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... 1 A Peer Mentorship Program for Clients at Community Rehabilitation Hospital North Kassidy Beckstein, OTS 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. Kelsey Robertson, OTR, OTD 2 Abstract From a therapists perspective, mental health frequently goes unaddressed in inpatient rehabilitation facilities, which has many negative effects on the clients as they are going through mentally and emotionally challenging times. Peer mentorship programs have been shown to reduce and improve clients mental health by promoting increased participation, coping skills, social connection, knowledge of available resources, and more (Baby et al., 2018; Richardson et al., 2020). A peer mentorship program manual was created and implemented for Community Rehabilitation Hospital North (CRHN) to better address the mental and emotional wellbeing of their clients. Through completion of a needs assessment, many interviews, a literature search and review, and continued communication with stakeholders, the site-specific program manual was created and implemented beginning with peer mentor recruitment. The results of the program were evaluated using an outcome assessment, in which therapists reported highly positive feedback. In conclusion, a peer mentorship program manual was successfully created and implemented for this doctoral capstone experience. Future implications include rehabilitation professionals encouraging clients to participate in peer mentorship programs for mental health benefits, re-evaluating the peer mentorship program, and implementing the program at other rehabilitation hospitals within Community Health Network. Keywords: mental health, inpatient rehabilitation, peer mentor, peer mentorship program 3 Introduction Community Rehabilitation Hospital North (CRHN) is an inpatient facility that offers intensive rehabilitative services and access to the latest equipment to improve individuals' lives with a broad range of diagnoses, including brain injury, spinal cord injury, stroke, and amputation (Community Health Network, 2021). CRHN has a specific goal for its clients. The goal of rehabilitation is to assist you in becoming as strong, safe, and independent as possible while educating you and your family or other caregivers about your care. We will be supporting you as you learn to do daily activities for yourself," (Community Health Network, 2021). While at CRHN, clients receive care to improve their physical, emotional, and mental health. They receive client-centered care to address their barriers to independence and discharge to the community. Time spent in inpatient rehabilitation facilities (IRFs) is pivotal for clients to develop skills related to good quality of life (Brown, 2017). However, mental and emotional health is often not addressed thoroughly enough due to limited time and resources. After completion of a needs assessment, CRHN therapy staff expressed a desire for a program to be created and implemented that would benefit the mental health of their clients. After a traumatic event, research shows that clients benefit from a more proactive intervention related to mental health (Roepke et al., 2019). Several researchers have noted the mental health benefits of peer mentorship programs for a variety of populations while in IRFs (Hibbard & Cesario, 2021; Richardson et al., 2020). Peer mentoring is a process in which a person who is a "veteran" of a specific life experience or diagnosis helps another person cope with a similar life event (Cesario, 2005). It was established that CRHN would benefit from the program development and implementation of a site-specific peer mentorship program for their clients to meet more of their mental health needs prior to discharge from the facility. 4 Background Currently, there is a significant amount of research correlating mental health concerns, decreased engagement, limited social connections, and difficulty with acceptance in clients with a variety of diagnoses during the recovery and rehabilitation process. Aaby et al. (2020) found that people with a spinal cord injury (SCI) reported reduced life satisfaction, poor social participation, depression, and anxiety. Psychological distress and negative mood states are common in individuals after SCI (Aaby et al., 2020; Craig et al., 2017). Researchers highly recommend addressing cognition and mental health while in rehabilitation, so clients do not further deteriorate after they discharge home (Craig et al., 2017). Additionally, Baby et al. (2018) found that psychiatric morbidity in people with amputations is also significantly high. Mental health concerns were related to depression, negative body image, negative feelings about the future, limited participation in activities of daily living, difficulty coping, and decreased wellbeing (Baby et al., 2018; Richardson et al., 2020; Roepke et al., 2019). imsek et al. (2020) stated that people with amputations required mental health support to develop coping skills and increase participation during the rehabilitation process. Other conditions frequently treated in IRFs that experience unmet mental health needs and decreased participation in ADLs include adults with: low vision (Sanecki et al., 2021), aphasia after stroke (Coles & Snow, 2011), acquired brain injury (Kuipers et al., 2014), and breast cancer (Brauer et al., 2016). As previously mentioned, a challenge for therapy staff who work in inpatient rehabilitation facilities is the lack of time for addressing the mental health of their clients. Frequently, the length of stay for clients is brief, and they have so many physical and cognitive health needs that must be met for them to discharge safely, that mental health needs go unaddressed. When the mental health needs of clients are unmet, it affects the acceptance, 5 quality of life, and overall functioning of the person (Aaby et al., 2020). An interview-style needs assessment was completed with CRHN staff. Therapy staff consistently expressed concern for their clients mental health needs. Therapists from a variety of teams such as amputation, brain injury, stroke, and spinal cord injury felt that mental health treatment was lacking and could benefit from the development of a new program. For example, a therapist from the spinal cord injury team mentioned her concern about the mental health of the clients she treats. Many of the clients in the spinal cord injury unit are young males in their 20s who experience severe depression and mental health concerns after such a traumatic, life-changing injury. The staff expressed a desire for the development of a peer mentorship program to offer mental and social support for current clients to improve their overall health. Additionally, a client who had previously been discharged from CRHN was back at the facility following another procedure. From his point of view, the mental health services were severely lacking as well. The client did not feel his mental health after limb loss was effectively addressed during his stay at CRHN, and he felt like mental health issues continued to affect him after his first discharge. The client said he would love to see a peer mentorship program developed so he could more intimately stay in touch and connect with a person who understands his situation or what he has been through. The client stated that it is helpful to see people with the same condition as you who have survived recovery and created their own meaningful life after a life-changing injury. Finally, the last time the Commission on Accreditation of Rehabilitation Facilities (CARF) surveyed CRHN, their survey results were that the existing peer visitor system in place was lacking and not up to their standards. CARF recommended that CRHN needed a wider variety of peer visitors/mentors. For example, there was only one visitor with an amputation, and it was a young female who had an amputation as a result of a traumatic 6 accident. Most clients at CRHN have vascular conditions or diabetes that cause their amputations. The stroke team also only had a few peer visitors. To more closely align with CARF standards, CRHN needed a peer mentorship program with a wider variety of mentors so they can be paired with current clients to better match their gender, age, level of injury, mechanism of injury, personal interests, and so on. Numerous amounts of research are available supporting peer mentorship programs due to their significant benefits for a variety of people and conditions. Aaby et al. (2020) found a correlation between greater levels of acceptance and decreased levels of depression in SCI clients after participation in a peer mentorship program. Peer mentorship programs have also been shown to promote participation and life satisfaction (Sweet et al., 2016). Other researchers found peer mentorship programs promote personal growth, increased participation, coping skills, social connection, and increased knowledge of available resources or opportunities for adults with SCI (Rocchi et al, 2018, Rocchi et al., 2021). Richardson et al. (2020) found that a peer mentorship program for people with an amputation resulted in mutually beneficial outcomes for all the participants regardless of the mentor or mentee role. The participants reported feeling supported and more hopeful, resilient, and connected (Richardson et al., 2020). Brauer et al. (2016) found peer mentorship programs for people with breast cancer helped decrease trauma symptoms and improve wellbeing. Singh et al. (2007) found that period of rehabilitation is a crucial time for teaching new skills and modifying the outlook of clients. Although there are significant amounts of research that report the benefits of peer mentorship programs for a variety of people and conditions, many research articles also note where there were problems or shortcomings within their program. 7 Some challenges with past peer mentorship programs include peer mentors feeling uncertainty and doubt about their mentoring abilities and maintaining the role (Richardson et al., 2020). Sweet et al. (2018) found that some mentees noted their mentors did not listen to their needs or felt that conversations were awkward at times. The researchers recommended developing training packages or resources to increase clarity for the peer mentor volunteers (Richardson et al., 2020). The peer mentorship program created for CRHN used the previous literature available, the specific needs of the site and its clients, and former CARF survey results and standards to create a new peer mentorship program to meet the needs of all stakeholders involved. Occupation-Based Model and Frame of Reference The occupation-based model that guided the peer mentorship program for CRHN was the Person-Environment-Occupation-Performance (PEOP) model. Within PEOP, dysfunction patterns occur because of deficits in abilities and skills due to a health condition, restrictive barriers, or lack of resources within the environment (Cole & Tufano, 2008). After experiencing a life-changing injury, some clients in IRFs encounter many deficits in their skills and abilities, creating dysfunction. PEOP identifies factors in the areas of personal performance capabilities or constraints and environmental performance enablers or barriers central to clients occupational performance (Cole & Tufano, 2008). Examples of personal barriers and enablers clients may face in the peer mentorship program are coping skills, mental health conditions, pain levels, and sensory or motor systems changes. Some examples of environmental factors clients may face in the peer mentorship program are support systems not being equipped or ready to offer support, pre-existing beliefs on disability, mental health, or accepting help from others. PEOP guided the peer mentorship program design to account for the person, environment, occupation, and 8 performance factors, as well as the influence of those factors on occupational performance and wellbeing. Through the application of PEOP, the program remained client-centered. The frame of reference that guided the peer mentorship program is Psychodynamic. This frame of reference focuses on helping individuals develop a strong sense of self, positive body image, self-identity, and self-esteem, which can serve as the basis of adaptive function (Cole & Tufano, 2008). Through therapeutic relationships, clients work to become aware of their emotions, motivations, and conflicts, and they begin learning and improving their overall functioning and wellbeing (Cole & Tufano, 2008). The peer mentorship program was designed to help clients develop a strong sense of self, body image, self-identity, and self-esteem to improve their adaptive functioning skills while in inpatient rehabilitation and once they discharge home. The psychodynamic frame of reference served to guide the peer mentorship program and the interactions and relationships built between the mentors and mentees. Project Project Design This project was developed to fulfill clients unmet mental health needs while at CRHN. Peer mentorship programs have been shown to support the mental health of a variety of ages, diagnoses, and conditions while in IRFs. Additionally, the project was developed in a way to not add any additional strain or work to the therapists at CRHN. The programs design allows therapists to discuss the peer mentorship program with clients during their already scheduled sessions. All members of the therapy team have access to the peer mentors' contact information to allow for initiation of the process as soon as a client would express interest. The goal of this design was to avoid the responsibilities of the program falling onto one therapist as a program director. However, in case of an emergency or abnormal situation, one therapist was designated 9 as the point person for this program for future sustainability. Lastly, the project was developed to better meet CARF standards on peer mentorship programs. This project was developed through a series of processes and collaboration with staff members at CRHN. First, a comprehensive needs assessment was completed consisting of multiple interviews with CRHN staff, an interview with a former client, and a review of CARF survey results. An in-depth literature search using a variety of databases was completed and followed by a review of the literature. Any necessary updates to the needs assessment were made before creating the program manual. Using the updated needs assessment, evidence-based practice research, and CARF standards, a peer mentorship program manual was developed for CRHN to be implemented by therapists in the future months. For this project, two outcome assessments were created: a client-centered assessment and an assessment for therapists who attended the peer mentorship program in-service. The purpose of the client-centered assessment was to evaluate the peer mentorship program experience and usefulness from the clients point of view. This assessment was developed specifically for future use to aid with program evaluation and re-evaluation. The purpose of the therapist assessment was to evaluate the overall program and its usefulness from the therapists point of view at the end of the doctoral capstone experience. Implementation This project was implemented over the course of 14 weeks, outlined in the project timeline (Appendix A). First, a peer mentorship program manual was created with outcome measures for program evaluation and re-evaluation. Following the creation of the manual, the implementation and recruiting process began. Previous CRHN clients that had been discharged back into the community and some other therapist-recommended people were contacted and 10 recruited to become peer mentors. An information meeting was held for potential volunteers to come in, learn more about being a peer mentor, and initiate the paperwork process with human resources. Towards the end of the 14 weeks, the project was disseminated via an in-service lecture to explain the official program to the therapists and answer any questions they had. At the end of the in-service, the therapists completed the assessment to evaluate the program and its usefulness from the therapists points of view. A challenge during the project was that the design process and creation of the manual took a significant amount of time because it needed to be much more thorough than anticipated. That left little time for implementation and recruitment of mentors. However, CRHN wanted to have a solid, detailed manual before moving forward with the program. Additionally, finding a large group of diverse peer mentors was challenging due to extremely limited time. Since the program creation took so much longer than intended, the goal became to just get a few peer mentors involved in the program initially, and then CRHN could continue to grow the program at a slow, steady pace. Some successes during the project were the numerous amounts of evidencebased practice research located supporting peer mentorship programs. Another success was the thoroughness of the peer mentorship program manual reducing the work for any therapists in the future. The program was also more closely aligned with CARF standards, so hopefully, the next time CRHN is surveyed, CARF will approve their peer mentorship program. Lastly, there was a good number of volunteers going through the process of becoming peer mentors by the end of the 14-week experience. The therapists also provided a lot of positive feedback after the program dissemination via the in-service. Project Outcomes 11 The assessment tool used to measure project outcomes was the feedback survey completed by therapists who attended the peer mentorship program in-service. The assessment for therapists evaluated the overall program and its usefulness from the staff perspective. The therapists filled out the assessment after the final in-service explaining the program and how to use it. Therapists rated their perspective using a Likert scale on topics such as the importance of addressing the mental health of their clients, if the mental health of clients sometimes goes unaddressed for a variety of reasons, if the program could be a good option for some of their clients, their willingness to mention/educate clients about the peer mentorship program, and their willingness to initiate the process of connecting their clients to a peer mentor (Table 1). The assessment concluded with one open-ended question for any additional comments the therapists had. The client-centered assessment mentioned previously was created for future use to evaluate or re-evaluate the program. Clients will rate their peer mentorship program experience using a Likert scale after participating in the program. The purpose of the scale is to assess their experience and if it aligns with the overall goals of the peer mentorship program such as enjoyment talking with a mentor, increased sense of connection, improved outlook on progress/potential, increased desire to engage in activities, and improved mental/emotional wellbeing. The assessment also measures whether or not the client would recommend the program continues to exist for other people who might want to use it in the future and concludes with one open-ended question for clients to leave any additional feedback. This assessment tool was designed with the intent of continued use by the hospital, so that they may track program outcomes over time. 12 The results of the assessment completed by the therapists were very positive. The therapists were able to rate each question on a scale from one through five with one being strongly disagreed and five being strongly agreed. As seen in Figure 1, every question received an average score of 4.3 or higher on a scale out of 5 (Figure 1). Therefore, most therapists either agreed or strongly agreed with the statement. Therapists provided positive feedback through the open-ended questions. Some of the comments included: Sounds like a great opportunity for patients!, Great job! There is a need for this here!, and Put together well. Seems like a quick and easy process for the therapists!. Table 1 Questions from the Outcome Assessment for Therapists Question 1 Question 2 Question 3 Question 4 Question 5 Question Number Question Content I feel like the mental health of my patients is important to consider/address when needed. I feel like the mental health of my patients sometimes goes unaddressed due to a lack of time, resources, etc. I feel like this program could be a good option for some of my patients to participate in. I am willing to mention that we have this peer mentorship program available to my patients. I am willing to initiate the process (call a mentor) for my patient to meet with. Figure 1 Outcome Assessment Results Completed by Therapy Staff 13 Summary In summary, CRHN needed this program to be created and implemented to meet the mental health needs of their clients while not adding additional role strain to their therapists. Mental health frequently goes unaddressed in the inpatient rehabilitation setting, which negatively impacts the clients (Aaby et al., 2020). Peer mentorship programs have significant amounts of research supporting their effectiveness in IRFs with a variety of populations, conditions, and ages (Richardson et al., 2020; Rocchi et al., 2021; Singh et al., 2007). Therefore, using the completed needs assessment, evidence-based practice research, and CARF standards, a peer mentorship program manual was developed and implemented specifically for CRHN. The therapy staff responded very positively to the program, which was evaluated using a Likert scale outcome assessment at the end of the doctoral capstone experience. Therapists also commented positive feedback related to the programs design and ability to meet the need of their clients. Overall, the program with disseminated to CRHN staff with the intent for them to continue to grow the contact list of peer mentors and begin pairing their current clients with similar peer mentors. Conclusion In conclusion, a peer mentorship program manual was successfully created and implemented for this doctoral capstone experience. The peer mentorship program was ready for CRHN to continue growing to have more and more diverse peer mentors and soon start pairing mentors with clients. The site benefited from the project because they now have an official program manual created for the peer mentorship program that they can rely on and use to their advantage, and they already have some peer mentors involved in the program. Previously, the therapy staff did not have enough time to do the background work necessary to get the peer 14 mentorship program up and running successfully. However, they are now set up for success to grow the peer mentorship program, improve the client experience at CRHN, and improve their CARF survey results. The project was translated and disseminated at the site with the therapy staff through a formal in-service lecture to explain the peer mentorship program, the manual, how to use the manual, and answer any additional questions. Many future implications for the profession and setting can be made based on this project. First, rehabilitation professionals should encourage clients to participate in peer mentorship programs for mental health benefits. Additionally, the peer mentorship program and the manual should be evaluated and re-evaluated at a future time by either a therapist, staff member, or future doctoral capstone student to ensure the program is fulfilling its purpose and make any necessary revisions or changes. Finally, the peer mentorship program and the manual could be implemented at other Community Health Network rehabilitation hospitals in the area with additional work and revisions in the future. 15 References Aaby, A., Ravn, S.L., Kasch, H., & Andersen, T. E. (2020). The associations of acceptance with quality of life and mental health following spinal cord injury: A systematic review. Spinal Cord, 58, 130148. https://doi.org/10.1038/s41393-019-0379-9 Baby, S., Chaudhury, S., & Walia, T. (2018). Evaluation of treatment of psychiatric morbidity among limb amputees. Industrial Psychiatry Journal, 27(2), 240248. https://doi.org/10.4103/ipj.ipj_69_18 Brauer, C. E. L., Clark, M. M., Nes, L. S., & Miller, L. K. (2016). Peer mentorship programs for breast cancer patients. Journal of Pain and Symptom Management, 51(5), e5e7. https://doi.org/10.1016/j.jpainsymman.2016.03.001 Brown, A. (2017). Community re-integration programming in an inpatient rehabilitation setting. SIS Quarterly Practice Connections, 2(1), 2325. Cesario, J. A. (2005). Community-based peer mentoring program for individuals with spinal cord injury: Program manual. https://icahn.mssm.edu/files/ISMMS/Assets/Research/Spinal%20Cord%20Injury/sci_co mmunity_based_peer_mentoring_manual.pdf Cole, M. & Tufano, R. (2008). Applied theories in occupational therapy: A practical approach. Thorofare, N.J.: SLACK Inc. Coles, J., & Snow, B. (2011). Applying the principles of peer mentorship in persons with aphasia. Topics in Stroke Rehabilitation, 18(2), 106111. https://doi.org/10.1310/tsr1802106 Community Health Network. (2021). Community Rehabilitation Hospital North. https://www.ecommunity.com/locations/community-rehabilitation-hospital-north 16 Craig, A., Guest, R., Tran, Y., & Middleton, J. (2017). Cognitive impairment and mood states after spinal cord injury. Journal of Neurotrauma, 34(6), 1156-1163. DOI: 10.1089/neu.2016.4632 Hibbard, M. R., & Cesario, J. (2021). A community-based peer mentoring program for individuals with spinal cord injury: Program manual. Icahn School of Medicine at Mount Sinai. https://icahn.mssm.edu/files/ISMMS/Assets/Research/Spinal%20Cord%20Injury/sci_co mmunity_based_peer_mentoring_manual.pdf Kuipers, P., Doig, E., Kendall, M., Turner, B., Mitchell, M., & Fleming, J. (2014). Hope: A further dimension for engaging family members of people with ABI. NeuroRehabilitation, 35(3), 475-480. https://doi.org/10.3233/NRE-141139 Richardson, L. J., Molyneaux, V., & Murray, C. D. (2020). Being a peer support mentor for individuals who have had a lower limb amputation: An interpretative phenomenological analysis. Disability and Rehabilitation, 42(26), 38503857. https://doi.org/10.1080/09638288.2019.1611954 Rocchi, M. A., Zelaya, W., & Sweet, S. N. (2018). Peer mentorship for adults with spinal cord injury: A static group comparison between mentees and non-mentees reported coping strategies. Spinal Cord, 56(11), 11021109. https://doi.org/10.1038/s41393-018-0197Rocchi, M. A., Shi, Z., Shaw, R. B., McBride, C. B., & Sweet, S. N. (2021). Identifying the outcomes of participating in peer mentorship for adults living with spinal cord injury: A qualitative meta-synthesis. Psychology & Health, 122. https://doi.org/10.1080/08870446.2021.1890729 17 Roepke, A. M., Turner, A. P., Henderson, A. W., Goldberg, S. B., Norvell, D. C., Czerniecki, J. M., & Williams, R. M. (2019). A prospective longitudinal study of trajectories of depressive symptoms after dysvascular amputation. Archives of Physical Medicine and Rehabilitation, 100(8), 1426. https://doi.org/10.1016/j.apmr.2018.11.024 Sanecki, B., Stratton, K., Robinson, M., & Knecht-Sabres, L. (2021). Development of a peer mentorship program for adults with low vision. Communique, 2, 2224. imsek, N., ztrk, G. K., & Nahya, Z. N. (2020). The mental health of individuals with posttraumatic lower limb amputation: A qualitative study. Journal of Patient Experience, 7(6), 16651670. https://doi.org/10.1177/2374373520932451 Singh, R., Hunter, J., & Philip, A. (2007). The rapid resolution of depression and anxiety symptoms after lower limb amputation. Clinical Rehabilitation, 21(8), 754759. https://doi.org/10.1177/0269215507077361 Sweet, S. N., Noreau, L., Leblond, J., & Martin Ginis, K. A. (2016). Peer support need fulfillment among adults with spinal cord injury: Relationships with participation, life satisfaction and individual characteristics. Disability and Rehabilitation, 38(6), 558-565. https://doi.org/10.3109/09638288.2015.1049376 18 Appendix A DCE Weekly Planning Guide On the following pages is the weekly planning guide used for this doctoral capstone experience. It specifies what was completed during each of the 14 weeks using a table format organized by goals, objectives, and tasks. Week 1 DCE Stage (orientation, screening/evalua tion, implementation, discontinuation, dissemination) Orientation Weekly Goal 1. Complete orientation by end of the week Objectives 1. 2. 3. 2 Screening/ Evaluation 1. 2. 3 Program Design/ Creation 1. Complete updating needs assessment by end of the week Complete search of the literature for previous peer mentorship programs and program evaluation measures 1. Begin creating a program manual and handouts for the peer mentorship program (focus on Evaluation Assessment for Therapists, Evaluation Assessment for Clients, and Resources for Peer Mentors section) 1. 2. 3. 4. 2. Tasks Meet with site mentor, other site personnel, and the site participants to introduce myself and educate them on why I am here/what I will be doing for the 14-weeks Document supervision plan and update MOU with site mentor Understand site environment/where to work/dress code/ etc. 1. Finalize Needs Assessment Explore New literature on peer mentorship programs and outcome measures Establish outcome assessment(s) Review outcome assessment(s) with site mentor & faculty mentor 1. Use previous literature and needs assessment to write a customized peer mentorship program manual for CRH North Create handouts for clients including details about the peer mentorship program 2. 3. 4. 2. 3. 4. 1. 2. 3. 4. 19 Date complete Set up meetings with key personnel Finalize MOU Ensure that all paperwork for orientation is complete Determine who to meet with and what questions to ask and set up meeting times 01/14/2022 Meet with site mentor to update and finish needs assessment Explore databases available through UIndy to find new research Create outcome assessments for the program Meet with site mentor and faculty mentor to approve outcome assessments Utilize previous literature and needs assessment Write a customized peer mentorship program manual Create handouts for clients with details and explanations about the program Check in with site mentor and faculty mentor to ensure the content being produced is on track with meeting expectations 01/21/2022 01/29/2022 20 4 5 6 Program Design/ Creation Program Design/ Creation Program Design/ Creation 1. 1. 1. 2. Continue creating a program manual and handouts for the peer mentorship program (focus on the Resources for Peer Mentors section) 1. Continue creating a program manual for the peer mentorship program (focus on the Resources for Peer Mentors section) 1. Continue creating a program manual and handouts for the peer mentorship program (focus on the Background Information section and Information Flyer) Meet with therapy manager and direction to discuss program manual and offer an update 1. 2. Use previous literature and needs assessment to write a customized peer mentorship program manual for CRH North Create handouts for clients including details about the peer mentorship program 1. 2. 3. 4. 2. Use previous literature and needs assessment to write a customized peer mentorship program manual for CRH North Create handouts for clients including details about the peer mentorship program 1. 2. 3. 4. 2. 3. Use previous literature and needs assessment to write a customized peer mentorship program manual for CRH North Create handouts for clients including details about the peer mentorship program Give an information presentation about progress with the program manual to management and answer questions 1. 2. 3. 4. 5. Utilize previous literature and needs assessment Write a customized peer mentorship program manual Create handouts for clients with details and explanations about the program Check in with site mentor and faculty mentor to ensure the content being produced is on track with meeting expectations Utilize previous literature and needs assessment Write a customized peer mentorship program manual Create handouts for clients with details and explanations about the program Check in with site mentor and faculty mentor to ensure the content being produced is on track with meeting expectations Utilize previous literature and needs assessment Write a customized peer mentorship program manual Create handouts for clients with details and explanations about the program Check in with site mentor and faculty mentor to ensure the content being produced is on track with meeting expectations Prepare and perform an information presentation to therapy management, 02/04/2022 02/11/2022 02/18/2022 21 7 Program Design/ Creation 1. 2. 8 Program Design/ Creation 1. 2. 9 Program Design/ Creation 1. Continue creating a program manual and handouts for the peer mentorship program (focus on the Background Information section) Meet with a therapist on-site with experience in previous programs 1. Continue creating a program manual and handouts for the peer mentorship program (focus on the Background Information section and Volunteer Requirements packet) Meet with the human resources manager to discuss volunteer application necessities) Continue creating a program manual and handouts for the peer mentorship program (focus on the Volunteer Requirements packet) 1. 2. Use previous literature and needs assessment to write a customized peer mentorship program manual for CRH North Meet with an experienced therapist to update her on current manual progress and receive feedback 1. 2. 3. 4. 2. Use previous literature and needs assessment to write a customized peer mentorship program manual for CRH North Meet with the human resources manager to discuss volunteers and paperwork 1. 2. 3. 4. 1. 2. Use previous literature and needs assessment to write a customized peer mentorship program manual for CRH North Write a dissemination plan and confirm with the site mentor 1. 2. 3. answer any questions, and take notes on suggestions for change Utilize previous literature and needs assessment Write a customized peer mentorship program manual Check in with site mentor and faculty mentor to ensure the content being produced is on track with meeting expectations Check in with an experienced therapist to receive feedback on manual Utilize previous literature and needs assessment Write a customized peer mentorship program manual Check in with site mentor and faculty mentor to ensure the content being produced is on track with meeting expectations Check-in with human resources manager to go over requirements for volunteers Utilize previous literature and needs assessment Write a customized peer mentorship program manual Check in with site mentor and faculty mentor to ensure the content being produced is on track with meeting expectations 02/25/2022 03/04/2022 03/11/2022 22 2. 10 Program Design/ Implementation 1. 2. 3. 11 Program Design/ Implementation 1. 2. 3. 12 Program Design/ Implementation 1. 2. Make a dissemination plan Begin final revisions of the program manual (all sections) Meet with the human resources manager again to update him on revised volunteer applications Begin recruiting mentors 1. 2. 3. Continue revisions to the program manual Meet with any necessary stakeholders Continue recruiting peer mentors and host an informational session 1. Make any final revisions to the program manual and handouts for the peer mentorship program Finalize the program manual and finish it 1. 2. 3. 2. 3. Begin reading through the entire program manual to make revisions for clarity and grammar Meet with the human resources manager again to discuss the new revisions to volunteer paperwork and ask questions Begin reaching out to volunteers to be peer mentors 1. Continue reading through the entire program manual to make revisions for clarity and grammar Check in with necessary stakeholders such as therapists, management, etc. Continue reaching out to volunteers to be peer mentors and host an informational session for volunteers 1. Final revisions to the program manual and handouts based on any therapist, management, or client feedback Finalize the program manual and print it and upload it to the K drive Meet with necessary therapy staff or 1. 2. 3. 2. 3. 2. Slowly read through all sections of the program manual multiple times to locate and correct any errors Check in with the human resources manager to go over changes in volunteer paperwork and ask final clarifying questions Begin contacting former patients that have expressed interest in becoming a peer mentor before Slowly read through all sections of the program manual multiple times to locate and correct any errors Check in with site mentor and faculty mentor to ensure the content being produced is on track with meeting expectations Continue contacting former patients that have expressed interest in becoming a peer mentor before and invite them to attend the informational session to get more details on the program Meet with site mentor and faculty mentor to discuss revisions to program manual and handouts Meet with the experienced therapist at the site to discuss any final 03/18/2022 03/25/2022 04/01/2022 23 3. 4. 13 Implementation /Dissemination 1. 2. 14 Dissemination/ Discontinuation 1. 2. 3. Meet with any necessary stakeholders Continue contacts with potential peer mentors 4. site/faculty mentors to discuss the program Continue email and phone call communication with potential peer mentors 3. 4. Disseminate the project by announcing to all therapists that the program is ready for use/implementa tion via inservice Program evaluation by therapists 1. Analyze program evaluation feedback Ensure there are no other things the site needs to continue with the program Meet with any necessary stakeholders 1. 2. Disseminate the project with the site therapists via in-service, ensure upload of manual to K drive, and ensure printed manual for the binder to leave in therapy offices Therapists complete program evaluation form after in-service 1. 2. 3. 2. 3. Analyze and report program evaluation feedback by therapists to the faculty mentor and site mentor Complete any final things needed by the site before leaving Meet with any necessary stakeholders to wrap up the DCE 1. 2. 3. revisions to the program manual Finalize program manual and print it and upload it to K drive for electronic access Continue email and phone call communication with potential peer mentors Host a formal inservice for all therapy staff to announce the program and explain manual Make sure staff has all the resources they need to continue with the program (electronic and paper copies of manual) Make sure all therapists in attendance of inservice complete and submit the feedback form Analyze the results of any completed surveys Create graphs and statistics to represent outcome measures Final meetings with any necessary stakeholders to wrap up the DCE and ensure the sustainability of the program manual 04/08/2022 04/15/2022  ...

... Moral Distress in the time of COVID-19: Occupational Therapy Practitioners Experiences Breanna Beckmann, Drew Flynn, Jon Haller, Macy Pohl, Kelsey Smith, & Scott Webb December 7, 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: Brenda Howard, DHSc, OTR, FAOTA MORAL DISTRESS IN THE TIME OF COVID-19 1 A Research Project Entitled Moral Distress in the time of COVID-19: Occupational Therapy Practitioners Experiences 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 Breanna Beckmann, Drew Flynn, Jon Haller, Macy Pohl, Kelsey Smith, & Scott Webb Approved by: st Research Advisor (1 Reader) 12/7/2022 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 MORAL DISTRESS IN THE TIME OF COVID-19 2 Moral Distress in the time of COVID-19: Occupational Therapy Practitioners Experiences Dr. Brenda Howard, Breanna Beckmann, Drew Flynn, Jon Haller, Macy Pohl, Kelsey Smith, & Scott Webb University of Indianapolis School of Occupational Therapy OTD 2023: Research Application December 9, 2022 MORAL DISTRESS IN THE TIME OF COVID-19 3 Abstract Background. COVID-19 has impacted the healthcare system, including the occupational therapy profession. Occupational therapy practitioners have had to adapt to these unknown times to best treat their clients. The conditions of COVID-19 have caused moral distress in practitioners. Purpose. The purpose of this study was to explore moral distress within the lived experiences of OT practitioners during the time of COVID-19. Method. Investigators utilized a stratified-purposeful sample to select occupational therapists in a variety of settings. Investigators conducted a semi-structured interview to explore their experience with moral distress during the time of COVID-19. The data were analyzed using a hermeneutical phenomenological approach to generate themes regarding the experience of moral distress. Findings. Investigators were able to identify commonalities in various settings as the COVID19 Pandemic impacted occupational therapy practitioners. These commonalities helped the investigators determine that the themes of the study were COVID-19, moral distress (MD) in OT, experiences, stressors, OT practitioner role, uncharted waters, managing moral distress, effects, personal protective equipment (PPE), COVID impact on roles, encouragement, mental health, vaccine impact, employment complications, and therapeutic relationships. Discussion. This studys findings brought awareness to the experience of OT practitioners during the pandemic and explored implications for preparing OT practitioners for future occurrences of moral distress. Keywords: COVID-19; ethics; mental health; moral distress MORAL DISTRESS IN THE TIME OF COVID-19 4 Moral Distress in the time of COVID-19: Occupational Therapy Practitioners Experiences Starting in December of 2019, cases of COVID-19, an acute respiratory syndrome that changed the world everyone knew (Turale et al., 2020), began to emerge. The COVID-19 pandemic has impacted everyone daily. However, individuals in the healthcare field work under unique challenges and unprecedented circumstances as the pandemic continues to impact individuals globally. COVID-19 has presented ethical and moral challenges in the healthcare field related to a scarcity of personal protective equipment (PPE), rationing of essential supplies and equipment, and other moral and ethical problems related to COVID-19 specific procedures and policies (Turale et al., 2020). The pandemic has impacted healthcare professionals as many navigated internal and external factors of distress related to COVID-19. The pandemic has resulted in ever-changing shortages and policies regarding COVID-19 care and PPE (Cacchione, 2020). In addition, the COVID-19 pandemic has posed moral challenges that have impacted practitioner performance, client relations, and the implementation of treatment as a whole (Cacchione, 2020). Occupational therapy (OT) practitioners and healthcare professionals often encounter clients facing adversity, which requires the clinician to exhibit empathy, understanding, and the ability to adapt. These situations often place practitioners in ethical problems and, if not adequately addressed, can lead to moral distress (Rivard & Brown, 2019). Jameton first defined moral distress as one knows the right thing to do, but institutional constraints make it nearly impossible to pursue the right course of action (Jameton, 1984, p. 6). Morley, Bradbury-Jones, & Ives (2021) broadened the definition of moral distress, stating, Moral distress is the psychological distress that is causally related to a moral event (p.2). In addition to moral distress, the experience of moral injury has also been present during the COVID-19 pandemic. MORAL DISTRESS IN THE TIME OF COVID-19 5 Moral Injury has been defined as difficult decisions made, high mortality, futility of treatment, and moral/ethical problems during the pandemic (Roycroft et al., 2020, p. 312). Occupational therapy practitioners have experienced emotional and mental trauma resulting from moral distress (Penny et al., 2014). The experience of moral distress has led to practitioner burnout within OT practice, which has led to a lesser quality of care for clients (Penny et al., 2014). Moral distress also has significantly impacted the practitioners personal life, including causing physical and emotional illnesses (Fourie, 2015). Moral distress has led to damaged practitioner rapport, including relationships with the client and their caregivers (Penny et al., 2014). The impact of moral distress during the COVID-19 pandemic among OT practitioners has not yet been fully explored. The investigators sought to answer the question, What has been the experience of moral distress in OT practitioners since the onset of the COVID-19 pandemic? A secondary purpose included finding out how OT practitioners had been managing moral distress during this time. Lastly, investigators sought OT practitioners' recommendations for managing moral distress. Investigators used a hermeneutical phenomenological methodology (Creswell & Poth, 2018) to answer these questions. Background Moral Distress and Occupational Therapy Moral distress has existed in OT practice in multiple countries, including Australia (Hazelwood et al., 2019), Canada (Drolet & Dsormeaux-Moreau, 2016; Drolet, 2018; Kinsella et al., 2008; Rivard & Brown, 2019), the United Kingdom (Bushby et al., 2015; Murray et al., 2015), Sweden (Kassberg & Skar, 2008), and the United States of America (Bennet et al., 2019; Erler, 2017; Penny et al., 2016; Slater & Brandt, 2009; Smith-Gabai et al., 2008). The literature MORAL DISTRESS IN THE TIME OF COVID-19 6 reports issues contributing to moral distress in health professionals that include conflicting values, failure to speak up, witnessing questionable behavior, systemic constraints, and experiences during the COVID-19 Pandemic. Conflicting Values Conflicting values significantly contributed to moral distress and ethical tensions, as reported in several studies (Bennett et al., 2019; Hazelwood et al., 2019; Kinsella et al., 2008; Rivard & Brown, 2019). Kinsella et al. (2008) discussed the nature of ethical tension experienced as a result of Conflicting values between practitioners and clients, between practitioners from different disciplines, and even between students and therapists'' (p.179). Bennet et al. (2019) stated that healthcare workers reported feeling like their professional values were incongruent with their job requirements'' (p. 9). Durocher et al. (2016) reported on conflicting values of patient care and management structures, stating, Services are shifted away from the provision of good-quality patient care and the fulfillment of professional values, and more emphasis is placed on implementing cost-saving measures and administrating budgets and resources'' (p. 1). Failure to Speak Up Failure to speak up has also contributed to moral distress and ethical tension (Bushby et al., 2015). Often, team members made comments about clients to the OT practitioner, placing them in an uncomfortable situation. Many practitioners have felt torn as advocacy is a staple in practice, but also feel the need to maintain a professional relationship (Hazelwood et al., 2019). Occupational therapy students on their Level II fieldwork have often experienced the failure to speak up when they felt uncomfortable speaking up for clients due to their lack of knowledge and inferior position to their supervisor and team members (Kinsella et al., 2008). MORAL DISTRESS IN THE TIME OF COVID-19 7 Witnessing Questionable Behavior From Other Healthcare Practitioners Occupational therapy practitioners and OT students on their Level II fieldwork rotations witnessed suspicious behavior from other healthcare practitioners (Slater & Brandt, 2009; Bushby et al., 2015; Hazelwood et al., 2019; Kinsella et al., 2008). Noted examples include (a) disrespectful and unprofessional behaviors from healthcare professionals toward clients (Hazelwood et al., 2019; Kinsella et al., 2008), (b) inappropriate conversations about clients (Kinsella et al., 2008), (c) referring to clients in the non-person-first language (Kinsella et al., 2008), (d) failure to communicate with patients about their prognosis (Kinsella et al., 2008), and (e) breaches of confidentiality (Kinsella et al., 2008). Systemic constraints Durocher et al. (2016) noted, ...systemic constraints [are] a predominant source of daily ethical tensions faced by occupational therapists in a variety of practice settings (p.225). The authors broke down systemic constraints into four domains, including (a) certain policies or instructions, (b) ineffective process implementations that hindered the overall therapeutic patient experience, (c) restrictions concerning good funds and resources, or (d) the lack of services. Sources of systemic constraints have included excessive caseloads, delays in receiving items to treat patients, advocating for resources, scarcity in staff numbers, and inadequate time to treat the patient correctly (Durocher et al., 2016). All of the above prevented practitioners from providing quality care to patients, leading to moral distress for OT practitioners (Bushby et al., 2015). Resources for coping with moral distress have been limited. Recognizing moral distress in the workplace has been the first step leading to potential interventions (Slater & Brandt, 2009). According to Penny et al. (2014), occupational therapy managers should promote team communication, improve care continuity, and benefit the teams skills and care strategies to treat MORAL DISTRESS IN THE TIME OF COVID-19 8 its clients. Improving communication has started with education among the entire interprofessional team. Facilitating interdisciplinary research, creating a healthy work environment, and promoting ethical leadership have been recommended as interventions as well (Slater & Brandt, 2009). Erler (2017) has suggested that OT practitioners could engage in ethics rounds. These open discussions about ethical tensions, concerns, and issues offered a space for OT practitioners to engage in thought about ethical tensions and the impact it has had on their lives (Erler, 2017). Although these authors offered suggestions for combating moral distress, studies demonstrating the efficacy of interventions for moral distress have not been found in the literature. Coronavirus-19 The novel coronavirus (COVID-19) pandemic in the United States started in March of 2020 when various governments and associations put lockdowns and restrictions on the healthcare system. Many parts of the healthcare system had to shift their principles to help protect the general public, themselves, and their loved ones (Berlinger et al., 2020). During the COVID-19 pandemic, there was a shift from patient-centered ethics to a public health focus (Angelos, 2020; Berlinger et al., 2020). This shift has caused health care workers to experience distressing ethical problems when making decisions regarding patients (Civaner et al., 2017). Additionally, the mass spreading of COVID-19 caused a great deal of distress to the health care workers, and as Turale et al. (2020) stated at the beginning of the pandemic, there were increasing numbers of videos... circulating showing nurses in tears or anger, telling their stories (p. 166). Recent literature has explored issues of concern during COVID-19 for rehabilitation professionals. Some articles directly addressed the topic of moral distress (Cacchione, 2020). MORAL DISTRESS IN THE TIME OF COVID-19 9 Others addressed burnout (Kellish et al., 2021), and the occurrence of moral injury due to extenuating circumstances (Roycroft et al., 2020). During this time of uncertainty, many authors have explored the impact of changing guidelines (Ness et al., 2021) and the impact of personal protective equipment (Cacchione, 2020; Turtle et al., 2020). Conclusions included the need for increased organizational support to reduce the occurrence of ethical problems resulting in moral distress (Ditwiler et al., 2021). Investigators completed a virtual interview with Kimberly Erler, OT, PhD, who is a Clinical Ethicist at Massachusetts General Hospital. In this interview, Dr. Erler discussed the topic of moral distress among OT practitioners during COVID-19 at Massachusetts General Hospital (Kimberly Erler, personal communication, February 24, 2021). Dr. Erler reported that in open forum meetings, occupational therapists discussed health disparities, lack of PPE, uncertainty regarding unapproved methods of cleaning PPE that was meant for single-use, the fear of transmitting COVID-19 from patient to patient through improper PPE re-use, and the anguish of weighing commitments to keep ones own family safe against the commitment to care for hospital patients. This interview reinforced the need for further investigation of moral distress during COVID-19 and informed the interview content. Healthcare Team and COVID-19 COVID-19 has impacted hospitals and other healthcare settings worldwide. Across the world, health care settings had constructed makeshift hospitals and quarantine centers overnight (Kumar et. al., 2020, p. S53) to help reduce the spread of the virus and to manage the influx of incoming patients. The staff members in these settings (doctors, paramedical staff, nurses, security guards, etc.) had to learn new protocols about caring for patients and managing their work aligned with the CDCs COVID guidelines (Kumar et al., 2020, p. S54). Occupational MORAL DISTRESS IN THE TIME OF COVID-19 10 therapy practitioners nationwide adapted to different roles, including participating in proning patients with COVID-19. Franzosa et al. (2021) explored the impact of COVID-19 on HomeBased Primary Care (HBPC). When the pandemic began, HBPCs goal shifted to gathering information about COVID-19 and how to prepare practices serving older adults nationwide. COVID-19 has severely impacted skilled nursing facility settings (Bagchi et al., 2021). Compared to the general population, residents in a nursing home setting were at a higher risk for morbidity and mortality in association with COVID-19 (Bagchi et al., 2021). There was also a sense of fear and vulnerability from healthcare workers and patients due to a lack of personal protective equipment (PPE), preparation, and proper planning (Turale et al., 2020, p. 165). There were patients that were dying without anyone by their side, due to visitors and visiting times being limited, which led to health social workers having moral distress (John et al., 2020, p. 514). Alleviation of Moral Distress Prior to the onset of the COVID-19 pandemic, OT practitioners had already developed strategies to alleviate moral distress. These strategies were based on beliefs and prior experiences, but there has been a need for more research supporting interventions for moral distress (Slater & Brandt, 2009). Recommendations for alleviating moral distress have included (a) identifying any ethical issues, (b) documenting possible causes of moral distress, (c) talking with persons in power to support good ethical action, (d) establishing safe spaces for expression, (e) using ethical resources when making decisions, (f) instructing pupils on ethical issues and possible solutions, (g) communicating and working together to find answers, (h) donating time, money, and power to larger professional bodies to help change employers, and (i) implementing collaborative management that focuses on values (Drolet, 2018). Despite interventions to MORAL DISTRESS IN THE TIME OF COVID-19 11 alleviate moral distress, OT practitioners have continued to face difficult and sometimes very personal decisions that have contributed to moral distress (Slater & Brandt, 2009). Summary Moral distress has occurred in a variety of healthcare settings and has been reported in several countries. Moral distress has highly impacted the effectiveness of healthcare workers, including OT practitioners (Erler, 2017; Bushby et al., 2015; Imbulana et al., 2021). While the literature has identified the prevalence of moral distress during the COVID-19 pandemic (Cacchione, 2020), more research is needed to define the experience of moral distress in OT practice during the pandemic and to create evidence-based interventions for combating moral distress. The purpose of this study was to explore moral distress among OT practitioners during the time of COVID-19. Investigators addressed this purpose through a hermeneutical phenomenological approach (Creswell & Poth, 2018). Methods This study was approved by the University of Indianapolis Human Research Protections Program as Exempt from Institutional Review Board review (Study #01423). Recruitment Investigators used a stratified-purposive sample to recruit participants in the spring and summer of 2021. The inclusion criteria included OTs and OTAs who were actively practicing. The exclusion criteria included OTs and OTAs who work exclusively in academics, OT or OTA students, and persons who work in other professions besides occupational therapy. Investigators recruited OT practitioners in a variety of practice settings through direct contact, snowball sampling, and social media (see Appendix A). Investigators directed the potential participants to a Google form (see Appendix B). The google form included the Informed Consent Document MORAL DISTRESS IN THE TIME OF COVID-19 12 (ICD), with instructions that completing the form constitutes assent to participate in the study, and an option to download the ICD. The form also collected demographic information, including age, gender identification, race/ethnicity/cultural identification, years in practice, and the setting they practiced in during the COVID-19 pandemic. Lastly, investigators asked the participants if they could reach out to the participant after the data analysis to complete member checking and requested they leave an email address if in agreement. Instrumentation In this phenomenological study, the investigators developed semi-structured interview questions based on the moral distress issues found in the literature and the investigators interview with Dr. Kimberly Erler (personal communication, February 24, 2021). Content experts examined the questions to improve and enhance the validity of the interview questions. See Appendix C for the interview questions. Procedures After recruitment, investigators conducted recorded Zoom semi-structured interviews with each participant in August of 2021. The participants selected a color identifier in order to help protect their identity. They were asked to change their name to this color identifier in the Zoom rename feature and to turn off their camera. Using Zooms transcript creation feature, investigators transcribed the interviews and edited them for accuracy. Investigators then analyzed the data using Dedoose 9.0.17 (Dedoose, 2021). Finally, investigators emailed a de-identified member checking survey using Google Forms to participants on 2/14/2022, which remained open for two weeks. The member checking survey addressed the clarity and relevance of the extracted themes and their definitions. Investigators left write-in options for participants to add anything else they wished to share. MORAL DISTRESS IN THE TIME OF COVID-19 13 Data Analysis To analyze the data, investigators used a hermeneutical phenomenological approach in which they analyzed the texts of the interviews to describe and interpret the experiences of the participants (Creswell & Poth, 2018). Investigators went through a deep reading process, then reduced and coded the transcripts to extract themes. At least three members of the team completed code comparisons on each transcript in order to validate the coding process. Following code comparisons, all team members met and discussed themes until a consensus was reached. Investigators then discussed each theme to come to a consensus on theme definitions and theme mapping. After completion of member checking, investigators included qualitative comments from the member checking survey in the dataset. Findings Sample In exploring the question, What has been the experience of moral distress in OT practitioners since the onset of the COVID-19 pandemic? investigators conducted semistructured interviews. Researchers were able to gather the responses of 18 total participants. Participants were mostly female, mostly white, and came from eight different practice areas. All participants were occupational therapists. See Table 1 for demographic information. Table 1. Demographics (n=18). Item Category Total n(%) Male 1 (5.6) Female 17 (94.4) 25-34 7 (38.9) Gender Age Range MORAL DISTRESS IN THE TIME OF COVID-19 14 35-44 8 (44.4) 45-54 1 (5.6) 55+ 2 (11.1) Skilled Nursing Facility 4 (22.2) Acute Care/Intensive Care Unit 5 (27.8) Adult Home Health 1 (5.6) Early Intervention 1 (5.6) Mental Health 1 (5.6) Outpatient Pediatrics 1 (5.6) Outpatient Orthopedics 1 (5.6) Multiple Settings 4 (22.2) 0-5 8 (44.4) 6-10 3 (16.7) 11-20 6 (33.3) 21-30 1 (5.6) White/Caucasian 16 (89.9) Asian 1 (5.6) Black or African American 1 (5.6) Midwest 15 (83.3) West 3 (16.7) Setting Years in Practice Race Area of the Country MORAL DISTRESS IN THE TIME OF COVID-19 15 Experiences of Moral Distress During COVID-19 Participants reflected on the sudden and fundamental shifts that COVID-19 brought about in health care. COVID has changed health care and we just have to work through it and decide this may be a new normal for us (member checking comments). Another participant reported that COVID-19 started The year healthcare will never look the same again (member checking comments). COVID-19 changed even the fundamental makeup of the healthcare team: In the beginning, we had decided that we would do a COVID team. There would be one OT and one PT to see the patient, so if we got COVID we could then move it down the list. The policy was that if you were over 60, or if you had an autoimmune disorder, that would eliminate you from being on the team. Therefore, when you went down through our group of OTs here, it left me. I was the last straw, but I didn't have much of a choice (Teal, Lines [L.] 30-33). Moral Distress in OT The theme of moral distress in OT has been defined as, The psychological distress that is causally related to a moral event (Morley et al., 2021, p.2). Occupational therapy practitioners participating in this study did report that they experienced moral distress during the COVID-19 pandemic. One participant identified their moral distress during the time of COVID-19, stating: I think there's an element of PTSD from it. I think it's a big part of why I switched jobs, I didn't want to be a part of it anymore. It was awful, the things that we saw. I cried a lot. It was an extremely stressful time and I don't think that anybody was okay from it. I think that was the hardest part, there was never time to recover from it because as soon as the numbers went down from COVID, the hospital census started picking back up because they started opening things back up and started doing surgeries. We never had time to regroup and reflect on what happened. In a lot of ways I probably didn't manage it (Purple, L. 43-47). Researchers asked