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... 1 Empowering the Needs of Caregivers: Use of Occupation-Based Workshops Abbie Alter 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: Taylor Gurley, MS, OTD, OTR 2 Abstract Research has demonstrated that around one-third of children will re-enter care after reunifying with family due to continued maltreatment (LaBrenz et al., 2020). The importance of a planned and purposeful process that involves preparation, intervention, and follow-up among all caregivers helps increase successful reunification (Ankersmit, 2016). The purpose of this doctoral capstone project is to provide caregivers with the knowledge and comfort to increase the quality of care. The continuous demand to increase family reunification led to a series of four educational workshops at Wellpoint Care Network. Topics covered consisted of co-regulation, habit training, and well-being. Pre-and post-surveys were administered to collect the workshop's effectiveness in providing knowledge and decreasing the discomfort level of the participants surrounding the caregiving skills. Results indicated that participants gained knowledge in all workshops while decreasing their discomfort in both the topics of co-regulations and well-being. Keywords: co-regulation, habit training, well-being, caregiver 3 Introduction Wellpoint is a nonprofit organization located in the heart of Milwaukee whose aim is to service the foster children and families of Wisconsin. Their mission is to facilitate equity, learning, healing, and wellness by restoring the connections that help children and families thrive while addressing the impact of trauma, preventing adversity, and promoting resilience for the individuals receiving their care (About Us, 2022). To serve its community, Wellpoint works to empower all individuals, regardless of background, to overcome barriers to increase their well-being. While Wellpoint offers various mental health and therapeutic services for the population it aids, stakeholders have stated that there is still a need to increase advocacy and address the needs of the biological parents of the children. While reunification of the families is the goal of all of the services at Wellpoint, it does not always happen. To help fill this gap this doctoral capstone project aimed to provide caregivers with the knowledge and hands-on experiences to increase the quality of care through educational workshops. Topics covered included approaches to co-regulation, methods to balancing activities through habit training, and the understanding of improved well-being. The educational workshops used the Trust-Based Relational Intervention theory and the cognitive behavioral frame of reference to focus on the project objectives of developing and implanting three to four educational workshops that addressed the needs of the biological parents and additional caregivers to increase the success of family reunification and the creation and dispersion of resources for future use. Pre- and post-surveys were utilized to assess the effectiveness and the acquired knowledge of the participants. The purpose of this capstone was to identify the role of occupational therapy and how it can be utilized to increase the effectiveness of parent education in regard to increasing reunification. 4 Background Wellpoint has supported children and their families for over 170 years while serving around 5,000 community members daily (About Us, 2022). The population they serve is diverse, with many biological parents and foster kinship families coming from a low socioeconomic status, with around 90% qualifying for Medicaid. The average age range of the children is 5- to 8-year-olds, with most of them staying in the foster care system for an average of 6 months to 1 year. The majority of the children and families served have complex needs as a result of traumatic histories (Our Services, 2022). The caregivers, especially the biological parents, experience a sustained lack of opportunities and fairness when it comes to services that enhance their mental health and ability to provide effective care for their children. They face challenges such as being less likely to receive any assistance addressing their mental health, substance use, or receiving any material resources (Cheng & Lo, 2021). With the Adoption Assistance and Child Welfare Act, the Adoption and Safe Families Act, and the Families First and Prevention Services Act there has been increased awareness of the importance of family connections and the reunification of families (LaBrenz et al., 2020). After completing a needs assessment through interviews and meeting with a couple of the stakeholders from Wellpoint, much was gained about the needs of the organization and the population that will be served. As with any organization, the stakeholders felt there were areas of services that could be improved. While the clinic has a strength in advocating for the children and even meeting the needs of the foster parents, the stakeholders mentioned that an area of improvement is providing more advocacy for the biological parents. When discussed further there were a number of areas that emerged that were believed needed to be addressed to help caregivers. The first identified area was addressing the parents' communication skills. By doing 5 so the stakeholders believe that it will increase the relationship between the biological parent and the foster parent. In turn, providing the biological parent with a continuous active role in their childs life. Increasing communication skills will also help the parent advocate for their children and themselves. Another identified area was addressing the mental health of the biological parents. The stakeholders mentioned that they have programs that help the children and the foster families with their mental health but not the biological parent. By ignoring the mental health of the parents, we are allowing a negative cycle of adverse childhood experiences to continue (Whitney, 2020). A large aspect of this mental health is the stress the parents face when they are reunited in their homes with their children without prior support and knowledge. To counteract this insufficiency this doctoral capstone focuses on the biological parents and their access to knowledge with the aim to increase reunification for the families. Many other studies have found the benefit of focusing on the parents through intervention. Studies done by both Shanks and Weitz (2020) and Oxford et al. (2016) found that interventions focusing on educating and providing guidance to parents about parenting skills increased the parent-child relationship and helped to decrease problematic child behavior. Furthermore, when provided with one-on-one home program intervention, parents could be taught and reinforce positive parenting skills, such as play, attention, involvement, listening, problem-solving, and non-aversive discipline strategies (Furlong et al., 2021). It has been shown that interventions that offer individualized support help to reduce the biological parents feelings of powerlessness and helped to increase their participation and influence (Shanks & Weitz, 2020). Additionally, Shanks and Weitz (2020) found that by advocating for the parents it led to relieving the parents perceived stigma and increased their willingness to speak up for themselves and their children. 6 While all of these studies have provided benefits for the parents, they only focus on one type of learning platform and do not address many of the barriers faced such as inadequate child care and transportation, unworkable office hours of providers, or other scheduling conflicts (Cheng & Lo, 2021). This doctoral capstone will take the concepts from previous studies and create educational modules or sessions to teach the parent the occupational skills needed to increase parenting skills while providing the parents the opportunity to learn and engage in numerous settings, such as at a community building, online, in groups, or one-on-one. It aims to cater to the parents by working around their schedule by providing one-on-one opportunities for parents unable to attend the group workshops. It also aims to reduce the additional barriers by providing childcare for the parents who need it throughout the workshops series. Use of in person-discussion, take-home resources, and informational videos will be used to convey the information in an accessible manner. Furlong et al. (2021) showed that the use of video and modeling is advantageous when providing care for biological parents. Wellpoint care networks team members, such as the Kinship Wellness Specialist, the Foster and Kinship Navigation Supervisor, and the Clinical Services Supervisor, agree with the importance of addressing the needs of the biological parents and the community with the director of community engagement stating that it is truly beneficial for the community. Theory In order to guide the doctoral capstone project, the Trust-Based Relational Intervention theory and the cognitive behavioral frame of reference were utilized. The Trust-Based Relational Intervention theory focuses on providing effective support and training to caregivers to increase the support and treatment for at-risk children (Purvis, 2013). By using this theory, it allowed a focus to be on addressing the needs of the biological parents through the theory's three main 7 principles; empowerment, connection, and correction. In addition, this theory helped guide this project by providing me with ways to address the ecological aspect, such as the external environment, and the physiological, internal, and physical, needs of the child (Purvis, et al., 2009). The main focus and goal were on building the connection between the parent and the child. The information gained from assessing an individual, specifically the biological parent, through the lens of this theory, will help promote the occupational skills needed to increase a familys reunification. In order to increase the success of a foster childs return home to their biological parents the psychological barriers of the biological parents need to be addressed. The cognitive behavioral frame of reference increases functions by addressing items such as negative thoughts, increasing self-efficacy and regulation, and helping develop consistent roles and occupational engagement (Cole & Tufano, 2020). By utilizing the Trust-Based Relational Intervention theory and the cognitive behavioral frame of reference, a deeper understanding of what the biological parents and other caregivers need for successful occupational engagement to reunify the families was developed. Project Design and Implementation Caregivers with children in the well-care system have been an overlooked population, with Malet et al. (2010) stating that parents feel that they receive insufficient support once their children are returned home. This capstone project aims to address this issue by providing educational workshops supported by current research. Lalayants et al. (2021) found that when parents received a parent advocacy intervention that targeted parental empowerment, engagement, and emotional support, it increased permanency and reunification. Additionally, by focusing on the individual needs of a family Maltais et al. (2019) found that you are able to increase parent engagement. 8 The layout of the project continued to change and develop throughout the design process in order to better fit the needs of the organization and the participants, see Appendix A for weekly outline. Three educational workshops were developed through discussion with Wellpoint team members covering the topics of co-regulation, habit training, and wellbeing. A fourth workshop was initially left undecided, in order to further assess the needs of the participants through the first workshops, however, due to increased interest in co-regulation, it was decided to be offered twice. The use of workshops was chosen due to a study done by Furlong, et al. (2021), demonstrating that the use of group discussions, modeling, and use of videos had a positive effect on mental health, parental satisfaction, and self-efficacy for the parents within their study. The workshops were initially focused on the biological parents, however, as a result of limited interest and participation the workshops were provided for all caregivers, including but not limited to biological, kinship, and foster parents. Parents were contacted through the distribution of flyers through the Wellpoint team and through posting on the organization's social media accounts. The workshops were delivered in person to small groups in order to facilitate group discussions, however, one-on-one sessions were offered for individuals unable to attend the designated time with child care provided at each workshop. After completing the first two sessions, the workshops were modified to provide both an in-person option and an online option in the hope to increase participation. To further support learning, handouts were created to assist each workshop, see Appendix B. Additionally, short videos were created and posted after the workshops for additional coverage of the topics and future implementations. An online folder was given to the organization containing all the resources and videos for future implementation and distribution. An outcome assessment of pre and post-surveys created by the doctoral student 9 was given at each workshop to determine the success of the workshops. The use of pre and postsurveys allowed for an evaluation of the format and materials of the workshops, see the Appendix C for each survey used during the workshops. Project Outcomes Qualitative data was collected through electronic and paper pre- and post-surveys aimed to measure the effectiveness of the workshops by assessing knowledge gained and the level of discomfort utilizing provided tools and materials. The level of knowledge and comfort obtained was measured utilizing a 5-point Likert scale based on research done by Dawes (2007), the survey questions are referenced below in the Appendix C. Knowledge gained was measured by 1 being no knowledge and 5 being excellent knowledge. Comfort was measured with 1 being no discomfort and 5 as high discomfort. Data from the surveys were calculated into a mean score in order to analyze outcomes, which is supported by literature (Sullivan & Artion, 2013). Table 1 represents the outcome of the Co-regulation workshop, which was completed by two kinship parents and one biological parent (n=3). When comparing the data from the pre- and post-surveys, it is shown that the implementation of the workshop led to an increase in knowledge obtained and a decrease in the discomfort caregivers felt around the tools used to help with co-regulation. Table 1 Co-regulation Outcome Measures Mean Pre-Test Score Mean Post-Test Score Total Change (%) N Knowledge 3.0 (60%) 4.0 (80%) + 20 3 Discomfort Level 2.2 (43.3%) 2.1 (40%) - 3.3 3 10 There was a total of one participant for the habit training workshop, a biological parent (n=1). When comparing the pre-and post-survey the individual reported an increase in knowledge gained however the participant's discomfort level remained the same when it came to utilizing the tools and strategies provided (Table 2). Table 2 Habit Training Outcome Measures Mean Pre-Test Score Mean Post-Test Score Total Change (%) N Knowledge 2.7 (53.3%) 4 (80%) + 26.7 1 Discomfort Level 2 (40%) 2 (40%) -0 1 Table 3 represents the outcome of the well-being workshop, which was completed by two kinship parents and one biological parent (n=3). When comparing the data from the pre and postsurveys, it is shown that the implementation of the workshop led to an increase in knowledge obtained and a decrease in the discomfort caregivers felt around the tools to help with coregulation. Table 3 Well-Being Outcome Measures Mean Pre-Test Score Mean Post-Test Score Total Change (%) N Knowledge 3.1 (62.2%) 4.2 (84.4%) + 22.2 3 Discomfort Level 3.0 (60%) 2.0 (40%) - 20 3 11 Summary Wellpoint is a community-focused, human-serving organization with deep roots in serving and supporting the diverse foster children and families of Wisconsin. The overall goal of Wellpoint is to address the impacts of trauma and promote resilience in order to increase family reunification. A needs assessment of the organization acknowledged that caregivers, experience a sustained lack of opportunities when it comes to services that enhance their mental health and ability to provide adequate care for their children. To help bridge the gap this doctoral capstone project aimed to provide caregivers with the knowledge and hands-on experiences to increase the quality of care through small group educational workshops. Three topics were covered over the span of four 45-minute sessions. The topics consisted of approaches to co-regulation, modifying habits through habit training, and addressing an individual's well-being. To address barriers faced in other studies, such as limitation to one type of learning platform, inadequate child care, and availability, the workshops offered provided childcare and one-on-one session for individuals unable to attend during the designated time (Cheng & Lo, 2021). Additionally, to further support learning the workshop offered handouts and post-workshop video to further cover the topic and future utilization. Modification of the workshops provided an opportunity for both in-person and online attendance for the last two workshops. Qualitative data was collected throughout the workshops in a pre and post-survey format aimed to assess the information provided and the level of comfort individuals felt surrounding the topics. Each workshop resulted in a 20% increase or more in regards to knowledge gained for the occupational skills covered as well as the co-regulation and well-being workshop lessening the discomfort individuals felt by 3.3% and 20% respectively. Increasing knowledge and comfort surrounding occupational skills needed for parenting is important for reaching the goal of reunification. 12 Conclusion This capstone project was conducted to address the needs of the caregivers of the children and families of Wellpoint. The primary goal of the project was to provide caregivers with the knowledge and tools to increase the quality of care and increase the success of family reunification. The completion of four educational workshops was accomplished during the capstone experience, with both the student and the organization benefiting. The organization acquired resources that guided them closer to the goal of increasing reunification by recognizing the need to aid the caregiver's mental well-being. While continuing to address the needs of children in the well-care system is important, occupational therapists need to also assist the caregiver's emotional, physical, social, and mental needs as well. More trauma-informed interventions and research that addresses caregivers needs are required to further increase reunification and break the negative cycle of adversity and trauma. 13 References Ankersmit, L. (2016). The reunification of partnership: Engaging birth parents and foster carers as collaborators in restoration casework. Australian Social Work, 69(30), 273-282. Cheng, T. & Lo, C. (2020) With their children placed in kinship, did parents get the services they needed?. Children and Youth Services Review 121, 1-9. Cole, M. & Tufano, R. (2020). Applied theories in occupational therapy: A practical approach (2nd Ed.). Thorofare, N.j. :SLACK Incorporated. Dawes, J. (2007). Do data characteristics change according to the number of scale points used. International Journal of Market Research 50(1). Furlong, M., McLoughlin, F., & McGilloway, S. (2021). The incredible years parenting program for foster carers and biological parents of children in foster care: A mixed methods study. Children and Youth Services Review, 126. LaBrenz, C., Fong, R., & Cubbin, C. (20). The road to reunification: Family- and state systems-factors associated with successful reunification for children ages zero-to-five. Child Abuse and Neglect, 99. Lalayants, M., Wyka, K., & Saitadze, I. (2021). Outcomes of the parent advocacy initiative in child safety conferences: Placement and repeat maltreatment. Children and Youth Services Review, 130. Malet, M., Mcsherry, D., Larkin, E., Kelly, G., Robinson, C., & Schubotz, D. (2010). Young children returning home from care: the birth parents perspective. Child & Family Social Work, 15(1), 7786. 14 Maltais, C., Cyr, C., Parent, G., & Pascuzzo, K. (2019). Identifying effective interventions for promoting parent engagement and family reunification for children in out-of-home care: A series of meta-analyses. Child Abuse and Neglect, 88, 362-375. Oxford, M., Marcenko, M., Fleming, C., Lohr, M., & Spieker, S. (2016). Promoting birth parents relationships with their toddlers upon reunification: Results from prompting first relationships home visiting program. Child Youth Services Review 61, 109-116. Purvis, K., Cross, D., Dansereau, D., & Parris, S. (2013). Trust-Based Relational Intervention (TBRI): A Systemic Approach to Complex Developmental Trauma. Child & Youth Services, 34(4), 360-386. Purvis, K. B., Cross, D. R., & Pennings, J. S. (2009). Trust-based relational intervention : Interactive principles for adopted children with special social-emotional needs. Journal of Humanistic Counseling, Education & Development, 48(1), 322. https://doi.org/10.1002/j.2161-1939.2009.tb00064 Shanks, E., & Weitz, Y. (2020). Supportive practices: perceptions of interventions targeting parents whose children are placed in out-of-home care. Adoption and fostering, 44(4), 349-362. Sullivan, G, M., & Artino, A, R. (2013) Analyzing and interpreting data from likert-type scales. Journal of Graduate Medical Education, 5(4), 541-542. Wellpoint Care Network. (2022). About Us, Our Mission. https://sainta.org/about-us Wellpoint Care Network (2022). Our Services. https://wellpointcare.org/services Wellpoint Care Network. (2022). Partners. https://sainta.org/about-us/partners/ 15 Whitney, R. (2020). Self-regulation as key factor in protection against the harmful effects of adverse childhood experiences: Critical role of occupational therapists. The Open Journal of Occupational Therapy, 8(1), 1-9. 16 Appendix A Weekly Timeline Week DCE Stage 1 Orientation Weekly Goal 1. Complete orientation by the end of the week 2. Complete the Needs Assessment by the end of the week Objectives Tasks Meet with the site mentor, Wellpoint staff, and the children and parents to introduce myself and educate them on why I am here and what I will be doing for the next 14 weeks Set up meetings with key personnelSite mentor and therapist Document supervision plan and update MOU with site mentor Date Complete 1/10/23 Ensure that all paperwork and training for orientation is complete Determine who to meet with and what questions to ask and set up meeting 1/9/23 Understand the site environment and atmosphere Finalize the questions for Needs Assessment Complete SWOT analysis Have parents 1/12/23 sign 17 2 3. Weekly observation Increase with OT clinical knowledge and skills Screening/Evaluation 1) Establish the Establish needs of the parent desired population (bio, Outcomes foster, etc.) 2) Finalize the topic of workshops Clinical Experience 3 3) Weekly observation with OT Screening/Evaluation 1) Create advertising material 2) Begin contacting parents for classes Clinical Experience 4 Implementation Clinical Experience 3) Weekly observation with OT 1) Continue advertising class 2) Weekly observation with OT permission to observe paperwork Review outcome assessments with the site mentor & faculty mentor 1/19/23 Met with faculty mentor Spread the word about the classes Get ahold of a marketing team member to approve the flyer 1/23/23(weekly meeting with Melanie to discuss)-flyer set out Increase Clinical knowledge and skills Contact clinicians and inform them about the purpose of the classes, for referrals Be prepared to educate parents on the material through an interactive method Begin creating handouts that will be given to attendees Increase Clinical knowledge and skills Continue to spread the word about the workshops Transfer workshop material into video format 1/19/23 1/26/23 02/02/23 18 5 6 Implementation 1)Finalize material for first class and list of attendees Clinical Experience 2) Weekly observation with OT Implementation 1) February 15: Present first workshop- Coregulation Complete a 45-minute informational session that will provide knowledge to parents 2) Weekly observation with OT Increase Clinical knowledge and skills Be prepared to educate parents on the material through an interactive method Clinical Experience 7 Implementation 1) Finalize material for the second class and list of attendees 2)embedded QR code into the video Clinical Experience 8 Increase Clinical knowledge and skills Implementation Be prepared for completion of the first workshop next week Increase Clinical knowledge and skills 3) Weekly observation with OT Increase Clinical knowledge and skills 1) March 1: Present 2nd Complete a 45-minute for future use Complete coregulation video and handouts 02/10/23 Presented Regulation kits 02/09/23 Complete 02/15/23- 2 pre and post- individuals knowledge attended survey 02/16/2023 (seen evaluation) Create a 02/24/23 handout that will be given to attendees Transfer workshop material into an information binder for future use 02/23/23 Complete 03/01/23 No pre and post- attendance 19 workshopTransforming Habits 9 Clinical Experience 2) Weekly observation with OT Implementation 1) Finalize material for the third class and list of attendees Clinical Experience 10 11 2) Weekly observation with OT informational session that will provide knowledge to parents Increase Clinical knowledge and skills Be prepared to educate parents on the material through an interactive method knowledge survey 03/02/2023 Create a handout that will be given to attendees Transfer workshop material into an information binder for future use Increase Clinical knowledge and skills Implementation 1) March 15: Present 3rd workshopWellbeing Complete a 45-minute informational session that will provide knowledge to parents Clinical Experience 2) Weekly observation with OT Increase Clinical knowledge and skills Implementation 1) Determine the additional needs/wants of the Cover any lasting 03/06/23 (1on-1 with parent for 1st and 2 workshops) Posted the first two videos on YouTube 03/08/23 (Completed pp and affirmation handout) 03/09/23 (saw d/c) Complete pre and postknowledge survey 03/15/23 Completed the third workshop online and in person 03/16/23 Create a handout that 3/21/23 Determine to 20 12 13 community in order to create 4th workshop- if needed needs that the group feels are important Clinical Experience 2) Weekly observation with OT Implementation 1) March 29: Present 4th workshop- TBD based on community needs Increase Clinical knowledge and skills Analysis 2) Begin to analyze the results of the workshops Clinical Experience 3) Weekly observation with OT Analysis 1) Analysis results of workshops Discontinuation 2) Plan/create dissemination to stockholders Complete a 45-minute informational session that will provide knowledge to parents will be given complete to attendees additional coregulation Transfer workshop workshop material into an information binder for future use Complete pre and postknowledge survey 03/31/23 Determine the use of means to compare data Assess learning that occurred throughout workshops Increase Clinical knowledge and skills Assess learning that occurred throughout the workshops Inform stakeholders of the data gathered and the benefits of 3/23/23 03/29/23 Completed final workshop online 03/30/23 Compare pre and post survey of each class Create visual diagram Create a presentation (PowerPoint, handouts) to share with site 4/3-4/7/23 Continue to work on throughout the week 21 educating parents Clinical Experience 14 Dissemination Clinical Experience 3) Weekly observation with OT Increase Clinical knowledge and skills 1)Disseminate capstone results to site stakeholders Inform stakeholders of the data gathered and the benefits of educating parents 2) Weekly observation with OT Increase Clinical knowledge and skills stockholders about 4/3-4/6/23 Present information Finish any side projects participated in 4/11/23 Presented data to Clinical site supervisor 4/10-4/13/23 22 Appendix B Co-regulation Handouts 23 24 25 Habit Training Handouts 26 27 Well-Being Handouts 28 29 Co-Regulation Surveys Appendix C Co-Regulation Workshop Pre-Survey Section 1: Background 1. Please list the type of caregiver you represent (foster, kinship, biological, professional, etc.) Section 2: Knowledge On a scale of 15, please indicate your current level of knowledge in dealing with the following topics as they relate to Co-regulations. 1. Rate your knowledge about co-regulation. No Knowledge 1 Limited Average o 2 3 o o 2. Rate your knowledge about dysregulation. No Knowledge 1 Limited Average o 2 3 o o Moderate 4 o Moderate 4 o 3. Rate your knowledge about co-regulation strategies. No Knowledge 1 Limited Average Moderate o 2 3 4 o o o Excellent Knowledge 5 o Excellent Knowledge 5 Excellent Knowledge 5 o Section 3: Comfort On a scale of 15, please indicate your current level of comfort in dealing with the following topics as they relate to Co-regulations. 1. Rate your comfort with using co-regulation strategies with children. No Discomfort High Discomfort 1 Low Neutral Moderate 5 o 2 3 4 o o o o 30 2. Rate your comfort with utilizing support and resources. No Discomfort 1 Low Neutral Moderate o 2 3 4 o o o High Discomfort 5 o Additional comments (hope to learn, get out of class, why your here): Co-Regulation Workshop Post-Survey Section 1: Knowledge On a scale of 15, please indicate your current level of knowledge in dealing with the following topics as they relate to Co-regulations. 4. Rate your knowledge about co-regulation. No Knowledge 1 Limited Average o 2 3 o o 5. Rate your knowledge about dysregulation. No Knowledge 1 Limited Average o 2 3 o o Moderate 4 o Moderate 4 o 6. Rate your knowledge about co-regulation strategies. No Knowledge 1 Limited Average Moderate o 2 3 4 Excellent Knowledge 5 o Excellent Knowledge 5 Excellent Knowledge 5 o 31 o o o Section 2: Comfort On a scale of 15, please indicate your current level of comfort in dealing with the following topics as they relate to Co-regulations. 3. Rate your comfort with using co-regulation strategies with children. No Discomfort High Discomfort 1 Low Neutral Moderate 5 o 2 3 4 o o o o 4. Rate your comfort with utilizing support and resources. No Discomfort 1 Low Neutral Moderate o 2 3 4 o o o High Discomfort 5 o Additional comments (how the workshop went, recommendations, future workshop ideas) Habit Training Surveys 32 Habit Training Workshop Pre-Survey Section 1: Background 2. Please list the type of caregiver you represent (foster, kinship, biological, professional, etc.) __________________________________________________________________ Section 2: Knowledge On a scale of 15, please indicate your current level of knowledge in dealing with the following topics as they relate to habits. 7. Rate your knowledge about what habits are. No Knowledge Excellent Knowledge 1 Limited Average Moderate 5 o 2 3 4 o o o o 8. Rate your knowledge of how habits are formed. No Knowledge 1 Limited Average o 2 3 o o Moderate 4 o Excellent Knowledge 5 9. Rate your knowledge about strategies to use through habit training. No Knowledge Excellent Knowledge 1 Limited Average Moderate 5 o 2 3 4 o o o o Section 3: Comfort On a scale of 15, please indicate your current level of comfort in dealing with the following topics as they relate to habits and habit training. 5. Rate your comfort in using tools and strategies to modify current habits. No Discomfort High Discomfort 1 Low Neutral Moderate 5 o 2 3 4 o o o o Additional comments (hope to learn, get out of class, why youre here): Habit Training Workshop Post-Survey 33 Section 1: Knowledge On a scale of 15, please indicate your current level of knowledge in dealing with the following topics as they relate to habits. 10. Rate your knowledge about what habits are. No Knowledge Excellent Knowledge 1 Limited Average Moderate 5 o 2 3 4 o o o o 11. Rate your knowledge of how habits are formed. No Knowledge 1 Limited Average o 2 3 o o Moderate 4 o Excellent Knowledge 5 12. Rate your knowledge about strategies to use through habit training. No Knowledge Excellent Knowledge 1 Limited Average Moderate 5 o 2 3 4 o o o o Section 2: Comfort On a scale of 15, please indicate your current level of comfort in dealing with the following topics as they relate to habits and habit training. 1. Rate your comfort in using tools and strategies to modify current habits. No Discomfort High Discomfort 1 Low Neutral Moderate 5 o 2 3 4 o o o o Section 3: Satisfaction On a scale of 15, please indicate your current level of satisfaction with this workshop. 1. Rate your satisfaction with the current workshop. Very Unsatisfied 1 Unsatisfied Neutral Satisfied o 2 3 4 o o o Very Satisfied 5 o Additional comments (how the workshop went, recommendations, future workshop ideas); 34 Well-Being Surveys 35 Well-Being Workshop Pre-Survey Section 1: Background 3. Please list the type of caregiver you represent (foster, kinship, biological, professional, etc.) __________________________________________________________________ Section 2: Knowledge On a scale of 15, please indicate your current level of knowledge in dealing with the following topics as they relate to well-being. 13. Rate your knowledge about what well-being entails. No Knowledge Excellent Knowledge 1 Limited Average Moderate 5 o 2 3 4 o o o o 14. Rate your knowledge about the 8 components of well-being. No Knowledge Excellent Knowledge 1 Limited Average Moderate 5 o 2 3 4 o o o 15. Rate your knowledge about strategies to use to improve overall well-being. No Knowledge Excellent Knowledge 1 Limited Average Moderate 5 o 2 3 4 o o o o Section 3: Comfort On a scale of 15, please indicate your current level of comfort in dealing with the following topics as they relate to well-being. 6. Rate your comfort with using tools and strategies to modify your current state of well-being. No Discomfort High Discomfort 1 Low Neutral Moderate 5 3 o 2 4 o o o o 7. Rate your comfort with using tools and strategies to modify your childs current state of well-being. No Discomfort High Discomfort 1 Low Neutral Moderate 5 o 2 3 4 o 36 o o o Additional comments (hope to learn, get out of class, why youre here): Well-Being Workshop Post-Survey Section 1: Knowledge On a scale of 15, please indicate your current level of knowledge in dealing with the following topics as they relate to well-being. 16. Rate your knowledge about what well-being entails. No Knowledge Excellent Knowledge 1 Limited Average Moderate 5 o 2 3 4 o o o o 17. Rate your knowledge about the 8 components of well-being. No Knowledge Excellent Knowledge 1 Limited Average Moderate 5 o 2 3 4 o o o 18. Rate your knowledge about strategies to use to improve overall well-being. No Knowledge Excellent Knowledge 1 Limited Average Moderate 5 o 2 3 4 o o o o Section 2: Comfort 37 On a scale of 15, please indicate your current level of comfort in dealing with the following topics as they relate to well-being. 8. Rate your comfort with using tools and strategies to modify your current state of well-being. No Discomfort High Discomfort 1 Low Neutral Moderate 5 o 2 3 4 o o o o 9. Rate your comfort with using tools and strategies to modify your childs current state of well-being. No Discomfort High Discomfort 1 Low Neutral Moderate 5 o 2 4 o 3 o o o Additional comments (how the workshop went, recommendations, future workshop ideas):  ...

... TEACHING TO IMPROVE STUDENT PERFORMANCE Teaching Teachers to Improve Student Occupational Performance Sydney Abbott, 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: Laura Aust, OTD, MS, OTR 1 TEACHING TO IMPROVE STUDENT PERFORMANCE 2 Abstract Students' ability to perform their best in school is partly affected by their inability to selfregulate, which holds true at Shawswick Elementary. Staff here do not have the education or resources to help grow students regulation skills. Previous studies have been conducted on improving student academic performance and behaviors through sensory regulation behaviors and/or educating teachers on how to provide sensory regulation interventions. Guided by the Person Environment Occupation Performance (PEOP) model and sensory integration frame of reference (FOR), this project sought to increase overall occupational performance. Seven teachers were chosen as participants to the study and each of their classrooms were evaluated using the Direct Behavior Rating Single Item Scale (DBR-SIS). Each classroom was then visited throughout the week implementing different sensory-based interventions. Post-implementation, classrooms improved roughly 12% in academic engagement and disruptive behavior. This helped prove that implementation of sensory regulation interventions in classrooms results in improved occupational performance. TEACHING TO IMPROVE STUDENT PERFORMANCE 3 Shawswick Elementary School is one of five elementary schools within the North Lawrence Community School (NLCS) district and is where 478 students attend and 52 staff are employed. According to their website, the mission of the school is to be a home for students, encouraging critical thinking in a safe, respectful, and nurturing environment with a rigorous curriculum. Similarly, their vision is to be a place where all students will learn at appropriate levels (Shawswick Elementary, n.d.). Currently, there are barriers that affect some students ability to fully perform in their school-related tasks and therefore are unable to fully achieve the mission and vision of the school. Students' ability to perform their best in school is partly affected by their inability to selfregulate. Previous research has proven that sensory processing and executive functioning skills, including focusing, are positively correlated (Diamant, 2021). However, conversations with stakeholders revealed a need to not only increase the students skill level in sensory processing and regulation, but also educate teachers on how to help their students build these skills. In this doctoral capstone project, the doctoral student set out to educate teachers on the principles of sensory regulation and how to implement sensory interventions in their classroom. Aligning with published research, this project will also demonstrate how performing these interventions increase a childs performance in their role as a student. Throughout this paper, further detailed information will identify how the needs of the school were determined as well as what the research has already demonstrated. Guided by the Person Environment Occupation Performance (PEOP) model and sensory integration frame of reference (FOR), the projects design and purpose were created along with corresponding assessment tools, goals, and objectives. Within the results, data showcasing improved student performance and educator knowledge will be shown along with intervention principles and TEACHING TO IMPROVE STUDENT PERFORMANCE 4 examples. In the end, conclusions are drawn to align with current literature and demonstrate the benefits of teaching sensory regulation in a students occupation of school. Background In order to gain accurate and specific information about the site, a needs assessment was conducted. Three different stakeholders were asked the same questions; within an analysis of the answers, major themes and needs were identified. First, there has been a noticeable decrease in students' ability to self-regulate since the Covid-19 pandemic. Though primarily observed in kindergarten through second grade classrooms, all stakeholders have noticed an increase in maladaptive behaviors such as verbal and physical outbursts, fidgeting movements, difficulty focusing, and overall refusal to task. As a result, there has been a disruption in students academic and social performance. These observations aligned with published research that found closures and changes in learning related to Covid-19 have resulted in learning losses and problematic behaviors (Spiteri et. al, 2023). Due to these new challenges, the principal has seen and identified a need to educate the staff on how to incorporate sensory and emotional regulation strategies in the classroom more than before. Though the pandemic plays a large factor in the cause of these behaviors, there are other external factors at play. For example, these behaviors could stem from events in their home life; overall, stakeholders reported families with children in the NLCS district fall in a low socioeconomic status and a high rate of poverty. Research has shown that young children in a family with a lower socioeconomic status tend to struggle with foundational social, emotional, and executive functioning skills (Cuartas et. al, 2022). Another external factor that could affect student self-regulation skills is their relationship with their primary caregiver. DePasquale (2020) conducted a systematic review of the literature and found that a caregiver-child relationship with TEACHING TO IMPROVE STUDENT PERFORMANCE 5 strong bonds and interactions typically helps a child build better self-regulation skills. Therefore, it can be assumed that if there were not a strong caregiver-child relationship, self-regulation skills would be decreased. Such factors and more can affect students ability to self-regulate, and when teachers are not trained to help build those skills, their performance in school becomes affected. From the needs assessment, stakeholders also identified the needs and capabilities of teachers to address dysregulation in their classroom. At the time of the interview, the majority of NLCS staff had undergone Trust-Based Relational Intervention (TBRI) training. TBRI is, a therapeutic model that trains caregivers [like teachers] to provide effective support and treatment for at-risk children (Purvis et. al, 2013). Other than TBRI, most have not had any sort of training relating to teaching and incorporating sensory or emotional regulation strategies into their classrooms. After gathering and analyzing the information from the needs assessment interview, the basis of the project came about. Originally, the focus was going to be on working directly with students on improving their sensory regulation skills and measuring how those improvements translated into academic and social performance. However, after the needs assessment, it became more important to educate the teachers to implement these interventions for carryover beyond the Capstone project. Thus, the projects purpose became to teach teachers how to implement sensory-based interventions into their classrooms with the intent to improve students academic and social performance in school. Numerous studies have been published investigating the subjects of students, teachers, and sensory regulation. Of those studies, several have shown how Ayres Sensory Integration (ASI) techniques improve student academic and social performance. One study applied ASI TEACHING TO IMPROVE STUDENT PERFORMANCE 6 techniques towards children with sensory processing motor disorder; application of such techniques led to a documented improvement of motor skills and self-regulation (Andelin et. al, 2021). A different study applied ASI techniques for an individual with autism spectrum disorder, providing deep vestibular and proprioceptive input for regulation. At the end of the data collection period, the individual was found to have met and exceeded all self regulation and modulation goals (Parham et. al, 2019). With the success of these interventions, a student conjunctively builds other skills along with it, like fine motor. Such strong qualitative data demonstrates examples of effective techniques for providing sensory-based interventions and could be used as a guide to help teach teachers. In support of the other half of this capstone project are studies that sought to teach and gain understanding of staff. One compiled sensory-based interventions and trained paraeducators on how to implement such interventions in the classroom. Through the use of these interventions, paraeducators reported a decrease in student maladaptive behaviors as well as an increase in educator positive perception of sensory interventions (Kaiser et. al, 2020). Similarly, a separate study interviewed teachers about their perceptions of sensory interventions; overall, their opinion was sensory interventions are beneficial to increasing student attention and concentration levels, but they have low confidence in implementing such interventions (Mills & Chapparo, 2018). This is an important result to address in this study as confidence in administering interventions will be key to increase the likelihood of project carryover. Perhaps the most similar to this project was a pilot study that taught teachers how to implement sensory-based interventions in their classroom. Afterwards, they measured their confidence levels with doing so, and found that, with education, teachers were confident and more likely to implement these interventions than if there were no education (Ruttledge & TEACHING TO IMPROVE STUDENT PERFORMANCE 7 Cathcart, 2019). While this study and the capstone project are similar, there is one major difference. There is a focus on teaching teachers on how to implement these interventions, but it is also to educate and show them first hand the effects of these interventions. Overall, the focus is equally on improving students occupational performance and educating teachers and staff. Theory/FOR As mentioned in the introduction, guiding this project was the PEOP model. The main point of PEOP is to maximize the interaction between an individuals personality, environment, and occupation to improve ones occupational performance. Interactions and results between the aspects not only vary from person to person but also from task to task (Cole & Tufano, 2020). Using this model, the researcher was able to choose an assessment tool that helped evaluate characteristics of each aspect and how it affected participants academic performance and behavior. Additionally, it was kept in mind during the creation of each intervention; though each intervention was sensory-based, each also had to have the intent of improving at least one of the three main concepts. Also mentioned in the introduction was the sensory integration FOR, which helped primarily guide the interventions. According to Cole & Tufano (2020), the focus of sensory integration is to examine how sensation affects an individual and their ability to navigate and perform in their environment. In the case of this project, the researcher sought to examine how students ability to self-regulate within their school environment affected their academic performance and disruptive behaviors. Further, this FOR helped guide each intervention that was created as each targeted at least one of the seven senses. With the implementation of these interventions, the driving purpose was to increase students ability to self-regulate and perform in following learning activities. TEACHING TO IMPROVE STUDENT PERFORMANCE 8 Project Through the brainstorming process of this project, it came to the knowledge of the researcher that rural areas typically do not have easy access to resources and trainings that more urban areas have. Training and educating professionals in broad areas such as mental health is essential in rural communities; it not only increases knowledge but increases confidence with administering interventions and caring for others and themselves (Robertson et. al, 2021). With this information, and the researchers passion for the pediatric population, the desired location of the project came about. Then, in conversations with the formed director of special education, the topic of sensory integration arose, and educating teachers over the subject was identified as a need. To gauge interest in the project and the knowledge teachers have about sensory integration, the researcher created and sent a Google survey to Shawswick teachers. Teachers were asked to give consent to participate in the survey and project, then answered questions about their years of experience, current grade levels taught, knowledge of sensory systems and interventions, and any trainings they have attended. There was a 70% response rate from the teachers, and of those, five were selected to be the first participants of the project: one fifth grade, one second grade, one first grade, and two kindergarten teachers. About two weeks into the implementation phase, another fifth and first grade teacher were added into the project as the researcher had more openings in their schedule. To evaluate classrooms both pre and post implementation, the researcher evaluated each classroom with the Direct Behavior Rating Single Item Scale (DBR-SIS) assessment tool. The DBR-SIS is an evaluative rating that is generated at the time and place that behavior occurs by those persons who are naturally occurring in the context of interest (Christ et. al, 2009). TEACHING TO IMPROVE STUDENT PERFORMANCE 