I would use as a foundation and build each of the five sessions off. The outline protocol I created as the foundation for each session can be found in Appendix B. From this protocol, I created informational handouts on each subtopic of resilience; self-awareness and self-efficacy, realistic views of experiences, and optimism, see Appendix C. After my site mentor and I finalized the day and time, I announced the therapeutic groups for the next two weeks during Morning Reflections - a required attendance morning meeting every weekday at 8:30am. As noted in Appendix D, by week 5, I implemented the first session. Each resident was given the pre-test at the beginning of the group, along with the expectation that they would attend for the following 5 weeks. With the nature of Dove Recovery House, it was difficult to maintain the same participants throughout or have consistent pre and post-test data. Participants either transitioned out of living at Dove and therefore no longer attended the sessions, or new residents would come and begin attending in the middle. This made it difficult to capture accurate information and feedback beyond individual sessions to determine effectiveness of the series. Despite this limitation, those who remained consistent throughout the program were very receptive to the knowledge and participated in every component of the program. Each participant engaged within the sessions and demonstrated learning through teachback in various moments within multiple sessions. Project Outcomes I designed a pre and post-test measure to evaluate education received from my program. The measure was designed using attitudes, knowledge, and comfort scales for each subject matter. The average score on a 1-5 likert scale either remained the same or increased by the minimum of .2 points, apart from a .3 decrease on the comfort of the subject shame. When administering the pre and post-test I realized this to be a limitation in the design of the measure. As shown in Appendix E, it is difficult to ask ones attitude toward or comfort of shame in the format I chose to do the likert scale, as the question seems counterintuitive. Additionally, the greatest limitation was again the inconsistency of residents as either new residents were moving in or residents that started in the program were no longer there to take the post-test. Although an increase in overall learning as measured by knowledge, attitudes, and comfort, can be argued by the small increases, having more residents to compile data on would portray more accurate data from the project. Table 1 Knowledge, Attitudes, and Comfort Pre and Post-test Question Pre-Test Average Post-Test Average Self-Efficacy Knowledge 2.3 3.3 Attitudes 3.5 3.5 Comfort 3.1 3.5 Knowledge 3.4 4.0 Attitudes 3.5 3.0 Shame Comfort 3.3 3.0 Knowledge 3.6 3.8 Attitudes 3.4 3.6 Comfort 3.2 3.7 Knowledge 3.4 4.0 Attitudes 3.7 3.7 Comfort 3.5 3.2 Knowledge 3.8 4.1 Attitudes 4.0 4.2 Comfort 3.7 4.0 Guilt Trauma and Substance Use Goal Setting Summary Dove Recovery House is an inpatient womens recovery house located in Indianapolis, designed to jumpstart women into a long-term journey to recovery and sobriety. The need for occupational therapy in this setting is undeniable. Apart from substance use serving as the primary unhealthy coping mechanism in each resident, there is also the presence of dualdiagnoses, lack of social support, lack of social skills, and minimal establishment of healthy roles and routines in each womans daily life. I designed a project to address resilience from an occupational health and wellness perspective. Addressing resilience from this lens is of utmost importance as resilience is one of the largest contributing factors to preventing relapse. This goal was achieved by designing 5 therapeutic group sessions to educate on, discuss, and apply the three main principles of resilience and its relationship to substance use. The overall vision of the project was guided by the completion of a needs assessment with stakeholders at the site through conversation and questionnaires. Additionally, the project was guided by the Contemporary Trauma Theory and Trauma Informed Care (CORE) model. To measure overall understanding of the information throughout the program, a pre and post-test measure was given to measure knowledge, attitudes, and comfort, on each of the 5 subject matters. Improvement in each category was noted with a minimum of .2 change in average, apart from the shame category which showed a decrease in average understanding. Conclusions The primary purpose of this experience was to design and deliver an occupational therapy group intervention on principles of resilience for the women served at DOVE. The site benefited greatly from the project as expressed in organic conversation and structured debrief sessions. Additionally, I could not have learned more from this experience. From an occupational therapy perspective, this project taught me the realities of project development, implementation, and analysis. Additionally, the research and advocacy required throughout the entirety of the project taught me the distinct role for occupational therapy within this setting. The skill set and knowledge occupational therapists possess is unique, skilled, and set apart from other professions serving this population. This project is one of many to have highlighted the benefit of occupational therapy programming within the substance use and recovery community. Despite its presence, this setting and its sister setting of mental health is still considered an emerging practice area of occupational therapy. The conclusion of this project led to an opportunity for Dove Recovery House to welcome their first occupational therapy staff. Through continued advocacy throughout the staff and to the nonprofit's board of directors, in addition to the culmination of the project, Dove Recovery House sees the value of an occupational therapist on staff full time. This creates grand opportunities for further research and clinical experience throughout the substance use population for occupational therapists. References Boles, J. (2017). Trauma-Informed Care: An Intentional Approach. Pediatric Nursing, 43(5). Buchanan, D. B. (2023, March 1). Coping orientation to problems experienced inventory (BriefCope). NovoPsych. Cole, M. (2018). Group dynamics in occupational therapy: the theoretical basis and practice application of group intervention (5th ed.). Slack incorporated. Davey-Rothwell, M. A., Crossnohere, N. L., Kimura, A., Page, K., Tobin, K., & Latkin, C. (2018). The role of perceived friend depression and perceived stigma on self-reported depression among individuals who use drugs. Journal of Community Psychology, 46(8), 11071113. doi:10.1002/jcop.22094 Goodman, R. (2017). Contemporary trauma theory and trauma-informed care in substance use disorders: A conceptual model for integrating coping and resilience. Advances in Social Work, 18(1), 186201. doi:10.18060/21312 Lathan, E. C., Selwyn, C. N., & LanghinrichsenRohling, J. (2020). The 3 es of trauma informed care in a Federally Qualified Health Center: Traumatic Event-and Experiencerelated predictors of physical and mental health Effects among female patients. Journal of Community Psychology, 49(2), 703724. doi: 10.1002/jcop.22488 Largest Women's Treatment Program - Dove Recovery House Indianapolis. Dove Recovery House. (2022, January 21). Retrieved March 7, 2022, from https://doverecoveryhouse.org/ Malinakova, K., Furstova, J., Kalman, M., & Trnka, R. (2020). A psychometric evaluation of the guilt and shame experience scale (GSES) on a representative adolescent sample: A low differentiation between guilt and shame. International Journal of Environmental Research and Public Health, 17(23), 8901. https://doi.org/10.3390/ijerph17238901 May, E. M., Hunter, B. A., Ferrari, J., Noel, N., & Jason, L. A. (2015). Hope and abstinence selfefficacy: Positive predictors of negative affect in substance abuse recovery. Community Mental Health Journal, 51(6), 695700. doi:10.1007/s10597-015-9888-y Melchior, H., Hsing, P., Grundmann, J., Lotzin, A., Hiller, P., Pan, Y., Driessen, M., Scherbaum, N., Schneider, B., Hillemacher, T., Stolzenburg, S., Schomerus, G., & Schfer, I. (2019). Substance abuse-related self-stigma in women with substance use disorder and comorbid posttraumatic stress disorder. European Addiction Research, 25(1), 2029. doi:10.1159/000496113 Petker, T., Yanke, C., Rahman, L., Whalen, L., Demaline, K., Whitelaw, K., Bang, D., Holshausen, K., Amlung, M., & MacKillop, J. (2021). Naturalistic evaluation of an adjunctive yoga program for women with substance use disorders in inpatient treatment: Within-treatment effects on cravings, self-efficacy, psychiatric symptoms, impulsivity, and mindfulness. Substance Abuse: Research and Treatment, 15, 117822182110266. doi:10.1177/11782218211026651 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-54-18 Taylor, O. D., & Williams-Salisbury, E. (2015). Coping skills and the self-efficacy of substanceusing women versus non-substance-using women. Journal of Human Behavior in the Social Environment, 25(4), 351359. doi:10.1080/10911359.2014.974428 Vatanasin, D. & Dallas J. C. (2022). Factors predicting self-stigma among youths receiving substance abuse treatment. Pacific Rim International Journal of Nursing, 26(1) 78-79. Yamashita, A., Yoshioka, S.-ichi, & Yajima, Y. (2021). Resilience and related factors as predictors of relapse risk in patients with substance use disorder: A cross-sectional study. Substance Abuse Treatment, Prevention, and Policy, 16(1). doi:10.1186/s13011-02100377-8 Appendix A CORE Model and Professional Reasoning Diagram Appendix B Generalized Group Protocol Format: (60 total minutes) Ice Breaker Educational concepts video structured handouts Interactive worksheets Discussion and reflection Debrief Description: 1. Ice breaker - name and one thing each member loves about themselves in sobriety 2. Educational concepts a. Provided an evidence-based video to capture attention and summarize the concepts to be taught on in the group-based session. b. Provided footnotes or outlines from a peer-reviewed article, along with summary points at an appropriate comprehension level. 3. Interactive worksheets a. Open-ended worksheets meant for brainstorming, discussion, and application to occupation-based roles, routines, and rituals in sobriety. 4. Discussion and reflection 5. Debrief Appendix C Informational Group-based Handouts Figures C1 and C2. Educational, research-based hand outs for the first group-based session that addressed self-efficacy. Figures C3 and C4. Educational, research-based handouts for the second group-based session that addressed shame and guilt. Figures C5 and C6. Educational, research-based hand outs for the third group-based session that addressed realistic views of experiences using a trauma informed approach. Figure C7. Educational, research-based hand out for fourth group-based session that addressed optimism through goal setting. Appendix D Weekly Planning Guide Appendix E Pre and Post-test 1. Rate your knowledge about self-efficacy. Very unconfident on the subject 1 o 2 o 3 o 4 o Confident enough to teach the subject 5 o 2. Rate your attitude toward the concept of self-efficacy. Strongly disagree on the concept 1 o 2 o 3 o 4 o Strongly agree on the concept 5 o 3. Rate your comfort on the topic of self-efficacy. Very uncomfortable to talk about it 1 o Very comfortable to talk about it 2 o 3 o 5 o 4 o 4. Rate your knowledge about shame. Very unconfident on the subject 1 o 2 o 3 o 4 o Confident enough to teach the subject 5 o 5. Rate your attitude toward the concept of shame Strongly disagree on the concept 1 o 2 o 3 o 4 o Strongly agree on the concept 5 o 6. Rate your comfort on the topic of shame. Very uncomfortable to talk about it 1 o Very comfortable to talk about it 2 o 3 o 4 o 5 o 7. Rate your knowledge about guilt. Very unconfident on the subject 1 o 2 o 3 o 4 o Confident enough to teach the subject 5 o 8. Rate your attitude toward the concept of guilt. Strongly disagree on the concept 1 o 2 o 3 o 4 o Strongly agree on the concept 5 o 9. Rate your comfort on the topic of guilt. Very uncomfortable to talk about it 1 o Very comfortable to talk about it 2 o 3 o 4 o 5 o 10. Rate your knowledge about the relationships between trauma and substance use disorder (SUD). Very unconfident on the subject 1 o 2 o 3 o 4 o Confident enough to teach the subject 5 o 11. Rate your attitude toward the concept the relationship between trauma and SUD. Strongly disagree on the concept 1 o 2 o 3 o 4 o Strongly agree on the concept 5 o 12. Rate your comfort on the topic of the relationships between trauma and SUD. Very uncomfortable to talk about it 1 o 13. 3 o 5 o 4 o 2 o 3 o 4 o Confident enough to teach the subject 5 o Rate your attitude toward the concept of goal setting. Strongly disagree on the concept 1 o 15. 2 o Rate your knowledge about goal setting. Very unconfident on the subject 1 o 14. Very comfortable to talk about it 2 o 3 o 4 o Strongly agree on the concept 5 o Rate your comfort on the topic of goal setting. Very uncomfortable to talk about it 1 o Very comfortable to talk about it 2 o 3 o 4 o 5 o  ...