each participant, on a scale of 0-5, with 0 being no moral distress and 5 being extreme moral distress, how would you rate your intensity of moral distress from March 2020 until now? Seventeen of 18 participants reported that their moral distress at the beginning of the pandemic (March 2020) was rated a 4 or a 5. As the pandemic continued, practitioners MORAL DISTRESS IN THE TIME OF COVID-19 16 explained that their moral distress was still present; however, they rated their moral distress as an average of 3 out of 5 at the time of the interview. As an example of moral distress, one participant stated they had a fear of treating people in physically close proximity but having a moral obligation to care for them despite my personal fears for myself (member checking comments). This comment demonstrated how the participant wanted to provide due care but felt conflicted due to their own fears of becoming ill. Experiences of Moral Distress Investigators have defined experiences of moral distress as each participants individualized encounter with COVID-19 and the impact the pandemic has had on their lives. The experience of living with COVID has affected interaction with all staff, brought up lots of issues with trust of employers, government, and changed how OT treats (member checking comments). The participants expanded upon their experiences with patients with COVID-19 and its impact on them emotionally: Your patient would be doing good, their oxygens great, and then you sit them up on the side of the bed, and you would crash your patient down into the 40s. They would not recover and then the next day, you would come in and they would be dead,or they would die within the next 24/48 hours. So it was the moral distress that you felt [as if] you weren't improving their quality of life, you caused trauma to them. It wasn't something that you did, but in the beginning [youre thinking] that's not what we OTs do, our job is to make people improve their quality of life (Teal L. 44-48). Some felt as if these times were a matter of life or death, stating, The consequences of the action were a lot higher to me (Red, L. 70). Stressors Investigators defined stressors as an internal or external event, force, or condition that causes physical or emotional distress (American Psychological Association, n.d.). Examples of stressors include: transmitting COVID to loved ones or clients, PPE, and mental health, MORAL DISTRESS IN THE TIME OF COVID-19 17 providing suboptimal care, and getting exposed to COVID-19. In response to asking about their current levels of distress, one participant answered: It is a background low level of stress, not to mention the terror of getting sick and dying. Working in a hospital, where early on they shut down all of the outpatient [surgery]. Everything's canceled and there were no visitors and anybody who's not direct patientfacing is working remotely, so the hospital's kind of a ghost town for a while. In that respect, it was less stressful because there was less traffic going to work and I always got great parking spaces and it wasn't so crowded. There was always that fear of what happens if I get sick, and what happens if I bring it home. So, I think it's very different from any other kind of stress because any other kind of stress that I've experienced has been time-limited, and who knows when this is going to end, if ever (Violet L. 107-112). Occupational Therapy Practitioner Role Many participants reported experiences that impacted their OT practitioner role during the time of COVID-19. The theme is defined as the responsibilities and capacity of OT practitioners to perform tasks within and outside of the scope of practice during the COVID-19 pandemic. Specific examples include proning, temperature checking, toileting, housekeeping, and providing emotional support. During the interviews, several practitioners identified their changed roles due to COVID-19. One participant stated: I don't feel it has put me in a position where I'm operating outside of my scope of practice because I feel the beautiful thing about [OT] is it's so dynamic and it's so inclusive. There's so much that we can do within our scope, so I felt my ability to be an educator and a coach increased more for my patients (Pink, L. 64-67). Alternatively, participants had identified that during the time of COVID-19, they were either asked or assigned job responsibilities and tasks that went outside their OT practitioner role. One participant discussed: I felt my job was more like a CNA than a therapist. Even when they allowed us to start doing therapy again, I was frequently having to come into a patient's room [around] two in the afternoon and could tell that they hadn't been touched all day (Olive, L.82-85). Uncharted waters MORAL DISTRESS IN THE TIME OF COVID-19 18 Participants reported experiencing things they had never seen before within their practice setting. Uncharted waters is defined as a feeling of uncertainty due to a lack of familiarity with new experiences and protocols related to the COVID-19 pandemic. Uncharted waters reported by participants ranged from uncharted COVID-19 protocols and PPE to unknown patient plans, such as not wanting to go to a SNF during COVID-19. One participant discussed the uncharted waters they experienced: It was super stressful because one day everyone is wearing a mask, the next day, nobody wears a mask unless you were sick. Then, it would be only wearing a mask if you're working with COVID patients. Finally, it came back to everyone wearing masks and then our hospital rationing PPE at first (Lavender, L.45-50). Personal Protective Equipment (PPE) Many participants discussed the lack of appropriate PPE in their workplace. The personal protective equipment theme (PPE) is defined as the presence, or lack thereof, of individual safety protocols and gear, provided through the workplace. Participants expressed the fear of not being protected from COVID or spreading it to patients or family. This led to an increase in stress and anxiety. I feel there's been a lot of situations of moral distress with the COVID pandemic. The first one that comes to mind is PPE in the beginning. We were unfortunately in one of those facilities where we had one surgical mask for a couple of months, then we had a COVID outbreak. We were limited with gowns and gloves and everything at one point. So providing the appropriate care with the limited resources that we had (Blue 2, L. 1316). Another participant discussed the distress they felt when their employment did not require masks at the beginning of the pandemic, and how the potential impact of not wearing masks could affect their clients lives and families. Early last March of 2020, I would say that [PPE usage] was the hardest because we didn't know what was going on. When everything started, [when] the world started to shut down, our practice didn't [shut down]. We weren't wearing masks and I felt very conflicted with my moral duty and ethical duty, that I felt we shouldn't be open. We don't MORAL DISTRESS IN THE TIME OF COVID-19 19 know what's going on, we don't know what we're doing, and that was the first time I cried at work. And I cried in my boss's office, saying I don't know what you guys are thinking, but this is not okay. She pretty much told me nobody knows what we're doing so if you feel you can't be here that's up to you, but I'm not going to say we're not going to make that call as a company yet. So I had a lot of internal struggles of not knowing, am I gonna kill my patients inadvertently? Knowing I have something wrong with me or not understanding what the symptoms are and how it's transmitted. For about a week, [I thought] I should quit or step back because I did feel I had patients [who were] taking care of elderly family members, or they had cancer or knew people [who had cancer]. I felt guilty that I shouldn't be there. But then when things kind of came out and we started wearing masks I felt a lot safer, but I struggled the first couple of weeks (Blue, L. 8-18). Even though PPE was a protective measure that created a safer environment, there were still nuisances that came with it. The therapeutic relationship between therapist and client was hindered due to a lack of personability throughout the session from the lack of close contact and hidden facial expressions. In the hospital, I'd say the main stressor for me is that they do a fit test when you are at a place that does things properly. They did a fit test when I got hired, and unfortunately, I failed the two masks that they had available at the time, so I had to wear a big half respirator mask that looks like a gas mask. It feels like it's really hard for patients to hear me in it. I'll be yelling and they can't hear me. Then you also have the fans in the room to try and keep the air as clean as they can and that's added noise plus if they're on a high flow oxygen system, it is added noise. So it's really hard for them to hear me and that can be frustrating (Olive, L. 140-156). There were even instances where the use of PPE violated clients autonomy, which caused moral distress to the participant. Patients weren't allowed to have their clothes, so everybody was in gowns and everybody was wearing masks. It seemed more like a prison. They were wearing uniforms and you cant see people's faces. A lot of what I doespecially in psych when you're doing group therapy, it's a lot of nonverbal stuff and you can't see people's expressions, and they can't see my slight subtle changes and expressions. I was really glad when patients got their clothes back, when they realized it's probably not going to be passed on by surfaces or clothing. We had to wear [PPE] until the CDC changed its guidelines. Until then, we had to wear eye shields for every patient-facing encounter. If I was in my office, I didn't have to, but I did anytime I walked out of my office. I say it took about a month or two before I didn't automatically leave my officebecause if you didn't have your goggles on or eye shieldsI had to go back into my office and grab them, so it was that unconscious pushing-up-glasses thing every time I walked out of my office. It was a good long time before that stopped (Violet, L. 62-77). MORAL DISTRESS IN THE TIME OF COVID-19 20 Effects of Experiencing Moral Distress Effects of experiencing moral distress reported by participants ranged from burn-out to dealing with death and loss. The effects of COVID-19 for some were long-lasting and initiated job and setting changes. The effects of experiencing moral distress are defined as the psychological, emotional, and physical impact of the practitioners experiences due to COVID19 on their well-being and quality of life. These impacts included effects on a practitioner's roles, their occupational performance, and their sense of self. A few key sub-themes included COVID19 burnout, exhaustion, and intense emotions. During the time of COVID-19, OT practitioners discussed feeling burnout within their practice setting due to the increased stressors that came along with COVID-19. One participant discussed their experience with COVID-19 burn out stating: I have worked in acute care for five years. I loved inpatient acute care, I loved ICU, that was definitely a passion setting of mine. I really do think that COVID was part of the reason, probably a big part of the reason, why I got burnt out and felt I needed to leave. I certainly didn't see myself going nonclinical after five years of OT work, I thought I'd be doing this for a lot longer. But it was extremely difficult to be doing things outside of our scope. I never thought that I would have been in a situation where I'm part of a code, where I'm the second person, no one else can respond and it was too hard seeing people literally die in front of you and I couldn't do it anymore. I switched roles and I do think that COVID was a big part of why I did that, and I think we're seeing that a lot right now with the nursing profession. I don't think it's specific to OT. Now we're seeing a lot of people leave, because of the PTSD, but also the extreme burnout that came from what we went through (Purple, L. 123-130). Investigators found that participants identified increased exhaustion as an effect of experiencing moral distress during the time of COVID-19. One participant explained their experience with exhaustion, stating Id come home exhausted and tearful and unable to do other things outside of my work, and come home and crash (Olive, L.287-289). MORAL DISTRESS IN THE TIME OF COVID-19 21 Occupational therapy practitioners identified experiencing intense emotions as a result of experiencing moral distress during the time of COVID-19. Participants identified intense emotions due to the COVID-19 experience while providing direct patient care, stating: Seeing those people sick and then they're staring at you, while you're in these big suits and you can't have that contact to touch them, hand in hand, because you have to wear two layers of gloves. It was very trying and emotional (Red 2, L.37-40). COVID Impact on Life Roles Not only did COVID impact OT Practitioners worker roles, it also spilled over into life roles. The investigators defined COVID Impact on Life Roles as the change in personal roles caused by providing health care during COVID-19. Examples include changes to work-life balance, hesitancy to interact with family and friends, and extra precautions taken to keep loved ones safe. One of the participants detailed their experience in relation to being a caregiver for their grandmother: The consequences of it, if I bring COVID home to my family. Normally I am a caregiver for my grandmother, my mom and I [both are], and I avoided her at all costs. I still helped out with managing things behind the scenes and getting things my mom needed, but I didn't go within six feet of her so that was pretty hard for a while. Going from being around her all the time and then staying away from her (Red 2, L. 90-96). When the pandemic first broke out, one participant stated COVID affected her overall well-being. It was definitely impacting my sleep; it was impacting different health behaviors. I do like to go to the gym, and at that time I wasn't completing, or wasn't partaking in a lot of my normal hobbies, just trying to stay healthy myself (Blue, L. 5961)/ Vaccine impact The COVID-19 vaccine production and distribution had varying effects and implications among the U.S. population that were due to the political undertones that developed throughout the pandemic. The vaccine impact theme is defined as the varying implications that came with the vaccine distribution within the United States such as co-worker disputes, family impact, and MORAL DISTRESS IN THE TIME OF COVID-19 22 personal health. One participant detailed their experience regarding conversations with their peers about the COVID-19 vaccine: Recently I had a conversation with a group of outpatient OT, PT, and cardiac rehab nurses in which they asked me if I was planning to get vaccinated. I responded with, I was vaccinated in January, why? Then it occurred to me that I didnt think they had been vaccinated. So I said to them, Are none of you vaccinated when they responded with No, and we dont plan to be. The words Well you are all idiots actually came out of my mouth. After I gathered myself, because I was shocked those words had come out, I apologized for calling them idiots. I asked what their reasoning for not getting vaccinated was. They told me that there was not enough research on long-term effects. I asked them if any of them had worked with COVID positive patients and they stated no. I said to them Well I will say this to you, we dont know the long-term effects of the vaccine, but we also dont know the long-term effects of COVID either. I assume that if any of you had seen the patients I have seen over the past year or been with patients who are intubated and still struggling with O2 sats, you would get the vaccine too. They told me I was overreacting and that the long-term worries outweighed the short term concerns. At that point I had to walk away, but on my way out the door I said to them, I do know the short term concerns of COVID and that is death, so yes I think everyone should get vaccinated so that you dont ever have to hold the hands of dying patients, like I have. Following my breath out of the room, I went to see my next patient and at the end of the day I did have one of the PTs tell me she was going to get vaccinated and that I had helped her see what she hadnt seen because she hadnt worked in acute [care] or a SNF during this pandemic. So, I was glad at least I helped one person out of the group be protected, but I still struggled working with these people the next few weeks and not wanting to scream at them (Red, L. 197-208). Some participants described their experience with the vaccine as hopeful. One participant describes the overall morale of the hospital being better because of the impact of the vaccine: I said to look at the positives of, now we are vaccinated, we have more research, and even our doctors feel better about treating these patients. I think just that general feeling around the hospital has gotten better (Lavender, L. 43-45). Employment complications The COVID-19 pandemic created various employment complications. The employment complications theme is defined as the various effects felt by practitioners in the workplace; from their employers during the pandemic relating to their employment status (e.g., hours cut, no new work available, short staffing); from coworkers, colleagues, and clients with attitudes and MORAL DISTRESS IN THE TIME OF COVID-19 23 opinions differing from their own. Sometimes these employment complications led to people switching roles, positions, and practice areas. One participant discussed a situation where COVID-19 caused them to switch roles and learn a completely new setting: They were banning any traveling workers, and that was a huge upset for me. I found myself almost unemployed, except for a couple hours a week, at one assisted living facility. I had to completely learn something new, taking the opportunity to help with the Telehealth clinics. I also ended up later in the fall doing some more adjunct teaching than I had done prior (Cyan, L. 44-48) . Another participant witnessed of people putting themselves and others at risk for an increase in pay: I worked at a SNF in May 2020 as PRN. The full-time staff would get premium pay if they agreed to work on the red (COVID-positive) units, and they also got additional premium pay if they themselves had contracted COVID and returned to work. I had a few of the employees tell me that they purposely had exposed themselves to COVID in order to test positive, so that they could return to work at a higher rate. I also had multiple people tell me that they would work the red units without appropriate PPE for the higher pay rate. I found out later that a CNA for this company made around $10/hour however if they meet these 2 other criteria they could make $30/hour. In this same facility, it was nursing home appreciation week, so the administration had decided they would provide some happiness and fun through the games and prizes. However what I witnessed was in the middle of the red unit, the nurses would take off their masks and PPE to play these games. The game consisted of using a straw to suck up M&Ms and move them from point A to point B (think minute-to-win-it type games). When I mentioned that this didnt seem like a good idea in a red unit, with a virus transmitted through air, they told me it was okay because they all wanted to get sick to receive the premium pay (Red, L. 168175). Therapeutic relationships Occupational therapy practitioners are called to create meaningful relationships to build rapport with their clients. COVID-19 made it more challenging to create these meaningful connections due to the contact limitations and personal disconnect due to the PPE. The therapeutic relationships theme is defined as the interrelated bond created between OT practitioners, healthcare workers, and clients through their shared experiences during the MORAL DISTRESS IN THE TIME OF COVID-19 24 COVID-19 pandemic. One of the participants provided an example of building therapeutic relationships during the COVID-19 pandemic: Sometimes I would push the limits and stay in the rooms a little bit longer. The patients, you could tell they appreciated that. They would be a little happier when I came back the next time; they were more willing to work with me. It's showing them that we do care instead of them just being a number or treatment we're trying to check off (Red 2, L. 109111). Managing moral distress Many participants discussed how they have or have not been managing moral distress during COVID-19. Investigators defined Managing moral distress as various ways that OT practitioners handled moral distress related to their experiences throughout the COVID-19 pandemic. Some examples of how practitioners managed their moral distress included seeking professional help, talking with family members or co-workers, or working out. One participant identified how talking about their moral distressed helped them manage it: I tried to be very open and to discuss these things. Especially when we have our meetings, because I find that most of the time, people are probably dealing with the same struggles that you're dealing with, and they may not feel so comfortable expressing how they feel. That's one of the things I've tried to be a proponent about, not holding it in and sharing what I think and what I feel (Pink, L. 101-105). Encouragement During COVID-19, many of the participants experienced ways in which they engaged in positive emotional and physical support that may have been provided by their coworkers, families, or employers. Some practitioners places of work planned virtual events or brought in something to try and boost morale. Other practitioners would focus on their physical health by exercising, and some would try to spend time with their families. Encouragement also came in the form of seeing a COVID-19 patient get healthier. One participant describes this experience as she got to see a patient go from the ICU to the main floor, to be successful at home: MORAL DISTRESS IN THE TIME OF COVID-19 25 I had started proning and supining a patient. And then he got into the main floor instead of ICU and I got to treat them over there, which was really cool to watch him progress from where he was before. Then I was interviewing for a home health position, and I happened to get to go to his house. They were seeing him, and he was walking and doing fantastic so that was cool to see that full spectrum of care, ICU to the regular floor, to at home, and being successful. You don't get that opportunity very often, so that was pretty cool to see (Sky blue 110-114). Mental health COVID-19 didnt just affect the worlds physical health. Some participants struggled with mental health through their emotional experiences. Investigators defined mental health in the context of this study as emotional experiences brought on by COVID-19, and the actions and resources taken by practitioners to cope with them. There were many emotional experiences that were precipitated by COVID-19, and many of the participants took action and used resources to help cope with those experiences. Several participants reported taking steps to advocate for mental health services during the time of COVID-19 as a result of realizing they need to make mental health a priority. I think there needs to be more resources available, and I do think that was the OT in me coming out a little bit, trying to coordinate something with the resources available in the community for the rest of the team, because I feel there wasn't a whole lot of conversation happening about what was going on. So I definitely think there's more opportunity for support and resource groups, as well as regular conversations. Maybe that's [providing] even more resources, as far as coping mechanisms, and going back to the basics of how we handle our basic stress levels, what are things that we can do in the workplace. And there was probably a lot of opportunity for more support groups and guided conversations that weren't happening (Purple L. 80-85). What we have learned The COVID-19 pandemic brought about a myriad of emotions and consequences, but there were still a lot of valuable lessons learned throughout these dark times that the OT profession can adopt. While this pandemic has caused a lot of pain and turmoil, OT practice can benefit from the lessons learned in self-care and advocacy for oneself and their patients. The MORAL DISTRESS IN THE TIME OF COVID-19 26 theme, what we have learned is defined as interventions and strategies that can be taken away from the COVID-19 experience about managing moral distress in order to mitigate it in the future. Some examples include recognizing moral distress, seeking professional help and social support, the importance of interprofessional relationships, maintaining a healthy work-life balance, and transparency and advocacy for ones own mental health to coworkers, clients, family, and friends. One of the participants shared their experience in how they learned to advocate for themselves to preserve their mental health: I think what I learned the most from this is that it's okay to ask for help. As a team member, I pretty much did COVID from March, because we had the first patient until I got COVID in April and I was out for two weeks. I came back to the COVID team. And then until I finally hit my breaking point, probably in November, and that's when I told my boss I can't do this anymore. And it was okay, and the team was very supportive and was surprised that I lasted that long. So I think, for me, learning it's okay to ask for help and not be the therapist that can fix things (Teal, L. 112-116). One of the participants added the importance of retaining a work-life balance for the sake of the patient: The biggest thing that we should do, in any profession, is to remember that there still is a work-life balance, even if you're in the middle of a worldwide pandemic. You can't pour from an empty cupWhen you're in these situations, you're pressured to be a caregiver. You go into this field because we want to help people, we want to take care of others. But then you start to feel the pressure when it keeps coming and coming, and then they want more and more. I think the biggest thing is setting boundaries and saying it's okay if I take a day off here, or an afternoon off. I need to take some time for myself to recoup, and then come back and be better for the patient's sake. It's usually not their fault when we get over-stressed, and they still need our help, and they are very sick (Lavender, L. 118-125). Another practitioner stated how important it was to feel emotions and recommended asking for help when needed: To feel the emotions. To have my first [patient loss] stick with me. [I was] trying to push all that in and not address it. It was a big one, so allowing myself to feel the emotions and ask for help when I needed it would probably be the biggest piece of advice (Red 2 L. 101-104). MORAL DISTRESS IN THE TIME OF COVID-19 27 Similarly, after experiencing distress, one participant expressed the need for transparency between therapist and patient on their own mental health in an empathetic way: I would have been more honest with my patients, not to give them my problems, or not to make them feel bad. But not to be, Oh I'm fine, it's okay, I'm here for you, but being more real with patients and letting them know that I'm a real person. I'm not up here with a white coat looking down on you telling you what to do, but more so, This is hard, and I haven't seen my family in nine months or hugged my mom, and it is really hard. But these are the things I've done to help me be more honest with them from a personal standpoint, rather than saying Oh medically, can I tell you what to do? I don't know and I feel like I don't have all the answers, so I shouldn't say anything. [The client] told me I needed therapy, so I went to therapy, but doing it from a personal perspective and being okay with my patients knowing that sometimes life's hard and that's okay (Blue, L. 94-102). Another participant expressed the importance and need for occupational therapy during these unprecedented times: OT has so much to offer, because I call this the year of occupational disruption, even though it's lasted more than a year. Its been nothing but occupational disruption for everybody, and if you can find me somebody who hasn't had something majorly disruptive, I want to talk to them about where they're living or what they're doing, because everybody's been challenged to give up or amend or adjust a role. As a society I'm not sure we have a lot of support for what that is when it happens and no teaser is uniquely placed for that because we think about the role and not from a psychological standpoint, we also think about it from a troubleshooting [standpoint], or a task analysis or an environment person standpoint (Turquoise 2, L. 125-131). Stories of COVID Time Many of the questions investigators asked of participants prompted stories. These stories are best told in their entirety, as they provide the best description of the lived experiences of moral distress during COVID time. Table 2 provides a summary of these stories. Table 2. Stories of COVID time. MORAL DISTRESS IN THE TIME OF COVID-19 Participant Excerpt Purple We are part of peoples discomfort. The hardest thing that I saw was pretty specific to being in an ICU setting and it wasn't even necessarily specific to OT practice. We saw a lot of patients whose care was kind of happening against their wishes. Patients who might have come into the hospital were diagnosed with COVID and immediately got placed on a ventilator. Those vented patients that had a previously stated DNR or they had some kind of living will that said that that was against their wishes but in [our state], you can go against that really at any point in time. Families or other next of kin can always go against those wishes. And so, we'd be working with patients while they're on the ventilator, which was extremely uncomfortable. They are very sick, very anxious, and the entire time you are, in the back of your head, knowing that that is completely against their wishes and what they would have wanted. But yet you still have to follow doctor's orders and go in there and do an evaluation or do a treatment, and that was extremely distressing to know that you were part of people's discomfort or just furthering their misery, really. Turquoise Three days later they were gone. I definitely saw a lot of patients who were doing great one day, and then two days later, they were no longer on the floor that I was on, and they were down in the ICU. People who went from being fine to being on the docket for being prone and a couple of people who three days after I saw them for an initial evaluation had passed away, and it's like, what? The thing about working in a hospital that's a Trauma Level 1 is you see really bad situations. It's not the first people that I've had passed away before, but man it's tough when you have somebody who seems like they're doing pretty good and they're only needing a couple of liters of oxygen, and three days later they're gone how do you handle that? The best thing you can do is just kind of talk it out with the folks that know what's going on and just try to focus on what's important in your life and not take anything for granted. I think that's why I like that focus on my family and just talking to them and reaching out to them via phone or zoom and spending time with my husband and my son was like a huge, huge help for me to balance some of that. 28 MORAL DISTRESS IN THE TIME OF COVID-19 Participant Excerpt Teal My breaking point. I think my breaking point was, I had a couple, they celebrated their 90th birthday party and the daughter decided that they needed to celebrate it, so she had a party for them, and half their guests wore masks, and the other half didn't. They sat with me, and they said, we've been really good, and we haven't gone out at all, until my daughter decided to have this party for us. And then they both ended up with COVID. We wheeled them in a room together and they held their hands and they died four minutes apart. And I had them both [as patients]. That was my endpoint because the daughter had a lot of guilt and would call in and cry and to watch the two of them, because they've been married for 70 some years. So that was that. Aqua Missing concerning signs on telehealth. I have had a lot of concerns about abuse and things like that that are happening in the home. Like during the virtual stuff that maybe we aren't catching or not seeing, because we're not entering the home, we're just seeing the picture they want us to see and that to me has weighed on my mind. I think, because of virtual, maybe I wasn't as quick to call DCS, to have them check out the place as I should have maybe. I just recently made a phone call. And it had kind of been on my mind, for you know, a couple months leading up to it. But I mean, I had not seen any abuse, so I just had kind of seen a lack of adults. It was a teenage mom; there were just never any adults around. And Mom was just really struggling to keep up with the therapy sessions and the baby was really medically fragile and in and out of the hospital. Finally, when she no-showed and I thought we're going to lose contact with this family, I thought I better call DCS and see if they can get someone in there to support them. She'd been bouncing around from different homes to homes, not really having a stable home environment. 29 MORAL DISTRESS IN THE TIME OF COVID-19 Participant Excerpt Turquoise Questionable management decisions and risks to personal health. And this patient had initially come in and tested negative. They moved her off the COVID unit. This therapist and I went to see her. She was on a BIPAP; she wanted to drink water and the PT helped her take the mask off to get a sip of water. And then later that night, her O2 sats started tanking again so they tested her again. She tested positive later that night for COVID, so whether she had a false negative we don't know, but this PT ended up getting COVID and the only exposure that they could figure where she didn't have the appropriate PPE on was this patient who had been negative, because we were only wearing surgical masks. Somehow, I was fortunate enough not to get it, and this PT was out for two months because of her battle with COVID. She literally got hospitalized for a short while, and then she was home. When [she got back], they asked her to be part of the prone team and Im like, this therapist is still probably recovering from having been out from like August to October, almost November. Having had COVID, why are you pulling her into this terrible swing schedule and asking her to do this? So, I think the prone team thing, I don't think that they accounted for who was really the appropriate choices for that team. There were plenty of other therapists who could have been pulled sorry, that's kind of opening a whole can of worms of my frustration with that choice. They should have asked if there were people who were willing to do it. I think that that could have been more well organized. Red Risks due to PPE shortage. Well, that would be the skilled nursing facility. That was very early in the pandemic and, as I said, the skilled nursing facility was, out of the 70 patients in the skilled nursing facility, there were two that were not positive, so not quite 100 percent positive. Everyone else was positive, and we had one set of PPE. We had one gown, we had one mask, one face shield. [Reusing face shields is] fine, you reuse those clean ones all the time, but I have one gown and one mask for weeks. I was also expected to treat the two patients who were not positive. But I was in the same PPE that I was [wearing into] COVID-positive rooms and so that was definitely, obviously, I felt like it was a huge problem, because I was exposing them with the same protective gear. I did try to mitigate some of that in that I would treat those two patients first during the day if they were on my schedule, and then go to the positive wings or the positive floors. Definitely PPE in that situation led to increased moral distress. 30 MORAL DISTRESS IN THE TIME OF COVID-19 31 Data Comparisons Themes and settings Upon comparing themes to their occurrence in practice settings, researchers found that participants in all settings described commonalities in how COVID-19 impacted their roles and the challenges it presented. In addition to role impact, many of the participants reported that they were working outside of their scope of practice. Another similarity among all practice areas was the experience of intense emotions. Practitioners who practiced in multiple settings experienced intense emotions and feelings of confliction at a higher rate. Table 3 indicates themes that occurred at a higher rate and what practice setting the themes occurred in. Table 3. Theme occurrence by setting Acute Care/ICU Multiple settings Skilled Nursing Facility Total theme occurrence among all settings COVIDs Impact on one's Roles 7 12 6 37 Dealing with death and loss 7 6 1 18 Feeling conflicted 1 14 0 25 Intense emotions 0 13 3 41 PPE Impact 13 12 7 48 Scope of practice issues 3 8 5 24 MORAL DISTRESS IN THE TIME OF COVID-19 Stories during COVID time 5 15 32 1 27 One notable difference between practice settings was the use and need of Personal Protective Equipment (PPE) and dealing with death and loss. The ICU, acute care setting, and various skilled nursing facilities were greatly impacted by death and loss as their patients were more vulnerable. Many therapists from these settings dealt with issues concerning PPE. They needed PPE to safely do their job, but therapists often found themselves having to re-use. This impact appeared to not be as significant among the other outpatient settings (i.e., pediatrics and orthopedics) as they were able to perform telehealth services as an alternative therapy option. Themes and years in practice Investigators analyzed data according to the participants' years in practice. (Refer to Table 1, Demographics). Many similarities existed in the responses among age groups, as a majority of the participants said that COVID had a significant impact on their roles. Practitioners stated that they had dealt with feelings of discouragement and exhaustion while working during the pandemic. To help cope with those feelings, practitioners of all ages stated they sought out professional help, relied on co-workers and friends/family, and performed mental health selfcare. Some examples of mental health self-care tasks include yoga/meditation, going for walks/exercising, and taking time for oneself. Researchers found that years in practice did correlate to some differences in the OT practitioner's experiences. Occupational therapy practitioners who had practiced from 0 to 5 years responded more to feeling conflicted, feeling as if they were offering less than optimal care, experiencing scope of practice issues, and having more overall moral distress experiences MORAL DISTRESS IN THE TIME OF COVID-19 33 than OT practitioners who had practiced from 11 to 20 years. Occupational therapy practitioners who practiced from 21 to 30 years had voiced the least number of responses regarding COVID's impact on their roles, how they dealt with intense emotions, and overall moral distress experiences. Co-occurrence of codes Researchers reviewed co-occurrence of codes to further understand how COVID-19 had impacted the participants in similar ways. One co-occurrence of codes was between intense emotions and feeling conflicted. Investigators coded participants statements as bridging both of these themes in 15 instances, suggesting a meaningful correlation. When participants began feeling conflicted in their roles and responsibilities, it would often result in intense emotions that could transfer into their professional and personal lives. In the codes, transcripts showed COVID-19 itself caused participants to feel conflicted about whether they were doing the right thing for their patients and families. Treating COVID-positive patients caused OT practitioners to fear bringing the virus home to their families. In turn, the conflicted feeling caused intense emotions in which participants identified what was happening both at home and in the workplace among patients and co-workers. In one co-occurrence of intense emotions and feeling conflicted, a participant stated: The one thing that I didnt mention in the interview, and to be honest I didnt mention it because I had one of the many experiences of this the day before, and it was too close and on my mind In the SNFs and ICUs, there were times that patients would ask me, Am I going to be okay? and sometimes I could answer honestly and say yes, you have made great progress. However, sometimes I would grab their hand and say yes, knowing that more than likely they would not survive the next 48-72 hours. (Red, 177-180) Discussion This study aimed to identify the experience of moral distress among OT practitioners since the onset of the COVID-19 pandemic, find out how OT practitioners had been managing MORAL DISTRESS IN THE TIME OF COVID-19 34 moral distress, and seek OT practitioners' recommendations for managing moral distress through a qualitative phenomenological study interviewing OT practitioners. Investigators found that moral distress had a significant impact on OT practitioners. Occupational therapy practitioners were impacted the most by fear of spreading COVID-19 to family, friends, co-workers, loved ones, and other patients. These findings were the results that the investigators expected. In addition, investigators found that OT practitioners who worked in acute care, the ICU, or skilled nursing facilities dealt with moral distress with more intensity than those in other practice areas based on code counts. Practitioners in these settings were also more prone to experience moral distress stemming from dealing with death/loss and PPE. Even though the COVID-19 experience was a trying time for individuals who worked in the health field, the differences that the researchers found between OT practitioners' years in practice and their responses can be seen as positive. These responses show newly graduated practitioners that things get better as time goes on with more experience. Investigators also found unexpected findings grouped into four themes. The COVID-19 pandemic exposed OT practitioners to unusual roles and sometimes conflicting roles. Occupational therapists are constantly advocating for this OT due to a lack of knowledge about the profession in the general public. The emergency situation of the COVID-19 pandemic only further affirmed the importance and need for OTs to better articulate the OT domain. Occupational therapys scope of practice is distinctly broad but does have limits. Although it is important to help wherever needed in a time of great distress, it is also equally important to make sure that patients are not getting lesser care or are not getting unethically billed because therapists are practicing outside their scope of practice. Another important finding from the study was the overall magnitude of the effects of COVID-19 on moral distress. While everyone in the world felt the impact of COVID-19, the MORAL DISTRESS IN THE TIME OF COVID-19 35 participants in this study articulated the excruciatingly overpowering and complex morally distressing issues that they navigated during this time. COVID-19 magnified moral distress because of the volume and complexity of the ethical and moral issues practitioners addressed all at one time; and it contributed to burnout, exhaustion, and emotions that sometimes drove practitioners from the OT field. While these findings have been observed anecdotally in OT and other professions (Cacchione, 2020; Dirette, 2020), few studies have reported on the direct impact of moral distress on the health professions during COVID (Smallwood et al., 2021). The COVID-19 pandemic also exposed the need for more moral distress interventions that address trauma in OT practitioners, in hopes to prevent burnout. OT practitioners felt the stress of the pandemic in many ways, but they didnt have the appropriate help, leading to them feeling burnout symptoms. Other authors have noted burnout and intense emotions (Kellish et al., 2021), employment complications, impact on therapeutic relationships and impact on the practitioners life rules (Smallwood et al., 2021) during the pandemic. Many of the participants of this study mentioned some type of trauma that COVID-19 caused, but few participants had access to professional help that helped them deal with the trauma. More in-depth research would be beneficial for OT practitioners, so there is a better understanding of how trauma contributes to burnout. One of the participants mentioned the need and usefulness of transparency for ones own mental and physical health. This transparency stems from a need in mental health as OT practitioners need to be able to humanely express their mental health status and needs to their employers, patients, family, friends, and themselves. As a holistic profession, it is imperative that the practitioners mental health is taken seriously in order to prevent burnout and high turnover rates. As stated before, burnout can lead to a lesser quality of care for clients (Penny et al., 2014). MORAL DISTRESS IN THE TIME OF COVID-19 36 Transparency with a client can also build more rapport in the therapeutic relationship, as trust can be built through sharing ones own experiences in life. It is also important that interdisciplinary healthcare practitioners advocate and support each other. It was demonstrated in the interviews that moral and social support could relieve anxious feelings and decrease burnout by asking for help from coworkers. Investigators expected to hear about the participants working outside of their scope of practice, as previous literature had discussed when occupational therapy practitioners had to operate outside of their scope of practice (Howard et al., 2020). However, when participants shared their experiences, it was unexpected that many OT practitioners were significantly involved in the death process, a new and impactful experience for OT practitioners. Moral distress has evolved through the COVID-19 pandemic. Previously, practitioners were experiencing moral distress with reimbursement, overall quality of care, and documentation discrepancies (Slater & Brandt, 2016; Penny et al., 2014). Recent research has looked into the impact COVID-19 has had on rehabilitation professionals and their experiences with moral distress due to the pandemic. Finding a place for occupational therapy practitioners to contribute during the beginning of the pandemic caused uncertainty within the scope of practice. As the pandemic progressed, moral distress experiences changed as the care guidelines became more unclear (Greenberg et al., 2020). In comparison with past literature, this study uses interviews with occupational therapists to further identify areas which need improvement. The literature correlated with the finding that it was important to allow for processing time for OT practitioners during the height of the pandemic (Roycroft et al., 2020). Research has also highlighted the importance of managing mental health throughout the pandemic (Greenberg et al., 2020). This was also a common theme MORAL DISTRESS IN THE TIME OF COVID-19 37 during the interviews as mental health was not prioritized during the height of the pandemic. Many of the participants in this study explained that there were very few coping strategies in place to allow them to process the current events. Researchers were able to gather valuable information from current research as well as the finding of this study to better understand the severity and impact COVID-19 has had not only on the occupational therapy profession, but healthcare as a whole. Clinical Implications The COVID-19 pandemic exposed the need for more moral distress interventions that address trauma in OT practitioners, in hopes to prevent burnout (Imbulana et al., 2021; Morley, Field, et al., 2021). Many of the participants of this study mentioned some type of psychological trauma that COVID-19 caused, but few participants had access to professional help that helped them deal with the trauma. Further research is indicated to understand the phenomena of trauma, burnout, and successful interventions to combat them in the unique roles that OT practitioners and other rehabilitation professionals occupy. Specifically, research is needed to address mental health in practitioners. It is also important that the interdisciplinary healthcare practitioners advocate and support each other. Participants in this study expressed that moral and social support relieved anxious feelings. Further investigation into how to build a structure of support into healthcare teams is needed (Berlinger et al., 2020; Roycroft et al., 2020; Smallwood et al., 2021). On the macro level, organizations, government agencies, and global systems need to have disaster and crisis management systems and standards in place to avoid confusion and mismanagement of resources when disasters strike (Leider et al., 2017). Occupational therapy practitioners need to be a part of the teams making decisions about crisis management systems and standards (AOTA, 2017; Howard et al., 2020). MORAL DISTRESS IN THE TIME OF COVID-19 38 Recent research has explored the impact COVID-19 has had on rehabilitation professionals and their experiences with moral distress due to the pandemic (Greenberg et al., 2020; Roycroft et al., 2020; Smallwood et al., 2021). Occupational therapy educators should address professional well-being and resilience in entry-level education as well as at the postgraduate level (Popova et al., 2022). Recommendations have included allowing time for practitioners to process their experiences (Roycroft et al., 2020) and managing mental health throughout the pandemic (Greenberg et al., 2020). These recommendations matched what participants stated they found helpful in their experiences. OT practitioners need to be mindful of the mental and emotional toll that comes with the profession, especially during crises like the COVID-19 pandemic (Roycroft et al., 2020). Professional mental health services may help reduce and prevent burnout (Kellish et al., 2021; Smallwood et al., 2021). Maintaining work-life balance and personal wellness activities are also warranted (Morley, Field, et al., 2021). Practitioners can be aware of resources pre-emptively to reference during times of uncertainty. These might include the AOTA Code of Ethics (AOTA, 2020a), OT Practice Framework (AOTA, 2020b), state or local laws pertaining to OT licensure, laws, rules, or policies pertaining to the setting in which the OT practitioner works. The Code of Ethics provides guidance on values and ethical principles to keep in mind (AOTA, 2020a) when making decisions during difficult times. Keeping these documents and organizational policies nearby will provide the practitioner with resources for addressing legal and ethical issues when they arise. Further, policies and procedures for managing crises must be put into place on the organizational and systemic level, thereby preventing moral distress by having the systems in place to assist with clinical decision making when resources are scarce (Berlinger et al., 2020; MORAL DISTRESS IN THE TIME OF COVID-19 39 Popova et al., 2022; Rivard and Brown, 2019). Rehabilitation services managers can work to build a culture in which speaking up is encouraged, not devalued (Popova et al., 2022). Education has been one effective intervention in combating moral distress (Morley, Field, et al., 2020). Education in advance of experiencing ethical problems may help to reduce moral distress, though current evidence is weak (Imbulana et al., 2021). Educators can develop curricula that facilitate speaking up when ethical tensions arise (Kinsella et al., 2008). Educators can provide current and future OT practitioners with the skills to self-advocate when ethical issues arise (Kinsella et al., 2008). Research Implications Currently, few research studies have addressed moral distress during the COVID-19 pandemic in occupational therapy or any other health care profession (Smallwood et al., 2021). Further research is needed to examine the impact of moral distress on OT practitioners and rehabilitation professionals, particularly during the COVID-19 pandemic. Smallwood et al. (2021) addressed moral distress in frontline health workers in Australia. Future investigators could focus on the differences in experiences of moral distress among various practice settings or in various geographic locations with differing health care systems. Investigators could also explore whether there are differences in experiences of moral distress during COVID between the health care professions within a setting type, or between OTs and OTAs. Since no OTAs responded to recruitment for this present study, future studies could explore recruitment methods that target this population, such as posting on social media sites specifically geared toward OTAs. Most importantly, research is needed to determine effective intervention approaches to combat moral distress among OT practitioners and rehabilitation professionals (Imbulana et al., 2021; Morley, Field, et al., 2021; Popova et al., 2022) and address the moral distress experienced MORAL DISTRESS IN THE TIME OF COVID-19 40 during COVID-19. Applying models of moral distress interventions established in nursing (Morley, Field, et al., 2021) to other health professionals may be beneficial in future studies. Strengths and Limitations As with any study, this study had strengths and limitations. One strength was that the investigators triangulated findings with member checking, which allowed the participants to review the results and determine if the results were indicative of their responses. Another strength was investigators were able to recruit participants from various settings, including acute care, the ICU, and skilled nursing facilities, which allowed investigators to gather data that was representative of the occupational therapy field. Lastly, multiple investigators completed code comparison and theme extraction for strengthening validity of the findings. One limitation was that the study contained a small sample size. Investigators attempted to mitigate the small sample size by stratifying by settings and geographical location. Another limitation was that there was a lack of demographic variability among the studys participants. Specifically, out of the eighteen participants, only one was male and two were non-white. No occupational therapy assistants (OTAs) responded to the call for participants; therefore, the perspectives of OTAs are not represented in this study. This study focused solely on the experiences of moral distress of OT practitioners and did not capture the similarities and/or differences between OT practitioners experiences and those of other health care practitioners during the COVID-19 pandemic. Lastly, a limitation of the study was self-selection bias as the participants willingly chose to participate in the study. Participants might have opted into this study due to experiencing moral distress at a higher prevalence compared to the general OT practitioner population. MORAL DISTRESS IN THE TIME OF COVID-19 41 Conclusion Moral distress has been a common occurrence in OT practice, and the COVID-19 pandemic has heightened experiences of moral distress among OT practitioners. The purpose of this study was to explore moral distress among OT practitioners during the time of COVID-19. Investigators examined experiences of moral distress, the effects of moral distress, and ways OTs managed moral distress during the COVID-19 pandemic. Recommendations for practice included highlighting awareness of moral distress and advocating for mental health support for practitioners. Research recommendations included studies for moral distress interventions with OT practitioners and other health care providers. The findings of this study can support OT practitioners efforts to acknowledge the unusual levels of moral distress during the COVID-19 pandemic and alleviate moral distress in practice. MORAL DISTRESS IN THE TIME OF COVID-19 42 References American Occupational Therapy Association. (2017). AOTAs societal statement on disaster response and risk reduction. 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Interventions to reduce moral distress in clinicians working in intensive care: A systematic review. Intensive & Critical Care Nursing, 66. https://doi.org/10.1016/j.iccn.2021.103092 Jameton, A. (1984). Nursing practice: the ethical issues. Englewood Cliffs, N.J: Prentice Hall John, S., Booth, S., & Venville, A. (2020). Dying in hospital during COVID-19: Isolation, despair, and moral distress. Australian Social Work, 73(4), 514515. https://doi.org/10.1080/0312407X.2020.1808268 Kassberg, A, & Skr, L. (2008). Experiences of ethical dilemmas in rehabilitation: Swedish occupational therapists perspectives. Scandinavian Journal of Occupational Therapy, 15(4), 204211. https://doi.org/10.1080/11038120802087618 Kellish, A., Gotthold, S., Tiziani, M., Higgins, P., Fleming, D., & Kellish, A. (2021). Moral injury signified by levels of moral distress and burnout in health science clinical educators. 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Journal of Nursing Management, 29(8), 24122422. https://doi.org/10.1111/jonm.13421 Penny, N. H., Bires, S. J., Bonn, E. A., Dockery, A. N., & Pettit, N. L. (2016). Moral distress MORAL DISTRESS IN THE TIME OF COVID-19 47 scale for occupational therapists: part 1. Instrument development and content validity. American Journal of Occupational Therapy, 70(4), p1p8. https://doi.org/10.5014/ajot.2015.018358 Penny, N. H., Ewing, T. L., Hamid, R. C., Shutt, K. A., & Walter, A. S. (2014). An investigation of moral distress experienced by occupational therapists. Occupational Therapy in Health Care, 28(4), 382393. https://doi.org/10.3109/07380577.2014.933380 Popova, E.S., Hahn, B., Morris, H., Loomis, K., Shy, E., Andrews, J., Iacullo, M., 7 Peters, A. (2022, April 28). Exploring well-being: Resilience, stress, and self-care in occupational therapy practitioners and students. OTJR: Occupation, Participation and Health. https://doi.org/10.1177/15394492221091271 Rivard, A. M., & Brown, C. A. (2019). Moral distress and resilience in the occupational therapy workplace. Safety, 5(1), 10. https://doi.org/10.3390/safety5010010 Roycroft, M., Wilkes, D., Pattani, S., Fleming, S., & Olsson-Brown, A. (2020). Limiting moral injury in healthcare professionals during the COVID-19 pandemic. Occupational Medicine, 70(5), 312314. https://doi.org/10.1093/occmed/kqaa087 Slater, D., & Brandt, L. (2009). Combating moral distress. OT Practice, 14(2), 1318. Smallwood, N., Pascoe, A., Karimi, L., & Willis, K. (2021). Moral distress and perceived community views are associated with mental health symptoms in frontline health workers during the COVID-19 pandemic. International Journal of Environmental Research and Public Health, 18(16), 8723. https://doi.org/10.3390/ijerph18168723 Smith-Gabai, H., Kuzminski, S., & Eldridge, E. (2018). Surveying moral distress among skilled nursing facility practitioners. OT Practice, 23(18), 2425. MORAL DISTRESS IN THE TIME OF COVID-19 48 Turale, S., Meechamnan, C. & Kunaviktikul, W. (2020). Challenging times: Ethics, nursing and the COVID19 pandemic. International Nursing Review, 67(2), 164 167 .https://doiorg.ezproxy.uindy.edu/10.1111/inr.12598 MORAL DISTRESS IN THE TIME OF COVID-19 49 Appendix A: Recruitment Paragraph Research Study: Moral Distress in the time of COVID-19: Occupational Therapy Practitioners Experiences Are you an occupational therapy practitioner? Have you been affected by COVID-19? Are you or have you experienced moral distress? If you answered yes to these questions, WE WOULD LOVE FOR YOU TO SHARE YOUR STORY WITH US! You may be eligible to participate in an IRB-approved research project that is designed to analyze occupational therapy practitioners' experience with moral distress during COVID-19. You will be asked to participate in a one-hour interview, a demographic questionnaire, and a 30minute follow-up interview if you would like. Participation is entirely voluntary and you may stop participating at any time. Possible harm may include experiencing distress when recounting events of the past year. Benefits include: helping future occupational therapy practitioners and other health care practitioners realize the repercussions that COVID-19 has caused on the world and the healthcare field. The results could also help indicate more effective ways to cope with and improve moral distress. MORAL DISTRESS IN THE TIME OF COVID-19 Appendix B: Informed Consent Document Informed Consent Document ICD IRB 50 MORAL DISTRESS IN THE TIME OF COVID-19 51 Appendix C: Interview Questions Moral distress is defined by Andrew Jameton (1984) as a situation when someone knows the right thing to do but is prevented from doing it due to systematic constraints. In other words, someone may feel constrained from doing what they believe is right due to outside factors, for example, organizational policies and rules. What, if anything, has been your experience of moral distress during the COVID-19 pandemic in your role as an OT practitioner? Building off this, on a scale of 0-5, 0 being no moral distress and 5 being extreme moral distress how would you rate your intensity of moral distress from March 2020 until now? What leads you to this score? How has Personal Protective Equipment impacted your moral distress? In what ways, if any, has the COVID-19 pandemic caused you to do things outside of your scope of practice? How have you managed your moral distress during COVID-19? In what ways, if at all, has moral distress in the time of COVID-19 differed from moral distress prior to the pandemic? In what ways has it been the same? In what ways, if any, did your employer advertise resources and/or offer assistance to combat moral distress? In what ways, if any, have you sought resources or assistance for combating moral distress outside of work or on your own as a result of the COVID-19 pandemic? How has the moral distress you have experienced as an OT practitioner during COVID19 transferred into other roles in your life, if at all? MORAL DISTRESS IN THE TIME OF COVID-19 52 If your current self could go back and say something to your March 2020 self, what would it be? What, if anything, have we learned about managing moral distress during this time that the occupational therapy profession should keep (or change) for the future?  ...