9 Typically used to evaluate individual students in the classroom, the researcher used it to evaluate the classroom as a whole. In the initial evaluation, classes were observed for a minimum of one continuous hour and scored on the assessments three behavioral categories: academic engagement, respectful, and disruptive (Direct Behavior Rating Single Item Scale, 2014). Common maladaptive behaviors stemming from sensory dysregulation can fall within the disruptive category, and the higher the disruptive score, the lower the scores of respectful and academic engagement. Because the targeted behaviors fall within the three categories, the DBRSIS made an excellent assessment tool to administer pre- and post-implementation. One large success of implementing this project was the high percentage of teachers filling out the survey, as well as the ~66% of those participants answering yes to being interested in receiving consultative services. Based on prior conversations, it seemed unlikely that more than 50% would fill out the survey, so this overall is an excellent response rate. Despite this success, the implementation did not come without its challenges. One of these challenges would be the reverse of the positive, being that some teachers still did not fill out the survey or, if they did, responded no or unsure to receiving consultative services as a part of the project. A second challenge relates to the difficulty in finding an assessment tool to apply towards the whole classroom. Though the DBR-SIS was able to be changed and used for a whole classroom, one specifically created for that purpose would be beneficial in the future. Outcomes In roughly a six to seven week period, various sensory interventions were implemented in each of the seven classrooms. Interventions worked to primarily stimulate the vestibular and proprioceptive systems. Specifically, these interventions included chair push-ups, spinning, jumping, and squatting. Additional interventions were designed to target the other five senses, TEACHING TO IMPROVE STUDENT PERFORMANCE 10 and in each intervention multiple systems were stimulated. The purposes of these interventions varied for each classroom, but generally either alerted and awoke students bodies to be ready to participate in work, or to expend energy the students bodies had and calm them to be able to sit and engage in the next activity. Depending on the classroom and time of day of observations, the initial assessment yielded different results. In the two fifth grade classrooms and one first grade class, assessment and implementation were completed in the first two hours of the school day when teachers reported they had a hard time engaging their students; some were falling asleep in class, had slumped posture, and took increased time to process and follow directions. With these initial results, sensory activities that promoted alerting behaviors were implemented and taught to teachers. After the implementation phase, the researcher again observed and filled out the DBRSIS at the same time as the initial evaluation. On average, these three classrooms improved 10% in academic engagement and disruptive behavior. The other four teachers participating in the study reported the opposite needs of their classrooms, stating their classrooms have high energy levels and have difficulty focusing during activities mainly in the afternoon. Their report was reflected in their initial assessment, where no classroom had higher than a 50% of on-task behavior. With this initial data, the researcher implemented more calming sensory activities into the classroom. On average, scores for these classes increased in academic engagement by 14% and disruptive behavior decreased by 12%. Further, in each time frame after implementation of such strategies, the researcher observed more regulated behaviors as well as an increased time of task attention. Summary TEACHING TO IMPROVE STUDENT PERFORMANCE 11 Previous researchers have conducted and published research on incorporating sensory regulation interventions into the general education classroom; others have educated teacher aides on the importance and benefits of doing such interventions. However, there has been little published studies at this time that combines the two. For this site specifically, there has been little to no previous training on sensory regulation, leading to a lack of knowledge of key concepts and terms. Some teachers were unknowingly implementing interventions, while others did not know the purpose of these interventions. After learning this background information, the researcher analyzed survey results and set out to perform sensory-based interventions in seven different classrooms. Such interventions provided vestibular and proprioceptive input to students bodies as well as interventions that allowed the body to focus and calm the present senses. Together, these interventions worked to allow students to decrease behaviors like fidgeting and verbally interrupting and increase their ability to focus and participate in a learning activity longer. The researcher would lead these activities in classrooms while also having the teacher participate and/or watch. This would allow them to lead the intervention(s) on days when the researcher was unable to be in their classroom. Prior to implementing the interventions, each classroom was evaluated using the DBRSIS. After eight weeks of implementation, the classrooms were again evaluated with the same assessment tool, but this time they received sensory regulation interventions prior to beginning their work. On average, each classroom improved by 12.15% in academic engagement and 12.85% in disruptive behavior. Beyond the data, teachers have also shared that they see an improvement in their students ability to focus and follow directions after completing the activities. Therefore, this study has further affirmed the principle that sensory regulation interventions can increase a students occupational performance in school. TEACHING TO IMPROVE STUDENT PERFORMANCE 12 Conclusion With this project, the initial hypothesis was proven correct: implementing sensory interventions in general education classrooms improves student academic performance and decreases maladaptive behaviors. Each classroom was different, and the same intervention could have different effects on different classrooms. However, the interventions still provided sensory input that elementary-aged students bodies crave. Some need more calming activities after, where some classes can go to a lesson after one stimulating intervention. Additionally, it was not just the researcher who noticed these effects in the students but also the teachers of the participating classrooms. Teachers who participated in the project reviewed their personal classroom data, noting the improvements recorded by the researcher. In addition to reviewing the assessment tool data, each teacher was given a packet of interventions that the researcher completed in their classroom. Later, participating and non-participating teachers were presented all of the data and interventions in a professional development meeting. During this meeting, teachers and staff had opportunities to review individual interventions and resources created by the researcher and learn how sensory-based interventions can positively impact student occupational performance. Not only did having these meetings further the project purpose of teaching teachers, but they also helped support previous data that an open, communicative relationship between teachers and OTs is essential (Miller-Kuhaneck & Watling, 2018). Now all teachers at the project site have the information and training to perform sensorybased interventions in the classroom. For this site, this allows teachers to implement these interventions beyond the researchers time. This will lead to positive repercussions like less classroom disruptions, less calling for assistance from administrative staff, and less consults for TEACHING TO IMPROVE STUDENT PERFORMANCE 13 an occupational therapist (OT). In the school setting, OTs often have busy schedules that make it difficult to add new students to caseload and provide general education services. In the future, it would be beneficial to continue education on sensory regulation related topics for teachers, but the staff at Shawswick have a new and good base of knowledge moving forward. TEACHING TO IMPROVE STUDENT PERFORMANCE 14 References: Andelin, L., Reynolds, S., & Schoen, S. (2021). Effectiveness of Occupational Therapy Using a Sensory Integration Approach: A Multiple-Baseline Design Study. American Journal of Occupational Therapy, 75(6), 114. https://doi.org/10.5014/ajot.2021.044917 Christ, T. J., Riley-Tillman, T. C., & Chafouleas, S. M. (2009). Foundation for the development and use of Direct Behavior Rating (DBR) to assess and evaluate student behavior. Assessment for Effective Intervention, 34, 201-213. Cole, M. & Tufano, R. (2020). Applied theories in occupational therapy: A practical approach (2nd Ed.). SLACK Incorporated. Cuartas, J., Hanno, E., Lesaux, N. K., & Jones, S. M. (2022). Executive function, self-regulation skills, behaviors, and socioeconomic status in early childhood. PLOS ONE, 17(11), e0277013. https://doi.org/10.1371/journal.pone.0277013 DePasquale, C. E. (2020). A systematic review of caregiverchild physiological synchrony across systems: Associations with behavior and child functioning. Development and Psychopathology, 32(5), 17541777. https://doi.org/10.1017/S0954579420001236 Diamant, R. (2021). Relationships Between Sensory Processing Behaviors, Executive Function, and Temperament Characteristics for Effortful Control in School-Age Children...American Occupational Therapy Association (AOTA) INSPIRE 2021 (Virtual), April 6-30, 2021. American Journal of Occupational Therapy, 75(Sup2), 11. https://doi.org/10.5014/ajot.2021.75S2-RP213 TEACHING TO IMPROVE STUDENT PERFORMANCE 15 Direct Behavior Rating Single Item Scale (DBR-SIS) Evidence Based Intervention Network. (2014, March 4). https://education.missouri.edu/ebi/2014/03/03/direct-behavior-ratingsingle-item-scale-dbr-sis/ Kaiser, L., Potvin, M.-C., & Beach, C. (2020). Sensory-Based Interventions in the School Setting: Perspectives of Paraeducators. Open Journal of Occupational Therapy (OJOT), 8(3), 111. https://doi.org/10.15453/2168-6408.1615 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(1), 111. https://doi.org/10.5014/ajot.2018.029017 Mills, C., & Chapparo, C. (2018). Listening to teachers: Views on delivery of a classroom based sensory intervention for students with autism. Australian Occupational Therapy Journal, 65(1), 1524. https://doi.org/10.1111/1440-1630.12381 Parham, L. D., Clark, G. F., Watling, R., & Schaaf, R. (2019). Occupational Therapy Interventions for Children and Youth With Challenges in Sensory Integration and Sensory Processing: A Clinic-Based Practice Case Example. American Journal of Occupational Therapy, 73(1), 19. https://doi.org/10.5014/ajot.2019.731002 Purvis, K. B., Cross, D. R., Dansereau, D. F., & Parris, S. R. (2013). Trust-Based Relational Intervention (TBRI): A Systemic Approach to Complex Developmental Trauma. Child & Youth Services, 34(4), 360386. https://doi.org/10.1080/0145935X.2013.859906 TEACHING TO IMPROVE STUDENT PERFORMANCE 16 Robertson, M. N., DeShong, H. L., Steen, J. S., Buys, D. R., & Nadorff, M. R. (2021). Mental health first aid training for Extension agents in rural communities. Suicide & LifeThreatening Behavior, 51(2), 301307. https://doi.org/10.1111/sltb.12705 Ruttledge, A., & Cathcart, J. (2019). An evaluation of sensory processing training on the competence, confidence and practice of teachers working with children with autism. Irish Journal of Occupational Therapy, 47(1), 217. https://doi.org/10.1108/IJOT-01-20190001 Shawswick Elementary / Homepage. (n.d.). Retrieved January 16, 2023, from https://www.nlcs.k12.in.us/http%3A%2F%2Fwww.nlcs.k12.in.us%2Fsite%2Fdef ault.aspx%3FDomainID%3D15 Spiteri, J., Deguara, J., Muscat, T., Bonello, C., Farrugia, R., Milton, J., Gatt, S., & Said, L. (2023). The impact of COVID-19 on childrens learning: a rapid review. Educational and Developmental Psychologist, 40(1), 517. https://doi.org/10.1080/20590776.2021.2024759 TEACHING TO IMPROVE STUDENT PERFORMANCE 17 Appendix Wee k 1 2 DCE Stage (orientation, screening/evaluation, implementation, discontinuation, dissemination) Orientation Weekly Goal 1. Complete site specific orientation Screening and Evaluation 1. Complete pre-work for conducting needs assessment Screening and Evaluation 1. Complete needs assessment 2. Determine beginning classrooms based on Google survey results Objectives Tasks 1. Meet with site mentor to explain DC project and experience 2. Learn sitespecific expectations and additional projects to be completed in 14 weeks 1. Meet with site mentor 2. Place additional tasks onto weekly checklist 3. Edit/finalize MOU 1. Finalize questions for needs assessment 2. Determine stakeholders to be interviewed in needs assessment 1. Analyze answers to questions of needs assessment 2. Compare answers of current questions to previous questions 1. Analyze results of Google survey 2. Determine classrooms with highest need 1. Compile needs assessment questions on google document 2. Compile teacher/staff list and introduce yourself 3. Determine stakeholders for needs assessment based on list 1. Reply/tabulate answers from questions sent in email 1/13 2. Edit most recent needs assessment draft to reflect new answers 3. Send one final follow up email for completion 1. List teachers who have completed survey, keep track of percentage to achieve objective 2. Send reminder email for completion by 1/20 3. Email participants who completed survey to determine best Date compl ete TEACHING TO IMPROVE STUDENT PERFORMANCE 3 Screening & Evaluation 1. Finalize list of 5 beginning teachers in project based on survey results Implementation 1. Complete DBR-SIS assessment tool when observing in 50% of targeted classrooms 4 Implementation 1. Complete DBR-SIS assessment tool in all classrooms 2. Return to classrooms for second visit, implementing initial sensory interventions 5 Implementation 1. Implement sensory-based interventions 1. Analyze and take notes on final survey results, identifying highest need classrooms 2. Speak with teachers on most dysregulated times of day 1. Review DBRSIS manual for proper completion and analysis of assessment tool 2. Schedule observation times in at least 3 classrooms this week 1. Schedule remaining initial observation times 2. Analyze and score assessment results 1. Analyze assessment notes for dysregulated behaviors 2. Research sensory interventions commonly done in classrooms 1. Review assessment results for common 18 times/days to come into classroom 1. Check final survey submission numbers and close survey 2. Highlight highest need teachers and select five to begin with 3. Speak to teachers for more specific dysregulated times in classroom 1. Print 1 copy of DBRSIS manual and 10 copies of DBR-SIS assessment tool 2. Share google sheet with teachers to sign up for observation times 3. Complete filling out tool and analysis of classroom at end of each day 1. Email teachers follow ups/rescheduling initial observations due to cancellations/2 hour delays 2. Scan assessment results into Google drive 1. Write what behaviors align with published literature 2. Visit websites like OT Toolbox for sensory intervention ideas 3. Create handouts to give to teachers explaining common dysregulated behaviors and interventions to try 1. Make a list of most common behaviors and already used TEACHING TO IMPROVE STUDENT PERFORMANCE 6 Implementation into all five participating classrooms dysregulated behaviors exhibited 2. Create individualized interventions to implement in classrooms 1. Continue to implement sensory-based interventions into all five participating classrooms 1. Continue to create individualized interventions to implement in classrooms 2. Provide participants with worksheets over activities to complete for desired outcomes based on needs 2. Begin revising schedule to try and observe classrooms 2x/week 7 Implementation 1. Review progress towards project and experience goals 1. Speak with teachers over current schedule and times, confirm they are ok with 2x/week 2. Add at least one more classroom into study this week 1. Meet individually with site and faculty mentor to discuss project and experience thus far 2. Review MOU goals and mark when goals were met 19 interventions based on survey and assessment results 2. Continue creating handouts for specific interventions and information for implementation 3. Speak with teachers and learn their primary need related to this project 1. Continue creating handouts for specific interventions and implementation 2. Continue to check in with teachers that their primary needs are being met with current interventions 1. Review current times and schedule on Google drive and propose specific days to be added to schedule 2. Email one more teacher to become a participant based on survey data 1. Email to schedule meetings with faculty and site mentor 2. Send reminder email to site mentor for completing evaluation 3. Review project timeline and write dates for when goals were met TEACHING TO IMPROVE STUDENT PERFORMANCE 2. Continue implementing interventions in seven classrooms 1. Continue research into calming and alerting activities to implement in classrooms 1. Continue to educate and incorporate alerting vs. calming activities in classrooms 2. Continue to create new individualized interventions for each classroom 1. Continue to educate and incorporate alerting vs. calming activities in classrooms 2. Continue to create new individualized interventions for each classroom 1. Continue to create and document new individualized interventions for classrooms 2. Continue to collaborate with staff on intervention suggestions and carryover 8 Implementation 1. Continue implementing interventions in seven classrooms 9 Implementation 1. Continue implementing interventions in seven classrooms 10 Implementation 1. Continue last week of implementing interventions in all remaining classrooms Discontinuation 20 1. Create sheets for student feedback in older classrooms 2. Continue making documents for added activities for teacher help 3. Continue documenting what activities were completed each week 1. Research more into tactile sensory based interventions for regulation in learning 2. Collaborate with teachers to learn lessons and reflect lessons in interventions 1. Collaborate with teachers and students to learn what activities they do and do not enjoy 2. Work on increasing activities with little to no extra resources/materials involved 1. Create interventions that align with student interests and project principles based on feedback from prior week 2. Create intervention sheets for future general resource binder in dissemination plan TEACHING TO IMPROVE STUDENT PERFORMANCE 1. Begin preparation of assessments for post implementatio n data collection after site spring break 11 Discontinuation Dissemination 12 Discontinuation/PostImplementation Dissemination 1. Print and label copies of postimplementation assessment tool for each classroom 2. Speak with site mentor and participating staff over ending of implementation phase 21 1. Relocate DBR-SIS in drive and print 7 copies 2. Email site mentor for reminder of last week of implementation and possible tasks to complete over site spring break 3. Remind participants this is last week of formal project implementation 1. End all 1. Remind teachers 1. Compile list of formal of final formal interventions done with intervention week of each teacher sessions in implementation 2. Print interventions participating phase and plans for out and give to teachers classrooms personal next week dissemination 1. Begin 1. Compile compiling 2. Outline and interventions for intervention complete teachers and schedule data to present dissemination plan prep time to share to site for site, both with interventions with individual individual participants participants and all 2. Create Powerpoint staff outline for full site dissemination 1. Collect post- 1. Fill out post1. Continue with typical implementatio implementation classroom visit n data from all DBR-SIS form in schedule for participants all 7 classrooms consistency 2. Complete DBR-SIS in same manner as previously conducted in 1. Continue 1. Finalize all classrooms compiling data intervention and preparing packets for 1. Organize and print for site participants intervention packets for 2. Continue dissemination participants developing 2. Add pre and postPowerpoint implementation data presentation onto powerpoint TEACHING TO IMPROVE STUDENT PERFORMANCE 13 Dissemination 1. Complete final preparations for dissemination to site and stakeholders 1. Complete and rehearse Powerpoint presentation 2. Prepare individual results for individual participants 14 Dissemination 1. Prepare and complete final interventions and resources for site 1. Print and laminate copies of all completed resources and interventions to leave at site 2. Organize binder and bulletin board for materials to be left and used by staff Discontinuation 1. Finalize all classroom visits and needs from teachers 1. Provide at least one more intervention session in each classroom 2. Confirm with teachers their understanding and confidence implementing interventions 22 1. Finish adding data and interventions on powerpoint 2. Meet with all study participants before public dissemination to share individual results 3. Share contact information and offer consultative services to all staff after presentation 1. Create categories in binder to sort interventions by 2. Place handouts into paper protectors and/or manilla envelopes 3. Discuss with Kelsey for where materials will be left 1. Give thank you notes to each participant for study willingness and participation 2. Provide final advice/consultation for student and sensory regulation within participating classroom 3. Provide consultative/educational sessions for additional interested teachers Doctoral Capstone Experience and Project Weekly Planning Guide  ...

... Myofascial Release Technique Therapy for Lateral Epicondylitis: A Scoping Review Michael Wroblewski May 3, 2022 A capstone project submitted in partial fulfillment for the requirements of the Doctor of Occupational Therapy degree from the University of Indianapolis, School of Occupational Therapy. Under the direction of the faculty capstone advisor: Dr. Christine Kroll, OTD, MS, OTR, FAOTA 2 Abstract Study Design: Scoping Review Introduction: Myofascial Release Therapy is a common intervention for clinical use on Lateral Epicondylitis; however, there is no current evaluation for the effectiveness of this treatment. Purpose of the Study: This scoping review examines current evidence on the effectiveness of Myofascial Release Therapy for treatment on patients with Lateral Epicondylitis. Methods: The PRISMA protocol for scoping reviews was used to conduct the scoping review. 12 peer-reviewed published articles were included in this study based on publication date, written in English, included in an academic journal, and limited to the full text of the article when searched in databases. Results: All twelve studies reported statistically significant data with outcome measures of pain reduction. Nine studies found significance for improved functional ability, and nine studies found significance for improved grip strength. Conclusions: Myofascial Release Therapy can provide a short-term improvement in pain reduction, improved functional ability and improved strength. Future studies are required to determine the long-term effects of Myofascial Release Therapy on Lateral Epicondylitis. 3 Introduction Lateral epicondylitis (LE), or tennis elbow, is a common chronic elbow condition that affects 1-3% of the general population each year and is a common problem among adults. LE causes a heavy socioeconomic burden resulting in lost workdays. Depending on the severity of LE, patients may be unable to work for several weeks (Lai et al., 2018). Individuals affected by LE have significant pain and functional impairment from repetitive gripping or wrist extension, radial deviation, and forearm supination (Lai et al., 2018). These motions most commonly result in microtears at the origin of the extensor carpi radialis brevis (ECRB) tendon (Cohen & Filho, 2012). Symptoms of pain and functional impairment can last from 6 months to 2 years, resulting in limited ability to complete work-related and necessary daily tasks (Dingemanse et al., 2014). Due to the long recovery period, costs, time away from work, and performance of daily activities can be substantial (Dingemanse et al., 2014). The clinical cause of LE is still unknown, however specific repetitive movements for at least 2 hours a day, handling loads of 20 kilograms a day (44 pounds), little control of work activities, and low social support at work are all high-risk factors for LE (van Rijn, Huisstede, & Koes, 2009). LE is a common condition that can affect a wide range of individuals. Even though several different treatment methods that can provide relief to this condition; there is currently no established consensus on the most appropriate form of treatment for lateral epicondylitis. Available treatment options include conservative measures, injections of platelet-rich plasma (PRP), and surgical debridement (Bateman et al., 2019). Conservative measures available to treat ME and LE include mobilization techniques, taping techniques through the use of kinesio tape, and electrophysical modalities, including ultrasound, extracorporeal shockwave therapy (ESWT), and low-level laser therapy (LLLT) (Lai et al., 2018). Surgeons offer surgical 4 treatments to individuals with ME and LE due to the recalcitrant nature of the condition and length of time symptoms can be prevalent (Bateman et al., 2019). PRP injections consist of an injection of autologous blood with a concentration of platelets above baseline values. The concentration of platelets is associated with enhanced healing at the injection site (Raeissadat et al., 2014). Myofascial release (MFR) is a therapeutic treatment that utilizes gentle, sustained pressure and stretching to address soft tissue restrictions. This pressure facilitates the release of soft tissue restrictions caused by injury, stress, repetitive use, and traumatic or surgical scarring (LeBauer, Brtalik, & Stowe, 2008). MFR is useful in alleviating muscle stiffness, reducing pain, and improving range of motion (Barnes, 1997). Two main types of MFR are currently in use: direct and indirect release. Direct MFR utilizes sustained few-kilogram pressure for 90-120 seconds directly on restricted tissue. Indirect MFR stretches restricted tissue via low-load longduration techniques (Laimi et al., 2018). The present scoping review included studies that utilized either type of MFR. The review did not include studies involving different types of massage, mobilization, or myofascial trigger point therapy. Myofascial trigger point release, which is theoretically different from MFR, is not a focus of this scoping review. Since myofascial trigger point therapy relies on a different theory than MFR, it is not appropriate to be included in this study (Laimi et al., 2018). The Model of Human Occupation (MOHO) model is appropriate to guide this scoping review. The MOHO model offers a systemic, holistic approach for persons of varying needs and populations across the lifespan (Cole & Tufano, 2008, p. 95). Individuals treated in hand therapy settings have varying ages and conditions, which commonly include, but are not limited to, flexor and extensor tendon injuries, tennis/golfers elbow, post-op shoulder surgeries, distal 5 radius fracture, and shoulder pain impingement. Gary Kielhofner developed the MOHO model on the basis of interrelated parts that make up the person (Kielhofner, 1980). These parts include volition, or the motivation for occupation, habituation, or the patterns and routines that shape the clients occupations, and performance capacity, or the physical and mental capacity to complete occupations (Cole & Tufano, 2008). The interrelated parts of volition, habituation, and performance capacity represent an individuals open system cycle. A shift in this open system cycle changes the individuals overall dynamic (Cole & Tufano, 2008). The inclusion of therapeutic, surgical, or injection intervention helps to change the individuals overall dynamic and leads to more productive outcomes. The MOHO is an appropriate model specifically for this DCE project because individuals affected by medial or lateral epicondylitis have experienced a shift in their overall dynamic. Side effects from medial or lateral epicondylitis can negatively impact an individuals performance capacity and make it more difficult to complete occupations. This scoping review will report on the efficacious use of MFR with LE and present an alternative treatment to other common interventions. The inclusion of intervention represents a shift in the open system cycle and will result in a new, more positive change in the individuals overall dynamic. When completing my DCE, it is important to understand that the factors that make up every individuals overall dynamic are different. The frame of reference (FOR) that will guide this DCE is the biomechanical FOR. Occupational therapists commonly use the biomechanical FOR approach with deficits in range of motion (ROM), strength, and endurance regarding musculoskeletal injury within the capacity of motion (Cole & Tufano, 2008). The biomechanical FOR applies the principles of physics to human movement and posture with respect to the forces of gravity (Cole & Tufano, 2008, p. 165). Function in the biomechanical FOR involves improving or maintaining strength, 6 endurance, and ROM within normal limits based on the individuals unique age, gender, and physical characteristics. Function also includes preventing injury or stress given an individuals current occupations (Cole & Tufano, 2008). The biomechanical approach is appropriate FOR specifically for this DCE because it helps restore client factors and addresses body function deficits (Cole & Tufano, 2008). Individuals affected by medial or lateral epicondylitis may have side effects that limit their body functions and occupational independence. These side effects can impair the individuals range of motion of the elbow, wrist and fingers and negatively impact muscle strength of the elbow, forearm, hand, and wrist. Therefore, it is appropriate to use the biomechanical FOR to help restore these individuals body functions and to allow them to regain occupational independence. This scoping review will focus on reporting current evidence of MFR usage on lateral epicondylitis patients; however, it is important to note that each research study explores different patient outcomes. Therefore, it will be important to present all applicable data and report the impact of MFR usage on patient outcomes. Despite the widespread clinical use of MFR in occupational therapy, there is no current evaluation of the effectiveness of this treatment on lateral epicondylitis. There are no systematic reviews in this area of focus, despite the potential benefits MFR can provide to alleviate symptoms of lateral epicondylitis. Despite the clinical usage of MFR to treat LE, there is relatively limited evidence in the form of randomized control trials (RCTs) to support using MFR in the treatment of LE. Therefore, the purpose of this scoping review is to examine the current available literature to determine the effectiveness of myofascial release treatment on lateral epicondylitis. The specific scoping reviews research question was to discover what evidence and best practices exist for the treatment of LE and MFR. 7 Methods A scoping review method was used based on the PRISMA-ScR outlined by Tricco et al. (2018). The PRISMA-ScR checklist includes 20 essential reporting items and two optional items to include when completing a scoping review (Tricco et al., 2018). Scoping reviews are useful to survey available literature and present an overview of the available research on a topic that has either not been extensively reviewed or is of a complex nature. This method is appropriate in situations where fields of research have only emerging levels of evidence (Brien et al., 2010). Completion of a scoping review allows researchers to become informed about the topic and develop research questions to address the current gaps in research (Pham et al., 2014). Due to the lack of randomized controlled trials for the effectiveness of myofascial release technique on individuals with lateral epicondylitis, a scoping review was considered to be the most appropriate approach. Protocol This protocol was drafted using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) revised by the research team and disseminated through the University of Indianapolis Doctoral Capstone program. Eligibility Criteria To be included in the review, papers needed to focus on lateral epicondylitis using the myofascial release technique as the method of treatment. Peer-reviewed journal articles were included if they were: published between the period of 2011-2022, written in English, an academic journal, and limited to the full text of the article when searched in databases. 8 Information Sources The following databases were searched in January 2022: Academic Search Complete, MEDLINE, CINAHL, BiblioMed, and Cochrane Library. There was also a search for grey literature in Google Scholar and Open Grey. The final search strategy for CINAHL can be found in Table 1. 9 Table 1: Search Documentation 10 Type of Database Search CINHAL CINHAL CINHAL Faceted Search Keywords myofascial release, lateral epicondylitis Database Boolean Search Operator AND Faceted Search myofascial release, tennis elbow AND Faceted Search MFR, lateral epicondylitis AND Number of articles generated without Filters filters used Published from 20112022, limited to academic journals, limited to full text of article, limited to english 12 language Published from 20112022, limited to academic journals, limited to full text of article, limited to english 8 language Published from 20112022, limited to academic journals, limited to full text of article, 3 limited to Number of articles remaining after filters Number of duplicate removed 6 4 3 11 english language CINHAL CINHAL Faceted Search Faceted Search MFR, tennis elbow myofascial release, lateral epicondylalgia AND published from 20112022, limited to academic journals, limited to full text of article, limited to english 2 language AND Published from 20112022, limited to academic journals, limited to full text of article, limited to english 0 language 2 12 Qualitative, quantitative, and mixed-method studies were included to consider different measures of treatment outcomes. Papers were excluded if they did not fit into the conceptual framework for the study or focused on myofascial trigger point therapy, as this relies on a different theory than myofascial release therapy. Selection of Sources of Evidence To ensure relevance of each article, the researcher reviewed the titles, the abstracts, and finally the full texts of the article identified by my search for relevant literature. The researcher alone determined relevant publications for use in the study. Data Charting Process The researcher developed a data charting form to determine which variables to extract. The researcher independently charted the data, reviewed the results, and updated the data charting form during the literature search. Data Items The researcher abstracted data using the following information categories: author, publication date, location of the research, sample population characteristics, population size, title, research approach, outcome measures, purpose of the study, and level of evidence. Critical Appraisal To perform a critical appraisal of the level of evidence included in this scoping review, the Johns Hopkins Evidence-Based Practice for Nurses and Healthcare Professionals Model (JHNEBP) was used for appraisal. The JHNEBP was created to assess and validate the level and quality of research and non-research evidence. The tool incorporates five levels of evidence to appraise research. Each level is listed below. Level 1: (e.g. Randomized Control Trials (RCTs), Systematic Review of RCTs) 13 Level 2: (e.g. Quasi Experimental Studies, Systematic Review of RCTs AND Quasi Experimental Studies) Level 3: (e.g. Non-experimental Studies, Qualitative Studies, Meta-Synthesis) Level 4: (e.g. Clinical Practice Guidelines, Consensus Statements, Position Statements, Regulatory Standards) Level 5: (e.g. Literature Review, Case Studies, Quality Improvement Programs, Expert Opinion) Synthesis of Results The researcher grouped the studies by the outcome measures abstracted from the articles. The researcher then summarized the study design and broad findings to plan for synthesizing evidence. Once full synthesis of the evidence was complete, the researcher created a table to define the outcome measures, and results of each study included in the scoping review. The table is listed below in Table 2. 14 Selection of Sources of Evidence Results Identification Figure 1: PRISMA Flow Diagram Records identified from*: Databases (n = 76) Records removed before screening: Duplicate records removed (n = 23) Included Screening Records after duplicates removed (n = 53) Records screened (n = 53) Records excluded** (n = 26) Full-text articles to be assessed for eligibility (n = 27) Reports excluded: Not myofascial release therapy related outcomes (n = 6) Involved myofascial trigger point therapy (n = 7) Unable to retrieve an article (n = 2) Studies included in review (n = 12) Characteristics of Sources Evidence The studies concerning myofascial release therapy on lateral epicondylitis are described in Table 1, which includes the author, studies location of origin, publication date, title, and level of evidence as according to the JHNEBP. The studies population, intervention, outcome measures, and results are described in Table 2. 15 Critical Appraisal within Sources of Evidence Table 2: JHNEBP Levels of Evidence Author Aijmsha Publication Date Country of Origin 2012 Kerala, India Balasubramaniam 2016 Coimbatore, India Chandran 2021 Kerala, India 2018 Vaghodia, India Gandhi Title Effectiveness of Myofascial Release in the Management of Lateral Epicondylitis in Computer Professionals Effectiveness of Myofascial Release Therapy and Active Stretching on Pain and Grip Strength in Lateral Epicondylitis A Study to Compare the Effect of Active Release Technique and Myofascial Release Technique on Pain, Grip Strength & Functional Performance in Subjects with Lateral Epicondylitis Effectiveness of Myofascial Release Versus Theraband Flex Bar Exercise in Tennis Elbow: Sports Players Level of Evidence Level I Level II Level II Level II 16 Hossain 2019 Khuman 2013 Kumar 2016 Mishra 2018 Prasad 2019 Shinde 2019 Effectiveness of Myofascial Release to Biceps Brachii, Latissimus Dorsi & Pectoralis Major in Structural Diagnosis and Management Dhaka, Protocol for Patients Bangladesh with Tennis Elbow Myofascial Release Technique in Chronic Lateral Epicondylitis: Gujarat, A Randomized India Controlled Study Comparison Between Myofascial Release Technique and Cyriax Manual Therapy on Pain and Disability in Jalandhar, Subjects with Lateral India Epicondylitis Effectiveness of MFR & Cyriax on Pain, Grip Strength, and Functional Status in patients with Lateral Epicondylitis- A Randomized Surat, India Controlled Trial Immediate Effect of Mulligan Mobilization vs. Myofascial Release on Pain, Grip Strength and Function in Maharashtra, Patients with Lateral India Epicondylitis Movement versus Myofascial Release Therapy on Pain and Grip Strength in Maharashtra, Patients with Lateral India Epicondylitis Level I Level I Level II Level I Level II Level I 17 Trivedi Trivedi 2020 Gujarat, India 2014 Gujarat, India Results of Individual Sources of Evidence Table 3: Critical Review of Studies Population Therapeutic Author n= Techniques Myofascial Release Technique with Virtual Reality Biofeedback in Lateral Epicondylitis- A Case Report Comparison of Active Release Technique and Myofascial Release Technique on Pain, Grip Strength, & Functional Performance in Patients with Chronic Lateral Epicondylitis Outcome Measures MFR vs. sham ultrasound PRTEE Balasubramaniam n = 42 MFR and active stretching vs. active stretching only VAS, HD Chandran MFR and ultrasound vs. ATR and ultrasound PRTEE, HD, VAS Aijmsha n = 68 n = 30 Level IV Level I Results No significant differences between the two groups at baseline (P=.472), but MFR group had a greater impact on pain reduction and improved functional ability in weeks 4 and 12 (P<.001) Adding MFR to active stretching produces significant reduction of pain and grip strength when compared to the control group Both MFR and ATR are effective in treatment of LE. MFR is slightly more effective at improving grip strength, pain reduction and disability than ATR after 8 weeks. 18 Gandhi Hossain Khuman Kumar Mishra n = 30 MFR vs. Flex Bar Exercise n = 20 MFR vs. conventional physiotherapy PRTEE, ROM, NPRS PRTEE, HD, NPRS n = 30 MFR & conventional physiotherapy vs. conventional physiotherapy n = 30 MFR & ultrasound vs. Cyraix manual therapy & ultrasound PRTEE, VAS n = 60 Conventional physiotherapy vs. MFR vs. Cyriax PRTEE, HD, NPRS HD, NPRS, TEFS Combined MFR and Flex bar exercise shows improved strength and reduced pain after 4 weeks Significant decrease in pain and improvement of functional performance (p<0.05) in MFR group compared to control group after 4 weeks. No significant difference in ROM between groups. Significant decrease in pain, improvement in grip strength and functional performance (p<0.05) in both groups after 4 weeks. However, MFR group was found more effective in all outcome measures. Both groups showed significant improvement (p<0.05) in PRTEE and VAS scores after 12 treatment sessions. However, difference in pain and disability scores between groups was not found to be significant (p>0.05) No statistic difference between groups preintervention. MFR technique found to be more effective after 4 weeks in pain reduction, improved grip strength, and functional ability (p<0.05) when 19 compared to Cyriax technique. Prasad Shinde Trivedi Trivedi n = 64 Mulligan's Mobilization (MWM) vs. Myofascial Release PRTEE, HD, NPRS n = 20 MVM vs. Myofascial Release VAS, HD n=1 MFR, VR biofeedback, ultrasound PRTEE, HD, NPRS Both MWM and MFR groups found to significantly reduce pain and improve function after 2 weeks. Researchers found no statistic difference between groups with pain reduction. MFR group found to have greater effect in grip strength and functional improvement than the MWM group. Both MVM and MFR were found to improve grip strength and pain reduction after 1 week and 2 weeks. No significant difference observed between groups after 1 week and 2 weeks. The patient had an improvement in pain reduction and PRTEE score, and increase in grip strength after 4 weeks. PRTEE, HD, NPRS Both MFR and ATR was effective in all outcome measures compared to the control group. MFR was more effective in increasing grip strength, reducing pain and n = 36 Conventional physiotherapy vs. MFR vs. ATR 20 disability (p<0.05) when compared to ATR. Key Definitions PRTEE= Patient Related Tennis Elbow Evaluation VAS= Visual Analogue Scale HD= Hand Dynamometer NPRS= Numeric Pain Rating Scale TEFS= Tennis Elbow Functional Scale ROM= Range of Motion Synthesis of Results Study Characteristics Of the twelve studies included in this scoping review, six articles were randomized controlled trials (RCTs), three were quasi-experimental studies, one was a comparative study, one was a case report, and one was a pretest-posttest comparative study. All studies included the use of MFR in populations with diagnosis of LE. Only three studies specified specific populations of individuals. Two studies performed MFR on populations of computer professionals, while one study performed MFR on a population of sports players. Length of Study Eight studies included in the scoping review examined the effects of MFR on LE after four weeks of intervention. Two studies examined MFR effect after two weeks of intervention, and two studies involved eight weeks of intervention. Only two studies conducted follow-up investigations. One study collected data twelve weeks after the conclusion of the study, while the 21 other study collected date four weeks post-completion, twelve weeks post-completion, and twenty-six weeks post-completion. Type of MFR Eleven studies referenced the utilization of direct MFR in their methodology. Of these, nine studies reported the specific type of direct MFR technique used on their participants. Two studies referenced the use of direct MFR only and did not include the specific type of direct MFR technique. One study simply stated usage of MFR on their participants and did not specify whether direct or indirect MFR was used in the study (Khuman et al., 2013). Outcome Measures Outcome measures focused on changes in levels of reported pain. Seven studies utilized the Numeric Pain Rating Scale (NPRS) to measure changes in reported pain. The NPRS is a reliable and valid tool commonly used to assess pain. The NPRS is an 11-point scale with scores of 0 to 10. A score of 0 equals no pain, while a score of 10 equals the highest possible pain (Michner, Snyder, & Leggin, 2011). All seven studies found significant improvements in pain scores. Hossain et al. and Khuman et al. both found a statistic significant difference in pain when compared to their control group (p. <0.05) after a four-week period. However, three studies did not show that MFR was the superior treatment method tested. Gandhi, Vithalbhai, and Dineshbhai found that while MFR was effective in pain reduction over a four-week period, theraband flexbar exercises achieved greater pain reduction (Gandhi, Vithalbhai, & Dineshbhai, 2018). Prasad et al. 2019 found no significant statistic difference in pain reduction between MFR and MVM groups (p = 0.7299), though researchers found that both groups had significant decrease in pain reduction. Chandran et al. found that both MFR and ATR were effective in pain reduction, no statistical significant difference was found between the two groups. 22 Four studies utilized the Visual Analog Scale (VAS) as an outcome measure for pain. The VAS is widely used as a psychometric pain scale used to measure subjective characteristics, using an 11-point scale rated from 0 to 10, with 0 being the lowest measure and 10 being the highest measure (Klimek et al., 2017). The studies measured MFR against groups who performed active stretching, Cyriax manual therapy, Active Release Technique, and Mulligans Mobilization. Three studies found statistically significant difference between groups. Kumar and Jetlys study did not find significant difference between groups, which utilized Cyriax manual therapy as their alternate group to MFR (Kumar & Jetly, 2016). One study utilized the Patient-Related Tennis Elbow Evaluation (PRTEE) to measure pain. The PRTEE consists of fifteen questions separated into two subscales of pain and function. Each subscale uses a scale of 0 to 10 to assess pain and function, with 0 indicating no pain or no difficulty completing a task, and 10 indicating worst pain imaginable, or inability to complete a task (MacDermid, 2012). Ajishma, Chithra, and Thulasyammal used the PRTEE to assess pain severity in their study, collecting PRTEE scale scores after one week, four weeks, and twelve weeks. The researchers found that MFR was more effective in reducing pain than sham ultrasound after four weeks and twelve weeks (p < 0.05) (Ajishma, Chithra, & Thulasyammal, 2012). Assessment of functional ability was measured by the PRTEE in nine studies. In addition to measuring pain, the PRTEE measures functional disability. Each of the nine studies utilized the PRTEE for assessment of improvement of functional ability. All nine studies found statistical significance for improved functional ability. Of these studies, only Kumar and Jetly found no significant difference between the two groups studied when measuring functional disability. 23 However, researchers did find that MFR was beneficial over a four-week period in improving functional disability (Kumar & Jetly, 2016). One study used the Tennis Elbow Function Scale (TEFS) to examine changes in strength. Researchers used the TEFS to measure pain-related elbow function using ten items, scored on a five-point scale. On the scale, 0 indicates no discomfort and 4 indicates the highest possible discomfort (Lowe, 1999). The researchers found statistically significant results to support the argument that MFR is more effective in reducing pain than Cyriax technique (p < 0.05) (Mishra, Mishra, & Bidja, 2020). Grip strength was assessed using a hand dynamometer (HD). Nine studies utilized a hand dynamometer to measure grip strength. No studies used any other method to assess grip strength. The HD is proven to be a reliable and valid instrument for measurement of grip strength. Due to the reliability and validity of the HD, it is commonly used as a reference standard for validation studies (Trampish et al., 2012). Of these studies, six studies found statistical significant difference between MFR and the alternative testing group. Only three studies found no significant difference between groups. Chandran et al. found that both MFR and ATR were effective in improving grip strength. Gandhi, Vithalbhai, and Dineshbhai found that while MFR was effective in improving grip strength, theraband flexbar exercises led to greater improvement in grip strength over a four-week period. Only one study assessed range of motion (ROM) using a universal goniometer. The universal goniometer is a reliable and valid tool for measurement of joint range of motion (Jones et al. 2014). Researchers did not note any significant change in ROM in either group at any point in their study (Hossain et al., 2019). 