... Increasing Wellness and Quality of Life of Sex Workers Allison Cattin 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: Dr. Beth Ann Walker, PhD, MS, OTR, FAOTA Abstract Sex workers are a marginalized population who experience low access to food, housing, and healthcare on top of increased levels of trauma, violence, and harassment. I worked with Made Strong, a nonprofit organization that provides case management services for individuals who are a part of the sex work community within Northeastern Indiana. As part of a doctoral capstone experience, four resource guides for use in client-centered and occupation-based case management sessions were developed and implemented. The four topics covered include financial management, cooking and grocery shopping, community access, and social interaction. Additionally, I worked with the onboarding case manager to develop a group therapy protocol and submitted two grants for the organization. Throughout my time onsite, I was able to see two clients through case management sessions. Project outcomes were disseminated through an interview with my site mentor as well as training sessions over the use of my project clinically with the case manager. Introduction Sex workers in the adult entertainment industry are a marginalized population who experience the same needs as any other marginalized group including limited access to food, housing, healthcare, mental health services, transportation, childcare, and education. However, people who work in the adult entertainment industry often face prejudice and harassment from providers the moment they come forward asking for assistance, as well as high rates of workplace violence, low social support, and high rates of trauma (McCausland et al., 2020). These factors have led to a population conditioned not to trust law enforcement, healthcare providers, ministries, and social service organizations even if they report a need provided by these professional groups (Hankel et al., 2016). Made Strong is a nonprofit organization that specializes in empowering and serving individuals who work in the adult entertainment industry in Northeastern Indiana. The founder of Made Strong is an occupational therapist who witnessed what the lack of resources can do to people in the adult entertainment industry while she was completing her degree in occupational therapy at the University of Indianapolis. The use of relational case management services has been mentioned in various studies as the most effective method to induce change, especially in marginalized populations (Davidson et al., 2018). Relational case management services is the adopted format of care provided by Made Strong to help address immediate and long-term needs of the clients they serve, but the current format at Made Strong does not address life skills and mental health for the individuals of the adult entertainment industry as much as it could. It is estimated that more than 80% of sex workers have experienced some form of trauma or abuse in their life (Argento et. al, 2020) and 70% of these individuals experience PTSD at some point within their life as well (Sawicki et. al, 2019). Background Although the adult entertainment industry brings in a minimum of 14 billion dollars annually in revenue in the US, the individuals who make up the front line of the industry typically do not see enough revenue to bring them above the poverty line (Sawicki, Meffert, Read, & Heinz, 2019). A majority of research conducted with this population may be outdated, written with bias about the population, or focuses on addressing specific aspects of sex work, such as condom use (Decker, 2020), HIV/STI rates (Miller et. al, 2020; Lyons et. al, 2020), stigma among sex workers with extra consideration towards male and nonbinary sex workers (Disogra, Marino, & Minichiello, 2005; Grittner & Walsh, 2020), and legalization or criminalization of sex workers around the world (Connelly, Kamerde, & Sanders, 2021). Very minimal literature has addressed the systematic links between the low outreach to healthcare, poverty levels, mental health, social support, or overall wellbeing of the population. Among the most recent research addressing the whole individual, the pre-existing barriers accessing basic needs this population faces have been increased by the Covid-19 pandemic (McBride et. al, 2023). Made Strong serves this population through outreach programs and case management services. Made Strong has over 30 partnerships with various local organizations. Some of these local organizations help with housing assistance, Medicaid, SNAP benefits, childcare vouchers, and mental health resources. Made Strong is an on-site partner of CONNECT Allen County, a collection of social service providers in the Fort Wayne area housed within the same office space. Community access and healthcare, including mental health care, are the major needs of the community (Knittel et. al, 2019). Although Made Strong has a connection with various partners in the community, a majority of their relational case management services are outsourcing care to community partners. Due to this, the site stated a need for the expansion of in-house case management materials in order to increase occupational engagement with their clients within their office. Made Strong is in need of case management materials across the following areas of care: addressing IADLs, community access, addressing mental health barriers, and enhancing social engagement. The goal of my project is to fill this gap at the site and help develop easily accessible materials to use in the case management services that fall within the occupational therapy scope of practice. A study conducted by Argento et al (2020) looked at the Toronto-based sex worker community and cited that 59% accessed resources similar to those provided by Made Strong and more than 80% disclosed previous trauma or abuse. A majority of the clients needed assistance addressing barriers that impact various IADLs and community engagement resources, such as managing finances, making meals with food pantry staples, time management, and socioemotional regulation (Argento et. al, 2020). A majority of sex workers get frustrated, miss appointments, lose important documents, and struggle to complete various difficult tasks such as applications for TANF or SNAP; all due to the long-term symptoms of various mental health problems. Case management is a collaborative process where the provider and the client work together to create goals, address barriers, and provide solutions to barriers. The case management materials that will be created are based around the mental health and IADL components of occupational therapy as it relates to these concerns. Feedback from the clients seen in 2022 set a foundation for this capstone project. Out of the 26 clients who engaged in case management services; All of the clients reported an income that falls in the bottom quartile of the federal poverty guidelines and identified mental health needs relating to PTSD, anxiety, and/or depression. 91% of people served reported being a victim of physical violence, sexual violence, and/or abuse, 75% of people served reported being homeless at some point in their life, 66% of people served are single parents, 33% of people served were identified as survivors of sex trafficking, and 33% of people served did not have their high school diploma. The most common needs addressed in 2022 within the sessions included food assistance, housing assistance, healthcare, mental health, and adult education, in that order. The occupation-based topics selected for the purpose of this capstone experience included meal preparation, grocery shopping, money management, community access, and coping strategies for stressful situations. Additionally, it was important that all materials were client-centered and built with the culture and specific needs of the clients in mind given common experiences of high levels of trauma and discrimination from multiple sources.. Theory and Frame of Reference The model used to guide my doctoral capstone experience is the Environmental- healthoccupation- wellbeing (E-HOW) model. This model emphasizes how health, environments, and occupational performance have a dynamic influence on quality of life and well-being of individuals. The E-HOW model looks at how a persons environment, health, and occupational participation affects their wellbeing/quality of life. The environment includes the social, physical, or cultural environment around them. Health can be of an individual, community, or population. Occupational participation can be occupations, occupational demand, skills, routines, and performance (Pizzi & Richards, 2017). The goal of my DCE is to increase the wellbeing of individuals in the adult entertainment industry by providing them with tools to address issues they may face. Using this model will help me make sure that all needed aspects of quality of life will be included in the DCE. The frame of reference (FOR) I chose to guide my DCE is the cognitive behavioral frame of reference. The cognitive behavioral frame of reference focuses on how thinking influences behavior (Cole & Tufano, 2008). Using this frame of reference to guide treatment can help overcome psychological barriers that block individuals from being able to actively engage in meaningful occupations. A cognitive behavioral approach was used to inform the design of therapeutic sessions and the development of intervention materials for the site. Due to the stressful and possibly unsafe conditions of this populations job, their mental health and wellbeing need to be a priority to reduce the negative health effects long term and increase their ability to engage in meaningful occupations as they see fit. Through the provision of resources or opportunities to increase positive behaviors or positive thoughts through meaningful changes should lead to positive quality of life outcomes. Project Design and Implementation The first step of any new client receiving case management services is to complete an intake assessment to address barriers, goals, and create a stepwise plan in order to reach said goals. The site currently uses four assessment tools: The Power and Control Wheel, The Gender Identity Unicorn, The Family Development Matrix, and the WHO-5 Well-being Index. The Power and Control Wheel addresses various forms of abuse and control an individual may feel from an abusive relationship (Chavis & Hill, 2008). This tool helps the site to screen for possible sex trafficking situations as sex trafficking is generally a relationship that involves one individual being coerced, forced, or manipulated into sex work (Chavis & Hill, 2008). The Gender Identity Unicorn looks at sexuality and gender expression on a sliding scale in order to provide LGBTQ+ resources if desired (Ho & Mussap, 2019). The Family Development Matrix is a strength-based assessment tool that measures success in the following areas: income, adult education, employment, housing, food, childcare, health care, transportation, utilities, support systems, family interaction, and addictions (Navarro, 2015). Scores are categorized as Crisis, Vulnerable, Stable, Self-Sufficient, and Thriving. Scores range from -15 at the lowest to 100 at the highest (Navarro, 2015). The WHO-5 screens for possible mental health needs. Although the site currently uses a handful of assessment tools, they expressed wanting different or new tools to get a clearer picture of the overall needs of the client (Topp et. al., 2015). After going through the initial training and orientation period of learning about the specific culture and stigma of the population, as well as learning about the site and more about nonprofits in Fort Wayne, I was able to begin designing my project. I used the information regarding culture and importance of working with traumatized individuals to develop client centered intervention plans and materials to match the plans. The topics of the interventions were based on feedback from the clients and then will be demonstrated to the clients in an intervention session. The materials and interventions were modified based on things that didnt go so well during the sessions. Challenges that arose during the development and implementation of my project included frequent cancellations, no shows, and difficulty getting clients in. This led to minimal clients being seen and the revision of the feedback strategy from using clients as the feedback source to using the staff alternatively. Outcomes Ten different evidence-based assessment tools in three different categories were presented to the site for possible inclusion within the intake session. The site selected the Perceived Stress Scale and My Vocational Situation as new assessment tools to use during intake sessions. The Perceived Stress Scale will be used as a new tool to screen wellbeing and mental health status and will replace their current assessment tool, the WHO-5. The Perceived Stress Scale is a strengths-based tool that the site chose for being more client centered as it addresses mental health in a less direct and easier to read way than the WHO-5. The My Vocational Situation assesses needs related to job access and assistance, which was seen as a gap in their current assessment tools after the completion of the needs assessment. I created 4 occupational therapy intervention resources and one 6-session group therapy protocol for the site. The occupation-based resources to be used in the intervention session targeted money management, food access, community access, and mental health. The money management resources aim to assist individuals with how to track income and expenses with or without a bank account, how to use a budgeting app on their phone in order to track things easier, and go over how to prioritize spending and paying off debt to be more effective. A majority of governmental assistance programs require individuals to report finances. Using the Mint app can help streamline reporting finances if needed to make the clients life easier. The food access resources included a cookbook, how to determine when and where to go for either food pantry staples or hot meals, and when and where to go for the most affordable cooking utensils around town. The cookbook includes healthy recipes that can be made with common food pantry staples while also addressing what dietary restrictions the meals meet (gluten free, nut free, and vegetarian), optional additional ingredients if they are available, as well as what cooking utensils are needed in order to cook the recipe. The cookbook was geared towards individuals who may be starting over with no food or cooking utensils in their kitchen, which can be common for sex trafficking survivors. The community access resource provides information on how to access affordable housing and cars. Information was also provided on how to complete a test drive when buying a car, how to avoid landlord scams, and other important information to keep individuals safe and give them the independence to access these items themselves. The mental health resources included information on how to talk to others when an individual is triggered into a PTSD or similar episode by something in the environment, how to identify triggers before they happen, how to use coping mechanisms and boundaries, and how to confront an individual appropriately when boundaries have been crossed. Summary Made Strong is a nonprofit organization that serves sex workers in the adult entertainment industry. The founder of Made Strong is an occupational therapist who saw the specific needs of the sex worker population and created a format or relational case management services based on her skills as an occupational therapy practitioner. The sex work community is a marginalized population who report high rates for trauma, abuse, and discrimination on top of the typical needs of individuals at or below poverty level (Argento et. al, 2020). Individuals in the sex worker population are often untrusting of healthcare and social services due to poor experiences when asking for help. The goal of my project was to provide resources to the site that are culturally appropriate and increase occupational engagement for the clients served by Made Strong. The materials for the sessions included money management, cooking and food access, transportation and housing access, trauma-related mental health needs, and a group therapy protocol that addresses these topics while aiming to create a peer support network to enhance a sense of community for the clients. The group therapy plan includes six sessions and was created interdisciplinary with the social worker who will be completing the group therapy sessions onsite within the following months. Upon completion of the materials, assessment tools, and grant submissions, the site stated that they expect the project to be sustainable, increase client satisfaction, and increase productivity of the employees at the site. Conclusion To disseminate and assist with the translational management of relative case management services at Made Strong, the CEO of the organization was interviewed to understand the likelihood of using the resources in the future, what she would like to change about them, and what she found to be the most helpful. Additionally, I completed a two-day training about the proper use of the resources with the newly hired case manager. We reviewed and modified the entire group therapy protocol together in order to make it more geared to her and her scope of practice as a social worker. The interview with the CEO took place during the 14th week on the 13th of April, 2023. All materials were re-reviewed together in person and open-ended questions were asked about the efficacy, client centered, and translational ability of the materials to be used beyond the 14week capstone. Through the dissemination process, the site stated that the project created will translate well into the case management services. Through the interviewing process, the CEO stated that the project is sustainable and will increase engagement and productivity of case management sessions. The site emphasized how the project materials will also empower clients at the site by not only assisting them with their immediate needs but teaching them skills to sustain their needs independently. Community based settings such as Made Strong are such a needed but an under looked setting for occupational therapy. Occupational therapy is deeply rooted in client-centered care, regardless of a persons background, cultural preferences, or anything else that can be used as a source of bias. Additionally, occupational therapists are able to address mental health challenges that interfere with occupational performance very effectively. When it comes to marginalized populations like the sex worker community, the argument can be made that the use of occupational therapy is the best answer for addressing the needs of the population. References Argento, E., Goldenberg, S., Braschel, M., Machat, S., Strathdee, S. A., & Shannon, K. (2020). The impact of end-demand legislation on sex workers' access to health and sex workerled services: a community-based prospective cohort study in canada. Plos One, 15(4), 0225783. https://doi.org/10.1371/journal.pone.0225783 Chavis, A. Z., & Hill, M. S. (2008). Integrating multiple intersecting identities: A multicultural conceptualization of the power and control wheel. Women & Therapy, 32(1), 121-149. Cole, M. & Tufano, R. (2008). Applied theories in occupational therapy: A practical approach. Thorofare, N.J.: SLACK Inc. Connelly, L., Kamerde, D., & Sanders, T. (2021). Violent and nonviolent crimes against sex workers: The influence of the sex market on reporting practices in the United Kingdom. Journal of interpersonal violence, 36(7-8), NP3938-NP3963. Davidson, D., Marston, G., Mays, J., Johnson-Abdelmalik, J. Role of Relational Case Management in Transitioning from Poverty. Australian Social Work. Jan2018, Vol. 71 Issue 1, p58-70. 