... The Impact of COVID-19 and Technology Use on the Relationships Between Grandparents and Grandchildren Caitlin Bachmann, Christina Christenson, Sarah Frisbie, Tyler Kramer-Stephens, Erika Murphy, Claire Petersen December 14, 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: Lucinda Dale, EdD, OTR, CHT, FAOTA IMPACT OF COVID-19 AND TECHNOLOGY USE ON RELATIONSHIPS 2 A Research Project Entitled The Impact of COVID-19 and Technology Use on the Relationships Between Grandparents and Grandchildren 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: Caitlin Bachmann, Christina Christenson, Sarah Frisbie, Tyler Kramer-Stephens, Erika Murphy, Claire Petersen Doctor of Occupational Therapy Students Approved by: Lucinda Dale Research Advisor 12/14/22 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 IMPACT OF COVID-19 AND TECHNOLOGY USE ON RELATIONSHIPS Abstract The purpose of our narrative research was to understand how grandparents used communication technologies (CTs) to participate in co-occupations and how CTs impacted relationships with their grandchildren during the COVID-19 pandemic. Researchers conducted, transcribed, and coded semi-structured interviews with two participants who experienced a direct or indirect impact from the COVID-19 pandemic. The Model of Human Occupation (MOHO) was used to guide the analyses of grandparents stories. Results showed that in order to participate in cooccupations with grandchildren, grandparents adhered to Centers for Disease Control and Prevention (CDC) guidelines to reduce exposure to COVID-19, established new routines with grandchildren that included using CTs, customized CTs to match the age and interests of their grandchildren, and learned new CTs to improve connection with their grandchildren. Competency and access to CTs impacted grandparents ability to communicate with grandchildren during co-occupations, as parents of grandchildren provided assistance with CT use. Keywords: Communication technology, grandparents, grandchildren, relationships, cooccupations 3 IMPACT OF COVID-19 AND TECHNOLOGY USE ON RELATIONSHIPS 4 Those who identify as grandparents represent a significant amount of the American population that is steadily increasing. According to the American Association of Retired Persons, the grandparent population has increased by almost 25% in the last 20 years and almost all adults aged 65 and older are grandparents (David & Nelson-Kakulla, 2019). The percentage of older adults in the population also continues to increase, suggesting that the number of grandparents will positively increase over the next decade (David & Nelson-Kakulla, 2019). Grandparents have used quality time with their grandchildren to reduce loneliness and self-isolation (Quirke et al., 2019), and those who spent more time with their grandchildren experienced less stress and greater life meaning (Park, 2018). According to Adegogke (2014), grandparents can have improved life satisfaction and a decrease in depressed mood states when they are able to spend time with their grandchildren. Many grandparents favorite activities involve their grandchildren (Marken & Howard, 2014) and these activities are considered co-occupations. Pickens and Pizur-Barnekow (2009) defined a co-occupation as that which involves aspects of shared physicality, emotionality, and intentionality, embedded in shared meaning (p. 151). Participating in co-occupations with grandchildren gives grandparents a plethora of opportunities to be physically and socially active, and develop interpersonal relationships (Marken & Howard, 2014). Grandchildren also benefit when their grandparents are present and involved in each others lives (Marken & Howard, 2014). Older grandchildren may fulfill the role of caregiver for a grandparent. Levine et al. (2005) reported that 12%-18% of family and friend caregivers were 18-25 years old (Burgdorf, 2020; Gonalve et al., 2011). Many grandparents have the role of a supplemental grandparent (Kim et al., 2017). A supplemental grandparent is a grandparent who does not take primary care responsibility of the grandchild but provides supplemental care for the grandchild IMPACT OF COVID-19 AND TECHNOLOGY USE ON RELATIONSHIPS 5 when the parents are working (Kim et al., 2017) and when grandparents wish to engage in specific occupations and activities with their grandchildren (American Occupational Therapy Association, 2020). When COVID-19 was declared a pandemic in 2020, public health officials from the Centers for Disease Control and Prevention (CDC, 2020) published social distancing and masking guidelines for the United States to reduce the spread of the virus that causes COVID-19. Considering older adults had a greater risk of becoming seriously ill from the COVID-19 virus (CDC, 2021), specific and intensive guidelines were released for their safety (CDC, 2020). When the guidelines were abided by, grandparents experienced decreased socialization with family members (Siette et al., 2020). The use of communication technologies (CTs) became a safe and reliable method to maintain contact with others (CDC, 2020) as in-person interactions decreased in prevalence (Kaysen, 2020). Communication technologies are digital platforms intended to process and transmit information between individuals (What is communication technology, n.d.). The increased reliance on CTs during the pandemic was more difficult for older adults who presented with less proficiency in using digital technology as grandparents may have less confidence with using CTs (Fuchsberger et al., 2021). Using CTs became more prevalent among the younger generational cohorts as the Digital Age took place in the latter half of the 20th century (Forghani & Neustaedter, 2014). Theorists have proposed additional explanations for why older adults use digital technology less frequently. According to the modernization theory, as individuals age, their ability to effectively and efficiently use new digital technology dissipates (Hossain, 2014). As CTs become the primary mode of personal conversation, individuals who lack skill and knowledge of CTs may feel left behind and undervalued (Hossain, 2014). IMPACT OF COVID-19 AND TECHNOLOGY USE ON RELATIONSHIPS 6 Hill et al. (2015) related the digital divide to older adults who are at a greater risk for not obtaining or sharing information, decreasing these older adults participation in society. Older adults who have decreased knowledge on how to use CTs are at increased risk of being alienated from generations that may be more adept in using CTs (Hill et al., 2015). Even among the older adult population, there is a difference in digital technology use; Smith (2014) found that individuals who are 65-69 years old use digital technology more often than individuals who are 80 years and older. This theory provides an understanding for possible lack of communication between grandparents and their grandchildren when in-person interaction is limited or nonexistent. Social exchange theory indicates the importance of mutual support within the relationships of grandparents, parents, and grandchildren (Park, 2018). For example, a grandparent may provide education and advice to a grandchild and the parent of the children may give the grandparents instrumental or physical assistance. There are benefits to this intergenerational interaction as it provides parents and grandchildren with a positive model of family and gives the grandparents a feeling of camaraderie (Park, 2018). Due to the COVID-19 pandemic and CDC guidelines (CDC, 2020), these physical interactions were limited or even eliminated. This forced grandparents and grandchildren to interact in alternative ways (Strouse et al., 2021). The Model of Human Occupation (MOHO) is an occupation-based theory used primarily by occupational therapists to understand why and how individuals choose the occupations they engage in (Kielhofner & Burke, 1980). Kielhofner states that humans are open systems meaning that there is constant interchange occurring between a person and the environment (Cole & Tufano [of Chapter 6], 2020). A singular change in the person, environment, or interchange will IMPACT OF COVID-19 AND TECHNOLOGY USE ON RELATIONSHIPS 7 affect one or all other parts of the system (Cole & Tufano [of Chapter 6], 2020). Kielhofner further argues that a person functions via the interaction among the self, the occupation, and the environment (Cole & Tufano [of Chapter 6], 2020). Kielhofner and Burke (1980) believed that individuals have an innate desire to participate in valued occupations. In this model, the person consists of their volition, habituation, and capacity to perform activities (Cole & Tufano [of Chapter 6], 2020). The persons environment and occupational performance affect one another and influence occupational participation, identity, competence, and adaptation (Cole & Tufano [of Chapter 6], 2020). We analyzed data from our study using MOHO terminology to create themes based on our participants lived experiences with where and how CTs were used to adapt to changes caused by the COVID-19 pandemic in order to continue co-occupations with their grandchildren. Grandparents perceptions of using CTs with grandchildren was an understudied concept since the World Health Organization (WHO) declared COVID-19 a pandemic in 2020. The purpose of our qualitative study was to understand grandparents perceptions of using CTs to stay connected with their grandchildren during the COVID-19 pandemic. We used a narrative design to focus on the lived experiences of grandparents during a specific time-frame (Creswell & Poth, 2018) to answer our research question: How do grandparents who are trying to stay connected with their grandchildren perceive the use of CTs during the COVID-19 pandemic? Literature Review We completed our initial review of the literature during August-December, 2020. Using the same databases and keywords, we conducted a second review of the literature during January-March, 2022. We conducted faceted and single database searches using the following databases: Academic Search Complete, Medical Literature Analysis and Retrieval System IMPACT OF COVID-19 AND TECHNOLOGY USE ON RELATIONSHIPS 8 Online, WorldWideScience, Cumulated Index to Nursing and Allied Health Literature, PubMed, PubMed Central, OhioLink, SocINDEX Full Text, APApsycINFO, Consumer Health Complete, Health & Medical Collection, Psychology and Behavioral Sciences Collection, and PsycEXTRA. To examine gray literature, we searched online resources including Google Scholar, American Association of Retired Persons, and American Health Care Association. To reduce publication bias, we did not limit the search to full text. The Scale for the Assessment of Narrative Review Articles (Baethge, 2019) was used to critique the research and report the findings for this review. Keywords and Boolean operators were used to conduct the literature search; these are listed in Tables 1 and 2. We used filters within the databases to include only articles published in English and between 2010 and 2020 for our initial literature search. While examining the current literature, we refined our inclusion and exclusion criteria. We reviewed studies that included supplemental grandparents and technologies that are used for communication between individuals, consisting of social media, telecommunication resources, email, and cell phone applications. Exclusion criteria consisted of technologies not previously listed. Fifteen studies were appraised and included in the initial literature review. All studies were published between 2012 and 2020. Seven of the 15 studies presented with a qualitative design, three were cross-sectional studies, two were longitudinal studies, one was a descriptive study, one was a narrative review, and one was a non-research literature review. All studies were rated as high or good quality based on criteria of the Johns Hopkins Nursing Evidence-Based Practice quality guide (Dang & Dearholt, 2017). Among the 15 studies that were reviewed, researchers found that grandparents were positively impacted by their relationship with their grandchildren. Additionally, researchers IMPACT OF COVID-19 AND TECHNOLOGY USE ON RELATIONSHIPS 9 found reasons why grandparents were resistant to learn and use digital technology. Lastly, researchers analyzed the attitudes of grandparents regarding the effectiveness of technology. The researchers only studied the perceptions of grandparents in regard to technology use, excluding the grandchildrens perceptions. Limitations of the studies reviewed included the following: participants of higher socioeconomic status, responses from grandparents that yielded no substantial or personalized information, limited diversity and age range, and small sample size. One researcher investigated use of technology but failed to specify the different types of technology used. Most of the studies were completed in the United States, but some were published in Europe or China. Due to the fact that the studies in our first literature review were published prior to the COVID-19 pandemic, we were unable to specifically answer our research question. From our second literature search, we identified literature published during the COVID-19 pandemic that more specifically addressed the impact of COVID-19 on grandparentgrandchild relationships and technology use. Four themes were identified after analyzing the studies from the initial review including the impact of relationships, barriers to technology use, willingness to learn technology, and improvement of connection through technology. Strom and Strom (2015) found that being socially active, especially through technology, can improve cognitive function and decrease the risk of dementia in older adults. Researchers also indicated that a close and meaningful relationship between grandchildren and grandparents can decrease depressive symptoms and improve grandparents psychological well-being (Fang et al; 2018; Mannson, 2013; Moorman & Stokes, 2014). However, a close relationship did not always result in improved well-being for grandparents. Although Moorman and Stokes (2014) did not describe the method of contact, they found that when adult grandchildren were successfully completing life milestones, they contacted their grandparents less frequently. When IMPACT OF COVID-19 AND TECHNOLOGY USE ON RELATIONSHIPS 10 adult grandchildren were not successful in meeting life milestones, they contacted their grandparents more frequently which worried grandparents and increased their depressive symptoms (Moorman & Stokes, 2014). This literature review revealed three factors that can influence grandparents willingness to learn new technology. These include the relationship between grandparents and their grandchildren, grandparents self-views and self-efficacy, and the attitude and views of the grandparents culture on technology. When grandchildren and grandparents have a strong relationship, grandparents have an increased willingness to learn how to use technology that their grandchildren often use (Hunt, 2012; Luijkx et al., 2015). Older adults are also more likely to buy, learn, and utilize technology when they feel confident in their ability to use technology (Hunt, 2012; Tsai et al., 2015). When other individuals in a community show a positive attitude and outlook toward technology, older adults within the community are more willing to learn new technology (Zambianchi et al., 2019). Gell et al. (2015) found that the older an individual is, the more likely that individual will be apprehensive about using technology. Participants being apprehensive led to a digital divide between those who do and do not use technology and can result in older adults becoming alienated from family members of younger generations (Hill et al., 2015). Individuals with severe disabilities or memory and vision impairments used technology less frequently than individuals without these disabilities or impairments (Gell et al., 2015). Gell et al. (2015) believed this was due to the individuals having decreased attention span and difficulty with transcribing text on technological platforms. Older adults who were new users of technology felt discouraged when learning technology due to their perceived complexity, lack of understanding, and financial burden (Hill IMPACT OF COVID-19 AND TECHNOLOGY USE ON RELATIONSHIPS 11 et al., 2015; Tsai et al., 2015). This may have caused decreased willingness to use technology and increased alienation from younger generations. However, other researchers reported that older adults appreciated technology as it could increase their connection to their families by providing an alternate way of communication (Charenkova & Gevorgianiene, 2018; Hunt, 2012; Strom & Strom, 2015; Tsai et al., 2015). Older adults enjoyed using certain technology applications to maintain or improve their communication and relationships with family members including their grandchildren (Tsai et al., 2015). Strom and Strom (2015) noted that older adults who used technology to communicate with their grandchildren felt more connected to them because they were able to view photos and social media posts from their grandchildren. In our second review of the literature conducted in January 2022, we found four studies involving the use of technology and the COVID-19 pandemic. Participants in three of these studies included grandparents; one study did not indicate if participants were grandparents. Technology became the new normal for older adults during the COVID-19 pandemic and helped older adults adapt and maintain pre-COVID-19 pandemic routines (Xie et al., 2021). Grandparents used CTs to maintain connection with family, particularly with grandchildren (Kremers et al., 2022; Strouse et al., 2021; von Humboldt et al., 2020). Older adults believed that CTs decreased feelings of loneliness during the COVID-19 pandemic (Kremers et al., 2022; von Humboldt et al., 2020). Families commonly participated in video chats because grandparents enjoyed seeing their grandchildrens faces and believed that it was easier to maintain grandchildrens attention through this method of communication (Strouse et al., 2021). Although grandparents enjoyed interacting with their grandchildren through CTs, CTs were not able to replace the satisfaction of in-person interactions (Kremers et al., 2022; Xie et al., 2021). Grandparents in two studies discussed missing hugs and human touch from grandchildren and IMPACT OF COVID-19 AND TECHNOLOGY USE ON RELATIONSHIPS 12 other family members. Some grandparents would meet with their family members and grandchildren in open areas such as a garden to feel more connected, but still the physical contact was lacking and utilizing CTs did not suffice for that (Kremers et al., 2022). Overall, much new literature regarding grandparent-grandchildren interaction during the COVID-19 pandemic indicated positive views of technology and its ability to help maintain relationships (Kremers et al., 2022; Strouse et al., 2021; von Humboldt et al., 2020; Xie et al., 2021). However, von Humboldt et al. (2021) indicated that some older adults were unmotivated to use technology due to its complexity, lack of security, and negative stigma about older adults competence. Strouse et al. (2021) discussed decreased attention span of grandchildren 10 years old and younger creating difficulties with video chat; they also mentioned the possibility of grandparents having increased feelings of missing out on their grandchildrens lives during video chats. In this literature review, Fang et al. (2018) found that the use of technology enhanced the well-being of older adults because it aided in the contact with family members. Authors found that older adults positively perceive technology because it allows for an increased number of opportunities to interact with their family (Charenkova & Gevorgianiene, 2018; Hunt, 2012; Strom & Strom, 2015; Tsai et al., 2015). Utilizing technology strengthened relationships between grandparents and their grandchildren because it increased interaction by allowing virtual communication to occur, not only in-person communication (Hunt, 2012; Strom & Strom, 2015). Moorman and Stokes (2014) found that adult grandchildren who weren't meeting traditional life milestones contacted their grandparents more often, which worried their grandparents and increased depressive symptoms. When there was a positive outlook towards using technology and the opportunity for social gain, personally or culturally, grandparents were IMPACT OF COVID-19 AND TECHNOLOGY USE ON RELATIONSHIPS 13 more likely to utilize technology as a mode of interacting with their grandchildren (Hunt, 2012; Luijkx et al., 2015; Tsai et al., 2015; Zambianchi et al., 2019). However, others (Gell et al., 2015; Hill et al., 2015; Tsai et al., 2015) indicated that when older individuals personally perceived technology as a nuisance, then they would be less likely to consider utilizing it to interact with younger generations. Gell et al. (2015) indicated that individuals with hearing or visual impairments, which are more prevalent in older populations, were also less likely to use technology secondary to decreased ability to use it functionally. Lastly, researchers and authors found that CTs can be particularly useful in maintaining communication and relationships during times when families should not be together in-person (Kremers et al., 2022; Strouse et al., 2021; von Humboldt et al., 2020; Xie et al., 2021). The main recommendation generated from this literature review was the need for more research on this topic that directly corresponds with occupational therapy and co-occupations between grandparents and grandchildren. There was no literature focusing on how relationships between grandparents and grandchildren were impacted by technology from an occupational therapy perspective. Other gaps include lack of specification in age of grandchildren, in variety of technological background, and in proficiency of grandparents. At the time of the first review of literature, it had only been five months since WHO officially labeled the virus that caused the COVID-19 pandemic so there was limited literature addressing the impact of technology use and the COVID-19 pandemic on the relationships between grandparents and grandchildren. When we completed our second review of the literature approximately two years after the start of the COVID-19 pandemic, we noted an increase in literature on this topic; however, there was still limited research. Much of the literature on this topic from both the first and second literature IMPACT OF COVID-19 AND TECHNOLOGY USE ON RELATIONSHIPS 14 review was from psychological and sociological perspectives, further emphasizing the importance of studying this topic through the holistic view of occupational therapy. Method Study Approach/Design We used a narrative design to construct the methodology of this research. Narrative research is a form of qualitative research that focuses on the stories and lived experiences of the participants during a specific time period (Creswell & Poth, 2018). We solidified the methodology in May of 2021 and began the enrollment process in August of 2021. Refer to Figure 1 for a timeline of this process and how the evolution of the COVID-19 pandemic impacted our study (CDC, 2022). Participants To be included in this study, participants were required to speak English; identify as a grandparent to a biological, adopted, or step-grandchild; and be able to use CTs such as a smartphone, tablet, or computer (Alder, 2019). Participants also needed to be directly or indirectly impacted by COVID-19. We defined directly impacted as participants who had COVID-19 and became ill (recovered at home or had to be hospitalized), or tested positive for COVID-19 and had to quarantine. We defined indirectly impacted as participants who remained healthy, but were exposed to COVID-19 by a family member, work colleague, or friend who was directly impacted, causing the participant or a family member to quarantine or follow CDC precautions for COVID-19 due to contact tracing. We excluded potential participants who were living in a skilled nursing facility (Charenkova & Gevorgianiene, 2018), were legally responsible for their grandchild(ren) (Saxena & Brotherson, 2013), or were residing in the same home as their grandchild(ren) (Saxena & Brotherson, 2013) who lived in the same household as their IMPACT OF COVID-19 AND TECHNOLOGY USE ON RELATIONSHIPS 15 grandchildren. We selected and invited two participants whose demographics included the following: impact of COVID-19, number of grandchildren, and visits with grandchildren prior to the COVID-19 pandemic were different. We accepted two participants, as deemed appropriate according to Creswell and Poth (2018), for narrative research. Materials and Measures Survey We developed a survey for potential participants that included questions on the following topics: participants age, sex, marital status, employment status, number of children and grandchildren, timed distance between grandchildren, impact of COVID-19, and frequency of visits with grandchildren. Survey topics were chosen to indicate distinct differences between participants in order for us to gather information from a variety of grandparents experiences. We sought feedback from professionals on the survey questions and received no feedback. In order to select two participants with varying demographics, impact of COVID-19, and experiences in regard to grandchildren and their COVID-19 pandemic experience, we designed the survey questions to gather detailed information about each prospective participant. See Appendix A for survey questions. Interview We used semi-structured individual interviews to gather data pertaining to grandparents stories and experiences (Creswell & Poth, 2018). We designed three broad, open-ended questions and eight prompts to ensure consistency and flexibility based on participants responses and the flow of the interview. We referenced Jovchelovitch et al. (2007) and Spradley (1979) for their expertise regarding narrative interviewing in the creation of the interview questions and prompts. We presented the interview questions to research and clinical IMPACT OF COVID-19 AND TECHNOLOGY USE ON RELATIONSHIPS 16 professionals to validate the questions suitability for this population, and to confirm that the questions directly pertained to the research question (Agee, 2009). These professionals provided us with additional resources to guide our interview process, improve our understanding of narrative research, and clarify our interview questions. Artifacts We invited participants to share artifacts (Creswell & Poth, 2018) to further explain stories. Artifacts included photographs, videos, or other meaningful objects that allowed the participants to explain co-occupations with their grandchildren in greater detail. Procedures Institutional Review Board (IRB) Due to the COVID-19 pandemic, administrators of the academic IRB instituted two, instead of one, levels of approval for faculty and students conducting research. Submission and approval were gained at the college level, followed by submission to the institutional IRB. We submitted our proposal to the IRB in May of 2021 and received approval in June of 2021. Training We completed the Collaborative Institutional Training Initiative to learn ethics of human subject research. Additionally, all student researchers completed doctoral coursework focusing on research methods, analysis, and application. Prior to data collection, we participated in a mock interview to ensure that questions were asked in an understandable manner. We practiced bracketing (Creswell & Poth, 2018) to encourage separating personal assumptions and experiences from those of the participants so that a new perspective could be considered during coding of interviews. We increased proficiency with navigating Zoom by scheduling mock IMPACT OF COVID-19 AND TECHNOLOGY USE ON RELATIONSHIPS 17 interviews, checking microphones, recording interviews, and using a transcription service simultaneously with Zoom. Recruitment To abide by suggestions from Creswell & Poth (2018) for recruitment of potential participants, we posted fliers on a university campus in compliance with the university policy, used the university email option in compliance with the university policy for recruitment, and maintained compliance with COVID-19 CDC recommendations during face-to-face recruitment. Those interested in participating contacted the primary investigator (PI) by email and were encouraged by the PI to share recruitment materials with others. We used purposive sampling (Patton, 2002) to identify and invite participants who met the inclusion criteria. Informed Consent Process and Enrollment Informed consent and enrollment occurred in two phases. In the first phase, the PI gave potential participants a copy of the consent form and a link to complete our survey. The PI informed interested participants that completion of the online survey indicated that they consented to collection and review of the data they provided in the survey. Five individuals met the inclusion criteria to be considered for participation in our research study after responding to survey questions. In the second phase, we invited two grandparents to participate in the interviews. These grandparents were selected by the research team based on answers to the survey. The PI provided the IRB-approved informed consent to potential participants prior to the process of selecting final participants and offered them an opportunity to ask questions about our study. Potential participants were notified that only two participants would be selected for the interview portion of the study. The PI contacted these two participants and sought consent for the IMPACT OF COVID-19 AND TECHNOLOGY USE ON RELATIONSHIPS 18 interview portion of the study. The two participants provided verbal consent during the interviews for artifacts to be recorded during interviews. We contacted the participants not selected for the interviews and advised them that we would retain their contact information in case of original participants choosing to discontinue data collection. We provided key information to potential research participants including our study title, contact information, the aims and purpose of our study, amount of time allotted to participate in the study, the reason specific participants were chosen, and potential risks and benefits. Participants were also informed on what would occur before, during, and after the study, as well as the rights of the participants. Participants were not required to provide an electronic signature on the informed consent document as only their verbal consent was required by IRB, and continued participation in our study was deemed informed consent. Lastly, the PI sought out and received verbal consent for the research participants to utilize artifacts during the interviews when applicable. The PI encouraged participants to keep a copy of the informed consent. Data Collection We collected data through two or three semi-structured interviews lasting 30-60 minutes with each participant between September 2021 and October 2021. Each interview session included three members of our research team, with one member asking interview questions, one recording field notes, and one monitoring the Otter.ai transcription as the interview occurred (https://otter.ai). The researcher recording field notes was responsible for noting the importance of artifacts (Creswell & Poth, 2018) and asking additional questions prompted by participants' responses. Using Otter.ai transcription allowed us to continually review data to ensure plausibility and credibility of our study. After completion of every interview, we shared the transcript with the participant for member checking which allowed them to verify accuracy and IMPACT OF COVID-19 AND TECHNOLOGY USE ON RELATIONSHIPS 19 add pertinent information. We allotted, on average, two weeks between interviews for member checking, individual coding, and collective coding. We considered the data to be saturated (Creswell & Poth, 2018) and concluded interviews when there were no new data produced. We de-identified, encrypted, and password protected participant information and interview data to ensure anonymity and data security. We utilized a shared Google Drive that had restricted access to only the research team in order to organize transcripts, data, field notes, and interpretations of the data, all providing for an audit trail (Creswell & Poth, 2018). After the participants member checked their respective transcripts, we preserved their anonymity by using pseudonyms chosen by the participants (Crewell & Poth, 2018). We planned for the PI to securely keep interview data for three years, after which data files were deleted. Data Analysis We manually completed independent and collective coding (Creswell & Poth, 2018). Then we transferred our information into a codebook to organize transcripts and identify themes in participants stories and experiences. In order to analyze the data, we used the Model of Human Occupation (MOHO) as a theoretical guide (Kielhofner & Burke, 1980). We developed a data analysis template (Appendix B) that included pertinent MOHO terms to categorize the raw data (Kielhofner & Burke, 1980). We used this model to create individual patterns of analysis documents for each participant using MOHO terms that helped researchers form codes in order to categorize the data. We combined the participants individual MOHO patterns of analysis documents to determine similarly categorized raw pieces of data. We then developed two stories from the data as one story was produced from one participant and another story from the other participant (Creswell & Poth, 2018; Jovchelovitch et al., 2007). Transferability (Creswell & Poth, 2018) minimally existed as generalizations were unable to be made due to the sample size. IMPACT OF COVID-19 AND TECHNOLOGY USE ON RELATIONSHIPS 20 However, we made comparisons between participants and individuals from our literature review that were in very similar situations. Dependability (Creswell & Poth, 2018) existed through our description of research procedures for an outside researcher to follow. Reflexivity (Creswell & Poth, 2018) occurred as each of us understood our role in the research process and how our prior experiences could be influential. Results The participants demographics and general information are described in Table 3. Figure 2 shows types of CTs that participants used. Tables 4 and 5 show explanations of how these CTs were used. Tables 6 and 7 indicate themes and subthemes of Domingo and Marie. Domingos Themes Grandparents and Grandchildren Made CTs a Part of Their Routine Domingo and his family used CTs to maintain and create new routines with their grandchildren, and demonstrated flexibility to engage in co-occupations when in-person interactions were not available. We simply roll with the changes hed [grandson] much rather see us in person, but if we dont have that option he enjoys seeing us [Domingo and wife] on video. To improve these virtual co-occupations, Domingo purchased additional equipment. I bought this little camera [because] the [computer] screen didnt have a camera. However, Domingo continued to prefer in-person interactions instead of using CTs. Ill see people live, which is preferred. Domingo and his wife ventured into other forms of CTs, such as social media platforms, in order to stay connected with their grandchildren. However, they believed this would only become the norm if necessary. That [a breakthrough COVID-19 case] would be the only reason we would start using social media [and] digital media on a regular basis. Domingo was IMPACT OF COVID-19 AND TECHNOLOGY USE ON RELATIONSHIPS 21 able to use unfamiliar CTs to communicate with his grandchildren during the COVID-19 pandemic because of his ability to transfer prior knowledge of CTs from the skills acquired in his career. I found [using technology] to be easier, a lot of things like Zoom meetings I didnt know how to use it before, before COVID. Domingo expected his family to use CTs in the future when in-person co-occupations are not achievable. [We will use technology] only when physical presence isnt convenient or possible. Grandparents planned to continue using CTs regardless of the pandemic and CDC restrictions because theyre convenient, theyre enjoyed by the grandchildren, and theyre a good substitute for when grandparents are not able to be physically present. So that stuff [communicating through technology] will continue because he [grandson] enjoys [it], he gets a kick out of those things, we [Domingo and wife] like to interact with him, even if though we're not there because we'll see him a few times a week, but not always. Grandparents and Their Families Adhered to CDC Guidelines for the COVID-19 Pandemic Domingo and his grandchildren altered in-person interactions with their grandchildren in an effort to adhere to the CDC social distancing guidelines for the COVID-19 pandemic. Domingo met outside his daughters house so he could physically visit his grandson while also following the physical distancing guidelines. These social interactions included Domingos grandchildren talking and waving through a window while he and his wife were outside. we [Domingo and his wife] would just walk along, we would stand outside the [his daughters] house. They'd [daughter and grandson] open up a window, and we could talk to him [grandson] or in the really cold we just wave but we could talk to him [grandson] through the open window from 15 feet away. IMPACT OF COVID-19 AND TECHNOLOGY USE ON RELATIONSHIPS 22 These adaptations were easy to make for Domingo and his family because they lived close to one another. Domingo reported, We're fortunate they live only a four minute walk away. So, we see them fairly [often] which is nice. However, grandchildren found it difficult to understand social distancing and the changes made to co-occupations with their grandparents. so at least he [grandson] could see us [Domingo and wife] and talk with us, but he wanted to come out and he wanted to come up to us like no you can't yet because we want to make sure that everybody's staying safe and healthy, and I think he [grandson] was having a hard time understanding that it was hard for us not to be able to hug them. Domingo and his family had a strong desire to meet in-person while remaining safe. Domingo and his family prioritized health and safety by restricting in-person co-occupations with grandchildren for three weeks in December of 2020 due to a family member contracting the virus that causes COVID-19. They experienced a disruption in their routine co-occupations because physical interactions like hugging and playing were strictly limited. Domingo said, It was hard for us not to be able to hug them, and hold them, and carry him [grandson] around and all the things that we had been doing. Domingo and his family desired to keep each other safe and continued to adjust to the uncertainty and challenges that were created secondary to the COVID-19 pandemic. Due to the fact that the viral transmission of the COVID-19 virus was not entirely understood at the time, Domingo collaborated with his daughter to determine a method he and his grandchildren would be able to safely participate in co-occupations. but there are certainly some hiccups in the process when COVID started we werent sure how it was being transmitted, we felt that we were pretty safe but we were our daughter was also wanting to make sure that her family was safe as well. IMPACT OF COVID-19 AND TECHNOLOGY USE ON RELATIONSHIPS 23 Domingo and his family created pods to adhere to the CDC guidelines for the COVID-19 pandemic, limit exposure, and decrease reliance on CTs for engagement in co-occupations. Domingo and his family agreed to create a family pod so they could gather in-person and take precautions together in regard to the COVID-19 pandemic. Once they felt it was safe to do so, grandparents and grandchildren resumed pre-pandemic in-person co-occupations with each other, but limited exposure to all other people. Domingos grandson expressed happiness when Domingo and his family created their pods as they were able to see each other in person. Once we finally made an agreement they were being careful [and] we were being careful so we agreed that we will be a family pod so then we were able to now see them, and hold the grandson, play with him, and he was much happier. After Domingo and his family created a family pod, in-person co-occupations resumed but CTs were still used as a supplement for engagement in co-occupations. We still do some Skype calls with them and fun Snapchats back and forth, but otherwise we see them face-to-face and play They came over yesterday evening, they were out walking and came to say, hey we're going to come by in about five minutes, so we just come out in the yard. Grandparents and Grandchildren Selected CTs Based on Ages, Interests, and Preferences of Each Family Member Family members used different CTs for specificity when engaging in co-occupations as the CTs that were used reflected their respective age, interests, and preferences. Domingo found it enjoyable to use CTs that involved photos because doing so provided an increased sense of connection with their grandchildren as they could visually see them. Through this method of communication, grandparents enjoyed limitless viewing of pictures and videos which helped IMPACT OF COVID-19 AND TECHNOLOGY USE ON RELATIONSHIPS 24 substitute for in-person interactions as cautioned by the CDC. And then, then the first thing we're doing is I want to make sure that, I want to receive this again, see this again watch it a second time. Domingo took advantage of this limitless viewing much more during the COVID19 pandemic than prior to the pandemic as Domingo and his family increased their use of CTs. Family members utilized CTs involving photos which helped substitute for times when they were not together. Grandparents enjoyed using Snapchat and other photo-sharing CTs in an effort to continue co-occupations with their grandchildren and family members when they could not attend in-person family events. She's [Domingos daughter] able to share the funny moments and the good times, even if we're not over there, [it] is nice. CTs allowed grandparents to witness milestones that they, otherwise, would not have been able to observe in real time. Our one-year-old grandson all of a sudden he was standing, and then within two days, he's walking 25-30 feet she [Domingos daughter] has heavily shared that and it was really nice to be able to see that too. Sharing photos and engaging in co-occupations through CTs also allowed grandparents to respect parents boundaries. Domingo and his daughters family lived very close to one another so in-person interactions often occurred when they were not isolated from one another during the COVID-19 pandemic. However, families still wanted their privacy along with having frequent connections. Domingo and his wife used CTs to participate in co-occupations with their grandchildren while not having to physically visit at their daughters home. Even though they're a block away we aren't there 24/7, and nor do they want us to be. Grandparents and their family used CTs as a way to not miss funny moments or good times but also to keep desired IMPACT OF COVID-19 AND TECHNOLOGY USE ON RELATIONSHIPS 25 boundaries between families. Even though we're only four minutes away, we cant always be there [at the grandchildrens house]. Domingo and his immediate family members utilized the CT application Zoom to interact with a larger group of family members, some of whom lived in distant geographical locations, as Zoom allowed for improved convenience and flexibility for the entire family. Domingo and his immediate family would coordinate times to participate in Zoom meetings with extended family, which also included the grandchildren. Due to the fact that some grandchildren had established bedtimes, Zoom worked well to set an appropriate time for communication. We were doing larger group Zoom [meetings] on the weekends when people had the time [on] Saturday [and] Sunday afternoons. It's hard to get people to find the time in the evening that works [due to family members being in different time zones], especially for our daughter since the kids [are getting] ready for bed by seven o'clock. Domingos parents, the great-grandparents, also wanted to participate in these Zoom gatherings; however, the great-grandparents required help to do so. Grandparents fulfilled the role of teacher by helping great-grandparents with CT use. Domingo or his brothers coordinated providing assistance so that the great-grandparents could participate in co-occupations with their greatgrandchildren through CTs. But I have to try to get my parents to figure out how to use it [Zoom] again. I have to make sure one of my brothers are [sic] with my parents and then they can walk them through the technology and we can then do a Zoom call or something else. When interacting solely with his grandchildren and their parents, FaceTime on iPhones proved to be the most convenient CT used for Domingo. It was easy and efficient to use FaceTime and was appropriate for his family as many members already owned iPhones and had IMPACT OF COVID-19 AND TECHNOLOGY USE ON RELATIONSHIPS 26 proficient experience with using them. I know we did some FaceTime videos with them because my daughter and son-in-law both have iPhones, I have an iPhone so doing FaceTime was easy. Domingo was comfortable and competent with this form of communication and stated that it was used frequently. FaceTime is probably the easiest one that we did. Due to Domingos grandchildren being three years old or younger, they lacked competence and required assistance from their parents when using CTs to engage in cooccupations with their grandparents as they were unable to use their parents iPhones independently. Grandchildren had difficulty maintaining attention during iPhone calls secondary to their young age. Domingo believed that telephone calls were more difficult when grandchildren did not have control of the communication. He [grandson] certainly needed help from his mom, our daughter, so that helped. But, otherwise he was fine and he started to lose attention if he couldnt hold the phone. Even when holding the phone, grandchildren would still get distracted, making co-occupations difficult at times. Sometimes he [grandson] would sit and talk or listen and other times he wanted to hold the phone, and walk around then all of a sudden it's like a monkey cam around the house. Beyond wanting to hold the telephone, losing attention, or not knowing how to use the CT, grandchildrens ages continued to be the most common CT barrier as they did not always understand how to use the CTs or why the CTs were necessary at that time. It was really difficult for our grandson I think from his age [two-three years old]. He was having a hard time kind of figuring out how it goes he's trying to look around on the computer or the phone or something like that then he started realizing that this is a device and it's kind of like watching them on television. So he can hear us and we can IMPACT OF COVID-19 AND TECHNOLOGY USE ON RELATIONSHIPS 27 hear him, which is nice. I think the biggest challenge was simply his inexperience with, kind of, how to communicate and understand what's going on. Domingo enjoyed using CTs to communicate and interact with their grandchildren but admitted that it was hard to have a relationship with a very young grandchild through CTs. However, grandparents believed that younger children were getting used to this way of life. The technology itself is good, and it works nicely. Whether or not you can have that relationship with a young child that's two years old, two and a half years old or something I think he [grandson] was about a year and a half old when COVID started, and now he's three. Despite these difficulties, family members continued using CTs often and experienced positive moments. While using CTs to engage in co-occupations, grandparents just wanted to ensure grandchildren were happy. When on FaceTime or other CTs, Domingo and his wife used toys in an effort to remind grandchildren of their pre-pandemic routines. We bring some toys up and we say hey these toys really want to play with you so pretty soon you'll be able to come back. Domingo stressed the importance of keeping virtual communication fun for his grandchildren when in-person interactions were not an option. We did some Zoom calls with them, we did FaceTime and he [grandson] was having fun. Grandparents tried to make it a joyful experience for their grandchildren and attempted to preserve former, playful cooccupations. So we make faces, we talk, we tell jokes we get smiles out of him [grandson] so he was, he was enjoying it and I think that was really the goal of him to just have a good experience, that moment and not really dwell on is this the way I'm going to be talking to my grandma and grandpa for forever. IMPACT OF COVID-19 AND TECHNOLOGY USE ON RELATIONSHIPS 28 Grandparents were happy to use Google Photos, Apple photos, and any other CT because they wanted to please their grandchildren by using a CT their grandchildren were interested in using. Even the grandsons I know kind of see that and they get involved we do post pictures, both to a Google Photos, as well as Apple photos it's been a lot easier for our grandson to even see all the pictures so he, his mom, dad, show pictures on their phone, so he's always happy to see them, which is nice. Maries Themes Grandparents and Their Families Adhered to CDC Guidelines for the COVID-19 Pandemic to Remain Safe Marie and her family prioritized adherence to CDC guidelines for the COVID-19 pandemic in an effort to prevent exposure and transmission of the virus. Marie and her family received vaccinations against the virus that causes COVID-19 as soon as they were available in an attempt to return to in-person family routines. My family, particularly by choice, is vaccinated [COVID-19 vaccine]. Marie and her family collaborated to maintain meaningful routines with each other by adhering to CDC guidelines, I was just practicing protocols but my daughters and my family, we established some ways we would meet where we could still stay connected. Furthermore, Marie was particularly disheartened that she was unable to see her grandchildren nor family members in-person for three consecutive months secondary to Marie and her family prioritizing safety during the COVID-19 pandemic. When the pandemic and lockdown began in March of 2020, definitely like the rest of the nation, everyone except for the essentials, [was] staying at home and isolating, as per the government guidelines so I did not see my grandchildren. In March, April [and] May I did not see any of them at all. IMPACT OF COVID-19 AND TECHNOLOGY USE ON RELATIONSHIPS 29 Marie was uncertain on how to initially navigate the COVID-19 pandemic when attempting to resume pre-pandemic routines and leisure activities with her family after observing inconsistent adherence of the CDC guidelines from others in the community. To comply with CDC guidelines, Marie interacted with her grandchildren in outdoor spaces, where they could appropriately physically distance themselves. Even in outdoor public spaces, Marie experienced apprehension as other members of society would not abide by CDC precautions in regard to the COVID-19 pandemic. We're not in a routine of doing some of those things that we used to do. Like Build-ABear. Maybe the park, but a lot of the other places are just still real iffy on if they're open and a lot of places wear masks, [other places] don't wear masks. Few times I've taken them [her grandchildren] to the park there's this weirdness I've got to kind of gravitate them away so we're not violating this [physical distancing], so there are challenges going places with them now. In general I would say we're not quite there yet [back to normal routines] Some of the places didn't even open their dressing rooms I would have normally taken [my granddaughter] shopping for some clothes in the fall. Marie's routines with her grandchildren were disrupted by the COVID-19 pandemic and Marie adapted to the continued disruption by utilizing CTs. You had this routine, then the routine got all shuffled and not quite up to where we were before it's just been that matter of different things have changed and it's just not quite there yet. When questioned about the impact of the disrupted routines with her grandchildren, Marie was frustrated that she was only able to see her grandchildren in-person for short periods of time. Marie overcame these challenges by using CTs to connect with her grandchildren. IMPACT OF COVID-19 AND TECHNOLOGY USE ON RELATIONSHIPS 30 I think that's the hardest part [not seeing your grandchildren for an extended period of time] and I just think having that routine where I could see them every week or two and I just like spending time with them so the workarounds [using CTs to preserve communication] made it work but it was frustrating because you just want to be part of their lives. Marie utilized CTs to participate in Zoom sessions to engage in co-occupations with her family and grandchildren. So then for my other grandkids [the two, four, and five year old grandchildren], we actually had a Sunday night Zoom time it was family too, it wasn't just grandkids, but it was sort of quick family time. As the weather got warmer, Marie gathered with her family exclusively in outdoor environments while adhering to COVID-19 CDC guidelines. This was done to begin in-person family interactions after three months of no in-person contact. Starting in June and July once in August I did see them in a real open location. According to Marie, a meaningful aspect of being a grandmother was being able to hug her grandchildren. Marie found it quite difficult to not physically interact with her family and grandchildren due to social distancing, but felt safer with the COVID-19 vaccine. It was really hard I mean I think even now, the hugging and with the variant picking up now when we are together I mean that's [getting the COVID-19 vaccine] definitely helped us feel better but just really staying away from their [the grandchildrens] face area and just being cautious around them, that's hard because I'm a hugger. When Marie met with her family members in-person, she maintained group pods and isolated between contact with separate group pods to follow the COVID-19 pandemic CDC guidelines and to protect the health of her grandchildren and other family members. IMPACT OF COVID-19 AND TECHNOLOGY USE ON RELATIONSHIPS 31 When talking about my grandkids, I think we were small enough [the number of people in this particular pod] we didn't have any more than 10 to 12 so I would say the answer to that is yes [responding to if she had a family pod] keeping that pod, but then I also had a separate pod with my mom and my brother and my nieces and nephew. But if I visited that pod [the first family pod] I always isolated the 14 days after I visited that pod [the second family pod] just to make sure I didn't get exposed to something at this end and then I'm going over with my grandkids with some kind of exposure. Grandparents and Grandchildren Used Different Methods of Communication to Engage in Co-Occupations, Including Technological and Non-Technological Forms Grandparents used different methods of communication to engage in co-occupations with their grandchildren, including technological and non-technological forms. The complexity of conversations Marie had with her grandchildren through CTs differed based on the age of the grandchild. Maries older grandchildren found using CTs easier than her younger grandchildren because