24 Impact on Pain Reduction Twelve studies examined the impact of MFR on pain reduction. All studies found significance for decreased pain reduction. Researchers found significance regardless of the length of study. Shinde and Purswani obtained statistically significant data in pain reduction after one week of treatment (p<0.0001). Aijmsha, Chithra, & Thulasyammal found statistical differences only after four weeks of treatment (p<0.01). Only two studies reported follow-up data. Ajishma, Chithra, and Thulasyammal collected data after four weeks and completed follow-up data collection after twelve weeks. The researchers reported 6.8% decrease in pain reduction scores after four weeks and 63.1% decrease after twelve weeks. Balsasubramaniam and Kandhasamy found significant improvement in pain reduction with MFR combined with active stretching after four weeks of treatment. Researchers found continued pain reduction after follow-up data collection at twelve and twenty-six weeks. Impact on Functional Ability Nine studies examined the impact of MFR on functional ability. All nine studies found significance for improved functional ability at the conclusion of the study. Hossain et al. found improvement in functional performance after four weeks (p<0.05) when compared to the control group. Chandran et al. found statistical difference to conclude that MFR was effective in improving functional ability after eight weeks. However, when compared to ATR after eight weeks researchers found no statistical significant difference between groups. Only one study that explored functional ability as an outcome measure collected follow-up data. Aijmsha, Chithra, & Thulasyammal found statistical difference (p<0.01) after four weeks. Researchers also found statistical difference (p<0.01) after follow-up data collection at twelve weeks. 25 Impact on Grip Strength Nine studies examined the impact of MFR on grip strength. All studies reviewed found significant improvement in grip strength following conclusion of the study. Certain studies found that a different treatment method resulted in statistical difference when compared to MFR, which included ATR and Cyriax technique. Two studies compared MFR to MWM with regards to grip strength. Prasad et al. found that while both MFR and MWM led to significant improvement in grip strength over a two-week period, MFR resulted in greater grip strength. However, Shinde and Pruswani found that there was no significant difference with regards to grip strength between groups after both one- and two-week periods. Only one study collected follow-up data for grip strength. Balsasubramaniam and Kandhasamy found significant improvement in grip strength after four weeks. Researchers found significant improvement in grip strength at follow-up data collected at twelve and twenty-six weeks when compared to the control group. Discussion The scoping review identified 12 research studies addressing MFR as a treatment method for adult individuals with LE published between 2011 and 2022, with seven of the studies being published in the last five years. These studies suggest that MFR is a useful clinical intervention for the treatment of LE. This scoping review assessed the evidence on the use of MFR for LE from 12 articles that included 431 participants in total, comparing outcomes on pain, grip strength, functional ability, and range of motion. The vast majority of studies (n=11) were conducted in India, with one study conducted in Bangladesh. Eleven studies reported the use of direct MFR techniques used in their methods. Nine studies reported the method of administration, including positioning of the individual, duration of administration, and process of release in the methodology to enable the reader to replicate the process. Researchers in one study 26 simply stated that they utilized direct MFR (Khuman et al., 2013). Researchers in one study did not reference which type of MFR they utilized (Chandran et al., 2021). The findings of this study suggest that there is evidence of a beneficial effect of the use of MFR in the treatment of LE in adults. A theme of this scoping review is that MFR may be able to provide improved patient outcomes in the immediate short-term. All twelve studies reported positive patient outcomes regardless of the duration of the study. The primary duration of studies was conducted over a period of four weeks, with length of study ranging from two weeks to eight weeks over all studies. All studies had relatively small sample sizes, ranging from one to 68. In spite of the short duration of study and small sample sizes included, this scoping review may provide a basis for future research into the benefits of MFR in the treatment of LE. Another theme that was found as a part of this scoping review was that MFR is a low-risk modality with few side effects. None of the twelve studies reported adverse events as a result of using MFR as a therapeutic modality. Khumen et al. found that MFR had a significant improvement in pain, functional performance, and hand grip strength when compared to conventional physiotherapy. Nine of the twelve studies reported detailed methodology on the techniques and positioning used in the process of MFR. The inclusion of this information allows for replication in future studies and in clinical usage with lower risk of side effect or harm to the individual. Three studies included in this scoping review addressed specific populations. Two studies utilized populations of computer professionals, while one study utilized a population of sports players. Each of these studies yielded statistically significant results, suggesting that MFR may be beneficial when used in specific populations. In spite of the significant results, the limited number of studies provides a need for further research. 27 While 12 studies provide only limited evidence supporting MFR, six were RCTs. Only a limited number of RCTs were available for inclusion in this scoping review, however, limited RCTs provide a high level of evidence that MFR is an effective treatment of LE. Researchers primarily targeted the common extensor tendon, periosteum of the ulna, and dorsal wrist between the head of the ulna and dorsal tubercle of the radius when performing MFR in their studies (Shinde & Purswani, 2019; Trivedi et al. 2014). However, Hossain et al. completed MFR to the biceps brachii, latissimus dorsi, and pectoralis major in Structural Diagnosis and Management (SDM) protocol for patients with LE. As referenced in table 3, researchers found a significant decrease in pain and improvement in functional performance after 4 weeks. These findings were consistent with Trivedi et al. 2014, who found a significant decrease in pain and disability after 4 weeks when using MFR targeting the common extensor tendon and periosteum of the ulna. Gandhi, Vithalbhai, and Dineshbhai utilized MFR with the elbow in 90 degree flexion position, as opposed to all other studies in this review, which utilized MFR with the elbow in 15 degree flexion. These researchers did target the common extensor tendon and periosteum of the ulna. Researchers found that MFR from this position resulted in improved grip strength after 4 weeks. Due to the findings of Hossain and Gandhis studies, further research is needed to evaluate these alternate methods of MFR. Limitations The main limitation of this scoping review was the short intervention timeframes for the studies. Only two studies included in this review collected follow-up data. It is important for future research of MFR to include follow-up data to examine long-term benefits and outcomes from the use of MFR. Another limitation is the country of origin of the studies. Eleven of the twelve studies were performed in India. No studies were found where MFR was performed in the 28 United States. This suggests a gap where relevant research is limited to one country, affecting the variety of populations studied where MFR is used in treatment of LE. In addition, a limitation of this scoping review was the lack of indirect MFR used for intervention. Eleven of the twelve studies included in this review reported use of direct MFR on participants, with one study not specifying usage of direct or indirect MFR. It is important for future research to include interventions of indirect MFR to examine the effects on LE, and to determine whether direct or indirect MFR is more effective in treatment of LE. Conclusions The data collected and overall findings of this scoping review suggests that MFR has a positive effect on the treatment of LE and can improve patient outcomes. In addition, MFR may be a more convenient and low-risk modality for usage in specialized fields, such as physical therapy, occupational therapy, and massage therapy. However, despite the widespread clinical use of MFR, further research is required to to identify the long-term benefits of MFR with relation to the outcomes discovered in this review. 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(2014). Concurrent validity and reliability of the simple goniometer iphone app compared with the Universal Goniometer. Physiotherapy Theory and Practice, 30(7), 512516. https://doi.org/10.3109/09593985.2014.900835 Kielhofner, G. (1980). A Model of Human Occupation, Part 3, Benign and Vicious Cycles. American Journal of Occupational Therapy, 34(11), 731737. doi: 10.5014/ajot.34.11.731 Khuman, P., Trivedi, P., Devi, S., Sathyavani, D., Nambi, G., & Shah, K. (2013). Myofascial Release Technique in Chronic Lateral Epicondylitis: A Randomized Controlled Study. International Journal of Health Sciences and Research, 3(7), 4552. Klimek, L., Bergmann, K.-C., Biedermann, T., Bousquet, J., Hellings, P., Jung, K., Merk, H., Olze, H., Schlenter, W., Stock, P., Ring, J., Wagenmann, M., Wehrmann, W., Msges, R., & Pfaar, O. (2017). Erratum to: Visual analogue scales (VAS): Measuring instruments for the documentation of symptoms and therapy monitoring in cases of allergic rhinitis in everyday health care. Allergo Journal International, 26(1), 2526. https://doi.org/10.1007/s40629-017-0010-6 Kumar, R., & Jetly, S. (2016). Comparison between myofascial release technique and Cyriax manual therapy on pain and disability in subjects with lateral epicondylitis. Indian Journal of Physiotherapy and Occupational Therapy - An International Journal, 10(3), 1217. https://doi.org/10.5958/0973-5674.2016.00075.7 32 Lai, W. C., Erickson, B. J., Mlynarek, R. A., & Wang, D. (2018). Chronic lateral epicondylitis: Challenges and solutions. Open Access Journal of Sports Medicine, Volume 9, 243251. https://doi.org/10.2147/oajsm.s160974 Laimi, K., Mkil, A., Brlund, E., Katajapuu, N., Oksanen, A., Seikkula, V., Karppinen, J., & Saltychev, M. (2018). 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Journal of Sport Rehabilitation, 20(1), 115128. https://doi.org/10.1123/jsr.20.1.115 33 Mishra, N., & Bidija, M. (2018). Effectiveness Of MFR & Cyriax on Pain , Grip Strength and Functional Status in patients with Lateral Epicondylitis A randomized controlled trial. International Journal of Research and Analytical Reviews, 5(3), 624630. Pham, M. T., Raji, A., Greig, J. D., Sargeant, J. M., Papadopoulos, A., & McEwen, S. A. (2014). A scoping review of scoping reviews: Advancing the approach and enhancing the consistency. Research Synthesis Methods, 5(4), 371385. https://doi.org/10.1002/jrsm.1123 Prasad, K., Athavale, N., Sancheti, P., & Shyam, A. (20191). Immediate Effect of Mulligan Mobilization vs. Myofascial Release on Pain, Grip Strength and Function in Patients with Lateral Epicondylitis. Journal of Physiotherapy Research, 3(2), 14. Raeissadat, S. A., Rayegani, S. M., Hassanabadi, H., Rahimi, R., Sedighipour, L., & Rostami, K. (2014). Is platelet-rich plasma superior to whole blood in the management of Chronic Tennis Elbow: One year randomized clinical trial. BMC Sports Science, Medicine and Rehabilitation, 6(1). https://doi.org/10.1186/2052-1847-6-12 Saha, S., Prakash, P., & Sinha, A. (2021). Grip Strength Evaluation in Hand Surgery. Indian Society for Surgery of the Hand, 117. Shinde, S. (2019). Movement versus Myofascial Release Therapy on Pain and Grip Strength in Patients with Lateral Epicondylitis. International Journal of Science and Healthcare Research, 4(1), 372377. 34 Trampisch, U. S., Franke, J., Jedamzik, N., Hinrichs, T., & Platen, P. (2012). Optimal jamar dynamometer handle position to assess maximal isometric hand grip strength in epidemiological studies. The Journal of Hand Surgery, 37(11), 23682373. https://doi.org/10.1016/j.jhsa.2012.08.014 Tricco, A. C., Lillie, E., Zarin, W., O'Brien, K. K., Colquhoun, H., Levac, D., Moher, D., Peters, M. D. J., Horsley, T., Weeks, L., Hempel, S., Akl, E. A., Chang, C., McGowan, J., Stewart, L., Hartling, L., Aldcroft, A., Wilson, M. G., Garritty, C., Straus, S. E. (2018). Prisma extension for scoping reviews (PRISMA-SCR): Checklist and explanation. Annals of Internal Medicine, 169(7), 467473. https://doi.org/10.7326/m18-0850 Trivedi, P., Arunachalam, R., Patel, R., & Vaittianadane, K. (2020). Myofascial release technique with virtual reality biofeedback in Lateral Epicondylitis a case report. Indian Journal of Public Health Research & Development, 11(6), 586591. https://doi.org/10.37506/ijphrd.v11i6.9845 Trivedi, P., Sathiyavani, D., Nambi, G., Khuman, R., Shah, K., & Bhatt, P. (2014). COMPARISON OF ACTIVE RELEASE TECHNIQUE AND MYOFASCIAL RELEASE TECHNIQUE ON PAIN, GRIP STRENGTH & FUNCTIONAL PERFORMANCE IN PATIENTS WITH CHRONIC LATERAL EPICONDYLITIS. International Journal of Physiotherapy and Research, 2(3), 488494. van Rijn, R. M., Huisstede, B. M., Koes, B. W., & Burdorf, A. (2009). 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... OT BINDERS FOR INPATIENT PSYCHIATRIC SETTING 1 Developing Evidence-Based Occupational Therapy Assessment and Intervention Binders for an Inpatient Psychiatric Setting Mary Grace Willis May, 2022 A capstone project submitted in partial fulfillment for the requirements of the Doctor of Occupational Therapy degree from the University of Indianapolis, School of Occupational Therapy. Under the direction of the faculty capstone advisor: Taylor Gurley, OTR, MS, OTD, CEIM, RYT-200 OT BINDERS FOR INPATIENT PSYCHIATRIC SETTING 2 A Capstone Project Entitled Developing Evidence-Based Occupational Therapy Assessment and Intervention Binders for an Inpatient Psychiatric Setting Submitted to the School of Occupational Therapy at University of Indianapolis in partial fulfillment for the requirements of the Doctor of Occupational Therapy degree. By Mary Grace Willis OTS, BSHS Approved by: Faculty Capstone Advisor Date Doctoral Capstone Coordinator Date Accepted on this date by the Chair of the School of Occupational Therapy: Chair, School of Occupational Therapy Date OT BINDERS FOR INPATIENT PSYCHIATRIC SETTING 3 Abstract I completed my doctoral capstone project at Sandra Eskenazis Mental Health Recovery Center. The objective of my DCE project was to focus on developing a standardized model of practice for occupational therapy services in this unit. Secondarily, I also aimed to gain advanced practice skills related to advocacy while working in this setting because this facility frequently works with an underserved population, addressing highly stigmatized conditions. My secondary goal was to gain experience in advocating for these clients, as well as in advocating for the best occupational therapy services in this unit. I compiled intervention and assessment binders of evidence-based practice suggestions in order for the occupational therapy staff on the unit to quickly access and utilized evidence-based practice for treatments. I conducted a pre- and postsurvey of satisfaction and documented increased satisfaction with OT services provided on the unit. Primary goals: Increase efficiency of occupational therapy services on the Mental Health Recovery Center (MHRC) through utilization of OT Intervention & Assessment Binders. Increase quality of care for patients by utilizing occupational therapy assessments and interventions that are evidence-based and supported by research. OT BINDERS FOR INPATIENT PSYCHIATRIC SETTING 4 Developing Evidence-Based Occupational Therapy Assessment and Intervention Binders for an Inpatient Psychiatric Setting The Midtown Mental Health Recovery Center is the inpatient mental health unit at the main campus of Eskenazi Health in Indianapolis. The ultimate goal of this site is to return patients to their homes and communities as soon as possible (Eskenazi Health, 2016). This site also emphasizes that its staff members are all aware of the stigma and challenges that come with many mental health conditions and they provide sensitive care, emphasizing the rights and dignity of all patients (Eskenazi Health, 2016). This setting is a mixed adult unit, meaning all clients are over the age of 18, and it has 30 beds. This setting provides care to the underserved, including people who are homeless, individuals with addictions, intellectual disabilities, dementia, and dual diagnoses. Most of the patients in this unit are on Medicare or Medicaid, but the hospital does not turn away individuals who cannot pay for their care. The hospital receives some state funding and grants to help cover the care of individuals who do not have insurance. A typical length of stay for patients in this unit is 3-4 days, but some patients stay for months because the site tries not to discharge clients until they are guaranteed a safe place to go home to, such as a boarding house, shelter, or an apartment or house. This unit is critical in providing necessary care because more than 50% of all people in the United States will be diagnosed with a mental illness or disorder at some point in their life, and people who experience early adverse life experiences such as trauma or abuse are at a higher risk of developing mental health conditions (CDC, 2018). This statistic is particularly relevant for an underserved population who may be at higher risk of experiencing trauma or abuse. My DCE project focuses on developing a standardized model of practice for occupational therapy services in this unit. However, I also focus on gaining advanced practice skills related to OT BINDERS FOR INPATIENT PSYCHIATRIC SETTING 5 advocacy while working in this setting because I will be working with an underserved population addressing highly stigmatized conditions. Throughout the development of my project, I will gain experience in advocating for these clients as well as in advocating for the best occupational therapy services in the development of my model of practice. The remainder of this report will emphasize relevant information about this population, the needs assessment I completed, research I conducted, the theories used to guide this project, details about project design and implementation, the outcomes of the project, and wrapping up with overall conclusions. Background When speaking to my site mentor at the Midtown Mental Health Recovery Center, she made it clear that one of the biggest issues that she would like to address in their unit is the lack of a standardized approach to providing occupational therapy services to patients in this setting (J. Button, personal communication, 2020). I plan to conduct research on outcome measures, functional assessments, and specific OT models to develop and present a specific model of evidence-based practice that can help improve the efficacy and efficiency of occupational therapy services in this unit. The primary goal in creating this set of practice guidelines for this unit is to increase the efficiency of occupational therapy providers on the unit, which is particularly important due to the fact that this site does not bill in the same way as some more traditional settings, and thus does not track productivity in any official capacity. Some of the occupational therapy services that practitioners frequently use in mental health settings include interventions addressing community reintegration, work and employment, and life skills or activities of daily living (ADLs) (Gibson et al., 2011; Gutman & Brown, 2018; Kirsh et al., 2019). These interventions focus on three of the most commonly impacted areas of occupation for individuals with mental health conditions and can help guide the creation of an OT BINDERS FOR INPATIENT PSYCHIATRIC SETTING 6 intervention guideline for my DCE project. Another approach to intervention that requires further research into its efficacy is the use of activity-based group work (Bullock & Bannigan, 2011). Activity-based group work can also include activities such as playing board games. In a study by Edel et al. (2017), researchers used this example of board games as an alternative to receiving occupational therapy services. They found that although both groups experienced a reduction in depressive symptoms, the group receiving occupational therapy services effectively reduced anxiety and other symptoms (Edel et al., 2017). These articles provide evidence to support the practice of occupational therapy interventions in mental health units such as the Midtown Mental Health Recovery Center and can guide my creation of an intervention guideline. Some of the assessments used in mental health occupational therapy services include the Mental Health Recovery Measure (MHRM), activity based assessment (BIA), the Brief Assessment of Cognition in Schizophrenia (BACS), the Schizophrenia Cognition Rating Scale, and the Social Functioning Scale (Chang et al., 2013; Eklund et al., 2008; Shimada et al., 2018). These assessments are all supported as valid and reliable assessment tools for occupational therapy providers to assess cognitive, emotional, and occupational performance skills in clients with mental health conditions. Understanding the research behind specific assessment tools will allow me to compile a list of acceptable and evidence-based assessments that can help improve the efficiency of occupational therapy services in this unit. Other research supporting occupational therapy in mental health settings include studies about the level of function at discharge as a predictor of readmission rates, predicting quality of life-based on engagement in meaningful activity, and the use of shared decision-making in inpatient mental health settings (OFlynn et al., 2018; Odes et al., 2011; Stacey et al., 2016). OT BINDERS FOR INPATIENT PSYCHIATRIC SETTING 7 Each of these studies promotes occupational therapy practices by emphasizing an individualized occupational therapy approach and supporting engagement in meaningful occupations to improve outcomes for individuals with mental health conditions. These are considerations that I will need to make when compiling intervention guidelines for occupational therapy practitioners at this site. Throughout my research of assessments and interventions commonly used or supported for use in mental health or psychiatric settings, I did not come across any form of resource that compiles these assessments or interventions into an easily understandable and quick reference for practitioners to use to validate their assessment and intervention choices. My goal in conducting this research was to find evidence that supports the use of different assessments and interventions and compile it into one resource that can be easily accessed and utilized by OT practitioners at the Midtown Mental Health Recovery Center. Theory The model/theory I chose to guide my DCE project is the model of human occupation (MOHO). I chose this because it is a holistic approach that addresses both external and internal barriers to engagement in occupation, which is particularly important for the mental health population that I will be working with (Cole & Tufano, 2008). Many of these individuals experience a great deal of environmental effects on their condition, as well as having to cope with the internal considerations that may be affected by their condition. It will be important for me to realize that each individual in this setting may have many different barriers or supports for engagement in occupations and that not every group session will be equally effective for all clients. My visual diagram demonstrates that an individuals volition, habituation, and OT BINDERS FOR INPATIENT PSYCHIATRIC SETTING 8 performance skills shape environmental inputs and interactions with others, affecting their output of performance, skills, and participation (Cole & Tufano, 2008). The frame of reference that I chose to guide my DCE is the Psychodynamic Frame of Reference. This frame of reference uses Freuds Psychodynamic theory as a guide and includes five primary areas as highlighted in my visual diagram: social participation and relationships; emotional expression and motivation for engagement in occupations; self-awareness through reality testing and feedback from others; defense mechanisms such as denial and sublimation through the symbolism of activities and occupations; and projective activities such as communication and clarification of occupational goals and priorities (Cole & Tufano, 2008). This frame of reference is very applicable to the mental health population that I will be working with because it addresses some of the most common concerns associated with mental health conditions. The Psychodynamic Frame of Reference has several similarities, including its foundation in Freuds theories, with the Psychosocial Rehabilitation theoretical perspective that has been critical in the development of mental health occupational therapy services (Morato & de Oliveira Lussi, 2018). Keeping this frame of reference in mind during my DCE will allow me to consider each client as an individual and appreciate how their conditions may impact their occupations, such as social participation and emotional engagement. Project Design For my project, I developed a portfolio of assessment tools and interventions for patients in an inpatient mental health setting and organized them based on the specific aspects of mental health or occupation that they address. I developed this portfolio by conducting research on some of the most popular and frequently used assessments and interventions in this population, as well as newer assessments or interventions that are evidence-based. After determining if an OT BINDERS FOR INPATIENT PSYCHIATRIC SETTING assessment or intervention had enough research to support its use, I would assess what areas of occupation and mental health are addressed within it and create a category for my portfolio. For the assessment binder, I separated assessments into categories based on the Occupational Therapy Practice Framework (AOTA, 2020). The categories include the following: outcome measures, occupational profile, occupational performance- ADLs/IADLs, occupational performance- leisure, performance skills- sensory, performance skills- cognition, performance skills- social interaction skills, performance patterns, and client factors. After assigning each assessment to one of the previously listed categories, I would then write a brief overview of the assessment, its uses, its cost, and where it can be purchased in order to give OT practitioners a quick method of determining whether or not that assessment will fit their patients needs at the time. The intervention portion of the binder was categorized by common areas of goals for patients in the unit. The intervention categories were as follows: communication, coping, future orientation, grief & loss, group activities, planning & scheduling, self-esteem, and wellness & mindfulness. In order to determine the success of my project, I decided to implement a pre- and post-test survey of the OT staff on the unit focused on their satisfaction with the evaluation and intervention process on the unit. Project Implementation Implementation of my project consisted of completing the portfolio and both printing a hard copy for the OT office as well as giving the OTR on staff a digital copy of the portfolio via email. After printing off hard copies and assembling them into physical assessment and intervention binders, I had to educate the OT staff on how to use the information within the binders. Some of the challenges I faced in implementing the project included finding research supporting assessment tools that had higher prices attached to the official test and not having 9 OT BINDERS FOR INPATIENT PSYCHIATRIC SETTING 10 access to them. Some of the successes during my research came from speaking to other students in the cohort who have experienced working in an inpatient mental health setting and could share some of the assessment tools and interventions that were successful at their site. Project Outcomes Results were calculated by implementing a pre- and post-intervention satisfaction survey among the Occupational Therapy staff on the unit. Areas that were addressed in the survey include the following: satisfaction with current evaluation process, whether or not patients needs are appropriately identified with current evaluation process, comfort with performing standardized assessments and evaluations, appropriateness of current assessments and evaluations for the population, whether current assessments and evaluations appropriately identify patients needs, patients benefit from current intake process, whether there is room for improvement in current intake process, if current intake process is evidence-based, satisfaction with current interventions, whether or not current interventions address patients needs, comfort with planning interventions to address patient goals, patients benefit from current interventions, room for improvement in interventions, and whether or not interventions are evidence-based. Overall, all areas of the survey were ranked as either the same or improved since implementation of the intervention and assessment binders on the unit. Areas in which improvement in the operations of the occupational therapy department was documented on the pre- and post-test surveys were the following questions: I am satisfied with the current OT evaluation process for our patients. I feel that the standardized assessments and evaluations used on this unit give OT providers appropriate knowledge of patients needs. I feel that the patients benefit from the current OT intake process. OT BINDERS FOR INPATIENT PSYCHIATRIC SETTING 11 I feel that the current OT intake process could be improved. The current OT intake process is up to date with evidence-based practice and supported by research. I am satisfied with current OT interventions being implemented on the unit. The current OT interventions being implemented on the unit address individual patients needs appropriately. I am comfortable planning OT interventions to address the individual goals and needs of our patients. I feel that the patients benefit from the current OT interventions being implemented on the unit. I feel that the OT interventions currently being implemented on the unit could be improved. The OT interventions currently being implemented on the unit are up to date with evidencebased practice and supported by research. Summary The major need that I identified at my site was a need for a more standardized approach to the method that OT practitioners on the unit use to address assessing new patients to determine goals as well as the methods that they use to address those goals through interventions. My project was to create a more standardized approach to providing OT services on the unit by creating intervention and assessment binders that include evidence-based research to support interventions and assessments that are commonly used in inpatient psychiatric settings. The goal was to increase efficiency of OT services and improve the quality of care that patients are receiving on the unit. In order to address this goal, I researched assessments and interventions and compiled organized binders. After implementing the binders on the unit and educating OT OT BINDERS FOR INPATIENT PSYCHIATRIC SETTING 12 staff about how to effectively utilize these binders, I conducted the post-survey to assess subjective satisfaction and compared results to the pre-survey. Overall, OT staff reported increased satisfaction with the methods of providing OT services on the unit. Conclusions Throughout this projection, I successfully created a resource of evidence-based interventions and assessments that are appropriate for an inpatient psychiatric setting and organized them in a way that will be easy to understand and utilize for OT staff on the unit. Occupational therapy practitioners at the Mental Health Recovery Center reported overall increased satisfaction with OT services provided on the unit after implementation of the OT intervention and assessment binders. The assessment and intervention binders address the goals of increasing efficiency of OT services on the unit and improving quality of care for patients by providing OT staff with resources of evidence-based practice that can be quickly applied to specific patient goals and utilized more quickly than prior interventions. Limitations of this project include limited opportunity to implement new standardized assessments due to high case load and limited time for OT practitioners to review new assessments. Another limitation is the cost of new standardized assessments, there may not be room in the units budget for purchasing new assessment tools. In order to continue to promote evidence-based practices in the OT department, the OT binders should be regularly updated with new information on assessments or interventions that are relevant to this population. This project can remain an ongoing focus for any OT setting in order to increase efficiency and quality of care that OT practitioners provide to their patients. OT BINDERS FOR INPATIENT PSYCHIATRIC SETTING 13 References American Occupational Therapy Association. (2020). Occupational therapy practice framework (4th ed.). American Journal of Occupational Therapy, 74(2). https://doi.org/10.5014/ajot.2020.74S2001 Bullock, A., & Bannigan, K. (2011). Effectiveness of activity-based group work in community mental health: A systematic review. American Journal of Occupational Therapy, 65, 257266. https://doi.org/10.5014/ajot.2011.001305 Centers for Disease Control and Prevention. (2018). Mental health basics. Retrieved from https://www.cdc.gov/mentalhealth/learn/index.htm Chang, Y. C., Ailey, S. H., Heller, T., & Chen, M. D. (2013). Rasch analysis of the mental health recovery measure. American Journal of Occupational Therapy, 67, 469-477. https://doi.org/10.5014/ajot.2013.007492 Cole, M. & Tufano, R. (2008). Applied theories in occupational therapy: A practical approach. Thorofare, N.J.: SLACK Inc. Edel, M-A., Blackwell, B., Schaub, M., Emons, B., Fox, T., Tornau, F., Vieten, B., Roser, P., Haussleiter, I. S., & Juckel, G. (2017). Antidepressive response of inpatients with major depression to adjuvant occupational therapy: A case-control study. Annals of General Psychiatry, 16(1). https://doi.org/10.1186/s12991-016-0124-0 Eklund, M., rnsberg, L., Ekstrm, C., Jansson, B., & Kjellin, L. (2008). Outcomes of activitybased assessment (BIA) compared with standard assessment in occupational therapy. Scandinavian Journal of Occupational Therapy, 15, 196-203. https://doi.org/10.1080/11038120802022110 OT BINDERS FOR INPATIENT PSYCHIATRIC SETTING 14 Eskenazi Health. (2016). Kathi & Bob Postlethwait Mental Health Recovery Center. Retrieved from https://www.eskenazihealth.edu/mental-health/acute/recovery-center Gibson, R. W., DAmico, M., Jaffe, L., & Arbesman, M. (2011). Occupational therapy interventions for recovery in the areas of community integration and normative life roles for adults with serious mental illness: A systematic review. American Journal of Occupational Therapy, 65, 247-256. https://doi.org/10.5014/ajot.2011.001297 Gutman, S. A., & Brown, T. (2018). A bibliometric analysis of the quantitative mental health literature in occupational therapy. Occupational Therapy in Mental Health, 34(4), 305346. https://doi.org/10.1080/0164212X.2017.1413479 Kirsh, B., Martin, L., Hultqvist, J., & Eklhund, M. (2019). Occupational therapy interventions in mental health: A literature review in search of evidence. Occupational Therapy in Mental Health, 35(2), 109-156. https://doi.org/10.1080/0164212X.2019.1588832 Morato, G. G., & de Oliveira Lussi, I. A. (2018). Contributions from the perspective of psychosocial rehabilitation for occupational therapy in the field of mental health. Brazilian Journal of Occupational Therapy, 26(4), 943-951. https://doi.org/10.4322/2526-8910.ctoARF1608 OFlynn, P., ORegan, R., OReilly, K., & Kennedy, H. G. (2018). Predictors of life among inpatients in forensic mental health: implications for occupational therapists. BioMed Central Psychiatry, 18(16). https://doi.org/10.1186/s12888-018-1605-2 Odes, H. Katz, N., Noter, E., Shamir, Y., Weizman, A., & Valevski, A. (2011). Level of function at discharge as a predictor of readmission among inpatients with schizophrenia. American Journal of Occupational Therapy, 65, 314-319. https://doi.org/10.5014/ajot.2011.001362 OT BINDERS FOR INPATIENT PSYCHIATRIC SETTING 15 Shimada, T., Ohori, M., Inagaki, Y., Shimooka, Y., Sugimura, N., Ishihara, I., Yoshida, T., & Kobayashi, M. (2018). A multicenter, randomized controlled trial of individualized occupational therapy for patients with schizophrenia in Japan. PLoS ONE, 13(4). https://doi.org/10.1371/journal.pone.0193869 Stacey, G., Felton, A., Morgan, A., Stickley, T. Willis, M., Diamond, B., Houghton, P., Johnson, B., & Dumenya, J. (2016). A critical narrative analysis of shared decision-making in acute inpatient mental health care. Journal of Interprofessional Care, 30(1), 35-41. http://dx.doi.org/10.3109/13561820.2015.1064878 OT BINDERS FOR INPATIENT PSYCHIATRIC SETTING 16 Appendix Wee k 1 DCE Stage (orientation, screening/evaluat ion, implementation, discontinuation, dissemination) Orientation Weekly Goal Objectives Tasks Date complet e 1.) Complete orientation by the end of the week Complete staff introductions and tour of the unit/facility Complete any orientation training/paperwork 1/14/20 22 Gain access to EPIC and get badge/keys Observe the role of OT on the unit Update/finalize MOU Review any documentation/resou rces the facility has on current practices for OT Observe current process for intake/evaluati ons of new patients 2 Screening/Evalua tion 1.) Complete needs assessment 2.) Complete literature search of inpatient mental health OT interventions by end of week Finalize questions for needs assessment Review needs with site mentor & faculty mentor Complete SWOT analysis Research interventions 1/21/22 OT BINDERS FOR INPATIENT PSYCHIATRIC SETTING 3 Screening/Evalua tion 1.) Observe administration of intakes/evaluati ons 2.) Create pre/post-test outcome measure for patients 4 Screening/Evalua tion 3.) Complete literature search on OT mental health assessments by end of week 1.) Complete literature search on OT mental health evaluations by end of week 2.) Begin data collection starting midweek 5 Screening/Evalua tion 6 Screening/Evalua tion 7 Implementation 1.) Compile rough draft of evaluation guidelines 1.) Complete final draft of evaluation guidelines 1.) Educate staff on new evaluation guidelines Establish outcome assessment Determine appropriate OT assessments for the unit 17 Review outcome assessments with site and faculty mentors Conduct intake Review data interviews collected with site with site mentor mentor 1/28/22 2/4/22 Conduct discharge interviews with site mentor Create evaluation guidelines for unit Send final draft to site and faculty mentor Meet with OT and COTA to review evaluation guidelines Review evaluation guidelines with site mentor 2/11/22 Revise draft as needed 2/18/22 Finalize posttest measure 2/25/22 OT BINDERS FOR INPATIENT PSYCHIATRIC SETTING 8 Implementation 1.) Continue Continue Collect data during implementation evaluations of intakes/discharges of evaluation patients with with patients guidelines and new guidelines data collection 9 Implementation 1.) Continue Continue Collect data during implementation evaluations of intakes/discharges of evaluation patients with with patients guidelines and new guidelines data collection 10 Implementation 1.) Continue Continue Collect data during implementation evaluations of intakes/discharges of evaluation patients with with patients guidelines and new guidelines data collection 11 Implementation 1.) Continue Continue Collect data during implementation evaluations of intakes/discharges of evaluation patients with with patients guidelines and new guidelines data collection 12 Implementation 1.) Continue Continue Collect data during implementation evaluations of intakes/discharges of evaluation patients with with patients guidelines and new guidelines data collection 13 Discontinuation 1.) Analyze survey results by end of week 14 Dissemination 1.) Present Disseminate Present project to project results DCE and site to site by end project of week Doctoral Capstone Experience and Project Weekly Planning Guide 18 3/4/22 3/11/22 3/18/22 3/25/22 4/1/22 4/8/22 4/15/22  ...