13p. DOI: 10.1080/0312407X.2017.1376102. Decker, M. R., Park, J. N., Allen, S. T., Silberzahn, B., Footer, K., Huettner, S., ... & Sherman, S. G. (2020). Inconsistent condom use among female sex workers: Partner-specific influences of substance use, violence, and condom coercion. AIDS and Behavior, 24, 762-774. Disogra, C., Marino, R., & Minichiello, V. (2005). Self-reported use of health services, contact with police and views about sex work organizations among male sex workers in cordoba, argentina. Journal of Psychology & Human Sexuality, 17(1/2), 181195. Grittner, A. L., & Walsh, C. A. (2020). The role of social stigma in the lives of female-identified sex workers: A scoping review. Sexuality & Culture, 24(5), 1653-1682. Hankel, J., Heil, M., Dewey, S., & Martinez, N. (2016). Characteristics of women seeking services at a transitional housing facility for women leaving street-based sex work: implications for social service providers. Journal of Social Service Research, 42(1), 41 56. https://doi.org/10.1080/01488376.2015.1077188 Ho, F., & Mussap, A. J. (2019). The Gender Identity Scale: Adapting the Gender Unicorn to measure gender identity. Psychology of Sexual Orientation and Gender Diversity, 6(2), 217. Knittel, A. K., Graham, L. F., Peterson, J., Lopez, W., & Snow, R. C. (2019). Access to health care services among young people exchanging sex in detroit. Journal of Urban Health : Bulletin of the New York Academy of Medicine, 96(3), 452468. https://doi.org/10.1007/s11524-018-0239-5 Lyons, C. E., Schwartz, S. R., Murray, S. M., Shannon, K., Diouf, D., Mothopeng, T., ... & Baral, S. (2020). The role of sex work laws and stigmas in increasing HIV risks among sex workers. Nature communications, 11(1), 773. McBride, B., Shannon, K., Pearson, J., Braschel, M., Krsi, A., McDermid, J., & Goldenberg, S. M. (2023). Association between interrupted access to sex work community services during the covid-19 pandemic and changes in sex workers' occupational conditions: findings from a community-based cohort study in vancouver, canada. Bmj Open, 13(1), 065956. https://doi.org/10.1136/bmjopen-2022-065956 McCausland, K., Lobo, R., Lazarou, M., Hallett, J., Bates, J., Donovan, B., & Selvey, L. A. (2022). 'it is stigma that makes my work dangerous': experiences and consequences of disclosure, stigma and discrimination among sex workers in western australia. Culture, Health & Sexuality, 24(2), 180195. https://doi.org/10.1080/13691058.2020.1825813 Miller, W. M., Miller, W. C., Barrington, C., Weir, S. S., Chen, S. Y., Emch, M. E., ... & PazBailey, G. (2020). Sex work, discrimination, drug use and violence: a pattern for HIV risk among transgender sex workers compared to MSM sex workers and other MSM in Guatemala. Global public health, 15(2), 262-274. Navarro, I. California Partnerships and The Pathway to Prevent Child Abuse and Neglect Outcomes: A Collaborative Framework for the Family Development Matrix Assessment and Case Management Model (2015). Pizzi, M. A., & Richards, L. G. (2017). Guest EditorialPromoting health, well-being, and quality of life in occupational therapy: A commitment to a paradigm shift for the next 100 years. American Journal of Occupational Therapy, 71, 7104170010. https://doi.org/10.5014/ajot.2017.028456 Sawicki, D. A., Meffert, B. N., Read, K., & Heinz, A. J. (2019). Culturally Competent Health Care for Sex Workers: An Examination of Myths That Stigmatize Sex-Work and Hinder Access to Care. Sexual and relationship therapy: journal of the British Association for Sexual and Relationship Therapy, 34(3), 355371. https://doi.org/10.1080/14681994.2019.1574970 Stoewen D. L. (2017). Dimensions of wellness: Change your habits, change your life. The Canadian veterinary journal = La revue veterinaire canadienne, 58(8), 861862. Topp, C. W., stergaard, S. D., Sndergaard, S., & Bech, P. (2015). The WHO-5 Well-Being Index: a systematic review of the literature. Psychotherapy and psychosomatics, 84(3), 167-176. Appendix - Doctoral Capstone Experience and Project Weekly Planning Guide Week DCE Stage 1 Orientation Implementation 2 Orientation Weekly Goal Objectives 1)Complete orientation by the end of the week Attend site meeting and meet with site mentor 2)Begin working on MOU goals begin working on MOU goals for grant funding and site material building 1)observe first client session with educator Tasks Attending site meeting and trainings Understand site environment: culture, procedures, dress code, etc Begin grant funding search Begin article search Begin first IADL literature for site Review all intake assessment paperwork Assist in session and observe how to complete intake assessments Research community resources for food access to present to client Present resources in an easy, understandable format Implementation 1)finalize first site material Complete research and development on budgeting materials Build materials Present to site for feedback Update materials by end of the week Date completed Present to client at the end of the week 2)continue grant writing objectives Research and present grant sources to site Research mission statements of grant sources and rank on likelihood to receive grants based on mission similarities of site and source Research important dates and requirements of each grant Present findings to site for collaborative choosing of grant source 3 Orientation 1)Attend public presentation Screening/evaluation 2)grant funding 3)scouting partnerships Attend public advocacy event rant by site educator about sex trafficking Learn how to advocate in a session Researching grant funding Research grant funding Reaching out foodbank Visiting local nonprofits and Learn about sex trafficking from an expert Creating logic model for grant funding Acquiring application for partnership Visiting local nonprofits 4)development of Creation of materials materials based on scouting creating materials to outline best location to get resources for IADLs for those in needs in the local Fort Wayne area 4 Implementation 1)Grant Funding Writing of grant through research, meetings, and writing Research articles to support need for funding at site Writing of start goals, executive summary, supporting evidence, and statement of need Stakeholders meetings to address goals, rough draft of executive summary and statement of need 5 Implementation 2)Development of materials Development of materials for site 1)Grant Funding Finalizing first grant proposal 2)development of Development of Recipe materials book Revision of money management materials Development of independent cooking materials Revision of final draft of grant proposal to check for errors and accuracy. Reaching out to grant connection to check if everything necessary is included Research of common food pantry donations Research on simple and healthy recipes using food pantry staples and minimal ingredients Development of cookbook in easy to read format Development of group therapy plans Creating group therapy session outline and expectations of leader and members of group Reaching out and making appointments with clients Reaching out to four clients about setting up meetings in the near future Being present for two meetings this week. 3)Meeting with Clients Preparing interventions with clients Reviewing and practicing current assessment tools that will be used on intake sessions Researching and practicing providing interventions based on governmental assistance 6 Implementation 1)Development of Materials Development of Recipe book Development of additional site materials Organizing donations and who they may be distributed to Rewrite recipes in a format that is easy to understand and mindful of individuals who may have limited equipment and experience food scarcity. All recipe book items can be made with common food pantry donations Beginning research on job evaluations and resources for job transitioning Beginning research on common car and landlord scams and tips for finding a new car or apartment 2)Client Interaction Reaching out and meeting with clients, Reading through client paperwork, assisting with client meeting, reaching out to clients to set up appointments 3) Assessment tools 7 Implementation 1)Onsite Experience Implementation Researching free, evidence based assessment tools that align with the sites population and goals based on mental health, job readiness and job transition, and community access. Advocacy of Preparation and implementation of advocacy occupational therapy and of occupational therapy and networking at networking with non-profit community resource event community members Meeting with board and possible funding sources for the advocacy of occupational therapy and the site Meeting with Site Mentor for midway evaluation Discussion of current goals met, continued creation of resources for site, and case management Cooking materials Physical development of cookbooks for distribution to clients Assessment tools Research and presentation of various assessment tools for three areas of need onsite 1)Client Interaction Community Resource Access Reaching out to new clients Beginning the development of resources on housing and transportation access Calls and emails with clients reaching out about scheduling and services offered 2) Grant Writing Grant Development Writing and researching second grant source for site 2)Development of Materials 8 Researching assessment tools 9 10 Implementation Implementation Onsite tour for possible grant source Assisting with providing tour of site to possible grant sources 3) Ongoing Training 1)Client Interaction Cultural training provided by site Client appointments Reading through provided resources addressing culture and Scheduling appointments 2)Grant Writing Grant Development Development of second grant for the site Grant Submission Submission of first grant for the site 3)Development of Resources Mental Health Resources Collection of research for mental health resources 3)Development of Resources Group therapy Resources Mental Health Resources Revision of group therapy resources based on feedback Collection of research for mental health resources Client no-show session Development of layout for resources 2)Grant Writing Community Access Resources Site evaluation and feedback on community access resources Revisions of grant Revision of second grant writing resource based on site feedback Dissemination 1)Dissemination Plan Development and review Development and review of dissemination of dissemination plan plan Feedback of plan from site 11 12 13 14 Implementation 1)Development of Resources Mental Health Resources Revisions of plan Development of mental health resources Feedback of resources from site Dissemination 1)Implementation Training on resources of Resources Training new case manager on use of resources for intervention sessions as follows in the dissemination plan Discontinuation 1)Grant Writing Submission of Grant Final submission of second grant for site 2)Revision of Resources Revision of group therapy plan Development of group therapy sessions with site case manager. 1)Revision of Resources Development of group therapy plan Development of group therapy sessions with site case manager. Final revision of all group therapy plans Final chance for feedback on resources from site prior to translational meeting in one week. Meeting for feedback from CEO of site for usability and efficacy of materials Discontinuation Dissemination 1)Dissemination Translational Meeting  ...

... 1 Increasing Fine Motor Coordination and Grip Strength in Rock Steady Boxing Members Shelby D. Cash 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 The purpose of this program was to increase fine motor coordination (FMC) and grip strength to improve the performance of activities of daily living (ADLs) and instrumental activities of daily living (IADLs) of individuals with Parkinsons disease at Rock Steady Boxing (RSB). A tenweek FMC and grip strength program was implemented to target reported challenges while incorporating competition. The Parkinsons Disease Questionnaire (PDQ-39) was completed by boxers to identify focus areas of stations and to compare the perceived ability to perform ADLs and IADLs pre- and post-implementation. There was no statistically significant difference in the nine-hole peg test (L p=0.85; R p=0.72), grip strength (L p=0.36; R p=0.14), or PDQ-39 (p=0.23) post-implementation due to a small number of participants. Boxers that participated weekly benefited from a FMC and grip strength stations to increase physical and perceived ability with daily tasks. Keywords: fine motor coordination, grip strength, Parkinsons disease, Parkinsons disease questionnaire (PDQ-39), activities of daily living (ADLs). 3 Increasing Fine Motor Coordination and Grip Strength in Rock Steady Boxing Members Rock Steady Boxing (RSB) is a gym exclusively for individuals diagnosed with Parkinsons disease (PD). The mission of RSB is ...to equip our affiliates and empower the coaches to improve the quality of life of people with Parkinsons disease through a non-contact, boxing-based fitness curriculum (Rock Steady Boxing, n.d.). Parkinsons disease is the second most common neurodegenerative disorder, categorized with motor and non-motor symptoms (Larson et. al, 2021). At RSB, the classes are split into four different skill levels from PD 1 to PD 4 which coincide with the progression of PD. Many of the individuals in the PD 1 classes are still working, driving, and can maneuver through their daily lives with minimal assistance, while the PD 4 classes need more assistance. Classes are modified to accommodate their functional abilities. It is shown that participation in classes at RSB increases the individual's QoL, decreases depression rates, allows the participants to feel an increase in social life and a decrease in fear of falling (Hermanns et. al, 2021; Larson et. al, 2021) This doctoral capstone experience (DCE) focuses on improving grip strength and fine motor coordination (FMC) to increase physical and perceived ability with activities of daily living (ADL) and instrumental activities of daily living (IADL). RSB focuses on gross motor movements and exercises related to boxing rather than the fine motor skills. Short bouts of occupational therapy are found to be very beneficial and show an increase in occupational performance (Welsby et. al, 2019), so implementing FMC and grip strength stations into classes that boxers attend multiple times a week will do just that. The aim of this project is to design and implement FMC and grip strength stations, created from deficits reported on the PDQ-39 and recorded from the 9HPT and grip strength, to support well-rounded functions that more gross movements do not. 4 Background Rock Steady Boxing (RSB) is a non-profit organization that provides boxing sessions for individuals who have been diagnosed with Parkinsons disease (PD). Parkinsons disease is the second most common neurodegenerative disorder affecting approximately 1 million Americans (Foster et. al, 2014, p. 39). Scott Newman founded RSB in 2006 after being diagnosed with early-onset Parkinsons at the age of 40. His goal was to not only slow the progression of his PD but others around the central Indiana area as well. RSB works extensively to provide the best training for their coaches as well as provide client-centered training in various class levels to each individual that comes through their door. By providing non-contact boxing classes at different levels, individuals can receive exercise that is critical to keep their body moving while slowing down the progression of their Parkinson's symptoms. After completing the interview and needs assessment it was determined that most participants that have a membership at RSB are 65-80 years old. There are some members that have early onset Parkinsons and some that are in their late 90s, but the majority are in the range listed and are mainly Caucasian males. RSB has tried and is actively trying to reach out and serve the underserved minorities around the city, but there has not been much success with reaching that population and improving access could be implemented into a future capstone project. Rock Steady Boxing is not a clinical site and insurance is not used to assist with membership fees. All members pay a monthly fee to attend classes and are offered multiple classes at their skill level each week. Mentioned above are classes ranging from PD1-4 and members are placed in the class section after their initial assessment. Individuals are assigned to an appropriately grouped class level, based on their assessment scores from PDQ-39, the 5 Fullerton advanced balance scale or Berg balance scale, the timed-up and go (TUG), and the 30second sit-to-stand. Community partnerships and relationships are crucial to keeping RSB doors open. RSB is a non-profit, the organization is funded through grants, sponsorships, partnerships, and memberships from the participants. RSB has developed relationships with many partners as well as local physicians. These partners not only help the organization out financially, but they also provide the members of the gym with discounted equipment and training. Partners and exceptional relationships have been the backbone of RSB for years prior and years to come. The needs assessment determined that incorporating a fine motor component into the RSB sessions will support an unmet need of the participants. These vigorous exercise sessions were found to increase an individual's QoL (Borrero et. al, 2020). In combination with vigorous exercise, the implementation of fine motor skills at RSB will provide a well-rounded session. When looking through research it was seen that fine motor components can help with an individual's hand dexterity and strength (Bryant et. al, 2018; Mateos-Toset et. al, 2016). The boxers are receiving intense classes that focus on gross motor movements but by integrating a fine motor component, there is hope that occupational performance will further increase. Occupational therapy can help with an individual's IADLs and engagement in meaningful activities throughout their day (Foster et. al, 2021; Ott & Kolodziejczak, 2022) and although this is not your typical medical model project, there will be new skills implemented into sessions to incorporate the profession of occupational therapy in more diverse ways. Rock Steady Boxing is unique in what they do for individuals with PD. A faceted search revealed limited articles on occupational therapy with PD and boxing. This is one shortcoming of literature and most literature found is centralized around physical therapy. Simmons (2019) 6 implemented different stations weekly throughout the project that ranged from stations with weights or stations that had the resistance of clothes pins and challenged the boxers with a competition that incorporated FMC tasks. One shortcoming found by Simmons (2019) was that there was significance in the left upper extremity but not the right upper extremity at the end of the project when comparing pre-and post-tests. There is hope that this new program implementation will counteract that and have significance in both upper extremities. Although the project by Simmons (2019) is very similar to implementing fine motor stations into the boxing stations, this project will be different in how the stations are set up and assessments administered. This project focuses on not only the results from the assessments preand post-implementation but also data collected from surveys about the boxer's perceived ability with ADLs/IADLs. Fine motor coordination and grip strength are important and implementing stations as well as providing compensatory strategies for other struggles will assist in improving their quality of life by increasing their perceived ability with tasks reported from the PDQ-39. Theory The