her older grandchildren had a better understanding of how to use technology and were able to better hold conversations. Obviously [having conversations with] the two year old who wasn't speaking as much, though he seemed pretty advanced for his age, and he could understand, that conversation was a little more show and tell but the four year old, and the five year old, then the seven year old. They're very talkative, talking about their day so I think there was more conversation. Marie experienced challenges in keeping younger grandchildren attentive to conversations using CTs, so it was easiest to call them on the phone as she did prior to the IMPACT OF COVID-19 AND TECHNOLOGY USE ON RELATIONSHIPS 32 COVID-19 pandemic. Using a phone call rather than a video call allowed the younger grandchildren to move around their environment while continuing to communicate with Marie. I mean in person there's [more control with] attention span [of the grandchildren], especially with the little ones [it is] easier to command their attention, whereas, using technology during COVID, that it was harder with the younger ones for the attention span [being] on the phone and talking work the best, I would say for the little ones. Just them talking on the phone carrying the phone around. Marie also used CTs to maintain co-occupations with her older grandchildren. She used CTs to communicate with her adopted grandson while they were apart, waiting for his adoption to be finalized. Maries daughter was in the process of adopting her son from the Ukraine but the process was delayed due to the CDC imposing travel restrictions during the COVID-19 pandemic. Marie used CTs to communicate with and provide reassurance to her future grandson. I can't even imagine what that would have looked like if there wasn't that technology available because it was hard to imagine what he was going through at the orphanage [discussing how difficult not interacting with Maries family would have been for her adopted grandson from the Ukraine without CTs]. It was hard to imagine what a day in his life was like, with the lockdown and I just think that him having that connection, that reassurance. I think without that [not being able to see his family] would have been really hard, hard [sic] on him. Marie was happy that she was able to communicate with her grandson from the Ukraine using the Messenger app, Instagram, and phone calls. It would be fun when my phone would ring, I'd look like oh it's [my grandson from the Ukraine] is calling, Messenger, yeah [answering that IMPACT OF COVID-19 AND TECHNOLOGY USE ON RELATIONSHIPS 33 she used Facebook Messenger to communicate with her grandson from the Ukraine, as well]. Marie was thankful that CTs allowed them to be connected while in different countries. I always stayed in somewhat contact with him [adopted grandson from the Ukraine] like Facebook Messenger, Instagram. So, for him, I just continued that kind of communication, messaging and I would say he typically messages me, would have messaged me at least once a week, and I was very thankful that we did have the technology. Marie appreciated having the means to afford an iPhone and used it to FaceTime her grandchildren. I feel thankful that I could afford an iPhone and the most recent one because I definitely think being able to call and do the FaceTime calls through that iPhone. I mean that was definitely an advantage. Using FaceTime allowed Marie and her grandchildren to see each others faces while talking, which was important to Marie and her grandchildren. They [the grandchildren] like to really see, they like to look and see the faces. Marie would also use FaceTime to share her environment with her grandchildren, such as showing them her dogs on FaceTime, and she would show them their art hanging on her refrigerator. Marie preferred FaceTime on iPhones as it allowed interactions with her grandchildren to closely mimic co-occupations that they would normally engage in when the grandchildren were at her home. They [the grandchildren] would send me pictures so then if we were on the iPhone, I would walk them to the refrigerator and show him where the pictures were hanging. And they would ask to see my - I have two Yorkies. So they would ask me to show them, so a lot of times, I would walk them around the house, where they could kind of IMPACT OF COVID-19 AND TECHNOLOGY USE ON RELATIONSHIPS 34 see where I'm at and I'd say, Okay, well now I'm on my deck. Do you notice things out there? But then they'd always want to also see my Yorkies that was exciting to them. When Marie visited her mom both before and during the COVID-19 pandemic, she called her daughter so the grandchildren could speak to their great-grandmother. Using the iPhone made it easier for Marie to facilitate interactions between her grandchildren and their greatgrandmother during the pandemic. It's not unusual for me to be out or visiting my mom, and then FaceTime my daughter, so my mom could talk to them [the grandchildren], so pre COVID, we could do that. During COVID, we can do that Honestly, [if] that technology wasnt in place, it would be a lot harder. When Maries family wanted to include more than one family member in the call, they used Zoom. They preferred to use Zoom rather than the phone because they could prepare for meetings by sharing a link, join when it was convenient for each family member, and avoid the difficulty of setting up group phone calls. The best of [CTs is] being able to have the Zoom call. And I would say where that probably came in handy was when we wanted more than one family [member] to be on the call Im probably more challenged with that, getting more than one person in a [phone] call but not on Zoom, so yeah, I think the Zoom, and being able to have more than one family have the link and pop in works really well. Marie and her family used CTs to participate in meaningful pre-pandemic activities. I think it was just that they're all pretty much fun activities I think we were able to do a lot of those types of things that we would normally have done in person. These included playing games together, sharing toys and artwork, and singing. Being in different places while playing IMPACT OF COVID-19 AND TECHNOLOGY USE ON RELATIONSHIPS 35 together limited their options for games. The one game I like playing with them is probably Yahtzee We tried doing a card game that wasn't that easy, but we were able to play battleship, because they had a battleship game, I had a battleship game. And we could do the numbers back and forth. With her younger grandchildren, co-occupations were based on their interests. Show and tell was one way Marie could connect with her grandchildren. I would say a lot of times, it was more show-and-tell, they really wanted to show me things, probably more because of their age, which I definitely enjoyed them showing me what pictures they drew or what they were playing with. If [my granddaughter] was playing with Barbie, she was showing me her whole little Barbie thing going on, and [my grandson] would show me his trucks and what his dinosaurs were doing. Marie and her grandchildren also enjoyed singing songs together, especially songs that encouraged individual grandchildren to respond. Oh, we did sing songs a lot too I'm not a singer but I make up songs and I made up songs for my kids. And so, somehow, some of them aren't made up songs but you know [the song] like [my granddaughter] stole the cookie from the cookie jar and she's like, who me, not me. This put further emphasis on preserving pre-pandemic routines within the family. Sometimes, rather than participate in activities during calls together, Marie would watch her grandchildren play and have conversations based on what they were doing. It was really more of me, kind of watching him [her grandson] navigate games but I would say but there were more cases where if we were on a call, they were showing me their toys or they were doing an activity like they were playing with playdough and IMPACT OF COVID-19 AND TECHNOLOGY USE ON RELATIONSHIPS 36 I was watching Oh what are you building, oh that looks really nice and so, probably not really games for their age, but more watching them be active. Marie and her family members used Zoom to replicate the feeling of being together when they could not meet in-person.These Zoom calls were informal with family members doing separate activities and occasionally engaging in conversation, similar to when they could visit inperson. This allowed the family to participate in modified versions of their usual co-occupations. When we [Marie and her family] had calls it wasn't a structured meeting, like what we're doing now [referring to researchers formally asking questions during the interview], it would be more like we're connected. One person [might] talk, that kid goes, another person comes in, my daughter might be cooking in the background. She'd [say] Hey Mom what did you do about that and then she would be off, but you felt like you were kind of in the room because my son-in-law might be able to watch the TV or football or whatever. So you were in the room, and kind of there if you were visiting, it really did feel more like that than a prescriptive, we're trying to accomplish this or we got these questions and stuff so it really felt more like that, and at different points. So, my spouse sometimes would pop in and say stuff, and then pop back out. I didn't, I don't think it was a case, I mean it definitely would pop down because they want to see Papa [her husband] too. What's Papa doing? Well, I don't know, let me get him up here and we get him up for the call. Due to the COVID-19 pandemic and impact on grandchildrens routines beyond cooccupations with grandparents, Marie recounted new conversations when using CTs with her grandchildren. IMPACT OF COVID-19 AND TECHNOLOGY USE ON RELATIONSHIPS 37 Then [my granddaughter] might ask more questions. I feel like she probably asked questions, or more statements like, I don't know, when we're going to go back to school or I miss my friends or maybe do you miss your friends or, but more comments. I think the questions to me like, things they didn't quite understand about not seeing their friends, or going to school. Marie and her grandchildren increased their utilization of the postal service to share items during the COVID-19 pandemic for engagement in co-occupations outside of technology. These non-technological interactions allowed Marie and her grandchildren to continue pre-pandemic routines by modifying their interactions to adhere to the CDC guidelines for COVID-19 safety. Marie discussed using food delivery services to maintain meaningful routines with her grandchildren during the COVID-19 pandemic. One of their favorite things is, and it's a little pricey when I say that, but [local bakery] cupcakes. We often will order that and have it for special, special occasions. So, the two different sets of families, like, I ordered cupcakes to be delivered I knew their favorite pizza place, for example, but I could order a pizza, and it could be delivered with one of the delivery services. Maries mom chose to communicate with her great-grandchildren via mail, rather than CTs, which encouraged Marie to start sending letters and gifts to her grandchildren through the postal service. The great grandkids would mail her [their great-grandmother] which my daughters had to help him with, but yeah, pretty regularly. I would say, I started mailing too. Marie described writing to her grandchildren as nostalgic: But I did write them back, and it was kind of fun. I was like, oh, I remember this - my pen pals! While describing these non- IMPACT OF COVID-19 AND TECHNOLOGY USE ON RELATIONSHIPS 38 technological interactions, Marie emphasized the importance of sending mail that would be meaningful to the grandchildren. I would send them [the grandchildren] just little note cards, but whatever I could tuck inside that could be mailed Stickers would be the main thing. I would pop in a one dollar bill or two dollar bills in that whenever the off chance when they would be going somewhere. Kids always like money. In response, her grandchildren sent her letters, which she found meaningful, I received some letters too from my grandkids which that did not really happen [before the COVID-19 pandemic] except thank you notes that's something we hadn't been doing before, and that was fun. Sharing letters and gifts through the mail allowed Marie and her grandchildren to engage in cooccupations without using CTs. Grandparents and Family Members Competency With and Access to CTs Affected CoOccupations With Grandchildren Grandparents and family members competency with and access to CTs influenced coordination of co-occupations among three households, assistance with CTs, the development of new technological skills, the types of CTs used, and technological challenges experienced. Marie demonstrated flexibility and ability to adapt to different CTs to ensure consistent participation in co-occupations with her grandchildren. Grandparents established competency with CTs prior to the pandemic helped them learn to use more types and features of CTs. Marie learned to use different functions, such as voice functions, of familiar CTs to aid in her participation in co-occupations with grandchildren throughout the pandemic. Marie demonstrated willingness to learn these new ways of communication in order to increase her contact with her grandchildren. IMPACT OF COVID-19 AND TECHNOLOGY USE ON RELATIONSHIPS 39 Using maybe more of the voice functions on some so even if I couldnt connect by phone I could record my voice and send them [voice recorded messages through CTs]. So to me, yeah, there were some improvements with just seeing other options for technology. Due to the younger grandchildrens ages preventing competent use of CTs, grandchildren had to rely on their parents to help them use CTs to engage in co-occupations with grandparents. Grandchildren also had difficulty understanding why they could not be in person with grandparents. Maries younger grandchildren found it more difficult than the older grandchildren to understand the COVID-19 pandemic and the guidelines set in place. My grandchildren are young enough that I dont know that they fully understood what was going on whereas like an older one and maybe it might have been more noticeable for maybe my seven year old granddaughter, shes a hugger too. Beyond the inability to understand the COVID-19 pandemic, Marie also believed that the limited number of CT devices to be shared and the younger grandchildrens decreased competency with CTs negatively affected the quality of cooccupations. I think the little ones are shoving each other to get the other one in front of the computer more so, even though we could get together it just wasn't as quality of time as you would in person and being able to just really connect. Maries family also relied on CTs for co-occupations because family members were not geographically close. However, communication through CTs was more difficult with family that lived in rural areas. Unstable internet connection challenged their ability to hear each other and engage in co-occupations without frequent interruptions. Okay, what did you say I don't know, I didn't hear you and so then it's like, okay, this is not going very well. Families with high IMPACT OF COVID-19 AND TECHNOLOGY USE ON RELATIONSHIPS 40 speed internet connection were able to participate in co-occupations more easily than families in rural areas who experienced a decrease in time and quality of CT use. And they had good Internet connection too, I think because they live in a bigger city and had the higher speed internet, but definitely a disadvantage for the rural family, who did not have the better internet service, to be able to drive the technology. At times of poor internet connection, family members adapted by rescheduling to ensure time was spent with one another we would just text and say we'll try again next time. So no, it usually ended up ending. Marie purchased new equipment to improve the quality of using CTs with grandchildren. Marie stated she was fortunate enough to already have high speed internet but she purchased a ring light for better quality lighting. I purchased one of those [ring lights] because I just realized that it [the room] turned out, it's kind of, I think it'll still see me but it's a little dark and depending on the time of day, it could be darker, but I did that [purchased a ring light]. The parents also purchased equipment to improve co-occupations between Marie and her grandchildren. Well my daughter, who works remote and my son in law did not have high speed internet, okay so I know that they changed their plan to be able to have more more of that They had the laptop but I'm, I'm sure they purchased a larger monitor, so that they have the bigger screen. Due to the variety of her grandchildrens ages, many grandchildren relied on their parents' devices and for their parents to coordinate times to communicate with Marie. they have to use their moms iPhone or, I mean, my grandkids, obviously didnt have, and being younger, the IMPACT OF COVID-19 AND TECHNOLOGY USE ON RELATIONSHIPS 41 younger ones didnt have technology really necessarily on their side. It was an adjustment for them. Coordination was occasionally problematic when parents werent available or when they needed to use their own device. Yeah, it was harder for sure a lot harder because you are using the adults device they need it for something else or it's kind of interfering with something else they've got going on. Coordination also influenced the type of CTs that grandchildren used to interact with their grandparents. Grandchildren sometimes used their parents' laptops and other times used their parents' phones. So when you have the technology piece, there's the making sure they have the technology or they have a laptop, or they have to use their mom's iPhone. Without the grandchildrens parents device and their willingness to let their children use their device, co-occupations between grandchildren and grandparents would not have been possible. Similarities and Differences Between Participants Similarities To protect the health and safety of their grandchildren and families, both participants adhered to the CDC guidelines during the COVID-19 pandemic which prompted participants to use CTs to maintain co-occupations with their grandchildren. Both participants preferred using FaceTime on iPhones as the application allowed for the participants to visually interact with their grandchildren and was a simple CT to use. Participants reported that their grandchildren showed them and played with toys during FaceTime calls. When larger groups of family members were meeting, both participants families utilized the CT application Zoom. Grandchildren of each participant were too young to independently use CTs, so their parents were involved in coordinating communication between the grandparents and grandchildren. IMPACT OF COVID-19 AND TECHNOLOGY USE ON RELATIONSHIPS 42 To maintain in-person contact and adhere to CDC-established physical distancing guidelines (CDC, 2020), participants communicated outside in open spaces with their grandchildren. Domingo talked with his grandchildren through open windows while Marie met with grandchildren in open, outdoor environments. Our participants reported it was emotionally challenging to not be able to hug their grandchildren during isolation periods for the COVID-19 pandemic. Our participants enjoyed engaging in co-occupations through CTs, but they missed being able to hold their grandchildren, and grandchildren missed hugging their grandparents. Both participants stated that their young grandchildren did not understand the need for physical distancing at the beginning of the pandemic nor why family members could not safely be among one another. Our participants experienced a disruption of routines secondary to the ramifications of the COVID-19 pandemic. Differences Domingo explained that telephone calls were his least preferred method of CT use when interacting with his young grandchildren due to their limited attention span and desire to see his face. However, Marie stated that telephone calls worked best for her younger grandchildren as they were able to walk around while talking which gave them something else to do. Participants differed in the length of time that they spent isolated from their grandchildren. For instance, Marie did not see her grandchildren in-person for several months, while Domingo was isolated from his grandchildren for a few weeks. Marie spent more time physically isolated from her grandchildren as compared to Domingo, insisting that the positive effects of using CTs during the COVID-19 pandemic were more important for Marie. Discussion Model of Human Occupation IMPACT OF COVID-19 AND TECHNOLOGY USE ON RELATIONSHIPS 43 We analyzed raw data using the occupation-based model MOHO (Kielhofner & Burke, 1980) to gain a better understanding of how participants used CTs to engage in co-occupations with grandchildren during the COVID-19 pandemic. We encountered challenges when using MOHO to analyze and categorize data because the same raw data matched multiple concepts within the model. We found that some of the raw data could be interpreted as fitting into more than one of the concepts including occupational competence, adaptation, skill, and participation. We identified a second challenge in using MOHO to analyze data: the environment and the COVID-19 pandemic influenced all co-occupations of grandparents with their grandchildren. The participants adapted their co-occupations because they adhered to the CDC guidelines to protect the health of the grandchildren and other family members. As CDC guidelines were modified, grandparents modified their co-occupations, primarily related to context. Although it was a challenge distinguishing concepts, this shows the value of using MOHO as it indicates the importance of grandparents environment and volition. We utilized MOHO to categorize raw data into the categories in the table below. We created themes and appropriately placed the raw data into each category. Table 8 indicates how participants data fit into each MOHO term and Figure 3 includes raw data that correlate with MOHO terms. Family Relationships and Positive Perceptions of CTs In our study, the participants found that CTs allowed them to engage in co-occupations with their grandchildren during times when they could not interact with their families in-person. Due to the strong relationships and established routines between our participants and their grandchildren, Marie and Domingo showed initiative to utilize CTs to maintain co-occupations with their grandchildren (Hunt, 2012; Tsai et al., 2015). Our findings indicated that a positive relationship between grandparents and parents of the grandchildren allowed for more frequent IMPACT OF COVID-19 AND TECHNOLOGY USE ON RELATIONSHIPS 44 and effective participation in co-occupations between grandparents and grandchildren through CTs. This positive relationship indicated that communication was easier to coordinate and increased enjoyment of co-occupations through using CTs. Strouse et al. (2021) also found this to be true in their study of video chat use during the COVID-19 pandemic. Our participants enjoyed using CTs to engage in co-occupations with their grandchildren and believed the interactions were worth overcoming the technological challenges. The reasons for enjoyment were often related to positive and enthusiastic responses and reactions of grandchildren and the ability to mimic family events. Grandparents from Strouse et al.s (2021) study enjoyed video chats for similar reasons. Using CTs also enabled many family events to continue despite not being in-person (Greenwood-Hickman et al., 2022). Marie participated in many family dinners using CTs while Domingo was able to engage in routine playtime by showing toys on the screen. Participants enjoyed using FaceTime and Zoom as it allowed them to see their grandchildrens faces which increased their feelings of closeness and connection, which is similar to Strouse et al. (2021). Although our participants preferred in-person interactions with their grandchildren, grandparents had a positive perspective towards CTs because it allowed them to maintain cooccupations with their grandchildren while adhering to CDC guidelines for distancing and masking during the COVID-19 pandemic. Our findings are similar to pre-COVID-19 pandemic literature which illustrate that CTs are more often used when individuals view them positively and recognize the advantages of using them to communicate (Hunt, 2012; Luijkx et al., 2015; Tsai et al., 2015; Zambianchi et al., 2019). These studies indicated how CTs were positively viewed as an extra form of communication along with in-person interactions. Our study also IMPACT OF COVID-19 AND TECHNOLOGY USE ON RELATIONSHIPS 45 indicates that CTs were not only an additional platform for communication, but replaced inperson communication. Picture-Sharing CTs Similar to the literature, our participants were grateful for introduction of CTs that were new to them, which allowed for innovative ways to participate in co-occupations with their grandchildren and maintain their relationships (Charenkova & Gevorgianiene, 2018; Hunt, 2012; Strom & Strom, 2015; Tsai et al., 2015; Weaver et al., 2022). Our participants believed that using CTs allowed for increased involvement in their grandchildrens lives through picturesharing technology that kept them relevant with family events. Similarly, Strom and Strom (2015) found that personal items, such as pictures, increased feelings of inclusion with families. By utilizing CTs that offered limitless sharing and viewing of pictures and videos, grandparents were able to repeatedly experience events that would have otherwise only been experienced a single time in-person or not at all. This was a preferred characteristic of CTs that our participants identified that was not reported in the literature we found. Shortcomings of Using CTs for Co-Occupations Grandparents in pre-COVID-19 pandemic studies enjoyed using CTs as an alternate method of participating in co-occupations with their family (Charenkova & Gevorgianiene, 2018; Hunt, 2012; Strom & Strom, 2015; Tsai et al., 2015). Similar to studies that occurred during the COVID-19 pandemic, our participants found that CTs helped them preserve interpersonal relationships with their family members and grandchildren (Strouse et al., 2021; Xie et al., 2021). The participants in our study experienced interconnectedness and happiness when using CTs to engage in co-occupations with their grandchildren during the COVID-19 pandemic, which is similar to the results of Hajek and Knig (2020). Both of our participants IMPACT OF COVID-19 AND TECHNOLOGY USE ON RELATIONSHIPS 46 expressed frustration with the shortcomings of strictly using CTs. Certain co-occupations and routines could not be performed together by solely using CTs, which negatively impacted our participants feelings of interconnectedness. Our participants indicated that the lack of in-person co-occupations and physical touch, such as hugging, with their grandchildren was emotionally difficult for the grandparents, which is supported by Kremers et al. (2022), Weaver et al. (2022), and Xie et al. (2021). Even with the shortcomings, engaging in co-occupations through CTs still eased this emotional strain as it allowed for alternative ways for grandparents to engage with their family and grandchildren (Kremers et al., 2022; Xie et al., 2021). In pre-pandemic studies, participation in co-occupations in-person (Mannson, 2013; Moorman & Stokes, 2014) as well as through CTs (Fang et al., 2018) improved grandparents state of psychological well-being. Results from the current study, in addition to results from Hajek and Knig (2020), indicate that psychological improvements also occurred by participating in co-occupations through CTs during the COVID-19 pandemic. Even though our participants were appreciative of CTs during the COVID-19 pandemic, the common complaint was still the lack of physical closeness to grandchildren. Similar to our studys participants, grandparents in COVID-19 pandemic studies longed for physical touch with their grandchildren and family members (Kremers et al., 2022; Xie et al., 2021). Comparable to Kremers et al. (2022), our participants would occasionally meet with family in outside environments but this did not replace human touch. Another challenge to engaging in co-occupations using CTs for our participants was the attention span of grandchildren younger than the age of five. Grandchildren would take the device and run around with it or get distracted and not pay attention to their grandparents. Strouse et al. (2021) also stated this to be true for grandchildren, ages 16 months to 10 years. IMPACT OF COVID-19 AND TECHNOLOGY USE ON RELATIONSHIPS 47 Grandparents and parents of Strouse et al.s (2021) study felt that directing these conversations was emotionally tiresome, while our participants believed that the decreased attention span limited the amount of meaningful connection. Similar to Gitlow (2014), internet connection was another common challenge of using CTs to communicate with family (Gitlow, 2014). Particularly for Marie, she had family members in rural areas who did not have good and reliable internet connection, resulting in ending Zoom and FaceTime calls. Establishing New Routines and Purchasing Equipment In the current study, participants not only maintained routine co-occupations with their grandchildren, such as family dinners and playing with toys, but established new routines through the use of CTs to preserve meaningful co-occupations with their grandchildren. Marie utilizing food delivery systems, such as DoorDash and Uber Eats, to gift treats to her grandchildren supports the 79% increase in use of food delivery systems between 2020 and 2021 (Jia et al., 2022). Marie established a new routine of Sunday night family dinners via Zoom that allowed her family to stay more in contact and Domingo began having extended family reunion chats on Zoom. Other studies such as Gilligan et al. (2020) indicate families making adaptations to gatherings, but the development of different routines by our participants is a new finding that contributes to the literature. Although Tsai et al. (2015) did not study grandparents, the authors found that some older adults believed digital technology was a financial burden which decreased their communication and alienated them on digital platforms. Dissimilar to the Tsai et al. (2015), our participants were not concerned with the cost of purchasing additional equipment because CTs improved interactions with their grandchildren and family members. Due to Marie and Domingos perspective on the importance of interacting with their grandchildren, they made sure to have IMPACT OF COVID-19 AND TECHNOLOGY USE ON RELATIONSHIPS 48 supportive CT supplies necessary for effective engagement in co-occupations with their grandchildren through CTs. Individualized Experiences With Grandchildren Marie and Domingo preferred to use CTs that allowed them to see grandchildrens faces to preserve their co-occupations with their grandchildren during the COVID-19 pandemic through individualized experiences. This is different from other COVID-19 pandemic studies which only included broad results about this relationship (Kremers et al., 2022; Strouse et al., 2021; von Humboldt et al., 2020; Xie et al., 2021). Domingo had the opportunity to observe his grandson's developmental milestones, a finding which matches that of Strouse et al. (2021). In other literature, grandparents reported missing out on these milestones and other family events (Greenwood-Hickman et al., 2022). Marie was able to appreciate her grandchildren's artwork through CTs and form a strong relationship with her grandson while he was living in Ukraine. The findings in the current study contribute to the literature as we found that CTs may also be effective in building and preserving grandparent-grandchildren relationships, internationally. Participants Confidence in Using CTs Older adults who are new users of digital technology may feel discouraged when learning to use new CTs due to the perceived complexity (Hill et al., 2015), a lack of confidence, and inaccessibility of education (Tsai et al., 2015), often leading to feelings of alienation from younger generations that are more technologically proficient. We found that our participants had an initial understanding of using CTs due to their employment requiring them to use technology prior to the pandemic, which reduced the need for the learning process required to effectively use CTs. The participants used a variety of social media platforms to engage in co-occupations with their grandchildren and were able to adjust to the trial-and-error aspects that accompanied IMPACT OF COVID-19 AND TECHNOLOGY USE ON RELATIONSHIPS 49 learning new skills. Each participant became competent with using several new forms of CTs to interact with their grandchildren because they were highly motivated to effectively maintain their role as a grandparent. Marie and Domingo claimed that their confidence in using CTs continued to improve as they explored different forms of CTs. Although our participants were not discouraged by the complexity of CTs and chose to embrace learning, older members of their family, such as great-grandparents, required assistance to use CT due to inexperience with, or disinterest in, newer forms of technology. We are unaware of Marie and Domingos parents' ages, but Gell et al. (2015) and Zambianchi et al. (2019) found that the older their participants were, the less likely they were to use CTs. Hunt (2012) and Luijkx (2015) found that grandparents who possessed and were proficient in utilizing CT equipment were more willing to learn how to use new CTs. Our participants confidence from experience in using CTs also led to increased willingness to learn new forms of CTs; this result has been found in pre-COVID-19 pandemic studies (Hunt, 2012; Tsai et al., 2015). Likewise, Gitlow (2014) found that older adults were already using cell phones and computers for communication. Our findings indicate similarity with the literature because our participants utilized CTs that they were previously competent in using in order to maintain co-occupations with their grandchildren. However, the data from our study indicate a new finding that preadolescent grandchildren relied on their parents' competence with using CTs in order to return engagement in co-occupations with their grandparents through CTs. Limitations Limitations to our study included having participants who were still employed and used CTs on a daily basis for their occupations, which resulted in our participants having a baseline competence with using particular CTs. Due to this, our participants had confidence in their IMPACT OF COVID-19 AND TECHNOLOGY USE ON RELATIONSHIPS 50 ability to use technology and were willing to learn new CTs. Our participants maintained proficiency in their technological skills to reflect their workplace culture. Secondly, both of our participants valued being compliant with the CDC guidelines for the COVID-19 pandemic. Other potential participants may not have had baseline competence with CTs or valued adhering to the CDC guidelines for COVID-19, which could have yielded different results to our study. Our findings could have been different if parents had strained relationships with the grandparents, parents were unable to schedule as much time for co-occupations through CTs, families chose not to get vaccinated causing potential conflict with others, and grandchildren were older and more proficient with CT use. 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Attitudes towards and use of information and communication technologies (ICTs) among older adults in Italy and Sweden: The influence of cultural context, socio-demographic factors, and time perspective. Journal of Cross-Cultural Gerontology, 34, 291306. https://doi.org/10.1007/s10823-019-09370-y IMPACT OF COVID-19 AND TECHNOLOGY USE ON RELATIONSHIPS Table 1 Keywords used when Searching Databases Keywords Technology use Older adult* Geriatric* Grandparent* Grandchild* Relationship Co-Occupation* Communication Occupational Therap* COVID-19 or Coronavirus or 2019-NCOV or Sars-Cov-2 or COV-19 59 IMPACT OF COVID-19 AND TECHNOLOGY USE ON RELATIONSHIPS Table 2 Boolean Operators And Grandparent* AND grandchild* AND relationship Relationship AND connection Grandparent* AND grandchild* AND technology use Grandparent* AND technology AND communication Grandparent AND grandchild* AND cooccupation AND/or Grandparent* or geriatric* or older adult* AND technology AND occupational therap* Covid-19 or coronavirus or 2019-ncov or sars-cov-2 or cov-19 AND grandparent* 60 IMPACT OF COVID-19 AND TECHNOLOGY USE ON RELATIONSHIPS Figure 1 Timeline of Recruitment, Data Collection, and Interview Data During the COVID-19 Pandemic Note. The timeline indicates pertinent data from the participants, when recruitment and data collection was started and discontinued, overlapped with major events during the COVID-19 pandemic. 61 IMPACT OF COVID-19 AND TECHNOLOGY USE ON RELATIONSHIPS 62 Table 3 Participant and Family Demographics Participant Pseudonym Age of Participant (years) Gender of Participant Number of Grandchildren Grandchild Demographics Gender (age in years) Domingo 59 Male 2 Grandson (1); Grandson (3) Distance from Grandchildren Visits Pre-COVID-19 Impact of COVID-19 <10 minutes Several times weekly Not directly or indirectly impacted, family directly and indirectly impacted Marie 60 Female 6 Granddaughter (newborn); Grandson (2); Granddaughter (4); Grandson (5); Granddaughter (7); Grandson (13) 30 minutes-60 minutes Once weekly Directly and indirectly impacted, family directly and indirectly impacted IMPACT OF COVID-19 AND TECHNOLOGY USE ON RELATIONSHIPS Figure 2 Types of CTs used by participants Note. The Venn Diagram indicates the similar and different CTs utilized by the participants to interact with their respective grandchildren during the COVID-19 pandemic. 63 IMPACT OF COVID-19 AND TECHNOLOGY USE ON RELATIONSHIPS Table 4 Domingos Types of CTs Used Types of CT Google Photos Google Duo Instagram FaceTime Zoom Snapchat Messenger Apple Photos Telephone calls Purpose of CT To share photos with family and to view picture/videos of grandchildren To one-on-one video chat with grandchildren when he could not use an iPhone for FaceTime (mostly for his wife who did not have an iPhone) To catch up on daughters posts; did not post on Instagram To communicate with daughter, son-in-law, and grandsons on iPhone as it was most convenient To meet, talk with, and see extended family in addition to grandchildren for interaction with a larger group of family for a flexible time period To share funny moments, good times, interact and communicate, and entertain the grandchildren at anytime To hold family group meetings through Metas Facebook Messenger in order to respond to multiple people to one question To share photos between family members To speak to daughter and son-in-law. Not often used to grandchildren due to their age 64 IMPACT OF COVID-19 AND TECHNOLOGY USE ON RELATIONSHIPS Table 5 Maries Types of CTs Used Types of CT WhatsApp Zoom Instagram FaceTime Messenger Telephone calls (landline and cell phone) Text messaging Purpose of CT To communicate with her grandson who was formerly in the Ukraine To play non-online games such as battleship, singing, and show-and-tell To view posts made by her grandchildren, nieces and nephews, and children as well as to view positivity posts made by celebrities (mostly just nieces and nephews and celebrities) To easily phone her grandkids via their parents iPhone for more casual conversation and to play games such as the following: battleship, singing, and show-and-tell. FaceTime calls were also used so she could show her grandkids her pets, objects, and familiar locations in her house To stay connected with her grandson from the Ukraine, sometimes via video chat To talk on the phone with her younger grandkids due to their decreased attention span To follow up with family members who lived rurally when telecommunication signal failed 65 IMPACT OF COVID-19 AND TECHNOLOGY USE ON RELATIONSHIPS 66 IMPACT OF COVID-19 AND TECHNOLOGY USE ON RELATIONSHIPS 67 Table 6 Themes and Subthemes for Domingo Grandparents and Grandchildren Made CTs a Part of Their Routine Domingo and his family used CTs as a last resort when inperson socialization was not feasible. Family made adaptations to maintain relationships and consistent communication with grandchildren by using a variety of CTs. Grandparents transferred previous knowledge and skills to unfamiliar CTs to communication with their grandchildren. Grandparents predicted that they will use CTs after the COVID-19 pandemic due to convenience. Grandparents and Their Families Adhered to CDC Guidelines for COVID-19 Grandparents and Grandchildren Selected CT Based on Ages, Interests, and Preferences of Each Family Member Grandparents and grandchildren adhered to the CDC guidelines and precautions for COVID-19 by adapting in-person interactions. Grandparents and their families had a strong desire to meet in-person, but also to stay safe. Grandparents and grandchildren used CTs that involved photos (Snapchat, Google photo share, Instagram) for connection and limitless viewing of pictures and videos. Grandparents and their families created pods to adhere to the CDC guidelines for COVID-19, limit exposure, and decrease reliance on technology for interactions. Grandparents respected space and privacy boundaries of parents by using CTs to interact with grandchildren. Grandparents experienced enjoyment from Snapchat and other CTs that allowed sharing photos as it enabled grandparents to see developmental milestones, share funny moments, and substitute for times when family members were not together. Grandparents and their families preferred Zoom for interactions with extended family and larger groups as it allowed a more flexible time frame, otherwise not possible due to geographical distance. IMPACT OF COVID-19 AND TECHNOLOGY USE ON RELATIONSHIPS 68 Table 6 Themes and Subthemes for Domingo Grandparents and Grandchildren Made CTs a Part of Their Routine Grandparents and Their Families Adhered to CDC Guidelines for COVID-19 Grandparents and Grandchildren Selected CT Based on Ages, Interests, and Preferences of Each Family Member Grandparents and their families believed that FaceTime on an iPhone was a convenient interaction. Grandsons age and inexperience with CTs created the most common technology difficulties. Grandparents prioritized their grandchildrens happiness and interests when making decisions about CT use. IMPACT OF COVID-19 AND TECHNOLOGY USE ON RELATIONSHIPS 69 Table 7 Themes and Subthemes for Marie Grandparents and Their Families Adhered to CDC Guidelines for COVID-19 to Remain Safe During the Pandemic Marie and her family adapted their communication methods by increasing their use of CTs due to their desire to adhere to CDC guidelines for COVID-19. Marie and her family adapted their communication methods by increasing their use of CTs due to their desire to adhere to CDC guidelines for COVID-19. Marie and her family utilized outside gatherings, 14-day long isolation periods in pods, and COVID-19 vaccinations to adhere to COVID-19 CDC guidelines. Grandparents and Grandparents and Grandchildren used Different Family Members Methods of Communication Competency With and to Engage in Co-Occupations, Access to CTs Affected Including Technological and Co-Occupations with Non-Technological Forms Grandchildren The recipients' ages and Grandparents technology skills competency determined which with technology forms of CTs were helped in used. learning to use more types of CTs. Grandparents used Younger grandchildren technology to maintain had more connection with their difficulty using grandchildren who lived far the away and with closer technology, had grandchildren they usually to rely on saw in-person. parents to use technology, and had difficulty understanding why they could not be together with grandparents. Grandparents and Grandparents grandchildren competency preferred FaceTime with technology on iPhones because it allowed them to allowed them to see use CTs that each other's faces. grandchildren enjoyed. IMPACT OF COVID-19 AND TECHNOLOGY USE ON RELATIONSHIPS 70 Table 7 Themes and Subthemes for Marie Grandparents and Their Families Adhered to CDC Guidelines for COVID-19 to Remain Safe During the Pandemic Marie's family used communication technology to stay connected when COVID-19 prevented in-person communication. Grandparents and Grandchildren used Different Methods of Communication to Engage in Co-Occupations, Including Technological and Non-Technological Forms Families preferred Zoom for communicating with people from multiple households at once. To stay connected with family and Grandparents benefitted from grandchildren during the efficient and COVID-19 pandemic, Marie convenient and her family established communication with new routines. their grandchildren by using an iPhone. Marie and her family found the physical distancing was particularly difficult due to being a family of "huggers." Grandparents with parents were involved in maintaining relationships between great-grandparents and greatgrandchildren. Grandparents and Family Members Competency With and Access to CTs Affected CoOccupations with Grandchildren Family members utilized new types of CTs that they had access to such as food delivery services (DoorDash, UberEats, etc.) to continue communication. Grandparents experienced technological challenges during communication with family members living in rural areas. Grandparents and family members purchased new equipment to increase the quality of communication with grandchildren IMPACT OF COVID-19 AND TECHNOLOGY USE ON RELATIONSHIPS 71 Table 7 Themes and Subthemes for Marie Grandparents and Family Members Competency With and Access to CTs Affected Co-Occupations with Grandchildren Grandparents and Their Families Adhered to CDC Guidelines for COVID-19 to Remain Safe During the Pandemic Grandparents and Grandchildren used Different Methods of Communication to Engage in Co-Occupations, Including Technological and Non-Technological Forms Marie experienced interruptions in her relationships with her grandchildren by not fulfilling meaningful routines due to the COVID19 pandemic. Grandparents preserved some Family members non-technology learned to aspects of coordinate use relationships with of CTs for grandchildren by communication. sharing pictures and letters, and cupcakes/pizza via postal service. Former methods of relationships with grandchildren emerged such as letter or note writing shared using the postal service. Grandparents also mailed gifts/cards and had gifts delivered during the COVID-19 pandemic as an extra way to bring joy (pretechnology method of sharing). Family utilized technology to maintain more than just communication as it allowed for playing games, having dinners, showing artwork and toys, and singing songs to be done together. As the CDC altered COVID-19 pandemic guidelines, Marie and her family modified communication practices, including more in-person interaction; however, Marie and her family have not been able to return to preCOVID-19 pandemic routines. IMPACT OF COVID-19 AND TECHNOLOGY USE ON RELATIONSHIPS 72 Table 7 Themes and Subthemes for Marie Grandparents and Their Families Adhered to CDC Guidelines for COVID-19 to Remain Safe During the Pandemic Grandparents and Grandchildren used Different Methods of Communication to Engage in Co-Occupations, Including Technological and Non-Technological Forms Marie and her family were unable to maintain in-person routines with one another due to CDC guidelines for the COVID-19 pandemic limiting socialization. Marie's family utilized CTs to maintain connection with their adopted grandson from the Ukraine during the COVID-19 pandemic. Family members used different types of CT to continue their routines and replicate the feelings of being together. Grandparents and grandchildren had new conversations as the CDC guidelines changed their routines. Marie established new routines with CTs to maintain interpersonal connection with her grandchildren and family members during the COVID-19 pandemic. Marie and her family were unable to maintain in-person routines with one another due to CDC guidelines for the COVID-19 pandemic limiting socialization. Marie and her family adapted their The recipients' ages and communication methods by technology skills increasing their use of CTs determined which due to their desire to adhere forms of CTs were to CDC guidelines for used. COVID-19. Grandparents and Family Members Competency With and Access to CTs Affected Co-Occupations with Grandchildren Grandparents competency with technology helped in learning to use more types of CTs. IMPACT OF COVID-19 AND TECHNOLOGY USE ON RELATIONSHIPS 73 Table 7 Themes and Subthemes for Marie Grandparents and Their Families Adhered to CDC Guidelines for COVID-19 to Remain Safe During the Pandemic Grandparents and Grandchildren used Different Methods of Communication to Engage in Co-Occupations, Including Technological and Non-Technological Forms Grandparents and Family Members Competency With and Access to CTs Affected Co-Occupations with Grandchildren Marie and her family adapted their communication methods by increasing their use of CTs due to their desire to adhere to CDC guidelines for COVID-19. Grandparents used technology to maintain connection with their grandchildren who lived far away and with closer grandchildren they usually saw in-person. Younger grandchildren had more difficulty using the technology, had to rely on parents to use technology, and had difficulty understanding why they could not be together with grandparents. Grandparents competency with technology allowed them to use CTs that grandchildren enjoyed. Marie and her family utilized outside gatherings, 14-day long isolation periods in pods, and COVID-19 vaccinations to adhere to COVID-19 CDC guidelines. Grandparents and grandchildren preferred FaceTime on iPhones because it allowed them to see each other's faces. Marie's family used communication technology to stay connected when COVID-19 prevented in-person communication. Families preferred Zoom for communicating with people from multiple households at once. Family members utilized new types of CTs that they had access to such as food delivery services (DoorDash, UberEats, etc.) to continue communication. IMPACT OF COVID-19 AND TECHNOLOGY USE ON RELATIONSHIPS 74 Table 7 Themes and Subthemes for Marie Grandparents and Grandchildren used Different Methods of Communication to Engage in Co-Occupations, Including Technological and Non-Technological Forms Grandparents and Family Members Competency With and Access to CTs Affected Co-Occupations with Grandchildren To stay connected with family and Grandparents benefitted from grandchildren during the efficient and COVID-19 pandemic, Marie convenient and her family established communication with new routines. their grandchildren by using an iPhone. Grandparents experienced technological challenges during communication with family members living in rural areas. Grandparents and family members purchased new equipment to increase the quality of communication with grandchildren. Grandparents and Their Families Adhered to CDC Guidelines for COVID-19 to Remain Safe During the Pandemic Marie and her family found the physical distancing was particularly difficult due to being a family of "huggers." Grandparents with parents were involved in maintaining relationships between great-grandparents and greatgrandchildren. IMPACT OF COVID-19 AND TECHNOLOGY USE ON RELATIONSHIPS 75 Table 7 Themes and Subthemes for Marie Grandparents and Family Members Competency With and Access to CTs Affected Co-Occupations with Grandchildren Grandparents and Their Families Adhered to CDC Guidelines for COVID-19 to Remain Safe During the Pandemic Grandparents and Grandchildren used Different Methods of Communication to Engage in Co-Occupations, Including Technological and Non-Technological Forms Marie experienced interruptions in her relationships with her grandchildren by not fulfilling meaningful routines due to the COVID19 pandemic. Grandparents preserved some Family members non-technology learned to aspects of coordinate use relationships with of CTs for grandchildren by communication. sharing pictures and letters, and cupcakes/pizza via postal service. Former methods of relationships with grandchildren emerged such as letter or note writing shared using the postal service. Grandparents also mailed gifts/cards and had gifts delivered during the COVID-19 pandemic as an extra way to bring joy (pretechnology method of sharing). Family utilized technology to maintain more than just communication as it allowed for playing games, having dinners, showing artwork and toys, and singing songs to be done together. As the CDC altered COVID-19 pandemic guidelines, Marie and her family modified communication practices, including more in-person interaction; however, Marie and her family have not been able to return to preCOVID-19 pandemic routines. IMPACT OF COVID-19 AND TECHNOLOGY USE ON RELATIONSHIPS 76 Table 7 Themes and Subthemes for Marie Grandparents and Their Families Adhered to CDC Guidelines for COVID-19 to Remain Safe During the Pandemic Grandparents and Grandchildren used Different Methods of Communication to Engage in Co-Occupations, Including Technological and Non-Technological Forms Marie and her family were unable to maintain in-person routines with one another due to CDC guidelines for the COVID-19 pandemic limiting socialization. Marie's family utilized CTs to maintain connection with their adopted grandson from the Ukraine during the COVID-19 pandemic. Family members used different types of CT to continue their routines and replicate the feelings of being together. Grandparents and grandchildren had new conversations as the CDC guidelines changed their routines. Marie established new routines with CTs to maintain interpersonal connection with her grandchildren and family members during the COVID-19 pandemic. Marie and her family were unable to maintain in-person routines with one another due to CDC guidelines for the COVID-19 pandemic limiting socialization. Grandparents and Family Members Competency With and Access to CTs Affected Co-Occupations with Grandchildren IMPACT OF COVID-19 AND TECHNOLOGY USE ON RELATIONSHIPS Table 8 MOHO Terms Used to Categorize Raw Data MOHO Terms Volition Habituation Performance Capacity Context Occupational Identity Competence Adaptation Skill Participation Raw Data Participants abided by CDC guidelines for COVID-19 to safely see their grandchildren, preserve quality family time, and use CTs. Participants altered family routines, roles, and obligations due to the ramifications of the COVID-19 pandemic. Participants and their grandchildren developed skills and capabilities of using CTs to preserve engagement in co-occupations. Participants environment constantly changed. Participants maintained their role as grandparents and grandchildren through the use of CTs. Participants successfully engaged in co-occupations through CTs. Participants modified their communication methods, often by utilizing CTs, preserve co-occupations with their grandchildren. Participants developed new capabilities when CTs were used to maintain co-occupations. Participants engaged in pre-pandemic co-occupations through use of CTs. 77 Figure 3 MOHO in Relation to Co-Occupations Note. This figure indicates how participants raw data aligned with distinct MOHO terminology.  ...