... 1 Creating a Cultural Competence Toolkit for Indiana First Steps Providers Fatima Tapia May 05, 2022 A capstone project submitted in partial fulfillment for the requirements of the Doctor of Occupational Therapy degree from the University of Indianapolis, School of Occupational Therapy. Under the direction of the faculty capstone advisor: Jenna Trost, OTD, OTR 2 Abstract The purpose of this capstone was to evaluate the effects of a cultural competence toolkit on early intervention (EI) providers self-reported levels of comfort in providing culturally competent services to minority families on their caseload. This quantitative, quasi-experimental design study used a pretest posttest method to assess change in comfort level scores relating to cultural awareness, knowledge, skills, and practice using an adapted version of the Cultural Competence Assessment Inventory (CCAI). Adaptation of the CCAI was completed to tailor the questions to the needs of the site and of the project. This capstone was conducted at a pediatric autism center with its affiliated EI service providers. Participants included 10 occupational, physical, speech, and developmental EI therapists (N= 10). Participants completed a pre-outcome measure and were then presented with the cultural competence toolkit that they completed and integrated for five weeks. Following the completion of the toolkit, EI therapists participated in an opendialogue, virtual reflection session. Immediately following, participants completed the postoutcome measure. Pre and post data were collected in Likert scale form and were later assessed using SPSS and the Wilcoxons signed-rank test. EI providers demonstrated a statistically significant improvement in comfort levels when addressing minority families after the intervention. Aggregate scores improved 3.9 points from 27.8 on the pretest to 31.7. Cultural competence education in an EI setting where providers must interact and step in-home with culturally diverse families significantly enhances attitudes, knowledge, communication, and advocacy in therapeutic services. Keywords: early intervention; cultural competence; multicultural diversity; ethnic minorities; pediatrics 3 Creating a Cultural Competence Toolkit for Indiana First Steps Providers All children have the right to equitable learning opportunities that help them achieve their full potential as engaged learners and valuable members of society (NAEYC, 2019). Within early intervention (EI) services and throughout the United States, minority populations continue to grow (Durand, 2010). This growth urges EI professionals to develop skills that support proficient, multicultural services. To develop skills that meet the needs of society, therapists need organizational support and readily available resources within the workplace. Unfortunately, therapists often report feeling unsupported by their organizations (Grandpierre et al., 2018; Martinez & Leland, 2015). Possibilities Northeast (PNE) is a pediatric therapy clinic in Fort Wayne, Indiana whose vision is to develop programs that meet the needs and unique differences of all children and families served (Possibilities Northeast, n.d.). The clinic offers EI services that address the needs of children aged zero to three from Burmese, Hispanic/Latino, African American/Black, Amish, and Mennonite backgrounds (C. Elder, personal communication, February 22, 2021). Population data is presented in Figure 1. First Steps, Indianas EI program, provides occupational, physical, speech, and developmental therapies to children from birth to three years of age who face developmental delays or disabilities. First Steps goal is to ensure that children receive help early to support them in their future. Reporting more than 20,000 families and children served, EI therapists see a multitude of cultures and ethnicities daily (Family and Social Services Administration, 2020). First Steps is guided on providing client-centered, culturally competent, and individualized services (Family and Social Services Administration, 2020). Without cultural competence development, EI professionals are unable to carry out the foundations that drive the program. 4 Figure 1 Populations Served by Indiana First Steps Providers at Possibilities Northeast Asian 11% Other: 4% Black/African American 32% Mennonite 4% Amish 14% Burmese 3% Hispanic/Latino 32% Note. Data collected was from 10 First Steps therapists (N=10). Response in Other category was Indian. Approximately 92% of EI staff at PNE is White (C. Elder, personal communication, February 22, 2021). With many diverse families seeking EI care, a predominantly White staff struggles to provide culturally competent services (C. Elder, personal communication, February 22, 2021). PNE fails to provide therapists with trainings that address diverse population care, resulting in decreased levels of comfort when caring for minority families (C. Elder, personal communication, February 22, 2021). A lack of confidence in multicultural care puts minority families at risk of not obtaining high quality services. The purpose of this capstone was to develop a cultural competence toolkit that enabled EI therapists to develop the necessary skills to address multicultural needs when providing in-home services. The toolkit included four modules (see Appendix A). This capstone aimed to increase organizational support and EI therapist comfort levels when providing services to minority families. 5 Background In 2015, the United States Census Bureau projected that by the year 2020, more than half of the nations children would belong to a minority race or ethnic group (U.S. Census Bureau, 2015). As U.S. minority populations grow, a cultural competency toolkit is necessary to prepare EI professionals to work with cultures different than their own (Agner, 2020). Govender et al. (2017) defines cultural competence as: A process by which individuals and systems respond respectfully and effectively to people of all cultures, languages, classes, races, and ethnic backgrounds in a way that recognizes, affirms, and values the worth of the individual and protects and preserves the dignity of each. (pp. 2) The continued advancement of the occupational therapy profession relies on the preparation of therapists to practice across multicultural settings (Sonn & Vermeulan, 2018). With a majorityminority nation ahead (U.S Census Bureau, 2015), culturally competent healthcare is vital to increasing patient satisfaction (Govere & Govere, 2016). Cultural competence programs have been created in variety of forms, but with similar aims to improve attitudes, knowledge, and skills of healthcare professionals (Jernigan et al., 2016). One study suggests that approximately 40% of programs have based their trainings on the foundations of Betancourt et al. (2003) that identifies attitudes, knowledge, and skills as necessary to build cultural competence. Attitudes and self-awareness measure healthcare professionals recognition of biases, curiosity, and empathy (Association of American Medical Colleges, 2022). As cultural competence cannot begin until one understands how personal cultural values affect their health care beliefs (Govender et al., 2017), understanding how ones own views affect work cross-culturally is imperative. Programs addressing attitudinal barriers 6 increased confidence among professionals (Kaul & Guiton, 2010; Lie et al., 2010; Campbell et al., 2011; Parisi et al., 2012). Improving culturally diverse knowledge is targeted among cultural competence programs. Some existing programs view culturally diverse knowledge as properly addressing families and identifying cultural customs (Dabney et al., 2016), while others view it as understanding how to enable understanding of cultural competence, racial awareness, and appropriate clinical behaviors (Webb & Sergison, 2002; Crandall et al., 2003). Many cultural competence programs lack providing healthcare professionals with the norms, values, and beliefs of the very minority populations they serve. Easy access to this information may allow therapists to be more open to learning about their clients cultures, leading to greater knowledge of their background, and increasing cultural competence. One factor consistent in determining patient satisfaction in minority populations is communication (Govender, 2017; Martinez & Leland, 2015; Mirza & Harrison, 2018). Occupational therapy relies on communication to deliver effective intervention (Govender, 2017). Without communication, exchanging vital information pertaining to intervention, recommendations, and parent/caregiver education will lack. As a result, language discordance can have a detrimental impact on cultural competence and therapeutic services (Govender et al., 2017). Several cultural competency training programs address cross-cultural communication through effective education on communication strategies and interpreter usage (Aeder et al., 2007; Crandall, 2003; Webb & Sergison, 2002; Cha-Chi et al., 2010). By incorporating crosscultural communication education, therapists may feel more comfortable and equipped to provide higher levels of care to minority populations (Brown et al., 2016). 7 An online cultural competency toolkit will not be effective on its own. Mirza and Harrison (2018) highlight the importance of combining online trainings with reflective assessments to produce long-term effects. To sustain long-term cultural competence, maintaining higher-level moral thinking through cultural awareness is necessary (Henderson et al., 2018). Involving healthcare professionals in open dialogue supports the advancement of culturally competent care (Manis, 2012). Different than other training programs, this toolkit included open dialogues with EI professionals to promote development of culturally competent skills. Sonn and Vermeulen (2018) found that therapists need to be supported in participating in culturally diverse situations. This toolkit pushed therapists beyond education and supported them in taking advantage of their position as EI professionals to apply their knowledge within in-home services. The repetition of self-reflection provides reinforcement of behaviors that lead to more culturally competent services (Mirza & Harrison, 2018). A needs assessment with therapists, directors, and First Steps coordinators of PNE determined that therapists require increased support and resources when addressing families with diverse cultures. Creating a cultural competency toolkit that addressed attitudes, knowledge and skills enabled PNE and their EI therapists to meet the unique needs and differences of all children and families served, as their vision statement delineates (Possibilities Northeast, n.d.). This unique toolkit enabled therapists to not only feel better prepared to conduct face-to-face interventions with multicultural families, but took a distinctive approach to cultural competence, more aligned with cultural humility. An encyclopedic knowledge of cultures was not expected from therapists; instead, the toolkit challenged therapists to undertake a lifelong commitment of self-evaluation, self-analyzation, and self-progression to create permanent changes in their crosscultural service delivery (Stubbe, 2020; Rajaram & Backrath, 2015). 8 Theory to Guide Practice Occupational Adaptation The Occupational Adaptation (OA) model focuses on the interactive processes between a person, their environment, and the internal adaptive process that occurs when the individual is engaged in occupations (Cole & Tufano, 2008). When an environment demands more than what the individual can competently meet, decreased occupational performance results (Cole & Tufano, 2008). PNE creates a high demand for culturally competent therapists but does not provide resources that prepare therapists to provide culturally competent services. The OA model delineates the importance of guiding change through intrinsic motivation (Cole & Tufano, 2008). Incorporating a cultural competence toolkit allowed therapists to self-reflect and recognize the need to change, modify, or adapt their services. This behavioral change allowed therapists to go through an adaptation response mechanism, or a plan for action (Cole & Tufano, 2008). Integrating a cultural competence toolkit enabled PNE to provide resources for therapists to meet their environmental expectations. Ecology of Human Performance The Ecology of Human Performance (EHP) guided satisfactory occupational, physical, speech, and developmental therapy services received by multicultural populations. The EHP focuses on the impact that context has on task performance (Cole & Tufano, 2008). The EHP looks at four constructs: the person, context, tasks, and how well the person can perform tasks in their environment (Cole & Tufano, 2008). For this DCE, a childs personal variables disrupt the way they can independently engage in occupations and roles. The toolkit addressed the contextual factors that minority families were in, having trickling effects that supported their childs personal variables. The cultural competence toolkit addressed how therapists can better 9 understand the families environment, culture, and expectations to equip them on how to modify, adapt, or establish tasks and roles (Cole & Tufano, 2008). The EHP guided the DCE project as it helped navigate how cultural competency trainings allow therapists to better adapt to the contextual needs of minority families. Project Design To measure EI therapist comfort levels when providing services to multicultural families, a quasi-experimental design with a pretest posttest method was used. Through convenience sampling, 10 EI therapists participated in completing the cultural competence toolkit. Prior to the completion of the toolkit, therapist comfort levels were assessed using the Cultural Competence Assessment Instrument (CCAI). The CCAI, a 36-item tool created by Suarez-Balcazar et al. (2011), measures cultural competence among rehabilitation practitioners who serve individuals with disabilities from diverse backgrounds. Demonstrating strong psychometric properties, the CCAI looks at four cultural factors: awareness, knowledge, skills, and practice. Due to our focus on comfort levels in these four areas, the CCAI was modified to consist of 13 items that are rated on a three-point Likert scale with a rating of 3 indicating very comfortable, a rating of 2 indicating somewhat comfortable, and a rating of 1 indicating not comfortable, to fit the needs of the site and of the therapists of being quick to use (Preston & Coleman, 2000). The pre and post outcome measures were developed on Qualtrics, an online survey software, and sent to EI therapists. The adapted version of the CCAI was administered during the second and 10th week of the DCE to obtain changes in comfort levels when serving minority families. Due to limitations in technology and usage by PNE EI providers, modules were created using Microsoft PowerPoint, a familiar system to all therapists, to increase effectiveness (Hode et al., 2018). An overview module was sent out, along with the pre-outcome measure, to provide 10 therapists with a background of the project. The other modules, created using evidence-based findings, included: Attitudinal Barriers, Learning About Cultures, Communication, and Resources. The capstone was divided into three phases: initial implementation, reflection, and dissemination. EI therapists who completed the pre-outcome measure, were sent an email containing a timeline of the project and attachments to all modules. Successful implementation of the capstone required delegating roles to different site stakeholders. The primary role of the executive director of PNE included sending out email communications, pre and post outcomes measures, and project files. Due to staff shortages, the director faced difficulties in sending out email communications on time, setting back the project timeline. This timeline setback forced an adjustment of dates for phase two which included open dialogue reflections. 10 EI therapists participated in a five-week implementation period where they completed the toolkit and actively implemented suggested strategies into their First Steps sessions. Due to COVID-19 concerns, communication with therapists occurred through email and Zoom, a video conferencing platform. After the implementation period, a reflection session was conducted via Zoom. By eliciting thought and innovation through open-ended questions, participants actively considered their and others thoughts and actions and used reflective thinking as a tool for continuous improvement (Helyer, 2015). Open-ended questions were guided by Gibbs reflective cycle to allow for reflection about their learned experiences (Markkanen et al., 2020; see Appendix B). To evaluate the efficacy of the toolkit, therapists were sent a post-outcome measure immediately following the reflection session. At the final dissemination, all participating therapists, and the director of PNE were presented with the project outcomes and discussed future directions and implications of the project. 11 Project Outcomes A total of 10 EI therapists participated in the completion of the cultural competence toolkit. Participants included occupational, physical, speech, and developmental therapists. All participating therapists were White females. Pre and post-test scores were compared for each of the 13 items on the modified CCAI. Data from the modified CCAI was imported into a Microsoft Excel spreadsheet and then analyzed in SPSS utilizing the Wilcoxon Signed Ranks Test. The Wilcoxon Signed Ranks Test produces a more sensitive statistical test when using it with paired data that are measured on at least an ordinal scale and is especially effective when the sample size is small (Doane & Seward, 2007; see Table 1). When examining the 13 items, statistically significant improvements, or positive ranks, were notable on 11 of the 13 items (see Figure 2). Additionally, therapists comfort level total scores (aggregate score for all 13 items) showed significant improvement after completion of the cultural competence toolkit (see Appendix C). Aggregate scores improved 3.9 points from 27.8 on the pretest to 31.7 on the posttest. A Wilcoxon signed rank test revealed that therapist comfort levels significantly increased after completion of the cultural competence toolkit (Md=2.4, n=13) compared to before (Md=2.1, n=13), z = -2.92, p=.004, with a large effect size, r = .57. These statistical results show that the presentation of a cultural competence toolkit significantly increased therapist levels of comfort when providing services to minority families. Figure 2 Modified CCAI Pre Outcome Measure Scores vs. Post Outcome Measure Scores 12 3 2.5 Score 2 1.5 Pre Score Post Score 1 0.5 0 1 2 3 4 5 6 7 8 9 10 11 12 13 Item Number on Modified CCAI Note. Information displayed demonstrates scores obtained from Modified CCAI (Cultural Competence Assessment Instrument). Table 1 Wilcoxon Signed Ranks Test Ranks N Negative Ranks Mean Rank Sum of Ranks 2.00 2.00 6.91 76.00 1a Posttest - Positive Ranks 11b Ties 1c Total 13 Pretest Note. Superscript a = posttest < prettest, superscript b = posttest > pretest, superscript c = posttest = prettest. 13 Therapists demonstrated increased scores in three areas: obtaining resources, having readily available resources, and advocating for the inclusion and healthcare of minority families. During the reflection session, therapists expressed that the cultural competence toolkit was the only resource given to them by their organization that addressed cultural competence needs. Many therapists stated that they found most use in the fourth module as they explored not only the resources made available to them, but the resources available through the state to give to their families. Therapists stated feeling like their role in advocacy needed to increase and felt supported through the toolkit to do so. Item six of the modified CCAI demonstrated a score decrease, meaning that therapists reported decreased comfort in providing quality services to non-English proficient minority families. Summary For therapists, it is important to understand their role in advancing equitable care. The demographics reported in this project are indicative of the rapidly growing minority populations needing EI services, increasing the urgency of developing culturally competent therapists. Organizations must rapidly follow suit to increase the support they give therapists to alleviate levels of comfort. Through the exploration of already existing cultural competence trainings, the importance of creating programs that meet the current needs of therapists and society was noted. Integrating innovative practices within the toolkit, such as open-dialogue reflection, further addressed the desired permanency of learned practices, skills, and used resources within therapists daily services. Examining the effects of implementation of a cultural competence toolkit within EI is important within OT intervention and all other EI services. This toolkit provided EI therapists with cultural competence resources for self-reflection, cultural knowledge, communication, education, and advocacy. The toolkit sought to identify changes in levels of 14 comfort when providing services to minority families using a pretest posttest measure and addressed gaps within already developed programs to target lifelong learning. Project outcomes demonstrated a statistical significance in the modified CCAI scores assessed, indicating increased levels of comfort with providing services to multicultural families after completing the cultural competence toolkit. Increased comfort levels in 11 items supported findings in the literature of the predicative relationship between higher organizational support and higher integration of equitable practice (Grandpierre et al., 2018; Martinez & Leland, 2015). The item with a negative rank demonstrated decreased levels of comfort in providing quality services. Based on this project's goal of helping therapists understand their own biases in culturally competent care, the negative rank may be indicative of therapists renewed understanding that their previous care did not meet the quality standards that they and their organizations once assumed. The decreased score can be reflected to be a positive change in guiding needed modifications within therapeutic practice to meet the needs of the eclectic cultures EI therapists serve. It is important to support therapists bridge their cultural knowledge gap when caring for families that share differing cultures. Addressing this gap may ultimately help create and maintain rapport with minority families. This capstone may help promote increased therapeutic outcomes in minority homes and help all children work towards a more purposeful and meaningful life. Conclusion The outcomes of the project were disseminated to therapists and directors of PNE through an in-person presentation that included tables, figures, and easy to understand data followed by a collaborative discussion. Given the significance of the results, the director spoke about the importance of implementing the toolkit within their onboarding programming. 15 Additionally, a physical therapist at the site is currently developing a project for EI therapists that delineates important contact information for different doctors and specialists in the Fort Wayne area. Due to the nature and topic of this DCE project, many therapists expressed the importance of including contact information of providers who focus on specific minority cultures as a resource for these families. Obtaining only a small sample size within a suburban city raises several opportunities for future research. This project was designed specifically with PNE at the forefront, but First Steps expands throughout the entire state of Indiana. To further elaborate on this projects findings, future research can venture out to other agencies to acquire data on a wider, more generalizable, scale. Additionally, demographics taken of EI therapists provided us with some knowledge of therapist background. Further investigating how comfort levels may be impacted by income, age, geographical location, socioeconomic status, and graduating year may provide a more accurate baseline depiction of pre outcome measure scores. Culture is complex and as a result, developing cultural competence will not occur overnight. As occupational therapists, cultural competence is a skill that is necessary to increase the effectiveness of client-centered care. The continued growth of the occupational therapy profession relies on therapists to effectively interact with diverse populations. Therapists are constantly expected to evolve their practices to meet the everchanging needs of the communities they serve but obtaining resources that are pertinent to those needs is not an easy task. Workplaces must be ready to support their staff in developing skills to meet their clients goals. Allowing EI therapists to complete a cultural competence toolkit provided them with the opportunity to seek and implement suggested strategies and learnings within their day-to-day care of minority families. This capstone readily addressed the needs of the site and of the 16 therapists and provided a foundation for which to improve the quality of care to the minorities they serve. 17 References Aeder, L., Altshuler, L., Kachur, E., Barrett, S., Hilfer, A., Koepfer, S., Schaeffer, H., & Shelov, S. P. (2007). The "culture osce"--introducing a formative assessment into a postgraduate program. Education For Health, 20(1), 11. Agner, J. (2020). 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Cultural Diversity Ethnic Minority Psychology, 15(2), 125136. 24 Stubbe, E. D. (2020). Practicing cultural competence and cultural humility in the care of diverse patients. Focus, 18(1), 49-51. Suarez-Balcazar, Y., Balcazar, F., Taylor-Ritzler, T., Portillo, N., Rodakowski, J., GarciaRamirez, M., & Willis, C. (2011). Development and validation of the cultural competence assessment instrument: A factorial analysis. Journal of Rehabilitation, 77, 413. Suh, E. E. (2004). The model of cultural competence through an evolutionary concept analysis. Journal of Transcultural Nursing, 15(2), 93- 102. Talevski, J., Wong Shee, A., Rasmussen, B., Kemp, G., & Beauchamp, A. (2020). Teach-back: A systematic review of implementation and impacts. PloS One, 15(4), e0231350. United States Census Bureau. (2015, March 3). New Census Bureau Report Analyzes U.S. Population Projections [Press Release]. https://www.census.gov/newsroom/pressreleases/2015/cb15-tps16.html Webb, E., & Sergison, M. (2002). Evaluation of cultural competence and antiracism training in child health services. Archives of Disease in Childhood, 88(4), 291-294. Woo, B., Fan, W., Tran, V. T., & Takeuchi, T. D. (2019). The role of racial/ethnic identity in the association between racial discrimination and psychiatric disorders: A buffer or exacerbator? SSM Population Health, 7, 1-10. Young, M. I. (2011). Justice and the politics of difference. Princeton University Press. Zippia. (2021, December 14). Developmental therapist demographics and statistics in the us. https://www.zippia.com/developmental-therapist-jobs/demographics/ Zippia. (2021, December 14). Occupational therapist demographics and statistics in the us. https://www.zippia.com/occupational-therapist-jobs/demographics/ 25 Zippia. (2021, December 14). Physical therapist demographics and statistics in the us. https://www.zippia.com/physical-therapist-jobs/demographics/ Zippia. (2021, December 14). Speech language pathologist demographics and statistics in the us. https://www.zippia.com/speech-language-pathologist-jobs/demographics/ 26 Appendix A Transcripts of Cultural Competence Toolkit Modules Cultural Competency Tool Kit Module 1: Attitudinal Barriers First Steps YOU ARE HERE! Lets Review What is Cultural Competence? Understanding Biases Who are YOU? o Understanding ones own values derived from family, background and position in society is critical for developing culturally responsive practice (Dewees, 2001). Lets Reflect o How do these things position you in society? Understanding Your Racial and Ethnic Identity Why are Identities Important? o Ones racial and ethnic identity is a foundation for self-identity as it is how we identify with a given groups culture, values, and beliefs. o These identities may influence individuals' perspectives of race/ethnic stressors and how they enable culturally competent practice. Information retrieved from: (Woo et al., 2019; Phinney & Ong, 2007; Carter, 2007; Stevenson & Arrington, 2009). Critical Self Reflection Self-Awareness is Key to Cultural Competence: An Example o We are shaped by the world around us, like our geographic location, culture, social groups, etc. o Example: Eye contact How we look at people is a basic and clear representation of our cultural values. One individual may be raised in a family on beliefs of look me in the eyes when I am talking to you! While the other individual may be raised in a family on beliefs of dont you dare look me in the eyes! The White Majority o Demographics: OTs: 78.8% White, 8.4% Asian, 6.2% Hispanic/Latino PTs: 73.9% White, 13.7% Asian, 6.0% Hispanic/Latino SLPs: 82.8% White, 8.2% Hispanic/Latino, 4.2% Black/African American Developmental Therapists: 68.1% White, 14.6% Hispanic/Latino, 8.4% Black/African American Information retrieved from: (Zippia, 2021). 27 Identity Development for White Practitioners However, Cultural Competence is NOT for White Practitioners Only o Research finds that workplaces often assume practitioners can competently interact with anyone who shares their skin color. o The problem? Some racialized individuals carry negative feelings about members of their own race. o Negative stereotypes and attitudes toward their own group are often adopted Information retrieved from: (Beckford, 2020; Clair and Denis, 2015; Livingston, 2002; Young, 2011). Bottom Line o All practitioners MUST be cautious not to project their own experiences and biases onto their clients. Cultural Bias: Explicit Bias o Cultural bias begins when we are no longer neutral, but rather we have a preference or aversion to a person or a group of people (Perception Institute, n.d.). o Explicit Bias: When individuals are aware of their prejudices and attitudes towards certain groups (Community Relations Service, n.d.). The positive or negative preferences are conscious. Examples: racism and racist comments Cultural Bias: Implicit Bias o How do Biases Impact Therapy o Examples of Biases Demonstrated by Therapists Assessing Your Bias Cultural Competence Self-Assessment Checklist Use this checklist to identify your strengths and weakness and to develop opportunities for continuous personal and professional development: https://www.avma.org/sites/default/files/2020-08/DiversityCulturalCompetenceChecklist.pd We will revisit this checklist at midterm and at the end of the project. The more points you have, the more culturally competent you are becoming. Up Next: Module 2: Learning Resources Cultural Competency Tool Kit Module 2: Learning About Cultures Lets Review Cultural competence is a continuous process with the goal of gaining the skills to work effectively with diverse groups and communities with a detailed awareness, specific knowledge, refined skills, and personal and professional respect for cultural attributes, both similarities and differences (Suh, 2004). 28 YOU ARE HERE! Why is Learning About Cultures Important? Knowledge is Key Where Early Intervention Falls Short o American Culture is Used as the Norm Understanding Cultures Gives Us Insight o Every interaction we have with a child is a cultural exchange (Parlakian & Sanchez, 2006). o Caregiver routines and traditions are a direct reflection of the values, beliefs, and cultures of families and communities around them (Hyun, 2007). Cultural Competence Expectations Early intervention professionals cannot be expected to develop encyclopedic knowledge of all values, beliefs, and practices in every culture. Instead, early intervention professionals should find ways to learn about and understand others cultures to more accurately deliver services that reflect practices and values of the families they serve. By increasing basic knowledge of cultures, early intervention professionals can more effectively integrate family caregiving practices, beliefs, and goals into their therapeutic services. Information retrieved from: (Jones & Lorenzo-Hubert, 2008; Melendez, 2005). In this Module o We will focus on providing quick fact sheets for 6 minority populations: Black/African American Hispanic/Latinos Burmese Amish Mennonite Afghan Why these Populations? Lets Get Started! Black/African American Cultural Norms Hispanic/Latino Cultural Norms Burmese/Myanmar Cultural Norms o Burmese and Myanmar Culture 'Burmese Cultural Norms Traditional Customs of Burmese Families The Karen The Chin o Amish and Mennonite Cultural Norms Understanding Amish and Mennonite Communities Many cultural norms are based on the families churchcommunity. Changes in the norms of social interaction between members of a church-community or between the church-community and the 29 outside world generally indicate changes in the religious beliefs that constitute the communitys sense of itself (Johnson-Weiner, 2007). o Understanding Amish and Mennonite Communities Amish and Mennonite individuals live in closed, well-defined communities. They follow a lifestyle that separates them from mainstream society. Marriages outside of their community is frowned upon and prohibited. Individuals very rarely convert to their faith. As a result of all these conditions, there is a high degree of genetic relatedness between parents. Increased prevalence of specific genetic disorders present within their communities. Information retrieved from: (Sieren et al., 2016). o Common Genetic Disorders in Amish and Mennonite Communities Amish and Mennonite Cultural Norms o Afghan Cultural Norms Understanding Ethnic Groups in Afghanistan Ones ethnicity is an instant cultural identifier in Afghanistan and usually defines peoples social organization (IU School of Medicine, 2021). Understand that experiences of persecution differ between ethnic groups. As a result, members of minority ethnicities may prefer to indentify by their ethnic affiliation (IU School of Medicine, 2021). Know that most Afghans are Asian, not Middle Eastern. The most common ethnic groups are the Pashtuns, Tajiks and Hazaras (IU School of Medicine, 2021). o Afghan Minority Populations o Research o Afghan Cultural Norms o Traditional Customs of Afghan Families Disclaimer! Cultural norms discussed are based on evidence-based research and are NOT based on direct in-home observations of individual families. Black/African American, Hispanic, Burmese, Amish, Mennonite and Afghan minority groups DO NOT all share the same culture. The cultural norms discussed may apply to only some of your families! Up Next: Module 3: Communication Resources Cultural Competency Tool Kit Module 3: Communication 30 Whats Next? We have discussed attitudinal barriers and the importance of cultural self-awareness. We have also dived deep into different minority populations and their cultural norms. How do we put these pieces together? YOU ARE HERE! Why is Communication Important? Culture Plays a Role in Communication o Cultural differences can lead to conflict between patients, families, and clinicians. o Culture defines how individuals make sense of the world around them. o Culture influences how people view the healthcare experience and how they make decisions. Information retrieved from: (Brown et al., 2016). Communication Alleviates Unequal Treatment of Minority Families Communication Allows EI Professionals to Adhere to Regulations o Non-English proficient minority families are aided by federal regulations that protect their rights by requiring that assessments and evaluations be completed in the language that is most dominant to the child, unless it is not feasible to do so (Puig, 2010). o EI professionals are expected to identify and assess linguistic resources that may be needed (Puig, 2010). o Many states EI programs acknowledge the need to assess the child in their native language but are often not equipped or required to provide their services in the dominant language of the child (Puig, 2010). o No requirements exist to support EI that builds upon families cultural and linguistic resources through direct work with children and families in their home languages (Puig, 2010). Communication Allows for Client-Centered Services Communication Increases Outcomes The Foundations for Effective Communication Step 1 o Like previously discussed in Module 1: Attitudinal Barriers & Module 2: Learning About Cultures Reflect. Understand the inherent beliefs, values, and biases you hold as a healthcare provider. Become aware of the influence your organization/workplace has on your services. Once providers become conscious of these factors, they are more receptive to the beliefs and values of their patients, especially when differences are present. Understand how minority families beliefs and values impact their views on the healthcare system and your roles as healthcare professionals. Step 2 o Use effective communication strategies that are: 31 Evocative Nonjudgmental Respectful o Cross-cultural communication includes: Strategies that address and acknowledge individual cultural traditions Consider ones own beliefs, values, and experiences Avoid generalizing patients beliefs or values (norms were provided in the previous module, but providers should be careful in addressing all patients on an individual basis Information retrieved from: (Brown et al., 2016). Communication Strategies for Initial Sessions Ask-Tell-Ask Strategy o Why is this strategy beneficial? Collaborative communication method Encourages a two-way conversation Asks open ended questions Assesses patients knowledge prior to disclosing more information Does not ask EI professionals to tell patients what to do, but rather ask patients what they are willing to do and moving forward in a collaborative manner after. Information retrieved from: (Brown et al., 2016). Examples of Open-Ended Questions When Trying to Better Understand Patients How to Properly Convey Information Integrating Culturally Competent Communication Strategies Linguistic Mismatch Ethical Considerations o Chabon et al. (2010) point out legal and ethical considerations within their decision-making framework in determining if the SLP should provide services at all. o However, it is not permissible to refuse services based on a cultural mismatch. o If a language matching SLP is not available, the only ethical consideration is to locate and work with an interpreter to provide culturally competent services. o We know how difficult this can be as an EI provider. Information retrieved from: (Chabon et al., 2010). SLP Difficulties in Early Intervention Communication During Treatment Sessions The use of appropriate language services and the right of families and children with limited-English proficiency to access healthcare are inextricably linked (Basu et al., 2017). o For families and children with limited-English proficiency, meaningfully communicating with an EI professional would indicate that EI professional is only using the child and families preferred language of care (Basu et al., 2017). Giving Access to Appropriate Language Services 32 o As early intervention services, we can begin this process by hiring staff who is bilingual (Basu et al., 2017). o However, hiring bilingual staff in all patients preferred language is not always possible (Basu et al., 2017). o So, we must have systems in place for accessing professional language assistance services rather than relying on ad hoc interpreters (Basu et al., 2017). Ad Hoc Interpreters Qualified Interpreters o The Department of Health and Human Services establishes competences required to be a qualified interpreter: Knowledge of specialized terminology Knowledge of interpreter ethics Skills to interpret accurately, effectively, and impartially o The use of qualified medical interpreters with LEP patients, improves comprehension, service utilization, clinical outcomes, and patient satisfaction with services. Information retrieved from: (Basu et al., 2017) Types of Interpreters o Research suggests that patients rate in-person translators higher than remote interpreter services. o However, when rating remote methods, patients demonstrated a high preference for video services. Information retrieved from: (Locatis et al., 2010) How to Appropriately Use a Medical Interpreter But What If Interpreters Arent Available? o CALD Assist Free application on Apple Store & Google Play. Once downloaded, no internet or is Wi-Fi required. Enables conversation with limited preset phrases led by healthcare professionals in 11 different languages. Specifically designed for healthcare settings. Preset phrases only cover topics or situations considered within the scope of everyday clinical conversation. Does NOT include topics/situations that require medical professional interpreters. Information retrieved from: (Panayiotou et al., 2019) How CALD Assist Works Why CALD Assists Limited Phrases is Actually a Good Thing Communication Methods at the End of a Treatment Sessions Teach-Back Method o Always check to ensure that communication with your LEP patients has been understood. o Asl parents/caregivers/families to explain and/or show you what you have completed with their child during your session that day. 33 o Asking them to recall strategies allows for increased carry over into the home. Information retrieved: (Talevski et al., 2020) Teach-Back + Video Support o Videos have a greater influence, when compared to infographics, to communicate healthcare information (Occa & Suggs, 2015) o Didactic messages delivered in video format have the most positive effect on awareness and knowledge (Occa & Suggs, 2015) o Use teach-back strategies first. o Example: Have the caregiver show you how to position their child during feeding. Once caregiver shows you, if they appear to struggle with the provided information, provide them with a video that demonstrates how to position a child. Send it to them via email after session to provide a reference for when they are helping child with feeding during the week. If family is willing, have them take video of you positioning their child in their natural environment. Teach-Back Strategy + Pictorial Support o Using pictorial support is shown to be effective for patients with low health literacy (Negarandeh et al., 2013). o Pictorial support is recommended to be used according to patients conditions (Negarandeh et al., 2013). o Example: Have caregiver show you how to apply different sensory techniques presented during the session. If they struggle showing you different methods, provide picture reminders of different techniques. BONUS: if the pictorial support is in their native language Remember Always Go Back to Teach-Back Up Next: Module 4: Obtaining Resources Resources Cultural Competency Tool Kit Module 4: Obtaining Resources Supporting Our Therapists YOU ARE HERE! Roles of Early Intervention Professionals Early intervention professionals have a role in helping families resolve difficulties that hinder the child from fully participating in EI services. o Because social workers are often scarce on caseloads, our role can extend to link families with resources or other services in their community. 34 Information retrieved from: (Family and Social Services Administration, 2022) Providing Resources for Families o TANF Cash Assistance o CHIP - Health Coverage o WIC Food & Nutrition o CCDF Child Care Financial Assistance o SNAP Food Assistance Familiarize Yourself First! In the Last Module We discussed how we could use the teach- back method with videos and pictorial supports to facilitate communication with families who have limited English proficiency (LEP). In the Next Slides Video Support Resources Obtaining Video Consent When Necessary o In Module 3, we discussed using the teach-back method with video support to further solidify carry over into the home with LEP families. o One method discussed was recording yourself and then recording the family completing intervention strategies provided during the session. o We understand that if you have not done this before, it may be uncomfortable to initiate this conversation. o This video may help in getting the ball rolling: https://www.youtube.com/watch?v=5--GzEeUops Intervention Resource: TEIS o This YouTube channel has great resources for therapists and parents alike. o Examples: Working with Picky Eaters, Symmetrical Movement, Tummy Time Activities, Leg, Arm, and Digestion Massage, Facial Strokes for Babies, Assisted Rolling, Movement/Sensory Play and Techniques, Variety of Play Activities, Crawling, Walking, and Many More! https://www.youtube.com/c/TeisincEarlyIntervention/videos Information Sheets: Pathways o Allows you and parents to quickly and easily look up milestones by age. o Provides quick explanations and videos to supplement what milestones should look like. o https://pathways.org/?fbclid=IwAR1UnM3zu8HqZKz6TuIITRFOFDZoRaxgmcyVv7YeOR5QLaQwDAqWx9bdr4 Pictorial Support Resources Information Sheet Resources o The Royal Childrens Hospital 35 This website provides occupational therapy information sheets with pictures Pathways Downloadable Brochures in English, Spanish, Hindi, Oriya, Turkish, and Greek Depicts developmental milestones by age and skills Provides explanations for parents to understand what is being addressed. In this picture, sensory integration is being explained. A checklist of signs is additionally provided for parents. Resources in Spanish A great resource to use with Spanish speaking families that explains early intervention, what OT does as a profession to help their child and outlines developmental milestones. Intervention Resources Therapy Street for Kids This website breaks activities down by skill areas and then provides a list of activities that will address those areas. Additionally, the website provides homemade play ideas. Mama OT This website provides play ideas using household items. Several of the links provided in the website will redirect you to Pinterest. Multidisciplinary Support Resources Tools to Grow OT Sections out skills by OT, PT, and SLP. However, has a neat section for handouts that can be used multidisciplinary. This may facilitate workload for families and help maintain in-home work to address all 3 therapies with one activity. This is how communication between therapists can be extremely useful! This website does require a subscription for some of their handouts, but many can be accessed free by simply signing up. o o o o Resources to Explain Therapy in Other Languages Explaining Therapy in Spanish o Occupational Therapy: https://www.youtube.com/watch?v=o2qhpRIMg2Q o Physical Therapy (0-1:36) https://www.youtube.com/watch?v=jS9YojHvxvI o Speech Therapy: https://www.youtube.com/watch?v=oi3LzsMzqy0 Explaining Occupational Therapy in Other Languages Addressing the Gaps Our Role in Advocacy Building Bridges 36 Other Potential Physician Roles Advocating for First Steps Services o Family Voices provides a concise fact sheet with a description of First Steps, eligibility criteria, services provided, cost, and how to get started. o Make sure to get updated links for families, as changes may occur with time. Clusters o First Steps is administered at a local level in regions. These regions are groups of counties known as "clusters. o IN.gov provides an interactive map where families can access offices near them. First Steps Resource for Spanish Speakers o The CDC provides a great Spanish description of First Steps and provides hyperlinks to resources and who to contact by their state. Fulfilling Your Role o By providing these resources to families, you are fulfilling your role. o The purpose of early intervention is to provide families/caregivers and early education practitioners with proper supports and resources to further enable their childs learning and development. Information retrieved from: (Disability Rights Pennsylvania, 2017) You Have Now Completed: o Your role now is to take information from all 4 modules and reflect, learn, and implement different strategies into your sessions with minority families on your caseload. Whats Next? Reflection! Resources Appendix B Reflective Session Discussion Questions Description Share an experience where cultural competence was necessary. Feelings 37 After completing the toolkit, how has your understanding of the term cultural competence changed? Evaluation After completing the toolkit, what did you determine as your strengths relating to cultural competency? Analysis Discuss your comfort levels then versus now in dealing with clients of varied cultures and language backgrounds? In what areas did you feel challenged or notice a need for growth? Conclusion How does your therapy change the most when working with clients/families who have a different culture and speak a different language than your own? Action Plan Did this program provide you with useful materials available in the languages and formats that you can readily use? What module would you see yourself referring back to the most? What other materials would you have liked to be included in this toolkit? Any changes you would like to see within the toolkit for its use in the future? Appendix C Modified CCAI Pretest and Posttest Score Comparisons Modified CCAI Items Question 1: How comfortable are you with integrating a client's culture into the therapy process? Pretest Mean Score 2.20 Posttest Mean Score 2.40 38 Question 2: How comfortable are you in asking your clients questions regarding their cultural beliefs and values ? 2.10 2.40 Question 3: How comfortable are you in obtaining resources to provide to minority families on your caseload? 1.90 2.80 Question 4: How comfortable are you in advocating for the inclusion and healthcare of minority children and families on your caseload? 2.30 2.70 Question 5: How comfortable are you in going into minority homes with readily available resources that reflect the cultures and backgrounds of minority families and children on your caseload? 1.80 2.30 Question 6: How comfortable are you in providing quality therapy services to nonEnglish proficient families and children? 2.0 1.90 Question 7: How comfortable are you working with culturally diverse backgrounds? 2.20 2.60 Question 8: How comfortable are you in identifying cultural beliefs that are not expressed by a caregiver but might interfere with therapy service delivery? 2.00 2.40 Question 9: How comfortable are you adjusting your therapeutic strategies when 2.30 2.30 39 providing therapy services to minority families and children? Question 10: How comfortable are you in using non-verbal communication when providing therapy services to non-English speaking families and children (ex: teach-back strategies, videos)? 2.10 2.20 Question 11: How comfortable are you in examining personal biases related to race and culture that may influence your behavior as a therapy service provider? 2.40 2.80 Question 12: How comfortable are you in considering the cultural values and beliefs of minority families and children when food is involved? 2.60 2.70 Question 13: How comfortable are you going into minority homes with adequate organization/workplace provided resources that help you promote cultural competence within my sessions? 1.90 2.20 TOTAL SCORE 27.8 31.7 Note. CCAI = Cultural Competence Assessment Instrument; scale 1 (not comfortable) to 3 (very comfortable). 40 Appendix D Doctoral Capstone Experience and Project Weekly Planning Guide Week DCE Stage (orientation, screening/evaluation, implementation, discontinuation, dissemination) Weekly Goal Objectives Tasks Date complete 41 1 2 3 4 Orientation Evaluation/Program Development Evaluation/Program Development Evaluation/Program Development 1) Complete orientation by end of the week 2) Complete and get survey out to Nancy 3) Complete Overview Module 4) Complete Module 1 1) Continue literature to build efficacy of tool kit 2) Complete Module 2 1) Complete Module 3 2) Talk to different staff/therapists to confirm best delivery method of tool kit 1) Complete Module 4 2) Finalize Tool Kit Meet with site mentor Create timeline for project Create survey for evaluation of current need for toolkit Send out preFinalize MOU survey by end of with any updates week and turn in Creation of 1st Complete module pre/post survey used for outcome measurement Send out Outcome assessment with one week deadline Send needs evaluation survey to participating therapists Meet with Chelsea to determine formatting of toolkit Continue to search literature to develop effective tool kit Create 2nd module Meet with critical stakeholders of the company to determine how this may be implemented after you leave Create 4th module Create 3rd module Complete draft of Introduction Complete draft of Background 42 5 6 Implementation Implementation 1) Tool kit to be received by at least 5 therapists 2) Meet with different therapists in clinic to determine caseload demographics 1) Develop written observations that are articulate and clear for later dissemination Meet with stakeholders to discuss the importance of the toolkit and present draft Open lines of communication to participating therapists and be available to respond to any questions or troubleshooting issues. Therapists will begin navigating though tool kit Create a documentation system for inhome observations Continue inhome observations of implementation of tool kit. Develop organization and distribution method to make handouts more readily available to therapists and families Continue work on clinic handouts. Begin going inhome with therapists serving minority families to Find individuals observe changes from community in services of prevalent cultures that can Work on help with increasing health increasing health literacy of clinic literacy of hand handouts outs Project Design Due 43 7 8 Implementation Implementation 1) Meet with participating therapists and develop good interviewing skills 1) Develop a continuous understanding of health literacy and how best to show that with clinic handouts Set up meetings with therapists via zoom individually or with group to discuss how things are going with navigating the tool kit Complete midterm reflections to increase efficacy of tool kit Ask questions about what they have learned, what they have changed, and how they will continue to grow with their cultural competence Continue inhome observations of implementation of tool kit Talk to some of the families (if able and they give permission) to determine some of the things they would like to see change within their care and how we can be better suited to serve them as minority families with minority children Continue inhome observations of implementation of toolkit Check in with participating therapists Continue work on clinic handouts 44 9 Implementation 1) Develop method for collection of data with post survey 2) Compile data of post survey Develop best Send out postway to distribute survey with post survey deadline for the end of the week Compile all data in an organized Continue inmanner home observations of Meet with implementation Chelsea to of toolkit review the findings together Continue work and discuss on clinic meanings handouts Determine what findings mean for the company and its future in cultural competency 10 Discontinuation 1) Create visual for data Meet with critical stakeholders such as Nancy and Jake to discuss the importance of the findings Gather all observations Meet with therapists/email therapists to have them give you final thoughts Compile all data Outcomes draft due 11 Dissemination 1) Develop most effective dissemination plan Gather final results Finalize results from survey Analyze results and their meaning Make visual of pre/post outcomes to 45 12 13 Dissemination Dissemination 1) Develop aesthetic and effective dissemination 1) Finalize all work Make clear written documentation for presentation in dissemination Discuss with Chelsea best avenue to present project to First Steps therapists Reach out to First Steps therapists and ask what they would prefer in presentation Continue to work on dissemination show changes (if any) Complete work on Summary Complete work on handouts Begin work on clinic Dissemination Continue work on Dissemination Work on presentation 14 Dissemination 1) Present final project Finalize schoolwork and any work for clinic Prepare to present Disseminate findings -location TBD  ...