model that will be utilized to guide the doctoral capstone experience (DCE) is the Person-Environment-Occupation (PEO) model. PEO is a model that looks at one's occupational performance in three aspects of the person, occupation, and environment and how the fit can be impacted if one is changed (Cole & Tufano, 2020). An individual with PD has the person aspect of the model being affected due to PD being a neurodegenerative disease. This in turn will negatively impact the fit of the model and decrease their occupational performance. Depending on the severity of the prognosis and the symptoms that they are experiencing the individual may struggle to get around in many environments and be limited in some of their occupations. The 7 goal is to incorporate FMC and grip strength into the sessions to give them the opportunity to increase their maximal fit and see an increase in their occupational performance. The frame of reference (FOR) that will be utilized along with PEO is the biomechanical frame of reference. The biomechanical frame of reference is one that focuses on an individual's prior movement, strength, and work and then helps restore some of those (Cole & Tufano, 2020). Throughout the boxing sessions, there will be a fine motor component integrated which will give exercises and techniques that individuals with PD can use to help increase their strength and fine motor movement. RSB focuses on gross motor movements that go along with boxing and with the integration of the biomechanical model and fine motor skills there are hopes to increase physical and perceived ability with ADL/IADLs. Given the degenerative nature of PD, these skills will likely not normalize but can be optimized so that participation in functional activities can be restored. Project Design Upon completion of the needs assessment, the researcher and site mentor decided that a program geared towards fine motor coordination as well as grip strength would be most beneficial to the boxers. Integrating fine motor movements along with gross motor movements of boxing will target all areas to assist in increasing quality of life. The Parkinson's disease questionnaire 39 (PDQ-39) was given to randomly selected gym members to collect data on the perceived ability of certain tasks. This 39-item questionnaire is one of the most widely used PD questionnaires that target quality of life and perceived abilities (Chen et. al, 2017). Among the boxers' assessment into RSB, they are asked to complete the PDQ-39. Reassessment during this project will allow RSB and the boxers to note any progress since their start date or most recent 8 reassessment in the program and also allow the researcher to gain insight into deficits that boxers reported in their perceived ability with tasks. The week following the PDQ-39, grip strength, and fine motor coordination were assessed with a dynamometer and the 9-hole peg test. Both assessments were chosen and can be compared to normative data depending on age. Earhart et. al (2011), concluded that the 9HPT test appeared to be a useful and appropriate measure for assessing upper extremity function in individuals with PD (p. 162). It was evident when administering this tool that it was a good challenge and easy to understand in the high-intensity environment of the gym. The boxers could see the differences depending on what side PD has impacted the most following the completion of the 9-hole peg test and grip strength using the dynamometer. Implementation Stations were implemented into the boxing classes throughout the span of the project. Coaches were informed at the start of the project that a fine motor, grip strength, or handwriting station will be placed into the rotation each week. These competitive stations included rice bins, resistive tweezers, and FMC games such as Jenga, Trouble, and Perfection. These stations were based on the results received from the PDQ-39 survey that was administered during the second week, the 9HPT, grip strength using the dynamometer, and discussions with coaches. Challenges arose throughout the project with the amount of time that some classes and rotations allowed to complete the activities. Some stations were rushed but boxers reported enjoying stations such as handwriting where they could trial many tools such as wider diameter pens, pencil weights, and different grips to encourage tripod grasp. Uzochukwu & Stegemller (2019) reported that if an individual with PD attempts to do something too quickly, it can actually slow them down. To prevent boxers from freezing or slowing down that is a result of rushing, stations were 9 monitored, and verbal cueing was provided to focus on quality movement. Stations were more successful when making them into a competition between boxers. Many boxers were at different levels in this progressive disease and enjoyed the camaraderie of competition when working with others on a similar path. Project Outcomes Upon completion of the program, grip strength with dynamometer and 9HPT test were administered for quantitative data to evaluate program effectiveness to the boxers. Both assessments, as well as the PDQ-39, were administered pre- and post-implementation. Multiple measures were beneficial as collecting physical abilities of fine motor coordination (FMC) with the 9HPT and grip strength are important and the perceived ability pre/post with ADLs and IADLs from the self-scored PDQ-39 represent indirect value for the participants as well. Grip Strength and Fine Motor Coordination Data collection and analysis (see Table 1) showed that out of the participants (N=5), there were differences in improvements depending on which hand was being utilized. If there was a decrease in strength or slower time in the 9HPT, it was seen to be with the side more affected by PD. When utilizing the right hand on the 9HPT, there were more improvements seen (n=4) than non-improvements (n=1). In comparison the left, which is the hand affected more by their PD, showed fewer improvements than the right (n=3) than non-improvements (n=2). Grip strength presented to be the more significant challenge throughout the program. It was determined that with the right hand, more participants increased in strength (n=4) than decreased in strength (n=1). While with the left hand, there were more participants whose strength decreased (n=4) rather than increased (n=1). Boxers tended to utilize their stronger hand throughout the program rather than their weaker ones and had to be reminded to utilize both to get better quality 10 movements and outcomes. Along with PD being a degenerative disease, this reliance on their less affected hand could have been a factor in how much progress was made or not made throughout the program. Perceived Ability Ten questions that target FMC, grip strength, and cognition were isolated from the PDQ39 (see Table 2) once completed by the participant, and each answer was given a numerical number from zero to four to calculate final outcomes with a total score being 40. Lower scores correlated with little to no problems with tasks, while high scores correlated with increased difficulty. Comparing initial and final outcomes from the PDQ-39 presented that three out of five boxers showed improvements in perceived ability, while one did not, and one stayed the same. The most improvements were shown in three questions that challenged the boxers from the PDQ-39, these included leisure activities, handwriting, and cognition, all of which were highly focused on throughout the program. Overall, the program was beneficial for most of the boxers, with improvements noted in fine motor coordination (FMC) and grip strength. Descriptive statistics showed that the program did correlate with physical improvements and increased perceived abilities with ADLs and IADLs. Paired sample t-tests were conducted to compare pre- and post-implementation scores on PDQ-39, 9HPT, and grip strength. There was no statistically significant difference in the ninehole peg test (L p=0.85; R p=0.72), grip strength (L p=0.36; R p=0.14), or PDQ-39 (p=0.23) post-implementation. Although improvements were noted on all of these measures, statistically significant changes could not be determined, most likely due to a small sample size (N=5) and the time frame in which the program was implemented. 11 Summary Rock Steady Boxing (RSB) is a non-profit organization that provides specialized exercise classes for individuals with Parkinsons disease. Classes at RSB were developed to target gross motor coordination (GMC) from boxing; this project implemented stations that targeted fine motor coordination (FMC) and grip strength allowing individuals a more well-rounded workout. This project sought to increase boxers' perception of their ADLs, IADLs, and physical capabilities. A ten-week FMC and grip strength program were designed and implemented to challenge specific problems from the PDQ-39 pretest. Only questions that included aspects of ADL and IADL were collected from the survey and were evaluated pre/post-implementation, along with data from the 9-hole peg test and grip strength. These stations included competitive exercises utilizing rice bins, resistive tweezers, and FMC games. Upon completion of data analysis, it was concluded that there was no statistically significant difference from pre/post-implementation due to the small participant group. Participant perception of ADL/IADL performance increased when measured with the PDQ-39. Fine motor coordination improved as determined by an increase in 9HPT scoring and grip strength measurements were inconsistent. Overall boxers reported they found it beneficial to work on FMC as well as GMC during classes. In the future, it would be beneficial to incorporate FMC and grip strength exercises and include OT within the curriculum at Rock Steady Boxing. Conclusion Integrating FMC and grip strength stations into RSB classes was beneficial and increased boxers' perceived and physical ability. Most of the scores improved for the 9HPT and PDQ-39 although a low N, and lock of power made the determination of significant change impossible. Boxers gained strength when completing FMC stations that challenged precision while still 12 incorporating competition throughout classes. RSB coaches, boxers, and caregivers benefited from the program by learning compensatory techniques for fine motor skills and gaining awareness of what OT can assist with in their daily lives. Boxers, caregivers, and coaches were all accepting of ideas and activities that were integrated and, in turn, had other questions following some of the tasks. Occupational therapy can play a crucial role in the lives of individuals with PD, and it was seen throughout the program just how much one could benefit. Stations were a challenge, which caused frustration at times for the participants. Nevertheless, boxers were motivated to continue and complete that task at hand. All involved developed an understanding of the importance of FMC and GMC. In the future, boxers can benefit from the addition of occupation-based therapeutic activities through the RSB curriculum. Inclusion of OT services such as these will allow a population of individuals with Parkinsons disease to improve their strength and coordination before they develop a need for a comprehensive rehabilitation program. 13 References Borrero, L., Miller, S. A., & Hoffman, E. (2020). The meaning of regular participation in vigorous-intensity exercise among men with Parkinson's disease. Disability and rehabilitation, 17. Advance online publication. https://doi.org/10.1080/09638288.2020.1836042 Bryant, M. S., Workman, C. D., Jamal, F., Meng, H., & Jackson, G. R. (2018). Feasibility study: Effect of hand resistance exercise on handwriting in Parkinson's disease and essential tremor. Journal of hand therapy : official journal of the American Society of Hand Therapists, 31(1), 2934. https://doi.org/10.1016/j.jht.2017.01.002 Chen, K., Yang, Y.-J., Liu, F.-T., Li, D.-K., Bu, L.-L., Yang, K., Wang, Y., Shen, B., Guan, R.Y., Song, J., Wang, J., & Wu, J.-J. (2017). Evaluation of PDQ-8 and its relationship with PDQ-39 in China: A three-year longitudinal study. Health and Quality of Life Outcomes, 15(1), 170. https://doi.org/10.1186/s12955-017-0742-5 Cole, M. & Tufano, R. (2020). Applied theories in occupational therapy: A practical approach. Thorofare, N.J.: SLACK Inc. Earhart, G. M., Cavanaugh, J. T., Ellis, T., Ford, M. P., Foreman, K. B., & Dibble, L. (2011). The 9-Hole Peg Test of Upper Extremity Function: Average Values, Test-Retest Reliability, and Factors Contributing to Performance in People With Parkinson Disease. Journal of Neurologic Physical Therapy, 35(4), 157163. https://doi.org/10.1097/NPT.0b013e318235da08 Foster, E. R., Bedekar, M., & Tickle-Degnen, L. (2014). Systematic Review of the Effectiveness 14 of Occupational TherapyRelated Interventions for People With Parkinsons Disease. The American Journal of Occupational Therapy, 68(1), 3949. https://doi.org/10.5014/ajot.2014.008706 Hermanns, M., Mastel-Smith, B., Donnell, R., Quarles, A., Rodriguez, M., & Wang, T. (2021). Counterpunching to improve the health of people with Parkinson's disease. Journal of the American Association of Nurse Practitioners, 33(12), 12301239. https://doi.org/10.1097/JXX.0000000000000598 Larson, D., Yeh, C., Rafferty, M., & Bega, D. (2021). High satisfaction and improved quality of life with Rock Steady Boxing in Parkinson's disease: results of a large-scale survey. Disability and Rehabilitation, 18. Advance online publication. https://doi.org/10.1080/09638288.2021.1963854 Mateos-Toset, S., Cabrera-Martos, I., Torres-Snchez, I., Ortiz-Rubio, A., Gonzlez-Jimnez, E., & Valenza, M. C. (2016). Effects of a Single Hand-Exercise Session on Manual Dexterity and Strength in Persons with Parkinson Disease: A Randomized Controlled Trial. PM & R : the journal of injury, function, and rehabilitation, 8(2), 115122. https://doi.org/10.1016/j.pmrj.2015.06.004 Ott, K. R., & Kolodziejczak, S. (2022). Occupational therapy interventions for people with Parkinsons disease. American Journal of Occupational Therapy, 76, 7601390010. https://doi.org/10.5014/ajot.2022.049390 Rock Steady Boxing. (n.d.). About. Rock Steady. Retrieved January 30, 2023, from https://rocksteadyboxing.org/about/ Rock Steady Boxing. (n.d.). Affiliate partners. Rock Steady. Retrieved January 30, 2023, from https://rocksteadyboxing.org/affiliate-partners-2/ 15 Simmons, Jessica. (2019). Implementation of Fine Motor Exercise Programming for Persons with Parkinsons Disease:Occupational Therapys Role .https://uindy.hykucommons.org/concern/generic_works/3507acd4-a1b1-4e21-921e9fc7eb06111e?locale=en Uzochukwu, J. C., & Stegemller, E. L. (2019). Repetitive Finger Movement and Dexterity Tasks in People With Parkinson's Disease. The American journal of occupational therapy : official publication of the American Occupational Therapy Association, 73(3), 7303205090p17303205090p8. https://doi.org/10.5014/ajot.2019.028738 Welsby, E., Berrigan, S., & Laver, K. (2019). Effectiveness of occupational therapy intervention for people with Parkinson's disease: Systematic review. Australian occupational therapy journal, 66(6), 731738. https://doi.org/10.1111/1440-1630.12615 16 Table 1 Pre- and Post-Implementation Data for 9HPT and Grip Strength Participant # Initial Left 9HPT (seconds) Post Left 9HPT (seconds) Initial Right 9HPT (seconds) Post Right Initial Left Post Left 9HPT Grip Strength Grip Strength (seconds) (lbs) (lbs) Initial Right Grip Strength (lbs) Post Right Grip Strength (lbs) 1 27.4 22 22.3 18.7 79.7 83.7 93.4 100.9 2 24.6 24.2 24.7 20.7 86.6 71.2 70.3 88 3 24.2 25.9 30.1 23.5 68 63.6 56.3 57.3 4 22.2 22 22.3 19.5 47 46.3 49.8 54.3 5 21.9 28 29.5 40.5 41 40.8 50.1 49.2 17 Table 2 Parkinsons Disease Questionnaire # Question (Scored on a scale of 0-4) Participant 1 (Pre-Post) Participant 2 (Pre/Post) Participant 3 (Pre/Post) Participant 4 (Pre/Post) Participant 5 (Pre/Post) 1 Had difficulty doing the leisure activities which you would like to do? 1-1 1-0 1-0 1-1 1-1 2 Had difficulty looking after your home, e.g. DIY, housework, cooking? 0-0 0-0 0-0 1-1 1-2 3 Had difficulty carrying bags of shopping? 0-0 0-0 1-1 1-1 1-1 4 Had difficulty washing yourself? 0-0 0-0 0-0 0-0 1-1 5 Had difficulty dressing yourself? 0-0 0-0 1-1 0-0 2-1 6 Had problems doing up your shoe laces? 0-0 0-0 0-0 0-0 3-3 7 Had problems writing clearly? 0-1 1-1 3-2 1-1 3-3 8 Had difficulty cutting up your food? 0-0 0-0 0-0 0-1 4-3 9 Had difficulty holding a drink without spilling it? 0-0 1-0 1-1 0-1 1-1 1-0 2-1 2-2 1-0 3-3 10 Felt your memory was bad? *Questions were selected based on the inclusion of ADL/IADLs * 0-Never; 1- Occasionally; 2- Sometimes; 3- Often; 4- Always 18 Appendix Weekly Planning Guide Week 1 2 3 4 DCE Stage Weekly Goal(s) Objectives Tasks Date Completed Orientation 1. Observe 1. Learn about Rock 2. Ask questions for a Learn about Rock Steady Steady Boxing survey Boxing and daily classes. curriculum 3. Finalize and get clearance 2. Observe classes on survey 1/14/23 Screening/Evaluation 1. Administer/ Send out PDQ-39 to selected participants in the gym. 2. Send out caregiver survey 1. Collect pre-assessment data from each level of class to create stations. 2. Collect data from caregiver survey 1/21/23 Implementation 1. Administer 9-hole peg 1.Start pretest and grip strength assessment (Pre-assessment) 1. Collect pre-assessment data from each level of class. 1/28/23 Implementation 1. Run handwriting station for the boxers 1.Start preassessment 1. Provide different writing utensils 2. Utilize visual aids 3. Provide compensatory strategies 1. Have boxers write with different writing utensils. 2. Write on different angled surfaces to target write extension 2/4/23 19 5 6 7 8 9 10 Implementation 1. Create and run two fine motor stations that coordinate with exercise 2. Start looking for PCPs and neurologists to take pamphlets too for RSB. Implementation 1. Create and run two grip strength stations 1. Increase grip - Rice bin and resistance strength grip with tweezers 1. Implement and modify grip strength station 2/18/23 Implementation Create and run two fine motor stations - Uno and tic-tac-toe 1. Increase FMC 1. Implement and modify FMC station 2/25/23 Implementation Create and run two fine motor stations 1. Increase FMC - Trouble and Perfection 1. Implement and modify FMC station 3/4/23 Implementation 1. Administer 9-hole peg 1. Start posttest and grip strength assessment - Post-assessment 1. Collect postimplementation data from 9-hole peg test and grip strength 3/11/23 1. Data analysis 2. Advocate for RSB 1. Send out post-survey 2. Analyze data 3. Pass out RSB pamphlet to offices in rural Morgan County 3/18/23 Implementation 1. Increase FMC and grip strength 1. Implement FMC station 2. Start advocacy for RSB 1. Continue postassessment 2/11/23 20 11 12 13 14 Discontinuation 1. Paper edits 2. Dissemination plan 3. Caregiver resource packet 1. Continue working on scholarly report edits 2. Start caregiver resource packet 3. Submit dissemination plan 1. Assist in classes 2. Finalize dissemination plan 3. Start caregiver resource packet from data collected week 3/25/23 Discontinuation 1. Complete edits to drafts 2. Experience goals 1. Continue working 1. Edits to the introduction on scholarly report and background edits 2. Assist in classes 4/1/23 Discontinuation 1. Submit abstract, 1. Complete abstract, summary, and summary, and conclusion conclusion 2. Start poster and voice 2. Start poster and thread PowerPoint PPT 1. Finalize abstract, summary, and conclusion 2. Pick poster and PPT template from brightspace Dissemination 1. Disseminate the project to site mentor and CEO 2. Complete Final Evaluation 3. Complete poster and voice thread PowerPoint 1. Disseminate to site mentor and coaches 2. Complete final evaluation on student and capstone site. 1. Final evaluation 2. Disseminate 3. Continue poster and PPT 4/8/23 4/15/23  ...