... Improving Quality of Life in an Assisted Living Facility: A Life Review Program Kelsey Yerem, OTS August 2021 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 faculty capstone advisor: Dr. Kate DeCleene Huber, Associate Professor IMPROVING QUALITY OF LIFE IN AN ALF 2 A Capstone Project Entitled Improving Quality of Life in an Assisted Living Facility: A Life Review Program Submitted to the School of Occupational Therapy at the University of Indianapolis in partial fulfillment for the requirements of the Doctor of Occupational Therapy degree. By Kelsey Yerem, OTS Approved by: Kate DeCleene Huber________________ Faculty Capstone Advisor (1st Reader) 2nd Reader____________________ Date____________________ Date____________________ Accepted on this date by the Doctor of Occupational Therapy Program Director: OTD Program Director: ____________________ Date: ____________________ Accepted on this date by the Chair of the School of Occupational Therapy: Chair, School of Occupational Therapy: ____________________Date: _________________ IMPROVING QUALITY OF LIFE IN AN ALF 3 Abstract The purpose of the present study was to analyze the effectiveness of a six-week life review program on the QOL of residents living in an assisted living facility. The study consisted of three males and four females. The participants ages ranged from 81-96. The outcome measure used for this study was the WHOQOL-BREF as a pre and post-test. The post-test scores indicated the most significant change from the life review program was the domain focused on social relationships. The domain focused on psychological QOL also increased after completing the life review program. Results of the present study provide supporting evidence that a life review program can assist in improving the QOL of older adults living in a long-term care facility. The outcome measure results indicate that a life review program can improve QOL in the areas of psychological health and social relationships. Results imply that occupational therapy plays a role in program development and creates meaningful social and leisure activities for residents living in a long-term care facility. Keywords: occupational therapy, life review program, older adults, program development, assisted living facility, quality of life, gerontology IMPROVING QUALITY OF LIFE IN AN ALF 4 Improving Quality of Life in an Assisted Living Facility: A Life Review Program The following literature review includes prior research on older adults living in skilled nursing facilities and assisted living facilities and how this affects their quality of life and mental health. Additionally, the literature review contains previous research about the benefits of a life review program in facilities such as these. Research indicates that residents of long-term care facilities, including assisted living facilities, often face loneliness and depression (Theurer et al., 2015). Despite participating in the activities provided at their residence, individuals report frustration and lack of meaning at their homes within the assisted living facilities (Theurer et al., 2015). Although entertaining, the activities offered at long-term care facilities fail to facilitate meaningful relationships or foster personal growth (McCann, 2013). Theurer et al. (2015) propose that long-term care facilities should shift their focus from solely entertaining activities to fulfilling and identity-provoking activities to enhance residents' quality of life. Individuals living in long-term care typically experience a poorer quality of life compared to older adults living independently. (Wren, 2016). The World Health Organization (2014) defines quality of life is an individual's perception of their position in life in the context of the culture and value systems in which they live and in relation to their goals, expectations, standards, and concerns. To increase quality of life, individuals living in assisted living facilities need to engage more often in meaningful occupations, including social participation and leisure activities, facilitated by a life review program with the help of occupational therapists intervention. According to Spetz (2015), by 2030, Americans aged sixty-five and older will make up twenty percent of the overall population. By the year 2050, the number of individuals IMPROVING QUALITY OF LIFE IN AN ALF 5 requiring long-term care will increase by more than double. Because of the growing older adult population, it is imperative to address these weaknesses now. Literature Review Impact of Decreased Quality of Life As the aging population continues to grow and life expectancy increases, researchers explore the importance of a positive quality of life in the older population, an often overlooked topic (Jahanbin et al., 2018). Residents living in long-term care facilities are often inactive because of their health status or absence of opportunity to engage in meaningful occupations (Ouden et al., 2015). If an individual is not interested in activities offered by the facility, they would rather watch television, which does not contribute positively to quality of life (Ouden et al., 2015). Not only were the residents inactive physically, but residents were socially engaged only 4-10% of the time. This inactivity can lead to decreased independence in ADL performance and a lower quality of life (Ouden et al., 2015). The study results indicate that nursing home staff needs to facilitate engagement in meaningful occupations and promote social participation (Ouden et al., 2015). Occupational engagement and quality of life are directly correlated. When residents are inactive, occupational deprivation becomes more common (Du Toit et al., 2019). Without this engagement, individuals are likely to demonstrate a lower perceived quality of life, which can also lead to negative self-perception. (Occupational Therapy Australia, 2016). Without meaningful occupations to engage in, residents are at risk for role loss and loss of identity (Du Toit et al., 2019). Research shows that some residents complete activities offered at assisted living facilities to occupy their time but do not always find the activities meaningful (Crenshaw et al., 2001). IMPROVING QUALITY OF LIFE IN AN ALF 6 Research shows that a push towards group participation in long-term care is beneficial. Viewing the residents, staff, and caregivers as a community promotes a sense of belonging, greater well-being, and improved quality of life (Du Toit et al., 2019). Greater quality of life and overall well-being can be achieved through meaningful occupations rather than the inactivity often seen at long-term care facilities (Du Toit et al., 2019). Park (2009) discussed the importance of social engagement of older adults living in assisted living facilities. Research demonstrated the importance of meaningful social and emotional relationships because the connections positively influenced overall health, including psychological well-being (Park, 2009). Park (2009) discovered that meaningful relationships with the assisted living facilities' staff were an essential factor for improved life satisfaction and quality of life for the residents. Regarding occupational deprivation, research shows that a significant category of occupational performance that is often neglected in skilled nursing and assisted living facilities is leisure participation (Causey-Upton, 2015). Participation in leisure activities is associated with greater health and enhancement of the quality of life of older adults (Causey-Upton, 2015). Leisure participation is also associated with the development of new life roles, a heightened sense of self, and the development of new relationships (Dube & Choyal, 2012). Older adults deprived of resources to complete leisure activities are more likely to have a lower quality of life. However, occupational therapists working with older adults have a distinct role in ensuring residents have the necessary tools to complete desired occupations. Residents must be able to participate in meaningful occupations such as leisure to facilitate health and well-being (CauseyUpton, 2015). Although the residents may have access to some leisure activities, not everyone prefers the typical bingo or crafts offered (Causey-Upton, 2015). Older adults must experience IMPROVING QUALITY OF LIFE IN AN ALF 7 autonomy and freedom of choice when it comes to leisure participation, directly correlated to perceived quality of life. (Duncan-Myers & Huebner, 2000). Life review and quality of life. Based on the evidence, assisted living facilities need programs designed to enhance the overall quality of life of those living in nursing homes and assisted living facilities. Limited research exists on life review programs in assisted living facilities as most research focuses on skilled nursing facilities. One program that improves the perceived quality of life in these facilities is a life review program. A life review program provides structured discussions and activities focused on stages of life starting from childhood into older adulthood (Rubin et al., 2019). A life review program allows the older adult to reexamine important events, role transitions, and coping strategies used in adjusting to lifes changes (Scaffa, Reitz, & Pizzi, 2010, pp. 460-461). Using life review as an intervention can positively influence life satisfaction and overall quality of life by improving social participation, ADL performance, and outlook on life living in a long-term care facility (Wren, 2016). Evidence also suggests that life review programs improve feelings of depression, self-esteem, and overall well-being (Preschl et al., 2012). Life review is a noteworthy intervention used in assisted living facilities to help older adults maintain or improve their sense of self and lifes roles. Occupational therapy practitioners have the distinct role of observing and facilitating personal and environmental growth to promote quality of life in assisted living facilities through the use of a life review program. Conclusion An abundance of research supports occupational therapys role in long-term care. Early findings from the literature suggest that residents in traditional long-term care facilities often feel bored and inactive (Wong, 2018). Wong (2018) found that engagement in meaningful IMPROVING QUALITY OF LIFE IN AN ALF 8 occupations is vital for residents; however, there were several barriers to this engagement, including staff time limitations. The researcher found that incorporating activities in small fragments, getting to know the residents personally, and involving family members are strategies that could increase engagement in meaningful activities (Wong, 2018). Based on prior research, it is evident that skilled nursing and assisted living facilities should implement life review programs to promote an increase in the quality of life of their residents. A life review program is beneficial for facilitating independence in occupations, facilitating new life roles, and decreasing feelings of depression (Preschl et al., 2012). A life review program encourages engagement in leisure and social participation, promoting a greater quality of life. Not only does a life review program facilitate a greater quality of life, but it can also decrease occupational deprivation that residents often face (Du Toit et al., 2019). Model and theory. The model used to guide the doctoral capstone experience (DCE) is the KAWA model. Obstacles in the river flow of life show dysfunction within this model. (Lim & Iwama, 2011). Some impediments that residents in the skilled nursing facility or assisted living facility experience may include their health status, lack of family support, or overall decreased quality of life. In addition to disruptions to the river flow of life, there are also aides that can enhance ones life, known as driftwood within the KAWA model (Lim & Iwama, 2011). It is imperative to take all of these factors into consideration and understand that each individuals river flow of life is unique. Thus, the interventions should be tailored to the individual. Lasletts Third Age Theory is used to guide the DCE. The Third Age Theory assumes that an individual goes through four ages of life. The first age of life is categorized as childhood and is characterized by dependency and education. The theory assumes that childhood IMPROVING QUALITY OF LIFE IN AN ALF 9 is preparation for the working world (Cole & Tufano, 2008). The second age in this theory is labeled as employment and raising a family. This age assumes independence and maturity. The third age spans from retirement until the onset of disability. The third age is characterized by self-fulfillment (Cole & Tufano, 2008). Finally, the fourth age begins with the onset of the disability and coming to terms with the end of life (Cole & Tufano, 2008). According to Lasletts theory, people in the fourth age focus on the present but do not necessarily reflect on their past. The DCE will focus on individuals in the third and fourth ages; however, they will be asked to reflect on their lives in their first and second ages through a series of activities and discussions. Methods Needs Assessment A survey was distributed to staff at the assisted living facility who have directly cared for and interacted with residents. The survey consisted of multiple-choice, open-ended, and Likert scale questions. At the beginning of the survey, the researcher provided background information about life review programs and how they can benefit the assisted living facility residents. Examples of survey questions are included in Appendix A. Six total people responded to the survey. The survey results show that there are staff limitations impacting quality of life at the assisted living facility. Additionally, the impact of covid-19 has affected the activities offered and has increased social isolation, which is correlated to poorer quality of life. Using the information obtained from past research, the researcher completed a face-toface semi-structured interview with 14 current residents regarding activities offered at the assisted living facility. The majority of the participants did not participate in the activities offered at the facility and felt that what was offered did not cater to their interests. Additionally, residents felt that their health status impacted their ability to participate in activities they wanted to IMPROVING QUALITY OF LIFE IN AN ALF 10 perform. None of the participants reported knowledge of what a life review program is or how it could be beneficial. Through skilled observation, the researcher noted minimal participation in the activities offered at the facility, with almost no males participating in the programs. Results of the needs assessments demonstrated a gap in efficiency and frequency of activities offered at the site; therefore, there was a need for a new program to be implemented at the site. Program development was key to provide more relevant activities for the residents at the facility. Participants Participants were recruited at an assisted living facility in central Indiana using convenience sampling. Flyers were distributed to residents of the facility, which resulted in seven total participants. The study consisted of three males and four females. The participants ages ranged from 81-96. Inclusion criteria for the study required participants to live at the assisted living facility and have no severe memory deficits. Exclusion criteria of this study included individuals with severe memory deficits, aphasia, or severe physical limitations, that could have impacted ones ability to participate in the program. Participants with mild physical limitations were assisted by a session leader as needed. Materials Quality of Life. The outcome measure used for this study was the WHOQOL-BREF. This self-report tool measures quality of life through four domains: physical health, psychological health, social relationships, and environment. The questionnaire consists of 26 Likert-scale prompts focused on quality of life and wellbeing, as seen in Appendix B (WHO Quality of Life-BREF (WHOQOL-BREF, 2013)). The WHOQOL-BREF was designed to measure changes in quality of life through a skilled intervention (WHO Quality of Life-BREF IMPROVING QUALITY OF LIFE IN AN ALF 11 (WHOQOL-BREF, 2013)). In older adults, the WHOQOL-BREF has shown excellent reliability and consistency (Hwang et al., 2003). Additionally, the measure has been determined to have excellent construct validity in community-dwelling older adults (Huang et al., 2009). Satisfaction Survey. At the end of the program, the researcher distributed a brief multiple-choice survey to measure the participants overall satisfaction with the program (Appendix C). Procedure Potential participants were invited to participate in the program through convenience sampling by a distribution of flyers and a 1:1 discussion about the life review program. The researcher limited the number of participants due to the COVID-19 pandemic to ensure the safety of the residents. The flyer consisted of a brief overview of the program, including why it would be beneficial as well as the length of the program. The flyer also included information about the leader of the life review program. The next week, the researcher followed up with the potential participants for their final confirmation of wanting to participate in the program. When the participants confirmed their willingness to participate, the researcher gathered demographic information and personal interests and hobbies from the individuals to assist in the creation of a personalized life review program. Weekly sessions of the program occurred at the assisted living facility in a convenient space. Participants and session leader were required to follow covid-19 guidelines set by the facility. At each session, attendance was taken by the researcher to track participation in the life review program. During the first and last weeks of the program, the researcher administered the WHOQOL-BREF with the participants as a pre and post-test to measure quantitative change throughout the program. The results of the outcome measure were scored and tracked by the researcher. IMPROVING QUALITY OF LIFE IN AN ALF 12 Results Using descriptive statistics, the mean (M) results of the WHOQOL-BREF were calculated using Microsoft Excel to analyze any changes in the scores before and after completing the program (See Figure 1). The pretest scores indicated that the lowest average quality of life domain was social relationships (M= 61.89). On the contrary, the highest average quality of life domain was the domain focused on physical aspects of quality of life (M= 86.22). The post-test scores indicated the most significant change from the life review program was the domain focused on social relationships with M=73.48. The domain focused on psychological quality of life also increased from M=75.93 to M=80.25. Attendance of each session was also tracked by the researcher, as displayed in Table 1. Table 1 also presents the topic and title of each session of the program. The satisfaction survey results indicated that all 7 participants enjoyed participating in the program and stated that if given the opportunity, they would participate in the program again. All of the participants felt that the program's environment was sufficient to meet their needs and recommended that the facility continue to implement this program. When asked if they felt that they learned how a life review program can benefit them, only 1 out of 7 participants marked, no. Figure 1 IMPROVING QUALITY OF LIFE IN AN ALF 13 Mean Scores WHOQOL-BREF Results 100 90 80 70 60 50 40 30 20 10 0 86.22 83.16 88.4 75.93 80.25 61.89 Domain 1: Physical Domain 2: Psychological Pretest 87.95 73.48 Domain 3: Domain 4: Social Environment Relationships Posttest Table 1: Session Topics and Attendance Weekly Session Topic & Title 1. Early Childhood: Cherished Childhood 2. Adolescence: Advice for Your Adolescence 3. Young Adulthood: Starting Your Life 4. Middle Adulthood: Managing Middle Adulthood 5. Older Adulthood: Reliving & Remembering 6. Wrap-Up: Circle of Life Attendance of Weekly Session 5/7 7/7 7/7 6/7 7/7 7/7 Discussion The results of the present study provide supporting evidence that a life review program can assist in improving the quality of life of older adults living in a long-term care facility. The results of the WHOQOL-BREF indicate that a life review program, more specifically, can improve QOL in the areas of psychological health and social relationships. On the other hand, IMPROVING QUALITY OF LIFE IN AN ALF 14 the program results show that some areas of QOL did not improve, including physical and environment. The results of the current study are consistent with previous literature. Research has shown that individuals living in an ALF value social relationships and find great meaning in consistent social interaction, especially in those with physical impairments (Jang et al., 2013). Findings suggest that long-term care facilities should promote meaningful social engagement for their residents (Jang et al., 2013). Similarly, previous research has shown that life review activities can have an impact on psychological well-being. An established sense of self and a feeling of belonging is associated with greater quality of life of residents living in ALF (Mansfield & Burton, 2020). The results of past research are comparable to the findings of the present study. Life review can positively affect feelings of depression and hopelessness (Hanaoka & Okamura, 2004). The satisfaction survey results demonstrate that individuals enjoy participating in a life review program and the majority of the participants felt that they benefitted from completing the program. Congruent with previous literature, older adults found that remembering their past was meaningful to them as someone was there to listen to their story (Binder et al., 2009). Research has also indicated that forming meaningful relationships with staff can contribute to psychological health and well-being (Park, 2009). Limitations One limitation of this study was the impact of the COVID-19 pandemic. Some of the activities of the program had to be altered due ever-changing to state and federal guidelines. Another limitation of this study was inconsistent attendance from the participants. Although the majority of the participants attended each session, participants who did not participate in every session may have had lower scores than those who consistently participated. Finally, due to the lack of a control group, other factors may have contributed to an increase or decrease in IMPROVING QUALITY OF LIFE IN AN ALF 15 participants scores, impacting the validity of this research. Despite these limitations, it is apparent that a life review program is effective and meaningful to residents living in long-term care facilities. Implications for OT The results of the assessments indicate that occupational therapy has a role in program development and in creating meaningful social and leisure activities for residents living in a long-term care facility. Occupational therapists have a unique role in finding and creating meaning for individuals to improve quality of life and facilitate lifes roles. Future studies should address further areas of QOL with program development, including physical and environmental health. Researchers should also continue to assess the effectiveness of life review in assisted living facilities. IMPROVING QUALITY OF LIFE IN AN ALF 16 References Binder, B. K., Mastel-Smith, B., Hersch, G., Symes, L., Malecha, A., & McFarlane, J. (2009). Community-Dwelling, Older Women's Perspectives on Therapeutic Life Review: A Qualitative Analysis. Issues in Mental Health Nursing, 30(5), 288294. https://doi.org/10.1080/01612840902753885 Causey-Upton, R. (2015). 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E., & Hamers, J. P. (2015). Daily (in)activities of nursing home residents in their wards: An observation study. Journal of the American Medical Directors Association, 16(11), 963 968. https://doi.org/10.1016/j.jamda.2015.05.016 Park, N. S. (2009). The relationship of social engagement to psychological well-being of older adults in assisted living facilities. Journal of Applied Gerontology, 28(4), 461481. https://doi.org/ 10.1177/0733464808328606 Preschl, B., Maercker, A., Wagner, B., Forstmeier, S., Baos, R., Alcaiz, M., . . . Botella, C. (2012). Life-review therapy with computer supplements for depression in the elderly: A randomized controlled trial. Aging & Mental Health, 16(8), 964-74. https://doi.org/10.1080/13607863.2012.702726 Rubin, A., Parrish, D. E., & Miyawaki, C. E. (2019). Benchmarks for evaluating life review and reminiscence therapy in alleviating depression among older adults. Social Work, 64(1), 6172. https://doi.org/10.1093/sw/swy054 Scaffa, M. E., Reitz, S. M., & Pizzi, M. (2010). Occupational therapy in the promotion of health and wellness. Philadelphia: F.A. Davis Co. Sharif, F., Jahanbin, I., Amirsadat, A., & Hosseini, M. (2018). Effectiveness of life review therapy on quality of life in the late life at day care centers of Shiraz, Iran: A randomized controlled trial. International Journal of Community Based Nursing and Midwifery, 6(2), 136-145 Spetz, J., Trupin, L., Bates, T., & Coffman, J. M. (2015). Future demand for long-term care workers will be influenced by demographic and utilization changes. Health Affairs (Project Hope), 34(6), 93645. https://doi.org/10.1377/hlthaff.2015.0005 IMPROVING QUALITY OF LIFE IN AN ALF 19 Theurer, K., Mortenson, W. B., Stone, R., Suto, M., Timonen, V., & Rozanova, J. (2015). The need for a social revolution in residential care. Journal of Aging Studies, 35, 201210. https://doi.org/10.1016/j.jaging.2015.08.011 WHO Quality of Life-BREF (WHOQOL-BREF). (2013). Retrieved from https://www.who.int/substance_abuse/research_tools/whoqolbref/en/ Wong, C. (2018). Meaningful engagement in a greenhouse nursing home. American Journal of Occupational Therapy,72(4). https://doi.org10.5014/ajot.2018.72s1-po4040 World Health Organization. (2014). WHOQOL: Measuring quality of life. Retrieved from https://www.who.int/healthinfo/survey/whoqol-qualityoflife/en/ Wren, R. (2016). Effect of life review on quality of life for older adults living in nursing homes. Physical & Occupational Therapy in Geriatrics, 34(4), 186204. https://doi.org/ 10.1080/02703181.2016.1268236 IMPROVING QUALITY OF LIFE IN AN ALF 20 APPENDIX A Needs Assessment with ALF Staff 1. What is your role at the facility? 2. What is your perception of the quality of life (QOL) of the current assisted living facility (ALF) residents? 3. What are the strengths of the ALF? 4. What are the weaknesses of the ALF? 5. How do you think QOL could be improved for ALF residents? 6. Do you think a life review program will benefit the ALF residents? IMPROVING QUALITY OF LIFE IN AN ALF Instructions 21 APPENDIX B WHOQOL-BREF This assessment asks how you feel about your quality of life, health, or other areas of your life. Please answer all the questions. If you are unsure about which response to give to a question, please choose the one that appears most appropriate. This can often be your first response. Please read each question, assess your feelings, and circle the number on the scale for each question that gives the best answer for you. 1. How would you rate your quality of life? Very poor: 1 Poor: 2 Neither poor nor good: 3 Good: 4 Very good: 5 2. How satisfied are you with your health? Very dissatisfied: 1 Dissatisfied: 2 Neither satisfied nor dissatisfied: 3 Satisfied: 4 Very satisfied: 5 The following questions ask about how much you have experienced certain things in the last four weeks. 3. To what extent do you feel that physical pain prevents you from doing what you need to do? Not at all: 1 A little: 2 A moderate amount: 3 Very much: 4 An extreme amount: 5 4. How much do you need any medical treatment to function in your daily life? Not at all: 1 A little: 2 A moderate amount: 3 Very much: 4 An extreme amount: 5 5. How much do you enjoy life? IMPROVING QUALITY OF LIFE IN AN ALF Not at all: 1 A little: 2 A moderate amount: 3 Very much: 4 An extreme amount: 5 6. To what extent do you feel your life to be meaningful? Not at all: 1 A little: 2 A moderate amount: 3 Very much: 4 An extreme amount: 5 7. How well are you able to concentrate? Not at all: 1 A little: 2 A moderate amount: 3 Very much: 4 Extremely: 5 8. How safe do you feel in your daily life? Not at all: 1 A little: 2 A moderate amount: 3 Very much: 4 Extremely: 5 9. How healthy is your physical environment? Not at all: 1 A little: 2 A moderate amount: 3 Very much: 4 Extremely: 5 The following questions ask about how completely you experience or were able to do certain things in the last two weeks. 10. Do you have enough energy for everyday life? Not at all: 1 A little: 2 Moderately: 3 Mostly: 4 Completely: 5 11. Are you able to accept your bodily appearance? Not at all: 1 22 IMPROVING QUALITY OF LIFE IN AN ALF A little: 2 Moderately: 3 Mostly: 4 Completely: 5 12. Have you enough money to meet your needs? Not at all: 1 A little: 2 Moderately: 3 Mostly: 4 Completely: 5 13. How available to you is the information that you need in your day-to-day life? Not at all: 1 A little: 2 Moderately: 3 Mostly: 4 Completely: 5 14. To what extent do you have the opportunity for leisure activities? Not at all: 1 A little: 2 Moderately: 3 Mostly: 4 Completely: 5 15. How well are you able to get around? Very poor: 1 Poor: 2 Neither poor nor good: 3 Good: 4 Very good: 5 The following questions ask you to say how good or satisfied you have felt about various aspects of your life over the last two weeks. 16. How satisfied are you with your sleep? Very dissatisfied: 1 Dissatisfied: 2 Neither satisfied nor dissatisfied: 3 Satisfied: 4 Very satisfied: 5 17. How satisfied are you with your ability to perform your daily living activities? Very dissatisfied: 1 Dissatisfied: 2 23 IMPROVING QUALITY OF LIFE IN AN ALF Neither satisfied nor dissatisfied: 3 Satisfied: 4 Very satisfied: 5 18. How satisfied are you with your capacity for work? Very dissatisfied: 1 Dissatisfied: 2 Neither satisfied nor dissatisfied: 3 Satisfied: 4 Very satisfied: 5 19. How satisfied are you with yourself? Very dissatisfied: 1 Dissatisfied: 2 Neither satisfied nor dissatisfied: 3 Satisfied: 4 Very satisfied: 5 20. How satisfied are you with your personal relationships? Very dissatisfied: 1 Dissatisfied: 2 Neither satisfied nor dissatisfied: 3 Satisfied: 4 Very satisfied: 5 21. How satisfied are you with the support you get from your friends? Very dissatisfied: 1 Dissatisfied: 2 Neither satisfied nor dissatisfied: 3 Satisfied: 4 Very satisfied: 5 22. How satisfied are you with the conditions of your living place? Very dissatisfied: 1 Dissatisfied: 2 Neither satisfied nor dissatisfied: 3 Satisfied: 4 Very satisfied: 5 23. How satisfied are you with your access to health services? Very dissatisfied: 1 Dissatisfied: 2 Neither satisfied nor dissatisfied: 3 Satisfied: 4 Very satisfied: 5 24. How satisfied are you with your transport? 24 IMPROVING QUALITY OF LIFE IN AN ALF 25 Very dissatisfied: 1 Dissatisfied: 2 Neither satisfied nor dissatisfied: 3 Satisfied: 4 Very satisfied: 5 The following question refers to how often you have felt or experienced certain things in the last two weeks. 25. How often do you have negative feelings such as blue mood, despair, anxiety, depression? Never: 1 Seldom: 2 Quite often: 3 Very often: 4 Always: 5 IMPROVING QUALITY OF LIFE IN AN ALF APPENDIX C Satisfaction Survey 1. Did you enjoy participating in this program? a. Yes b. No 2. Do you feel that the environment that the program was held in was sufficient to meet your needs? a. Yes b. No 3. Do you feel that you learned how a life review program can benefit you? a. Yes b. No 4. If given the opportunity, would you participate in a program like this again? a. Yes b. No c. Maybe 5. Would you recommend the facility continue implementing this program? a. Yes b. No 6. What, if anything, would you change to the program and why? 26  ...

... OT AND SCHOOL BASED MENTAL HEALTH INTERVENTIONS A Look Into School Based Mental Health Interventions: An Occupational Therapists Perspective Sydney Abbott Jillian Heidenreich Emily Hughes Megan Newton Olivia Voss December 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: Dr. Taylor Gurley, Assistant Professor 1 OT AND SCHOOL BASED MENTAL HEALTH INTERVENTIONS A Research Project Entitled A Look Into School Based Mental Health Interventions: An Occupational Therapists Perspective Submitted to the School of Occupational Therapy at the University of Indianapolis in partial fulfillment for the requirements of the Doctor of Occupational Therapy degree. By Sydney Abbott Jillian Heidenreich Emily Hughes Megan Newton Olivia Voss Student Approved by: Taylor Gurley Research Advisor (1st Reader) Date 2nd Reader Date Accepted on this date by the Doctor of Occupational Therapy Program Director: OTD Program Director Date Accepted on this date by the Chair of the School of Occupational Therapy: Chair, School of Occupational Therapy 2 OT AND SCHOOL BASED MENTAL HEALTH INTERVENTIONS 3 Abstract Introduction: Occupational therapists are qualified to treat mental health concerns within the school system. Many students have diagnoses of mental health conditions, especially adolescents with autism spectrum disorder (ASD) (Cage et al., 2018). Poor mental well being of a student can greatly affect their ability to engage in school occupations and create meaningful relationships. Methodology: Participants for this study were recruited via stratified sampling from a collective pool of occupational therapists practicing in school-based settings across the state of Indiana. A survey was sent to all participants whose emails were collected. Inclusion criteria for participants was determined prior to beginning the interviews. Results: 42 participants completed the survey and five participants were selected to complete two interviews. Ten interviews were recorded and transcripts were used to generate codes and themes between interviews in order to analyze and draw findings. Four main themes were determined and used to organize findings for this study: barriers, collaboration, mental health interventions and student support. Discussion: Interviews were used to understand what mental health interventions occupational therapists are currently using in the school setting and the obstacles that prevent the interventions from being delivered formally. Conclusion: Occupational therapists can administer interventions to treat mental health concerns and increase mental well being; however, occupational therapists are not being utilized in their fullest capacity. An increased understanding in occupational therapy (OT)s role and reduced caseload would allow occupational therapists to devote more time to address mental health needs. Keywords: Mental health, ASD, school setting, occupational therapy, interventions OT AND SCHOOL BASED MENTAL HEALTH INTERVENTIONS 4 The main goal of occupational therapy (OT) is to provide therapeutic interventions through the clients occupations that are both meaningful and enjoyable to them (American Occupational Therapy, 2020). OT is one of the few professions that are equipped to meet the emotional, academic, and cognitive processing aspects of mental health. Mental health is described as the ability to recognize, express and modulate ones own emotionsto cope with adverse life events, and function in social roles (Galderisi et al., 2015 p. 231-232). An individuals mental health impacts nearly all aspects of their occupations, daily routines, and performance skills (Kielhofner, 2002). Autism spectrum disorder (ASD) affects one in 44 children in the United States (US), and in schools, it affects one in 68 students (CDC Estimates 1 in 68, 2016). In the US, ASD is the third most common developmental disability (Maenner et al., 2021). With this high prevalence, students diagnosed with ASD are at an increased risk for receiving diagnoses of co-occurring mental health conditions. As a result, they have decreased performance in their occupational role of being a student, peer, and member of their school community (Cage et al., 2018). Occupational therapists in the school setting are able to treat mental health concerns, however, therapists are not formally addressing these needs in their treatment sessions. Some challenges include a lack of recognition of occupational therapists as a qualified mental health professional (QMHP) and a misunderstanding of who can treat mental health concerns. Further advocacy is needed to establish OTs role in mental health. Literature Review Autism Spectrum Disorder and Dual Diagnoses ASD is a developmental disability that affects an individuals social skills, behaviors, and ability to communicate with others (Atchison & Dirette, 2012). These difficulties can contribute to an individuals restrictive and repetitive behaviors (Devlin & Scherer, 2012). The Diagnostic OT AND SCHOOL BASED MENTAL HEALTH INTERVENTIONS 5 and Statistical Manual of Mental Disorders-5th edition (DSM-V) categorizes ASD into three different severity levels (see Table 1) (American Psychiatric Association, 2013). Out of individuals diagnosed with ASD, 34% also have dual diagnoses of depression, anxiety, and bipolar disorder (Cage et al., 2018). Individuals with dual diagnoses have difficulties identifying social cues, which can often lead to poor social judgment, self-managing of behaviors, regulating emotions, and lack of interpersonal relationships (Ratcliffe et al., 2015). Adolescents with social communication deficits have a greater risk of self-harm with suicidal ideation and suicidal plans by the age of 16 than others without social deficits (Culpin et al., 2018). Table 1 Autism Severity Levels. Adapted from the DSM-V (American Psychiatric Association, 2013) Severity Level Social Communication Repetitive Behaviors Level 1 Requiring very substantial support Verbal and nonverbal social communication skills severely impacting social interactions Deficits in coping and distress with change, repetitive behaviors interfere with daily functioning Level 2 Requiring substantial support With supports in place, social impairments noticeable, can speak simple sentences but limited to special interests, has different nonverbal communication Deficits with coping and distress with change, noticeable to observers, interfere with daily functioning in multiple environments Level 3 Requiring support Can engage in social conversation with full sentences without support, but difficulty initiating social interactions and appear to have decreased interest and success in peer conversations to make friends Behaviors can interfere with one or more environments, trouble transitioning activities, planning, and organizing OT AND SCHOOL BASED MENTAL HEALTH INTERVENTIONS 6 Despite the increasing rates of mental health conditions in adolescents with ASD, traditional services to address these issues have not been available (Maddox, 2019). Many professionals, such as counselors, special education teachers, applied behavioral analysis (ABA) therapists, and social workers provide mental health services in schools. ABA therapy primarily focuses on eliminating unfavorable behaviors and teaching individuals how to modify or cope with these behaviors (Booth et al., 2018). Special education teachers frequently implement social stories to teach social skills (Rashed, 2019). Cognitive behavioral interventions, used by many psychotherapists, assist in managing emotions by changing negative thought patterns into positive ones (Wood, 2015). Although these interventions are in OTs scope of practice, their role is less recognized (Cahill, 2017). A need exists to spread awareness on how OT can promote a positive environment for adolescents with mental health conditions in the school setting. Defining OTs role and educating individuals about the value of OT services helps establish a foundation for occupational therapists (Cahill, 2017). Literature Search Results A PRISMA Flow Chart was implemented to compile the literature search results and determine a total number of articles appraised by the research group (Moher et al., 2009). Researchers gathered articles that were found in each faceted search, then added filters, and removed duplicates. Each articles abstracts were reviewed for relevance to the research topic and omitted as needed. The remaining articles were appraised and divided into either the qualitative or quantitative category. Initially, 785 scholarly articles were found; in the end, 42 qualitative and 29 quantitative studies were leveled and appraised. Application of The Model of Human Occupation OT AND SCHOOL BASED MENTAL HEALTH INTERVENTIONS 7 The Model of Human Occupation (MOHO) provides a framework for addressing how occupational therapists treat mental health needs by using a holistic approach to examine an individuals volition, habituation, and performance skills when providing client-centered interventions (Kielfhofner, 2002). An integrated review was selected to synthesize evidencebased literature on mental health interventions for adolescents with ASD in the school setting, utilizing MOHO for application as a framework. For the purpose of the literature review, MOHO creates a structure for categorizing literature into the concepts defined below. Within MOHO, human occupation is defined through an open system concept with the view of the interaction between the person and their environment. (Kielhofner & Burke, 1980). Volition refers to the beliefs, values, personal causations, and interests of the client that motivates a specific occupation (Kielhofner & Burke, 1980). Habituation involves habits and roles that assemble an occupation into routines or patterns, determining a sense of self and leading to certain behaviors and attitudes (Kielhofner, 2002). Performance skills are goaloriented physical and mental actions that make up and help understand daily life occupations (Kielhofner & Burke, 1980). Feedback loops are open systems that interact with the environment through input, output, throughput, and feedback (Kielhofner & Burke, 1980). Occupational Therapy and its Role in Mental Health Mental health conditions can significantly impact the occupational performance of adolescents (Rouse & Hitch, 2014). For occupational therapists to provide mental health interventions, they must become recognized as a quality provider of these services (Cahill & Egan, 2017). Currently, the majority of states in the US do not recognize occupational therapists as QMHPs (Increasing Access to Behavioral Health, 2022). Occupational therapists demonstrate competence by supporting students in schools through their use of specialized, OT AND SCHOOL BASED MENTAL HEALTH INTERVENTIONS 8 targeted, and universal interventions to enhance optimal classroom performance (Ball, 2018). Advocacy for occupational therapists in the school setting is essential because they can assist in improving the status of mental health conditions for students while maintaining their educational and occupational successes. Unlike a typical mental health therapists approach, an occupational therapists specific work in activity-based interventions sets them apart from the rest (Rouse & Hitch, 2014). Therefore, occupational therapists are QMHPs that provide a unique aspect to mental health interventions. Occupational therapists can provide a variety of mental health interventions. For instance, social skill interventions are helpful in teaching an adolescent with ASD how to engage in appropriate conversations, convey their needs, and cope with uncontrollable situations without the reliance of someone else (Aldabas, 2019). One study found that using social stories as an intervention for oppositional behaviors in children and adolescents with ASD were effective and had no adverse side effects (Ghanouni et al., 2019). This has been a safe way for teachers and parents to effectively interact with the adolescent to understand better what the child is experiencing and ways to help calm them down. Specific Interventions Provided by OTs For individuals who encounter bouts of aggression, developing coping skills is essential for regulating these emotions (Williams et al., 2018). Further, peer-mediated interventions such as modeling, social stories, scripting, visual supports, and self-management also showed improvement in communication and social skills in individuals with ASD (Hungate et al., 2019). Support groups have also been beneficial for individuals with ASD as this allows them to engage with others to create meaningful relationships and engage in social interactions (Ghanouni et al., OT AND SCHOOL BASED MENTAL HEALTH INTERVENTIONS 9 2019). Aldabas (2019) utilized social skill interventions in teaching adolescents with ASD how to participate in conversations with others using social stories. Pan and Frey (2006) concluded that physical activity in children with ASD is important for overall health, thus increasing physical activity interventions for youth is deemed critical. This study also found a major importance for physical activity to be incorporated within a childs daily routines as it can elicit positive self-esteem, behavior, happiness, and intellectual and social outcomes. A systematic review of 14 articles concluded that animal therapy (including dogs, guinea pigs, llamas and bunnies) increased a students playfulness, social interactions, language, well-being, safety, and freedom (OHaire, 2013). Occupational therapists have several available interventions to treat adolescents performance skills with ASD, including teaching coping strategies for aggressive and upsetting behaviors (Williams et al., 2018). Some of these problematic behaviors include bouts of anxiety that result in increased restrictive and repetitive behaviors (Factor et al., 2016). These behaviors could impact a childs performance in their habits and daily routines (Bowling et al., 2019). Looking long-term, these behaviors could adversely lead to less participation in a mainstream classroom and less interest in school (Falkmer et al., 2012). For these reasons and more, occupational therapists need to intervene in schools to help prevent the further development of an individuals mental health condition (Rouse & Hitch, 2014). OT differs from a typical practitioner who addresses mental health conditions due to the occupational therapists activity-based nature (Rouse & Hitch, 2014). Some studies look at an occupational therapists role in a school system, but few to none address their ability to collaborate on a shared client's mental health treatment. After further education of OTs potential role, even traditional mental health providers agree that an occupational therapist would be a OT AND SCHOOL BASED MENTAL HEALTH INTERVENTIONS 10 beneficial collaborator when treating mental health treatment (Cahill & Egan, 2017). The end goal is to provide all occupational therapists with the resources to become a listed QMHP in every state in the US. Methodology Study Design This study utilized a case study methodology, single-case design (Yin, 2018). Schoolbased occupational therapists defined the case being researched. Stratified sampling was applied through an initial survey for recruitment of participants. Recruitment Stratified sampling divides a population into smaller strata groups. The strata were created based on the shared characteristics of the members. Afterwards, a random sample from each strata was taken, proportional to the stratums size when compared to the population. Finally, the subsets of the strata were pooled to form a random sample (Sharma, 2017). This method was chosen to reduce potential human bias while selecting cases to be included in the sample. Thus, the stratified sampling provided a sample that is highly representative of the population being observed (Sharma, 2017). Participants Participants for this study were recruited from a collective pool of occupational therapists practicing in school-based settings across the state of Indiana via email. Researchers located the schools occupational therapist(s) contact information online; if that was not available, an email was sent to the schools administrative assistant to retrieve that information. Inclusion criteria: Licensed occupational therapist in the state of Indiana, practicing in a school setting. OT AND SCHOOL BASED MENTAL HEALTH INTERVENTIONS 11 Exclusion criteria: Occupational therapists who have not worked in a school system in the last 5 years and certified occupational therapy assistants (COTA). Measures & Procedures Researchers selected school based occupational therapists who are currently practicing in Indiana. All possible participants were sent a Google survey that included questions about their caseloads and common interventions they performed. The survey included a consent form on the first page; if the participant chose to participate, they were proceeded to the next set of questions of the survey. If the participant chose to not participate, the survey ended and they were prompted to leave the browser. The survey was posted to be anonymous, but participants had the option to leave contact information if they wanted to partake in the interview portion. Based on the answers from the survey, five participants were selected to partake in a two, standardized and open-ended interview series. Prior to beginning the interviews, each participant signed a formal consent form. Names of each participant are identified as A, B, C, D, & E to maintain anonymity. Transcripts were yielded from the Zoom platform and were sent to participants to gain further consent to verify and use the gathered information. Results Five school based occupational therapists were interviewed twice for a total of ten interviews. From the interviews, 77 codes were identified and 21 were recognized as main concepts, being that they were cross referenced from at least five interviews. Four primary themes were identified along with subthemes. The themes described in this section are supported by examples from the interviews and direct quotes taken from the transcripts. Each participants interviews demonstrated significant results that were generalized into universal findings among members to support our identified subthemes. OT AND SCHOOL BASED MENTAL HEALTH INTERVENTIONS 12 Theme 1. Barriers The theme barriers'' addresses the challenges occupational therapists and students face within the school environment. These obstacles affect their ability to be successful when engaging in daily activities. Within this theme, four subthemes were identified. These subthemes are defining mental health, addressing mental health needs, utilizing OT, and obstacles. Ambiguity exists between how occupational therapists perceive and define mental health which became the first identified barrier when conducting the interviews. To start, participants were asked to provide their definition of mental health and how it impacts a student's daily functioning. Two of the participants defined mental health as their ability to interact with peers and take care of themselves. Participant E stated that mental health is, the self confidence piece of feeling good about yourself and feeling able, [which] leads to the ability to interact with other kids and make sure everything in their brain and body is taken care of. Similarly, participant D expressed that mental health is when a student is mentally able to come to school and interact with their peers, cope with all the demands that are put on them and learn to be able to progress alone. On the contrary, participant B stated, that mental health [is more] traditional [including] depression, anxiety This participant claimed they did not feel occupational therapists should be involved in treating mental health when defined in terms of depression and anxiety. Similar to varied definitions given by the occupational therapists, teachers and staff display a lack of understanding on what occupational therapists role is in addressing mental health in the school settings. Two participants stated that staff members within the school system are uninformed of the profession and therefore are not utilizing OT services to their fullest capacity. Participant C stated, I don't think people really know what we do; [a lot of times] we OT AND SCHOOL BASED MENTAL HEALTH INTERVENTIONS 13 get grouped and categorized as other fields. Additionally, participant A reported, our schools don't know that's what we do, or that we can [provide mental health interventions]. The most substantial barrier that occupational therapists face within the school system is lack of time and increased number of students on their caseloads. Four participants stated that due to time constraints they are limited to the services they are able to provide. Participant D stated, [I am] not making a difference due to time constraints. The participant further explained, the caseloads we carry have a lot of students and many of them we work with in groups. We don't have the time to really dig deep as we generally would have in a 30 minute session. Additionally, participant C stated, if the school can prioritize and line up the time for my position and teachers and staff get training, I think it would go a long way. Furthermore, two participants indicated that they are unable to address mental health with their students due to larger concerns taking priority. Participant E expressed, occupational therapists in the school are busy but we're also spread so thin in the district that we don't have the time to pick up [the mental health] piece as well. Participant C added, time is purely a caseload issue as I have so many students and not enough time to really dive into those [mental health] things. Additionally, two therapists reflected on the amount of pushback they receive in the school system when trying to get staff members to implement a new strategy. Participant B expressed, if you have an idea, getting the teacher to implement it is the biggest [problem] across the board, whether it's mental health or anything. Additionally, the same participant stated, a lot of it is showing the teachers and the paraprofessionals strategies and things to do because we [only] see kids once a week and they need to do it more. Participant A voiced, were having a hard time getting all of our general education teachers to buy into it and our special education teachers tell us they dont have enough time to do it. OT AND SCHOOL BASED MENTAL HEALTH INTERVENTIONS 14 Theme 2. Collaboration The theme of collaboration examined the interactions between staff, resources provided by the school, and the various roles within school staff. Four subthemes were identified and used to guide important findings. These subthemes include dividing responsibilities, educating staff, interprofessional education, and mental health resources. Occupational therapists collaborate closely with teachers and other paraprofessionals in the school system to offer comprehensive care for students. Three participants indicated additional professionals, besides occupational therapists, that address mental health concerns within the school system. Participant C stated, Our counselors are a great resource; they address [mental health] more holistically. Three participants indicated that their school system utilized external resources from the community to support mental health needs of students. These varied between behavioral therapists, mental health therapists, psychologists, and social workers. Due to the increased involvement staff members typically have within the school system, teamwork is critical among staff members to support and encourage one another during difficult times. Participant E expressed, I think working together as a team is the most important part and lifting each other up. So the teachers, resource [staff], and the therapists are all working together. Participant A elaborated, three of [the OTRs] share a wall in an office and so we're together usually, at least once a week and then, if you look at our text record we communicate daily. A supportive staff is vital for a productive and manageable work environment in order to ensure occupational therapists are providing the best possible care for their students. Participant D envisioned teamwork as, we collaborate and maybe do some groups together and work on similar things, then I could reinforce that during OT sessions. OT AND SCHOOL BASED MENTAL HEALTH INTERVENTIONS 15 Additionally, occupational therapists support staff within the school system by educating them on different techniques to implement within the classroom. Participant D explained, many things that we have been educated on [like] emotional issues, we know strategies that we can offer kids and try to help coach [students] and teach them those strategies. On the other hand, three participants felt frustrated due to the lack of teacher training and follow through on implementing strategies. Participant C discussed that if the teachers had more additional training, they would feel more comfortable addressing mental health needs. As noted above, occupational therapists have difficulty, at times, receiving buy-in from general and special education teachers. One example participant E noted is frustration from teachers when a strategy does not immediately work with a student therefore carryover is limited, increasing hesitancy in effective collaboration. Theme 3. Mental health interventions The theme of mental health interventions'' looks at a child's ability to regulate their bodies and emotions to be able to participate in daily occupations (Chan et al., 2017). Within this theme, two subthemes were identified including determining eligibility and informal mental health interventions. Before mental health interventions could be analyzed the process for determining eligibility was discussed. Since OT is a related service, students must have a predetermined individualized educational program (IEP) before receiving services within the school. All five participants supported this statement and indicated what their role as an occupational therapist is during this process. Participant B stated that OT is considered a related service meaning that in order to qualify for OT in the schools a child must have an IEP in place. OT AND SCHOOL BASED MENTAL HEALTH INTERVENTIONS 16 Participant C added: ...being a related service. I love my position and that I'm not the one facilitating the meeting [and] I get to kind of be the outsider that looks in but also is kind of on the inside, too, so I work really hard at listening to the concerns and issues, because in all fairness, usually those meetings are to address their issues [but] we always try to start with our strengths and address their deficits. I feel like Im kind of a troubleshooter and problem solver and try to accomplish strategies and interventions that will make their classroom life better and then also support their teacher. So I have kind of an interesting role in that I'm kind of like the jack of all trades and trying to solve all these issues, but yet I don't know as much as the teacher because I'm not necessarily there with them every day, but my role is interesting, but I think it's very helpful and very important. IEPs are the main eligibility requirement to receive OT services; however, few participants mentioned other qualifications for receiving services include having a 504 plan or other health impairment. Some examples that participants mentioned as other health impairments include ADHD, emotional disability, anxiety, or other diagnoses determined by the school psychologist. Table 2 lists various informal mental health interventions that schools are currently implementing to address students needs. Table 2 Illustrative Examples Supporting the Theme: Informal mental health interventions Category Intervention Supporting Quotes OT AND SCHOOL BASED MENTAL HEALTH INTERVENTIONS 17 3.1 Social interactions Video modeling Now I've also done some role modeling and/or video modeling with a couple peers, to try and help just social interactions in general. Its more like how to play a game and interact, as opposed to how to have a conversation. -Participant A Role modeling They don't get modeling from [neurotypical] peers that maybe would [demonstrate] more [positive] verbal and social [behaviors]. When most students have these deficit areas and are located in the same environment it makes for very deficient classrooms. Participant B 3.2 Self-regulation Mindfulness The ability to regulate themselves, that's a little more sensory, but I really think it impacts mental health too. They might even lump attention into that, to a degree, like are they in a place where they can function [to make decisions]. -Participant B OT AND SCHOOL BASED MENTAL HEALTH INTERVENTIONS 18 Breathing activities Each week we do some sort of breathing activity or talk about ways to keep the body calm while in the classroom. -Participant E Role play [For example] if you're with friends and we talk about situations, you know if you're on the playground and somebody hurts your feelings, what would you do? That sort of thing. -Participant E Cognitive behavioral And then definitely regulation, in particular therapy (CBT) frustration threshold. Either they can't do something so they get frustrated or someone didn't understand them/what they meant in a social interaction and they get frustrated. So that anger frustration, I would say, would be the mental health piece, and then trying to figure out how to regulate it. -Participant C Zones of regulation Zones of regulation is the basis of what I do with the students in terms of having better control of their bodies. We talked about the different zones, we talked about the different OT AND SCHOOL BASED MENTAL HEALTH INTERVENTIONS 19 areas within that, how do we move from zone to zone, how do we [use the zones] when we're sitting in the classroom, how do we get to the point where we're on in green we're ready to learn. -Participant E Being able to participate in age-appropriate tasks without refusals or meltdowns or knowing the zones, being able to identify the zones and strategies that make you be able to function independently in the room. Participant C 3.3 Sensory regulation Alternative sensory Some kids have hokki stools, like those seating wobbly stools that wobble when you sit on it. We don't use therapy balls too much anymore [within the classrooms]." -Participant B Sensory circuits I have put a little sensory circuit in some of the classrooms or in the hallways for kids if they need to just do some heavy work, get out of the classroom and have a break, or reorganize their body. They can go out in the hallway and go through that circuit and do OT AND SCHOOL BASED MENTAL HEALTH INTERVENTIONS 20 those activities, working their way [through the] stations. -Participant E Sensory equipment We have a sensory room and it has all kinds (e.g. fidgets, of fidget things on the wall that you can do. It theraputty, crash has an exercise bike, treadmill, trampoline, pads, therapy balls) scooter boards and balance boards, body socks, weighted blankets, a crash pad, the swing and a whole bunch of stuff in there, I can't even name it all. -Participant D Bucket of activities Things that I found that really calm [some calm down corner students] down and help keep them in a good head space for learning [is to] create a little basket or a bucket of activities that might help that kid in a calm down corner in their classroom. -Participant B 3.4 Executive functioning Role scenarios I would say [we] do that more with [our] older kids like teaching them what those executive functioning skills are, like what they mean, and then using [them in] different scenarios and games. I've got some really fun OT AND SCHOOL BASED MENTAL HEALTH INTERVENTIONS 21 scenario games that we play to practice those skills. -Participant D Task sequencing Checklists and organizational tools that they can use in the classroom and collaborating with teachers. -Participant D 3.5 Social emotional Small groups (e.g. That is something that [our school] learning social groups) struggles with. I definitely think that they have their groups, and they promote different things they target, especially certain kids. They have groups to target that, so they'll do social groups. -Participant C Second Steps It is part of the whole curriculum. So every morning all of the students get a social emotional learning program called Second Steps in our district, which is the program that they're using. For the preschoolers it's not really mandated, but in elementary school every student is getting that Second Steps, which is talking about relationships with peers, talking about interactions, when to talk OT AND SCHOOL BASED MENTAL HEALTH INTERVENTIONS 22 to an adult, when to tattle and not to tattle. Participant E Theme 4. Student support The theme of student support investigated the students life focusing on family interactions, engagement in age appropriate activities, and participation within the classroom. Within this theme, five subthemes were identified. These subthemes include inclusion, communicating with family, engaging in physical activity, pushing into the classroom, and addressing resilience. While the topic of resilience was addressed in the interviews and is included as a subtheme it became a gap in the collected data. A recurring concept among participants is inclusion within their school among neurotypical students and students with a diagnosis. More specifically, four participants indicated that their school aims to include students that are in special education classes to allow them to socially interact with their peers. Participant E stated, primarily, we make sure that they are with their same age peers for recess, for lunch, and for their specials. Our participants feel that inclusion is extremely beneficial and schools are continually developing new opportunities for full inclusion. Another way that occupational therapists are supporting students is by involving family in the therapeutic process. This can allow parents to give their input about what goals they would like their child to work on. Participant C stated, I definitely do think that [families are] always given that opportunity and they're asked for their input. Four of the participants elaborated on different ways they communicate with caregivers about their childs progress. Participant D OT AND SCHOOL BASED MENTAL HEALTH INTERVENTIONS 23 stated, the minimum contact would be that [the family] would attend the case conference. Participant E included the following: If I want to make a change to the IEP and am not going to be able to be at the meeting, I call [the caregivers] and I talk to them to have that true interaction with them and kind of talk through it before the meeting. Due to busy schedules, school staff and families utilize different electronic applications as a way to communicate with one another. The participants indicated that ClassDojo, ParentSquare, and TalkingPoints are just a few of the apps they are currently using. One significant finding that was addressed by all participants, was that movement is key to emotional and mental well being. Many schools promote physical activity through recess, gym class, brain and movement breaks. Participant D stated, we encourage [physical activity] as a schoolwe have events like a fun run and we have different active activities that [students] can be involved in [which] has a lot to do with emotional [and] its been shown in research that it's definitely important to be active. Although schools seem to be promoting physical activity more, recess continues to be the first activity that is taken away when behavioral issues arise, which participant E supported. The participant elaborated, it is a snowball effect for the rest of the day, because they need that time to be able to do what they want to do [and] be able to get that physical activity. Participants indicated supporting students through both providing OT services within and outside of the classroom. Three participants stated that they provide OT services in the classroom when the students are working on occupation based activities. Participant B stated that, I tend to push in. I know their schedule and what the class is doing so if I'm pushing in, it's during OT AND SCHOOL BASED MENTAL HEALTH INTERVENTIONS 24 writing time typically. Because our goal [in general education] is usually related to handwriting. Additionally, participant A added, it kind of depends on what they're doing in class. If it's functional, then I just go in and sit next to them and try to give verbal or visual cues as they're writing or whatever they're doing. In contrast, participants indicated situations that are inappropriate for OT within the classroom, including when a child has a behavioral issue, has other goals outside of the classroom, or is easily distracted. Table 3 illustrates examples of participant opinions on when it is appropriate to pull students from the classroom for services. Table 3 Illustrative Examples When Pulling Students Out of the Classroom is Appropriate Participant A And then, sometimes we pull out to get some more intense instruction, especially for my very distractible kids, so it just kind of varies on the student, I guess and sometimes the day, what we need to work on. Participant B They may have some resource support where they get pulled out for like a social skills group or if they have some academic issues, some of them might get some extra academic help, but for the most part they are [getting pulled out]. Again we're related to their academic goals so somewhat depends on the gen ed setting. For K-4, so my younger K-1, I will oftentimes pull them out and do more intervention as far as if they have any fine motor needs, they need a different pencil grip, or if they need to practice. OT AND SCHOOL BASED MENTAL HEALTH INTERVENTIONS 25 Participant D I would say when they're younger my tendency is to pull them out more because I feel like I need one on one time to work on that skill. Sometimes I can go in the classroom and do that with them if they're doing something in the classroom that is [working towards their OT goals]. But if [therapy is during] storytime and I'm working on fine [motor skills, then] I'm going to pull them [out] to do that, but we do, I would say we do a pretty good combination of both. Participant E So we have kids who are in resource so they're mostly in gen. ed. and they're pulled for focus groups. Ill pull students either one, two, sometimes three of them. And we'll work on cutting with scissors, well work on those fine motor skills that they need to work on. If they need to go to the bathroom I'm in there, helping them figure out how to pull their pants up, pull their pants down, wash their hands, make sure they wipe, make sure you flush the toilet, that sort of thing in the kids and diapers I worked on just that dressing piece. Snack time we work on independence with feeding and then, when they leave, that's putting our coat on. Can they engage the zipper? When they're a little bit older putting their backpacks on and just being. But I pull them [preschool kids] aside and work more individually with those students, because they need a little bit more help so more hands-on work, then the elementary kids I feel like to. OT AND SCHOOL BASED MENTAL HEALTH INTERVENTIONS 26 Discussion Students in the school system face many challenges, specifically mental health concerns that affect their ability to engage in their occupations. Individuals with a diagnosis, compared to their normal peers, are seen to have a difficult time with managing their task demands within the school environment (Semino et al., 2018). Children and adolescents with developmental disorders, such as ASD or intellectual disability (ID), and those who have previously been diagnosed but do not have a current diagnosis, are ill-equipped to deal with the challenges they encounter in a variety of areas (Hilton et al., 2020). In addition, children exhibit a wide range of maladaptive behaviors as well as significant levels of anxiety (Grandisson et al., 2020). One role of OT entails modifying and adapting the environment for individuals to handle the obstacles they face. Occupational therapists are capable of handling these concerns in addition to other mental health needs, however due to constraints, are not directly addressing these areas in school-based practice. The following outlines in greater detail the barriers found within and outside of the profession which limits OTs ability to meet mental health needs in the school system, as well as opportunities for occupational therapists to be used to their full advantage. During the interviews, the first obstacle within the profession became clear when the participants were asked to define what mental health of students means to them in this setting. Four of the participants defined mental health as the students ability to come to school and engage in classroom activities, whereas the other interpreted it as only obtaining a diagnosis. These two substantial contradictions indicate that occupational therapists view mental health differently which illustrates why OT practitioners are not aware of their role when addressing mental health needs. Further, occupational therapists are unable to spend sufficient time with students due to high caseload numbers and other professional responsibilities including OT AND SCHOOL BASED MENTAL HEALTH INTERVENTIONS 27 advocating for the role of OT, educating staff, and communicating with families. Therefore, they are unable to devote more time to evaluate new referrals and build relationships with current students (ODonoghue et al., 2021). Combined with high caseload numbers, an occupational therapists daily routine continually changes when OT sessions are both pushed into and pulled out of the classroom, a determination made from clinical judgment. One benefit for pushing in is being able to provide services to children in their natural environment (Christner, 2015). However, one challenge with pushing in is the level of distraction to the other students which can affect overall functioning, and make addressing mental health needs, such as management of anxiety, nearly impossible. For this reason, pulling out of the classroom can also be beneficial depending on the students needs, especially if goal areas are not related to what is currently being done in the classroom. Another obstacle identified is the lack of understanding of an occupational therapists role among school staff. There is a common misconception in school-based settings that occupational therapists are only capable of addressing handwriting and other fine motor skills. However, there are multiple other areas within the scope of practice that are beneficial for student success (Bonnard & Anaby, 2016). An improved understanding of how OT practitioners can support students mental health needs could lead to better service integration and efficient utilization of OT services (Cahill & Egan, 2017). Most of our participants agreed that collaboration between occupational therapists and other staff in a school system is vital to provide students with the best opportunities to be successful. During collaboration, individuals can contribute unique viewpoints to help develop the most appropriate plan of care to meet a student's individual needs (Christner, 2015). Although collaboration is being used in the school setting currently, there is still room for improvement among interprofessional communication. OT AND SCHOOL BASED MENTAL HEALTH INTERVENTIONS 28 These improvements include increased flexibility with implementing strategies and understanding occupational therapists role to promote follow through of strategies to meet the students needs. The largest obstacle outside of the profession was identified when most of our participants indicated that their school systems typically hire external companies to provide mental health services for their students. These external companies employ therapists to address social emotional learning, behavioral challenges, and other mental health related needs. Although these individuals are beneficial for providing additional resources on how to address mental health concerns, occupational therapists are qualified to treat mental health in the school, however are not always being used in this capacity. While there is a growing need for schoolbased mental health services, various school districts are forced to subside their students mental health needs in order to fulfill rigorous academic accountability standards (Cahill & Egan, 2017). Although occupational therapists may not be formally addressing mental health needs due to internal and external obstacles, they are informally providing opportunities to support the mental health of students through various interventions that target multiple skills. For example, our participants listed ways they informally address executive functioning (EF) including games, role-play scenarios, organizational checklists, and task sequencing interventions which also provide mental health benefits. Students who lack EF skills have difficulty paying attention and participating in the classroom. Kenworthy et al. (2014) documented the use of EF interventions to develop improvements in problem-solving, flexibility, social skills, planning, and organizing. Evidence supports that occupational therapists who incorporate EF in treatment plans promote participation in school activities, particularly in the ability to resist impulsive behavior and regulate emotional responses (Zingerevich & LaVesser, 2009). OT AND SCHOOL BASED MENTAL HEALTH INTERVENTIONS 29 Social emotional learning interventions are beneficial ways for students to promote independence in school activities and informally address mental health needs. Factors of social emotional regulation, including self-awareness, self-control and interpersonal skills, are crucial for students to have successful engagement in school activities (Wallender et al., 2020). A commonality among participants was the importance of including students in special education classrooms with their neurotypical peers due to the increased benefits of social participation. Bonnard & Anaby (2016) emphasized the importance that all students, regardless of diagnosis, should be given the same opportunity in all areas of occupations, not just what is related to core academics. Social groups are used to handle situations between peers when incidents arise. Additionally, neurotypical peers can serve as role models to display appropriate behaviors and responses to social situations for their neurodivergent classmates (Locke et al., 2010). The participants supported these findings as they encourage neurodivergent students to attend recess and eat lunch in the cafeteria amongst their peers. Occupational therapists should continue to motivate neurodivergent students to participate in general education settings as it promotes increased social participation, therefore, simultaneously improving their mental well-being with new learned skills and relationships. Physical activity is an alternative way to promote social interaction and create meaningful relationships with peers as it fosters friendship, broadens children's interests, and improves family life satisfaction (Potvin et al., 2013). Research encourages neurodivergent children who participate in physical activity, demonstrate improvements in behavior, mental health, and additional skills (Arnell et al., 2018). In the interviews, all participants stated that movement is key to emotional and mental well being and it is encouraged through recess, special classes, movement breaks, and clubs such as martial arts or gymnastics. Although it appears physical OT AND SCHOOL BASED MENTAL HEALTH INTERVENTIONS 30 activity is being promoted more in schools, recess is often the first thing taken away when a negative behavior occurs. Occupational therapists can encourage staff to find alternative consequences instead of taking away recess as physical activity helps regulate their bodies and control their actions. Limitations The research team cataloged numerous districts and found contact information for over one hundred occupational therapists, however not every Indiana school district was included. More recruitment could have been sought out through Indiana Occupational Therapy Association (IOTA) to receive any contact information for school occupational therapists that they did not have access to through the public domain. Each interview participant had a positive view and wanted to incorporate mental health interventions into their sessions, however the number of participants was limited and may not represent all thoughts of school based occupational therapists. The initial research referred to adolescents with ASD, while participants mostly engaged in conversation about elementary-age students. It was learned that each participant has a large caseload with a wide variety of diagnoses. As a result, interventions discussed were not specific to the ASD population as originally intended. In the future, research regarding students with ASD specifically should be conducted. The literature review described various interventions being utilized in the school setting with a primary focus on the adolescent population. However, the participants interviewed in the study did not primarily see this population nor implement all interventions mentioned, therefore the literature review is not entirely representative of our findings. A gap in the study was tied to responses to the question, how do you define resilience? as researchers noticed a variety of responses and additionally found no significant OT AND SCHOOL BASED MENTAL HEALTH INTERVENTIONS 31 findings. Future research is needed to understand how resilience is addressed within the school and its impacts on occupational participation in the classroom. Implications to OT This study supports the notion that the scope of OT is under-utilized in the school system. While there is an abundance of research that supports occupational therapists treating mental health in the school system, the act of doing so is limited. This could be due to high caseloads and demands, role perceptions of occupational therapists, and lack of carry-over from school staff. This study demonstrates the necessity for mental health interventions to be a priority, because if this is not addressed then the childs hierarchy of needs is interrupted and their ability to engage in higher level learning is affected. Advocacy efforts and interprofessional education may make it more attainable for occupational therapists to be viewed as mental health providers. Despite the fact that current evidence supports OT practitioners role in addressing mental health difficulties in school settings, few practitioners feel prepared to do so (Blackwell & Bilics, 2018). Once occupational therapists are recognized as QMHPs, they will feel more confident in providing these services. Conclusion This study investigated the perceptions of school-based occupational therapists working with adolescents regarding their role in providing mental health services. It is clear that occupational therapists have a role in mental health; however, they are not being utilized to their fullest capacity due to numerous factors. It is evident that school-based occupational therapists have varying perspectives on the scope of occupational therapy in the schools. The results of the themes and subthemes, see Appendix, suggest the importance of occupational therapists OT AND SCHOOL BASED MENTAL HEALTH INTERVENTIONS 32 addressing mental health concerns in schools since they are directly affecting students learning, function, and independence at school. More education and awareness will be needed for colleagues, families, and other healthcare practitioners to fully understand the services that occupational therapy practitioners can provide in the schools to address mental health needs. Additionally, more occupational therapists should be hired in school districts to allow more one-on-one time with the students. 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The contribution of executive functions to OT AND SCHOOL BASED MENTAL HEALTH INTERVENTIONS 40 participation in school activities of children with high functioning autism spectrum disorder. Research in Autism Spectrum Disorders, 3(2), 429-437. https://doi.org/10.1016/j.rasd.2008.09.002 Appendix  ...