... 1 Evaluating Perceived Competence After Taking a Cancer Survivorship Elective with an Embedded Service Learning Component Taryn Springgate, Megan Yingling, Sierra Kern, Ashton Williams, Shelby Cash, & Kate Kelley 12/16/2022 A research project submitted in partial fulfillment for the requirements of the Doctor of Occupational Therapy degree from the University of Indianapolis, School of Occupational Therapy. Under the direction of the research advisor: Katie M. Polo DHS, OTR, CLT-LANA 2 A Research Project Entitled Evaluating Perceived Competence After Taking a Cancer Survivorship Elective with an Embedded Service Learning Component Submitted to the School of Occupational Therapy at University of Indianapolis in partial fulfillment for the requirements of the Doctor of Occupational Therapy degree. By: Taryn Springgate, Megan Yingling, Sierra Kern, Ashton Williams, Shelby Cash, & Kate Kelley Doctor of Occupational Therapy Students Approved by: Katie M. Polo, DHS, OTR, CLT-LANA Research Advisor Date Accepted on this date by the Chair of the School of Occupational Therapy: Kate E. DeCleene Huber, OTR, MS, OTD Chair, School of Occupational Therapy Date 3 Abstract Community engagement models (CEMs) encompass teaching pedagogies used to provide students an opportunity for hands-on application of classroom learning while servicing local populations (Bandy, 2019). Incorporating service learning into a curriculum aligns with the Experiential Learning Theory, which is a dynamic, holistic process of learning from experience (Kolb & Kolb, 2017). The purpose of this study was to examine if students CEM experience shaped their perceived competence. Researchers used a sequential explanatory mixed methods design consisting of an online survey, several virtual focus groups, and interviews to assess perceived competence and impressions of the CEMs effects. Participants were alumni of an entry-level doctorate of occupational therapy (OTD) programs cancer survivorship elective. In total, ten alumni completed the survey and eight of those alumni participated in virtual focus groups and interviews. Results from qualitative data suggest that after participating in cancer survivorship education and taking part in a service-learning component, entry-level OT alumni felt competent and confident in their ability to treat cancer survivors. Alumni reported increased interest in treating cancer survivors and a better understanding of the role of OT in the community. No significant correlations between quantitative and qualitative research in terms of perceived competence were found. Given the literature and call for further curricular development in cancer survivorship content, programs should consider developing course content that includes a service learning component to support their graduates competence and confidence in working with cancer survivors. Keywords: cancer survivorship, curriculum design, service learning, education 4 Introduction Community engagement models (CEMs) encompass teaching pedagogies that provide students an opportunity for hands-on application of classroom learning and foster student skill development while simultaneously addressing community needs (Bandy, 2019). CEMs are a crucial part of an occupational therapy (OT) curriculum because they provide practitioners with hands-on experience, which can improve self-confidence, increase cultural awareness, and improve professional development (Jacobs, 2020; Keane & Provident, 2017; Mu et al., 2016; Peterson et al., 2014). Service learning can increase students' knowledge of their field, enhance clinical skills, and improve overall competency (Alt et al., 2011; Kaf & Strong, 2011; Peterson et al., 2014; Ten Tusscher et al., 2020). Service learning pedagogies are categorized as CEMs and incorporate learning goals and meaningful community involvement to encourage student and community growth (Bandy, 2019). Competence encompasses performance, application, and integration of knowledge and skills, including applying standards of care and appropriate policies and procedures in an educational or clinical setting (Moyers, 2002). Competence also includes the ability to use knowledge, skills, attitudes, and values that allow an individual to perform successfully in a profession or occupation (Moyers, 2002). The ideology of incorporating service learning into a curriculum aligns with the Experiential Learning Theory (ELT) (Healey & Jenkins, 2000; Kolb & Kolb, 2017). Kolb & Kolb (2017) defined the ELT as a dynamic, holistic theory of learning from experience that contains four cyclical components: a concrete experience, reflective observation, abstract conceptualization, and active experimentation (see Figure 1). In ELT, two 5 elements encompass the student experience, including learning the basic concepts and reflecting on what students learned. Additionally, two components transform the students' experience, including conceptualizing and actively carrying out what was learned (Kolb & Kolb, 2017). Service learning pedagogies implement these principles by having students learn knowledge from classroom instruction and then apply skills in a hands-on, community experience. Figure 1 Kolbs Experiential Learning Theory (2017) Kaf and Strong (2011) discussed that only some students have the opportunity to be involved in CEMs, which could influence the students outcomes, establishing a need for a CEM provided to all students. Within Kaf and Strong's (2011) study, 48 students participated in a service learning pediatric audiology course, while a control group of ten other students did not participate in the course. The researchers found that 87% of the students that engaged with service learning reported an increase in their overall knowledge and clinical skill development, and 42% reported an increased interest in working with pediatric audiology as a career (Kaf & Strong, 2011). Overall, the students 6 who participated in a service learning component had better outcomes than those who did not (Kaf & Strong, 2011). Mu et al. (2016), Kohlbry (2016), and Keane & Provident (2017) also established a need for integration of CEMs to within classes rather than taking place following the completion of the course, a concept supported by ELT (Kolb & Kolb, 2017). CEMs with service learning pedagogies are utilized across disciplines within academia, especially within healthcare fields. For example, students in baccalaureate and post-baccalaureate healthcare programs engage in the community, service-based learning opportunities within the curriculum to gain hands-on, real-life experience (Alt et al., 2011; Kaf & Strong, 2011; Peterson et al., 2014; Ten Tusscher et al., 2020). Literature supports the use of service learning pedagogy in healthcare education, such as OT. However, limited research exists for OT academia regarding service learning. Ashby et al. (2016) established a need for further research into the curricula and other processes that help students form a professional identity, including service learning. Many published articles also demonstrate a need for a smooth transition from learning knowledge and skills to applying those in CEMs (Mollica & Hyman, 2016; Merritt & Murphy, 2019; Martinez-Mier et al., 2011), and service learning would bridge this gap. Within many emerging fields of OT practice, such as cancer care, the benefits of a service-learning approach have not been explored despite a call for specific education and training, including CEMs (Ten Tusscher, 2020; Baxter et al., 2017; Childress & Gorder, 2012). Further research is needed to evaluate the benefits felt by students after completing a course with a service learning component CEM. Purpose & Aims 7 The purpose of this study was to examine if the service learning experience in an entry-level OTD cancer survivorship elective shaped alumnis competence. This study aimed to evaluate the perceived competence of OTD alumni after taking the elective with an embedded community service learning component. Research Questions The research questions that guided this study were: 1. What is the experience of perceived competence that alumni in the OTD 620 elective describe? 2. What is the relationship between years of experience and the perceived competence scale? 3. What is the difference among practice settings on the perceived competence scale? 4. How do the themes generated from the focus groups support, modify, or contradict the perceived competence scale findings? Methods Research Design Researchers used a sequential explanatory mixed methods design (Feldhacker & Greiner, 2022) to examine perceived competence among OT alumni that took the cancer survivorship elective. We chose this method to promote data triangulation and provide sufficient data for interpretation (Guy et al., 2020). Quantitative data was gathered first and included a non-experimental, descriptive design with a five-point Likert scale survey to assess alumni's perceived competence. The qualitative portion followed a case study design and consisted of semi-structured, virtual focus groups and 8 interviews to further explain quantitative findings. Using this design, researchers examined trends from reported data and built upon the existing quantitative data (Guy et al., 2020). Course Description Since 2016, a cancer survivorship elective with a service learning component has been offered yearly to OTD students. The university offers a cancer survivorship elective with a service learning component to OTD students that are interested. The elective's structure reflected ELT (Kolb & Kolb, 2017), which includes four cyclical steps: concrete experience, reflective observation, abstract conceptualization, and active experimentation. The elective began with concrete experience, including several weeks of lecture content related to the basics of cancer, including OT's role within the cancer population, typical side effects of cancer treatment, and the impact of cancer on occupational performance. Students engaged in abstract conceptualization by reviewing evidence-based interventions to improve an individual's occupational performance and well-being. The instructor scheduled a meeting with the cancer support site to conduct a needs assessment each year of the elective, so the delivery of interventions varied year-to-year depending on the site's needs. For the final three to four weeks, the students engaged in active experimentation and reflective observation as they went to a cancer-specific community setting and performed various interventions under the instructor's supervision. Examples of these interventions included one-on-one evaluations, individualized interventions, group education, and delivery of a scripted, evidence-based intervention designed by the instructor, followed by small group problem-solving and follow-up each week. 9 Participants and Sampling Alumni were recruited by University of Indianapolis staff using class rosters from the elective in academic years 2016-2019 using non-probability convenience sampling. An uninvolved university staff member emailed a recruitment flyer describing the study to those eligible using email addresses retrieved from course alumni contact lists in order to maintain the alumnis anonymity. University staff also provided researchers with phone numbers from the contact lists used to perform cold calls to recruit alumni to participate. Alumni then filled out a quantitative survey, indicated their interest, and were contacted by a single researcher for focus group scheduling. Researchers collected names and email addresses of alumni from a survey question but de-identified data before the primary researcher analyzed data to reduce potential bias. The criteria for inclusion in the study were as follows: enrollment and participation in the OTD 620 Cancer Survivorship Elective ability to comprehend English ability to participate in virtual surveying and video calls Exclusion criteria included any alumni who did not take the elective. Data Collection Instruments/Measures Quantitative. Researchers developed a virtual survey consisting of demographic questions and a 15-item perceived competence scale using a five-point Likert scale in which 1 indicated no competence to 5 indicated expert competence. Questions were based on a questionnaire designed to evaluate the perceived competence of occupational therapists in mental health (Cottrell, 1990) and adjusted to be specific to 10 the cancer survivorship elective. The itemized survey included questions regarding evaluation, intervention, and foundational concepts/core knowledge in occupational therapy cancer care (see Table 1). The content validity of the survey was established by collecting feedback from oncology experts within the occupational therapy field (Taylor, 2017, p. 285-286). We collected names and email addresses of alumni from a survey question, but de-identified data before the primary researcher analyzed data to reduce potential bias. An uninvolved staff member sent the quantitative surveys via email to maintain the alumni's anonymity. Table 1 Quantitative Survey Questions on Perceived Competence of Alumni # 1 2 3 4 5 6 7 8 9 10 11 12 13 Question Describing OTs role in oncology and cancer survivorship to multidisciplinary and/or interdisciplinary healthcare teams. Describing OTs role in oncology and cancer survivorship to individuals with cancer and/or living beyond cancer. Engaging with cancer survivors in a community treatment setting. Understanding the impact of cancer culture on cancer survivors. Providing culturally competent care to cancer survivors from diverse backgrounds. Knowing the typical side effects of cancer and cancer treatments. Understanding the unique needs of cancer survivors. Evaluating cancer survivors symptoms and side effects of cancer treatment and their impact on occupational performance. Designing and leading educational and self-management groups or individual interventions with cancer survivors. Designing interventions for cancer survivors. Providing interventions to cancer survivors given the common side effects of cancer treatment to improve occupational performance. Facilitating self-management behaviors for symptoms of cancer and cancer treatment. (i.e. fatigue, cancer-related cognitive impairments etc.) Using evidence-based practice and providing proper educational, community, and technology resources (i.e. apps) for intervention support 11 14 15 for those with and living beyond cancer. Providing shared decision making (working together with the client to make decisions) on modifications and adaptations in daily activities to improve occupational performance of cancer survivors. Using current research findings relevant to the nature of oncology and cancer survivorship in interventions with cancer survivors. Qualitative. Focus groups and interviews allowed alumni to reflect on their experiences within the course and their current practice. We scheduled focus groups and interviews based on convenience. Individuals that could not attend the focus groups had an interview. Ideally, researchers aimed for five to eight participants in each focus group (Krueger & Casey, 2014). Researchers utilized a semi-structured interview guide (See Table 2), developed from the quantitative survey to ensure elaboration of answers in the focus groups (Schoonenboom & Johnson, 2017). Table 2 Semi-Structured Focus Group Questions 1. The cancer survivorship course was structured differently from year-to-year and some of you most likely took it during different years. Can you describe the structure of the cancer survivorship elective when you took it? 2. What does your current practice with cancer survivors look like? a. For those who have not answered yet, can we assume you have not worked with cancer survivors? 3. What aspects of what you learned in the elective carry through to your daily practice? 4. Can you briefly describe your learning experiences at the community site? 5. Can you explain if the hands-on experience in the community affected your practice? a. Did you learn any transferable skills? 6. Can you explain if you feel more competent in treating cancer survivors after taking the elective? a. Can you please expand on that feeling? 12 7. Reflecting on your current practice, what additional information would have been helpful for you to receive during the elective? 8. Can you explain if you feel more aware of the social norms within the cancer community after taking the elective? a. If so, how do you feel that awareness affects your practice? 9. Can you explain if you feel comfortable connecting cancer survivors with resources and education after taking the elective? 10. Has your experience with the cancer survivorship elective increased your interest in working with the cancer survivor population? Procedures After approval by the Institutional Review Board at the University of Indianapolis, researchers attempted to contact alumni multiple times via email and phone and gauge interest in participation. After agreeing to informed consent, alumni completed a Qualtrics survey which gathered descriptive data that were later de-identified to maintain anonymity. Researchers chose Google Meets as the virtual platform to conduct focus groups and interviews over the following weeks and months due to the programs audio and video recording features and transcription capabilities. Data was de-identified and transcribed verbatim using a Google Chrome extension and placed in a secure Google Drive. The primary investigator, the course instructor, was not present during focus groups or interviews to limit bias in responses. Additionally, the primary investigator only had access to de-identified transcripts and data to decrease potential bias in data analysis. Data Analysis A researcher, who was not the primary investigator, exported de-identified data into a password-protected Microsoft Excel spreadsheet. Quantitative data were analyzed using descriptive statistics, including independent t-tests, to compare 13 demographic and perceived competence variables (Chen & Price, 2020; Norman, 2010). Then, researchers categorized total calculated competence scores into four levels of competence, and an ANOVA was used to compare perceived competence data with specific descriptive data (see Table 3). Data from individuals who did not complete the full quantitative survey were not analyzed to maintain consistency across the results. Researchers analyzed qualitative data using thematic analysis framework from Roberts et al. (2019) to support rigor, credibility, and replicability. The framework consists of a multiphasic thematic analysis, including generating initial codes, searching for codes within the transcripts, reviewing codes, refining codes and subcodes, and developing a report (Roberts et al., 2019). Researchers analyzed qualitative data line by line using direct quotes from alumni and utilized constant comparative analysis throughout the coding process (Boeije, 2002). Researchers followed qualitative data analysis guidelines from Roberts et al. (2019), unanimously agreed on themes and sub-themes to ensure reliability and consistency, and re-read transcripts until no new themes were found indicating data saturation (Roberts et al., 2019). Researchers used a connection model of mixing both quantitative and qualitative data; the point of integration occurs in the results using a joint display (Schoonenboom & Johnson, 2017). For integrative analysis, quantitative data was transposed into qualitative data, coded, and then integrated into the existing qualitative data. Researchers coded Likert-scale questions and compared the quantitative data results to the qualitative results. Results 14 Quantitative Data Ten alumni completed the study's quantitative portion (n=10), and eight participated in the qualitative focus group/interview (n=8). All were white, between 25 and 48 years old, two were male, and eight were female. The alumnis current practice settings included inpatient acute care (n=4), inpatient rehabilitation (n=2), inpatient pediatrics (n=1), long-term acute care (n=1), burn unit (n=1), combined inpatient/outpatient care (n=1), and no longer practicing (n=1). Fifty percent of alumni had 1-2 years of experience (n=5), 40% (n=4) had 3-4 years of experience, and one alumnus had less than one year of experience. Alumni reported how frequently they worked with cancer survivors in current practice and the number of cancer survivors on their annual caseload. Sixty percent of the alumni often worked with cancer survivors (n=6), seeing one survivor each week, and 50% of alumni had more than 20 cancer survivors on their annual caseload (n=5). See Table 3 for Participant Demographics. Table 3 Participant Demographics Descriptive Data Number of Participants (n=) Gender Male 2 Female 8 Current Practice Settings Inpatient acute care 4 Inpatient rehabilitation 2 Inpatient pediatrics 1 15 Long term acute care 1 Burn unit 1 Inpatient/outpatient care 1 No longer practicing 1 Years of Experience Less than 1 year 1 1-2 years 5 3-4 years 4 Number of Cancer Survivors on Annual Caseload Less than 5 2 6-10 1 16-20 3 More than 20 5 Frequency Working with Cancer Survivors Rarely (1 survivor annually) 1 Occasionally (1 survivor monthly) 3 Often (1 survivor weekly) 6 Always (1 survivor daily) 1 In the 15-question survey, alumni rated their perceived competence in various knowledge and skills built into the elective from 1 (no competence) to 5 (expert competence). Total perceived competence scores were calculated for each alumnus by adding their rating of each question from 15 to 75 (see Table 4). Table 4 Alumnis Total Perceived Competence Scores Score Range Level of Competence Alumni Responses 16 15-28 Below Basic Competence 0% (n=0) 29-42 Basic Competence 10% (n=1) 43-59 Advanced Competence 80% (n=8) 60-75 Expert Competence 10% (n=1) Total perceived competence scores ranged from 41 to 63, indicating that overall, alumni of the elective feel that they have basic competence or above when working with the cancer population. Ninety percent of the alumni (n=9) perceived having an advanced or expert competence level. The mean scores for perceived competence for each question indicated that all alumni perceived having at least a basic level of competence in each aspect of working with cancer survivors. Table 5 shows the frequency of perceived competence scores by each question. Among alumni, the years of experience as an OT and total perceived competence exhibited a positive, yet weak, correlation of r(8) = 0.102, p = .778. Researchers performed a one-way ANOVA to compare the effect of the current practice setting on perceived competence scores. Some practice settings only had one participant response, so researchers recategorized data to run the one-way ANOVA. Both adult and pediatric acute care settings were combined into an inpatient acute care setting. Researchers merged settings such as burn unit, LTAC, and outpatient and inpatient into an other category. The one-way ANOVA revealed no statistically significant difference between at least two groups in the current practice setting (F(2, 6) = 0.519, p = .619). Researchers found that the mean value of perceived competence score was not significantly different between any of the three categories of practice settings when compared side-by-side after a post hoc Bonferroni test for multiple comparisons. 17 Table 5 Frequency of Perceived Competence Scores by Scale Item (n = 10) Frequency # Question No competence (n=) 1 Describing OTs role in oncology and cancer survivorship to multidisciplinary and/or interdisciplinary healthcare teams. 2 Describing OTs role in oncology and cancer survivorship to individuals with cancer and/or living beyond cancer. 3 Engaging with cancer survivors in a community treatment setting. 4 Understanding the impact of cancer culture on cancer survivors. 5 Providing culturally competent care to cancer survivors from diverse backgrounds. 6 Knowing the typical side effects of cancer and cancer treatments. Less than basic competence (n=) Basic competence Advanced competence Expert competence Mean Score (1-5) M (n=) (n=) (n=) 2 8 3.8 3 7 3.7 3 7 3.7 6 4 3.4 1 2 7 3.6 1 3 6 3.5 18 7 Understanding the unique needs of cancer survivors. 8 Evaluating cancer survivors symptoms and side effects of cancer treatment and their impact on occupational performance. 9 Designing and leading educational and self-management groups or individual interventions with cancer survivors. 10 Designing interventions for cancer survivors. 11 Providing interventions to cancer survivors given the common side effects of cancer treatment to improve occupational performance. 12 Facilitating self-management behaviors for symptoms of cancer and cancer treatment. (i.e. fatigue, cancer-related cognitive impairments etc.) 13 Using evidence-based practice and providing proper educational, community, and technology resources (i.e. apps) for intervention support for those with and living beyond cancer. 1 1 1 2 6 1 3.7 2 8 3.8 3 6 3.5 4 6 3.6 3 6 3.5 4 6 3.6 2 8 3.8 19 14 Providing shared decision making (working together with the client to make decisions) on modifications and adaptations in daily activities to improve occupational performance of cancer survivors. 15 Using current research findings relevant to the nature of oncology and cancer survivorship in interventions with cancer survivors. 4 4 2 3.8 7 2 1 3.4 20 Qualitative Data Eight alumni participated in focus groups or individual interviews after completing the quantitative perceived competence survey. Researchers ran three virtual focus groups and conducted two interviews based on the availability of the alumni. Analysis of the focus groups revealed six main themes: 1. Hands-on experience 2. Perceived gain of knowledge and skills 3. Deeper understanding of the community setting and cancer culture 4. Gained confidence in working with cancer survivors 5. Ability to apply the course to current practice 6. Interest in the cancer survivorship field. See Table 6 for quotes from alumni supporting each theme. Theme 1: Hands-On Experience Alumni in the focus groups felt that hands-on experience through the CEM portion of the elective was crucial to their learning following the lecture portion. One alumnus talked about how the hands-on experience solidified aspects of treatment in their mind due to the trial by fire nature of direct client care, and another shared it helped them gain perspective on what they had learned in the classroom. A subtheme of the hands-on experience was the context of the cancer-specific community site, as alumni felt that it enhanced their understanding of survivors stories and experiences. Alumni thought the hands-on experience was crucial to developing skills such as problem-solving, intervention planning, and advocacy. They also felt that interacting with actual clients in the community allowed them to understand the clients' interpersonal, 21 emotional, and social experiences. Witnessing empathetic peer support that is key to the cancer survivorship community was a growth opportunity for alumni. See section 1.0 of Table 6 for quotes supporting hands-on experience. Theme 2: Perceived Gain of Knowledge and Skills Through the cancer survivorship elective, alumni reported a gain of knowledge and skills relating to OT practice and treating cancer survivors. Subthemes included increased knowledge, client-centered care, adaptability, shared decision-making, empathy, self-guided learning, evidence-based practice, and therapeutic use of self. During focus group sessions, alumni discussed feeling more competent in treating cancer survivors. They noted that interacting with different clients in this setting helped further their skills in providing client-centered care. Alumni felt that their knowledge of cancer survivors' differing needs increased throughout the elective, improving their skill of adaptability. One alumnus mentioned carrying over the skills of self-guided learning and evidence-based practice from the cancer survivorship setting into their current practice setting, including finding and providing client resources. See section 2.0 of Table 6 for quotes supporting this theme. Theme 3: Deeper Understanding of the Community Setting and Cancer Culture A deeper understanding of the community practice setting following the elective was expressed in the focus groups. This theme included the importance and uniqueness of peer support amongst cancer survivors and social norms surrounding the cancer community. Alumni also had a deeper understanding of the stigma surrounding cancer and how to deal with other aspects of cancer culture after taking the elective. They particularly noted healthcare practitioners' discomfort around cancer and how they 22 often felt the need to take the lead in interprofessional education about cancer. Finally, alumni discussed a better understanding of cancer's short- and long-term side effects after having seen them first-hand at the community site. See section 3.0 of Table 6 for quotes supporting the alumnus' understanding of the community setting and cancer culture. Theme 4: Gain Confidence in Working with Cancer Survivors Along with new knowledge and skills, alumni in the focus groups reported that they felt their confidence increased after working with cancer survivors. Sub-themes related to gained confidence included advocacy, increased comfort working with survivors, and a better understanding of OTs scope of practice, including when to make referrals. Overall, alumni described feeling more comfortable providing OT care to cancer survivors following the CEM portion of the elective. They felt better prepared to address the topic of cancer with future clients after engaging with cancer survivors, noting that there are some instances in their current practice where they are the most knowledgeable about cancer care and survivorship in a given care team. Reflecting on the hands-on experience, alumni reported that they overcame the nerves of discussing a cancer diagnosis in an individual session with a client. One alumnus mentioned that they felt they would need a specialty in that area despite what was learned in the elective if they were to work solely with the cancer population. See section 4.0 of Table 6 for supporting quotes for this theme. Theme 5: Ability to Apply Course to Current Practice Alumni expressed that they have been able to apply what they learned and experienced during the elective course to their current practice as occupational 23 therapists in varied practice settings. For example, an alumnus felt that strategies learned in the elective helped build up their practice across many populations. At the same time, another mentioned the solid foundation the elective gave them, supporting the subtheme of transferability of skills across settings and populations. Other alumni discussed using energy conservation strategies learned during the elective with current clients. Alumni discussed the subtheme of using resources and the importance of providing community resources to clients to facilitate community support. However, two alumni reported that it has been difficult for them to provide community resources in their current practice due to limited time and referral options in acute care, as well as practicing in states with fewer community resources than where they were educated. In addition to using resources to support cancer survivors, alumni discussed the importance of educating the client, caregivers, and other healthcare professionals. Alumni acknowledged the importance of addressing cancer, even as a secondary diagnosis, and recognizing how it can impact the clients life. Alumni also mentioned educating other healthcare professionals on the needs of cancer survivors, such as giving them rest breaks during activity, as an actual application to current practice. See section 5.0 of Table 6 for quotes supporting this theme. Theme 6: Interest in the Cancer Survivorship Field Finally, multiple alumni reported increased interest in working with cancer survivors after graduation. Most stated that their interest in working with this population increased after taking the elective. In contrast, several indicated that they had a personal connection to cancer, which fueled their interest in the elective in the first place. However, others stated that working exclusively with the cancer population would 24 be too emotionally draining, so they would prefer more variety in their caseload. See section 6.0 of Table 6 for quotes about alumnis interest in the cancer survivorship field. Course Recommendations Researchers asked alumni to provide recommendations to improve the course and suggest changes or additions that would have increased the benefits gained from participation. These recommendations were: expanding the lecture content to include information about the most common diagnoses and symptoms in cancer care, the cancer treatment and cancer care continuums, planning and utilizing assessment tools and interventions that are appropriate for different stages of severity and treatment (e.g., at time of the first diagnosis versus when entering remission), and how to connect both practitioners and patients with appropriate support and resources. 25 Table 6 Supporting Quotes of Alumni for Themes from Focus Groups Theme Quotes from Focus Group to Support 1.0 Hands-on Experience 1. So being able to kind of play with that [community] environment and . . . motivate others into like Hey you're not alone. But I'd say that was the coolest aspect was seeing patients kind of interact with one another, and you know they kind of feed off each other where I've been there before or are easily able to be empathetic toward one another. 2. It's better if you just kind of trial by fire that and just experience it [direct client care] because then you're not gonna forget it. 3. So I got to apply those problem solving skills that the graduate program teaches us. But also I got to get first-hand experience on how we can modify and adapt some of the cancer survivors activities of daily living in order to promote their independence . . . And I think just having that experience there it kind of helped me kind of initiate and start the process of thinking about those activity analyses we were taught in graduate school and how we can just take little tweaks and changes into an activity of daily living or a simple strategy in order to maximize their independence. I also learned a lot about the power of advocating and giving the patient or the cancer survivors their power to advocate for themselves. 4. I think the benefit of going to the cancer support community for our class and me personally, was just to see the impact, emotionally and socially that cancer can have on someone's life. 5. So I know having that hands-on experience and interacting with them in particular was an incredible learning opportunity that shaped my overall perspective of this process. 6. It was an actual person with an active condition and they were coming to us as like a free resource, but it really felt like I had the opportunity just to use my skills and see what I could do to help the person. And that's something that I've taken with me from that. It might have been a short experience, but yeah, it was definitely valuable. 2.0 Perceived Gain of Knowledge and Skills 1. But this [the cancer survivorship elective] was the first class where I was able to kind of get creative on my own and try things and see what would happen and I think that was really valuable. 2. I definitely feel more competent in dealing or treating cancer survivors. 3. Just getting to know them and talk to them on a personal level helped me further in my practice. 4. I think it [the cancer survivorship elective] allowed us to like do a lot of self-guided learning and learn the importance of evidence-based practice and carry that over to like the education with the different people that attended and just carry that into like practice just getting that foundation and learning different things 26 and resources that you could provide people. 5. I think since I was given the opportunity through this elective course since I was able to get hands-on experience like advice, education, I feel like it has made me more competent. It's also made me more accountable, where all cancer survivors are completely different. 3.0 Deeper Understand ing of the Community Setting 1. If one of them [the CSC clients] is having a hard day they can relate and they can kind of you know go at a different pace and kind of bring them up and motivate them. I know we all can kind of relate like if you're having a bad day and someone's, you know, trying to help cheer you up a little bit and make your day better. And, you know, it can be little things like that. and you know, a lot of the patients verbalized that they felt that way. 2. The community setting is a great place to learn that because these most of these patients are past their acute treatment and are in remission and they're still having some sort of side effect or problem that's affecting them. So, getting to see that's something that does last as long, if not longer than treatment and you know, can be years later was definitely something that's more of a norm that I wasn't aware of. 3. I think a lot of times it [cancer] might . . . be brushed over almost with some patients. Like it's just in their [patients] list of things that they have going on, cancers one of them. And sometimes I feel like people even have a difficult time like bringing it up, like they dont want to talk about it. Even healthcare practitioners, just kind of like avoid it. 4.0 Gained Confidence in Working with Cancer Survivors 1. So I feel like that [classroom knowledge] helps me be more confident in approaching the subject, especially for the patients who initially find out [about their diagnosis]. . . . They [the CSC clients] had cancer and you know I can be better prepared and more confident and competent in kind of going into that and meeting my patients, where they're at today? 2. So, it [the cancer survivorship class] helped me personally get over my nerves. Those first few sessions I was very nervous. You know making sure like you know Do I have everything I need? Am I gonna mess this up? But kind of just you know, building that confidence in myself as an OT at that time as a student . . . And I definitely think it's helped with my confidence with survivors in general like working with them when they come in for the one-on-ones. Like getting to say, you know, . . . I've had more experience than just that working with cancer survivors and I've got to see, you know, a range of the effects that it can have on survivors. So I think it's definitely helped a lot with my practice in general. 3. Yes. It definitely led to my interest and just my comfort too with working with that population. 4. Sometimes you might be the one who knows the most about just that diagnosis and how it's impacting that person 5. I think in the elective that having that time to actually be with real people, real cancer survivors, and kind of work with them really provided a good opportunity that way when I went into practice, it was something that I was already very comfortable with even like as a student in my fieldwork. 27 5.0 Course Application 1. So, it [strategies learned from the course] really helps kind of build up your practice with whatever population you're working with. 2. I still use a lot of the energy conservation strategies that the instructor taught us. I actually still actually use the handout that we created as a group in her elective that I give out to survivors, kind of just using the therapeutic use of self that the instructor pushed a lot. 3. I don't think until this elective I understood the power of community resources and the power community support can have on a patient, especially a cancer survivor. Just being able to help those survivors or even patients in any way when they go home . . . I feel the more resources the better and this gives them the the power to delegate and the power to take back their lives where they felt cancer took it [control] away from them. 4. It [the cancer survivorship elective] provided a really good foundational component to be able to go out and then learn further into whatever setting you practice in after that. 5. But even if that [cancer] is not their primary diagnosis or why we're seeing them, I try to address that [cancer] and how it's impacting their occupations, whether it's the fatigue, lymphedema, decreased sleep habits. . .Trying to incorporate that in relating it back to like, You might be here for something else, but this still is part of your life. And how can we best address that to meet your daily needs? 6. I do try to educate family or staff members about how to best like meet a person's needs and giving them [cancer survivors] breaks instead of trying to rush them through whatever they're doing which can be hard in healthcare these days. 6.0 Interest in Field 1. I think I, it kind of started my competency in the area. Before I took her elective, I had no interest really in survivorship. . . . . It definitely fueled my interest in it, so that I continued with it in my capstone and now in my career and doing more research, and I wouldn't say, like, everything I know now is because of that, but it definitely jump started it, and gave me the foundation that I felt competent and confident enough that I wanted to continue with it. 2. I have had cancer survivors on both sides of my family so I already had that interest and passion. It was one of the reasons why I wanted to become an OT but taking this cancer survivorship elective definitely heightened my interest for the population. I did my capstone on it. Anytime we get an oncology patient, I'm the one who sees them therapy wise at my place just because I know a lot and they have that special population place in my heart. I just love working with them and trying to help them through their battle. 28 Integration of Mixed Methods and Visual Diagram There were common intersections between qualitative themes seen throughout the data. Hands-on experience gave alumni a better understanding of the community setting, better awareness of cancer culture, and more comfort working with cancer survivors. The elective also gave alumni the confidence to discuss cancer with other healthcare providers, clients, and families who might be uncomfortable with it. Alumni learned skills in the elective, such as group-based education, that can be applied beyond the cancer population to all populations in alumnis current practice settings. Additionally, knowledge, skills, and a better understanding of the cancer culture through hands-on experience in the course fostered alumnis confidence with application into their current practice. Finally, alumni felt their gained knowledge, skills, and cultural awareness was transferable to current practice. Upon qualitative and quantitative data integration, researchers found multiple areas of agreement between all components (Table 7). Alumni reported increased competence in qualitative themes of a gain of transferable knowledge and skills along with a better understanding of community setting and cancer culture, where they said basic to above basic competency. Alumni also reported above or advanced competency in confidence in working with cancer survivors and applying course content to practice. The Integrative Logic Diagram (Figure 2) is a visual representation of connections between areas of agreement in our data. During and after participation in the CEM, alumni gained transferable knowledge, skills, and a deeper understanding of the community setting and the cancer culture. These contributed to greater confidence in working with cancer survivors, which empowered them to apply course material and 29 experience in their current practice. Throughout all of this, the alumni experienced an increased perceived competence in treating cancer survivors. Overall, the Integrative Logic Diagram in Figure 2 demonstrates qualitative and quantitative data integration as they correspond with increased perceived competence after participating in the cancer survivorship elective. Table 7 Integration Coding of Mixed Methods Analysis Theme (Qualitative) Survey Question (Quantitative) 1. Gain of Transferable Knowledge and Skills - Alumni gained knowledge and client-centered skills required for clinical practice from the elective. - Take-aways from the elective include adaptability, empathy, shared decision making, therapeutic use of self. Corresponding Survey Questions: 1, 2, 10, 11, 12, 14 - Above basic competency was found for the skills of describing OTs role, designing interventions, and providing interventions. - Alumni reported high levels of perceived competence for shared decision making. 2. Better Understanding of the Community Setting and Cancer Culture - Alumni gained a better understanding of treatment in the community setting, whether it be in a group or individual sessions, and overall knowledge of cancer culture from the elective. Corresponding Survey Questions: 3, 4, 5, 6, 7 - Majority of alumni reported above basic competence for providing culturally competent care and understanding cancer culture and cancer-specific side-effects. - More alumni reported basic competence for understanding the impacts of cancer culture on cancer survivors than above basic competence. 3. Gain of Confidence in Working with Cancer Survivors - Alumni showed an increase in confidence and competence of skills while working with cancer survivors after completion of the Corresponding Survey Questions: 8, 9 - Most alumni reported advanced competence for evaluating clients with cancer and cancer survivors. - Majority of alumni reported above average competence in designings 30 elective. and implementing groups for cancer survivors. 4. Ability to Apply Course to Current Practice - Alumni stated application of knowledge gained from course content such as learned conditions or common symptoms to guide current treatment sessions. - Resources or handouts created during the elective are utilized in current practice. Corresponding Survey Questions: 13, 15 - Almost all alumni reported advanced competence for using evidence-based practice and providing resources as a means of intervention support for cancer survivors. - Each alumnus reported at least basic competence in using current research within interventions for cancer survivors. 5. Increased Interest in the Cancer Survivorship Field - Alumni showed an increased interest and comfort in working with cancer survivors following the completion of the elective. No corresponding survey question. Corresponding Interview Question: 10 Figure 2 Integrative Logic Diagram 31 Discussion This study adds to the current literature on cancer care and curriculum development within OT programs, supporting and expanding on the previously-studied benefits of CEMs. Previous researchers found that CEMs improve self-confidence, increase cultural awareness, and improve professional development (Jacobs, 2020; Keane & Provident, 2017; Mu et al., 2016; Peterson et al., 2014). Yet from this study, we found that CEMs are associated with an increased skill set and knowledge transferred into course alumni's current practice. Alumni reported feeling that the elective improved competence in working with cancer survivors. Its design reflected the ELT (Kolb & Kolb, 2017), suggesting that using ELT for curriculum design benefits learning. Both quantitative and qualitative findings reflected that the service-learning course component is associated with alumni's feelings of competency, preparedness, and confidence in practice. Ninety percent of the alumni who took the cancer survivorship elective reported having advanced or expert competence in working with cancer survivors upon entering into practice, suggesting that the elective could have helped prepare them. The findings of Kaf and Strong (2011) further support this elective design, who stated that embedding a service learning component into a pediatric audiology course increased student interest, readiness to evaluate clients, comfort level with patient care, and general knowledge of that specific field. Finally, researchers found a weak, positive correlation between alumnis years of experience in practice and competence scores, implying that with more years of experience, alumni feel more confident working with cancer survivors. 32 Due to the low number of participants in the study, there was not a statistically significant difference in competence scores across alumnis current practice settings. Despite the statistical insignificance of the data, qualitative results suggest improved skills such as adaptability, shared decision-making, empathy, self-guided learning, evidence-based practice, and therapeutic use of self. Even alumni who were not working directly with the cancer population at the time of data collection noted that they treat patients who have cancer as a secondary diagnosis and feel more prepared to work with cancer survivors because of the hands-on experience within the elective course. A theme that emerged from focus groups and interviews is alumni having a better understanding of the community setting and cancer culture. Alumni in the elective expressed increased awareness of social norms that exist in community cancer culture, and an increased confidence in navigating these norms in current practice situations. These results are similar to those in existing literature highlighting CEMs impact on cultural competence. Results from Keane & Provident (2017), Merrit & Murphy (2019), and Mu et al. (2016) also indicate that service-learning courses can increase confidence in working with diverse populations and improve overall cultural competence. These studies integrated international service learning opportunities and showed that students had increased cultural awareness following cultural immersion, supporting hands-on experience in CEMs. While alumni of the elective didnt have an international experience, they did have the chance to be immersed into community cancer culture and expressed how this impacted their cultural competence in working with individuals 33 with cancer. Increased cultural competence following CEMs contributes to practitioners having a more holistic approach to patient care. Other skills gained from the cancer survivorship course that carried over to alumnis current practice include increased confidence, empathy, and therapeutic use of self. In addition to self-awareness and self-efficacy, these skills aligned with personal outcomes uncovered in a literature review investigating student development in service learning (Myers, 2020). Therefore, including CEMs in curricula also supports students self-development and professional identity. Limitations Researchers encountered several limitations while completing this study. After an extensive review of the literature, researchers did not find an appropriate survey to measure the perceived competence of alumni. Therefore, researchers developed a new scale to measure perceived competence, modeling the structure and scoring after an existing scale (Cottrell, 1990). However, due to time constraints, the survey needed to be thoroughly tested for reliability and validity before administration which could impact the dependability of our quantitative results. Researchers had a small number of individuals who qualified to participate in this study, which limited our results' generalizability, significance, and strength. The ideal number of participants required for a focus group was not achieved due to scheduling conflicts, running the study during a global pandemic, and a limited number of potential participants. Interviews did not provide the opportunity for alumni collaboration, potentially impacting data saturation (Krueger & Casey, 2014). Finally, the professor 34 who taught the elective was involved in the coding and analysis process, creating a potential for confirmation bias. Impact on Occupational Therapy Education This study shows that, after participating in a cancer survivorship elective with a CEM service-learning component, entry-level occupational therapists felt competent and confident in their ability to treat cancer survivors, applying the knowledge and skills gained through the CEM. The findings of this study suggest that educators should consider building CEMs, such as service learning, into OT courses to support competence and confidence in the future practice of OT students. Alumni reported that being in this course increased their interest in practicing with cancer survivors and provided them with a better understanding of the scope of OT. The elective also helped them better understand how interprofessional teamwork benefits the patient. These skills learned through hands-on experience are crucial for the future support of OT in cancer care. Therefore, future educators are encouraged to consider embedding CEM components into cancer survivorship courses to foster perceived knowledge, skills, cultural awareness, confidence, and student interests. Future Recommendations Baxter et al. (2017) recommend using CEMs to enhance students learning and suggest integrating cancer care education and courses into OT curricula. Therefore, the creation and implementation of further cancer survivorship courses in OT education should utilize a service learning approach to increase knowledge and confidence in an emerging practice field. 35 Future research about the effect of CEMs in OT education should utilize pre- and post-test measures of perceived competence to grasp these courses' impact better. It would also be beneficial to compare the results of these measures between alumni who have taken the course and those who have not. For courses of this type created in the future, we recommend implementing the course improvement recommendations provided by alumni as described in the Results section of this paper. Additionally, this course took place over only half of a semester. We recommend instead including more course content and patient interaction over an entire semester. Conclusion The results of this study suggest that implementation of CEMs in OT education according to the ELT (Kolb & Kolb, 2017) provides a deeper understanding of the community setting, increased interest in emerging fields of practice, and improved confidence in treatment as an entry-level practitioner. Alumni reported increased confidence, interest, and understanding of treating within an emerging field of practice and reported the benefits of the hands-on model. Graduate-level OT programs should implement CEMs in their curricula to gain knowledge and skills as entry-level practitioners and for transferability into future practice. More research using various forms of CEM in OT curricula is needed. 36 References Alt, K. L., Nguyen, A. L., & Meurer, L. N. (2011). The effectiveness of educational programs to improve recognition and reporting of elder abuse and neglect: A systematic review of the literature. 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... 1 Canine-Assisted Interpersonal Development in an Independent Living Setting for Adults with Developmental Disabilities Anna Slusser May, 2022 A capstone project submitted in partial fulfillment for the requirements of the Doctor of Occupational Therapy degree from the University of Indianapolis, School of Occupational Therapy. Under the direction of the faculty capstone advisor: Dr. Beth Ann Walker, PhD, MS, OTR, FAOTA 2 Abstract Many individuals with ID/DD have challenging behaviors (CB) which may cause household conflict (Bowring et al., 2019; McGill et al., 2018). Scorzato et al. conducted a pilot study and found animal-assisted therapy (AAT) had a significant effect on basic social skills, communication, cooperation, and participation, specifically in group settings, for individuals with intellectual and/or developmental disabilities (Scorzato et al., 2017). A six-session CanineAssisted Team Building Program was designed and implemented to increase Core Members team skills to reduce household conflict by focusing on problem-solving, decision-making, communication, participation, and collaboration. Program outcomes were determined through Core Member reports on the pre/post-test assessment, the Team-Effectiveness Scale, and the Animal-Based Program Feedback Survey. Using narrative analysis, outcomes indicated an improvement in team-building skills and knowledge in all areas and participants reported positive feedback regarding therapy dog incorporation. These outcomes show that canineassisted group sessions focused on team-building can improve individuals' knowledge of conflict resolution skills. According to the CASS Housing staff and Core Members, the therapy dog intraining motivated individuals to attend and participate in classes as well as work together as a team. Keywords: canine-assisted, team-building, adults with intellectual/developmental disabilities 3 Canine-Assisted Interpersonal Development in an Independent Living Setting for Adults with Developmental Disabilities CASS Housing is a non-profit organization in Fort Wayne, Indiana, that assists adults with developmental disabilities (DD) and intellectual disabilities (ID) by providing different levels of community living, programs to attend to improve their cooking skills, money management, wellness, and knowledge on healthy relationships, and support they need throughout their transition and new living experience. The acronym, CASS, represents the mission and purpose of this organization: to create and maintain Customizable, Affordable, Sustainable, and Safe living arrangements for individuals with developmental and/or intellectual disabilities that promote independent living skills (CASS Housing, 2021, para. 3). CASS Housing offers Independent Living housing models for individuals who require minimal to no assistance and complete daily tasks independently. CASS has five Independent Living houses built so far, which house 13 individuals, also known as Core Members (CASS Housing, 2021). According to the Director of Residential Services, there is frequent conflict among the 13 Core Members (C. Stackhouse, personal communication, December 7, 2021). To reduce household conflict, I proposed and implemented a program focused on team building that will provide core members with conflict resolution skills to lessen conflict within their home and community. A unique quality of this program is that it is animal-assisted. Cooper, a therapy dog in-training, will attend and participate in all sessions of the program in hopes to encourage participation, open communication, and collaboration, all critical qualities of a successful team. This paper will determine gaps in the literature, provide a program layout, and determine if CASS core members and staff find this program helps reduce conflict between core members by providing them with conflict resolution skills. 