... Increasing occupational therapists knowledge of wounds in a hand therapy clinic Breanna Beckmann 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: Erin Peterson, DHSc, OTR, CHT WOUND CARE & OT PRACTIONERS 2 Abstract A persons occupational participation and performance are negatively affected by upper extremity injuries, specifically wounds. Specific wound care principles reduce impairment and improve overall function for desired occupations. Although wound care management is within occupational therapys scope of practice, wound care is considered an advanced clinical skill. The primary purpose of this capstone was to increase the wound care knowledge of occupational therapists at Advance Physical Therapy. A secondary purpose included creating a media platform for colleagues at Advance Physical Therapy to access the wound care educational module, a documentation educational presentation for new hires and students, and any future resources following the conclusion of the capstone. The capstone student developed a wound care educational module with a pre/post survey and learning objectives. The student presented it to four occupational therapists and one fieldwork student. This program development increased the wound care knowledge and confidence of occupational therapists. Keywords: Wound management; occupational therapy; upper extremity; wound care WOUND CARE & OT PRACTIONERS 3 Doctoral Capstone Project Scholarly Report Advance Physical Therapy is a collection of rehabilitation clinics offering physical therapy, occupational therapy, and sports medicine services. With the mission to help patients advance (About us: Advance physical therapy), Advance Physical Therapy aims to improve a persons health and well-being while remaining rooted in a client-centered approach (About us: Advance physical therapy). Four full-time occupational therapists practice at the Quincy, Illinois, location, including an assistive technology professional (ATP) and two certified hand therapists (CHTs). No physical therapists or certified occupational therapy assistants treat patients with upper extremity injuries at this location. The site mentor expressed interest in obtaining more knowledge for entry-level occupational therapists and future fieldwork students in wound care for the upper extremity. The site mentor also expressed interest in utilizing a multi-media platform for therapists to access other educational resources. This capstone aimed to increase the wound care knowledge of occupational therapists and students at Advance Physical Therapy. The capstone student utilized reverse mentoring. The [less experienced] mentor provides advice to the [more experienced] mentee, and the mentee gives the mentor a new insight to stimulate growth and reflection in the mentor (Clarke et al., 2019, p. 694). By increasing knowledge about wounds and how to care for them, therapists can improve patient satisfaction and patient function (Esterhuizen et al., 2021; Kuhnke et al., 2019). This capstone project offered evidence-based research into wounds and the effects of wounds on various occupational outcomes. The educational module included general information about wounds, occupational therapys role in wound care, wound factors to consider during evaluation, interventions, and further wound care education recommendations. A secondary purpose included creating a media platform for colleagues at Advance Physical WOUND CARE & OT PRACTIONERS 4 Therapy to access the wound care educational module and any future resources. This platform would provide Advance Physical Therapy with an improved onboarding process and sustainability after the capstone project concludes. Background Role of Occupational Therapy in Wound Care According to the American Occupational Therapy Association (AOTA), the prevention and amelioration of wounds and their impact on daily life occupations are within the scope of occupational therapy practice (Role of Occupational Therapy in Wound Management p. 1, 2018). An occupational therapists purpose is to assist in enabling the patient to participate in significant and consequential occupations that lead to increased quality of life and satisfaction. The therapeutic use of self, the knowledge of various factors that affect wound healing, and the expertise of wound healing principles constitute occupational therapists as adequate clinicians to treat wounds (Constantine et al., 2022). Each state has a unique practice act which may include different regulations on occupational therapy practice. It is up to practitioners to be aware of third-party payer requirements, federal laws, and state regulations on wound care and wound interventions (Role of Occupational Therapy in Wound Management, 2018). Occupational therapists should also be mindful of their competence and confidence before treating wounds. Effect of Wounds on Occupations Wounds can negatively affect a persons roles, routines, and other meaningful occupations. With a wound, a person may have difficulties or require assistance with activities of daily living (ADLs), wound bed management, and wound garments (Role of Occupational Therapy in Wound Management, 2018). Wounds also affect a persons psychological well-being and can adversely affect the quality of life (Role of Occupational Therapy in Wound WOUND CARE & OT PRACTIONERS 5 Management, 2018). Patients with hand wounds specifically are at an increased risk for infection, pain, and hospitalization (Skirven et at., 2020). Most importantly, patient education on the wound and overall care is vital to healing (Role of Occupational Therapy in Wound Management, 2018). Patients could suffer from scar adhesions, contractures (burns), infection, pain, sensory issues, edema, among other complications. Such effects require the involvement of occupational therapists; without the help of occupational therapy, patients are at risk for life altering changes in functional use of the upper extremity, and decreased independence, (Williams & Berenz, 2017) Barriers in Wound Care Although wound care management is within occupational therapys scope of practice, this is considered an advanced clinical skill. Esterhuizen et al. (2021) noted access to supervision/mentorship, access/availability to wound care instruments and supplies, access to courses or educational materials, lack of knowledge/skill, and perceived perception of occupational therapys role as just a few. If wounds are discussed in formal education, pressure ulcers often precede post-operative wound care (Garber et al., 2022; Heerschap et al., 2020). To recognize wound complications, clinicians must have a deeper understanding of the skin and how a wound follows the phases of physiological healing (Skotak & Stockdell, 1988). Short et al. (2018) stated that practitioners do not fully develop practice skills, intervention selection, and techniques in complex and chronic upper extremity conditions until one year into practice. Many general occupational therapists may not feel comfortable or adequately prepared to evaluate and treat wounds based on the entry-level education received (Esterhuizen et al., 2021). In a study about the latest practice techniques in upper extremity rehabilitation, investigators questioned 1,690 hand therapists about wound care within their practice. In the WOUND CARE & OT PRACTIONERS 6 survey, investigators aimed to determine the frequency and criticality of 15 techniques and tools associated with wound care within the hand therapy profession (Keller et al., 2016). Therapists performed seven of the fifteen techniques less than monthly, as reported by Keller et al. (2016). Within the same survey, researchers asked when respondents acquired the skills needed for wound care management techniques. Less than 20% of respondents acquired wound care techniques during their formal education, with many learning in the first two years of hand therapy practice (Keller et al., 2016). Skilled wound care is critical to improving function, but this survey data of hand therapists suggest such care is often infrequently used. If an occupational therapist does not address or manage an upper extremity wound, then who will? Health professionals such as doctors and surgeons have heavy caseloads. Recent shifts in the post-operative protocols have patients coming to therapy days after surgery. Therapists can also monitor wounds more closely, as many patients do not return to their doctor or surgeon for weeks (Esterhuizen et al., 2021). With patients following up with the therapist more frequently, it is more convenient for the patient to receive wound care as part of their therapy treatments (Esterhuizen et al., 2021). Accurate wound assessment, treatment, documentation, and care help promote proper healing while achieving functional outcomes (Skirven et at., 2020). Needs Assessment Wounds are among the top ten diagnoses hand therapists treat (Esterhuizen et al., 2021). In a 2020 survey about current practices of occupational therapists providing wound management interventions to patients with hand injuries in South Africa, investigators found that 71.7% of patients presented to the clinic with a wound monthly (Esterhuizen et al., 2021). Specific populations, including those with hand injuries, are at an increased risk for wounds (Esterhuizen et al., 2021). At Advance Physical Therapy, no occupational therapist WOUND CARE & OT PRACTIONERS 7 addressed wound management in their formal education. Only one occupational therapist participated in a wound continuing education course taught by a nursing professional not specific to the upper extremity. With several post-operative evaluations coming in monthly, postoperative wounds are encountered frequently. This demand has accentuated the need for improved education and guidance for occupational therapists. (Esterhuizen et al., 2021). Continuing education and evidence-based practice are foundational to improving patient outcomes (Roberts, 2015). A wound care module benefits therapists as well as patients. With proper training and early intervention, occupational therapists can help expedite the healing of wounds and prevent or recognize infection sooner (Kuhnke et al., 2019). Theory and Frame of Reference The Communities of Practice (CoP) social theory of learning guides this capstone. Although not an occupation-based model specific to occupational therapy, this adult learning theory and its impact on education in healthcare fields have been widely studied (Mukhalalati & Taylor, 2019). Professions including occupational therapy, physical therapy, nursing, pharmacy, and surgical medicine have used Communities of Practice (Mukhalalati & Taylor, 2019). Characterized by knowledge sharing and creation, CoPs address the learning needs of professionals by supporting adult engagement with active and relevant learning (Roberts, 2015, p. 2). Rooted in reflective thinking and evidence-based practice, CoP can increase knowledge sharing. Within the context of this capstone, this model guides learning for practitioners and students as they gain advanced clinical skills in wound care supported by evidence-based practice. This adult learning theory can facilitate new learning, relearning, and adjusting of perspectives of previously learned concepts (Roberts, 2015, p. 17). With various knowledge and WOUND CARE & OT PRACTIONERS 8 experiences in Advance Physical Therapy, the CoP social theory tailors to the therapists receiving and utilizing the module. The biomechanical/rehabilitative frame of reference serves as a lens for the wound care educational module program development. In outpatient orthopedic settings, occupational therapists see patients with various upper extremity injuries who need postoperative rehabilitation, non-operative or conservative intervention, preventative care, or industrial ergonomic consultation (What we do, n.d.). The biomechanical/rehabilitative lens is the most used frame for individuals with musculoskeletal disorders (Cole & Tufano, 2020). The biomechanical frame focuses on the movement of the human body with deficits identified as lack of motion or strength, fatigue, avoidance, and pain levels (Cole & Tufano, 2020). The rehabilitative frame identifies environment or task barriers that can be changed to compensate for functions that cannot (Cole & Tufano, 2020). Pairing the rehabilitative frame with the biomechanical frame will help visualize the patient holistically rather than as an injured body part or wound. This frame complements the chosen theory and aims of this capstone. Project Participants and Design The Institutional Review Board at the University of Indianapolis deemed this program development, not human subjects research. Stakeholders in this development included four fulltime occupational therapists and one level two occupational therapy fieldwork student. The completed program encompassed a wound care educational module with learning objectives, a pre-post confidence survey/knowledge check, a documentation system educational module, and a multi-media platform to house the modules. Challenges included a need for an understanding of WOUND CARE & OT PRACTIONERS 9 the capstone project by the site and a shorter timeline due to changing project ideas. Successes include positive feedback from the site mentor about the project's purpose. Educational Drive The student created a company-based electronic shared drive to store the wound care module and presentation recordings. The capstone student also produced folders that contained relevant hand therapy topics; such folders included resources developed or located by the student. Folder headings included resources on conditions commonly treated in the outpatient setting, interventions, pediatrics, adaptive mobility, student resources, and modalities. Although these folders contained some resources, they could not be fully developed due to the time limitations of the doctoral capstone. With the electronic drive completed, the site had sustainability following the discontinuation of the capstone. The student also created a second (online) presentation on the documentation system to make onboarding easier for new graduates and other students, as formal training was unavailable before this capstone. Wound survey development and analysis The capstone student assessed each stakeholder's confidence using a Likert scale and their knowledge using multiple-choice questions from Wietlisbach et al. (2020). The student utilized a web-based anonymous survey to identify learning objectives and content. The capstone student created relevant content based on a needs assessment conversation and a detailed literature review. Competence areas addressed included wound cleansing, debridement, dressings, wound care education, and wound assessment and documentation. The student administered a pre-survey to stakeholders before the educational presentation, with the postsurvey delivered after attending part two of the presentation. Wound presentation WOUND CARE & OT PRACTIONERS 10 Following the anonymous pre-survey results, the capstone student analyzed data to tailor wound care educational presentations. The capstone student updated the presentation