... Establishing Routines for Sensory and Emotional Regulation in Schools Colleen Yeldell, OTS May 3, 2021 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 Establishing Routines for Sensory and Emotional Regulation in the Schools 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 Colleen Yeldell, OTS Approved by: Research Advisor (1st Reader) Date 2nd Reader 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 Running Head: ESTABLISHING ROUTINES FOR SENSORY AND EMOTIONAL 1 Abstract Self-regulation is an important skill for children that is comprised of sensory, emotional, and behavioral components (Shonkoff & Phillips, 2000). The COVID-19 pandemic has created new challenges for school based occupational therapists striving to support their students in selfregulation. Many schools operated under virtual learning or hybrid learning formats with students frequently experiencing changes in routines. The purpose of program development was to promote self-regulation skills in elementary school students within both traditional and hybrid learning formats. Program development and implementation occurred within 3 elementary schools over a span of 14 weeks. Students participated in hybrid learning from weeks 1-8 and completed in-person learning from weeks 9-13. The program developer planned and implemented 4 groups to support students in developing self-regulation skills with tools incorporated from The Zones of Regulation. Students in 1 group met completely virtually while students in the other 3 groups met in person. Students checked in and out of each session listing their emotional state or zone. The program developer recorded each students emotional state to determine if each student was able to self-regulate within the session. The results varied in each group. Students responded positively when creating a graphic organizer of preferred regulation strategies, participating in sensory stations, and play-based activities that promoted self-regulation. School-based occupational therapists should collaborate with staff and parents to provide students with meaningful, occupation-based routines to build self-regulation skills. ESTABLISHING ROUTINES FOR SENSORY AND EMOTIONAL 2 Introduction The COVID-19 pandemic has significantly impacted the health and wellness of families and children (Fegert, Vitiello, Plener, & Clemens, 2020). A group of researchers found that at least 28-34% of subjects in quarantine exhibited symptoms of post-traumatic stress syndrome (PTSS) including fear, depression, irritability, insomnia, and emotional exhaustion (Brooks, Webster, Smith, Woodland, Wessely, & Greenberg, et al, 2020). Families have experienced a multitude of traumas including social isolation, economic hardship, and the death of loved ones (Pfefferbaum, & North, 2020). Amidst these increased stressors, a disproportionate number of minority families have experienced reduced access to mental healthcare with fewer in-person services available (SAMHSA, 2020a). Many children with pre-existing mental health conditions experienced barriers to receiving services, further exacerbating their condition (Fegert et al., 2020). In addition, children who experience familial abuse may have suffered from an increase of Adverse Childhood Experiences (ACEs) when under quarantine (SAMSHA, 2020b). Children have experienced substantial changes in their education and extracurricular activities with transitions from in person classes to virtual learning environments. Some children attend schools that participate in hybrid models in which students switch off between virtual classes and in person learning. Events like pandemics can increase mental health, behavior, and communication difficulties (Huremovi, 2019). For children that desire routine, such as many children with autism, the lack of certainty may result in an increase in mental distress requiring intervention (Turan, Kocarslan, Gulsen, & Dursun, 2020). Many children have also had fewer opportunities for leisure and social participation with after-school activity groups cancelled or more challenging to access (Stark, White, Rotter, & Basu, 2020). With increased trauma related to the pandemic and frequent changes, students may need an increase in purposeful activities and ESTABLISHING ROUTINES FOR SENSORY AND EMOTIONAL 3 routines in and outside of the school environment. In addition, students may benefit from emotional and sensory regulation techniques to overcome stressors. Occupational therapists are skilled at examining the interaction between the person, environment, and occupation, and are thus suited to fostering skills related to self-regulation (Anderson, Bartholow, Snow, Stratiner, Nash, & Jirikowic, 2017). Occupational therapists can provide emotional and sensory regulation curriculum through intensive, targeted, or universal interventions within the school environment (AOTA, 2014). Social Emotional Learning (SEL) is an important curriculum within school systems (CASEL, 2012). Occupational therapists in the school setting must collaborate as part of a multidisciplinary team with other therapists, teachers, staff members, and parents to provide students with opportunities for SEL. Social emotional learning is important as students experience more stressors during the COVID-19 pandemic including frequent changes to their learning environment. Occupational therapists can support students by establishing routines for sensory and emotional regulation that are conducive to changing learning environments. The purpose of program development was to promote selfregulation, social emotional skills, and wellness in elementary school students within both traditional and hybrid learning formats. Literature Review Students Impacted by Trauma About 34 million children in the United States experience trauma (Child and Adolescent Health Measurement Initiative, 2017). Almost half of all children ages 0-17 have experienced at least one adverse life experience (ACE), and more than 20% of children have experienced two or more ACEs (Child and Adolescent Health Measurement Initiative, 2017). Adverse life experiences can include living on a limited income, having divorced or separated parents, and ESTABLISHING ROUTINES FOR SENSORY AND EMOTIONAL 4 experiencing a death in the family. Other examples of ACEs include witnessing or being a victim of violence, living with a family member with clinical illness, and having a family member with a substance abuse disorder (Child and Adolescent Health Measurement Initiative, 2017). Children who have experienced ACEs are more likely to suffer from chronic health conditions or to have a parent who is in poor health (Bethell, Newacheck, Hawes, & Halfon, 2014). Students who have experienced ACEs are more likely to repeat a grade, have decreased educational engagement, and to struggle academically (Bethell et al., 2014). Traumatic experiences often impact children the most at earlier ages during critical periods of development (Bethell et al., 2014). Young children process trauma at a sensory level as they lack the verbal or cognitive ability to process complex trauma (Finn, Warner, Price, & Spinazzola, 2018). The Neurological Implications of Trauma Sensory Integration is the ability of the nervous system to take information from the environment, organize the information, and interact with the environment effectively (Fraser, MacKenzie, & Versnel, 2017, p. 201). Trauma impacts a childs neurological development, sensory integration, emotional regulation, and occupational performance (Fraser et al., 2017). Students experiencing trauma exist in prolonged states of hyper-arousal resulting in neurological changes and dysfunction (Rinne-Albers, van der Wee, Lamers-Winkelman, & Vermeiren, 2013; Tomalski & Johnson, 2010). Rinne-Albers et al. conducted a systematic review of 27 neuroimaging studies with individuals across the lifespan who experienced trauma. The researchers concluded that individuals exposed to trauma had reduced area and connectivity of the corpus callosum, an important structure for sensory regulation (Rinne Albers et al., 2013). The corpus callosum contains around 190 million axons that transmit sensory information between hemispheres in the brain (Paul, 2011). Reduction in the corpus callosum results in poor ESTABLISHING ROUTINES FOR SENSORY AND EMOTIONAL 5 comprehension, adaptive response, and perception, all of which are essential functions for students within the school environment (Rinne Albers et al., 2013). Additionally, individuals experiencing trauma in childhood have shown structural changes in stress regulating areas of the brain, such as the medial prefrontal cortex, amygdala, and the hippocampus (van der Werff et al., 2013). Therefore, students experiencing trauma have difficulties responding to stress which results in poor self-regulation (Siegel, 2012). When children experience stress from traumatic experiences it affects their ability to modulate sensory stimuli and utilize appropriate coping strategies (Fraser, MacKenzie, & Versnel 2019). Occupational therapists need to use a neurological approach to understand each students needs and plan appropriate interventions. The Neurosequential Model and Sensory Integration The Neurosequential Model of Therapeutics (NMT) states that therapists should address the clients foundational neurological needs before requiring higher neurological processing (Perry, 2006). The therapist should meet the clients basic needs at the brainstem before moving on to the midbrain, limbic system, and cortex respectively (Perry, 2006). Students who have experienced trauma can regulate brainstem functions when given safe, predictable, repetitive sensory input (Perry & Hambrick, 2008, p. 43). Perry & Hambrick state that a childs success depends upon a trusting therapeutic relationship and effective sensory interventions (2008). The Neurosequential Model aligns with the key tenants of the Ayres Sensory Integration frame of reference. Sensory integration researcher and founder Dr. A. Jean Ayres believed that sensory systems work together simultaneously to integrate information. She referred to the vestibular and proprioceptive senses at the brainstem as the foundational, body-centered senses (Ayres, 1974). the child must have vestibular and proprioceptive needs met to successfully interact in ESTABLISHING ROUTINES FOR SENSORY AND EMOTIONAL 6 higher brain functions involving the cortex (Ayres, 1974). A student relies on foundational proprioceptive and vestibular input to integrate vision while reading. A student relies on proprioceptive and vestibular input to maintain postural stability and sit upright in their chair. The student relies on the vestibular sense to aid in gaze stability as they follow each word on the page. Students who have experienced trauma often need additional vestibular and proprioceptive input to modulate and integrate sensory information in the school setting (Whiting, 2018). Students who have experienced trauma often face challenges participating in meaningful learning activities and engaging with their peers (Cahill & Pagano, 2015). Occupational therapists should use neurosequential, sensory-based therapies to meet the students foundational sensory needs, promote self-regulation, and improve academic performance and social participation (Smith Roley, Bissell, & Frolek Clark, 2015). Interventions for Self -Regulation Self-regulation is the ability to regulate sensory information, emotions, and behavior (Shonkoff & Phillips, 2000). Kuypers (2013) states that there are 4 elements of self-regulation: sensory processing, emotional regulation, cognitive regulation, and considering the perspectives of others. Therefore, successful intervention for self -regulation includes both sensory and social emotional components. Occupational therapists commonly utilize both cognitive and occupationbased intervention strategies for self-regulation (Pfeiffer, Clark, & Arbesman, 2018). Occupation-based strategies include students engaging in occupations which promote selfregulation such as yoga, meditation, exercise, etc. Cognitive interventions include metacognitive and mind-body strategies to process and regulate information (Pfeiffer, Clark, & Arbesman, 2018). Common cognitive programs for self-regulation include Kuypers The Zones of Regulation (2013) and Williams and Shellenbergers Alert Program for Self-Regulation ESTABLISHING ROUTINES FOR SENSORY AND EMOTIONAL 7 (1996). Occupational therapists should teach children to use both cognitive and occupation-based strategies for self-regulation. The Role of the School Based Occupational Therapist Occupational therapists have an important role in providing trauma informed selfregulation interventions within the school system. School based occupational therapists must consider client factors, performance patterns, contexts, and environments as they collaborate with the school team to offer students opportunities for self-regulation. Occupational therapists must educate other school professionals on how trauma has impacted a childs self-regulation, educational engagement, and performance. Overall, occupational therapists play a role in consulting and collaborating with a multidisciplinary school team; analyzing environments, tasks, and routines with a trauma-informed sensory-based approach; and providing direct occupational therapy (Whiting, 2018, p. 291). Individuals that school based occupational therapists collaborate with may include other therapists, teachers, principals, teachers, aides, parents, and many other individuals. The PEOP Model for Self-Regulation The Person-Environment-Occupation-Performance (PEOP) model is beneficial to support students with self-regulation. The PEOP model considers the person, environment, and occupation to increase occupational performance (Baum, Christiansen, & Bass, 2015). Considering these three important elements is crucial for sensory integration. The PEOP model considers the physiological, cognitive, spiritual, neurobehavioral, and psychological components of the person. These components are all necessary to understanding the child who has experienced trauma and has sensory needs. When occupational therapists utilize appropriate ESTABLISHING ROUTINES FOR SENSORY AND EMOTIONAL 8 adaptations within a sensory friendly environment, they can increase the childs occupational performance and participation (Schaff, Hunt, & Benevides, 2012). Person. It is critical to understand the sensory and occupational needs of the child to promote occupational engagement and wellbeing. Occupational therapists need to thoroughly assess and understand a childs sensory needs using both formal and informal assessments. OTs can use assessments such as the Sensory Profile, the Sensory Processing Measure (SPM), the Sensory Integration and Praxis Test (SIPT), combined with detailed observation in the school environment. Occupational therapists also must understand the childs attempts at selfregulation. Students who are unaware of self-regulation techniques often worry that they will remain overwhelmed and do not have the ability to self-soothe (Gratz & Roemer, 2004). The occupational therapist must first teach students to identify emotions in themselves and others (Kuypers, 2013). Once students can identify their emotions, the occupational therapist should teach the student to utilize self-selected coping strategies for sensory and emotional regulation (Warner & Koomar, 2014). Occupational therapists should allow students who have experienced trauma to choose their own appropriate coping mechanisms to instill a sense of self-control in the school environment (Petrenchik & Weiss, 2015). Environment. Occupational therapists can support students who have experienced trauma by analyzing and adapting the school environment to meet the students sensory needs. Students who have experienced trauma and have sensory processing disorder often need calming environments to decompress. Calming environments such as sensory rooms encourage students to develop strategies to modulate and integrate sensory information (Lebel & Champagne, 2010). Occupational therapists should collaborate with other professionals at the school to modify classrooms, lunchrooms, and playgrounds to be more sensory friendly environments that ESTABLISHING ROUTINES FOR SENSORY AND EMOTIONAL encourage occupational participation. Additionally, occupational therapists can collaborate with staff to meet student needs within a hybrid learning environment. Occupations. The school based occupational therapist needs to evaluate the occupations that the child engages in at school. These occupations primarily consist of education, social participation, and play. The occupational therapist needs to understand how a childs sensory processing difficulties impede their learning. The OT can then apply interventions to meet sensory needs and increase educational engagement. One of the childs primary occupations is play. Occupational therapists need to incorporate play into sensory interventions. Sensory approaches including play and drawing can help students to process trauma and receive sensory input (Steele & Kuban, 2014). Occupational therapists also need to consider how a childs sensory processing difficulties impact their social participation. Occupational therapists need to promote school wide education on sensory processing difficulties to promote acceptance and inclusion. Conclusion Students who have experienced trauma can have resulting neurological dysfunction including sensory processing difficulties. Sensory processing difficulties can result in decreased engagement in academics, play, and social participation. Occupational therapists must use a client-centered, neurosequential approach to meet foundational sensory needs, teach social emotional skills, and increase occupational participation. Additionally, school based occupational therapists must utilize a team-based approach in analyzing the student, their environment, and their occupations. The therapist can then create adaptations and interventions for the student to increase occupational performance. 9 ESTABLISHING ROUTINES FOR SENSORY AND EMOTIONAL 10 Program Development Needs Based Assessment The programs developed occurred in a public-school district in Central Ohio. The programs took place in three elementary schools. The participating district was in Central Ohio where the population had a median income of $42,753 (U.S. Census Bureau, 2019). Participants included students identified and receiving services through IEPs and 504 plans as well as typically developing peers. According to the Ohio Department of Education, 4.8% of students in this district were Asian or Pacific Islander, 25.4% were black, 7.4% were Hispanic, 9.0% were multiracial, and 53.4% were white (Ohio Department of Education, 2019). Within the district, 14.2% of students had disabilities, 9.5% were English Language Learners, and 36% were economically-disadvantaged (Ohio Department of Education, 2019). The program planning and implementation occurred over a span of 14 weeks with students participating in hybrid learning from weeks 1-8 and students completing in-person learning from weeks 9-14. Each school building completed a needs-based assessment. The preliminary needs-based assessment consisted of a series of related questions for principals delivered via email or during meetings on Google meets. The questions were to assess the social emotional and sensory needs of the students at each school building within a hybrid learning format. Here are the preliminary questions from the needs-based assessment: 1. What additional supports do you think students need to meet their sensory and social emotional needs within the physical school environment? 2. What additional supports do you think students need to meet their sensory and social emotional needs within the virtual environment? ESTABLISHING ROUTINES FOR SENSORY AND EMOTIONAL 11 3. What routines (lunch, recess, morning check-in, end of the day wrap-up, etc.), could benefit from changes to promote wellness? Describe any changes that you think would be helpful. 4. What sustainable programming could benefit the students at the school? For example, social emotional lessons saved for staff, training staff on sensory and social emotional support, etc. The program developer met with related professionals including principals, teachers, the occupational therapist, speech therapist, and school counselors at each building to form a specific plan based on the results of the preliminary needs-based assessment. The staff at each building identified the highest priority needs for their students. Building A The principal and teachers at building A identified check-ins for self-regulation to be the greatest need for their students. The principal and school counselor identified 6 students as needing additional support in self-regulation. The students had varying qualification criteria for receiving special education and or related services in the school environment. Of the 6 students included, 2 students qualified under the category of Autism, 1 qualified under Other Health Impairment (OHI) for anxiety, 1 qualified under OHI for ADHD, 1 qualified under Traumatic Brain Injury (TBI), and 1 qualified under Speech and Language Impairment. Of the 6 students included, 2 students received special education services for educational and behavioral goals, 4 students received direct occupational therapy services in the school, and 2 students received consultative occupational therapy services. The students represented multiple grade levels with 1 student in kindergarten, 2 students in 2nd grade, 1 student in 3rd grade, and 1 student in 5th grade. ESTABLISHING ROUTINES FOR SENSORY AND EMOTIONAL 12 Building B The principal and therapy staff at building B identified that social emotional programming with an emphasis on self-regulation in a group setting would be most beneficial for students. The school previously had a social group called Lunch Bunch in place prior to the COVID-19 pandemic and stated that restarting a similar program would be beneficial for students. The school lost their school counselor prior to the start of program development and needed to offer social emotional programming for students. The building hired a new school counselor in the middle of program implementation. The principal, occupational therapist, and speech and language pathologist identified students that demonstrated social emotional needs and would benefit from additional support. The staff identified 6 students who qualified for special education and related services under the Autism qualification category, 2 students qualified under OHI with ADHD, 1 student qualified with a Specific Learning Disability (SLD), 1 student still in the identification process, and 4 students from the general education classroom to serve as peer models. Building C Morning Meeting. The principal and guidance counselor at building C identified that students in 4th grade required additional support on their virtual weeks. The students participated in asynchronous learning during their virtual weeks and did not have daily check-ins in the morning. The participants at building C included 2 classes of 4th grade students divided into 2 cohorts. Cohort A included 24 students and cohort B included 26 students for a total of 50 students. Within both cohorts, 5 students received special education services through an IEP, 1 student received services under a 504 plan, 3 students were ELL (English Language Learners), and 2 students received speech services. ESTABLISHING ROUTINES FOR SENSORY AND EMOTIONAL 13 Afternoon Meeting. The occupational therapist identified 5 students who would benefit from support in self-regulation. All the students participated in a specially designed learning classroom. Of the 5 students chosen to participate, 4 of the students spent more than 60% of their day in a specially designed learning classroom, and 1 student spent between 21-60% of their day in the specially designed learning classroom. The 5 students met different qualification criteria with 3 students qualifying under Autism, 1 student qualifying under Intellectual Disability, and 1 student qualifying under Developmental Disability. The students were in different grades levels with 1 student in 1st grade, 1 student in 2nd grade, 2 students in 4th grade, and 1 student in 5th grade. Most students, (3/5) were already receiving occupational therapy services for fine motor, handwriting, and sensory needs. Program Planning Core Curriculum Each building had students with identified self-regulation and wellness needs. The district was already incorporating elements of the self-regulation curriculum The Zones of Regulation (Kuypers, 2013). The Zones of Regulation is a curriculum designed to teach students to recognize their emotional needs and utilize strategies for self-regulation. The Zones of Regulation uses colors to correspond to emotional states. A student is in the blue zone when they are feeling sad, sick, tired, bored, or are moving slowly (Kuypers, 2013). A student is in the green zone when they are feeling happy, calm, focused, and ready to learn (Kuypers, 2013). A student is in the yellow zone when they start to lose control and feel frustrated, worried, silly/wiggly, or excited (Kuypers, 2013). A student is in the red zone when they feel angry, terrified, and have lost control (Kuypers, 2013). Most of the students at each building were already familiar with basic language from the Zones of Regulation from exposure in their general ESTABLISHING ROUTINES FOR SENSORY AND EMOTIONAL 14 education and special education classrooms. However, there were also new students to the district who were less familiar with the curriculum and required an introduction to the material. Self-regulation Sessions, Circle of Friends and Afternoon Meeting The Self-regulation Sessions at building A, Circle of Friends group at building B, and Afternoon Meetings at Building C all shared the same goal and objectives with similar activities. All 3 programs needed to contain curriculum to help students identify their social emotional and sensory needs, identify effective self-regulation strategies, and effectively utilize strategies to self-regulate. The activities utilized in each building varied based on the needs and skills of the students, the environment (virtual or in-person), and the number of students participating in each session. Goals and Objectives. Goal: Students will effectively utilize an effective coping strategy to self-regulate when they are dysregulated. Objectives: Students will identify which emotions are associated with each zone. Students will correctly identify a self-regulation strategy for a character to use in a social story or video clip. Students will identify the zone they are in at the beginning and end of each session. Students will identify 2-3 strategies that they can use to self-regulate when in each zone. Students will practice using sensory strategies for self-regulation. Morning Meeting The virtual morning meetings fulfilled a similar function to the morning meetings the 4th grade participants had with their classroom teachers. The teachers and principal wanted students to maintain purposeful routines during their virtual learning days. The program developer created ESTABLISHING ROUTINES FOR SENSORY AND EMOTIONAL 15 the sessions to fulfill the routine the students had in place as well as to facilitate opportunities for students to develop strategies for self-regulation and wellness. Goals and Objectives. Goal: Students will effectively utilize an effective coping strategy to self-regulate when they are feeling dysregulated. Objectives: Students will identify which emotions are associated with each zone. Students will identify the zone they are in at the beginning and end of each session. Students will identify 2-3 strategies that they can use to self-regulate when in each zone. Students will practice using sensory strategies for self-regulation. Program Implementation Building A- Self-regulation Sessions The 6 students participated in 30-minute, in-person sessions twice a week for a total of 9 sessions. Most of the students met for individual sessions, only two students attended the sessions together. Each session focused on selecting and utilizing self-regulation strategies. Students participated in activities to identify the emotions in each zone. After learning the emotions and behaviors associated with each zone, students created a graphic organizer with pictures of 2-3 strategies they would use to self-regulate in each zone (see Appendix B). The program developer gave teachers, therapists, and other related professionals a copy of each students self-regulation preferences so staff could support their students in self-regulation. Students participated in the discussion of social stories related to self-regulation. Students practiced self-regulation techniques such as movement breaks, heavy work, the use of fidgets and other sensory tools, belly breathing, meditation, and more (see Appendix C). Students reported their zone during the beginning, end, and often middle of the session to determine if ESTABLISHING ROUTINES FOR SENSORY AND EMOTIONAL 16 students were effectively utilizing self-regulation strategies to return to a regulated state (the green zone). The program developer notified relevant staff if a student was in the yellow or red zone during a session to allow for extended or more frequent breaks as needed. Building B- Circle of Friends Social Emotional Group Teachers and therapists supported the program developer in selecting students for social emotional groups based on need. The teachers and therapists selected 10 students receiving special education and related services to participate. The groups also consisted of 4 students from general education classrooms to serve as peer models. All students were in grades 2-5. An OT graduate clinician, SLP graduate clinician, and school counselor planned and led the sessions. The group met once a week for 30 minutes for 6 weeks. Students participated in social stories, games, movement breaks, and discussion centered around emotional regulation. Students met virtually for the first meeting and in person for the last 5 sessions. The first 4 sessions each focused on a different zone or emotional state in the Zones of Regulation along with strategies to self-regulate when in that zone. The last 2 sessions focused on expected and unexpected behaviors, flexible thinking, and related self-regulation Building C Morning Meetings. Two cohorts of 4th grade students participated in virtual morning meeting sessions with each cohort switching between in person and virtual learning every other week. Students met for sessions on Mondays-Fridays unless they had the day off from school. Due to snow days and other scheduling restraints, cohort A met for 11 sessions and cohort B met for 3 sessions. Morning Meetings consisted of social emotional check-ins using the Zones of Regulation curriculum, a thought-provoking question of the day, and a sensory based movement activity such as yoga. The program developer also taught students strategies for self-regulation ESTABLISHING ROUTINES FOR SENSORY AND EMOTIONAL 17 throughout the session. Students checked in at the beginning of the session, listing their emotional state or zone on a survey made and tracked in google forms. Students checked out of the morning meeting by again listing their emotional state or zone to measure their progress in self-regulation across sessions. Afternoon Meetings. Five students participated in afternoon meetings as a group within their specially designed learning classroom. The group met twice a week for a total of 10 sessions. The intervention specialist and classroom aides also participated in facilitating the group and assisting students. Students identified the emotions in each zone, identified 2-3 strategies they would use to self-regulate in each zone, discussed social stories, and practiced self-regulation techniques. Each session consisted of discussion about strategies for selfregulation, a related fine motor or sensory activity, and a movement break that included yoga and deep breathing. Students reported their zone during the beginning, end, and often middle of the session. The program developer recorded each students emotional state or zone along with whether the student effectively utilized a self-regulation strategy to return to a regulated state (the green zone). Program Evaluation, Results, and Limitations Self-Regulation Sessions at Building A Program Evaluation. The program developer recorded each students emotional state at the beginning and end of each session to determine if each student was able to self-regulate. The students self-reported state was the state recorded unless the student showed overt signs of being in another zone. For example, if a student stated that they were in the green zone but showed observable signs of frustration or sadness such as kicking, yelling, or crying, then the program developer recorded the zone that matched the behaviors the students portrayed (yellow, red, or ESTABLISHING ROUTINES FOR SENSORY AND EMOTIONAL 18 blue zone). The program developer recorded which students were able to use coping strategies if they were dysregulated to return to a regulated state at any point in the session. This means the student was in the yellow, red, or blue zone at some point of the session and was able to get to the green zone by the end of the session. When students were able to go from a dysregulated state to a regulated state, the program developer labelled this as a positive change. The program developer recorded the number of students who experienced a positive change in each session. Results. The percentage of students ending each session in a regulated state ranged from 60-100% (see Table 1). There was a range of 1-4 positive changes per session. This meant that 14 students per session were able to successfully regulate when they were dysregulated. Students responded well when participating in movement breaks at the beginning of the session. Students were often more successful in self-regulating when they had a movement break prior to the start of fine motor or discussion-based activities. Many students reacted positively to sensory movement stations and play based movement breaks such as Simon Says that allowed for interaction with peers. Table 1 Self-Regulation During Self-Regulation Sessions Session 1 2 3 4 5 6 7 8 9 Percentage of students who were self-regulated by the end 100% 100% 83.3% 83.3% 60% 83.3% 83.3% 100% 100% 1 2 1 2 2 4 3 3 3 of the session The number of students who were dysregulated and returned to a regulated state Limitations. The program developer relied on the students to report their emotional state unless the students portrayed overt signs of being in another zone. Students reported their own emotional state verbally and students may not have always been accurate in reporting their ESTABLISHING ROUTINES FOR SENSORY AND EMOTIONAL 19 emotional state. The program developer only collected data within 30-minute sessions during a scheduled time frame. The data is not reflective how students were able to self-regulate across different environments or times in the day. Building B-Circle of Friends Social Emotional Group Program Evaluation. The program developer recorded each students emotional state at the beginning and end of the session to determine if each student was able to self-regulate within the session. Like the self-regulation sessions in Building A, the students self-reported state was the state recorded unless the student showed overt signs of being in another zone. The program developer also recorded the number of students who were able to self-regulate or have a positive change in emotional state. Students completed a 6-question pre-assessment in-person during the second session with verbal instructions and each question read aloud (see Appendix A). Students rated their social emotional awareness and self-regulation capabilities by responding to statements on a scale of always, sometimes, and never. Statements included, If I have a problem, I can solve it or find someone to help me solve it and When I am upset, I can get back to the green zone. Students responded to the survey as a post-test in a paper and pencil format during the last session to examine their skills in self-regulation. Results. Many students, (70%) left the first virtual session feeling regulated and in the green zone (see Table 2). There were 3 positive changes in the first session. This means 3 students started the session feeling dysregulated (in the blue, yellow, or red zone) and ended the session feeling regulated (in the green zone). Students had difficulty adjusting to the changes that occurred with the transition to in person meetings during session 2. Due to scheduling restrictions, the students were only able to meet during a time that impacted their recess. Many ESTABLISHING ROUTINES FOR SENSORY AND EMOTIONAL 20 students commented that they were frustrated or sad to have less recess time. Fewer students ended the session in the green zone (33.3%-36.4%) during sessions 2 and 3 (see Table 2). During session 3 there was a slight improvement as 3 students were able to self-regulate with a movement break and get to the green zone by the end of the session. Students had a longer movement break at the start of session 4 and the session was shorter to allow students to have more recess time. During session 4 there was some improvement with 60% of students ending the session in the green zone. The staff and program developer were able to implement changes to allow students to have a full recess and still meet for group during sessions 5 and 6. The group facilitators split the group of students into 2 smaller groups based on grade level for the last 2 sessions. The 2 groups of students met outside for the final 2 sessions to allow more physical activity and social distancing. The students responded positively to these changes with most students starting the last 2 sessions in the green zone. All the students who were dysregulated at the beginning of the final 2 sessions (2 students in session 5 and 1 student in session 6) were able to regulate to get back to the green zone. Students responded to the 6-question social emotional assessment at the start of the sessions and after the completion of the sessions (see Figures 1-6). There were 5 students who participated throughout the program. This means the pre and post assessment data only reflects these 5 students. One less student responded never on each question on the post test. For example, on the pre-test a student claimed that they never knew how others felt, however on the post-test they responded that they sometimes knew how others felt (see Figure 5). All students at least felt that they sometimes understood how others felt. Two students responses reflected that they felt understood by others more frequently and could work well with those in their class more frequently (see Figures 2 and 3). It is important to note that 2 students reported ESTABLISHING ROUTINES FOR SENSORY AND EMOTIONAL 21 most of the positive changes in the assessment data and the other 3 students had responses which remained largely unchanged. Table 2 Self-Regulation During Circle of Friends Social Emotional Group Session Percentage of students who were self-regulated by the end of the session The number of students who were dysregulated and returned to a regulated state 1 2 3 4 5 6 70% 33.3% 36.4% 60% 100% 100% 3 1 3 2 2 1 Figure 1 Pre-test "If I have a problem, I can solve it or find someone to help me solve it." Never 1 (20%) Always 2 (40%) Post-test "If I have a problem, I can solve it or find someone to help me solve it." Never 0% Sometimes 3 (60%) Always 2 (40%) Sometimes 2 (40%) Always Sometimes Never Always Sometimes Never ESTABLISHING ROUTINES FOR SENSORY AND EMOTIONAL 22 Figure 2 Pre-test "I feel understood by others" Always Never 0 (0%) 1 (20%) Sometimes 4 (80%) Always Sometimes Never Post-test "I feel understood by others" Never 0 (0%) Always 1 (20%) Sometimes 4 (80%) Always Sometimes Never Figure 3 Pre-test "I can work well with anyone in my Never 1 (20%) class" Always 1 (20%) Post-test "I can work well with anyone in my class" Never 0 (0%) Always 2 (40%) Sometimes 3 (60%) Sometimes 3 (60%) Always Sometimes Never Always Sometimes Never Figure 4 Post-test Pre-test "I know how I feel." Never 1 (20%) Sometimes 2 (40%) Sometimes 1 (20%) Always "I know how I feel." Never 0 (0%) Always 3 (60%) Always 3 (60%) Sometimes Never Always Sometimes Never ESTABLISHING ROUTINES FOR SENSORY AND EMOTIONAL 23 Figure 5 Pre-test "I know how others feel." Never 1 (20%) Always 2 (40%) Sometimes 2 (40%) Always Post-test "I know how others feel." Never Always 0 (0%) 1 (20%) Sometimes 4 (80%) Sometimes Never Always Sometimes Never Figure 6 Pre-test When I am upset, I can get back to the green zone. Never 0 (0%) Always 1 (20%) Never 1 (20%) Sometimes Always 1 (20%) Sometimes 4 (80%) Sometimes 3 (60%) Always Post-test When I am upset, I can get back to the green zone. Never Always Sometimes Never Limitations. The group facilitators and students experienced challenges in scheduling due to restrictions and safety procedures related to COVID-19. Students were upset by earlier changes in routine which is evident in the results from sessions 2-4. Only 6- 8 students participated in the last 2 sessions to maintain social distancing and keep students within their homeroom groups. Only 5 students participated throughout the sessions and were able to provide pre and post assessment data. The group facilitators created the pre and post assessment which was not a validated assessment. It would be beneficial to use a validated assessment that is sensitive to change. The answer choices of never, sometimes, and always may have been too divergent to accurately portray each students self-perceived social emotional skills and measure change. The ESTABLISHING ROUTINES FOR SENSORY AND EMOTIONAL 24 assessment may have been more accurate and sensitive to change if it included a greater gradation of answer choices. It is important to note that the self-reported assessment data is subjective, based on the students perception and understanding of each question which may not be accurate in all cases. Building C Morning Meetings. Program Evaluation. Students met virtually for 20-minute sessions on Google Meets. The number of students attending varied each session. The program developer sent a link to a survey on Google Forms in the chat box. Students accessed the form at the beginning and end of each session and selected their emotional zone through the survey. The results listed in Table 3 and Table 4 depict how many students left the session in a regulated state (in the green zone). Tables 3 and Table 4 list how many students went from a dysregulated state (blue, yellow, or red zone) to a regulated state (green zone). Results. The percentage of students ending the session in the green zone was variable and ranged from 44.4% to 88.9%. The most common zone that students listed other than the green zone was the blue zone which corresponds with feeling sad, tired, bored, or sick. Students frequently responded that they felt tired during morning meetings since it occurs at the start of their day. Many students responded positively to fast paced exercise activities completed at the start of morning meetings and stated that these activities helped them go from feeling tired (in the blue zone) to feeling alert and ready to learn (in the green zone). There was a range of 1-5 positive changes per session. This means 1-5 students felt dysregulated at the beginning of the session but were able to self-regulate by the end of the session. ESTABLISHING ROUTINES FOR SENSORY AND EMOTIONAL 25 Table 3 Self-Regulation in Cohort A of Morning Meetings Session 1 2 3 4 5 6 7 8 9 10 11 Percentage of students who were self- 60% 44.4% 72.7% 81.8% 50% 50% 66.7% 50% 54.5% 70% 71.4% 2 2 1 3 2 2 2 2 3 5 3 regulated by the end of the session The number of students who were dysregulated and returned to a regulated state Table 4 Self-Regulation in Cohort B of Morning Meetings Session Number of students who were self-regulated by the end of the session The number of students who were dysregulated and returned to a regulated state 1 2 3 76.9% 88.9% 75% 3 2 1 Limitations. Students were unable to meet on several days due to snow days, and district holidays. Cohort B was only able to meet for 3 sessions due to scheduling constraints. The sessions were in a virtual format through Google Meets with approximately 8-15 students participating per session. The virtual format along with the larger number of participants made it more challenging to check in with students individually to monitor self-regulation. Additionally, many students logged in for part of the session, only completing the survey either at check in or check out. The program developer was unable to analyze student data for changes in emotional state if that student did not both check in and out of the session. Afternoon Meetings. ESTABLISHING ROUTINES FOR SENSORY AND EMOTIONAL 26 Program Evaluation. Students in this group also checked in at the beginning and end of the session with their emotional state. The students self-reported state was the state recorded unless the student showed overt signs of being in another zone. The program developer recorded the number of students who ended the session feeling regulated (in the green zone) as well as the number of students who experienced a positive change during each session. Results. The percentage of students ending the session in the green zone typically ranged from 80-100% (see Table 5). All students stayed regulated and in the green zone during session 4. During the 6th session, 50% of students (2/4) ended the session in the green zone. There was a range of 1-3 students per session who experienced a positive change as they were able to utilize coping strategies to go from a dysregulated state to a regulated state. Students in this group also responded positively to sensory stations and all students self-regulated by the end of the sessions which included sensory stations. Table 5 Self-Regulation in Afternoon Meetings Session 1 2 3 4 5 6 7 8 9 10 11 12 Number of students who were self- 100% 80% 80% 100% 100% 50% 80% 100% 100% 100% 100% 100% 1 1 1 2 1 2 1 2 2 3 1 regulated by the end of the session The number of students who were dysregulated and returned to a regulated state All students stayed regulated Limitations. The Afternoon Meetings were like the Self-Regulation Sessions in structure and program evaluation. The program developer only collected data within 30-minute sessions during a ESTABLISHING ROUTINES FOR SENSORY AND EMOTIONAL 27 scheduled time frame. The data is not reflective how students were able to self-regulate across different environments or times in the day. Discussion and Impact Establishing Self-Regulation Routines Amid Changing Contexts The program developer implemented each program in the middle of the COVID-19 pandemic with students and staff experiencing frequent transitions. The purpose of each program was to support students in creating purposeful routines for self-regulation. It was important to adapt to changing contexts and implement necessary changes while still maintaining elements of routine and consistency for students. The program developer and staff at Building C planned the Morning Meetings to allow 4th grade students to maintain their purposeful morning routine and promote wellness and selfregulation. The program developer maintained many elements of their previous morning meetings to allow for consistency. As students participated in Morning Meetings, it became apparent that many students were tired and needed to engage in physical activity at the start of their day to regulate. Students responded well to participating in exercises at the start of the meeting, before engaging in cognitive or discussion-based activities. Many students also responded that they preferred faster paced aerobic exercises versus slower exercises to feel more alert. Maintaining the overall routine of morning meetings while making these small changes resulted in positive feedback from several students. The Circle of Friends social emotional group experienced many changes with the transition from virtual to in-person learning as well as scheduling changes to allow students to still have their recess time. Students were happier and more regulated when they had their full recess and participated in the group outside. Students were engaged when participating in play- ESTABLISHING ROUTINES FOR SENSORY AND EMOTIONAL 28 based activities with peers. The group now has a more ideal schedule and structure moving forward. The SLP, OT, and school counselor will continue to plan and implement the group. The Personal Nature of Self-Regulation Self-regulation is personal, and each student required a unique set of strategies to selfregulate. The students who participated in Afternoon Meetings and the Self-Regulation Sessions all listed strategies in a graphic organizer that they would find helpful to utilize to self-regulate in each emotional zone. Each students graphic organizer looked different with a distinct combination of preferred strategies. Students were more successful when staff provided them with opportunities to try new strategies, allowed them to reflect on which strategies were helpful, and supported them in applying strategies in context. Each student required different support to engage in a strategy when dysregulated. Some students would independently choose a coping strategy. Other students were able to select a strategy from a graphic organizer, while some students needed physical objects to cue them. For example, one student was able to choose appropriate sensory materials to self-regulate when presented with an exercise ball to bounce on or a weighted crate to pull. Some students needed to talk about a topic of interest to distract them from the problem which troubled them. Other students responded well to a break in a quiet corner or hallway. It was important to recognize each students needs, and the visible signs they gave in the moment to support students in utilizing appropriate coping strategies. The Importance of Occupational Engagement for Self-Regulation Students experienced positive outcomes when they engaged in occupations that promoted self-regulation. Students engaged in occupation by using sensory materials, performing exercises, creating artwork, and engaging in play-based activities with peers and staff. The sensory movement stations allowed students to explore sensory materials and engage in ESTABLISHING ROUTINES FOR SENSORY AND EMOTIONAL 29 occupation. Students responded well to these stations and many students were able to identify which activities they would engage in based on what zone they were in with more certainty after engaging in the activity. Students responded well to activities like emotions charades and Simon Says to develop social emotional and self-regulation skills. When students participated in playbased activities with peers they were often more engaged and regulated. Throughout the project many students identified self-selected occupations such as painting and meditation that were interest based and became effective self-regulation strategies. Students were successful both when engaging in meaningful occupations individually and when interacting in play-based activities with peers. Conclusion Occupational therapists can support students by providing meaningful routines that promote self-regulation. It is crucial that occupational therapists maintain meaningful routines for their students while also applying necessary changes to program implementation. Occupational therapists will need to collaborate with a variety of individuals including other staff members, administrators, and parents to make their mission successful. Occupational therapists must recognize the personal nature of self-regulation and support students in utilizing individualized strategies. Additionally, occupational therapists should include occupation-based interventions, giving students opportunities to try a variety of strategies. ESTABLISHING ROUTINES FOR SENSORY AND EMOTIONAL 30 References Anderson, S., Bartholow, B., Snow, J., Stratiner, M., Nash, J., & Jirikowic, T. (2017). Developing self-regulation in children with FASD using the Zones of Regulation. OT Practice, 2(4), 57. American Occupational Therapy Association. (2014). AOTA practice advisory on occupational therapy in response to intervention. Retrieved from https://www. aota.org//media/corporate/files/practice/children/browse/school/rti/aota%20 rti%20practice%20adv%20final%20%20101612.pdf Ayres, A. J. (1974). The development of sensory integrative theory and practice. Dubuque, IA: Kendall Hunt. Baum, C. M., Christiansen, C. H., & Bass, J. D. (2015). The person-environment-occupationperformance (PEOP) model. In C. H. Christiansen, C. M. Baum, & J. D. Bass (Eds.), Occupational therapy: Performance, participation, and well-being (4th ed., pp. 49-56). Thorofare, NJ: SLACK Incorporated. Bethell, C. D., Newacheck, P., Hawes, E., & Halfon, N. (2014). Adverse childhood experiences: Assessing the impact on health and school engagement and the mitigating role of resilience. Health Affairs (Project Hope), 33(12), 21062115. https://doi.org/10.1377/hlthaff.2014.0914 Brooks, S.K., Webster, R.K., Smith, L.E., Woodland, L., Wessely, S., Greenberg, N., et al. ESTABLISHING ROUTINES FOR SENSORY AND EMOTIONAL 31 (2020). The psychological impact of quarantine and how to reduce it: Rapid review of the evidence. Lancet, 395(10227), 912920. Cahill, S. M., & Pagano, J. L. (2015). Reducing restraint and seclusion: The benefit and role of occupational therapy. Bethesda, Maryland: AOTA School Mental Health Toolkit. Champagne, T. (2011). Attachment, trauma, and occupational therapy practice. OT Practice, 16(5), C1C8. Child and Adolescent Health Measurement Initiative. (2017). A national and across-state profile on Adverse Childhood Experiences among U.S. children and possibilities to heal and thrive. Retrieved from https://www.cahmi.org/wpcontent/uploads/2018/05/aces_brief_final.pdf Collaborative for Academic, Social, and Emotional Learning. (2012). CASEL program guides: Effective social and emotional learning programs. Retrieved from http://www.casel.org/guide/ Fegert, J. M., Vitiello, B., Plener, P. L., & Clemens, V. (2020). Challenges and burden of the coronavirus 2019 (COVID-19) pandemic for child and adolescent mental health: A narrative review to highlight clinical and research needs in the acute phase and the long return to normality. Child & Adolescent Psychiatry & Mental Health, 14(1), 111. https://doi.org/10.1186/s13034-020-00329-3 Finn, H., Warner, E., Price, M., & Spinazzola, J. (2018). The boy who was hit in the face: Somatic regulation and processing of preverbal complex trauma. Journal of Child and ESTABLISHING ROUTINES FOR SENSORY AND EMOTIONAL 32 Adolescent Trauma, 11(3), 277288. doi:10.1007/s40653-017-0165-9 Fraser, K., MacKenzie, D., & Versnel, J. (2017). Complex trauma in children and youth: A scoping review of sensory-based interventions. Occupational Therapy in Mental Health, 33(3), 199216. Fraser, K., MacKenzie, D., & Versnel, J. (2019). What is the current state of occupational therapy practice with children and adolescents with complex trauma? Occupational Therapy in Mental Health, 35(4), 317338. doi:10.1080/0164212X.2019.1652132 Gratz, K. L., & Roemer, L. (2004). Multidimensional assessment of emotion regulation and dysregulation: Development, factor structure, and initial validation of the difficulties in emotion regulation scale. Journal of Psychopathology and Behavioral Assessment, 26, 4154. http://dx.doi.org/10.1007/ s10862-008-9102-4 Huremovi, D. (2019). Psychiatry of pandemics: A mental health response to infection outbreak. Springer International Publishing. Kuypers, L. M. (2011). The zones of regulation: A curriculum designed to foster self-regulation and emotional control. Social Thinking. Kuypers, L. (2013). The zones of regulation: A framework to foster self-regulation. Sensory Integration Special Interest Section Quarterly, 36(4), 14. Ohio Department of Education. (2019). Westerville city: District details. 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From neurons to neighborhoods: The science of early childhood development. Washington, DC: National Academy Press. Siegel, D. J. (2012). The developing mind: How relationships and the brain interact to shape who we are (2nd ed.). New York, NY: The Guilford Press. Smith Roley, S., Bissell, J., & Frolek Clark, G. (2015). Occupational therapy for children and youth using sensory integration theory and methods in school-based practice. American Journal of Occupational Therapy, 69, 120. Stark, A. M., White, A. E., Rotter, N. S., & Basu, A. (2020). Shifting from survival to supporting resilience in children and families in the COVID-19 pandemic: Lessons for informing U.S. mental health priorities. Psychological Trauma: Theory, Research, Practice & Policy, 12, S133S135. https://doi.org/10.1037/tra0000781 Steele, W., & Kuban, C. (2014). Healing trauma, building resilience: SITCAP in action. Reclaiming Children and Youth, 22, 1821. ESTABLISHING ROUTINES FOR SENSORY AND EMOTIONAL 35 Substance Abuse and Mental Health Services Administration (SAMHSA). (2020a). Double jeopardy: COVID-19 and behavioral health disparities for Black and Latino communities in the US. https://www.samhsa.gov/sites/ default/files/covid19-behavioralhealthdisparities-black-latino-communities.pdf Substance Abuse and Mental Health Services Administration (SAMHSA). (2020b). Intimate partner violence and child abuse considerations during COVID-19. https://www.samhsa.gov/ sites/default/files/social-distancingdomestic-violence.pdf Tomalski, P., & Johnson, M. (2010). The effects of early adversity on the adult and developing brain. Current Opinion in Psychiatry, 23(3), 233238. doi:10.1097/YCO. 0b013e3283387a8c Turan, B., Kocarslan, N., Gulsen, M., & Dursun, O. B. (2020). Your country is your routine: the evacuation, quarantine, and management of behavioral problems of a child with autism during COVID-19 pandemic. Dusunen Adam: Journal of Psychiatry & Neurological Sciences, 33(3), 310312. https://doi.org/10.14744/DAJPNS.2020.00095 U.S. Census Bureau. (2019). Quick facts: Westerville City Ohio. Retrieved from https://www.census.gov/quickfacts/fact/table/westervillecityohio/PST045219 van der Werff, S. J. A., Pannekoek, J. N., Veer, I. M., van Tol, M.-J., Aleman, A., Veltman, D., van der Wee, N. J. A. (2013). Resting-state functional connectivity in adults with childhood emotional maltreatment. Psychological Medicine, 43(9), 18251836. doi:10.1017/S0033291712002942 Warner, E., Cook, A. W. A., & Koomar, J. (2014). SMART sensory motor arousal regulation ESTABLISHING ROUTINES FOR SENSORY AND EMOTIONAL 36 treatment: A manual for therapists working with children and adolescents: A bottom up approach to treatment of complex trauma (2nd ed.). Brookline, MA: Trauma Center at JRI. Whiting, C. C. (2018). Trauma and the role of the school-based occupational therapist. Journal of Occupational Therapy, Schools & Early Intervention, 11(3), 291301. Williams, M. S., & Shellenberger, S. (1996). How Does Your Engine Run?: A Leaders Guide to the Alert Program for Self-regulation. TherapyWorks, Inc. ESTABLISHING ROUTINES FOR SENSORY AND EMOTIONAL Appendix A Circle of Friends Assessment 1. If I have a problem, I can solve it or find someone to help me solve it. o Always o Sometimes o Never 2. I feel understood by others. o Always o Sometimes o Never 3. I can work well with anyone in my class. o Always o Sometimes o Never 4. I know how I feel. o Always o Sometimes o Never 5. I know how others feel. o Always o Sometimes o Never 6. When I am upset, I can get back to the green zone. o Always o Sometimes o Never 37 ESTABLISHING ROUTINES FOR SENSORY AND EMOTIONAL 38 Appendix B Session to Identify Self-Regulation Strategies Adapted with materials from Zones of Regulation Lesson 13: The Toolbox (Kuypers, 2011, p. 136) Introduction: We all have different strategies that help us to feel calm and get back to the green zone. We might need something different when we feel mad versus when we feel sad. For example, we might want a hug when we feel sad, but we might need a quiet break to be alone when we are mad. Some people like to lift heavy things or exercise when they feel anxious or worried. Today we are going to talk about strategies that might help you to feel better. These strategies are like tools in your toolbox that you can use to get back to the green zone (Kuypers, 2011, p.136). Activity: Give students a graphic organizer that has each of the zones listed on it (yellow, red, green, blue). Next to each zone have a section where students can write or cut and paste pictures of strategies in each zone to self-regulate. The book The Zones of Regulation: A Curriculum Designed to foster Self-regulation and Emotional Control has this type of graphic organizer to assess a students preferred self-regulation strategies (Kuypers, 2011, p.142). Read students a social story about what our bodies look and feel like in each zone. Use a social story that also includes potential strategies that students could use in each zone. After reading about each zone, pause and ask students what strategies they prefer to use in each zone. Have the students write or cut and paste images of the strategies they would use in each zone. When the graphic organizer is complete, you may laminate it for use. Alternatively, you can add Velcro to the pictures of strategies to make them into movable pieces instead of pasted onto the paper. ESTABLISHING ROUTINES FOR SENSORY AND EMOTIONAL 39 Appendix C Sensory Movement Stations Introduction: Last time we talked about what strategies you might use to get back to the green zone. Today we are going to try using different strategies to see what might work for you. Activity: 1. Set up stations with a variety of materials that students previously identified as being helpful when they created their graphic organizers. For example, if students identified that they would like to pull something heavy, include a heavy crate with a rope tied to it so that students can try pulling the crate. You can also put out additional materials for students to try. Other materials could include desk cyclers, exercise balls, a quiet corner with headphones, a sensory walk, and more. 2. Introduce each station and demonstrate how to properly use each item. You can also relate these items to how you like to use them to provide an example. For example, you might say, At this station you can pull a heavy crate. I like to pull heavy things when I am feeling frustrated. You can see if you like it too. 3. Set timers for each station and allow students to try each station. Supervise each student and give them feedback on how to use the materials. 4. Ask students how they like each strategy and what zone they would use that strategy in. 5. Edit the students graphic organizer to reflect new choices for strategies based on the results of the activity. Notify related staff to each students preferred strategies. ESTABLISHING ROUTINES FOR SENSORY AND EMOTIONAL Kuypers, L. (2013). The zones of regulation: A framework to foster self-regulation. Sensory Integration Special Interest Section Quarterly, 36(4), 14. 40  ...