4 Background Schalock, Luckasson, and Tass (2019) define an intellectual disability as significant limitations both in intellectual functioning and in adaptive behavior as expressed in conceptual, social, and practical adaptive skills (p.224). Developmental disability is defined as a set of abilities and characteristics that vary from the norm in the limitations they impose on independent participation and acceptance in society (Odom, Horner, and Snell, 2009, p.4). Common intellectual and/or developmental disabilities experienced by CASS residents include ADHD, Autism, Cerebral Palsy, Down Syndrome, and Developmental Delay. Needs Assessment During the needs assessment, CASS staff identified concerns for resident behavioral issues which may contribute to conflict between residents. I proposed creating a Canine-Assisted Team Building Program to work on communication, problem-solving, decision-making, and collaboration to provide the Core Members with skills to reduce the occurrence of behavioral issues and conflict between Core Members. A Doctoral Capstone Experience (DCE) Weekly Planning Guide was developed and utilized throughout the 14-week capstone to ensure every task was completed in a timely manner (see Appendix A). Challenging Behaviors and Conflict Challenging behaviors (CB) are a recurring problem in supported community living settings for individuals with ID (McGill et al., 2018). According to Bowring et al. (2019), CB may lead to reduced quality of life and negative personal outcomes for adults with ID. Poor quality of life and personal outcomes can result in limited friendships and inclusion, interfere with the individuals development and ability to learn, and are also associated with higher rates of self-injury and injury to caretakers (Bowring et al., 2019; McGill et al., 2018). Individuals 5 with ID/DD who present with CB increase potential conflict within households as their behaviors affect those around them. Bowring et al. (2017) categorized CB of individuals with ID into three categories: aggressive destructive behaviors, self-injurious behaviors, and stereotyped behaviors. Aggressive destructive behaviors consist of biting others, being verbally abusive, and bullying and had a prevalence rate of 8.3%. Self-injurious behaviors include self-scratching, hair pulling, head hitting, and teeth grinding. These behaviors were prevalent in 7.5% of the individuals within this study. Lastly, stereotyped behaviors included repetitive finger and hand motions, rocking/repetitive rocking movements, pacing, jumping, bouncing, running, yelling and screaming, and waving or shaking arms. Stereotyped behavior is most common and has a 10.9% prevalence rate (Bowring et al., 2017). All of these behaviors can result in increased tension and stress in community living settings for the individual, their housemates, and the staff of the organization. Therefore, residents who experience challenging behaviors may benefit from instruction-based interventions such as communication training and discussions regarding selfmanagement skills (Montgomery et al., 2014). Team Building and Collaboration A good team consists of individuals with developed interpersonal skills such as problemsolving, decision-making, communication, as well as participation among each team member (Montgomery et al., 2014). A crucial role of a team is conflict management and resolution through the use of their interpersonal skills and trust in one another (Behfar, Peterson, Mannix, & Trochim, 2008). High trust leads to greater commitment, greater effort, and greater cooperation (Driskell, Goodwin, Salas, and OShea, 2006, p. 262). Therefore, if team members have mutual trust, they will be more likely to give and receive feedback, engage in activities 6 related to conflict resolution, and stimulate healthy, open communication (Driskell, Goodwin, Salas, and OShea, 2006). Addressing the above skills will support conflict resolution in their independent living models and within the CASS community. Individuals with ID/DD often have difficulty with communication skills which may hinder their ability to work well as a team. Communication skills are needed to develop and maintain relationships, have a meaningful job, live independently, and be more likely to face challenges and obstacles in academic settings (Pennington, Bross, Mazzotti, Spooner, and Harris, 2021). Providing support and communication strategies to individuals with ID/DD can promote positive outcomes regarding their communication skills, therefore, leading to a more successful team. Animal-Assisted Therapy and Intellectual Disabilities According to Giuliani and Jacquemettaz (2017), animal-assisted therapy (AAT) is defined as the positive interaction between an animal and a patient within a therapeutic framework (p. 13). Numerous studies found AAT beneficial to individuals with anxiety, a common comorbidity of ID (Cajares et al., 2016; Giuliani & Jacquemettaz et al., 2017; Holman, et al., 2020; Maber-Aleksandrowicz et al., 2016; Phung et al., 2017). However, research limitations exist on the effectiveness of AAT and intellectual disabilities. Giuliani and Jacquemettaz (2017) conducted an observational study where participants with ID completed the State-Trait Anxiety Inventory (STAI) before and after a therapeutic session, either with the therapist and dog or only the therapist. The researchers found that participants had significantly lower scores on the STAI after sessions with the dog than without the dog, demonstrating decreased anxiety levels. 7 Scorzato et al. (2017), conducted the first study addressing the effects of AAT on behavior, basic social skills, and communication in adults with ID, which are all major components of a functional team. Researchers found significant results in incorporating AAT with specific interventions such as fine motor, visuomotor coordination, and basic social skills. Researchers also found that the sole presence of a dog demonstrated positive improvements in individuals basic cognitive abilities, including attention, memory, and communication. Basic cognitive abilities assist with understanding our environment as well as how we respond to our surroundings. Therefore, improved attention, memory, and communication are crucial for performing activities of daily living (ADLs), overall motor development, and social interaction (Scorzato et al., 2017). The impact AAT has on basic cognitive functioning for individuals with ID has the potential to encourage the development of communication skills and positive social interactions and behaviors (Scorzato et al., 2017). Scorzato et al. also found significant results with AAT regarding participation and collaboration in group activities (2017). Based on this study and the above evidence, the Core Members may benefit from canine-based experiences to promote communication skills, social behaviors, and team-building techniques in hopes to reduce household conflict. My program differs from other studies as it focuses on individuals with ID/DD in independent living and will measure the effectiveness of canine-assisted activities regarding team skills. According to Scorzato et al. (2017), there is a lack of research regarding AAT and individuals with ID/DD. I am hoping to provide findings that support canine-assisted activities with this population to begin bridging this literature gap. Theoretical Foundations of Project 8 The Canadian Model of Occupational Performance (CMOP) focuses on the harmonious relationship between the person, environment, and occupation. According to the CMOP, disability is a disruption in one or more areas of occupation that causes difficulty in having those relationships (Cole & Tufano, 2008). Household conflicts between residents are a primary concern of this organization, therefore, demonstrating the residents are in a state of disability. To promote a healthy relationship between the person, environment, and occupation, Core Members should have opportunities to learn and develop team-building skills, conflict resolution skills, and techniques to manage intense behaviors to maintain positive occupational performance. The Canine-Assisted Team Building Program may provide these opportunites as a dogs presence provides a safe environment for many individuals and the dog may act as a motivator to attend and participate in class (Scorzato et al., 2017). Additionally, the Lifespan Development Frame of Reference (FOR) focuses on assisting individuals with transitional tasks and providing developmentally appropriate interventions (Cole & Tufano, 2008). The Core Members recently moved into an independent living home with minimal to no support, therefore, transitioning into adulthood and learning to live independently. Issues encountered during transitions may arise as the individuals are going through new experiences with new individuals. The aim of the Canine-Assisted Team Building Program would be to provide developmentally appropriate interventions for individuals with ID/DD that target problem-solving and decision-making strategies to assist them through this new part of their life. As previously discussed, individuals with ID/DD often experience challenging behaviors (McGill et al., 2018). To provide effective interventions, I am also using the CognitiveBehavioral FOR to encourage successful outcomes as this approach is crucial for developing 9 social skills (Cole & Tufano, 2008). Throughout the program, I will ensure I am providing each individual with an environment in which they can succeed and encourage the individuals to use cognitive processes to reason and create accurate self-perceptions. Tasks will be upgraded and downgraded as needed to motivate the Core Members and to provide them with a safe space to practice their social skills. The Canine-Assisted Team Building Program offers a unique opportunity to practice social skills with one another and with a therapy dog in training. Program Design and Implementation Program Design A program for individuals with intellectual disabilities should be holistic, align with goals related to their lifespan and interest, and have long-term effects (Kishore et al., 2019). Based on the needs assessment and collaboration with the site mentor, the focus for this program centered on reducing conflict by focusing on team-building skills. The goal of the Canine-Assisted Team Building Program was that the Core Members will review and learn two new conflict resolution techniques to lessen conflict within CASS homes and community through improved interpersonal and team-building skills as measured by the pre/post assessment. To gather data on such a specific topic with a particular population, two outcome measures were developed to inform my assessment. The open-ended Team Effectiveness Scale (TES) was used as a pre/post-test to measure how participants viewed themselves as a team member and how they viewed their team as a whole before the program compared to after the program (see Appendix B). The Team Performance Scale guided the development of the Team Effectiveness Scale (Thompson et al., 2009). The TES measures problem-solving, decisionmaking, communication, and interpersonal skills, as well as participation through situationalbased questions and straightforward general questions geared toward the topics of the program. 10 To measure the use of the therapy dog and gather the Core Members' views on the therapy dog, I developed the Animal-Based Program Feedback Survey (see Appendix C). I used the AnimalAssisted Therapy Patient Feedback Survey as a reference when developing this outcome measure (Markovich, 2011). The Animal-Based Program Feedback Survey consists of eight open-ended questions related to the program and was administered during the last session to gather the Core Members' thoughts on the therapy dogs involvement in the program. Both outcome measures were completed in a group setting where the instructor would read each question and have the individuals go in a circle to provide feedback. Program Implementation The Canine-Assisted Team Building Program consisted of six, 60-minute sessions. The overarching theme of the program was team-building and interpersonal skills. Session topics included a general team-building introduction, problem-solving, decision-making, communication, participation, and collaboration. Each session consisted of an activity related to the corresponding topic and reflection following the activity focusing on processing and generalizing the information then applying what they discussed. Sessions had two learning objectives each, one focusing on during the session and the other focusing on takeaways from the session (see Appendix D). The therapy dog in-training was directly involved in every session by assisting with the demonstration of the activity or being incorporated in the activity. Two weeks before the start of the program, flyers and schedules were passed out to core members and were provided to each house. The flyer had a very large picture of the therapy dog on it. On average, seven core members attended each session, eight completed the pre/post-TES, and nine completed the Animal-Based Program Feedback Survey. Program Outcomes 11 The open-ended pre/post-TES measured what the Core Members learned throughout the program regarding their team-building skills. The Animal-Based Program Feedback Survey gave the instructor insight into how the Core Members viewed the therapy dogs involvement in the program as well as what couldve been done differently if replicated. Both tools were developed using pre-existing, similar tools allowing for increased understanding by the Core Members. Due to familiarity with group discussions, the tools were open-ended and completed in a group setting. The TES determined the Core Members growth in knowledge regarding problemsolving, decision-making, communication, participation, and collaboration. The Core Members identified three problem-solving strategies for the pre-TES, and six strategies for the post-TES as a group. For the situational question about decision-making, the participants identified four techniques in the pre-TES and seven in the post-TES. When asked to define good communication skills, the participants pinpointed five factors in the pre-TES and seven in the post-TES. When administering the pre-TES, many of the participants struggled to define a team and the importance of working together. However, during the post-TES, every participant was able to define a team, the skills necessary for a successful team, and the importance of everyones participation and contribution to the team. Individuals reported that their participation changed positively throughout the program as many expressed how critical it is to collaborate and work together. Based on this analysis, the participants, as a whole, demonstrated increased knowledge with team-building skills and activities. According to the Animal-Based Program Feedback Survey, all participants enjoyed having the therapy dog in class as well as being involved in the activities. The Core Members reported that they were more motivated to come to class knowing Cooper would be in 12 attendance. In the opinion of one of the Core Members, Cooper helps us work as a team. None of the participants were able to identify a challenge when working with Cooper and only reported positive feedback. However, one challenge observed by the leader was that Cooper can be a distraction to the Core Members and they can become fixated on him throughout the session. Though, based on the feedback from this survey, Cooper was an asset to the program and provided the Core Members with unique memories and experiences that will help them remember the skills learned in future situations. Cooper attended the majority of the classes and programs offered during the 14-week rotation, not only the Canine-Assisted Team Building Program. Core Members and the Program Director provided positive feedback regarding attendance and participation in other programs when Cooper was present. For instance, some of the feedback included, I am sad when Cooper isnt in class, I go to class to see Cooper, Cooper increases participation and moods during classes, and Cooper motivates me to come to class and learn. Any time Cooper entered the classroom, the room would be filled with joy, laughter, and excitement. When Cooper was in class he would act as an icebreaker and increase conversations between participants who are typically very shy and anxious when engaging in social situations. Another participant reached out to me multiple times reporting that Cooper calms her down and reduces her panic attacks. Cooper was able to make an impact on so many of the individuals in different ways than I had initially anticipated. To encourage the continued development of team-building skills and conflict resolution skills, I developed a CASS Housing Team Building Activity and Resource Binder (see Appendix E). The binder consists of activities completed within the program and 25+ new activities that focus on aspects of team-building discussed throughout the program. Each activity has 13 instructions, supplies needed, and occupations/skills addressed. This binder aims to promote program sustainability as the Core Members can complete these activities together without the help of CASS staff. Summary CASS Housing offers living models for individuals with ID/DD. Prior to housing individuals, staff may have neglected to think about recurring problems and conflicts that arise within the houses and between Core Members. According to McGill et al., CB are a recurring problem in supported community living settings for individuals with ID (2018). Individuals with ID/DD who present with CB increase potential conflict within households as their behaviors affect those around them. Therefore, the needs assessment guided the students capstone project as there was a need for conflict resolution techniques among the Core Members. Though many populations have found AAT beneficial, there is little research on AAT with adults with ID/DD. A pilot study concluded that AAT had a significant effect on basic social skills, communication, cooperation, and participation, specifically in group settings, for individuals with intellectual and/or developmental disabilities (Scorzato et al., 2017). All of the previously listed skills and qualities are components of a successful team (Montgomery et al., 2014). A crucial role of a team is conflict management and resolution through the use of their interpersonal skills and trust in one another (Behfar, Peterson, Mannix, & Trochim, 2008). From the literature review and background research, the topics of the program were developed: problem-solving, decision-making, communication, collaboration, and participation. The program consisted of six, 60-minute sessions. Each session consisted of an activity related to the corresponding topic and reflection following the activity to discuss what went well, what went poorly, alternative methods to the activity, etc. The therapy dog in training was 14 directly involved in every session by assisting with the demonstration of the activity or being incorporated in the activity. Results were determined through Core Member reports on the preTES, post-TES, and Animal-Based Program Feedback Survey. Using narrative analysis, outcomes indicated an improvement in team-building skills and knowledge in all areas (problemsolving and decision-making strategies, communication skills, ways to participate, and the importance of collaborating), and participants reported positive feedback regarding therapy dog incorporation. These findings show that canine-assisted group sessions focused on team-building can improve individuals' knowledge of conflict resolution skills. However, improvements in conflict resolution performance and translation into real-life situations take an extended period of time to achieve. Conclusions This DCE project provided me with ample opportunities to further my personal growth and knowledge as an occupational therapy practitioner. I interacted with the CASS staff, Core Members, and other local organizations on a frequent basis through written, oral, and nonverbal communication. Despite being at a site without an occupational therapist, I still expanded my proficiency in ways that benefit my future practice. For instance, I gained knowledge related to the following topics: adults with ID/DD, animal-assisted therapy, CASS Housing organization, grant writing, leadership, and advocacy. Furthermore, this site and experience allowed me to develop and implement a program that improved my creativity and ability to grade tasks on the spot. Prior to this experience, I had little background in program development and implementation. I was unaware of how in-depth this process was. I advanced my research, creativity, and leadership skills throughout this process. I discovered the importance of flexibility 15 throughout my program sessions as not everything goes as planned. I learned to advocate for the occupational therapy profession and animal-assisted therapy as many individuals have heard of the term occupational therapy, but few knew what it meant. I also became aware that most people thought a therapy dog was the same thing as an emotional support animal. Therefore, I found myself defining a therapy dog and describing its role in therapy often. CASS Housing benefitted from the Canine-Assisted Team Building Program as Core Members are now able to identify conflict resolution strategies and the importance of working together. For program sustainability, an activity binder was given to each CASS Housing home as well as shared electronically with the Directors of CASS. The binder consists of activities that were completed within the program and 25+ new activities that focus on aspects of teambuilding. Each activity has instructions, supplies needed, and occupations/skills addressed. The CASS Housing staff and Core Members were extremely thankful for this resource. The staff is looking forward to the Core Members taking initiative and participating in the activities on their own time and for them to use the binder to further their knowledge and skills regarding teamwork and conflict resolution. The DCE project and activity binder encourage continued development of teamwork and conflict resolution skills among the Core Members. After an extended period of time, I hope the CASS Housing staff observe a positive change regarding household conflict and cooperation. This project also demonstrates the benefits of AAT. The Animal-Based Program Feedback Survey, observations, interviews, and general feedback received from the Core Members, daily service providers, and the directors demonstrated the positive impact the therapy dog had on the participants. The findings of this project assist in bridging the gap between AAT and individuals with ID/DD. 16 References Behfar, K., Peterson, R., Mannix, E., & Trochim, W. (2008). The critical role of conflict resolution in teams: A close look at the links between conflict type, conflict management strategies, and team outcomes. The Journal of Applied Psychology, 93, 170188. https://doi.org/10.1037/0021-9010.93.1.170 Bowring, D. L., Painter, J., & Hastings, R. P. (2019). Prevalence of challenging behaviour in adults with intellectual disabilities, correlates, and association with mental health. Current Developmental Disorders Reports, 6(4), 173181. https://doi.org/10.1007/s40474-019-00175-9 Bowring, D. L., Totsika, V., Hastings, R. P., Toogood, S., & Griffith, G. M. (2017). Challenging behaviours in adults with an intellectual disability: A total population study and exploration of risk indices. British Journal of Clinical Psychology, 56(1), 1632. https://doi.org/10.1111/bjc.12118 Cajares, C., Rutledge, C., & Haney, T. (2016). Animal assisted therapy in a special needs dental practice: An interprofessional model for anxiety reduction. Journal of Intellectual Disability - Diagnosis and Treatment, 4(1), 2528. https://doi.org/10.6000/22922598.2016.04.01.3 CASS Housing. (2021). https://www.casshousing.org/. Cole, M. & Tufano, R. (2008). Applied theories in occupational therapy: A practical approach. Thorofare, N.J.: SLACK Inc. Driskell, J. E., Goodwin, G. F., Salas, E., & OShea, P. G. (2006). What makes a good team player? Personality and team effectiveness. Group Dynamics: Theory, Research, and Practice, 10(4), 249271. https://doi.org/10.1037/1089-2699.10.4.249 17 Giuliani, F., & Jacquemettaz, M. (2017). Animal-assisted therapy used for anxiety disorders in patients with learning disabilities: An observational study. European Journal of Integrative Medicine, 14, 1319. https://doi.org/10.1016/j.eujim.2017.08.004 Holman, L. F., Wilkerson, S., Ellmo, F., & Skirius, M. (2020). Impact of animal assisted therapy on anxiety levels among mentally ill female inmates. Journal of Creativity in Mental Health, 15(4), 428-442. Kishore, M. T., Udipi, G. A., & Seshadri, S. P. (2019). Clinical practice guidelines for assessment and management of intellectual disability. Indian journal of psychiatry, 61(Suppl 2), 194210. https://doi.org/10.4103/psychiatry.IndianJPsychiatry_507_18 Maber-Aleksandrowicz, S., Avent, C., & Hassiotis, A. (2016). A systematic review of animalassisted therapy on psychosocial outcomes in people with intellectual disability. Research in Developmental Disabilities, 4950, 322338. https://doi.org/10.1016/j.ridd.2015.12.005 Markovich, K.M. (2011) An evaluation of an animal-assisted therapy program in an adult inpatient hospital rehabilitation unit. (Publication No. 3484535) [Doctoral dissertation, Adler University]. ProQuest Dissertations Publishing. McGill, P., Vanono, L., Clover, W., Smyth, E., Cooper, V., Hopkins, L., Barratt, N., Joyce, C., Henderson, K., Sekasi, S., Davis, S., & Deveau, R. (2018). Reducing challenging behaviour of adults with intellectual disabilities in supported accommodation: A cluster randomized controlled trial of setting-wide positive behaviour support. Research in Developmental Disabilities, 81, 143154. https://doi.org/10.1016/j.ridd.2018.04.020 Montgomery, J., Martin, T., Shooshtari, S., Stoesz, B. M., Heinrichs, D. J., North, S., Dodson, L., Senkow, Q., & Douglas, J. (2014). Interventions for challenging behaviours of 18 students with autism spectrum disorders and developmental disabilities: A synthesis paper. Exceptionality Education International, 23(1). https://doi.org/10.5206/eei.v23i1.7701 Odom, S. L., Horner, R. H., & Snell, M. E. (Eds.). (2009). Handbook of developmental disabilities. Guilford Press. Pennington, R. C., Bross, L. A., Mazzotti, V. L., Spooner, F., & Harris, R. (2021). A review of developing communication skills for students with intellectual and developmental disabilities on college campuses. Behavior Modification, 45(2), 272296. https://doi.org/10.1177/0145445520976650 Phung, A., Joyce, C., Ambutas, S., Browning, M., Fogg, L., Christopher, B. A., & Flood, S. (2017). Animal-assisted therapy for inpatient adults. Nursing2020, 47(1), 63-66. Schalock, R. L., Luckasson, R., & Tass, M. J. (2019). The contemporary view of intellectual and developmental disabilities: Implications for psychologists. Psicothema, 31.3, 223 228. https://doi.org/10.7334/psicothema2019.119 Scorzato, I., Zaninotto, L., Romano, M., Menardi, C., Cavedon, L., Pegoraro, A., Socche, L., Zanetti, P., & Coppiello, D. (2017). Effects of dog-assisted therapy on communication and basic social skills of adults with intellectual disabilities: A pilot study. Intellectual and Developmental Disabilities, 55(3), 125139. https://doi.org/10.1352/1934-955655.3.125 Thompson, B. M., Levine, R. E., Kennedy, F., Naik, A. D., Foldes, C. A., Coverdale, J. H., Kelly, P. A., Parmelee, D., Richards, B. F., & Haidet, P. (2009). Evaluating the quality of learning-team processes in medical education: Development and validation of a new 19 measure. Academic Medicine, 84(Supplement), S124S127. https://doi.org/10.1097/ACM.0b013e3181b38b7a 20 Appendix A DCE Weekly Planning Guide Week 1 DCE Stage (orientation, screening/evaluation, implementation, discontinuation, dissemination) Weekly Goal Orientation - - 2 Orientation - - Learn about the history of CASS Complete orientation of site/employee s/core members Review project with site mentor and begin brainstorming topics for sessions Continue building a relationship with core members Meet all 15 core members Finalize timeline for my program Objectives - - - Tasks Meet with site mentor, core members, and directors to introduce myself and educate on OT. Update MOU, if needed Shadow directors to see different roles Meet core members and begin to develop a rapport. - Confirm session topics with site mentor Shadow program director and attend vocational classes CASS offers to core members - - - - - Finalize and submit MOU Begin working on methodology of project Determine main theme of project Begin creating templates/outli nes for each session Begin looking for grants for CASS Confirm CASS submitted the background check Set up a recurring meeting with faculty mentor Find 2 grants for CASS to apply for Create PowerPoint about my 21 - Continue literature search - Help core members ramp down the gardens - 3 Screening/Evaluati on & Program Development - - Continue literature search Complete any necessary pretesting/screeni ng Continue working on session plan Have a rough draft of methodology Begin writing introduction - Present program to CASS directors Finalize outcome measures Finalize session 14 plan Determine core members interest - - - 4 Program Development - Continued program planning Finish lit review Score any pretests and review screenings - Finalize session 5 and 6 Schedule rooms for sessions Set up session times Make a physical calendar for core - - project to present in week 3 to directors Attend a quarterly meeting Observe a house tour Observe administration of independent living scale Confirm outcome measures with site mentor Edit literature review Edit/write methodology Continued attendance in established programs at CASS Continue grant work Rough draft of introduction Meet with faculty mentor Meet/communi cate with core members and staff to determine time of sessions Make calendar for core 22 - Continue working on methodology - members with sessions on it Determine and gather necessary supplies - - 5 Implementation - - Introduce therapy dog to core members/site/ staff Implement session 1 - Execute activities within session Complete pre/post test for session Introduce program to core members Review session with site mentor and receive feedback members and staff Schedule space in turnstone for location of program Gather supplies Continue grant work Attend classes and events with therapy dog - Plan Valentines Dance - Confirm meeting time/space for program Record observations throughout session Score pre/post test Edit methods section as sessions occur Continue grant work Attend classes and events with therapy dog Meet with faculty mentor - - Finalize Valentines Dance 23 6 Implementation - Implement session 2 - Execute activities within session Complete pre/post test for session Introduce program to core members Review session with site mentor and receive feedback - - - - 7 Implementation - Implement session 3 - Execute activities within session Complete pre/post test for session Introduce program to core members Review session with site mentor and receive feedback - - - Confirm meeting time/space for program Confirm meeting time/space for program Record observations throughout session Score pre/post test Edit methods section as sessions occur Continue grant work Attend classes and events with therapy dog Confirm meeting time/space for program Record observations throughout session Score pre/post test Edit methods section as sessions occur Continue grant work Attend classes and events with therapy dog 24 8 Implementation - Implement session 4 - Execute activities within session Complete pre/post test for session Introduce program to core members Review session with site mentor and receive feedback - Plan another social event for Core Members - Confirm meeting time/space for program Record observations throughout session Score pre/post test Edit methods section as sessions occur Continue grant work Attend classes and events with therapy dog Meet with faculty mentor - - 9 Implementation - Implement session 5 - Execute activities within session Complete pre/post test for session Introduce program to core members Review session with site mentor and receive feedback - - - Confirm meeting time/space for program Record observations throughout session Score pre/post test Edit methods section as sessions occur Continue grant work Attend classes and match 25 making events with therapy dog 10 Implementation - Implement session 6 - Execute activities within session Complete pre/post test for session Introduce program to core members Review session with site mentor and receive feedback - Administer ILS to Core Members - Confirm meeting time/space for program Record observations throughout session Score pre/post test Edit methods section as sessions occur Continue grant work Attend classes and events with therapy dog - - 11 Discontinuation - Have core members complete post program test - Score and review all screens and tests Gather feedback from core members and staff about the program - Administer ILS to Core Members - Plan themed movie night for Core Members - Attend classes and events with therapy dog Meet with core members individually to complete post program test - 26 - 12 Discontinuation - - - 13 Dissemination - Create physical binder for each house Create an electronic binder and share with site mentor for future houses to have Meet with core members who have pets to show them animal assisted strategies they can use when stressed/anxio us - Present findings to staff via PPT - - - Discuss findings of program with core members and staff Ask core members their preference on binder layout Have staff review binder prior to giving to the homes Create PPT of results Discuss how program can be continued Begin discussing therapy dog leaving to prepare core members Meet with faculty mentor Gather feedback from staff and core members - Administer ILS to Core Members - Gather supplies for binder Find additional resources for binder that werent used in the program Provide additional activities for the core members to further their skills - - - Administer ILS to Core Members - Meet with directors, staff to discuss my findings Pass out binder to Core Members - 27 14 Dissemination - Create poster and VT for UIndy dissemination - Create first draft of poster for UIndy Record VT - Reduce therapy dogs time at CASS - Have site mentor and faculty mentor review poster Write conclusion/sum mary/ and abstract - 28 Appendix B Open-ended TES PRE 1. What is a team? a. What are some qualities and skills of a good team? 2. What are some strategies you know to solve problems? Example: 3. Say you are going to a friends house and someone suggests playing games. What are some ways the group can decide which game to play? 4. What are good communication skills? 5. Say you are in class and your teacher wants everyone to participate in an activity. What are some ways you can participate? 29 POST 1. How did your participation change throughout the program? 2. What strategies did you learn for problem-solving? 3. What is something you learned during the team-building program? 4. Say you are going to a friends house and someone suggests playing games. What are some ways the group can decide which game to play? 5. What are good communication skills? 6. Say you are in class and your teacher wants everyone to participate in an activity. What are some ways you can participate? 30 Appendix C Animal-Based Program Feedback Survey Name: ___________________________________________ Date: ___________________ 1. Did you enjoy the Animal-Based Program? Why or why not? 2. What did you enjoy most? 3. What did you least enjoy? 4. How will Cooper help you remember conflict resolution skills in the future? 5. How did Cooper help you become a better team member? 6. How did Cooper make the CASS team stronger? 7. What was challenging about involving Cooper in group activities? 8. Is there anything else you would like me to know about using Cooper in group activities? 31 Appendix D Learning Objectives of Program Sessions Session 1: Participants will collaborate with one another to complete a timed, team-building activity under 2 minutes. After completing session 1, the participants will be able to identify three skills or qualities necessary for a good team. Session 2: Participants will discover the importance of communication and name two components of good communication. After completing session 2, participants will specify three factors of good communication. Session 3: Participants will list three reasons why collaborating and participating is important when working as a team. After successful completion of session 3, participants will identify three problem-solving strategies. Session 4: Participants will make a decision as a team eight times throughout the session. After session 4, participants will identify three decision-making strategies they can use in a group setting. Session 5: 32 Participants will demonstrate team-building knowledge by planning an event with minimal assistance and cueing from program leader. After session 5, participants will list at least five tasks that goes into planning an event. Session 6: Participants will recall three problem-solving and decision-making strategies they can use when resolving conflict. After session 6, participants will evaluate the event and determine any mistakes or forgotten tasks of planning an event. 33 Appendix E CASS Housing Team Building Activity and Resource Binder CASS Housing Team-Building Activity Binder 2022 Developed by Anna Slusser, University of Indianapolis Occupational Therapy Student 34 Impromptu Skits Areas of Occupation Addressed: - Social skills Social interaction Communication Participation Teamwork Supplies Needed - Paper, pen Scenarios to act out Directions: 1. Come up with multiple scenarios that you want to act out. 2. You can pick to act the skits out in small groups or one large group. 3. Have each group pick a scenario. 4. Take 10-15 minutes to figure out every persons role and practice the skit. 5. When everyone is ready, take turns presenting the skits. Have fun with it! Space Needed Indoor 35 Telephone Areas of Occupation Addressed: - Social skills Social interaction Communication Recall memory Participation Active Listening Supplies Needed - Nothing - just a group of people! Directions: 1. Have everyone sit in a circle or a line. 2. Pick what side of the line will start. 3. The first person thinks of a sentence, word, saying, anything! Once you know what you will say, whisper it into the next persons ear. 4. Once the word has been told to the next person, they will whisper it to the person next to them. 5. When it gets to the end of the line, the last person will say what they heard and see if you got it right. 6. Take turns going first so everyone has a chance to think of a new phrase. Space Needed Indoor or outdoor 36 Get to Know You Bingo Areas of Occupation Addressed: - Social skills Social interaction Communication Recall memory Participation Supplies Needed - People Bingo sheet Marker, pen, or pencil Directions: 7. Print off enough People Bingo sheets for everyone playing. 8. Give everyone a sheet. 9. Ask anyone you see the prompts in the boxes. If you find someone who has done whatever is in the box, have them sign that box. 10. The first person to get 5 boxes in a row (up and down, side to side, or diagonally) calls out BINGO! 11. Once someone calls bingo tell everyone what boxes you got signed. Space Needed Indoor 37 38 Social Jenga Areas of Occupation Addressed: - Social skills Social interaction Quick thinking Decision-making skills Hand-eye coordination Fine motor skills Turn-taking Communication Supplies Needed - Jenga Table to play on Directions: 1. Set-up Jenga 2. Decide who is starting and pick one Jenga block out of the tower. 3. After getting the block out, place it on top of the tower. 4. Then ask either the group a question or tell a fun fact about yourself. 5. Continue this with each player until the tower falls. 6. Repeat until everyone is done playing. Space Needed Indoor or outdoor, weather permitting 39 Talent Show Areas of Occupation Addressed: - Social skills Social interaction Public speaking or performance Event Planning Collaboration/Participation Communication Decision-Making Problem-Solving Supplies Needed - Speaker Chairs Paper Coloring and decorating supplies Items for each individual performance Directions: 1. Everyone thinks of what they want to perform. If you want to have a host, choose one. Otherwise, you can decide the order of acts. 2. Make and decorate signs for each act. 3. Set up chairs for the audience and other performers. Turn on the speaker and have the songs ready to play for the performers. 4. Take turns performing, cheer each other on and have fun! Space Needed Indoor or outdoor, weather permitting 40 Fishbowl Areas of Occupation Addressed: - Communication management Play participation Leisure participation Social participation Teamwork Problem-Solving Supplies Needed - Paper slips Pen/pencil Bowl/basket Timer Notepad Directions: 1. Divide into 2 even teams 2. Each person writes down 5 things that they like on individual paper slips 3. Fold up each slip and place them in the basket 4. (Round 1) Each team will take turns alternating who will select a slip from the basket and explain selected words without using any word written on the slip of paper to get their team to guess as many words as possible in 30 seconds. 5. Once the words in the basket are exhausted, count up the number of words each team guessed (each word guessed is 1 point) then record the score on a notepad. 6. (Round 2) Each team will take turns alternating who will select a slip from the basket and use one word to convey a clue regarding their selected word without using any word written on the slip of paper to get their team to guess as many words as possible in 30 seconds. 7. Repeat step 5. 8. (Round 3) Each team will take turns alternating who will select a slip from the basket and act out their selected word without speaking to get their team to guess as many words as possible in 30 seconds. 9. Repeat step 5. 10. Add up the points from all three 41 rounds for each teams final score. Whichever team received the highest score is the winner. Space Needed Inside or outside 42 Kemps Areas of Occupation Addressed: - Communication management Play participation Leisure participation Social participation Teamwork Decision-making Problem-Solving Supplies Needed - Deck of cards Table Chairs Directions: 1. Divide into even teams of 2 players each 2. Have each pair meet to determine a secret, subtle signal. This signal needs to be non-verbal and nothing too obvious. 3. Once all pairs have decided on a good signal, have everyone sit in a circle facing each other. Partners should be seated across each other. 4. Say, Ready, set, go! and begin the round. Each player can discard a card from their hand and then grab any card from the center of the table. It is an ongoing process without structured turns; players simply exchange single cards from their hands with cards that show up on the table. Again, a player cannot have more than four cards in their hand at the same time. 5. The goal is for you (or your partner) to get four of the same rank (e.g., four 8s, or four Queens, etc.). If no players want any of the four cards that are in the center, the dealer can remove the four cards and deal out four new cards and the process continues. Once you successfully have four-of-a-kind, use your secret signal to try to get your teammate to yell Kemps! If Kemps! is called on a person, that person must reveal their hand to show whether or not they have four-of-a-kind. 6. If your partner yells Kemps! and you 43 have four-of-a-kind (or vice versa), then your team gets a point and wins the round. If your teammate yells Kemps! but you dont have four of a kind (or vice versa), then your team loses a point. You can also yell Kemps! and point to an opponent if you think they have four-of-akind. If successful, you also win a point, but if you are wrong, you lose a point. 7. The team that earns four points (or whatever point value you wish) first, wins. Space Needed Inside or outside 44 Short Outdoor Walk Areas of Occupation Addressed: - Communication management Play participation Leisure participation Social participation Health management Supplies Needed - Good walking shoes Directions: 1. Go as a pair or as a group 2. Tell other team members in charge where you are going before you go. 3. Stay on the sidewalk and watch for oncoming traffic when crossing the street Space Needed Outside 45 Outdoor Scavenger Hunt Areas of Occupation Addressed: - Communication management Team-Building Collaboration Play participation Leisure participation Social participation Health participation Supplies Needed - Scavenger hunt list (can find several others on Pinterest or Google) Pen/pencil Directions: Space Needed 1. Work together as a group to find all of the items on the list 2. Mark off each item as you find them 3. Stay together as a group Outside 46 47 Music/Karaoke Areas of Occupation Addressed: - Communication management Play participation Leisure participation Social participation Collaboration Supplies Needed - Phone with music or musical instrument Speaker (optional) Your voice! :) Directions: Space Needed 1. Pick different songs and sing either individually, with a partner, or as a group 2. (Optional) Have someone play a musical instrument for each song or play a song on someones phone/speaker/etc. 3. Sing! Inside or outside 48 Hot Potato/Musical Ball Areas of Occupation Addressed: - Physical activity Play participation Teamwork Problem-Solving Decision-Making Supplies Needed - Small or large ball Music/Speaker Directions: 1. Have players sit in a circle 2. One person starts holding the ball 3. Turn on the music and have one person in charge of stopping/starting music 4. Pass the ball around the circle as quickly as possible 5. Have one person stop/start music randomly 6. If the ball stops on you when the music stops, you are out! 7. Play until only one person is left in the center of the circle Space Needed Outside 49 Movement Chain Areas of Occupation Addressed: - Physical activity Play participation Cognition Social participation Teamwork Decision-Making Supplies Needed - None Directions: 1. Everyone stands in a circle where you can view each player 2. Nominate someone to start the chain 3. This nominated person does a movement/pose (ex. Thumbs up, kick, jumping jack, yoga pose) 4. Go around the circle, the next player does the first players movement and then a movement of their own in sequence 5. Continue around the circle repeating prior movements in order and adding your own/new movement to the end of sequence 6. Continue until everyone adds a movement to the sequence Space Needed Inside or outside 50 Group Storytelling Areas of Occupation Addressed: - Social participation Creativity Cognition Communication Participation/Collaboration Supplies Needed - None Directions: 1. One individual or group decides the topic of a story they will tell 2. The first person tells one sentence to start the story 3. Each person then adds a sentence to the story one at a time, taking turns 4. Continue to add sentences to the story until each player has added one sentence or the story is ready to end Space Needed Inside 51 Medusa Areas of Occupation Addressed: - Play participation Teamwork Collaboration Supplies Needed - None Directions: 1. Players stand in a circle with arms around each other OR can stand at a distance from each other 2. All players bow heads/look at the ground 3. At the count of 3 everyone looks up at another player 4. If 2 people are looking at each other, they are frozen and out of the game 5. The game continues until there are only 2 players left Space Needed Inside or outside 52 Junk in the Trunk Areas of Occupation Addressed: - Physical activity Play participation Problem-Solving Supplies Needed - Tissue box String/rope/belt Glue or tape 8 ping pong balls Directions: 1. Attach tissue box to string/rope/belt to make it look like a waist pouch or bum bag 2. Remove plastic from the tissue box so there is a clear opening, and expand the opening of the tissue box into a rectangle shape 3. Put ping pong balls in a tissue box 4. Have player tie box around waist 5. Players get one minute to shake body to try to get ping pong balls out of the box, cannot use their hands! 6. The person who gets the most balls out in a minute is the winner Space Needed Outside 53 Sleeping Beauty Game Areas of Occupation Addressed: - Play participation Creativity Social participation Communication Problem-Solving Decision-Making Supplies Needed - None Directions: 1. One person is sleeping beauty and has to bow their head/lay their head down on table 2. Each player who is not sleeping beauty tries to take a turn waking up sleeping beauty- making them open their eyes, laugh, make a sound, etc. 3. The player who wakes up sleeping beauty gets the turn at being sleeping beauty Space Needed Inside or outside 54 Blindfold Drawing Areas of Occupation Addressed: - Play participation Social participation Creativity Teamwork Problem-Solving Decision-Making Supplies Needed - Paper Drawing utensils Pictures to copy Directions: 1. Divide group into teams of 2 players 2. One player holds a picture. The other player has a piece of paper and a drawing utensil. 3. The player with the picture must not show their other teammate the picture 4. The person with the picture describes to the other person what to draw, but they can not explicitly state what the picture is; they must use adjectives and directions 5. Set a time limit for the teammate to stop drawing, at end of the time limit both players view the picture and draw Space Needed Inside 55 Whats my Name? Areas of Occupation Addressed: - Social participation Play participation Communication Participation Teamwork Problem-Solving Decision-Making Supplies Needed - Name tags/labels Directions: 1. On name tags, write down famous people or stereotypes that all players would know (Moana, Olaf, doctor, athlete, Mickey Mouse, etc.) 2. Can make it Disney-themed so that all players are a Disney character, or more specific like Frozen-themed where all players are a Frozen character 3. Put name tags/labels on players backs so they cannot see who they are 4. Walk around, mingle, answer and ask questions to various players about who they are and who you are 5. Try to figure out your label 6. As each player figures out who they are and guesses correctly, they can exit the game or only answer questions 7. Play until all players figure out who they are Space Needed Inside or outside 56 Who is Most Like the Easter Bunny? Areas of Occupation Addressed: - Leisure participation Peer group participation Play participation Communication Decision-Making Supplies Needed - Pencils, pens, or markers Attached printout or similar optional paper or whiteboard for tallying Directions: 1. Hand out copies of the attached handout for all group members, with writing utensils 2. Instruct members to circle all activities or items on the sheet that match what they are wearing, what they did this week, etc. 3. Consider reading options out loud to make this activity more synchronous 4. Have members tally up all points for the activities they circled and write their score on the blank at the bottom of this sheet 5. The person with the most points wins! Space Needed Indoor or Outdoor, weather permitting 57 58 The M and M Game Areas of Occupation Addressed: - Leisure participation Social participation Peer group participation Teamwork Collaboration Supplies Needed - A bag or two of M and Ms (feel free to substitute with any multi-colored candy if any group members have food allergy concerns) Handout with color definitions below Directions: 1. Distribute a handful of M and Ms to each person 2. Pick one person to start the game by picking up M and M from their pile and answering the question corresponding to the color of M and M they chose 3. Refer to the attached handout for color questions. Again feel free to modify colors if using different candies. 4. Repeat around the group as each member chooses a color and answers the question This builds team member familiarity and increases social participation with peers Space Needed Indoor or Outdoor, weather permitting 59 60 SPUD Areas of Occupation Addressed: - Play participation Leisure participation Friendships Peer group participation Teamwork Communication Supplies Needed - One soft or squishy ball Directions: 1. Have the group stand in a circle and choose one person from the group to be it 2. The it person gets the ball and stands in the center of the circle 3. The it person throws the ball in the air and calls one persons name while everyone runs as fast as they can. 4. The new person whose name is called runs back to the center and grabs the ball, yelling STOP. 5. As soon as STOP is called, everyone freezes in place. 6. The new it person with the ball can take four big steps to reach the closest person (SPUD, four letters and four steps) 7. AFter these steps, the new it person tosses the ball and tries to hit the closest person and tag them out. 8. If the closest person dodges the ball or catches it, the new it person is out and the closest person is now it 9. If the closest person is hit with the ball, they are out and the new it person remains it 10. Everyone forms a new circle and the game starts again 11. Keep playing until there is one player left Space Needed Outdoor parking lot or grass space 61 Staring Contest Areas of Occupation Addressed: - Social participation Leisure participation Play participation Peer group participation Friendships Eye contact - communication Supplies Needed - None Directions: 1. Divide group members into pairs and have them sit or stand facing each other 2. On the count of three, have each pair maintain eye contact without blinking for as long as they can 3. For each pair, the person who blinks first is out 4. Pair winners from each pair with the winner from another pair and repeat the staring contest 5. Continue until there is one person left, the ultimate staring contest winner Space Needed Indoor or Outdoor, weather permitted 62 Up and Down the River Card Game Areas of Occupation Addressed: - Social participation Leisure participation Play participation Peer group participation Decision-Making Problem-Solving Supplies Needed - Deck of cards Directions: Preparing a score sheet: 1. Take a blank page and write all the names of players at the top of it. 2. On the left-hand side, make a column to write the number of rounds being played. 3. Start with the number 10 and continue writing the numbers in descending order. 4. Once you reach 1, start writing the numbers again in ascending order till 10. 5. In total, you will have 19 rounds. Playing the Game 1. Players take a seat in a circle. 2. A dealer is chosen among the 3. 4. 5. 6. players to shuffle the deck and pass around 10 cards to each player. The players can look at their cards. Rest of the deck is kept in the middle with the top card turned face up. This card is not used in the game. The suit of that card will be considered a trump suit for that round of the game. It means that while playing the tricks or hands, any card from that suit will beat other suits of cards. After the revelation of the trump card, each player bids the number of tricks he believes he can win. 63 The bid can vary from zero to 10 as players have 10 cards each. 7. After the bidding, a player sitting on the left of the dealer will begin a new trick of the round. He will draw a card from his stack and place it in the middle. 8. The turn will go clockwise as every player will draw 1 card each. 9. After cards from each player are drawn, the player who has the highest card in the drawn stack wins that trick or hand. 10. The winner gets a chance to draw a card for a new trick. 11. The game continues till all the cards are taken. 12. The cards from the trump suits are used to win the hands. However, if the hand contains more than one trump card, the trump card of the highest value wins that hand. 13. As the game is being played, each player needs to collect as many hands or win as many tricks as he had bid at the beginning of the round. 14. At the end of one round, the scores are tallied and written on the score sheet. 15. After all the 19 rounds end, the highest scorer wins the game. Rules and scoring for the game: Ace is the highest, while two is the lowest. Trump cards are used to win the hand while playing tricks. While playing a trick, if a player draws a trump card, it will win that player that trick even if the other 64 Space Needed cards of different suits are higher in value. Each won trick earns a point for the player. A player needs to win as many tricks as he bids. This earns him bonus points. For example, if a player bids 5 tricks when won, he earns 5 points plus 10 bonus points. If a player wins more tricks than he had actually bidden, he loses points. For example, if the player has bid for only 5 tricks, but wins 7, then he gets only 2 points. If a player bids 0 tricks and succeeds in winning no trick, he receives 5 points. Indoor or outdoor, weather permitting 65 Name that tune Areas of Occupation Addressed: - Social participation Leisure participation Teamwork Decision-Making Communication Supplies Needed - A phone to play music Directions: 1. Split your group into two teams. Teams will be playing head to head in this game the entire time. 2. Play your first song from your playlist. When you play a song, teams will try to be the first ones to shout out the name and artist of the song. The first team to guess the song and artist will earn points for their team. 3. Points can be split across the two teams for each song if one team guesses the song first and one song guesses the artist. You can also give additional points if the song is from a movie, Broadway musical, etc. but its completely up to you. Space Needed Indoor or Outdoor, weather permitted  ...