slideshows weekly to address the various learning objectives. Due to the depth of information on wounds and the need for wound experience, the student split the presentation into a two-part series. Part one discussed wound healing principles, OTs role in wound care, barriers and problems in wound care, certifications, client factors that affect how a wound heals, wound terms, wound assessments, and wound characteristics to include in the documentation. Part two contained information on wound interventions: incision care, infection, dressing options, debridement options, wound cleaning, patient education, scar management, and a case study. Project Outcomes The capstone student utilized the pre-survey to gain information about the baseline knowledge of the four occupational therapists and one fieldwork student. Of the occupational therapy personnel surveyed, no person received wound care information during formal education. The capstone student evaluated the results of the Likert-based confidence questions for means and ranges to measure if knowledge occurred and confidence increased (Table 1). The student analyzed the correct answer from multiple-choice questions into percentages (Table 2). The capstone student also asked two short answer questions to understand baseline knowledge, and the answers were not remarkable. Quantitative analysis of the post-survey results indicated that personnel met learning objectives following the presentation. The mean and range scores of the Likert-scale confidence questions improved from the pre-survey to the post-survey. Six of the eight multiple-choice knowledge questions had improvements in how many responders answered the question correctly. The capstone student did not complete further inferential statistics due to WOUND CARE & OT PRACTIONERS 11 the small sample size. Based on these findings, the wound care presentation increased wound care knowledge and confidence of occupational therapy personnel at Advance Physical Therapy. Summary Occupational therapists encounter wounds frequently. This demand has accentuated the need for improved education and guidance for occupational therapists (Esterhuizen et al., 2021). This capstone aimed to provide occupational therapy personnel with evidence-based research into wound care to improve confidence and knowledge. With proper training and early intervention, occupational therapists have expedited the healing of wounds, prevented and recognized infection sooner, and prevented wounds from occurring. Occupational therapy personnel at Advance lacked training and experience with wound care. With a multimedia platform created, the wound care seminar and future educational resources are available to the clinic. This platform provided sustainability following the departure of the capstone student and will aid the clinic if turnover is to occur. Conclusion Through this capstone, Advance Physical Therapy occupational therapy personnel increased their overall wound knowledge and confidence levels when treating wounds, as evidenced by the post-survey results. The clinicians and the capstone student mutually benefited from this capstone project through reverse mentoring. Ultimately, the use of reverse mentoring and communities of practice adult learning theory developed both the mentor and mentee. The clinicians learned about a unique niche within the occupational therapy profession not well covered in entry-level curricula. At the same time, the student gained experience and refined practice skills, intervention selection, and techniques in complex and chronic upper extremity conditions. Although knowledge occurred and confidence increased, this capstone student WOUND CARE & OT PRACTIONERS 12 surveyed only five participants. This capstone project involved a small sample size; limited results cannot be generalized to the occupational therapy profession. Additional research and an increased occurrence of wound-care information in higher education are recommended. Possible recommendations for further education at Advance include a mentorship with a more experienced therapist, continuing education courses, another capstone student, and interprofessional educational in-services to identify gaps in knowledge or confidence. WOUND CARE & OT PRACTIONERS 13 References About us: Advance physical therapy. Advance Physical Therapy. (n.d.). Retrieved December 4, 2022, from https://advancept.net/about Clarke, A. J., Burgess, A., van Diggele, C., & Mellis, C. (2019). The role of reverse mentoring in medical education: Current insights. Advances in Medical Education and Practice, Volume 10, pp. 693701. https://doi.org/10.2147/amep.s179303 Cole, M. & Tufano, R. (2020). Applied theories in occupational therapy: A practical approach (2nd Ed.). SLACK Incorporated. Constantine, R. S., Le, E. L. H., Gehring, M. B., Ohmes, L., & Iorio, M. L. (2022). Risk factors for infection after distal radius fracture fixation: Analysis of impact on cost of care. Journal of Hand Surgery Global Online, 4(3), 123127. https://doi.org/10.1016/j.jhsg.2021.12.011 Esterhuizen, L., Naidoo, D., & Govender, P. (2021). Examining wound management in hand therapy within the South African context. South African Journal of Occupational Therapy, 51(3). https://doi.org/10.17159/2310-3833/2021/vol51n3a6 Garber, S. L., & OSullivan-Drombolis, D. (2022). History, current practice, and the future of wound care for occupational and physical therapists. Advances in Skin & Wound Care, 35(8), 416419. https://doi.org/10.1097/01.asw.0000822704.43332.7d Heerschap, C., Nicholas, A., & Whitehead, M. (2018). Wound management: Investigating the Interprofessional decisionmaking process. International Wound Journal, 16(1), 233242. https://doi.org/10.1111/iwj.13017 WOUND CARE & OT PRACTIONERS 14 Keller, J. L., Caro, C. M., Dimick, M. P., Landrieu, K., Fullenwider, L., & Walsh, J. M. (2016). Thirty years of hand therapy: The 2014 practice analysis. Journal of Hand Therapy, 29(3), 222234. https://doi.org/10.1016/j.jht.2016.02.011 Kuhnke, J. L., Keast, D., Rosenthal, S., &; Evans, R. J. (2019). Health professionals' perspectives on delivering patient-focused wound management: A qualitative study. Journal of Wound Care, 28(Sup7). https://doi.org/10.12968/jowc.2019.28.sup7.s4 Mukhalalati, B. A., & Taylor, A. (2019). Adult learning theories in context: A quick guide for healthcare professional educators. Journal of Medical Education and Curricular Development, 6, 238212051984033. https://doi.org/10.1177/2382120519840332 Roberts, G. I. (2015). Communities of Practice: Exploring Enablers and barriers with school health clinicians. Canadian Journal of Occupational Therapy, 82(5), 294306. https://doi.org/10.1177/0008417415576776 Role of occupational therapy in Wound Management. (2018). The American Journal of Occupational Therapy, 72(Supplement_2). https://doi.org/10.5014/ajot.2018.72s212 Short, N., Sample, S., Murphy, M., Austin, B., & Glass, J. (2018). Barriers and solutions to fieldwork education in hand therapy. Journal of Hand Therapy, 31(3), 308314. https://doi.org/10.1016/j.jht.2017.05.013 Skirven, T. M., Osterman, A. L., Fedorczyk, J. M., Amadio, P. C., Feldscher, S. B., Shin, E. K., Barrett, N., & Parrish, K. (2020). Wound Classification and Management. In Rehabilitation of the hand and upper extremity (7th ed., Vol. 1, pp. 197207). Chapter 17, Elsevier. Skotak, C. H., & Stockdell, S. (1988). Wound management in hand therapy. Occupational Therapy In Health Care, 4(3), 1735. https://doi.org/10.1300/j003v04n03_04 WOUND CARE & OT PRACTIONERS 15 Wietlisbach, C. M. (2020). Wound Care. In Cooper's fundamentals of hand therapy: Clinical reasoning and treatment guidelines for common diagnoses of the upper extremity. Mosby. Williams, T., & Berenz, T. (2017). Postburn upper extremity occupational therapy. Hand Clinics, 33(2), 293304. https://doi.org/10.1016/j.hcl.2016.12.015 WOUND CARE & OT PRACTIONERS 16 Table 1 Pre and Post-Likert survey results How confident comfortable are you in cleaning a wound? PreSurvey Mean PostSurvey Mean Change occurred PreSurvey Ranges PostSurvey Ranges How confident and comfortable are you in performing debridement of wounds How confident and comfortable are you in choosing the appropriate dressing based on the wound and its stage of healing How confident and comfortable are you at accurately assessing, describing, and documenting wound characteristics 2.8 How confident and comfortable are you in educating the patient on various wound principles such as cleaning, decreasing risk factors, recognizing infection, etc.? 3 2.2 2.2 2.2 3.8 3.8 3.2 3.6 4.2 +1.0 +0.8 +1.0 +1.4 +2.0 (1-5) (1-5) (1-4) (1-4) (1-4) (2-5) (2-5) (2-5) (2-5) (3-5) WOUND CARE & OT PRACTIONERS 17 Table 2 Pre and Post multiple-choice survey comparisons Multiple Choice question Pre-survey percentage correct 80% 80% Post-survey percentage correct 80% 100% 60% 80% Mechanical debridement... 20% 40% When should the therapist use the clock method? 40% 60% Wet-to-dry dressings are beneficial for clients as they provide an appropriate balance of wound moisture. 40% 100% During an initial evaluation, it is believed tunneling has occurred; what should the therapist do? 40% 80% You notice a patient has eschar and slough on a wound. What type of debridement is the safest and most effective option to remove the wound characteristics described above? 40% 20% Wound beds should have little to no moisture When cleaning a healing wound, what is the best solution? Although there is no evidence to support the use of Epsom Salt and its effect on wound healing, soaking a wound in a sterile solution has been proven effective WOUND CARE & OT PRACTIONERS 18 Appendix A Weekly Planning Guide Week DCE Stage 1 Re-Writing Literature Review Weekly Goal Complete new literature review. Objectives Tasks Search literature about wound care, OTs role, barriers, why wound care in OT is necessary. Send literature review to the faculty mentor for review and finalization. Write an indepth literature review to prepare for capstone project. Date complete 01/13/20 22 Implement edits from the faculty mentor. Create subsections of lit review to improve the flow. Send literature review to site mentor. 2 3 Screening/Evaluati on/ Orientation Screening/Evaluati on Complete needs assessment via conversation with site mentor. Create pre-test and presentation. Identify an outcome measure to assess if a knowledge increase occurred. Meet with 01/20/20 site mentor 23 to discuss roles, goals, and overall needs. Search nursing literature on benefits of pre-post survey. Meet with Send new DCC, faculty MOU for mentor, and site signatures. 01/27/20 23 WOUND CARE & OT PRACTIONERS Create or identify a universal and accessible platform for resources. 19 mentor to finalize plans. Locate resources regarding Advances EMR and documentation system. Finalize MOU. 4 Implementation Complete pre-test for clients to take. Create questions regarding confidence of five wound topics chosen to Create outline for presentation/slidesh disseminate on: ow for wound care. wound cleaning, wound Create outline for dressing, remote EMR wound educational education, module. wound debridement, and wound Discuss with the site mentor about creating google drive for the company. Discuss with site mentor about general learning objectives wanting to be accomplish ed through the educational resource. Search literature and resources for wound knowledge check questions. Establish deadline to take survey as Feb 6th. Meet with faculty mentor to 02/3/202 3 WOUND CARE & OT PRACTIONERS 20 assessment & documentation. Create questions regarding knowledge of five wound topics chosen to disseminate on: wound cleaning, wound dressing, wound education, wound debridement, and wound documentation. discuss project progress. Send email with pre-survey link Wednesday Feb 1st. 5 Implementation View results of survey. Work on presentation for wound care. Work on presentation for EMR. Analyze results to better inform presentation and create concrete wound care learning objectives to guide presentation. Finish at least 5 slides from the wound care presentation. Search literature to inform wound care presentatio n slides. Create means and ranges for confidence potion of pretest. 02/10/20 23 WOUND CARE & OT PRACTIONERS 21 Finish at least 5 slides from the EMR presentation. 6 Implementation Work on presentation for wound care. Work on presentation for EMR. Finish at least 5 slides from the wound care presentation. Finish at least 5 slides from the EMR presentation. Meet with faculty mentor to discuss project progress. Continue to search literature to inform wound care presentatio n slides. 02/17/20 23 Watch NetHealth introductio n videos. Meet with faculty mentor to discuss project progress. 7 Implementation Work on presentation for wound care. Finish at least 5 slides from the wound care presentation. Discuss midterm with site mentor. Identify goal progress from MOU. Ask about observing a day in the wound care clinic. Meet with faculty mentor to discuss project progress. Call wound clinic nurse to set up an observation time. Watch Nora Barrett lecture on wounds and OT. 02/24/20 23 WOUND CARE & OT PRACTIONERS 8 Implementation Work on presentation for wound care. Work on presentation for EMR. Observe in wound clinic. 9 Implementation Finalize both presentational slide shows. Develop various handouts for therapists during presentation. 10 Implementation Practice presentation. Get feedback and confirmation on handouts from CHTs for relevant and accurate information. 22 Finish at least 5 slides from the wound care presentation. Finish at least 5 slides from the EMR presentation. Find 03/03/20 helpful 23 resources to include in presentatio n for more information . Explain to nurse who I am and what I am doing. Ask nurses about beneficial products, tips for outpatient wounds, and when to refer. Discuss with site mentor thoughts on both slide shows. Practice presentatio n. 03/10/20 23 Check references and make sure everything is cited. 03/17/20 23 Create chart for dressings. Create wound care patient educational handout. Make any changes as needed per feedback. Record EMR presentation. Print out handouts as needed for WOUND CARE & OT PRACTIONERS 11 12 Implementation Implementation 23 Present part one wound care presentation to clients. Ask for feedback to better improve part two. Identify dissemination plan. Identify any experience goals that have not been yet achieved. Present part two of wound care presentation. Have clients take post survey. Record wound presentation for sustainability. presentatio n. Transfer all data from school Google drive to company Google drive. 03/24/20 23 Upload 03/31/20 recordings 23 of EMR presentatio n to Google Drive. 13 Discontinuation Analyze post survey results and feedback. Create means and ranges for confidence potion of posttest. Put data into a slideshow format to present to site. 04/07/20 23 14 Dissemination Disseminate to site via virtual video recording. Share survey results. Offer my services if any problems, questions, or concerns arise from my materials provided. 04/14/20 23 Discuss with site improvements and learning that occurred. Offer future recommendatio ns.  ...