... Employability development: A two generation approach Erika Wilson May, 2021 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: Dr. Taylor McGann, MS, OTR,OTD A Research Project Entitled Employability development: A two-generation approach 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 Erika Wilson Occupational Therapy Student Approved by: Research Advisor (1st Reader) Date 2nd Reader 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 2 Running head: EMPLOYABILITY DEVELOPMENT: A TWO-GENERATION APPROACH Employability development: A two generation approach Erika Wilson University of Indianapolis 3 Employability development: A two-generation approach Abstract 4 Objective: Develop a program providing education and skill development to increase employability for success in the 21st century work force. Background: Families face many sources of risk and barriers to long-term success. Poverty and low economic status can be the most significant barrier. One way to address these obstacles is through a two generation approach. This approach aims to address challenges in an intergenerational concept to achieve greater success. Method: A pilot study was conducted with staff members of a mental health organization. A pilot program was completed due to barriers in participant recruitment for the program. The program is titled R.E.A.C.H and has four educational topics: mindset, self-efficacy, work competency skills, and launching a career. Conclusion: The program successfully met its goal of developing employment skills for the 21st century workforce. The program did not reach a two generation implementation due to recruitment challenges. The program can be successfully implemented in the future with improvement in recruitment and marketing efforts. Implication: This program is the first two generation program to develop the skills for increased employability in parents and children simultaneously. This program increases individuals autonomy and fulfillment in the occupation of work. R.E.A.C.H addresses sources of risk to break down barriers for long-term success. Key words: two-generation approach, risk, skill development, parents, employability, life-long outcomes Running head: EMPLOYABILITY DEVELOPMENT: A TWO-GENERATION APPROACH 5 Employability development: A two-generation approach Introduction A working definition for at-risk youth is an adolescent experiencing personal, contextual, or environmental barriers to healthy and age-appropriate occupations (Shae & Jackson, 2015). At- risk youth may face many different obstacles to success, including learning and emotional disabilities, economic disadvantages, psychosocial challenges, and adverse childhood experiences (Balisteri & Alvira-Hammond, 2016; Shae & Jackson, 2015). Contributing risk factors can come from both internal and external sources. Internal risk includes mental and psychosocial challenges. Data on mental health diagnosis for children and adolescents in 2019 shows that from ages 3 to 17, approximately 4.5 million individuals have a diagnosis of a behavior problem, 4.4 million have a diagnosis of anxiety, and 1.9 million have a diagnosis of depression (Ghandour, 2019). The COVID-19 pandemic has undoubtedly raised these numbers substantially in not only adolescents but in all ages (Usher, Durkin, and Bhullar, 2020). External sources of risk include family relationships, environment, economic status, and adverse childhood experiences (ACE). Adverse childhood experiences occur with emotional, physical, or sexual abuse, household substance abuse, household mental illness, or incarceration of a parent (Balisteri & Alvira-Hammond, 2016; Wade et al., 2016). Experiencing one or multiple ACEs has detrimental impacts on future health outcomes and well-being (Balisteri & Alvira-Hammond, 2016; Wade et al., 2016). The environment, in which one lives, can also have detrimental impacts throughout the lifetime. Living in environments involving poverty, access to drugs and weapons, family instability, violence, or criminal actions can create long-term negative impacts (Balisteri & Alvira-Hammond, 2016; Gruendel, 2015; Wade et al., 2016). Poverty can negatively Employability development: A two-generation approach 6 affect multiple generations. Chronic poverty creates biochemical changes in brains of adults and children that has negative implications on physical health, mental health, and executive functions (Mani, Mullainathan, Shafir, & Zhao, 2013). Not only can poverty have negative health implications, but it can also lead to lifelong educational, career, and financial downfalls. Adults who grew up in poverty as children complete two fewer years of schooling, and by age 30 will earn less than half the salaries of individuals who did not experience poverty in childhood (Duncan, Magnuson, and Votruba-Drzal, 2014). Addressing risk sources, both internal and external, is essential to improving life-long outcomes. A Two Generation Approach One way to address the needs of at-risk youth is through a two generation approach. Two generation approaches aim to address challenges in an inter-generational concept to achieve greater success. Programs developed using this approach are designed with coordinated agendas to work with both youth and adults simultaneously. This approach has historically aimed to interrupt the cycle of poverty (Gruendel, 2015; Lombardi, Mosel, Patel, Schumacher, & Stedron, 2014). In low-income homes, children cannot thrive when there is parental struggle to make ends meet; conversely, parents cannot succeed without meaningful support for their children (Gruendel, 2014). Two generation programs consider the importance of attending to the needs of parents and children for improved success in long-term outcomes. This approach addresses a need to provide early educational assistance for children and simultaneously work with parents to improve the home environment and family dynamics through employment training and skill development (Chase-Lansdale & Brooks-Gunn, 2014). Through two-generational programs, youth obtain higher quality education and developmental skills while parents address jobreadiness, work support, social capital, and parent-child relationship enrichment (Lombardi et al., Running head: EMPLOYABILITY DEVELOPMENT: A TWO-GENERATION APPROACH 2014). Research shows positive impacts of participation in two generation programs including, 7 higher levels of earning over a five year period for parents and significantly higher school readiness scores in children (Chase-Lansdale & Brooks-Gunn, 2014). Participation in coordinated programs by parents and children can lead to multiplier effects for multigenerational impact, and create lasting change in families (Scott, Popkin, & Simington, 2016). Current Programs A non-profit organization in central Indiana, Reach for Youth (RFY), created a youth program titled R.E.A.C.H.. Reach for Youth is a mental health based organization with a mission to empower youth and their families through prevention, intervention, counseling and youth development initiatives. R.E.A.C.H. stands for Relationships; Education and Employment readiness; Access to needed resources; Community, Collaboration, and Collegiality; and Hope. This unique initiative was developed around 21st Century employment needs and ensuring readiness for the competitive workforce demands in a global market. The program is adapted from the textbook Learning and Earning in the 21st Century. What You Need to Know and How to Succeed. The R.E.A.C.H program was piloted with youth ages eleven to eighteen in early 2020. Reach for Youth believes in the importance of two generation learning and the development of a parent-centered program that parallels the R.E.A.C.H youth program concepts is essential. The purpose of this new program will be to develop employment, financial, and educational skills necessary for success in the workforce for parents, and or guardians. Secondary data of the area codes the Reach For Youth provides services shows the high school graduation rate is only at 76 percent, and the percent of children living below the poverty line is at 25 (County Health Rankings and Roadmaps, 2020). This data shows the need for a program that improves education on employment and financial skills for improved outcomes for Employability development: A two-generation approach parents and their children. Currently, there are no other programs offered in the United States 8 that work with parents and children simultaneously to address employment and educational skills. This program is the first of its kind and will be used to address the needs of the local community and provide improvements in life outcomes. Occupational Therapy Impact The development of the parent R.E.A.C.H program will be unique in that it will be developed through an occupational therapy lens. Occupational therapy is the therapeutic use of everyday life activities (occupations) with individuals or groups for the purpose of enhancing or enabling participation in roles, habits, and routines in home, school, workplace, community, and other settings (American Occupational Therapy Association, pg S1, 2017). The development of this program, using the pillars of occupational therapy, allows for targeted improvements in the occupations of education and work that can have positive impacts in the lives of participants. Occupational programs allow participants to improve participation in meaningful occupations for improvement in health and well-being, and instill autonomy and self-worth (Bazyk & Bazyk, 2009). This program will provide pertinent education and development of skills necessary for greater attainment in the occupations of work and education and other important life skills. Theoretical Framework The theoretical framework utilized for developing the parent R.E.A.C.H. program is the Model of Human Occupation (MOHO). MOHO is based upon the interdependence of a persons motivation, behaviors, and occupational performance (Cole & Tufano, 2008). Both internal and external factors can affect occupational performance in this model. Internal factors include volition, habituation, and mind-body connection (Cole & Tufano, 2008). The internal processes of an individual enable ones motivation, habits, and roles. Externally, the environment to which Running head: EMPLOYABILITY DEVELOPMENT: A TWO-GENERATION APPROACH one is subjected also influences occupational performance. Environment can be composed of 9 both social and physical aspects (Cole & Tufano, 2008). Examples of environment could include family and social relationships, cultural practices, home location, and physical surroundings. The interplay of environment and internal processes influences the behaviors and occupations completed by individuals. The MOHO aligns with problems being addressed in this project. The R.E.A.C.H program aims to address and change volition and habituation by providing education and resources for skill development. Through skill development and occupational engagement, individuals volition and habituation will increase, leading to improved occupational competence. Long-term outcomes of the program are to improve motivation and occupational competence to create change in external factors. Full system change and development can be made from participation in the R.E.A.C.H. program. Purpose Creating lasting impacts on at-risk families is a challenging task. This doctoral capstone project aims to address these various challenges in an innovative program, taking a two generation approach. The goal of the R.E.A.C.H program is to develop necessary skills, through education to improve employability, financial opportunity, and life-long outcomes. Methods Participants Potential participants for this program were identified through a partnership with a local Indiana high school. Staff working at the partner high school developed a list of students who would benefit from additional educational resources, or students who display negative behaviors in the classroom. These students became enrolled in the R.E.A.C.H program. A list of these students was provided to Reach For Youth with student and parent information. With permission Employability development: A two-generation approach 10 of the school, I used parent contact information to reach out to parents for possible participation in our new parent program. I contacted parents via email and phone. In emails sent to parents a flyer describing the R.E.A.C.H program, as well as an introductory video for the parent program with links for registration were provided. Emails were sent out on February 8th 2021, to fifty-two potential participants. A follow up email was sent out the following week on February 15, 20201. I did not receive any responses via email from participants. I contacted twenty-three participants via phone, by numbers provided by the school. No participant sign ups were obtained from any of the contacts provided from the list of fifty-two parents and or guardians. With no participant sign ups, the implementation plan of the program was reassessed. Providing education and skill development for increased employability in parents is still a significant need in the community that should be addressed. I chose to develop a pilot program to be implemented with Reach For Youth staff. This pilot program will use staff members as program participants. This provides the opportunity for full presentation of program materials with the ability to receive feedback for quality improvement. The implementation of this pilot program with staff is necessary to work towards reaching the goals of this project. Procedure A human subjects research determination form was submitted to the university research review board, at which this study was being completed, prior to the start of this doctoral capstone. It was determined this study did not classify as human subject research and could continue without further submission for ethical approval. Identification of the needs and topics of education to be addresses through the R.E.A.C.H program was the first developmental step. Due to no parent participant registration, I was unable to obtain information on specific areas of need. It was decided to move forward with educational Running head: EMPLOYABILITY DEVELOPMENT: A TWO-GENERATION APPROACH topics that parallel the curriculum used in the youth program. I collaborated with Dr. Angella 11 Reeves, the author of the R.E.A.C.H curriculum textbook, and the head clinical director of Reach For Youth, Denise Senter, to identify the most important skills and topics to improve employability skills in adults. Upon in-depth discussion, four developmental areas were chosen, mindset, self-efficacy, work competency skills, and launching a career. Upon identification of areas of need, I developed corresponding educational materials for these four topics. The R.E.A.C.H parent program consist of four educational videos and three learning activities. The four videos range from 9 minutes to 15 minutes in length. Each video covers a different learning topic that include PowerPoint-like presentations with voice- over, engaging discussion points, and learning activities. The first video covers the topic of mindset. This video focuses on the difference between a growth and fixed mindset, and building a growth mindset for success. The second video centers on self-efficacy. This video provides education on the definition of self-efficacy and its four sources. The third video focuses on work competency skills. This video teaches the top-four competency skills employers look for, communication, collaboration, creativity, and critical thinking. The final video in the series is about launching a career. This video educates on building a resume and cover letter, tips for interviews, and online resources for job searching. The four videos were sent out via email to six staff members with instructions to view fully before attending the discussion group. The email encourages staff to take notes and come to the discussion group with any questions, points of confusion or any additional thoughts to add to the discussion. The group discussion took place in the Reach For Youth boardroom with six total participants. The discussion group began with a review of educational topics and a discussion between all participants. Next, I lead the group by completing three group activities on mindset, Employability development: A two-generation approach self-efficacy, and work competency skills. At the conclusion of the meeting, professional 12 feedback was given by the staff for program improvements. Staff provides honest and beneficial feedback in our discussion. Measures The original implementation plan for this study utilized survey methodology to measure pre and post knowledge on specific educational topics. Data was to be collected pre and post program completion to identify participants growth in knowledge. In this pilot program, the primary method of data collection occurs in the form of a discussion group with staff members at Reach For Youth providing verbal feedback. Due to staff having prior knowledge on the program topics the original questionnaire data would not have shown significant growth in knowledge. The discussion group has guided questions to provide qualitative feedback for improvements on educational material being provided in the program from experts. Results Feedback from the staff allows expert improvements to be made to the video presentations, discussion topics, and learning activities. One point of improvement was to insert points of pause in the videos so that participants are able to write down notes and thoughts or be able to discuss the educational points being made. Inserting pauses in the video will improve the ability of participants to digest and comprehend the information. Second, addressing language and term usage comprehension was necessary. Due to the target population of the group, reading and comprehension levels need to be taken into consideration. Rewording language and terms in the videos to meet reading comprehension of all future participants was critical for learner engagement and understanding. Thirdly, finding ways to increase the engagement of participants during dense educational material is important. The goal is to keep participants engaged and Running head: EMPLOYABILITY DEVELOPMENT: A TWO-GENERATION APPROACH entertained through out the video presentations. I can improve participant engagement when 13 dense educational topics are being presented. A specific example given came from the presentation of the self-efficacy video. A staff member states focus more on the direct meaning of what you are saying and do not add additional wording for explanation. Overuse of words and extended explanations of topics can lead to loss of attention among participants and decrease learning. Lastly, a large concern of the staff was for participants who speak alternative languages to English. I will need to have a plan for interpretation for future videos. Results from the online survey echo those from the discussion group. No new feedback was provided from this survey. These results show that staff feels that the program videos successfully address educational topics and is satisfactory in engaging participants. Discussion This project is a pilot for a two-generation educational program to improve employability and long-term outcomes. Due to unsuccessful attempts to recruit participants, educational material was developed and piloted with Reach For Youth staff members. The program did reach its goal of developing employment skills for success in the workforce but is unsuccessful in reaching a two-generation delivery approach. In the future, this pilot program will be ready for direct implementation with parents to reach the goal of completing two-generational learning. All of the educational materials of this pilot coordinate with the agenda of the youth program, paving the path for multi-generational implementation and learning. This pilot was necessary to complete with Reach For Youth staff to allow quality improvements to be made for best learning to occur with future participants. It is essential to discuss the barriers that lead to the need for a pilot program to be completed, in place of a program with active parent participation. The two-generation design of Employability development: A two-generation approach this program requires the participation of both a parent and or guardian, and their child. Due to 14 this design, a limited pool of participants were eligible for participation in R.E.A.C.H. Of the participants eligible, I was unsuccessful in recruitment efforts. There are multiple reasons why parent participation was unsuccessful. First, participant recruitment was initiated and aimed at a short list of potential participants. Eligibility was contingent on parents having a child currently or previously enrolled in the youth R.E.A.C.H. program. Due to the youth program also being new, only a small sample size was available to market the program towards. With this small participant sample, it was difficult to gain enough interest and participation to form a group out of the eligible parents. Secondly, recruitment was occurring through a contact list provided by a local high school. This second hand source of contact data was not ideal for participant recruitment. I reached out to participants via email and phone; however, I did not have confirmation that all contact information was valid. It was difficult to establish contact with complete list of participants via telephone or email. Limited successful contact was made with parents from this contact list. Lastly, participants I did gain successful contact with did not feel they could commit the necessary time to participate in this program. This program requires individual work to be completed on their schedule but also requires a weekly synchronous discussion group. Many participants voiced that they had hectic schedules that would prevent them from committing their time. Participant recruitment and participation could be a challenge in the future implementation of this program. Obtaining the participation of both a parent and child can be difficult. For the progression of the program to be sucuessful, there will need to be new recruitment strategies. Marketing for this program should go beyond the partnership with the local high school. Mass marketing across social media, as well as in the community could Running head: EMPLOYABILITY DEVELOPMENT: A TWO-GENERATION APPROACH 15 enhance interest of parents and youth. Additionally, finding ways to adapt the program to fit into the parents busy lives will be crucial. Each group may require a different group schedule for maximal participation. Identifying the best dates and times to work with the schedules of parents will be an evolving and crucial task for the success of the program. Ideally, once in-person meetings can occur, the parent program can take place simultaneously with the youth program. This would allow parents to plan one meeting time a week for both themselves and their children. Successfully completing this program across two generations will require flexibility and adaptation. Implications Although this program has not been completed with a parent group, there is still positive implication from this pilot. This program provides necessary education on employment skills to improve participation and success in the occupation of work. The development of these employability skills can fulfill individuals search for meaningful work. This program builds autonomy in choice of career and employment. Increasing participation in meaningful occupations has long-term benefits in overall well-being and self-worth (Bazyk & Bazyk, 2009). Improvement in employability can also affect one's economic status. Poverty and low economic status have shown to create long-lasting negative impacts (Balisteri & AlviraHammond, 2016; Gruendel, 2015; Mani, Mullainathan, Shafir, & Zhao, 2013; Wade et al., 2016). Improving employment and autonomy in choice of career can directly improve economic status and create pathways to success for positive lifelong impact. Local data in Indianapolis, where Reach For Youth is located, shows that 25 percent of children are living below the poverty line (County Health Rankings and Roadmaps, 2020). This program has the ability to develop necessary skills to decrease poverty through successful employment. Employability development: A two-generation approach 16 A final implication for this program is the possibility to be the first-ever two generation program in the United States to develop and build employment skills in both youth and adults simultaneously. Research has shown that two generation programs can have more significant, positive impacts on participants and can help interrupt the poverty cycle (Gruendel, 2015; Lombardi, Mosel, Patel, Schumacher, & Stedron, 2014). A two generation program is so powerful because it attends to the needs of both adults and children and provides education to meet their needs in their respective stages of life. This program has the potential to make true changes and positive long-term impacts on families. Limitations A few limitations influence the results of this study. The largest and most impactful limitation on this study was the inability to gain parent participation. Without parent participation, I could not collect a need assessments to tackle the specific needs of parents in the target demographic. The program material developed in this pilot program coincides with material and educational topics being used in the youth group. However, parents may benefit from learning different material, or in new ways, that were unable to be identified during this pilot study. A second limitation is, the staff in which this program was piloted, have a great amount of previous knowledge on the educational topics presented. Due to this prior knowledge, staff is not being taught new information, which could have affected their understanding and feedback to the material. Prior knowledge on the topics makes it easier to be presented and understood. The program materials I developed may not properly explain the educational topics in a way for new participants to fully understand and comprehend. A final limitation of this program was the impacts of COVID-19. Due to health restrictions, all program material and presentations had to be virtual. This could have impacts on learning for some participants. Running head: EMPLOYABILITY DEVELOPMENT: A TWO-GENERATION APPROACH Virtual learning is not always the best form of education. Additionally, a global pandemic can 17 add enormous stress to individuals' lives that make it more difficult to commit time to participate in a new weekly program or decrease their motivation to participate. Conclusion The purpose of this study was to improve employability, financial opportunity, and lifelong outcomes through an innovative two-generation program. Such a program is needed for atrisk adults and youth to create better life-long outcomes. This program provides education and skill development for parents, which can help reduce the risk of experiencing personal, contextual, or environmental barriers to healthy and age-appropriate occupations for themselves and their children. This program has met its goal of providing education and development of skills for increased employability, financial opportunity, and life-long outcomes. However, due to complications and unsuccessful recruitment of participants this program is only a pilot and was unable to be implemented for two-generation learning. In the future, with increased marketing and expanded participant samples for recruitment, this program can reach its goal of creating multigenerational learning. This program has the proper set-up and outline in place to be implemented among families for two-generation learning. This program is important in helping to address poverty, external risk, and prevention of negative life outcomes. The R.E.A.C.H program has the ability to positively affect at-risk adults and youth through improvement in the occupation of work. Being the first program of its kind to focus on the development of employability skills and improvement of life outcomes across two generations can create impactful and long-lasting change for future generations. The R.E.A.C.H program can provide positive development and growth in families that face the most significant barrier to long-term success. Employability development: A two-generation approach 18 References: American Occupational Therapy Association. (2017). Occupational therapy practice framework: Domain and process (3rd ed.). American Journal of Occupational Therapy, 68(Suppl. 1), S1-S48. https://doi.org/10.5014/ajot.2014.68s1 Balistreri, K. S., & Alvira-Hammond, M. (2016). Adverse childhood experiences, family functioning and adolescent health and emotional well-being. Public Health, 132, 72-78. https://doi.org/10.1016/j.puhe.2015.10.034. Bazyk, S., & Bazyk, J. (2009). The meaning of occupation-based groups for low-income urban youths attending after-school care. American Journal of Occupational Therapy, 63, 6980. https://doi.org/10.5014/ajot.63.1.69 Chase-Lansdale, P. L., & Brooks-Gunn, J. (2014). Two-generation programs in the twenty-first century. 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K. (2016). A Theoretical Framework for Two-Generation Models: Lessons from the HOST Demonstration. Washington, DC: Urban Institute. Employability development: A two-generation approach Shea, C. K., & Jackson, N. (2015). Client perception of a client-centered and occupation- 20 based intervention for at-risk youth. Scandinavian journal of occupational therapy, 22(3), 173-180. https://doi.org/10.3109/11038128.2014.958873 Usher, K., Durkin, J., & Bhullar, N. (2020). The COVID19 pandemic and mental health Impacts. International Journal of Mental Health Nursing, 29(3), 315. Wade Jr, R., Cronholm, P. F., Fein, J. A., Forke, C. M., Davis, M. B., Harkins-Schwarz, M., ... & Bair-Merritt, M. H. (2016). Household and community-level adverse childhood experiences and adult health outcomes in a diverse urban population. Child abuse & neglect, 52, 135-145. https://doi.org/10.1016/j.chiabu.2015.11.021  ...

... SPECIAL NEEDS MINISTRY VIDEO TRAINING Special Needs Ministry Video Training Melody L. White 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 capstone advisor: Christine Kroll, OTD, MS, OTR, FAOTA 1 SPECIAL NEEDS MINISTRY VIDEO TRAINING 2 Abstract Children with special needs often lack support in faith communities. I analyzed the effect of a 35-minute pilot occupation-based video training program on the knowledge, confidence, and implementation fidelity of volunteers working with children with special needs in a church. Volunteers knowledge increased 5% after training. Those who volunteered in the special needs ministry were more confident than those who served in the childrens ministry, but confidence levels remained the same after training. Volunteers found the video training format effective and rated it 4.6 out of 5 points. Due to the potential to increase an inclusive atmosphere with minimal training, church leaders should place a higher priority on teaching their volunteers specific techniques for working with children with special needs. Keywords: children with disabilities, volunteer training, pre-tests & post-tests, religious communities, functional behavioral assessment SPECIAL NEEDS MINISTRY VIDEO TRAINING 3 Special Needs Ministry Video Training The number of children with special needs in the United States is substantial and growing. The most recent National Health Interview Survey indicated that the prevalence of developmental disabilities in children ages 3-17 in the United States increased from 16.2% in 2009 to 17.8% of children in 2017 (Zablotsky & Black, 2020). As the percentage of the population of children with disabilities continues to rise, so does the necessity to provide services to these individuals. Many trained professionals focus on meeting the physical, social, or psychological needs of kids with disabilities, yet few address spiritual needs (Carter et al., 2015). The American Association on Intellectual and Developmental Disabilities (AIDD) and The Arc (2015) asserted that religious involvement, spiritual expression, and faith community participation are fundamental rights of people with disabilities. Furthermore, strong religious faith is associated with a higher quality of life in families with children with disabilities (Boehm et al., 2015). In their position statement, the AIDD and The Arc (2015) included an appeal for faith communities to increase their ability to support families and children with special needs, specifically requesting the development of training and resources to accomplish this aim. Occupational therapists can be an integral asset to support families with children with special needs in faith communities (Hoyland & Mayers, 2005). Although they are not spiritual counselors, occupational therapists address religious and spiritual expression as instrumental activities of daily living (IADLs) with their clients (American Occupational Therapy Association, 2020). Occupational therapists can use their understanding of the sensory, social, emotional, cognitive, and physical needs of children with disabilities to train volunteers in churches seeking to include these families. SPECIAL NEEDS MINISTRY VIDEO TRAINING 4 Literature Review People who value their faith need meaningful communal religious and spiritual participation to thrive, whether they have a disability or not (Carter, 2020). Findings from Liu et al. (2014) and Carter and Boehm (2019) indicated that youths ages 13-21 with intellectual disabilities find value and purpose in spiritual expressions such as praying, serving others, participating in congregational activities, and spending time with people of the same faith. Individuals with special needs also want others to consider them as helpful, contributing members of their faith communities (Hobbs et al., 2016). Participatory inclusion in faith communities is important to families as well. Several researchers have found a connection between faith and health in families who have children with special needs. In a study by Boehm et al. (2015), the strength of religious faith in parents of youths (ages 13-21) with intellectual and developmental disabilities was one of the strongest predicting factors of family quality of life. Baines and Hatton (2015) learned that parents of children with special needs rely on their faith to help them cope with the fact that their child has a disability. Boehm and Carter (2019) found that parents of children with intellectual disabilities find peace and optimism through their religious practices and beliefs. Although not all families with children with disabilities are religiously involved, those that are depend on their religion and spirituality for their wellbeing. Individuals with and without disabilities place a similar amount of value on spiritual expression, yet children with disabilities are less likely to attend church. Michaelson et al. (2020) found a statistically non-significant difference between the percent of religiously involved students with and without disabilities who reported that connection to others (77.8, 85.0, respectively), connections to self (80.3, 87.4, respectively), connections to nature (65.9, 65.2, SPECIAL NEEDS MINISTRY VIDEO TRAINING 5 respectively), and connections to the transcendent (62.0, 62.3, respectively) were important. Nevertheless, researchers for the Kessler Foundation/National Organization on Disability (2010) found that people without disabilities were 7% more likely than people with disabilities to attend religious services at least once per month. In an analysis of the National Survey of Childrens Health, Whitehead (2018) found a comparable difference of up to a 7.7% decrease from children without disabilities to children with a variety of different disabilities who never attended religious services. These reports indicate a disparity in religious and spiritual involvement for people with disabilities. According to parents of children with special needs, this disparity is due to a lack of support for the familys needs within faith communities. In a study by Ault et al. (2013), of 416 parents attending church with their children with special needs, only 42.5% of parents felt that their congregations were inclusive of their children, and 12.7% felt that their congregations were not at all inclusive. Almost all parents (91.5%) reported that a welcoming attitude towards people with disabilities was helpful for inclusion, but only 81.8% reported seeing that attitude in the church. Due to lack of support and inclusion for their children in their place of worship., 56% of parents prevented their children from engaging in some religious activities, 47% had not engaged in some religious activities themselves, and 33% changed their place of worship. Additionally, 21% of parents reported that their children with disabilities did not participate in any congregational activities available to children. Carter et al. (2016) likewise found a lack of support in the church reported by parents of children with special needs. In this study, parents (n=433) identified the supports available to them in their congregations, such as physical accessibility, disability awareness programming, parent support group, and respite care, from a list of 14. Each support was unavailable to most SPECIAL NEEDS MINISTRY VIDEO TRAINING 6 (67%-96%) parents. Almost half (44.9%) of the parents reported that none of the supports were available to them in their faith communities. Furthermore, Carter et al. (2016) found that parents satisfaction with a faith communitys inclusivity was significantly positively correlated (r = .23) with the number of congregation-provided supports for their children with special needs, which is concerning due to the prevalence of congregations who offered no supports in this study. The reality is that families with children with special needs do not feel like their children are wellprovided for in the church (Ault et al., 2013; Baines & Hatton, 2015; Carter et al., 2016). Although churches do not intend to exclude children with special needs, misunderstandings or a complete lack of knowledge on methods of inclusion prevent an accepting and hospitable atmosphere within places of worship (Annandale & Carter, 2014; Carter et al., 2016; Hobbs et al., 2016). Congregations that want to accommodate the needs of families with children with disabilities may not have members who feel confident when working with these children. Church members who help with special needs ministries are often volunteers without any background in working with children with disabilities (Baggerman et al., 2015; Carter et al., 2016). Many church members have expressed a desire to receive training about the needs of people with special needs before working with them (Finn & Utting, 2017; Milliner, 2020). Pediatric occupational therapists are trained professionals who understand how to support these children and can educate untrained church members. A variety of staff or volunteer training has been successful in the past for people working with students with special needs. In the school environment, Ling and Mak (2012) found that an introduction to functional behavioral analysis, autism psychoeducation, and emotional management techniques increased special education staffs knowledge of autism and improved perceived competence when working with students with autism. In a case study by Brock et al. SPECIAL NEEDS MINISTRY VIDEO TRAINING 7 (2017), training for a paraprofessional on the benefits of a rewards chart and a first/then chart with pictures led to increased implementation of those tools by the paraprofessional to manage challenging behavior when working with a student with ADHD. The student also improved their performance in transitioning between activities, meeting educational goals, and communicating. Providing educational resources on disability-related issues is positively correlated with the inclusion of people with disabilities in a faith community (Griffin et al., 2012). Nevertheless, in my research review, I found only one study on methods for training volunteers about the needs of kids with disabilities in the church environment, which was a case study by Baggerman et al. (2015). In this study, a Sunday school teacher learned inclusion strategies to provide students with moderate to severe disabilities the opportunity to participate in class, respond to questions, and receive behavior-specific praise (Baggerman et al., 2015). The training involved a sequence of education, trainer demonstration, trainee practice with feedback, and live performance with feedback. As a result, the Sunday school teacher increased the use of inclusion strategies in her classroom and reported the training was valuable to her work with a student with disabilities. Research has not yet explored the benefit of video training in the church setting for volunteers working with children with special needs. In the school setting, video modules paired with performance feedback led to increased implementation of desired teaching strategies by a paraprofessional working with a child with severe disabilities and challenging behaviors (Brock et al., 2017). In a study by Brock and Carter (2016), special education teachers used a combination of video modeling, coaching, and performance feedback to train paraprofessionals on methods to teach desired social behaviors to students with special needs. The paraprofessionals reported that the training was more effective than the typical training they received. Additionally, 75% of the students (n=4) increased their social interactions with peers SPECIAL NEEDS MINISTRY VIDEO TRAINING 8 after the paraprofessionals implemented the training. Although churches traditionally use faceto-face training, as did Baggerman et al. (2015) in their case study, video training modules guarantee consistency across training sessions, can be reviewed on a participants own time, are inexpensive, and may be utilized for many years to train new volunteers. Therefore, the purpose of this project is to analyze the effect of a pilot occupation-based training program, with didactic training, video modeling, rehearsal, and live performance feedback components, on the knowledge, confidence, and implementation fidelity of volunteers working with children with special needs in the church. Theory and Frame of Reference The Ecology of Human Performance (EHP) theory and the Lifespan frame of reference (FOR) guide the current study. In the EHP model, the tasks a person can complete are considered their performance range (Dunn et al., 1994). Their abilities are the lens through which they interpret their environment and determine which tasks are plausible (Dunn et al., 1994). Children with special needs may consider activities in the church excluded from their performance range due to their disabilities. Furthermore, some tasks may not be developmentally appropriate for them, which is an important consideration in the Lifespan FOR (Cole & Tufano, 2008). However, volunteers at church want these children to do tasks like participating in Sunday school and learning more about the Bible. Volunteers can use the EHP model to influence task performance by modifying the childrens environment (Dunn et al., 1994). This change improves the childrens ability to complete developmentally appropriate tasks. This project aimed to impact the environment so the students could broaden their performance range to include tasks related to religious participation and spirituality. In particular, volunteers who worked with these students received training about how to alter their care based on the abilities of their students. SPECIAL NEEDS MINISTRY VIDEO TRAINING 9 This way volunteers encouraged an appropriate level of involvement so that the students did not lose motivation to participate in church (Cole & Tufano, 2008). Hopefully, as the students mature, their performance range will include more tasks that they can complete successfully at church. Method Participants The University of Indianapolis Human Research Participant Program Committee determined this project was not human subjects research. After receiving this authorization, I recruited volunteers at a large church (>5,500 attendees) with a special needs ministry to participate in this program. The church was in a suburban community in a midwestern state. They defined special needs as any need for additional support in the church classrooms, including physical, emotional, intellectual, and behavioral supports. The special needs ministry was named supportive services and will be referenced as such throughout the rest of this paper. Participation fluctuated in the various components of this training, including the needs assessment, performance observations (baseline and performance feedback), and training session (with the pre-post test). The inclusion criteria for the needs assessment were that participants were volunteers and working with children with special needs while serving at the church. I took a convenience sample of the volunteers by sending emails to everyone at each of the churchs four campuses who met the inclusion criteria. I contacted 49 supportive services volunteers and 97 standard childrens ministry volunteers. The number of volunteers who responded were 6 and 10, respectively. The needs assessment occurred before any training. For the training session, only supportive services volunteers at the churchs main campus were recruited because the other volunteers were preoccupied with simultaneous training. SPECIAL NEEDS MINISTRY VIDEO TRAINING 10 Volunteers were recruited via phone calls, church announcements, and personal invitations. Of the 23 invited volunteers, three participated. All participants at the training session completed the pre-post test during the timeframe. Performance observations were conducted both the weekend before and immediately after the training. I was only able to observe supportive services volunteers at the churchs main campus due to time limitations. I observed the volunteers that were present to serve in the ministry on these days, which did not allow me to observe all volunteers who participated in training. Eight volunteers participated on the baseline collection weekend, and three participated on the performance feedback weekend. Only one volunteer was present for both baseline and performance feedback days. Experimental Design and Procedures The outline for the program procedure is depicted in Figure 1. A more detailed description of each program component follows. Needs Assessment I designed a survey consisting of three sections and 45 questions to send to all participants on a free, survey-generating website. The first section was adapted from the Ten Myths about Autism Measure created by Ling & Mak (2012) and included ten questions in a true or false format to measure knowledge about children with special needs. I changed the terminology from phrases like autistic people (p. 269) to people who require supportive services or to people with challenging behaviors to encompass a larger range of special needs. I also changed the word savant (p. 269) to extremely intelligent to adapt the wording to the health literacy of the volunteers. The second section was an adaption of the Attribution Questionnaire by Ling et al. SPECIAL NEEDS MINISTRY VIDEO TRAINING 11 (2010), which included a vignette describing a students challenging behavior in a classroom and subsequent questions to assess respondents attitudes and reactions. Responses to questions indicated the strength of the respondents anger, sympathy, perceived control, helping behavior, and punitive behavior based on the given situation. The questionnaire included twenty-nine questions on a seven-point scale from strongly agree to strongly disagree. I changed the wording of the vignette and questions to apply to the church setting. However, the questions remained the same overall. For example, phrases like if I were [the students] teacher (p. 249) were changed to if I worked with [the student] . The third section was adapted from the Staff-Perceived Self-Efcacy Scale by Hastings and Brown (2002) to measure volunteers perceived competence when working with children with special needs. I altered the format of each prompt to sentence format and added terminology that reflected phrases familiar to church volunteers. For example, I wrote, I feel confident when working with supportive services in the childrens ministry, for the confidence prompt. Five prompts were given on a seven-point scale from strongly agree to strongly disagree. I added an open-ended response question at the end of this survey asking for any additional information that would be beneficial to include in the training. The free, survey-generating website I utilized allowed up to ten questions per survey. Therefore, the survey was sent to all participants in one email. Five separate links were included with instructions. I sent an original survey to the entire supportive services team. I sent a copy of the survey via email to the childrens ministry volunteers, with the wording changed slightly to reflect the role of the childrens ministry workers, but with the same questions. Intervention Based on the results of the needs assessment, I developed five training videos, each four SPECIAL NEEDS MINISTRY VIDEO TRAINING 12 to six minutes long, to address gaps in the knowledge and confidence of the volunteers. Topics included functional behavior assessment, sensory processing, behavior management, inclusion techniques, and Bible lesson adaptation. It is well documented that educational training alone does not lead to behavior change (Brock & Carter, 2015; Ling & Mak, 2012; Sullivan et al., 2002; Warin, 2018). Therefore, I designed a 35-minute in-person training session to incorporate video training with rehearsal and discussion components for the supportive services volunteers. The training session was held on a Monday, eight weeks after I mailed the needs assessment survey. The training occurred at the churchs main campus and employed the tell, show, try, apply (TSTA) model (Browder et al., 2012). The tell and show portions of the training were integrated into the videos with didactic training on techniques to use in the classroom, followed immediately by modeling said techniques. I showed only one video during the training session due to time limitations. The video explained functional behavioral assessments with descriptions of the four functions of behavior and best responses to behaviors, as summarized by Howell (2019). I also provided a worksheet for the volunteers to fill out that followed the outline of the video. For the try portion of the training, I planned to prompt volunteers to partner up with one another to practice the techniques previously modeled. However, because only three volunteers participated in the training, I simultaneously facilitated practice for the entire group. The centralized family ministries pastor also provided feedback to the group as needed. For the apply portion of the training, volunteers answered questions in a small group to process, generalize, and apply their learning as outlined in the model by Cole (2018). I facilitated discussions, and the family ministries pastor gave feedback as they had done during rehearsal. At the end of the training, I provided handouts to the volunteers to summarize the trainings main points and to provide information on how to access the video for review at SPECIAL NEEDS MINISTRY VIDEO TRAINING 13 home. Two days later, I emailed the video and the handout to all supportive services volunteers at the churchs main campus. Measures I utilized a multiple-probe research format by collecting data at each consecutive step of the training sequence (Horner & Baer, 1978). This method was employed to assess the effects of training on volunteer knowledge, confidence, and implementation fidelity when working with kids with special needs in the church. Data was gathered through a pre-post test conducted at the start and finish of the training session. I also completed observations before the training session with a baseline performance assessment and after the training session with a performance assessment that included performance feedback. Pre-Post Test. I designed a 22-question pre-post test survey utilizing the online platform Qualtrics to assess knowledge and confidence. The survey format and questions were adapted from the work of Mitchell et al. (2021). The survey included 12 multiple choice questions to assess knowledge of presentation, causes, and management of challenging behaviors. It also included two Likert scale questions to assess confidence on a scale of 1 (not at all confident) to 4 (extremely confident) in the ability to identify causes for and respond to challenging behaviors of children in the ministry. The last eight questions of the survey were only included in the post-test to evaluate the training format. Five questions were in Likert scale format to evaluate the effectiveness of this training method on a scale of 1 (strongly agree) to 5 (strongly disagree). The remaining questions included the following: one rank order question about the four components of the training (educational material, video demonstrations, practicing with a partner, and small group SPECIAL NEEDS MINISTRY VIDEO TRAINING 14 discussions), one open-ended question about the reasoning for the ranking of the top-ranked component, and one open-ended question about how to improve the training. I provided the participants with a link to the pre-test survey at the start of the training session and a new link to the post-test survey upon completing all the training components. Participants completed the prepost tests in person. Performance Assessment. I collected baseline data on volunteer behavior the weekend directly before the training session to assess implementation fidelity. I explained to volunteers that I would observe but did not specify what data I was collecting. I aimed to observe classroom activities from an unobtrusive place in the supportive services classroom for one hour at each of the three services. I was only able to observe without assisting the volunteers for one service. I took notes on a self-created checklist that I designed based on the instructions given in the training video. On this checklist, I recorded each challenging behavior apparent and the response used by the volunteers. I then categorized each behavior as a function of either sensory stimulation, escape, attention, or access to a tangible object. Whether the volunteers utilized the best response to behaviors was also noted. Some children left to attend worship and the Bible lesson with peers for part of the hour each service, so I remained with the group that required the most support from the volunteers. The group that required the most support during the first service attended the preschool classroom, and the group that required the most support during the third service remained in the support room. I provided no feedback to volunteers during this phase. The weekend directly after the training session, I collected post-intervention data in the SPECIAL NEEDS MINISTRY VIDEO TRAINING 15 same manner as in the baseline phase to assess volunteer implementation of functional behavioral assessment techniques. I again attended all three services, but only the third service had students. Due to a high adult-to-child ratio, I assisted and only collected data on the behavior of other volunteers. When children left to attend different classes, I observed the group that required the most support, the students who remained in the support room. None of the volunteers at this service had attended the training session, but one reported having watched the video at home. At the end of the class, I presented my observations to the participants as a group by providing positive reinforcement for the correct implementation of the training. Challenging behaviors that were not addressed or were addressed incorrectly were reviewed. Techniques to address specific behaviors were also reemphasized. I then asked the volunteer who had watched the video for a subjective report about their perspective on the training with these questions: What did you think about the training? On a scale of 1-10, how confident do you feel about using this training independently going forward? Do you have anything you still want to know? Data Analysis Needs Assessment I compiled results of the needs assessment onto spreadsheets to calculate and compare results from both groups. Performance on the needs assessment was calculated in three sections: knowledge, attribution, and confidence. The knowledge score was the percent of correct answers on the true or false section. Five attribution scores were calculated as the average response in the second section for each of the following categories: anger, sympathy, perceived control, helping behavior, and punitive behavior. Reverse scoring was used on questions that implied the opposite of a given attribute so that all scores indicated the presence of a given attribute. The confidence score was the average response in the third section, and reverse scoring was again used for SPECIAL NEEDS MINISTRY VIDEO TRAINING 16 questions that indicated a lack of confidence. Performance Assessment Implementation fidelity was calculated as the percent of student behaviors that the volunteers responded to correctly. I also calculated the average confidence level after the feedback session and compiled subjective feedback into one document to complete a qualitative assessment. Pre-Post Test I organized the results of the pre-post test surveys onto spreadsheets to calculate and compare results. Performance on the pre-post test surveys was calculated in three sections: knowledge, confidence, and training assessment. The knowledge score was the average percentage of correct answers on the multiple-choice section. The confidence and training assessment scores were the average responses in the second and third sections of the survey. I also calculated the rank of each portion of the training. I collected subjective reasons for choosing the highest-ranked portion of the training and suggestions for improving the training onto a single document to complete a qualitative assessment. Results Needs Assessment Table 1 presents the average response for each section of the questionnaire for the childrens ministry and support services volunteers and the number of participants in each section. On individual questions, the difference between averages for the childrens ministry and support services groups ranged from -.13 to .16 for the knowledge section, -1.8 to 1.2 on the SPECIAL NEEDS MINISTRY VIDEO TRAINING 17 attribution section, and -4.1 to -1.3 on the confidence section with negatives indicating a lower score for the childrens ministry group. These results show that although scores were comparable in the knowledge and attribution sections, the childrens ministry group was greater than one point below the confidence score of the supportive services group for all questions in the confidence section. The one response to the open-ended question was from a childrens ministry volunteer who reported a lack of exposure to children with special needs. The volunteer stated that training would be incredibly beneficial for them. Table 1 Average Scores on Needs Assessment Test CM SS Difference Section 1 n= 9-10 Knowledge 0.9 6 0.9 0.0 Section 2 n= Anger Helping Behavior Punitive Behavior Perceived Control Sympathy 4-5 2-3 2.5 6.3 2.1 2.3 5.4 1.7 6.9 1.8 2.6 5.5 0.8 -0.7 0.2 -0.3 -0.1 Section 3 n= Confidence 5 3 4.2 6.4 -2.2 Note. CM=Childrens Ministry, SS=Supportive Services. The score in Section 1 is on a scale of 0-1. The scores in Sections 2 and 3 are on a scale of 0-7. Pre-Post Test The participants knowledge score increased after training, and their confidence score remained the same (Table 2). The overall assessment of the training was positive, with a near- SPECIAL NEEDS MINISTRY VIDEO TRAINING 18 perfect score. The average rankings of the training components were equal (3 on a scale of 4) for video education, video demonstrations, and small group discussions. Practicing with a partner was ranked the least helpful portion of the training with an average score of 1. Table 2 Average Scores on Pre-Post Test Test Pre Post Knowledge 0.64 0.69 Confidence 2.83 2.83 Training Assessment N/A 4.6 Note. Training assessment was not part of the pre-test. The knowledge score is on a scale of 0-1. The confidence score is on a scale of 1-4. The training assessment score is on a scale of 1-5. Subjective reasons for choosing the top-ranked portion of the training included I liked that it gave examples of the behaviors and the causes of them. I liked that it was easy to follow, to describe the video education and, I was able to absorb and learn from others in the room, to describe the small group discussion. Subjective reports of ways to improve the training included slowing the video down to leave enough time to fill out the accompanying worksheet and providing the opportunity to practice the techniques with students. The video had cues to pause