... 1 The Role of Occupational Therapy in the Care of Post-Thrombectomy Patients: A Narrative Review Sara Skarshaug, OTS May 2022 A capstone project submitted in partial fulfillment for the requirements of the Doctor of Occupational Therapy degree from the University of Indianapolis, School of Occupational Therapy. Under the direction of the faculty capstone advisor: Katie Polo, DHS, OTR, CLT-LANA 2 Abstract Cerebrovascular accidents (CVA), also known as strokes, are the leading cause of neurological impairment in adults in the world. As a result, stroke treatments have evolved to reduce strokerelated disabilities in patients. The current standard of care includes mechanical thrombectomies for patients who qualify. Occupational therapy (OT) practitioners and other rehabilitation professionals are skilled at restoring function by adapting tasks and environments and remediating skills lost due to stroke. However, the role of OT practitioners in the care of postthrombectomy patients is not well documented in the literature. This narrative review discusses the frequency and timing of OT services, as well as potential interventions used by OT practitioners with post-thrombectomy patients. Suggestions for future research, limitations of current literature, and limitations of the present paper are discussed. Keywords: occupational therapy, thrombectomy, stroke rehabilitation 3 Background Cerebrovascular accidents (CVA), also known as strokes, are the leading cause of neurological impairment in adults in the world (Feigin et al., 2017). When a patient presents to the hospital with stroke-like symptoms, there are many different treatment options, depending on the type of stroke and the duration of the symptoms. In the care of patients who have had a stroke, early intervention is crucial. Currently, mechanical thrombectomies are the standard of care for patients who present to the hospital within 24 hours of symptom onset, and it involves a quick procedure in which a neurosurgeon removes a blood clot from a cerebral artery or vein (Oliveira-Filho & Samuels, 2022). Mechanical thrombectomies paired with medical management post-procedure are associated with lower incidences of disability after 3 months, compared to medical management alone, and earlier procedures are associated with better functional outcomes (Saver et al., 2016). These procedures are also associated with shorter hospital stays (Fuhrer et al., 2019), causing stroke rehabilitation hospitals worldwide to add these procedures to their services (Mathews & De Jesus, 2022). In 2018, the Joint Commission established a Thrombectomy-Capable Stroke Center certification program to designate hospitals that are capable of performing this service (Joint Commission, 2021). Hospitals who receive this designation perform mechanical thrombectomies 24 hours per day, 7 days per week, and have an acute stroke team present at bedside within 15 minutes (Joint Commission, 2021). In Michigan, where this narrative review took place, there are three Thrombectomy-Capable Stroke Centers (Michigan Department of Health and Human Services, 2021). Across the country, 44 hospitals are Thrombectomy-Capable Stroke Centers, and this number will likely grow as the procedure becomes more widely utilized (Baker et al., 2020). 4 Post-thrombectomy, a multidisciplinary rehabilitative care team is necessary, including occupational therapy (OT), physical therapy (PT), and speech therapy (ST) (Leslie-Mazwi et al., 2017). Due to the growing popularity of the thrombectomy procedure, it is important to understand the role that each member of the rehabilitation team has in recovery to minimize any complications. Potential complications post-thrombectomy include hemorrhages, reocclusion of the vessel, cerebral edema, and complications with the access site, typically the femoral artery (Krishnan et al., 2021). In this paper, I will discuss the role of OT in post-thrombectomy recovery. Needs Assessment With the growing prevalence of thrombectomies in stroke rehabilitation, the current practice guidelines for post-thrombectomy care do not include OT specifically (Jadhav et al., 2018; Leslie-Mazwi et al., 2017). Additionally, rehabilitation services are not always mentioned beyond early mobilization protocols, which are controversial in their effectiveness (Jadhav et al., 2018). For this reason, a review of the literature is warranted to determine the role of OT practitioners in the functional independence and mobility of these patients. This narrative review took place in a regional hospital in Michigan that performs thrombectomies but is not classified as a Thrombectomy-Capable Stroke Center. Much of the literature surrounding successful thrombectomies highlights a quick return to functional independence and increased use of upper extremities (Fuhrer et al., 2019; Pego Prez et al., 2021). However, the literature surrounding the impact of the rehabilitation team, particularly OT practitioners, is less prevalent. Chang et al. (2020) noted that successful thrombectomies are associated with increased scores on functional measures such as the Barthel Index. However, the authors did not discuss the role that rehabilitation professionals have in maximizing functional outcomes (Chang et al., 2020). 5 Given OT practitioners clear role in general stroke rehabilitation (AOTA, 2015), it is likely that the profession has a significant role post-thrombectomy as well. However, it is unclear whether there are certain precautions or considerations that OT practitioners need to be aware of with these patients and there is a paucity of literature reviews on this topic. The purpose of this narrative review is to investigate the available literature regarding the role of OT in stroke rehabilitation post-thrombectomy, and the interventions that OT practitioners commonly implement. The presence of this literature may reinforce the need for OT with this population and begin the discussion for formalized best practices to guide practitioners in their interventions. Theoretical Base The Occupational Therapy Intervention Process Model serves as a guide for this review as this model identifies the unique focus of OT in helping to restore function, which is the goal of this narrative review. According to Fisher (1998), OT practitioners utilize a top-down approach in four domains: exercise, contrived occupation, therapeutic occupation, and adaptive occupation (p. 509). The model also discusses the OT practitioners role throughout the evaluation, intervention, and discharge process, including specific factors relating to the patients personal context and the specifics of their diagnosis (Fisher, 1998). The model exemplifies the goal of this narrative review in delineating OT practitioners unique role in the rehabilitation process, this review will specifically investigate the role of OT practitioners in the care of postthrombectomy patients. The Motor Learning frame of reference serves as a guide for this review as the goal is to determine the role of OT in post-thrombectomy recovery and, more specifically, the different tasks and interventions that are involved in regaining function. The ultimate goal of this frame of 6 reference is for patients to achieve recovery, where their post-stroke functioning is the same as their pre-stroke functioning (Cole & Tufano, 2008). Patients can achieve recovery through continuous practice of skills until a transfer of learning occurs, whereby the patient is able to perform tasks in a variety of environments (Cole & Tufano, 2008). Methods Given the wide scope of this review, articles met the inclusion criteria if they included OT or rehabilitation in their analyses of adult post-thrombectomy patients, or if they used an outcome measure used by OT practitioners (i.e. Barthel Index, Functional Independence Measure, AMPAC), and they must be written in English if they are international articles. Articles were excluded if they did not mention rehabilitation therapies, if they did not include patients received thrombectomies, or if they were below a Level IV evidence rating according to the Johns Hopkins Evidence-Based Practice Model (Johns Hopkins University School of Nursing, 2017). The aim of this paper is to review the available literature on OTs role in the care of postthrombectomy patients, and the types of interventions used with these patients. Databases used for the article search included CINAHL, Medline, and Academic Search Complete databases, as well as Google Scholar. Filters included publications within the last 10 years, peer-reviewed articles, and articles in English. Keywords included occupational therapy and thrombectomy, and rehabilitation and thrombectomy. Thirty-one studies were included in the initial analyses with a full article review, and fourteen articles were included in the final analysis. Articles were then synthesized into an evidence chart and organized into themes for further discussion. See Table 1. for information on the articles retrieved. 7 Table 1 Articles Retrieved from Literature Search Database Used Keywords Filters Used Articles Remaining after Filters Full-articles Reviewed Articles Included in Appraisal UIndy Library Database Occupational therapy and thrombectomy Last 10 years, peer-reviewed, English 14 4 3 UIndy Library Database Early mobilization and thrombectomy Last 10 years, peer-reviewed, English 24 2 2 Google Scholar Occupational therapy and thrombectomy Last 10 years, peer-reviewed, English 2,360 25 9 Note. One researcher participated in retrieving and appraising all articles. Results Fourteen articles were included in the final analysis discussing the role of OT in postthrombectomy care. Five themes emerged from the analyzed articles: frequency and timing of OT services, OT as a part of the interdisciplinary care team, ADL independence after thrombectomy, upper extremity function after thrombectomy, and psychosocial symptoms after thrombectomy. See Appendix A. for a summary table of each article in terms of bias and quality of evidence. Frequency and Timing of Occupational Therapy Services Nine articles included in the final analysis discussed frequency and timing of OT services. This theme contained three articles of Level II evidence, five articles of Level III evidence, and one article of Level IV evidence, ranging from moderate to high quality (Johns 8 Hopkins University School of Nursing, 2017). Potential biases for this theme include small sample sizes, selection bias or missing information due to retrospective study designs, limited generalizability due to highly specialized study sites, and limited discussion of patients with poor outcomes. Frequency and timing of OT services are important clinical decisions in the rehabilitative care plan. Early mobilization is a program that encourages rehabilitation professionals to assist patients with out of bed activity early in the recovery process. OConnor and colleagues (2019) conducted a retrospective case-control study in which one group received early mobilization and one group received routine treatment. The early mobilization group was seen by OT and PT an average of 16 hours sooner and their length of stay was over 1.5 days shorter than those with routine treatment (OConnor et al., 2019). Burch and colleagues (2018) supported these findings by reporting that earlier evaluations from OT and physical therapy (PT) yielded higher functional scores on the Kansas University Hospital Physical Therapy Acute Care Functional Outcomes Tool in a population of 127 post-thrombectomy patients. Patients who did not receive OT and PT evaluations scored higher on the National Institute of Health Stroke Scale at discharge compared to those who did, indicating higher levels of functional independence in patients who were seen by rehabilitation professionals (Burch et al., 2018). Additionally, Thabet and colleagues (2015) recommended OT evaluations within 48 hours post-thrombectomy to determine discharge plans and any safety concerns that arise. These findings highlight the importance of early participation with therapy when working with post-thrombectomy patients. However, Stuchiner and colleagues (2019) found that mobilization within 24 hours with postthrombectomy patients did not have a significant impact on 90-day outcomes. Regarding frequency, there is evidence that intensive rehabilitation is effective in improving functional outcomes (Belgaje et al., 2014). Researchers conducted a study in which 9 participants in skilled nursing facilities (SNF) and inpatient rehabilitation facilities (IRF) with similar medical comorbidities were compared based on their functional outcomes. Researchers found that patients discharged to a SNF were less likely to achieve a good outcome compared to those discharged to IRFs, with 25% of patients in SNFs and 46% in IRFs achieving good outcomes (Belgaje et al., 2014). Chiu and colleagues (2021) reaffirmed the idea that early and intensive rehabilitation yields more favorable outcomes by comparing a group of patients that did not receive acute rehabilitation with a group that did. Those who received acute rehabilitation experienced shorter stays in the hospital and were able to transfer to intensive inpatient rehabilitation facilities more quickly (Chiu et al., 2021). Occupational Therapy as a Part of the Interdisciplinary Care Team Four articles included in the final analysis discussed OT as a part of the interdisciplinary care team. This theme contained four articles of Level II evidence ranging from moderate to high quality (Johns Hopkins University School of Nursing, 2017). Potential biases for this theme include small sample sizes, selection bias due to retrospective study designs, limited generalizability due to highly specialized study sites, and a limited discussion of patients with poor outcomes. OT is an established profession in stroke rehabilitation, including after endovascular treatments including thrombectomies (Leslie-Mazwi et al., 2017). Leslie-Mazwi and colleagues (2017) emphasized the importance of OT evaluations in their practice guidelines for neuroradiologists, neurologists, and neurointerventionalists working with post-thrombectomy patients. Specifically, researchers stated that all post-thrombectomy patients should be seen by an interdisciplinary rehabilitation team, including OT, PT, and speech therapy, while in the acute care setting (Leslie-Mazwi et al., 2017). In multidisciplinary practice guidelines created by the Society for NeuroInterventional Surgery, Pierot and colleagues (2018) restated the role of OT in 10 the care of the post-thrombectomy patient, specifically in rehabilitating the patient and assisting with community reintegration following discharge. The two practice guidelines shared the belief that an OT practitioner should, at minimum, evaluate the patient acutely to identify barriers for safety at discharge, and ideally provide intensive rehabilitation services post-thrombectomy (Leslie-Mazwi et al., 2017; Pierot et al., 2018). However, researchers stated that more research is needed on this topic since the widespread usage of mechanical thrombectomies is still relatively new (Pierot et al., 2018). Chiu and colleagues (2021) emphasized the importance of OT practitioners and the rest of the rehabilitative care team in ensuring favorable outcomes. Researchers found that a cohesive rehabilitation care team is essential to establishing a care plan for patients to support a safe discharge to the community (Chiu et al., 2021). Chu and colleagues (2020) supported the recommendation for a comprehensive rehabilitation team including OT. Specific recommendations for OT interventions included posture training, transfer training, ADL training, cognitive training, and constraint-induced movement therapy (Chu et al., 2020). Reuter and colleagues (2016) reported a 30% undersupply of OT practitioners in a large hospital network in Germany, which has implications for stroke rehabilitation. The result of this is that patients with either very favorable or very unfavorable outcomes are less likely to receive OT in an attempt to optimize resources when there is a shortage of practitioners (Reuter et al., 2016). Specifically, stroke patients with a modified Rankin score from two to five at discharge received the highest number of therapy sessions compared to patients who fully recovered or died in the hospital (Reuter et al., 2016). 11 ADL Independence After Thrombectomy Four articles included in the final analysis discussed ADL independence after thrombectomy. This theme contained one article of Level I evidence, one article of Level II evidence, and two articles of Level III evidence ranging from moderate to high quality (Johns Hopkins University School of Nursing, 2017). Potential biases for this theme include small sample sizes, selection bias due to retrospective study designs, limited generalizability due to highly specialized study sites, and participant attrition due to changes in neurological status. Maximizing intervention time by focusing on high-value interventions is crucial. According to Aoki and colleagues (2019), an early focus on training in activities of daily living (ADLs) and swallowing function during feeding is fundamental to ensuring safe discharges to the home setting. Since OT practitioners are skilled in providing intervention surrounding ADLs, they are a valuable component of the multidisciplinary rehabilitation team and supporting independence at discharge. Independence in ADLs is crucial for a safe discharge home, as patients need to take care of themselves or have the support at home to complete these tasks. Revert-Vallarroya and colleagues (2020) found that thrombectomy treatments compared to best medical treatment yielded increased functional independence, as evidenced by scores on the Barthel Index three months post-stroke. Researchers also identified significantly greater improvements in scores on the National Institute of Health Stroke Scale, modified Rankin Scale, and Stroke Impact Scale after three months in the thrombectomy group (Revert-Villarroya et al., 2020). A major limitation of this study was the lack of discussion on rehabilitation professionals role in these improvements. It is unclear whether OT practitioners were involved during the participants 12 hospital stay, but it is possible due to the use of the Barthel Index as an outcome measure, a commonly used OT assessment for ADL independence (Revert-Villarroya et al., 2020). Belgaje and colleagues (2014) advocated for the implementation of intensive therapies post-thrombectomy due to their impact on return to ADL independence during recovery. Researchers attributed good outcomes to the presence of intensive rehabilitation services, including OT, PT, speech therapy, and physical medical and rehabilitation physicians (Belgaje et al., 2014). Chiu and colleagues (2021) supported these findings by highlighting the impact that post-acute care rehabilitation has on functional outcomes, especially Instrumental Activities of Daily Living (IADLs). Patients that received post-acute care rehabilitation improved significantly more in all functional outcomes including ADL performance, oral intake, cognitive function, IADLs, quality of life, and balance, compared to those who did not receive post-acute care rehabilitation (Chiu et al., 2021). Upper Extremity Function After Thrombectomy Two articles included in the final analysis discussed upper extremity function after thrombectomy. This theme contained two articles of Level III evidence, both of moderate quality (Johns Hopkins University School of Nursing, 2017). Potential biases for this theme include small sample sizes and selection bias due to retrospective study designs. A necessary component of ADL training post-stroke is increasing function and involvement of the affected upper extremity. Branco and colleagues (2021) recommend a variety of interventions for OT practice including bimanual coordination, mirror therapy, transcranial magnetic stimulation, and constraint-induced movement therapy if appropriate. Researchers emphasized the importance of therapeutic intervention in the first twelve weeks post-stroke, the period of time in which the most functional gains typically occur (Branco et al., 2021). Additionally, those who underwent a 13 successful mechanical thrombectomy demonstrated greater improvements than those who did not (Branco et al., 2021). Conversely, Tokuda and colleagues (2021) found no significant differences in improvements in upper extremity function between patients who underwent mechanical thrombectomy and patients who did not. However, both groups demonstrated significant gains in upper extremity function according to the Fugl-Meyer Assessment following 20-40 minute sessions with OT five to six times per week for approximately six weeks (Tokuda et al., 2021). Psychosocial Symptoms After Thrombectomy Two articles included in the final analysis discussed psychosocial symptoms after thrombectomy. This theme contained one article of Level I evidence and one article of Level IV evidence, both of moderate quality (Johns Hopkins University School of Nursing, 2017). Potential biases for this theme include a lack of appraisal of articles reviewed by Thabet et al. (2015) and participant attrition due to changes in neurological status. Psychosocial concerns post-stroke are another common place for rehabilitation professionals to assess and intervene. According to Thabet and colleagues (2015), 30% of post-stroke patients may experience symptoms of depression, requiring the need for skilled intervention. Researchers also stated that this is within the scope of rehabilitation professionals including OT practitioners (Thabet et al., 2015). Regarding interventions, one study compared health related quality of life (HRQoL) and coping strategies between post-thrombectomy patients and patients who received best medical treatment (Revert-Villarroya et al., 2020). Researchers found that HRQoL was higher among the post-thrombectomy patients and the best medical treatment group demonstrated higher levels of coping skills (Revert-Villarroya et al., 2020). However, Revert-Villarroya and colleagues (2020) discussed how this may be because post-thrombectomy patients are not required to develop coping skills due to their quick functional improvements. Nevertheless, 14 coping skills, specifically problem-based coping skills, are important for approaching and overcoming challenges related to potential post-stroke deficits, and should be addressed by rehabilitation professionals when assessing for safety upon discharge from the hospital (RevertVillarroya et al., 2020). Discussion Since thrombectomies are the standard of care currently (Oliveira-Filho & Samuels, 2022), it is essential that the role of each healthcare professional is clearly delineated. As outlined in this paper, OT practitioners and rehabilitation professionals in general have a large role in the care of post-thrombectomy patients. With the growing amount of literature on the effectiveness of thrombectomies in stroke treatment, further delineation of OTs specific role in their rehabilitation post-operation is warranted. The analyzed studies discussed the role of OT in the care of post-thrombectomy patients and delineated some common interventions or assessments. The findings of the discussed studies have multiple implications for OT practice. First, there was a consensus among the studies that frequent OT intervention is indicated for a return for functional independence (Thabet et al., 2015; Burch et al., 2018; OConnor et al., 2019), however the impact of earlier evaluations on functional outcomes is inconsistent (Stuchiner et al., 2019). The importance of high frequency interventions places a greater role on the OT practitioner and other rehabilitation professionals to advocate for IPR placements for these patients (Beljage et al., 2014; Chu et al., 2020; Chiu et al., 2021). Second, OT practitioners should focus on ADL training, UE strengthening and coordination, and discussions surrounding coping and mental health in their interventions (Aoki et al., 2019; Revert-Vallarroya et al., 2020; Branco et al., 2021; Tokuda et al., 2021). The OT interventions discussed in the analyzed studies are congruent with current practice guidelines for stroke rehabilitation in general (AOTA, 15 2015). In practice, OT practitioners should pay close attention to the precautions and guidelines provided by the endovascular neurosurgeon, while utilizing current best practices for stroke rehabilitation with post-thrombectomy patients. Limitations One common limitation to the articles analyzed was that many of them were retrospective studies (n= 7), so the researchers had no control over the treatment protocols given to their participants. Very few studies (n= 3) had a control group. Only one study included randomization in their study design. Small sample sizes also limited several of the discussed studies (n= 5). The present paper has limitations. First, only one researcher reviewed and selected each article, leaving room for potential selection bias. To limit this bias, I used guidelines from the Johns Hopkins University School of Nursing (2017) to appraise articles. However, bias may still exist. Second, due to the limited literature available on the topic, the inclusion criteria widened after the search process began. This resulted in the inclusion of articles that may not describe OT in detail but may have discussed concepts associated with OT, including ADLs and functional independence. A common limitation with narrative reviews in general is a lack of systematic methods relating to the acquisition of articles (Pae, 2015). However, this paper utilized recommendations from Green et al. (2006) which describes a systematic protocol for searching for and reviewing articles, including using a variety of databases and clearly outlining all methods. Future Research Due to the limitations of the discussed studies, more research is needed to solidify the role of OT in the care of post-thrombectomy patients. The benefit of OT with post- 16 thrombectomy patients is not fully understood and the profession would benefit from further investigation. Specifically, information regarding the efficacy of high value interventions is largely missing from the literature currently. With a deeper understanding of the interventions that yield the highest functional improvements, practice guidelines for OT practitioners can be established. Future research should specifically include randomized controlled trials in their methodology in order to provide consistent, high-level evidence pertaining to the timing, frequency, and focus of OT interventions. Conclusion OT practitioners play an important role in the care of post-thrombectomy patients. The current literature has some significant gaps regarding the specific interventions for postthrombectomy patients and the efficacy of those interventions. With the prevalence of strokes projected to continue increasing (Kuriakose & Xiao, 2020), understanding the role of rehabilitation professionals after stroke treatment is crucial. Current literature discusses the benefits of early, high frequency, high intensity rehabilitation targeting ADLs and upper extremity function. OT practitioners can use this information to maximize interventions and restore function in patients. 17 References American Occupational Therapy Association. (2015). The role of occupational therapy in stroke rehabilitation. American Occupational Therapy Association. Retrieved January 17, 2022, from https://www.aota.org/About-Occupational-Therapy/Professionals/RDP/stroke.aspx Aoki, K., Suzuki, H., Miyata, T., Ogino, T., & Iguchi, A. (2021). Predictors of discharge outcomes following percutaneous mechanical thrombectomy in patients with acute ischemic stroke: Comparisons between the home discharge group and hospital transfer group. The Showa University Journal of Medical Sciences, 33(1), 914. https://doi.org/10.15369/sujms.33.9 Baker, D. W., Tschurtz, B. A., Aliaga, A. E., Williams, S. C., Jauch, E. C., & Schwamm, L. H. (2020). Determining the need for thrombectomy-capable stroke centers based on travel time to the nearest comprehensive stroke center. The Joint Commission Journal on Quality and Patient Safety, 46(9), 501505. https://doi.org/10.1016/j.jcjq.2020.06.005 Belagaje, S. R., Sun, C.-H. J., Nogueira, R. G., Glenn, B. A., Wuermser, L. A., Patel, V., Frankel, M. R., Anderson, A. M., Thomas, T. T., Horn, C. M., & Gupta, R. (2014). Discharge disposition to skilled nursing facility after endovascular reperfusion therapy predicts a poor prognosis. Journal of NeuroInterventional Surgery, 7(2), 99103. https://doi.org/10.1136/neurintsurg-2013-011045 Branco, J. P., Rocha, F., Sargento-Freitas, J., Santo, G. C., Freire, A., Lans, J., & Pscoa Pinheiro, J. (2021). Impact of post-stroke recanalization on general and upper limb functioning: A prospective, observational study. Neurology International, 13(1), 4658. https://doi.org/10.3390/neurolint13010005 18 Burch, D., Drake, A., Steuber, T., Nihart, J., Abner, E., Stafford, W. L., & Fraser, J. (2018). Abstract TP157: Patient and physical therapy/occupational therapy characteristics associated with functional mobility outcomes after mechanical thrombectomy. Stroke, 49(Suppl_1). https://doi.org/10.1161/str.49.suppl_1.tp157 Chang, Y.-J., Liu, C.-K., Wu, W.-P., Wang, S.-C., Chen, W.-L., & Lin, C.-M. (2020). The prediction of acute ischemic stroke patients long-term functional outcomes treated with bridging therapy. BMC Neurology, 20(1). https://doi.org/10.1186/s12883-020-1610-1 Chiu, C.-C., Wang, J.-J., Hung, C.-M., Lin, H.-F., Hsien, H.-H., Hung, K.-W., Chiu, H.-C., Jennifer Yeh, S.-C., & Shi, H.-Y. (2021). Impact of multidisciplinary stroke post-acute care on cost and functional status: A prospective study based on propensity score matching. Brain Sciences, 11(2), 161. https://doi.org/10.3390/brainsci11020161 Chu, C.L., Chen, Y.P., Chen, C.C.P., Chen, C.K., Chang, H.N., Chang, C.H., & Pei, Y.C. (2020). Functional recovery patterns of hemorrhagic and ischemic stroke patients under Post-Acute Care Rehabilitation program. Neuropsychiatric Disease and Treatment, 16, 19751985. https://doi.org/10.2147/ndt.s253700 Cole, M. B., & Tufano, R. (2008). Applied theories in occupational therapy: A practical approach. Slack. Feigin, V.L., Abajobir, A.A., Abate, K.H., Abd-Allah, F., Abdulle, A.M., Abera, S.F., Abyu, G.Y., Ahmed, M.B., Aichour, A.N., Aichour, I., Aichour, M.T.E., Akinyemi, R.O., Alabed, S., Al-Raddadi, R., Alvis-Guzman, N., Amare, A.T., Ansari, H., Anwari, P., rnlv, J., Vos, T. (2017). Global, regional, and national burden of neurological disorders during 19902015: A systematic analysis for the Global Burden of Disease Study 2015. Lancet Neurological, 16, 877897. doi: 10.1016/S1474-4422(17)30299-5 19 Fisher, A.G. (1998). Uniting practice and theory in an occupational framework. American Journal of Occupational Therapy, 52(7), 509521. doi: https://doi.org/10.5014/ajot.52.7.509 Fuhrer, H., Forner, L., Pruellage, P., Weber, S., Beume, L.-A., Schacht, H., Egger, K., Bardutzky, J., Weiller, C., Urbach, H., Niesen, W.-D., & Meckel, S. (2019). Long-term outcome changes after mechanical thrombectomy for anterior circulation acute ischemic stroke. Journal of Neurology, 267(4), 10261034. https://doi.org/10.1007/s00415-01909670-w Green, B. N., Johnson, C. D., & Adams, A. (2006). Writing narrative literature reviews for peerreviewed journals: Secrets of the trade. Journal of Chiropractic Medicine, 5(3), 101117. https://doi.org/10.1016/s0899-3467(07)60142-6 Jadhav, A. P., Molyneaux, B. J., Hill, M. D., & Jovin, T. G. (2018). Care of the postthrombectomy patient. Stroke, 49(11), 28012807. https://doi.org/10.1161/strokeaha.118.021640 Johns Hopkins University School of Nursing. (2017). Johns Hopkins nursing evidence-based practice: Appendix D. The Johns Hopkins Hospital. https://www.mghpcs.org/eed/ebp/Assets/documents/pdf/2017_Appendix%20D_Evidence %20Level%20and%20Quality%20Guide.pdf Joint Commission. (2021, April 20). The Joint Commission stroke certification programs Program concept comparison. Oakbrook Terrace; The Joint Commission. Krishnan, R., Mays, W., & Elijovich, L. (2021). Complications of mechanical thrombectomy in acute ischemic stroke. Neurology, 97(20 Supplement 2), S115-S125. 20 Kuriakose, D., & Xiao, Z. (2020). Pathophysiology and treatment of stroke: Present status and future perspectives. International Journal of Molecular Sciences, 21(20), 7609. https://doi.org/10.3390/ijms21207609 Leslie-Mazwi, T., Chen, M., Yi, J., Starke, R. M., Hussain, M. S., Meyers, P. M., McTaggart, R. A., Pride, G. L., Ansari, S. A., Abruzzo, T., Albani, B., Arthur, A. S., Baxter, B. W., Bulsara, K. R., Delgado Almandoz, J. E., Gandhi, C. D., Heck, D., Hetts, S. W., Klucznik, R. P., Fraser, J. F. (2017). Post-thrombectomy management of the Elvo Patient: Guidelines from the Society of Neurointerventional Surgery. Journal of NeuroInterventional Surgery, 9(12), 12581266. https://doi.org/10.1136/neurintsurg2017-013270 Mathews S, & De Jesus O. (2022) Thrombectomy. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK562154/ Michigan Department of Health and Human Services. (2021, October 11). Michigan stroke hospitals. Lansing; Michigan Department of Health and Human Services. O'Connor, K., Frazure, A., Campbell, M., Polly, M., Reckner, K., & Lee, J. D. (2019). Abstract TP345: Early mobilization following recombinant tissue plasminogen activator administration and/or mechanical thrombectomy reduces length of stay. Stroke, 50(Suppl_1). https://doi.org/10.1161/str.50.suppl_1.tp345 Oliveira-Filho, J., & Samuels, O.B. (2022). Mechanical thrombectomy in acute ischemic stroke. In J.F. Dashe (Ed.), UptoDate. Pae C. U. (2015). Why systematic review rather than narrative review?. Psychiatry Investigation, 12(3), 417419. https://doi.org/10.4306/pi.2015.12.3.417 21 Pego Prez, E. R., Fernndez, I., & Pumar, J. M. (2021). Functional outcomes of patients with stroke treated with thrombectomy by aspiration. Brain Injury, 35(4), 476483. https://doi.org/10.1080/02699052.2021.1887519 Pierot, L., Jayaraman, M. V., Szikora, I., Hirsch, J. A., Baxter, B., Miyachi, S., Mahadevan, J., Chong, W., Mitchell, P. J., Coulthard, A., Rowley, H. A., Sanelli, P. C., Tampieri, D., Brouwer, P. A., Fiehler, J., Kocer, N., Vilela, P., Rovira, A., Fischer, U., Karel, T. (2018). Standards of practice in acute ischemic stroke intervention: International recommendations. Journal of NeuroInterventional Surgery, 10(11), 11211126. https://doi.org/10.1136/neurintsurg-2018-014287 Reuter, B., Gumbinger, C., Sauer, T., Wiethlter, H., Bruder, I., Diehm, C., Ringleb, P. A., Hacke, W., Hennerici, M. G., & Kern, R. (2016). Access, timing and frequency of very early stroke rehabilitation insights from the Baden-Wuerttemberg Stroke Registry. BMC Neurology, 16(1). https://doi.org/10.1186/s12883-016-0744-7 Revert-Villarroya, S., Dvalos, A., Font-Mayolas, S., Berenguer-Poblet, M., Sauras-Coln, E., Lpez-Pablo, C., Sanjuan-Menndez, E., Muoz-Narbona, L., & Suer-Soler, R. (2020). Coping strategies, quality of life, and neurological outcome in patients treated with mechanical thrombectomy after an acute ischemic stroke. International Journal of Environmental Research and Public Health, 17(17), 6014. https://doi.org/10.3390/ijerph17176014 Saver, J. L., Goyal, M., Van der Lugt, A. A. D., Menon, B. K., Majoie, C. B., Dippel, D. W., Campbell, B.C., Nogueira, R.G., Demchuk, A.M., Tomasello, A., Cardona, P., Devlin, T.G., Frei, D.F., de Rochemont, R.D.M., Berkhemer, O.A., Jovin, T.G., Siddiqui, A.H., van Zwam, W.H., ... & HERMES Collaborators. (2016). Time to treatment with 22 endovascular thrombectomy and outcomes from ischemic stroke: A meta-analysis. JAMA, 316(12), 1279-1289. Stuchiner, T. L., Clark, D., Lucas, L., Robison, J., & Yanase, L. (2019). Abstract TP380: Impact of early mobilization on 90-day outcomes in thrombectomy patients. Stroke, 50(Suppl_1). https://doi.org/10.1161/str.50.suppl_1.tp380 Thabet, A., Josephson, S., & Meisel, K. (2015). Acute care of ischemic stroke patients in the hospital. Seminars in Neurology, 35(06), 629637. https://doi.org/10.1055/s-00351564301 Tokuda, K., Takebayashi, T., Koyama, T., Fujita, T., Hanada, K., & Okita, Y. (2021). Effects of mechanical thrombectomy for post-stroke patients with upper limb hemiparesis: Use of propensity score matching. Clinical Neurology and Neurosurgery, 202, 106520. https://doi.org/10.1016/j.clineuro.2021.106520 23 Appendix A: Evidence Table 24 25 26 Appendix B: DCE Weekly Planning Guide Wee k 1 DCE Stage (orientation, screening/ evaluation, implementation, discontinuation, dissemination) Weekly Goal Objectives Orientation 1) Complete Meet with orientation by site mentor the end of the and OT staff. week Begin to shadow OTs to meet patients and educate them on the goal of my DCE. Screening/ Evaluation 2) Complete Needs Assessment by the end of the week 2 Screening/ Evaluation 1) Begin faceted search for narrative review Begin looking into resources provided by the site for patient handouts. Finalize questions for Needs Assessment Select databases to use Tasks Date comple te Attend morning huddle meetings to learn about how the OT staff functions. 1/10 Ensure all paperwork for orientation is complete. 1/10 Tour the facility 1/11 Observe team meeting with various departments Determine what resources to focus on during DCE. Ask site mentor Needs Assessment questions Search databases and determine which ones are appropriate for finding articles regarding OTs 1/10 1/13 1/13 1/21 27 role with postthrombectomy patients. 3 2) Update MOU Determine specifics for updated project and experience. Discuss needs established with site mentor from last week, and determine goals for project and experience. 1/17 3) Conduct needs assessment with OT staff Determine usage of patient binders by OT staff Determine inclusion and exclusion criteria of articles Create and disseminate survey 1/18 Document inclusion and exclusion criteria 1/26 Determine usage of patient binders by OT staff Determine quality and level of evidence found Analyze responses from survey (ongoing) 1/242/10 Analyze articles using John Hopkins tool 2/3 Synthesize articles using evidence chart 2/3 Screening/ Evaluation 1) Conduct literature search 2) Conduct needs assessment with OT staff 4 Implementation 1) Continue literature search 2) Begin interdisciplin ary outreach 3) Continue working with Seek PT and Attend PT huddle SLP feedback to educate about with survey survey 2/1 Begin looking into resources that 1/31 28 the patient binder 5 Implementation 7 Implementation Implementation Begin updating resources Continue updating resources 1) Continue working with patient binder 2) Determine OTs role in care of postthrombectom y patients at site. 6 need to be updated in the patient binder 3) Consolidate information gathered from survey 1) Consolidate information gathered from neuro team Get feedback from neuro team on therapies Set up meeting with neurosurgery team Attend meeting with neurosurgery team Finish presentation with information from survey Prepare for meeting next week with therapy team Create presentation with information on thrombectomy update 2) Consolidate information from updated patient handouts Organize handouts with folders for before and after to present to OT team next week 3) Share survey results 1) Continue work on narrative review Meet with DOR to discuss survey results Finish introduction/ background section 2/2 2/11 2/8 2/10 2/11 2/18 2/18 2/18 2/25 29 8 Implementation 2) Evaluate progress on patient handouts and patient binders 1) Continue work on patient binders Present updates to OT team Attend team meeting and present handouts Clarify schedule sheet on front of binders Create updated schedule sheet 2/28 Present updated schedule sheet to OTs 3/2 Pass folder with updated handouts around in the OT offices to obtain feedback (ongoing) Complete methods section 2/283/13 Find template for narrative review presentation 3/7 Create outline for presentation 3/8 Email neurosurgery PA to ask about plans for the stroke centers growth Finish background slide in presentation. 3/7 Double check guidelines for reporting results 3/15 2) Seek final feedback on handout updates 9 Implementation 1) Continue work on narrative review 2) Begin presentation for OT role in postthrombectom y patients 3) Continue research on thrombectomi es at my site 10 Implementation 1) Continue narrative review presentation 2) Edit narrative Research leading hospitals for thrombectom ies 2/23 3/8 3/16 30 review as needed 3) Continue updates to patient handouts 11 12 13 Discontinuation Discontinuation Dissemination from narrative review. Take in feedback from therapists on handouts Decide what changes are necessary 3/14 Make updates to patient handouts with guidance from therapists feedback. Place an order with the printing company 3/17 Shadow therapists/assist with treatments 3/24 & 3/25 1) Finalize handouts Prepare handouts for the file cabinet 2) Get more experience with patient care 1) Finalize narrative review presentation Identify therapists to shadow Finish all slides for site mentor review next week 3/29 2) Finish full draft of narrative review Prepare paper Finish abstract to send to Katie for Finish conclusion review Finish results 3/28 1) Continue review process of narrative review paper Receive feedback from faculty mentor 2) Disseminate patient handouts Finalize file cabinet (Attend AOTA Conference) Send draft to Katie for review Receive handouts from printing company 3/23 3/29 3/28 3/304/3 4/5 4/4 31 Organize final handouts in file cabinet 3) Finalize presentation for OTs Began 4/5 Send presentation to site mentor for review 4/4 Discuss edits for presentation with site mentor 4/5 Add personal/professio 4/6 nal takeaways from DCE experience 14 Dissemination 1) Continue dissemination of patient handouts 2) Disseminate presentation to OTs 3) Shadow OTs Gain clinical experience in acute/ IPR settings Send presentation to site mentor for dissemination Finish organizing file cabinet 4/7 Site mentor will send presentation to OTs 4/11 Shadow on ortho floor 4/11, 4/12, 4/15 Shadow on surgical floor 4/14 4/13  ...