... Packages of Resources Efficiency and Effectiveness of Patient Education in Inpatient Settings Caitlin Bachmann, OTS 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: Kelsey Peter, OTR PACKAGES OF RESOURCES IN INPATINET SETTING 2 Abstract Cape Fear Valley Rehabilitation Center expressed a need for educational handouts for patients. Research in patient education reported the importance within patient care, however, can be confusing to patients without prior medical terminology knowledge. From January - April 2023, 12 packages of resources (POR) were created for the most common conditions at the Rehabilitation Center that included explanation of diagnosis, signs and symptoms, interventions, and community resources; each POR had below an eighth grade reading level. A pre-survey and post-survey were sent to the staff and collected opinions on importance of patient education in Case Management, Nursing, Physical Therapy, Occupational Therapy, and Speech Therapy as well as their opinion on effectiveness and efficiency of their patient education before and after implementation of the PORs. After nine weeks of implementation, the results varied between disciplines; Nursing had the most negative effect and Occupational Therapy had the most positive effect. Introduction I completed Doctoral Capstone Experience (DCE) at my Cape Fear Valley Rehabilitation Center (CFV) in Fayetteville, North Carolina. I performed a needs assessment with the facilitys Occupational Therapy Student Fieldwork Coordinator in March of 2022. Through the needs assessment, it was determined to create a multitude of educational handouts for different diagnoses that the inpatient rehabilitation staff can use in patient care as a package of resources (POR) for patients throughout their stay and take home at discharge to improve patient education (PE) effectiveness and efficiency. PE is an important aspect for all disciplines within the healthcare setting. In inpatient rehabilitation settings, occupational therapists (OTs), physical therapists (PTs), speech therapists PACKAGES OF RESOURCES IN INPATINET SETTING 3 (SLPs), case managers (CM), and nurses are all an integral part of PE, however, most research is solely about nursing PE. I expanded my project to other disciplines to fill in gaps within current research. The POR included the explanation of the diagnosis, explanations of signs and symptoms, simple intervention strategies, and community/online resources for the patient and their families. I condensed the PORs for staff to educate patients on their diagnosis or medical condition that is easily understood. Each handout was created with a low readability score to improve patient understanding by avoiding medical verbiage. To evaluate my project, I created a pre- and postsurvey that anonymously collected general opinions on PE from nursing, OT, PT, SLP, and CMs at CFV before my PORs were created and after my PORs were implemented. Their responses were collected, and three main points were concluded from the changes seen in the surveys that involve the different perspectives on PE within the varying disciplines. Background PE is now an integral part of treatment in any setting, but it was not always a priority. Before 1960, medical professionals oversaw of diagnosis and treatment of the individual. Patients at the time were a mere subject rather than actively participating in the process (Wittink & Oosterhaven, 2018). It was not until the 1990s that patients had the right to give informed consent to all steps in medical healing processes (Wittink & Oosterhaven, 2018). Today, PE has shifted from being solely a transfer of knowledge to the co-creation of knowledge (Wittink & Oosterhaven, 2018, p. 120). PE allows patients the autonomy to manage their condition when medical professionals are not present (Jppinen et al., 2020; Papadakos et al., 2021; Wittink & Oosterhaven, 2018). PE has been shown to be an effective part of rehabilitation because patients can use this knowledge PACKAGES OF RESOURCES IN INPATINET SETTING 4 to transfer to their independent lives (Jppinen et al., 2020). Patients need to learn how to manage their condition which requires a gain in knowledge and a shift in self-management (Wittink & Oosterhaven, 2018). Papadakos et al. (2021) explains how PE offers patients with information that allows them to manage their current side-effects and identify symptoms early to seek medical attention when appropriate or necessary. The goal of PE is to enhance a patients recovery through their gain in knowledge about their recovery to improve their physical functioning, activities of daily living and participation (Jppinen et al., 2020). PE allows for the opportunity for patients to have higher satisfaction in their rehabilitation, a better quality of life, a better assurance of care, improved outcomes, and decrease in treatment costs (Arad et al., 2021; Papadakos et al., 2021). Multiple studies have shown that increased PE and quality of PE has led to improved health outcomes due to the patient having a greater knowledge in their treatment and of their condition (Arad et al., 2021; Cashin et al., 2022; Grose et al., 2021; Holbrook et al., 2021; Papadakos et al., 2021; Sinatti et al., 2022). Although PE is agreed to be an important part in the treatment of patients, it is not always delivered efficiently and effectively due to heavy workloads and lack of time in the hospital setting create barriers for nurses to deliver proper PE (Latimer et al., 2021; Maddox et al., 2022). Due to the lack of PE, patients often resolve to seeking medical information from the internet (Grose et al., 2021; Li et al., 2021). Li et al. (2021) also found that websites used for seeking medical information tend to have poor accountability and only cover treatment and symptoms while avoiding important factors in medical conditions including prevention and risk factors. Even if online medical resources are accurate, they often include language that is too difficult for someone not in the medical field to understand (Grose et al., 2021; Karimi et al., PACKAGES OF RESOURCES IN INPATINET SETTING 5 2023). In a 2021 study, the researchers found that nearly half of Canadian and American adults have a limited ability to understand their own health information and therefore act accordingly (Grose et al., 2021). Health literacy is a large factor when delivering PE as it can become a barrier of effectiveness if the information is not understood by the patient. According to Wittink & Oosterhaven (2018), health literacy is defined as The personal, cognitive and social skills which determine the ability of individuals to gain access to, understand, and use information to promote and maintain good health (p. 121). It is recommended that any information printed or virtual be written at or below a sixth grade reading level (Li et al., 2021; Wittink & Oosterhaven, 2018). However, multiple studies that have analyzed readability from medical websites and other PE materials have found that the language, on average, is way above the recommended level (Li et al., 2018; Papadakos et al., 2021). Providing patients with an appropriate readability level in their education can lead to a better understanding by the patient and their families which could lead to improved outcomes (Papadakos et al., 2021; Wittink & Oosterhaven, 2018). Papadakos et al. (2018) reports that health literacy entails peoples knowledge, motivation, and competencies to access, understand, appraise, and apply health information in order to make judgements and take decisions in everyday life to maintain or improve quality of life during the life course (p. 3514). By creating a POR for patients, my goal is to improve effectiveness and efficiency for medical staff and patients. Latimer et al., (2021) found that a care bundle of information for patients was viewed by both patients and nursing as a useful resource. In my POR, I will also include any visuals that are appropriate as it can aid in a patients understanding of information (Wittink & Oosterhaven, 2018). PACKAGES OF RESOURCES IN INPATINET SETTING 6 The evidence that is available on PE surrounds the profession of nursing. Through my project, my goal was to examine the importance of a collaborative, multidisciplinary approach to PE at CFV. Through my anonymous pre-survey, I had multiple comments made about creating a more cohesive PE program that spanned across rehabilitation therapists and nursing. My PORs were available to not only nursing staff, but also CMs, PTs, OTs, and SLPs. These PORs were utilized within CFV by multidisciplinary medical professionals to improve PE effectiveness and efficiency. Following the implementation of the PORs, I received multiple anonymous comments in my post-survey about how excellent and concise they were and benefitted the patients by allowing them to understand what is happening with their body. Theory The PEOP model was originally created by Charles Christensen and Carolyn Baum and focuses on a persons occupations and their occupational engagement (Cole & Tufano, 2020). Within the PEOP Model, the patients' physiological self is represented by their medical condition. The psychological self is represented by an increased confidence in self. The neurobehavioral self is represented by their ability to regulate their emotions around their medical condition. The spiritual self is represented by their belief in the information they are receiving. The cognitive self is represented by their gain in knowledge on their medical condition. The patients environment is represented by the hospital POR created about their specific medical condition. The POR will provide low-cost and support group resources. The POR will be readable by non-medical professionals. The patient and the hospital POR are combined to allow the patient to understand and utilize the information in the POR to improve their health management skills to increase health outcomes. PACKAGES OF RESOURCES IN INPATINET SETTING 7 Transformative Learning is a theory created by Jack Mezirow that focuses on the idea that people can change their thinking by exposure to new information (Western Governors University, 2020). In my diagram the process starts when the patient receives the POR on their condition. This POR then causes a chain reaction where the patient then gains knowledge and chooses to believe in the knowledge. The patients belief in the knowledge allows the patient to regulate their emotions and feelings revolving around their condition and have an increased confidence in themselves about their condition and what is happening to their mind or body. This new information can alter their thoughts and feelings which change behavior to optimize health management outcomes. This theory and model combined will help me connect the importance of education, health literacy, and its impact on occupational performance of the patients. See Figure 1 for visual representation of combined theories. Design and Implementation I completed my DCE from January 9th, 2023, through April 14th, 2023, see Appendix A for DCE Weekly Planning Guide. CFVs Occupational Therapy Student Fieldwork Coordinator presented me with the project to create informative handouts on the facilitys most common conditions to improve efficiency of PE. The handouts I created contained easy-to-understand verbiage to increase the effectiveness of the PE. To assess my project, I created a pre- and postsurvey that the staff completed. The surveys addressed the opinions of the staff on the importance of PE and their current efficiency and effectiveness of their PE that they deliver to their patients. I chose a pre- and post-survey because it is a common tool to evaluate the PORs and their impact on PE from the staff that utilized them (Simon Fraser University, n.d.). A summative evaluation was completed within the first four weeks of my DCE with the pre-survey and the weeks 9-12 of my DCE with the post-survey completed by the staff on PE efficiency and PACKAGES OF RESOURCES IN INPATINET SETTING 8 effectiveness. I reassessed the POR program by implementing the post-survey after the duration of nine weeks that the PORs were utilized by the staff. The first week of my DCE, I created a pre-survey with nine questions through Qualtrics.com, see Appendix B. The survey was anonymous; however, I did ask what discipline that the participant was a part of to determine if there were any trends in opinions of PE between disciplines. I chose a Likert scale for most questions to compare the numerical scores of the presurvey to the post-survey. The final question was optional to allow for anyone who wanted to share their ideas had the space to do so. In week 9, I created the post-survey with four similar questions to see if there was any direct change in the responses from the beginning of my DCE project and the final question for feedback, see Appendix C. The biggest challenge I encountered was getting responses from the staff in a timely manner. The pre-survey was open for three weeks with multiple reminders sent out. I received 20 responses, a 57% response rate. The postsurvey was also open for three weeks to allow participants to have time to complete the survey. I received 15 responses, a 43% response rate. In the first week of my DCE, I created a generalized template on VistaCreate to use as a guide when I created each POR for each condition, see Figure 2 and 3. From week two until week nine I created a POR each week following the template, and I made changes to individual PORs when appropriate. After the pre-survey closed, I distributed each completed POR to the appropriate physical and virtual sites at CFV. Primarily, each POR included the definition of the condition, signs and symptoms of the condition, helpful things to do after discharge from the rehabilitation center for the specific condition, and online and community resources. Each POR was below an eighth grade reading level; although the recommended level is a sixth-grade level, it was impossible to include types of conditions and names without increasing the reading level. PACKAGES OF RESOURCES IN INPATINET SETTING 9 Outcomes A pre-survey was sent to 35 staff members at CFV that included CMs, Nurses, PTs, OTs, and SLPs. The pre-survey was open from January 19, 2023, to January 31, 2023, with a 57% response rate, see Table 1 for average values from pre-survey. From January 13, 2023, to April 15, 2023, 12 amount of PORs were created, see Table 2 for full list of conditions covered. Of the 12 handouts created, nine handouts were created during the implementation phase from January 19 - March 10, 2023. The remaining three handouts were created after the implementation phase from March 13 - April 15, 2023, per the request of CFV during the remaining time of my DCE. The staff was alerted every Wednesday at the department meeting which POR was newly available and was utilized as a scheduled time to receive any verbal feedback on my PORs for quality improvement. Each POR was made available physically in the resource hub and virtually in the CFV shared resource drive. The post-survey was sent to the same 35 staff members. The post-survey was open from March 10, 2023, to March 29, 2023, with a 43% response rate, see Table 1 for average values from post-survey. The questions were presented as a Likert scale. Each option was translated to a numerical value from one to five to determine direct changes and amount of change, positive or negative, from the pre- to post- survey. Refer to Appendix B and C for full questions and answer options with numerical scale applied. The three questions I asked about again were how much time PE took, how effective their PE is, and how efficient their PE is. I chose to ask these three questions again to see how effective my POR were to the staff by any changes in the scores. Idealistically, I wanted the average time score to decrease while the average score for effectiveness and efficiency to increase. As an entire staff, the average time score increased from 2.95 to 3.20; the average PACKAGES OF RESOURCES IN INPATINET SETTING 10 effectiveness score increased from 3.25 to 3.47; the average efficiency scores also increased from 3.15 to 3.47. As seen in Figure 4, CMs were the only discipline that reported their time on PE decreased. Nursing and SLPs had the largest increase in time, which differed from other studies, however, only one nurse and one SLP completed the post-survey, so the results were not a collective opinion. Nurses had the greatest negative effect from the POR; however, communication was not as constant with nursing staff due to location within the building and their responsibility to patient care. OTs showed an increase in effectiveness and efficiency with no change in time, see Figures 4-6 for average changes by each discipline. Their average time score was the lowest in the pre- and post-survey. The PORs were created for the entire rehabilitation staff, however, it was created with the mindset of OT, therefore the PORs had the most overall positive effect. Conclusion The overall average scores for effectiveness and efficiency in PE with the PORs increased, however the overall average of time consumed in PE also increased. I learned that this could have been due to outliers in my post-survey with only one nurse completing; it could have also been due to the time allowed for each staff member to utilize the PORs as only one staff member would get to provide them when appropriate to each patient. I learned that it could take time and further project development to have a larger, more positive impact on the site, the staff, and their patients. Although I did not get all positive results, the staff relayed positive feedback and gratitude for my project. In my post-survey, I provided space for any feedback. Although anonymous, I received feedback from a SLP, an OT, and a PT. These comments included [the PACKAGES OF RESOURCES IN INPATINET SETTING 11 PORs] were excellent They were concise and to the point (Anonymous, 2023). [The PORs] were great and explained what the patient needs to know (Anonymous, 2023). And thank you for your time and effort into [the PORs] (Anonymous, 2023). After my dissemination, the rehabilitation team thanked me for all the work I had done and were excited to continue to utilize the PORs for PE in the future. After my dissemination, I proposed that future work could be done by other students or staff, by all disciplines, to create more PORs covering more conditions as well as more research into the patient understanding of the PORs I completed. The PORs I created were focused on health literate information to ease the understanding of the condition on the patient. OTs as well as all other medical professionals could benefit from understanding how important health literacy is in PE to improve health outcomes. Overall, throughout the experience, it was found that these POR were beneficial to the interdisciplinary staff at CFV by improving their effectiveness and efficiency in PE. Summary I completed my DCE at CFV where I created 12 PORs that covered the most seen conditions at the rehabilitation center. Each POR was designed to explain the diagnosis, common signs and symptoms, interventions to continue after discharge, and community/online resources. Research indicated the importance of PE and how it can lead to better quality of life, improved health outcomes, and decreased treatment costs. However, due to lack of time and resources, PE was not always effective or efficient, leading patients to complete their own education online. Online resources could be hard to understand and inaccurate, so my PORs were written at or below an eighth grade reading level. PACKAGES OF RESOURCES IN INPATINET SETTING 12 I evaluated my project with a pre- and post-survey that translated verbal opinions on personal PE effectiveness and efficiency into numerical data to make direct comparisons before and after implementation of my PORs. These surveys were distributed to CMs, nurses, PTs, OTs, and SLPs at CFV as PE is a vital part of treatment for all disciplines in inpatient rehabilitation. After compiling the results, the average score across all disciplines for the amount of time to gather and deliver PE by 0.25; the average score for effectiveness of PE increased by 0.22; the average score for efficiency of PE increased by 0.32. CMs were the only discipline to decrease in time, while Nurses increased the most in time. Nurses had the most negative impact; however, it could be due to low survey completion. OTs had the most positive impact by increasing in effectiveness and efficiency while keeping the same score for time. Due to the positive impact seen with OTs, it further demonstrates the need for health literate and condensed educational resources like my PORs in OT PE intervention. PACKAGES OF RESOURCES IN INPATINET SETTING 13 References Arad, M., Goli, R., Parizad, N., Vahabzadeh, D., & Baghaei, R. (2021). Do the patient education program and nurse-led telephone follow-up improve treatment adherence in hemodialysis patients? A randomized controlled trial. 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Feasibility and acceptability of implementing a patient education pressure injury prevention care bundle in acute care: an interview study. Wound Practice & Research, 29(3), 163170. https://doi.org/10.33235/wpr.29.3.163-170 Li, Z. H. J., Wang, M., & Ingledew, P.-A. (2021). Depression in cancer: quality assessment of online patient education resources. Psycho-Oncology, 30(3), 400407. https://doi.org/10.1002/pon.5591 Maddox, T., Fitzpatrick, T., & Chmielewski, C. (2022). Using Learning Science to Optimize Chronic Kidney Disease Education for Patients and Providers. Nephrology Nursing Journal, 49(1), 3944. https://doi.org/10.37526/1526-744X.2022.49.1.39 Papadakos, J. K., Giannopoulos, E., McBain, S., Forbes, L., Jain, P., Samoil, D., Wang, J., Zwicker, V., Fox, C., Moody, L., & McLeod, R. (2021). Quality assessment of cancer patient education materials: the current state of systemic therapy patient education in fourteen cancer centres across Ontario, Canada. Supportive Care in Cancer, 29(7), 3513 3519. https://doi.org/10.1007/s00520-020-05859-2 Simon Fraser University. (n.d.). Post-Pre Survey Resources. Simon Fraser University Engaging the World. Retrieved April 8, 2022, from https://www.sfu.ca/istld/faculty/resources/postpre.html#:~:text=A%20post%2Dpre%20su PACKAGES OF RESOURCES IN INPATINET SETTING 15 rvey%20is,their%20future%20behaviour%20and%20aspirations. Sinatti, P., Snchez Romero, E. A., Martnez-Pozas, O., & Villafae, J. H. (2022). Effects of Patient Education on Pain and Function and Its Impact on Conservative Treatment in Elderly Patients with Pain Related to Hip and Knee Osteoarthritis: A Systematic Review. International Journal of Environmental Research and Public Health, 19(10), 6194. MDPI AG. Retrieved from http://dx.doi.org/10.3390/ijerph19106194 Western Governors University. (2020, October 21). What is the transformative learning theory. WGU Indiana. Retrieved March 25, 2022, from https://www.wgu.edu/blog/whattransformative-learning-theory2007.html Wittink, H., & Oosterhaven, J. (2018). Patient education and health literacy. Musculoskeletal Science and Practice, 38, 120-127. https://doi.org/10.1016/j.msksp.2018.06.004 PACKAGES OF RESOURCES IN INPATINET SETTING 16 Table 1 Average Score from Pre-Survey and Post-Survey for Each Discipline Discipline Question What is your discipline at Cape Fear Valley Rehabilitation Center? In your professional opinion, how important is it for your specific discipline (case management, nursing, PT, OT, SLP) to provide patient education? How much of your time is taken up by patient education (gathering and delivery of information)? How often do patients ask you about their specific medical condition? How often do patients ask you about resources (community or online) for their specific condition? How often do you have to re-explain patient education due to a patient not understanding medical terminology found on the internet or previously explained by another medical professional? How effective do you think that the patient education you provide is to a patient who is discharged? How efficient do you think your current way of providing patient education is? Case Nurse Management Pre Post Pre Post 3 2 5 1 4.0 3.0 5.0 2.5 3.4 Physical Therapy Pre Post 4 4 4.5 5 2.8 Occupational Therapy Pre Post 7 7 4.6 2.8 2.7 Speech Therapy Pre Post 1 1 5.0 3.2 3.0 3.7 4.2 3.5 3.3 4.0 4.3 3.2 2.8 3.3 2.0 3.7 4.0 3.5 3.4 3.0 4.0 2.7 3.0 3.4 3.0 3.0 3.8 3.4 3.4 4.0 4.0 3.0 3.0 3.2 3.0 2.8 3.5 3.3 3.6 4.0 4.0 PACKAGES OF RESOURCES IN INPATINET SETTING 17 Table 2 Conditions Covered in PORs Cerebrovascular Accident (CVA)* Traumatic Brain Injury (TBI) * Hip Fracture* Spinal Cord Injury (SCI) / Autonomic Dysreflexia* Parkinsons Disease* Multiple Sclerosis (MS)* Total Knee Replacement* Amputations (AKA/BKA)* Post Spinal Surgeries* Orthopedic Surgeries** Debility** Critical Illness Myopathy** *Created and utilized during the implementation phase from January 19, 2023 - March 10, 2023. **Created following implementation phase from March 13, 2023 - April 14,2023. PACKAGES OF RESOURCES IN INPATINET SETTING Figure 1 Visual Representation of PEO and Transformative Learning Theory Combined 18 PACKAGES OF RESOURCES IN INPATINET SETTING Figure 2 Page 1 of POR Template Note. The 3D design of the POR is a trifold brochure, this 2D design shows the front cover on the far right and middle insert on the far left. 19 PACKAGES OF RESOURCES IN INPATINET SETTING Figure 3 Page 2 of POR Template Note. The 3D design of the POR is a trifold brochure, this 2D design shows the inside of the brochure. 20 PACKAGES OF RESOURCES IN INPATINET SETTING 21 Figure 4 Change in Pre-Survey to Post-Survey for How much of your time is taken up by patient education? Case Management Nursing Physical Therapy Occupational Therapy Speech Therapy 1 None at all 2 3 4 5 All of my time PACKAGES OF RESOURCES IN INPATINET SETTING 22 Figure 5 Change in Pre-Survey to Post-Survey for How effective do you think your patient education is? Case Management Nursing Physical Therapy Occupational Therapy Speech Therapy 1 Not effective at all 2 3 4 5 Extremely effective PACKAGES OF RESOURCES IN INPATINET SETTING 23 Figure 6 Change in Pre-Survey to Post-Survey for How efficient do you think your patient education is? Case Management Nursing Physical Therapy Occupational Therapy Speech Therapy 1 Not efficient at all 2 3 4 5 Extremely efficient PACKAGES OF RESOURCES IN INPATINET SETTING 24 Appendix A DCE Weekly Planning Guide Week DCE Stage (orientation, screening/evaluation, implementation, discontinuation, dissemination) 1 Orientation 2 Objectives 1) Complete 1) Complete orientation online trainings Screening/evaluation 2) Create 2) Complete Pre-survey IRB documentation Implementation 3) Complete 3) Determine POR website to create PORs 4) Create general template 5) Create CVA POR as prototype Screening/evaluation 1) Create 1) Receive Pre-survey condition list Implementation 3 Weekly Goal Tasks Introduce self and project to staff Create survey on Qualtrics Create template on VistaCreate 1/11 1/13 1/12 1/13 Create CVA handout Send out survey 2) Create list of conditions 2) prioritize conditions Finalize MOU 3) Complete POR 3) create Hip Fracture POR Complete hip fracture POR Screening/evaluation 1) Increase responses on presurvey 2) Complete Implementation POR Literature Documentation search Date complete 1) Weekly Remind staff at Rehab meeting meeting to fill out survey 2) Send out email reminder Complete TBI handout for survey 3) Update Finish literature literature search search 1/19 1/20 1/20 1/25 1/27 1/27 PACKAGES OF RESOURCES IN INPATINET SETTING 4 5 Screening/evaluation 1) Create list of side projects 2) Increase responses Implementation on presurvey Complete POR Screening/evaluation 1) Compile Pre-survey results Implementation 2) Complete POR 6 Implementation Implementation 1) Complete POR 2) Inform staff on next Screening/evaluation phase 3) Create visuals for results 25 1) Receive list of side projects from supervision 2) Order list by priority create SCI POR 1) Close survey 2) compile results 2) Create Parkinsons POR 1) Create MS POR 2) Speak in team meeting 3) Complete tables and figures for three main questions Create SCI handout Close survey and record responses Create Parkinsons handout Create MS handout Implementation 1) Complete POR 8 Implementation 1) Complete 1) Create POR amputation 2) POR Dissemination plan 1/30 2/3 2/8 2/10 2/17 Lead meeting 2/14 about implementation 2/17 Compiling responses from survey into tables and figures Shadow home evaluation class 1) Create Knee Complete knee Arthroplasty arthroplasty POR handout 7 Dissemination Sent reminder for survey Complete amputations handout 2/24 3/3 3/3 PACKAGES OF RESOURCES IN INPATINET SETTING 9 Implementation Discontinuation 10 Implementation Dissemination Dissemination 1) Complete POR 2) Complete Post survey 26 2) Dissemination plan 1) Complete Post spinal POR 2) Complete Post survey 1) Complete POR 1) Complete orthopedics POR 2) 2) Dissemination Dissemination Plan plan 3) 3) Dissemination Dissemination presentation presentation 11 Implementation Dissemination Dissemination 12 Discontinuation Discontinuation 13 Dissemination 14 Discontinuation Discontinuation 1) Complete POR 1) Complete debility POR 2) 2) Dissemination Dissemination presentation presentation 1) Increase post survey completion rate 2) Complete results 1) Disseminate 1) Complete DCE 1) Receive results from post-survey 2) Complete results from post survey 1) Disseminate to site 1) Complete dissemination files Dissemination plan post spinal surgery POR send out post survey Create orthopedics POR Complete dissemination plan Begin work on dissemination PowerPoint Debility Working on PowerPoint Begin working on poster Send out survey reminder 3/10 3/10 3/17 3/17 3/17 3/24 3/24 3/24 3/28 3/31 Compile results Dissemination 4/5 Finished poster 4/15 Finished scholarly report 4/15 PACKAGES OF RESOURCES IN INPATINET SETTING 27 Appendix B Qualtrics Pre-Survey Questions 1. What is your disciple at Cape Fear Valley Medical Center? 1. Case Management 2. Nursing 3. Physical Therapy 4. Occupational Therapy 5. Speech Therapy 2. In your professional opinion, how important is it for your specific discipline (case management, nursing, PT, OT, SLP) to provide patient education? 1. Not at all important 2. Slightly important 3. Moderately important 4. Very important 5. Extremely important 3. How much of your time is taken up by patient education (gathering and delivery of information)? 1. None at all 2. A little 3. A moderate amount 4. A lot 5. All of my time 4. How often do patients ask you about their specific medical condition? 1. Never 2. Rarely 3. Sometimes 4. Frequently 5. Constantly 5. How often do patients ask you about resources (community or online) for their specific condition? 1. Never 2. Rarely 3. Sometimes 4. Frequently 5. Constantly 6. How often do you have to re-explain patient education due to a patient not understanding medical terminology found on the internet or previously explained by another medical professional? 1. Never 2. Rarely 3. Sometimes 4. Frequently 5. Constantly 7. How effective do you think that the patient education you provide is to a patient who is discharged? PACKAGES OF RESOURCES IN INPATINET SETTING 1. Not effective at all 2. Slightly effective 3. Moderately effective 4. Very effective 5. Extremely effective 8. How efficient do you think your current way of providing patient education is? 1. Not efficient at all 2. Slightly efficient 3. Moderately efficient 4. Very efficient 5. Extremely efficient 9. Is there anything you would like to change about the way patient education is gathered and/or delivered at CFVH currently? 28 PACKAGES OF RESOURCES IN INPATINET SETTING 29 Appendix C Qualtrics Post-Survey Questions 1. What is your discipline at Cape Fear Valley Medical Center? 1. Case Management 2. Nursing 3. Physical therapy 4. Occupational Therapy 5. Speech Therapy 2. How much of your time is taken up by patient education (gathering and delivery of information)? 1. None at all 2. A little 3. A moderate amount 4. A lot 5. All of my time 3. After using the patient education handouts, how effective do you think your patient education is for a patient who is discharged? 1. Not effective at all 2. Slightly effective 3. Moderately effective 4. Very effective 5. Extremely effective 4. After using the patient education handouts, how efficient do you think your current way of providing patient education is? 1. Not efficient at all 2. Slightly efficient 3. Moderately efficient 4. Very efficient 5. Extremely efficient 5. What could have made the educational handouts better?  ...