... SOCIAL PARTICIPATION INTERVENTIONS, QUALITY OF LIFE, AND DEMENTIA Social Participation Interventions for Quality of Life Among Individuals with Dementia Elizabeth Siegfried May 4, 2022 A capstone project submitted in partial fulfillment for the requirements of the Doctor of Occupational Therapy degree from the University of Indianapolis, School of Occupational Therapy. Under the direction of the faculty capstone advisor: Dr. Brenda Howard, DHSc, OTR, FAOTA 1 SOCIAL PARTICIPATION INTERVENTIONS, QUALITY OF LIFE, AND DEMENTIA 2 Abstract Dementia is an irreversible disease that impacts individuals in all areas of life and decreases quality of life (QOL) (Hsiao et al., 2018). I have identified that there is limited research stating specific ways to increase QOL and improve social participation among individuals with more progressed dementia. Utilizing the Functional Behavior Profile (FBP), I identified five individuals who required assistance and had more progressed dementia. I participated in activities such as exercise classes, crafts, and baking, alongside specific residents and utilized visual, verbal, and tactile cues as well as minor activity modifications when needed to create a just-right challenge. This promoted increased activity satisfaction and overall mood. I monitored individuals activity enjoyment via perceived satisfaction and their reports. This research provided evidence that continued participation in social activities with adaptations improves QOL. I recommend further research at a larger scale to expand on the effects of social activity interventions on QOL among older adults with progressed dementia. SOCIAL PARTICIPATION INTERVENTIONS, QUALITY OF LIFE, AND DEMENTIA 3 Social Participation Interventions for Quality of Life Among Individuals with Dementia Alzheimers disease (AD) and dementia are irreversible illnesses (Hsiao et al., 2018). Although reversing memory illness is not an option, there are numerous non-pharmacological ways to slow the progression or potentially delay onset (Hsiao et al., 2018; Letts et al., 2011; Quail et al., 2020). Non-pharmacological activities can include physical, kit-based, leisure, activities of daily living (ADLs), instrumental activities of daily living (iADLs), musicstimulated family visits, and dance (Charras et al., 2020; Huang et al., 2020; Jones et al., 2020; Letts et al., 2011; Shigihara et al., 2020; Smit et al., 2016). Activity participation typically involves physically and mentally participating in an activity, but Beerens et al. (2018) discuss that engagement via observation of activity performance feels like participation for many. Meanwhile, for some residents, structuring activities to meet their abilities will provide greater success and promote more active than passive participation (Kolanowski & Buettner, 2009). Considering both active and passive activity participation is important to identify because as adults age, they may not find themselves able to or interested in participating; rather, observing loved ones and other residents engage together is providing them with mood satisfaction and activity enjoyment (Beerens et al., 2018). Benefits of Activity Participation Activity participation provides numerous benefits for older adults, especially those with dementia. In some instances, skilled nursing facilities and assisted living facilities focus on medical care, but there are rising concerns regarding psychological care. Participating in meaningful activities can contribute to increased psychological well-being, quality of life (QOL), and better sleep performance (Beerens et al., 2018; Huang et al., 2020; Jones et al., 2020; Letts et al., 2011; Smit et al., 2016). In research by Charrass et al. (2020), their original hypothesis SOCIAL PARTICIPATION INTERVENTIONS, QUALITY OF LIFE, AND DEMENTIA 4 focused on dance interventions promoting physical well-being. Their research ultimately did not support this hypothesis, but it supported increased positive self-perception in older adults. Specifically, dance as an activity intervention helped older adults with dementia improve their behavior, cognition, QOL, social participation, and self-perceived balance (Charrass et al., 2020). Beerens et al. (2018) discussed the importance of activity engagement and social interaction. Researchers identified a positive correlation between participation and older adults' mood with increased engagement (Beerens et al., 2018). Participating in meaningful activities is important and stimulating for both the individual with the disease as well as their caregivers. By modifying occupations and leisure activities to promote participation from the older adult with dementia, caregivers felt a greater sense of satisfaction for their loved ones (Letts et al., 2011). Benefits of Social Participation Beerens et al. (2018) identified that the type of activity that older adults with dementia participate in is as essential as social engagement. Social participation can be beneficial to slow the loss of verbal expression and reduce cognitive decline, both being common symptoms of AD (Duong et al., 2017; Letts et al., 2011; Quail et al., 2020). Activity engagement with a socialbased approach can include any activities that an older adult finds interesting and involve communication. Quail et al. (2020) specifically discussed validation therapy, music therapy, art therapy, reminiscence therapy, talking therapy, reality orientation, cognitive training, smell therapy, food therapy, sensory stimulation, garden therapy, and physiotherapy (p. 2). Meaningful occupations that promote physical activity can also contribute to strengthening meaningful relationships and promote more social participation, as well as reduce depression and increase ADL performance (Huang et al., 2020). Challenges with Activity and Social Participation SOCIAL PARTICIPATION INTERVENTIONS, QUALITY OF LIFE, AND DEMENTIA 5 Activity engagement and social participation are significant factors in psychological wellbeing and QOL if they are activities or topics that are interesting and provide the appropriate cognitive stimulation for the older adult participating (Smit et al., 2016). Creating client-centered activities of interest is important, but for them to be entirely meaningful and reach the overall goal of engagement, the activities must meet the just-right challenge for one's cognitive status (Beerens et al., 2018; Cole & Tufano, 2008). While numerous researchers have collectively confirmed that activity and social participation are positively correlated with increased QOL and satisfaction (Huang et al., 2020; Letts et al., 2011; Smit et al., 2016), Beerens et al. (2018) also identified that an increased negative mood often occurs when older adults with dementia attempt to socially participate and receive no response. Identifying the challenge that social participation can present is essential to understanding that a balance between engagement and disengagement is necessary for QOL (Beerens et al., 2018). Respecting an older adults need for mental relaxation is person-dependent and crucial to promoting activity engagement (Beerens et al., 2018). Overview of Site Clarendale St. Peters is an independent and assisted living facility with a wing devoted to memory care located in St. Peters, Missouri. Clarendale has approximately 40 beds for memory care, with 20 occupied at the time of research (M. Bruner, personal communication, March 3, 2021; R. Muzzey, personal communication, January 27, 2022 ). Facility leaders divided the memory care side into two neighborhoods to provide a smaller, more intimate experience. Uniquely, if spouses both have dementia, they can reside in a larger room together in memory care. Muzzey discussed that he encourages this in many situations because it is a level of familiarity that will help with transitioning (R. Muzzey, personal communication, February 15, SOCIAL PARTICIPATION INTERVENTIONS, QUALITY OF LIFE, AND DEMENTIA 6 2022). Clarendale employees encourage activity participation among all residents in memory care, regardless of cognitive level. Activities in the memory care neighborhood are planned monthly and posted on calendars throughout the neighborhoods so residents and families can look ahead if interested, but are often not discussed until the day prior and that morning to avoid confusion. When meeting with Muzzey, Director of Memory Care, he identified a need for small group activity adaptations and additional supports that promote social participation among individuals in memory care neighborhoods who require more visual, verbal, and tactile cues as well as more time to process these cues. These activities are essential contributions to Clarendale because social connections tend to decline as dementia progresses, leading to quicker cognitive regression (Dyer et al., 2021; Hsiao et al., 2018). Muzzey reports an interest in ways to maintain inclusivity by integrating these residents more successfully into group activities. Theory and Application The Person-Environment-Occupation (PEO) Model and Allen's Cognitive Levels (ACL) Frame of Reference are essential to guide the construction of activity adaptations and supportive cueing for individuals with dementia. The PEO model focuses on an individual's occupational performance formed from interactions between the person, environment, and occupation. At the center of the PEO model is participation with the goal being to guide occupational therapists in helping individuals create and maintain a level of involvement (Degenholtz et al., 2006). ACL Frame is a beneficial frame of reference to utilize for older adults with memory illnesses because it focuses on one's cognition, routines, physical context, social context, and activity demand (Cole & Tufano, 2008). Using ACL Frame to evaluate one's cognitive ability serves as a guide to promoting meaningful participation in activities at a just-right challenge level. Encouraging SOCIAL PARTICIPATION INTERVENTIONS, QUALITY OF LIFE, AND DEMENTIA 7 participation in activities that meet one's level of capacity motivates individuals to utilize their cognitive abilities (Cole & Tufano, 2008). Utilizing the PEO model and ACL Frame to guide the Doctoral Capstone Experience will ensure client-centeredness and the ability to screen and evaluate which individuals qualify for the interventions. This client-centeredness will lead to the outcome goal of providing appropriate visual, verbal, and tactile cues for older adults with more progressed dementia to improve social activity participation, thus increasing their QOL. Expanding Research There is an abundance of research on the importance of activity engagement amongst older adults with dementia. However, there is limited research regarding benefits of small group social activities and levels of assist for older adults who benefit specifically from more support and cueing. This Doctoral Capstone Experience is intended to expand on current research to identify the benefits of social participation on QOL among a specific group of individuals with dementia. Project Design Clarendale St. Peters Memory Care is devoted to providing activities for residents to participate in, both individually and in the group setting. I created this project because there was an identifiable need for support and activities that meet the just-right challenge of older adults with more progressed dementia. Prior to this research experience, some residents participated passively due to needing more cueing to be successful and there was not an employee who was designated to offer these supports. In some instances, some residents chose to participate passively or observe because the activity may not meet their interests or needs. Outcome Assessments SOCIAL PARTICIPATION INTERVENTIONS, QUALITY OF LIFE, AND DEMENTIA 8 First, to identify residents who meet the qualifications of the research, I utilized the FBP to gain information about ADLs, cognition, functional mobility, life participation, patient satisfaction, problem-solving, and social relationship (Functional Behavior Profile, n.d.). These are all areas of an individuals life that can affect ones QOL. Nursing staff and activities coordinators collaborated to complete the FBP because they are ultimately the day-to-day caregivers and know each resident deeply and personally. Residents who scored at or below 50% (22/24) in Task Performance or Social Interaction qualified for my program development, which was working side by side with individuals to provide more assistance and cueing to promote more social engagement and activity participation. I utilized the FBP to identifying individuals who would benefit from additional cues and modifications during small group activities to promote satisfaction and improved QOL in events related to weaker areas of performance. This may include cognition, activity participation, following commands, socializing when others initiate the conversation, and time spent attending tasks (Baum et al., 1993). Project Implementation Employees at Claredale in the memory care neighborhoods work closely with the residents every day and build strong relationships with them and their families. Thus, were excellent resources for information regarding each residents personality, challenges, and preferences. Every day is incredibly structured for the activities coordinators because they are the only ones leading activities every day except when they take a lunch break. The nursing staff is also incredibly busy throughout the day. The activities coordinators answered most questions, allowing me to ask the nursing staff fewer questions since I do not see them as often so it would SOCIAL PARTICIPATION INTERVENTIONS, QUALITY OF LIFE, AND DEMENTIA 9 have been more challenging to find time to discuss more details. It took approximately two weeks to finalize and score all FBP assessments. Utilizing the FBP helped me to identify the common weaker areas among residents, specifically Task Performance and Social Interaction. Often, residents who scored lower were able to complete tasks asked of them with much assistance and additional time. It became apparent that many of the residents who qualified for additional support from me had the physical capabilities to participate. This provided evidence that individuals were capable of some level of participation but would be most successful with additional cueing to support their cognitive level of functioning. Project Outcomes The FBP served as an excellent resource to identify residents who would benefit from additional cues to promote an increased QOL. This gives me a foundation that assists in better understanding residents' current abilities at baseline and how to create the just-right challenge that meets each individuals needs. When observing nursing staff and resident interaction, much of the communication was regarding medication, helping with ADLs, and participating in activities led by activities coordinators. Often, nursing staff provided much encouragement for every resident to participate in all activities but were not considering if each activity would meet the needs of each resident. Activities coordinators reported that some activities are not interesting to each resident and were sometimes not all appropriate for everyones cognitive level of functioning. However, I worked alongside activities coordinators to join in on activities of interest with qualifying residents to potentially improve the QOL among residents through social engagement, activity participation, and minor activity adaptations. SOCIAL PARTICIPATION INTERVENTIONS, QUALITY OF LIFE, AND DEMENTIA 10 Residents who scored below 50% (22/44) in Task Performance or Social Interaction on the FBP qualified for me to work alongside. It is essential to identify that an individual with dementia will not improve in any areas of the FBP independently due to dementia being a progressive disease. However, in the moment and with assistance, residents can increase their level of participation, thus, improving their QOL through meaningful activities. There are fourteen residents residing at Clarendale St. Peters Memory Care, with five who scored below 50% in Task Performance of Social Interaction on the FBP. Other residents who did not qualify scored between 52% and 79.5% (23/44 and 35/44). The individuals who scored below 50% often appeared isolated. I spoke with activities coordinators and nursing staff, who reported that it is difficult to spend enough time helping individuals with more progressed dementia engage in activities, so they often do not receive the level of assistance needed for engagement. This can contribute to their overall dementia progression (Freak-Poli et al., 2022). I sat next to residents to provide additional cues, serve as a visual aid, and modify activities as needed. This proved to be successful based on residents responses after each activity. I communicated with Muzzey, Director of Memory Care, and Cribb, Activities Coordinator for Memory Care, to discuss ways to gain feedback regarding the success of activity engagement. Immediately at the end of each activity, I asked residents, "Did you enjoy this activity?". This allowed residents at different cognitive levels to respond either verbally or nonverbally. While I participated in activities alongside qualifying residents, I also observed how residents acted during each activity. I looked for facial expressions, eye contact with other residents, and some level of maintained engagement. For individuals with dementia, working with them to create an increased QOL is dependent on that specific moment in time because that is what they know and are aware of (L. SOCIAL PARTICIPATION INTERVENTIONS, QUALITY OF LIFE, AND DEMENTIA 11 Cribb, personal communication, January 27, 2022; R. Muzzey, personal communication, February 8, 2022). Muzzey explained that individuals with progressed dementia often cannot look beyond the current moment but happiness in a specific moment can increase their mood for some time after the activity, even if the resident cannot express or recall why they are happy (R. Muzzey, personal communication, February 8, 2022). Therefore, evaluating a resident's perceived satisfaction and QOL must occur during and immediately after each activity. While working alongside activities coordinators and nursing staff, I helped identify ways to adapt current activities for all residents to participate in. This includes visual aids for the entire group, sitting next to the individuals who need more auditory cues, visual cues, hand-over-hand tactics, explaining directions simply, and frequently prompt one-on-one conversations. Employees of Clarendale and myself identified a need for an additional activities coordinator with a background in dementia to promote greater activity engagement and improved QOL. Muzzey and Cribb complete paperwork with families that identify residents backgrounds, careers, and areas of interest. They utilize these to create daily activities. This may be a contributing factor to why my research was successful. Many of the residents enjoy all the activities and the level of socializing they offer. During 10 weeks of research implementation, I successfully incorporated the qualifying residents into the activities and assisted with providing additional cueing, leading them to actively participate more. When reviewing the data, I identified that 85% of the times I participated in activities alongside residents to provide support, the residents reported satisfaction and displayed enjoyment throughout the activity. One resident reported being bored throughout craft activities. When I asked her if she would be interested in participating, she often said yes and attended but then quickly lost interest. Through discussions with the family, I learned crafts have never been a strong interest. I continued to be mindful by SOCIAL PARTICIPATION INTERVENTIONS, QUALITY OF LIFE, AND DEMENTIA 12 still inviting her to join but also asking if she would like to sit and watch others participate. It was very common for all residents, not just those who I was working with, to observe an activity that they did not want to participate in. Muzzey often encourages this because it still provides more opportunities for conversation and social interaction. Limitations Although there were identifiable limitations, they were minimal. Muzzey, Cribb, and I identified that one resident often had anxiety attacks in the mornings if she was wearing a specific pair of jeans. We believed they were too tight or rough, leading to increased levels of sensory stimulation. To limit this and increase her opportunity to participate in morning activities, Muzzey talked with nursing staff to not encourage her to wear those pants. Another limitation was hospital visits. If a resident was taken to the hospital then later returned, it reduced the residents level of interest in activities, leading them to require more encouragement to participate and attempt to return to their baseline. These limitations are valid but were unaccounted for during research preparation. Discussion Activity participation is crucial for residents days in a memory care neighborhood. Participating in activities provides meaningful engagement and a purpose for many residents while improving their QOL (Huang et al., 2020; Letts et al., 2011; Smit et al., 2016). However, I have identified that meeting the just-right challenge is necessary for all meaningful activities. Throughout the program development, I identified that if an activity was too challenging or there was no one to assist the resident, they may become frustrated and cease participating entirely. SOCIAL PARTICIPATION INTERVENTIONS, QUALITY OF LIFE, AND DEMENTIA 13 Utilizing the FBP to identify lower scoring individuals and provide appropriate intervention proved successful in contributing to increased QOL and small group engagement. Residents who utilized additional support during activities were inclined to participate and socialize throughout the activity more than prior to research interventions. Individuals participating either verbalized, nodded, or gave a thumbs up or down to report their small group activity enjoyment. Researchers identified that for some with more progressed dementia, observing someone participate provides the same level of satisfaction and socializing (Beerens et al., 2018). Two individuals often participated passively in this program development due to their medical status and progression. I maintained my level of assistance alongside the residents and observed resident satisfaction throughout the activities, more so than prior to the program development and implementation. These residents often held more eye contact with other residents that typically expected, as well as laughed more than employees have reported observing in some time. To further summarize, I determined that activity participation for all residents, specifically residents with more progressed dementia, contributed to increased QOL and perceived satisfaction. It provides evidence that verbal, visual, and tactile cues contribute to more participation and comfort with activities in small groups. I believe having an additional life enrichment coordinator provides dignified support during activities, thus, leading more residents with progressed dementia to feel comfortable and willing to participate and enjoy their day, overall increasing their QOL. Conclusion In conclusion, my research provides evidence that additional cues and support during activities can improve QOL and activity satisfaction among residents with more progressed SOCIAL PARTICIPATION INTERVENTIONS, QUALITY OF LIFE, AND DEMENTIA 14 dementia. St. Peters Clarendale activities coordinators benefitted from observing this research, improving many older adults' level of participation and satisfaction. Employees have learned how to adapt activities and offer additional support to meet the needs of every resident who wants to participate. Overall, residents with more progressed dementia had increased activity participation and reported satisfaction immediately following the activity. Further work on a larger scale is necessary to expand research on the benefits of increased activity participation on QOL among older adults with advanced dementia. However, this research is an excellent start to providing evidence that additional support during activities is not only an advantage but a crucial part of improving overall QOL among older adults with more progressed dementia. SOCIAL PARTICIPATION INTERVENTIONS, QUALITY OF LIFE, AND DEMENTIA 15 References Baum, C., Edwards, D. F., & Morrow-Howell, N. (1993). Identification and measurement of productive behaviors in senile dementia of the Alzheimer type. The Gerontologist, 33(3), 403408. https://doi.org/10.1093/geront/33.3.403 Beerens, H. C., Zwakhalen, S. M. G., Verbeek, H., E.S. Tan, F., Jolani, S., Downs, M., de Boer, B., Ruwaard, D., & Hamers, J. P. H. (2018). The relation between mood, activity, and interaction in long-term dementia care. Aging & Mental Health, 22(1), 2632. https://doi.org/10.1080/13607863.2016.1227766 Charras, K., Mabire, J.-B., Bouaziz, N., Deschamps, P., Froget, B., de Malherbe, A., Rosa, S., & Aquino, J.-P. (2020). Dance intervention for people with dementia: Lessons learned from a small-sample crossover explorative study. The Arts in Psychotherapy, 70, 101676. https://doi.org/10.1016/j.aip.2020.101676 Cole, M.B., & Tufano, R. (2008). Applied theories in occupational therapy: A practical approach. Thorofare, NJ: SLACK, Inc. Degenholtz, H. B., Miller, M. J., Kane, R. A., Cutler, L. J., & Kane, R. L. (2006). Developing a Typology of Nursing Home Environments. Journal of Housing For the Elderly, 20(12), 530. https://doi.org/10.1300/J081v20n01_02 Duong, S., Patel, T., & Chang, F. (2017). Dementia: What pharmacists need to know. Canadian Pharmacists Journal / Revue Des Pharmaciens Du Canada, 150(2), 118129. https://doi.org/10.1177/1715163517690745 Dyer, A. H., Murphy, C., Lawlor, B., & Kennelly, S. P. (2021). Social networks in mild-tomoderate Alzheimer disease: Longitudinal relationships with dementia severity, cognitive SOCIAL PARTICIPATION INTERVENTIONS, QUALITY OF LIFE, AND DEMENTIA 16 function, and adverse events. Aging & Mental Health, 25(10), 19231929. https://doi.org/10.1080/13607863.2020.1745146 Functional Behavior Profile. (n.d.). Shirley ryan ability lab. Retrieved February 9, 2022, from https://www.sralab.org/rehabilitation-measures/functional-behavior-profile Freak-Poli, R., Wagemaker, N., Wang, R., Lysen, T. S., Ikram, M. A., Vernooij, M. W., Dintica, C. S., Vernooij-Dassen, M., Melis, R. J. F., Laukka, E. J., Fratiglioni, L., Xu, W., & Tiemeier, H. (2022). Loneliness, not social support, is associated with cognitive decline and dementia across two longitudinal population-based cohorts. Journal of Alzheimers Disease: JAD, 85(1), 295308. https://doi.org/10.3233/JAD-210330 Hsiao, Y.-H., Chang, C.-H., & Gean, P.-W. (2018). Impact of social relationships on Alzheimers memory impairment: Mechanistic studies. Journal of Biomedical Science, 25(1), 3. https://doi.org/10.1186/s12929-018-0404-x Huang, X., Li, B., Yu, F., Zhou, J., Wan, Q., & Chang, H. (2020). Path analysis from physical activity to quality of life among dementia patients: A dualpath mediating model. Journal of Advanced Nursing, 76(2), 546554. https://doi.org/10.1111/jan.14260 Jones, C., Liu, F., Murfield, J., & Moyle, W. (2020). Effects of non-facilitated meaningful activities for people with dementia in long-term care facilities: A systematic review. Geriatric Nursing, 41(6), 863871. https://doi.org/10.1016/j.gerinurse.2020.06.001 Kolanowski, A., & Buettner, L. (2008). Prescribing activities that engage passive residents. An innovative method. Journal of gerontological nursing, 34(1), 1318. https://doi.org/10.3928/00989134-20080101-08 Letts, L., Edwards, M., Berenyi, J., Moros, K., ONeill, C., OToole, C., & McGrath, C. (2011). Using occupations to improve quality of life, health and wellness, and client and SOCIAL PARTICIPATION INTERVENTIONS, QUALITY OF LIFE, AND DEMENTIA 17 caregiver satisfaction for people with Alzheimers disease and related dementias. American Journal of Occupational Therapy, 65(5), 497504. https://doi.org/10.5014/ajot.2011.002584 Quail, Z., Carter, M. M., Wei, A., & Li, X. (2020). Management of cognitive decline in Alzheimers disease using a non-pharmacological intervention program: A case report. Medicine, 99(21), e20128. https://doi.org/10.1097/MD.0000000000020128 Shigihara, Y., Hoshi, H., Shinada, K., Okada, T., & Kamada, H. (2020). Non-pharmacological treatment changes brain activity in patients with dementia. Scientific Reports, 10(1), 6744. https://doi.org/10.1038/s41598-020-63881-0 Smit, D., de Lange, J., Willemse, B., Twisk, J., & Pot, A. M. (2016). Activity involvement and quality of life of people at different stages of dementia in long-term care facilities. Aging & Mental Health, 20(1), 100109. https://doi.org/10.1080/13607863.2015.1049116 SOCIAL PARTICIPATION INTERVENTIONS, QUALITY OF LIFE, AND DEMENTIA 18 Appendix Doctoral Capstone Experience Project Weekly Planning Guide Week 1 DCE Stage (orientation, screening/evaluation, implementation, discontinuation, dissemination) Orientation Weekly Goal 2 Orientation 1. Complete orientation and tour by the end of the week 2. Meet with Site Mentor and key personnel, introduce Complete myself, provide Needs education as to Assessment what my role is and intended DCE. 3. Discuss workspace, dress code, dementia training course. 4. Review and edit Needs assessment questions Safety training 1. Finish identifying any Observe new literature residents, make notes 2. Establish outcome Complete assessment tool literature search 3. Touch base with mentor Finalize MOU regarding possible Evaluate and changes to score FBP, MOU identify and Complete orientation Screening/Evaluation Screening/Evaluation Objectives Tasks Date complete Identify key 1/15/22 points to discuss in meeting with site mentor Have a meeting with my site mentor Discuss sites needs and plans for observing OTR Get to know residents, understand their interests and level of function Organize new literature Save outcome assessment tool, discuss it with mentor Review MOU in greater detail 1/21/22 SOCIAL PARTICIPATION INTERVENTIONS, QUALITY OF LIFE, AND DEMENTIA compose list of residents who qualify, discuss 4. Become familiar with results with residents who mentor qualify for research 5. Observe qualifying residents 3 Implementation 4 Implementation 5 Implementation 1. Increase social Provide cues participation and participate amongst group alongside members residents with more progress dementia Utilize verbal and visual procedure to understand residents level of satisfaction 1. Increase social Complete participation small group amongst group social activities members for memory care residents with lower functioning skills Utilize verbal and visual procedure to understand residents level of satisfaction 1. Increase social Complete participation small group amongst group social activities members for memory care residents with lower Complete screening on just-right challenge tasks for residents Discuss areas of interest for residents participating Utilize verbal, visual, and tactile cues to maintain participation Utilize verbal, visual, and tactile cues to maintain participation 19 1/28/22 2/4/22 2/11/22 Utilize verbal, visual, and tactile cues to maintain participation, SOCIAL PARTICIPATION INTERVENTIONS, QUALITY OF LIFE, AND DEMENTIA 20 functioning skills 6 7 8 Implementation Implementation Implementation Utilize verbal and visual procedure to understand residents level of satisfaction 1. Increase social Complete participation small group amongst group social activities members for memory care residents with lower functioning skills Utilize verbal and visual procedure to understand residents level of satisfaction 1. Increase social Complete participation small group amongst group social activities members for memory care residents with lower functioning skills Utilize verbal and visual procedure to understand residents level of satisfaction 1. Increase social Complete participation small group amongst group social activities members for memory care residents with lower 2/18/22 Utilize verbal, visual, and tactile cues to maintain participation, 2/25/22 Utilize verbal, visual, and tactile cues to maintain participation, 3/4/22 Utilize verbal, visual, and tactile cues to maintain participation, SOCIAL PARTICIPATION INTERVENTIONS, QUALITY OF LIFE, AND DEMENTIA 21 functioning skills 9 10 11 Implementation Implementation Implementation Utilize verbal and visual procedure to understand residents level of satisfaction 1. Increase social Complete participation small group amongst group social activities members for memory care residents with lower functioning skills Utilize verbal and visual procedure to understand residents level of satisfaction 1. Increase social Complete participation small group amongst group social activities members for memory care residents with lower functioning skills Utilize verbal and visual procedure to understand residents level of satisfaction 1. Increase social Complete participation small group amongst group social activities members for memory care residents with lower 3/11/22 Utilize verbal, visual, and tactile cues to maintain participation, 3/18/22 Utilize verbal, visual, and tactile cues to maintain participation, 3/25/22 Utilize verbal, visual, and tactile cues to maintain participation, SOCIAL PARTICIPATION INTERVENTIONS, QUALITY OF LIFE, AND DEMENTIA 22 functioning skills 12 Implementation 13 Discontinuation 14 Dissemination Utilize verbal and visual procedure to understand residents level of satisfaction 1. Increase social Complete participation small group amongst group social activities members for memory care residents with lower functioning skills Utilize verbal and visual procedure to understand residents level of satisfaction Finish small group activity modifications and assist for residents with lower functioning skills Present findings to 4/1/22 Utilize verbal, visual, and tactile cues to maintain participation, 1. Collect/organize Organize 4/8/22 all information spreadsheet regarding with activities, level residents of participation, (initials used and subjective for privacy), feedback activities they participated in, their subjective rating of the activity, and how I perceived their participation, enjoyment, and satisfaction 1. Confirm date, 4/15/22 Create time, and handouts, SOCIAL PARTICIPATION INTERVENTIONS, QUALITY OF LIFE, AND DEMENTIA leaders of memory care department regarding my findings location of presentation, prepare notes, and handouts answer any final questions, provide copies of handouts and relevant resources 23  ...

... 1 Myofascial Release as a Treatment Option for Tongue Ties and Other Congenital Issues Lyndsay Shepherd April 22, 2022 A capstone project submitted in partial fulfillment for the requirements of the Doctor of Occupational Therapy degree from the University of Indianapolis, School of Occupational Therapy. Under the direction of the faculty capstone advisor: Dr. Taylor Gurley, MS, OTR, OTD, CEIM 2 Abstract This doctoral capstone project focuses on tight fascia as a secondary concern to tongue ties, torticollis, and other congenital issues and the benefits of utilizing myofascial release (MFR) to treat these populations. IU Norths Outpatient (OP) Clinic expressed interest in learning more about MFR to gain referrals and meet the needs of these populations. The researcher utilized a cost-benefit ratio and acceptability-perception survey to identify the need for and benefits of utilizing MFR in the OP clinic. The cost-benefit analysis results indicated that the benefit of utilizing MFR would outweigh the costs of training needed to practice in this area. The acceptability perception survey results indicated that the occupational and physical therapists were very likely to utilize MFR if given the appropriate training and patient population. Through this doctoral capstone project, IU Norths Outpatient Clinic gained several resources and further knowledge on tongue ties, tight fascia, and myofascial release. Keywords: tongue tie, ankyloglossia, myofascial release, outpatient therapy 3 Introduction The Indiana University (IU) Health North Outpatient (OP) Pediatric Clinic, located in Carmel, IN strives to ensure that the highest quality of individualized, developmentally supportive, and family-centered care is provided for all patients (H. Krodel, personal communication, February 23, 2021). Common diagnoses within the outpatient pediatric clinic include, but are not limited to, autism spectrum disorder (ASD), down syndrome, neonatal abstinence syndrome (NAS), developmental delay, cerebral palsy (CP), sensory processing disorder, chromosomal abnormalities, and other genetic disorders (H. Krodel, personal communication, February 23, 2022). Occupational therapists utilize a holistic approach and work collaboratively with speech-language pathologists, physical therapists, and families to provide specialized care to every patient (Krodel, 2021). Occupational therapy practitioners play a crucial role as developmental specialists in addressing skills needed to achieve developmental milestones in self-care, play, leisure, and social participation (AOTA, 2016). This doctoral capstone project focuses on myofascial release (MFR) as a treatment option for tight fascia secondary to tongue ties, torticollis, and other congenital issues. According to H. Krodel (personal communication, January 20, 2022), several previous babies discharged from the NICU return to the OP clinic as toddlers with concerns often associated with congenital issues. This raised the initial question, why are we not catching these issues sooner? According to K. Thomas (personal communication, January 27, 2022), lactation consultants often refer babies to OP pediatric therapy services to address tight fascia secondary to tongue tie, torticollis, and other congenital issues. However, IU Norths OP Pediatric clinic has not received many, if any, of these referrals. This raised additional questions: what training is needed to address these issues, and how can IU North become a referral source for these patients? This paper addresses 4 secondary concerns associated with congenital issues, treatment options to address these issues, reason(s) for referrals to occupational therapy services by lactation specialists, and the costbenefit ratio of implementing MFR to address tight fascia secondary to tongue tie, torticollis, and other congenital issues. Background When picturing the tongue, and the role it plays within the human body, many think of the oral cavity, chewing, swallowing, breathing, and speaking (Bordoni et al., 2018). However, according to Bordoni et al. (2018), the tongue interacts with the entire body and even plays a role in muscle strength and posture. The omohyoid muscle and anterior belly of the digastric muscle allow movement between the tongue and neck when flexing, extending, and rotating the neck and cervical tract. Furthermore, the fascia involved with the tongue connects to the sternocleidomastoid muscle and musculature within the thoracic outlet. Bordoni et al. (2018) state that muscles, whether in direct or indirect contact with the tongue, produce contractile tonus to allow the tongue to work effectively via the central and peripheral nervous system. Mills et al. (2019) describes that lingual frenulum as a dynamic structure formed by a central fold of fascia that spans the floor of mouth and together with the overlying oral mucosa it forms the roof of the sublingual space. Ankyloglossia, or tongue-tie, involves this part of the tongue. Kotlow (2004) describes the four classes of tongue tie as: (Class IV) mild: 10-12 mm, (Class III) moderate: 7-9 mm, (Class II) severe: 4-6 mm, and (Class I) complete: 0-3 mm. According to Birch et al. (2021), tongue ties affect up to 11% of infants, with males typically affected more than females. However, a limited number of trained professionals exist to address tongue ties, causing difficulty for this population to access services (Birch et al., 2021). 5 According to H. Krodel (personal communication, February 23, 2021), IU Norths outpatient pediatric therapists noticed several infants born at IU North Hospital returning to the outpatient clinic as toddlers with issues associated with tongue ties and other congenital issues. Some common issues noted during assessment of these toddlers included abnormal body postures, delayed gross motor skills, poor tolerance of prone positioning, and delayed mobility due to tightness or rigidity. This raised the question: why is this concern not caught sooner, and how can we catch this concern sooner? One possible solution to address these concerns sooner involves referrals from lactation specialists. Lactation specialists play an important role in addressing breastfeeding concerns related to tongue ties (Birch et al., 2021; K. Thomas, personal communication, January 27, 2022). In speaking with IU Norths lactation coordinator, she mentioned that common issues associated with tongue ties include, but are not limited to: reflux, swallowing difficulties, jaw development, tightness, fatigue when nursing, fussiness and arching away from the breast, and easily falling asleep at the breast (K. Thomas, personal communication, January 27, 2022). Lactation specialists offer specialized services to address these concerns and often refer infants for frenotomies depending on the severity of the tongue tie. Despite the frenotomy procedure and receiving specialized care from lactation specialists, some infants continue to experience issues associated with the tongue tie. Several infants with moderate to severe tongue ties experience tight fascia that often causes tightness or rigidity elsewhere in the body (K.Thomas, personal communication, January 27, 2022). According to K. Thomas (personal communication, January 27, 2022) myofascial release targets tight fascia within the body and helps to alleviate postural issues. Freed & Coulter-OBerry (2006) and Park et al., (2006) also found MFR to be an effective treatment 6 option for infants with torticollis. According to Barnes (n.d.), myofascial release is defined as, a safe and very effective hands-on technique that involves applying gentle sustained pressure into the myofascial connective tissue restrictions to eliminate pain and restore motion. Watts & Lagouros (2020) report that an infants tightness often releases quickly with little force applied. Myofascial release for infants typically focuses on the thoracic inlet. The MFR technique to address this population consists of the following steps: (1) reach over the top of the infant's shoulders and places fingertips on the chest wall over the upper ribs with the thumbs lying overtop the shoulder blade, (2) engage the superficial layers of skin and fasciae and move hands gently toward the infant's head, then feet, then to the left, and to the right, (3) feel for areas of restriction, and (4) rotate the fasciae into a position of ease or of greatest laxity, gently moving the tissue until that familiar release is felt (Watts & Lagouros, 2020). The two main goals of this MFR technique include: (1) loosening tissue surrounding the lymphatic duct and (2) reducing mechanical strain to improve breathing, sucking, and swallowing when breast or bottle feeding. Currently, little to no peer-reviewed research articles focus on the role occupational and physical therapists play in utilizing MFR to address issues associated with tongue ties. IU Norths lactation coordinator refers approximately fifteen infants suffering from issues associated with tongue ties to an MFR therapist each month (personal communication, January 27, 2022). Approximately 90% of Thomas patients referred to this therapist saw improvements post treatment (K. Thomas, personal communication, January 27, 2022; L. Lafuze, personal communication, February 8, 2022). Given the high number of referrals and long waitlists, the lactation coordinator expressed the need for more therapists to utilize MRF in treating issues associated with tongue ties (K. Thomas, personal communication, January 27, 2022). The goal of 7 this project is to gather enough evidence to support the use of myofascial release to gain referrals and treat issues associated with tongue ties and other congenital issues early on at IU Norths OP Pediatric Clinic. The Ecology of Human Performance (EHP) model helped guide the students doctoral capstone experience. This model describes dysfunction as the disruption between the person, context, and tasks (Cole & Tufano, 2008). Dysfunction leads to flawed human performance. If the infant or toddlers personal factors do not support their participation in feeding, social bonding, and play, there will be flaws in their performance. The EHP model helped identify how tight fascia may hinder the infants participation in everyday occupations such as feeding and play. The biomechanical frame of reference (FOR) also guided the students doctoral capstone experience. This FOR addresses deficits with range of motion (ROM), strength, and endurance (Cole & Tufano, 2008). Dysfunction occurs when restriction in ROM, strength, or endurance impacts the individuals participation in everyday occupations (Cole & Tufano, 2008). Utilization of this FOR helped the student understand how tight fascia limits participation in ones occupations due to restricted ROM and endurance. The student utilized the biomechanical FOR and collaborated with IU Norths OP team to identify techniques for improving ROM and endurance in patients that suffer from tight fascia secondary to tongue tie, torticollis, and other congenital issues. Project Design and Implementation Development of this project consisted of identifying the need, completing extensive research on the need, identifying ways to address the need, determining outcome measures, and meeting with the lactation specialist, myofascial release therapist, site mentor, faculty mentor, 8 and professor of the DCE class. According to L. Lafuze (personal communication, February 08, 2022) and K.Thomas (personal communication, January 27, 2022), several infants with moderate to severe tongue tie and torticollis experience secondary concerns such as feeding dysfunction, reflux, irritability, poor endurance, arching, and tightness. Despite these additional concerns, IU Norths OP Pediatric Clinic receives little to no referrals on this population until later in the childs life. Singh & Anekar (2018) discuss the importance of intervening earlier in a childs life to enhance their cognitive, physical, social, and emotional skills needed to meet developmental milestones. This identified the need for IU Norths OP Pediatric Clinic to investigate the reasoning for the lack of referrals and answer the question, How can we see this population sooner? Lactation specialists often work with infants with tongue ties to address breastfeeding concerns (Birch et al., 2021). If the infants deficits exceed the lactation specialists scope of practice, the lactation specialists often refer the infant to outpatient therapies such as occupational therapy, physical therapy, or speech therapy (University of Michigan, 2016). The student set up a meeting with the lactation coordinator at IU North Hospital to gain more information on this population. The lactation coordinator offered a wealth of information regarding the population she serves, common concerns noted among this population, and the treatment options available. She reported referring several infants with secondary concerns related to tongue-tie to myofascial release services each month and mentioned the desire for IU Norths OP pediatric clinic to begin utilizing this type of treatment (K. Thomas, personal communication, January 27, 2022). After meeting with the lactation coordinator, the student reached out to the physical therapist that receives referrals for this population and asked to discuss her method of treating 9 this population. This physical therapist owns a non-affiliated private practice and solely utilizes myofascial release to treat tight fascia secondary to congenital issues. She provided detailed examples on the purpose of using myofascial release to treat infants with tight fascia and described the referral process, billing codes, typical goals, and average number of MFR sessions needed to treat this population. To further the students knowledge on myofascial release, the physical therapist allowed the student to observe three sessions and receive myofascial release herself. After meeting with the lactation coordinator and physical therapist, the researcher gained pertinent information to help guide development of the cost-benefit analysis and acceptability perception survey. The researcher also used this information to locate and identify appropriate MFR resources to provide to the outpatient pediatric therapists during dissemination. The researcher was unable to meet with any additional lactation specialists and myofascial release therapists due to limited time and a limited number of healthcare professionals interested in using myofascial release for tongue-tie related issues. Project Outcomes Assessment Tools After identifying the need, completing extensive research, and determining how to address the need via conversations with the site mentor and faculty mentor, the researcher chose a cost-benefit analysis (Misuraca, 2014) and acceptability perception survey (Proctor et al., 2011) to measure the projects outcomes. The cost-benefit analysis determines if the benefit(s) of a service outweigh the cost(s) to implement that service (Misuraca, 2014). Therefore, the researcher chose the cost-benefit analysis to show the OP staff and rehabilitation manager(s) the 10 benefits of utilizing myofascial release as a treatment option compared to the costs of training OP staff to implement this service. The acceptability perception survey addresses a specific intervention within a particular setting to determine the agreeability, palatability, or satisfactory of implementing that intervention (Proctor et al., 2011). Therefore, the researcher created an acceptability perception survey for IU Norths OP pediatric therapists to determine the agreeability and palatability of implementing myofascial release as a treatment option into the outpatient pediatric clinic. Cost-Benefit Analysis The researcher planned to take the average hourly OP therapist rate (X) average number of referrals (X) average number of visits (X) cost of training and compare this number to the average number of referrals (X) average number of visits (X) insurance reimbursement rate to determine the cost-benefit ratio. Despite great efforts, the researcher was unable to gather information on insurance reimbursement rates and the average hourly OP therapist rate from IU Norths clinic. Therefore, the measurability of the cost-benefit analysis changed from quantitative to qualitative due to this missing information. The researcher decided to include the following information on the cost-benefit spreadsheet: MFR training courses recommended for the pediatric population, cost of each training, benefit of the training, number of referrals made each month for this population, and CPT codes used for MFR treatment (see Appendix B). Although the researcher could not provide a dollar amount for the cost-benefit ratio, the outpatient therapists indicated that their team was less worried about the cost and more worried about the benefits of the service and number of potential referrals. Appendix B provides the breakdown of the cost-benefit analysis provided to the outpatient pediatric therapy team. 11 The results show that approximately fifteen referrals are made to MFR therapy each month due to tongue-tie related issues, and an average of four visits are typically required to resolve these issues. (K. Thomas, personal communication, January 27, 2022; L. Lafuze, personal communication, February 07, 2022). IU Norths OP therapy manager indicated that the hospital has an education fund that often covers training courses for therapists. Therefore, the profit gained from using MFR to treat infants with tight fascia secondary to congenital issues would outweigh the cost of training. Acceptability Perception Survey Four of the five outpatient pediatric therapists responded to the myofascial release acceptability perception survey. Of the respondents, results indicated that 100% of the therapists were very likely to utilize myofascial release techniques if given the appropriate training and patient population. When asked what percentage of their caseload could benefit from myofascial release, three therapists responded 46-60% and one therapist responded +91%. Three of the outpatient therapists reported yes to currently using myofascial release techniques in some of their treatment sessions. Figure 1 Percentage of IU North OP therapists current caseload that could benefit from myofascial release. 12 Figure 2 Percentage of IU North OP Pediatric Therapists Current Caseload Receiving Myofascial Release When asked, On a scale of 0 to 10 (1= nothing at all and 10= everything there is to know), how much do you know about myofascial release, the therapists reported 50% of less. Given these results, the therapist compiled several MFR resources including, but not limited to, articles, websites, FAQ sheets, and therapist-specific information for using myofascial release within their treatment sessions. Several of these resources directly relate to the pediatric population suffering from fascial restrictions secondary to tongue tie, torticollis, and other congenital issues. 13 Figure 3 IU North OP Pediatric Therapists Current Knowledge on MFR Figure 4 Descriptive Analysis of IU Norths OP Therapists Current Knowledge on MFR Techniques (scale 0-10). 14 Summary In this doctoral capstone project, I investigated the cost-benefit analysis of utilizing myofascial release as a treatment option for tight fascia secondary to congenital issues and determined the OP therapists agreeability to utilizing this type of treatment. Birch et al. (2021), found that approximately eleven percent of infants have tongue tie(s). Tongue tie consists of a short lingual frenulum, and depending on the severity, limits the tongues mobility (Fernando, 1998; Rowan-Legg 2015). Severity of a tongue tie depends on the distance of the lingual frenulum between the tongue and floor of the mouth. Infants with moderate to severe tongue tie are often referred to lactation consultants due to breastfeeding concerns (Ricke et al., 2005; Rowan-Legg, 2015). In meeting with IU Norths lactation coordinator, I learned that several babies are referred each month to myofascial release therapy to treat tight fascia secondary to tongue tie. She mentioned one referral source, a physical therapist at a non-affiliated clinic, that utilizes MFR as her primary treatment option for this population. The physical therapist invited me to observe three sessions, receive MFR treatment myself, and ask thorough questions to better understand the details of using MFR for this population. Through extensive research and meeting with the lactation coordinator and physical therapist, I determined that implementation of MFR into IU Norths Pediatric OP clinic would help gain referrals to treat this population at an early age. Appendix B highlights the results of the cost-benefit analysis and suggests that the benefits of implementing MFR into IU Norths OP clinic outweigh the costs of the training courses. The acceptability-perception survey results indicated that the pediatric OP therapy team was very likely to utilize MFR as a treatment option if given the appropriate training and patient population. The therapists also mentioned that 15 MFR training would help advance their skills as a clinician and at least 46-60% of their current caseload could benefit from MFR. Conclusions I collaborated with IU Norths OP pediatric occupational and physical therapists to identify MFR as a beneficial treatment option to utilize with babies with tight fascia secondary to tongue tie, torticollis, and other congenital issues. Through this doctoral capstone project, IU Norths Outpatient Clinic gained several resources and further knowledge on tongue ties, tight fascia, and myofascial release. The occupational and physical therapists can utilize this information to gain referrals and enhance their clinical skills to appropriately treat this these populations. Limitations within this project exist. I did not complete a pre/post survey. Therefore, the participants perspective on the benefits of utilizing myofascial release to address tight fascia secondary to tongue tie, torticollis, and other congenital issues may be skewed secondary to limited knowledge on myofascial release. Only four of the five OP pediatric occupational and physical therapists responded to the acceptability perception. Of those four, 100% reported a 5 or less on a scale of 0-10 on perceived knowledge on MFR. However, 100% of the participations responded very likely to utilize MFR if given the proper training and patient population. Despite these limitations, I identified implications for future practice. IU Norths OP Pediatric Clinic would benefit from further research to determine a combination of treatment techniques to utilize with babies with tight fascia secondary to congenital issues. The clinic would also benefit from further knowledge on how MFR can benefit other patient populations to add to the types of treatment options offered at IU North. 16 References American Occupational Therapy Association (AOTA). (2016). Occupational therapys distinct valueChildren and youth: Resource for administrators and policy makers. American Occupational Therapy Association. https://www.aota.org/~/media/Corporate/Files/Secure/Practice/Children/distinct-valuepolicy-makers-children-youth.PDF. Barnes, J. (n.d.). What is myofascial release? Myofascial Release Treatment Centers and Seminars. https://www.myofascialrelease.com/about/definition.aspx. Birch, A., Bowen, N., Lumsden, H., Penn, K., & Williams, L. (2021). Ankyloglossia management: a collaborative approach to educating healthcare professionals. British Journal of Midwifery, 29(12), 706711. https://doi.org/10.12968/bjom.2021.29.12.706. Bordoni, B., Morabito, B., Mitrano, R., Simonelli, M., & Toccafondi, A. (2018). The Anatomical relationships of the tongue with the body system. Cureus, 10(12), e3695. https://doi.org/10.7759/cureus.3695. Cole, M. & Tufano, R. (2008). Applied theories in occupational therapy: A practical approach. Thorofare, NJ: SLACK Incorporated. Fernando, C. (1998). Tongue tie: From confusion to clarity. Sydney, Australia: Tandem Publications. Freed, S. S., & Coulter-OBerry, C. (2004). Identification and treatment of congenital muscular torticollis in infants. Journal of Prosthetics & Orthotics (JPO), 16(4 Suppl), S18-s23. https://journals.lww.com/jpojournal/fulltext/2004/10001/identification_and_treatment_of _congenital.7.aspx. 17 Kotlow, L. (2004). Oral diagnosis of abnormal frenum attachments in neonates and infants: evaluation and treatmen of he maxillary and lingual frenum using Erbium: YAG laser. Journal of Pediatric Dental Care, 10, 11-14. Krodel, H. (2021). Occupational therapy in the neonatal intensive care unit. [PowerPoint slides]. ACE@UIndy. https://ace.uindy.edu/portal/site/202020-OTD-583-01. Mills, N., Pransky, S. M., Geddes, D. T., & Mirjalili, S. A. (2019). What is a tongue tie? Defining the anatomy of the in-situ lingual frenulum. Clinical Anatomy (New York, N.Y.), 32(6), 749761. https://doi.org/10.1002/ca.23343. Misuraca, P. (2014). The effectiveness of a costs and benefits analysis in making federal government decisions: A literature review. Center for National Security, The MITRE Corporation. https://www.mitre.org/sites/default/files/publications/cost-benefit-analysisgovt-decisions-14-0929.pdf. Park, T. K., Kim, J. R., Park, R. J., & Cho, M.S. (2006). Effect of myofascial release therapy on newborns and infants with congenital torticollis. The Korean Society of Physical Therapy, 18(5):1-11. http://www.kptjournal.org/journal/view.html?spage=1&volume=18&number=5. Proctor, E., Silmere, H., Raghavan, R., Hovmand, P., Aarons, G., Bunger, A., Griffey, R., & Hensley, M. (2011). Outcomes for implementation research: Conceptual distinctions, measurement challenges, and research agenda. Administration and Policy in Mental Health and Mental Health Services Research, 38(2), 6576. https://doi.org/10.1007/s10488-010-0319-7. 18 Ricke, L., A., Baker, N., J., Madlon-Kay, D., J., & DeFor, T.A. (2005). Newborn tongue-tie: Prevalence and effect on breast-feeding. J Am Board Fam Pract. 18(1):1-7. doi:10.3122/jabfm.18.1.1. PMID: 15709057. Rowan-Legg A. (2015). Ankyloglossia and breastfeeding. Pediatrics & child health, 20(4), 209 218. https://doi.org/10.1093/pch/20.4.209. Singh, P., & Anekar, U. (2018). The importance of early identification and intervention for children with developmental delays. Indian Journal of Positive Psychology, 9(2), 233 237. University of Michigan (2016, July). Breast feeding support program. https://medicine.umich.edu/dept/pmr/patient-care/therapeutic-otherservices/occupational-physical-speech-therapy/breast-feeding-support-program. Watts, K. B., & Lagouros, M. (2020). Osteopathic Manipulative Treatment and Breastfeeding. Clinical Lactation, 11(1), 2834. https://doi.org/10.1891/2158-0782.11.1.28. 19 Appendix A 20 Appendix B Cost-Benefit Analysis Spreadsheet 21 22 Appendix C DCE Weekly Planning Guide Week DCE Stage Weekly Goal 1 Complete orientation and onboarding process by the end of the week. Orientation Objectives 2 Tasks Meet the team (OT, PT, ST, RT, Nursing staff, dieticians, lactations specialists, and physicians). Introduce myself and DCE plans. Address supervision plan and MOU with site mentor Familiarize myself with the hospital environment and their policies/procedures Date Completed Introduce self to staff and 01/12/22 build rapport with the team. Set up meetings with essential personnel Create a short elevator speech regarding my project Finalize MOU Ensure Ive completed the onboarding process and am fully ready to begin my project. 01/28/22 01/26/22 01/21/22 Screening/ Evaluation Finish needs assessment by end of the week Finalize the need for my project Screening/ Evaluation Complete additional literature search for program evaluation measurements Establish outcome assessment Review and discuss outcome assessments with the site mentor and faculty mentor 01/28/22 Address referrals for babies with tongue ties Meet with lactation specialists to discuss referrals for tongue-tie related issues 01/27/22 Determine the agreeability and palatability of implementing myofascial release as a treatment option into the Administer survey to OT/PTs in OP clinic regarding their confidence in addressing the target population 03/01/22 Complete referral meeting Create MFR acceptability perception survey 01/26/22 23 outpatient pediatric clinic 3 Screening/ Evaluation Complete data on referral sources 4 Implementation Complete observation and exploration of sites currently receiving referrals related to tongue ties 5 6 Implementation Implementation Understand how, where, and why babies are referred for issues associated with tongue ties Gain insight into best practices for addressing tonguetie related issues Review and compile referral information into document 02/27/22 Visit sites to observe and explore their OP clinic Research sites that currently receive tongue tie referrals Explore MFR and its effectiveness in treating target population 02/09/22 Identify MFR trainings and cost to attend Identify MFR training that are most relevant to treating targeted population Understand MFR mechanisms and techniques utilized during treatment sessions Meet with MFR therapist to gain knowledge and receive treatment Complete outline for best training protocols/programs for OT/PT using MFR to target tight fascia secondary to congenital issues Complete data collection from OT/PT acceptability perception survey 03/04/22 02/08/22 03/14/22 Research and gather additional information on MFR trainings, their cost, and CEU credits Understand MFR on a deeper level by being treated myself Provide staff with MFR training opportunities 03/18/22 Create a document/pamphlet/excel sheet with detailed explanation of trainings offered for therapists interested in treating this population Understand OT/PTs perspectives on implementing MFR Review and compile survey results into document 02/18/22 03/11/22 24 7 Implementation Locate and identify helpful MFR resources Filter through websites, research articles, helpful tips, and other MFR resources Receive feedback from site mentor on cost-benefit analysis Determine best options for dissemination Determine which resources are most beneficial and related to the targeted population 03/11/22 8 Implementation Finalize costbenefit analysis Make changes to costbenefit analysis as appropriate 03/15/22 9 Implementation Create dissemination plans draft Meet with site mentor to discuss ideas for dissemination 03/22/22 10 Implementation Finalize helpful MFR resources Compile and organize resources by topic Create a website to compile and organize gathered MFR resources 03/25/22 11 Implementation Finalize dissemination plans Create dissemination planning guide Send out poll to OP therapy team to determine date and time to meet for dissemination Create handout summarize results 04/01/22 04/01/22 12 Discontinuation Complete project Wrap up project and tie up all loose ends Meet with site mentor to discuss dissemination and final weeks 04/03/22 13 Dissemination Meet with outpatient therapy team Provide team with project results Provide team with handout summarizing project and results 04/06/22 Schedule dates and times to meet with therapy team members Meet with therapy team members to receive and give feedback 04/14/22 14 Dissemination Disseminate project Receive and provide feedback from end users and dissemination partners  ...