at the end for practicing with a partner and for discussion questions, but not throughout the didactic training and video modeling portions that required the bulk of notetaking. Performance Assessment I only observed one classroom at both baseline and performance feedback. When comparing data across time, I observed no significant change, so the data is insufficient to report. The subjective report of the one volunteer who watched the video and participated in SPECIAL NEEDS MINISTRY VIDEO TRAINING 19 performance feedback indicated appreciation for the video portion of the training. They also reported a confidence level of 10 out of 10, which they reported did not change after training. They did not have anything else they would like to learn after training because of their extensive experience with children with special needs. Discussion Initial findings of the pilot occupation-based training program indicate that the training format effectively increased the knowledge, but not the confidence or implementation fidelity of volunteers working with children with special needs in the church. Knowledge The childrens ministry and supportive services groups had equal scores on the knowledge section in the needs assessment despite the notable differences in confidence. This finding agrees with research by John et al. (2018) who found that misperceptions about people with autism are common in people with a range of familiarity with autism. Furthermore, Ling et al. (2010) found no significant relationship between the amount of training on special education and knowledge of autism. Therefore, volunteers with various experiences with students with special needs may have similar levels of knowledge about this population. Volunteers who participated in the pre-post test demonstrated a 5% increase in knowledge of ways to care for students with special needs. Long-term maintenance of this knowledge is crucial for improving the quality of care in special needs ministries. Ling et al. (2010) argued that training in special education is often superficial and does not lead to permanent knowledge gains because it often does not target the emotional responses of staff. I aimed to avoid this mistake with my training. Volunteers mildly demonstrated the detrimental attributions of anger, perceived controllability, and punitive behavior during the needs SPECIAL NEEDS MINISTRY VIDEO TRAINING 20 assessment, so I tried to address these attitudes in my training videos. For example, the script included, It can be really easy to get frustratedand actually disciplining them [children with special needs] might not be the best response. The emotional elements of the training may have contributed to the demonstrated increase in knowledge and will likely enhance the volunteers retention of the lessons learned. Because the childrens ministry volunteers scored slightly higher on the needs assessment for anger and punitive behavior and lower for sympathy and helping behavior, they may benefit even more from the training. Without an effective attitude change, an increase in knowledge may not lead to a more welcoming atmosphere for children with special needs. Therefore, churches should consider how to convey training information to volunteers in a meaningful way. Confidence On the needs assessment, the largest difference between groups was in confidence levels. The childrens ministry volunteers averaged two points lower than the supportive services volunteers. This result was not surprising because people who have little experience with children with special needs often feel unconfident when starting to work with them (Finn & Utting, 2017; Lindsay & Cancelliere, 2018). Lindsay and Cancelliere (2018) found that volunteers at a pediatric rehabilitation hospital reported discomfort around people with disabilities due to a lack of knowledge, interaction, or experience. Participants in the study reported that their confidence grew with exposure to disability-related topics but solidified when working directly with people with disabilities (Lindsay & Cancelliere, 2018). Although training is a step in the right direction, volunteers will most likely not be fully confident to work with children with disabilities until interacting with them. The absence of interaction with children during training may be why volunteer confidence did not increase on the pre-post test and why SPECIAL NEEDS MINISTRY VIDEO TRAINING 21 one volunteer suggested including practice with children to improve the training. Baggerman et al. (2015) and Carter et al. (2016) reported that volunteers for special needs ministries are often untrained individuals. However, many volunteers for the supportive services ministry in the current program had experience with children with special needs either as parents or professionals. Some volunteers were occupational therapists. They often provided instruction to the other volunteers, advocated on behalf of the children in the ministry, and felt confident handling the most challenging behaviors. Boyle (2014) found that occupational therapists who served as volunteers offered valuable services to a variety of organizations due to their skills in analyzing the interaction between a person, their environment, and their occupations. Other volunteers with professional experience, including applied behavior analysts and special education teachers, were integral special needs ministrys success. Not everyone who serves children with special needs in a church will have professional training before volunteering. Individuals who do have professional training can instruct inexperienced volunteers on techniques to use in the classroom. Childrens ministry volunteers knowledge and confidence in working with students with disabilities can increase through occupation-based video training. Churches could use the current program in the tiered approach that educators use to address students with challenging behaviors. In this approach, special education teachers or professionals with similar expertise coach general education teachers on basic classroom principles to use for all children to address classroom management strategies on tier 1 (Hanisch et al., 2020). Teachers also learn more specific techniques to use on tier 2 for children with moderately challenging behavior (Hanisch et al., 2020) . Specialists provide individualized interventions to children on tier 3 who have severely challenging behaviors (Hanisch et al., 2020). Childrens ministry volunteers will inevitably interact with children who SPECIAL NEEDS MINISTRY VIDEO TRAINING 22 require additional support and would benefit from training videos on tier 1 and 2 strategies such as inclusion techniques, adapting Bible lessons, and sensory processing. Students with the most challenging behaviors in the church on tier 3 should be cared for by either professionals or highly competent volunteers who have training on functional behavioral assessment and behavior management. Volunteers responsibilities should parallel the amount of training they undergo for the safety of both the children and the volunteers (Brock et al., 2017). A church seeking to increase their capacity to welcome children with special needs and their families should provide training to more volunteers and may choose to recruit assistance from individuals with professional experience. Implementation Fidelity Although implementation fidelity did not improve, the context likely prevented me from observing much change. None of the volunteers present for performance feedback were participants in the in-person training session. The one classroom I observed for both performance assessment dates had a lower level of challenging behaviors and a higher percentage of volunteers with experience with children with special needs. Due to time constraints, I was unable to collect data from all classrooms to obtain a more accurate representation of the changes that resulted from the training. Nevertheless, a change in implementation fidelity might have occurred for volunteers with less experience and continuous performance feedback. In a study by Vasquez et al. (2017), educators learned functional behavioral assessment in a virtual environment and increased their implementation fidelity within three training sessions despite having no physical training. The impact of the training in the current program on volunteer implementation fidelity is unclear, and further research is warranted. However, the lack of growth does not negate the realized and potential benefits of the program. SPECIAL NEEDS MINISTRY VIDEO TRAINING 23 Training Assessment Subjective and objective data indicate that volunteers were highly satisfied with the format and quality of the training. Volunteers ranked practicing with a partner as the least helpful portion of the training, but this may be because they completed the practice component of the training as a group. Because this training format was enjoyable and helpful for the volunteers, they may be more likely to participate in future training events at the church. Limitations and Future Research The most significant limitation to the current study was the low compliance rate during each component of the program. Compliance with the needs assessment would likely increase if I sent the survey in a single link rather than multiple, separate links. Nonetheless, the sections with the highest response only had 12% participation from the volunteers. I think low participation in surveys and training events is common for volunteers in community settings due to the nonobligatory nature of their service. Low participation may be why so little research exists about training volunteers in the church setting. The program also occurred amidst the COVID-19 pandemic, which likely affected some volunteers willingness to participate in various training components. Minimal participation and specificity of the training to the site limit the generalizability of this program. Future research should seek a larger sample size with greater diversity in race, geographical location, and socioeconomic status. As this program was a pilot study, further research is needed to analyze the effectiveness of this format of training. According to Samudre et al. (2020), the components of the training in the current study are common for instructing amateurs on functional behavioral assessment, but other methods, including individual work on reading and applied activities or personal coaching, SPECIAL NEEDS MINISTRY VIDEO TRAINING 24 may be effective as well. I only collected cross-sectional data after the training due to time limitations. Studies that evaluate long-term outcomes of training would better measure the effectiveness of this form of training on volunteer maintenance of knowledge, confidence, and implementation fidelity. Future research could also measure the impact of volunteer training on student outcomes. Implications for Practice Volunteers who serve children with special needs are essential for churches seeking to be more inclusive, and churches should pursue better training and support for these individuals. After only 35 minutes of training, volunteers demonstrated improvements in knowledge about addressing childrens challenging behaviors. Occupation-based video training with rehearsal and performance feedback components can be an inexpensive, enjoyable, and efficient way to support volunteers in a special needs ministry at a church. Churches can pursue occupational therapy consultation to develop similar programs tailored to their individual needs. Utilization of skilled training has the potential to significantly improve the quality of care that children with special needs and their families receive from churches. SPECIAL NEEDS MINISTRY VIDEO TRAINING 25 References American Association on Intellectual and Developmental Disabilities/The Arc. (2015). Spirituality. https://www.aaidd.org/news-policy/policy/position-statements/spirituality American Occupational Therapy Association. (2020). Occupational therapy practice framework: Domain and processFourth edition. 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... Burnout Program for Forensic Nurses Working in the Emergency Room during COVID-19 Alexandria Watkins May 2021 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: Alissia Garabrant, MS, OTR Stephanie Glover, RN, SANE-A, SANE-P Running Head: FORENSIC NURSING TRAUMA AND BURNOUT A Capstone Project Entitled Burnout Program for Forensic Nurses Working in the Emergency Room during COVID-19 Submitted to the School of Occupational Therapy at the University of Indianapolis in partial fulfillment for the requirements of the Doctor of Occupational Therapy degree. Alexandria Watkins, OTS 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 2 Running Head: FORENSIC NURSING TRAUMA AND BURNOUT Burnout Program for Forensic Nurses Working in the Emergency Room during COVID-19 Alexandria Watkins, OTS University of Indianapolis 3 Running Head: FORENSIC NURSING TRAUMA AND BURNOUT 4 Abstract Forensic nurses are prone to vicarious trauma, burnout, and occupational imbalance, especially during the COVID-19 pandemic and silent pandemic of domestic violence. This quasi-experimental case study assesses burnout awareness and implications of burnout before and following a four-part educational program. This study revealed forensic nurses experienced moderate-to-severe burnout levels in all three categories of the Copenhagen Burnout Inventory (CBI). Additionally, the burnout program allowed the forensic nurses to become more self-aware and more knowledgeable on how to deal with trauma, the burnout cycle, and how to change the routine to become occupationally balanced. This study shows that burnout programs are essential for forensic nurses to increase well-being, reduce turnover, and increase patient care. Literature Review Research shows burnout is common in sexual assault nurse examiners (SANE) and other medical professions; however, there is limited research on how to decrease burnout within the medical field. With the rise in coronavirus disease (COVID-19), burnout in the medical field is at an all-time high. Medical professionals are under extreme pressure and care for patients with COVID-19 (Chor et al., 2020). An increase in vicarious trauma and burnout have crept in on the lives of frontline healthcare workers due to the decrease in staff, increase in domestic violence cases, and increase in anxiety over contracting COVID and spreading it to family members (Chor et al., 2020; Jahan et al., 2021; Orru et al., 2021). SANE nurses are experiencing high burnout and vicarious trauma due to anxiety of COVID-19 and an increase in domestic and Running Head: FORENSIC NURSING TRAUMA AND BURNOUT 5 sexual violence cases (Peternelj-Taylor, 2020). Therefore, SANE nurses are at greater risk for decreased quality of life and chronic health issues due to increased anxiety and burnout. This study aimed to create burnout and trauma-informed care program to support SANEs and new hires, which will increase the quality of life and job sustainability within the forensic nursing team. Additionally, determining the need for occupational therapy services to prevent and treat mental health and wellness for emergency room staff. The program will be an educational series of informative coping strategies and techniques to use in and out of the workplace to increase mental and physical well-being. Frontline workers are in dire need of a solution to decrease burnout and vicarious stress during a pandemic, political discord, and an increase in high-stress job demands. Burnout Statistics/Background The definition for burnout is a psychological syndrome that leaves one emotionally exhausted, decreased personal accomplishment, and depolarization (Maslanch, 1982). The COVID-19 pandemic has created a hectic environment within the health care system worldwide due to quick changes to health care policies, uncontrollable external factors, and implementation of terminology to compare COVID-19 as a medical war (Restauri & Sheridan, 2020). The pandemic has increased stressors in the health care system and frontline workers, which has increased burnout in response to workplace stress (Restauri & Sheridan, 2020). Around the world, people were asked to change their daily routines, roles, and habits to "flatten the curve," participate in social distancing and wear a mask to help overwhelmed health care workers. However, in the United States, there was discord for following COVID-19 protocols due to health behavior becoming politicized, such as social distancing and wearing masks (Rothgerber Running Head: FORENSIC NURSING TRAUMA AND BURNOUT 6 et al., 2020). Therefore, adding increased stress in workplaces between following new COVID19 policies and working with co-workers with differing views. Restauri and Sheridan, 2020, found burnout and PTSD contribute to external stress and have overlapping consequences and drivers. The overwhelming amount of external stress and burnout is demonstrated in the healthcare industry, especially the ICU and emergency department (ED) healthcare workers who are in direct contact and caring for COVID-19 patients. Before COVID-19, emergency healthcare workers experienced the highest level of burnout within the medical profession at 76.1% (Lin et al., 2019). Healthcare workers that work in ED during COVID-19 now demonstrate a moderate-to-severe personal burnout compared to other departments at 90.4% (Chor et al., 2020). Frontline healthcare nurses experience the highest prevalence of burnout during the COVID pandemic (Chor et al., 2020). One department in the ED, which could be at a greater risk for burnout, is the SANE team. SANE nurses are not only dealing with the COVID-19 pandemic, but they are also dealing with the silent pandemic called domestic violence due to long periods of quarantine. Forensic Nursing Forensic nursing is defined as specialized training to treat sexual and domestic abused patients, collect evidence, collaborate with law enforcement, and testify in court (Girardin, 2005). SANEs work with the health and legal needs of patients who experienced trauma such as sexual abuse or trafficked, gunshot wounds, vehicle accidents, etc. (Berishaj et al., 2020). Tasks forensic nurses perform include gathering the narrative from the victim, collecting evidence such as blood, salvia, a swab of the vaginal area, hair, skin under fingernails, clothes, any object injected into the patient (bullet, knife, etc.), and documentation (Ledray, 1995). In a study by Running Head: FORENSIC NURSING TRAUMA AND BURNOUT 7 Shana Maier (2011), SANEs discussed that the most challenging part of their job included: vicarious trauma, emotional demands of their career, burnout, and increased anxiety. SANEs can be affected by their job through vicarious trauma by being exposed to traumatic narratives. More than 51% of SANEs experienced vicarious trauma from treating rape victims (Shana Maier, 2011). In an interview study of five different forensic data researchers, it was discovered that after reading the data and narratives from trauma victims, the data collectors started to experience emotional distress and vicarious trauma. The symptoms of the data collectors included: sleep disorders, fear of injuries, anger, and dreams (Alexander et al., 1989). Therefore, SANEs may experience reduced well-being, increased absences from work, poor quality of care to patients due to burnout, vicarious stress, and compassion fatigue (Newman et al., 2020). Additionally, SANEs are more likely to experience burnout/compassion fatigue if they are young, personally dealt with past trauma, have little experience in the field, work long shifts, or have a heavy workload (Dickinson & Wright 2008). Before COVID-19, the nurses licensing map (2020) found around 41% of SANEs experienced burnout in 2019. All together, SANEs are exposed to the most trauma in the ED, whether physically witnessing the trauma with the patients, reading the narratives in charts, or listening to the patient's story to document for legal use. SANEs are not only dealing with the COVID-19 pandemic, but they are dealing with the silent pandemic due to the increased cases of domestic violence. With the rise of COVID-19 and regulations to social distance and quarantine, there has been a rise in increased psychological and physical diagnosis, loneliness, and economic vulnerability (BradburyJones & Isham, 2020). For many people, home is not considered a safe place, especially for children and women. Due to Running Head: FORENSIC NURSING TRAUMA AND BURNOUT 8 quarantine, there was a significant escalation in domestic violence cases. Many cases went unreported due to limited access (via phone, little contact with other people, or inaccessibility with the police (Bojaruniec, 2020). The Women's Right Center in Poland, which helps advocate for victims of domestic violence, reported a 50% increase in reports to the helpline (Bojaruniec, 2020). Now that lockdown demands are decreasing, domestic violence, sexual assault, and child abuse cases are emerging due to more accessibility to resources (Bojaruniec, 2020). After the first five weeks of lockdown in India, an increase of 92% reported domestic violence cases by India's National Commission for Women (Vora et al., 2020). In a study by, Piquero et al., 2020, the researchers found evidence of a spike of domestic violence cases in the first two weeks of stay at home order in Dallas, Texas. Hospitals are now implementing the role of forensic nurses due to the increase in violence within society (Sekula, 2005). SANEs take on both the pandemic of COVID-19 disease and the silent pandemic of increased domestic violence cases due to the increase of mental illnesses. SANEs have an increased domestic violence caseload leading to more burnout and turnover. Burnout and Coping Programs There is a shortage of SANEs, and the profession cannot afford to lose any qualified nurses to burnout (Karakachian & Colbert, A, 2019). In 2022, it is predicted that there will be a need for 1.1 million nurses in the United States due to 500,000 experienced nurses retiring (American Nurse Association, 2018). Researchers analyzed the Stress Management and Resiliency Training (SMART) program in a quasi-experimental study through blended learning. The SMART program, through blended learning, demonstrated improvements in reliance, stress, anxiety, burnout, and mindfulness within eight weeks (Magtibay et al., 2017). Since nurses work Running Head: FORENSIC NURSING TRAUMA AND BURNOUT 9 three to four 12-hour shifts, blended learning would be essential to an educational series to allow all nurses to participate. In a systematic review, six areas of potential burnout and solutions for oncology nurses were found: workload, control, reward, community, fairness, and values. Health care facilities that implement burnout programs and encourage self-care will have reduced burnout, decrease turnover, increase patient care and procedures, and increased retention (Barbara Henry, 2014). Similarly, a 2019 systematic review analyzed interventions to prevent burnout in nurses and physicians. The authors found that interventions to reduce burnout included: communication skills, teamwork, psychological interventions (yoga and mindfulness), and group participation (Aryankhesal et al., 2019). The authors pointed out that it is essential to consider the individual for burnout interventions (Aryankhesal et al., 2019). Individuals experience and recover from burnout differently than one another. It is crucial to explore individuals' internal and external factors of stress-related stressors to their careers. Burnout programs can help educate nurses about burnout factors and develop self-awareness to stressors to overcome vicarious trauma and burnout. Forensic Occupational Therapy Occupational therapy is a profession that is designed on the client-centered approach. The impact of trauma on occupational performance can be detrimental. Occupational therapy's emerging role in trauma-informed care can help understand the detectable and invisible factors impeding participation in daily life activities and overall quality of life (Lynch et al., 2020). Forensic occupational therapists are defined as therapists that work with individuals in the criminal justice system with occupational performance problems (Hitch et al., 2016). Like Running Head: FORENSIC NURSING TRAUMA AND BURNOUT 10 forensic nurses, forensic occupational therapists can help improve the quality of life of sexual abuse, domestic violence, or any trauma victims and help with the recovery process of participating in ADLs that may be occupationally deprived due to triggering events. Forensic occupational therapists also analyze roles, habits, and routines that may prevent occupational balance (Ozkan et al., 2018). Occupational therapy interventions can target basic living skills, self-care, creative arts, stress management skills, adaptive coping skills, and vocational skills (Ozkan et al., 2018). Occupational therapy can be applied in medical facilities to educate employees on burnout, reduce stress, and increase occupational balance. Hospital facilities and physicians should take proactive steps to help with the effects of burnout with the acute stressors of COVID-19 (Restauri & Sheridan, 2020). Therefore, occupational therapists could be utilized in the emergency department setting to alleviate vicarious trauma, burnout and help with overall occupational balance. The purpose of this study is to create an educational series on burnout, vicarious trauma, and occupational balance for SANEs working in the ED through an occupational therapy perspective. The goal is for forensic nurses to increase the self-awareness of stressors and occupational imbalance to improve quality of life and create a healthier work environment. Model of Human Occupation (MOHO) is the theory that will be used for this study. The main focus of the MOHO is to use a holistic approach to analyze the mind/body connection and how motivation (internal) and performance of occupations (external) are intersected (Cole & Tofano, 2008). Hence, the researcher used the MOHO model to examine what motivates the nurses to continue their work and the effects of their job on their current occupations and performance patterns. For this study, the researcher set up the environment that met the needs of SANEs to Running Head: FORENSIC NURSING TRAUMA AND BURNOUT 11 continue their career while moving through the complete burnout cycle. The last part of the educational series consisted of a video interview with SANEs to reflect on their experiences during the COVID-19 pandemic and the silent pandemic. Methods Study Design This quasi-experimental case study involved developing a burnout educational program for SANEs working in the emergency department during the COVID-19 pandemic and silent pandemic due to increased domestic violence cases. The Institutional Review of the Board of the University of Indianapolis accepted the study, and the program did not require formal informed consent. However, forensic nurses were provided electronic documentation describing the educational program, notifying that participation was voluntary, and asking for participation. Pre and post-surveys were used to assess the knowledge of burnout topics and the effectiveness of the burnout program. Additionally, the Copenhagen Burnout Inventory was completed before the start of the educational series and after to assess burnout recovery and the effectiveness of the program. Participants This study was conducted at a Pediatric Children's Hospital in Indianapolis, Indiana, in an Emergency Department working with the SANE program called, The Center of Hope. The Center of Hope houses the forensic nursing department in the emergency room that works with both the adult and pediatric sides of the emergency rooms. The Center of Hope is open for 24 hours for seven days a week. Participants consisted of 10 full-time and part-time working SANEs employed at The Center of Home. The eligibility criteria for this educational program Running Head: FORENSIC NURSING TRAUMA AND BURNOUT 12 study included being an employee of The Center of Hope at Peyton's Manning Children's Hospital. Participants were excluded if they were employed as PRN. Screening and Evaluation The first three weeks consisted of observing forensic nurses and the participants completing the initial CBI and BRS. The participants demonstrated their skills by working with patients of all traumas brought into pediatric and adult emergency rooms. Within the first three weeks, the researcher observed the trauma and possible symptoms of burnout by the participants. A written needs assessment created on Google Forms was sent via email by the SANE manager to SANE employees. A visualization of the written needs assessment survey is presented in Table 1. Educational Program Series Procedure A 4-week educational burnout program titled "Overcoming Burnout and Living an Occupational Balanced Life" was implemented with six forensic nurses. Before starting the burnout program series, the participants took the Copenhagen Burnout Inventory and Brief Reliance Scale using Google Forms. The program focused on completing the burnout cycle, occupational balance and self-care, and strategies to develop resiliency. The educational program series consisted of three PowerPoint videos on VoiceThread and could be viewed at any time. The three PowerPoint VoiceThread sessions consisted of intro, pre-survey, session content, therapeutic activity, and post-survey. The last week of the program series consisted of a therapeutic group activity. The therapeutic activity included reflection questions of the year 2020 and was recorded on video. Participants were provided the interview questions through email to allow for reflection before recording. As part of the educational series, participants watched an Running Head: FORENSIC NURSING TRAUMA AND BURNOUT 13 edited video of all responses compiled into one video at a meeting. Following the group session and meeting, the participants retook CBI and BRS assessments via Google Forms. Measurements Pre and Post Surveys. The pre and post surveys asked three and six questions regarding knowledge and confidence on the pertaining topic in the burnout program series. The questions used a 3-point Likert Scale, 1=not knowledgeable to 3=very knowledgeable and administered using Google Forms. The two additional questions were added to the post-survey to give feedback to the presenter. The pre and post-surveys were completed before and after watching the educational series for that week. Copenhagen Burnout Inventory (CBI). The CBI is used to measure burnout and contains three subdivisions: personal burnout, work-related burnout, and client-related burnout (Kristensen et al., 2005). Each sub-division has a 5-point scale: "always, often, sometimes, seldom, never. Examples of questions include How often do you feel worn out? and Is your work emotionally exhausting? The inventory was reliable and high values of Cronbach Alpha in each scale (Sestili et al., 2018). Brief Resilience Scale (BRS). The BRS is used to determine resilience in a participants life (Smith et al., 2008). Six statements asked the participants using a 5-point Likert Scale: "strongly disagree, disagree, neutral, agree, strongly agree." Examples of statements include "I tend to bounce back quickly after hard times. and It does not take me long to recover from a stressful event.". A higher score indicates a higher level of resilience, which can help increase recovery from burnout. The BRS tool has demonstrated high reliability when assessing factors from bouncing back from stress (Smith et al., 2008). Running Head: FORENSIC NURSING TRAUMA AND BURNOUT 14 Data Analysis Microsoft Excel for Mac was used for statistical analysis. The median scores from the pre and post-surveys were used to analyze the educational knowledge and effectiveness of the pilot burnout program. Scores CBI and BRS were analyzed on Google Forms and Microsoft Excel. Results Participants At the beginning of the educational program, eight forensic nurses participated in the initial surveys. As time went on, a decrease in participation occurred from pre to post-surveys. Due to scheduling conflicts and work schedules, two part-time nurses did not complete the program, and two full-time nurses did not complete the post-survey. During the educational series, the average participation of pre and post-surveys were of full-time forensic nurses. CBI Of the forensic nurses that completed the CBI (N=8), the average initial scores of clientrelated burnouts were identified at a low to moderate level of burnout (37.5). At the same time, work (53.57) and personal (41.67) burnout identified at an average of moderate to a high level of burnout. After the burnout educational series, forensic nurses retook the CBI survey (N=4). All areas on the CBI: personal (62.5), work-related (57.14), and client (45.83) increased in scores. The data was calculated by finding the average of each category. See Table.1, Table. 2, and Table. 3 for initial and final results of CBI surveys. BRS The forensic nurses (N=8) average initial scores on the BRS recognized at a 4/5, meaning the average forensic nurse entails a normal resilience level (Smith et al., 2013). After the Running Head: FORENSIC NURSING TRAUMA AND BURNOUT 15 educational series scores, BRS recognized at a 3.5/5, meaning the average final forensic nurse (N=4) entails normal resilience (Smith et al., 2013). See Table. 4 for the initial and final results of BRS surveys. Pre/Post-Educational Series Surveys Participants completed pre-and post-surveys for each of the three educational series to determine how knowledgeable one was to the material. Of the eight forensic nurses, five forensic nurses completed both pre and post-surveys to all three educational series. Data were analyzed by comparing the average scores of the pre-presentation responses to the post-presentation responses. Refer to Table. 5, Table. 6, and Table. 7, for pre-and post-survey responses. Overall, forensic nurses demonstrated increased knowledge in the somewhat to very knowledgeable categories indicating increased confidence and expertise on topics presented on trauma, burnout, and occupational balance. Discussion The purpose of this study was to examine the assessed burnout program outcomes between forensic nurses' burnout and resilience scores during the COVID-19 pandemic and forensic nurses' burnout and resilience scores after burnout educational series. The evidence revealed forensic nurse's initial work-related burnout scored at a moderate-severe level on the CBI. The scores show the nurses are vulnerable to client and personal burnout due to external stressors at work and home. Additionally, forensic nurses demonstrated a normal resilience score to combat trauma and burnout. Similar to a study conducted by Chor et al., 2020, which showed a burnout score of 49.2, researchers found that emergency room nurses experienced moderate-tosevere burnout using the CBI. The forensic nurses in this study had a mean initial personal Running Head: FORENSIC NURSING TRAUMA AND BURNOUT 16 burnout score of 41.67, which is an average of moderate burnout. However, some forensic nurses indicated moderate-to-severe burnout scores. They generalized Educational Series. Several studies examine possible burnout intervention programs to decrease burnout and increase the quality of life in healthcare workers. One unique strategy that occupational therapists use is the therapeutic use of self to improve emotional and physical well-being (Cole & McLean, 2003). Increasing self-awareness aids healthcare workers to emotionally connect with others and develop a healthier work environment (Perkins & Schmid, 2019). The overall point of occupational therapy is to improve and restore participation in meaningful life activities. This project is the first burnout educational series that used an occupational therapy perspective and included a therapeutic activity at the end of every educational series to apply education to current situations. The point of the therapeutic activity was to use self-awareness to educational topics such as burnout, trauma, and occupational balance to change habits or routines to decrease burnout. The results from the three-part educational series demonstrated forensic nurses increased knowledge on all topics: burnout, trauma on the body, and occupational balance. The forensic nurses had advanced understanding of burnout and trauma on the body topics with pre scores that averaged somewhat knowledgeable to post scores that averaged very knowledgeable. On the other hand, forensic nurses' average pre-survey score for occupational balance was not knowledgeable to somewhat knowledgeable, while post-survey score reported somewhat knowledgeable. Therefore, forensic nurses still are unsure of maintaining occupational balance within their work and personal life. Therapeutic activities are essential because it helps increase self-awareness. Self-awareness has shown improvements in well-being, decreased stress, and Running Head: FORENSIC NURSING TRAUMA AND BURNOUT 17 predictors to success in one's career (Romanelli et al., 2006; Slaski & Cartwright, 2003). With increased education on occupational balance, forensic nurses can create new and healthier routines on what they need to do and what they want to do to decrease burnout. Final CBI and BRS Surveys. After the forensic nurses completed the three-part educational series and therapeutic video reflection, the nurses retook the CBI and BRS surveys to examine the effects of the burnout educational series. The forensic nurses' CBI scores in all three areas: personal, work-related, and client burnout, increased from initial scores. See Table. 5. There may be a couple of reasons why burnout scores increased after the educational series. One reason the score might have changed is through increased self-awareness. Self-awareness is a conscious awareness of knowing oneself and influencing one in different ways (Rasheed, 2015). With increased self-awareness, one can continuously understand one's own identity, roles, habits, behavior, traits, and motivations (Rasheed, 2015). Through the therapeutic self-awareness activities and increased knowledge on the educational series, forensic nurses may have increased self-awareness of how their body reacts to trauma and burnout. An alternative reason for increased scores for post-CBI surveys could be continued heavy work cases at work and external stressors outside of work. Lastly, participation (N= 8) from the initial CBI and BRS survey decreased to the final CBI and BRS survey (N=4) due to inconsistent PRN scheduling and time to complete surveys. Limitations This study was conducted at a single site, The Center of Hope. Therefore, findings may not be generalizable to other forensic nursing ED departments. The results of this study are relatively small due to overall participation from beginning to end (N=4). Thus, findings should Running Head: FORENSIC NURSING TRAUMA AND BURNOUT 18 be lightly considered. Furthermore, there is not a control group for this study. Further research with increased participation and a control group is needed. The educational series was conducted on VoiceThread to provide blended learning, and it gave access to all shift forensic nurses. However, almost all forensic nurses had a hard time navigating to different sites such as VoiceThread, Google Forms, and therapeutic activity. A more concise and organized platform to place all forms and PowerPoints on would help increase the number of participants and decrease confusion. Implications for Forensic Nurses Forensic nurses are still processing and dealing with the stressors of the COVID-19 pandemic and the increased cases of domestic violence and sexual assault. In this current study, forensic nurses experienced moderate-to-severe levels of burnout using the CBI, even though forensic nurses find their job rewarding. Additionally, almost all nurses stated that they would not tell anyone if they felt overworked, overwhelmed, or burnt out during the reflective video portion. Many of the forensic nurses also noted that the educational series was helpful, and they were able to process more of what they were going through in the last year. The findings of this study show that forensic nurses are experiencing burnout, trauma, and occupational imbalance. This results in many forensic nurses having reduced well-being, an increase in mental illness, and an increase in the likelihood of career termination. Burnout programs are necessary to increase knowledge on trauma, burnout, and occupational balance, increase self-awareness and build community and connection within the forensic nursing department. Burnout programs should focus on an educational piece and a therapeutic activity to enhance the carry-over of knowledge. Other factors that can help reduce burnout are a time to Running Head: FORENSIC NURSING TRAUMA AND BURNOUT 19 debrief severe cases and networking with local legal facilities to help find closure with cases. To complete a full cycle of burnout, one must fully experience the full emotions and require an action plan to cope with stressors (Nagoksi & Nagoski, 2020). Overall, rather than burnout programs educating on how to prevent burnout, burnout programs need to be explaining how to fully complete the burnout cycle to increase resilience and develop self-awareness of what type of coping strategy the individual needs. Burnout is not preventable. However, burnout can be decreased by creating and expanding an individual's occupational balance and finding the right coping strategies for that individual. Implications for Occupational Therapy Occupational therapy (OT) can play a huge role in helping healthcare facilities reduce burnout, work stress and increase overall wellness by creating wellness burnout programs and being the facilitator to the program. Since the COVID-19 pandemic, mental illness has become a public health crisis (Fitzpatrick et al., 2020). Nurses and frontline healthcare workers are burnout, depressed, and anxious due to the impact of the pandemic. OT can help fight nursing turnover, mental illness in the workspace, and overall well-being. Occupational therapists can transform and cultivate a healthy workspace by implementing wellness and burnout programs through an OT lens. Many nurses are educated on burnout and workspace stressors before starting a job. However, facilities do not continue education or help carry over knowledge of how to cope with trauma from work and balancing work, personal life, and client caseload. OTs can help fight nursing turnover and overall well-being in the healthcare field. Running Head: FORENSIC NURSING TRAUMA AND BURNOUT 20 References Alexander, J. G., de Chesnay, M., Marshall, E., Campbell, A. R., Johnson, S., & Wright, R. (1989). Research note: Parallel reactions in rape victims and rape researchers. Violence and Victims, 4(1), 57-62. DOI:10.1891/0886-6708.4.1.57 American Nurses Association. (2018). The nursing shortage. Retrieved from http://www.nursingworld.org/ Ardebili, M. E., Naserbakht, M., Bernstein, C., Alazmani-Noodeh, F., Hakimi, H., & Ranjbar, H. (2020). Healthcare provider's experience of working during the COVID-19 pandemic: A qualitative study. American journal of infection control. https://doi.org/10.1016/j.ajic.2020.10.001 Arslan, G., Yldrm, M., Tanhan, A., Bulus, M., & Allen, K. A. (2020). Coronavirus stress, optimism-pessimism, psychological inflexibility, and psychological health: Psychometric properties of the Coronavirus Stress Measure. 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(2020). Using a Public Health Model as a Foundation for Trauma-Informed Care for Running Head: FORENSIC NURSING TRAUMA AND BURNOUT 23 Occupational Therapists in School Settings. Journal of Occupational Therapy, Schools, & Early Intervention, 13(3), 219-235. https://doi.org/10.1080/19411243.2020.1732263 Magtibay, D. L., Chesak, S. S., Coughlin, K., & Sood, A. (2017).Decreasing stress and burnout in nurses: efficacy of blended learning with stress management and resilience training program J. Nurs. Adm., 47 (2017), pp. 391-395, 10.1097/nna.0000000000000501 Maier, Shana. (2011). The emotional challenges faced by Sexual Assault Nurse Examiners: ER nursing is stressful on a good day without rape victims." Journal of Forensic Nursing, 7(4), 161172. DOI:10.1111/j.19393938.2011.01118.x Maslach, C. (1982). Burnout: The cost of caring. Englewood Cliffs, NJ: Prentice Hall Maslach, C., & Leiter, M. P. (2016). Burnout. In Stress: Concepts, cognition, emotion, and behavior (pp. 351-357). Academic Press. https://doi.org/10.1016/B978-0-12-8009512.00044-3 Nagoski, E., & Nagoski, A. (2020). Burnout: the secret to unlocking the stress cycle. Ballantine Newman, C., Jackson, J., Macleod, S., & Eason, M. (2020). A survey of stress and burnout in forensic mental health nursing. Journal of forensic nursing, 16(3), 161-168. DOI: 10.1097/JFN.0000000000000271 Orr, G., Marzetti, F., Conversano, C., Vagheggini, G., Miccoli, M., Ciacchini, R., ... & Gemignani, A. (2021). Secondary Traumatic Stress and Burnout in Healthcare Workers during COVID-19 Outbreak. International Journal of Environmental Research and Public Health, 18(1), 337. https://doi.org/10.3390/ijerph18010337 Ozkan, E., Belhan, S., Yaran, M., & Zarif, M. (2018). Occupational therapy in forensic settings. Running Head: FORENSIC NURSING TRAUMA AND BURNOUT 24 In Occupational Therapy-Therapeutic and Creative Use of Activity. IntechOpen. DOI: 10.5772/intechopen.79366 Perkins, N. A., & Schmid, A. A. (2019). Increasing Emotional Intelligence through Self-Reflection Journals: Implications for Occupational Therapy Students as Emerging Clinicians. Journal of Occupational Therapy Education, 3 (3). https://doi.org/10.26681/jote.2019.030305 Peternelj-Taylor C. (2020). Forensic Nursing in the Wake of COVID-19. Journal of forensic nursing, 16(2), 6162. https://doi.org/10.1097/JFN.0000000000000292 Piquero, A.R., Riddell, J.R., Bishopp, S.A., et al. Staying Home, Staying Safe? A Short-Term Analysis of COVID-19 on Dallas Domestic Violence. American Journal of Criminal Justice 45, 601635 (2020). https://doi.org/10.1007/s12103-020-09531-7 Rasheed, S. P. (2015). REVIEW PAPER. Self-Awareness as a Therapeutic Tool for Nurse/Client Relationship. International Journal of Caring Sciences, 8(1), 211216. Ray, S. L., Wong, C., White, D., & Heaslip, K. (2013). Compassion satisfaction, compassion fatigue, work-life conditions, and burnout among frontline mental health care professionals. Traumatology, 19(4), 255-267.DOI: 10.1177/1534765612471144 Restauri, N., & Sheridan, A. D. (2020). Burnout and posttraumatic stress disorder in the coronavirus disease 2019 (COVID-19) pandemic: intersection, impact, and interventions. Journal of the American College of Radiology, 17(7), 921-926. https://doi.org/10.1016/j.jacr.2020.05.021 Romanelli, F., Cain, J., & Smith, K. (2006). Emotional intelligence as a predictor of academic and/or professional success. American Journal of Pharmaceutical Education, 70(3), 1-10. Running Head: FORENSIC NURSING TRAUMA AND BURNOUT 25 https://doi.org/10.5688/aj700369 Rothgerber, H., Wilson, T., Whaley, D., Rosenfeld, D. L., Humphrey, M., Moore, A. L., & Bihl, A. (2020, April 22). Politicizing the COVID-19 Pandemic: Ideological Differences in Adherence to Social Distancing. https://doi.org/10.31234/osf.io/k23cv Sekula, L. K. (2005). The advanced practice forensic nurse in the emergency department. Advanced Emergency Nursing Journal, 27(1), 5-14 Sestili, C., Scalingi, S., Cianfanelli, S., Mannocci, A., Del Cimmuto, A., De Sio, S., ... & La Torre, G. (2018). Reliability and use of Copenhagen burnout inventory in an Italian sample of university professors. International journal of environmental research and public health, 15(8), 1708. https://doi.org/10.3390/ijerph15081708 Simon, C. E., Pryce, J. G., Roff, L. L., & Klemmack, D. (2006). Secondary traumatic stress and oncology social work: Protecting compassion from fatigue and compromising the workers worldview. Journal of Psychosocial Oncology, 23(4), 1-14. DOI: 10.1300/J077v23n04_01 Slaski, M., & Cartwright, S. (2003). Emotional intelligence training and its implications for stress, health and performance. Stress and Health, 19(4), 233-239. https://doi.org/10.1002/smi.979 Smith, B. W., Dalen, J., Wiggins, K., Tooley, E., Christopher, P., & Bernard, J. (2008). The brief resilience scale: assessing the ability to bounce back. International journal of behavioral medicine, 15(3), 194-200. DOI: 10.1080/10705500802222972 Smith, B.W., Epstein, E.E., Oritz, J.A., Christopher, P.K., & Tooley, E.M. (2013). The Running Head: FORENSIC NURSING TRAUMA AND BURNOUT 26 Foundations of Resilience: What are the critical resources for bouncing back from stress? In Prince-Embury, S. & Saklofske, D.H. (Eds.), Resilience in children, adolescents, and adults: Translating research into practice, The Springer Series on human exceptionality (pp. 167-187). New York, NY: Springer. https://doi.org/10.1007/978-1-4614-4939-3_13 Talaee, N., Varahram, M., Jamaati, H., Salimi, A., & Attarchi, M. (2020). Stress and burnout in health care workers during COVID-19 pandemic: Validation of a questionnaire. Journal of Public Health: From Theory to Practice, 16. https://doi.org/10.1007/s10389-020-01313-z Vora, M., Malathesh, B. C., Das, S., & Chatterjee, S. S. (2020). COVID-19 and domestic violence against women. Asian journal of psychiatry, 53, 102227. https://doi.org/10.1016/j.ajp.2020.102227 Running Head: FORENSIC NURSING TRAUMA AND BURNOUT Appendix A. Interview Questions (Ardebili et al., 2020). 1. What did you experience during the COVID-19 pandemic"? 2. What changes did you experience in your work or private life? 3. How did the pandemic change your life?, 4. How did your feeling change over time? 5. "What was the hardest part of work during a pandemic?" 6. What changes in your mental status did you feel? 7. What do you think about the consequences of working in this pandemic? 27 Running Head: FORENSIC NURSING TRAUMA AND BURNOUT 28 8. If you are close to being burnout, would you say it to someone, and what would be your first step? 9. How do you handle heavy cases you see here at The Center of Hope? 10. Discuss your journey through the pandemic and silent pandemic in one word. 11. What is one word you would describe forensic nurses? Appendix B Needs assessment survey questions and responses: Survey used to analyze Forensic Nurses perspectives of Burnout, Compassion Fatigue, and overall Quality of Life. 1. Have you worked at The Center of Hope for 5 or more years? Yes No 2. Are you currently in Grad School or planning to attend Grad School within the next year? Yes No 3. Have you experienced any sort of trauma in your past? Yes No Running Head: FORENSIC NURSING TRAUMA AND BURNOUT 4. 29 Have you had COVID within the last year? Yes No 5. Is there a need for burnout, compassion fatigue, and coping skills programs for The Center of Hope? Strongly Disagree (1) Disagree (2) Neutral (3) Agree (4) Strongly (5) 6. Do you think the Burnout, compassion fatigue, and coping skills program would be beneficial for new hires at the Center of Hope? Strongly Disagree (1) Disagree (2) Neutral (3) Agree (4) Strongly (5) 7. Do you feel like you have become more hypervigilant or increased arousal off working hours? Strongly Disagree (1) Disagree (2) Neutral (3) Agree (4) Strongly (5) 8. What interventions or educational programs would be the most beneficial for you to improve the overall quality of life and work-life balance? Calming strategies Therapeutic skills Video Reflective Series Grounding exercises Evidence-Based Research/Stats in the field The cycle of burnout-How to get out Series Empathic without Remorse Series Occupational Balance (overall quality of life w/ work series) Running Head: FORENSIC NURSING TRAUMA AND BURNOUT 30 Other: 9. Do you think a pamphlet on Sexual Health and OT would be beneficial for future patients with sexual trauma? Yes No 10. What are barriers in the workplace that cause burnout or increased stress? 11. Any questions or comments for me? Appendix C. Link to Reflection Video: https://www.youtube.com/watch?v=WCO77q3T88k&t=13s Running Head: FORENSIC NURSING TRAUMA AND BURNOUT Table 1. 31 Running Head: FORENSIC NURSING TRAUMA AND BURNOUT Table 2. 32 Running Head: FORENSIC NURSING TRAUMA AND BURNOUT Table 3. 33 Running Head: FORENSIC NURSING TRAUMA AND BURNOUT Table 4. 34 Running Head: FORENSIC NURSING TRAUMA AND BURNOUT Table 5. 35 Running Head: FORENSIC NURSING TRAUMA AND BURNOUT Table 6. 36 Running Head: FORENSIC NURSING TRAUMA AND BURNOUT Table 7. 37  ...

... Perceived Effectiveness of Occupation Based Kits in Improving Occupational Performance Among Refugees Kendra Voth A research project submitted in partial fulfilment 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: Jennifer Fogo, PhD, OTR A Research Project Entitled Perceived Effectiveness of Occupation Based Kits in Improving Occupational Performance Among Refugees Submitted to the School of Occupational Therapy at University of Indianapolis in partial fulfilment for the requirements of the Doctor of Occupational Therapy degree. By Kendra Voth OTS Approved by: ________________________________ Research Advisor (1st Reader) ______________ Date ________________________________ 2nd Reader _____________ 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 1 Perceived Effectiveness of Occupation Based Kits in Improving Occupational Performance Among Refugees Jennifer Fogo, PhD, OTRa* and Kendra Vothb a School of Occupational Therapy, University of Indianapolis, Indianapolis, United States of America; bSchool of Occupational Therapy, University of Indianapolis, Indianapolis, United States of America *jfogo@uindy.edu 2 Perceived Effectiveness of Occupation Based Kits in Improving Life Skills Among Refugees After facing occupational deprivation and occupational imbalance, refugees need to establish new home routines (Huot, Kelly, Park, 2016; Mayne et al., 2016). Based on the needs assessment with Catholic Charities of Indianapolis Refugee and Immigrant Service, I developed seven occupation-based kits to improve the daily life skills of refugees. The kits were effective in teaching life skills, indicated by a GAS T score of 81.23. Staff perceived the kits as effective, indicated by an average 1.3-point increase on a pre/post-survey. Occupationbased kits were effective in facilitating valuable relationships and bridging the gap between classroom learning and life skills. Keywords: occupational therapy, refugees, resettlement, life skills, activities of daily living Introduction In many countries, people face dangerous or unsafe conditions resulting in displacement from their homes. In 2019, the world witnessed the highest displacement rate, with about 79.5 million displaced people (UNHCR, 2020). Of that number, 26 million were refugees, and 4.2 million were asylum seekers (UNHCR, 2020). Indiana resettled 322 refugees in Fiscal Year (FY) 2020, with 222 refugees from Burma (Refugee Processing Center, 2020). This lower number reflects the impact of the COVID-19 pandemic on refugee resettlement as Indiana resettled 865 refugees in FY 2019 (Refugee Processing Center, 2019). Catholic Charities of Indianapolis is one of four organizations that provide resettlement services in Indiana (Indiana State Department of Health, n.d.). Occupational therapy practitioners work in a variety of settings from hospitals and nursing homes to schools, clinics, or even prisons. They focus on improving health, well-being, and quality of life through independence in occupations. Occupations include basic activities of daily living (bathing, dressing, grooming, etc.), instrumental 3 activities of daily living (home maintenance, childcare, community mobility, money management, etc), health management, rest and sleep, education, play, work, leisure, and social participation (AOTA, 2020). Occupational therapy practitioners work with individuals, groups, or communities to facilitate participation in everyday activities. Occupational therapy practitioners modify the environment, the task, or the persons skills and abilities to improve independence in meaningful occupations. Literature Review Occupational Therapy and Refugees The role of occupational therapy in refugee services is relatively new. However, researchers have found refugees often face occupational deprivation, occupational imbalance, occupational adaptation, and occupational change (Huot, Kelly, Park, 2016). These disparities fall within occupational therapys scope of practice and practitioners can work with refugees to improve well-being and quality of life. Current occupational therapy contributions in this field are mainly individualistic, addressing issues such as poor access to healthcare (Trimboli et al., 2019). Occupational therapy practitioners need to advocate for refugees to have access to basic healthcare and rehabilitation (Blankvoort, Arslan, Tonoyan, Damour, & Mpabanzi, 2018). Occupational therapy practitioners can also work with refugees on skill development, occupational engagement, and community integration (Winlaw, 2017). With improved participation in meaningful occupations, refugees experience increased confidence, purpose, mental well-being, self-esteem, and reduced isolation (Winlaw, 2017). Blankvoort et al. (2018) also identified the need for occupational therapy practitioners to act as cultural translators. Refugees face many barriers when attempting to integrate into a new culture. They must learn about new places, new habits, cultural practices, and people (Mayne et al., 2016). This process can be overwhelming and 4 difficult. Occupations play a role in helping refugees transition from their previous life to life in their new country (McCarthy et al., 2020). However, just as language translation is a two-way process, cultural translation needs to be a two-way process (Blankvoort, et al., 2018). It is not enough for occupational therapy practitioners to work with refugees to ensure they understand the new culture. OTs need to work with members of the host culture who will interact with the refugees (Blankvoort et al., 2018). Occupational therapy practitioners need to work with employers, teachers, and neighbors to ensure they understand where the refugee is coming from and to advocate for accepting cultural differences in occupations (Blankvoort et al., 2018). Occupational therapy practitioners play a role in improving the mental health of refugees. More than 50% of refugees present with mental health problems (Trimboli & Taylor, 2016). However, engagement in occupations can address or mitigate some of these problems (Trimboli & Taylor, 2016). Occupational therapy practitioners know that engagement in meaningful occupations improves well-being and quality of life. Occupational therapy practitioners can use occupations related to art or theatre to provide refugees a way to express their emotions without a language barrier (Trimboli & Taylor, 2016). Engagement in occupations provides a way for refugees to take their minds off their problems for a little while, improving mental health (Thornton & Spalding, 2018). Experiences of Refugees Researchers have identified several common experiences of refugees as they move to an unfamiliar country and adjust. Mayne et al. (2016) found refugees needed to establish occupational routines in their new home; however, they had difficulty adjusting to so many new things. Smith (2015) also found refugees wanted to develop new routines in their host country; however, it was difficult to adjust to a new culture 5 and language. Refugees may experience culture shock when moving to an unknown country because of the number of new experiences, people, places, and traditions to adjust to (Huot & Veronis, 2018; Mayne et al., 2016). Having a routine and staying busy combats depression and sadness for refugees (Kjrsti Raanaas et al., 2019). Engagement in occupations serves to provide them with a sense of normal and improves mental health (Kjrsti Raanaas et al., 2019; Thornton & Spalding, 2018). Researchers have found refugees often face occupational deprivation both before and during the resettlement process (McCarthy et al., 2020; Suleman, 2013). Occupational deprivation is a state in which people are precluded from opportunities to engage in occupations of meaning due to factors outside their control (Whiteford, 2000, p. 200). Researchers have described refugee camps as prison-like, with engagement in occupations significantly limited (Suleman, 2013). Refugees who have experienced prolonged occupational deprivation, such as those who have spent years in refugee camps, may take longer to adjust to a new culture and acquire new skills (Suleman, 2013). Thus, occupational deprivation before resettlement continues to affect refugees as they begin to build their new lives. As refugees adjust to a new culture with new expectations, they might feel overwhelmed due to the magnitude of changes they face (Baird, 2012). Refugees have communicated that they felt out of place because of differences in routines, activities, religion, and dress (McCarthy et al., 2020). Occupations, such as home maintenance, can even pose a safety hazard to refugees who have not had experience with electricity or proper food storage (Crandall & Smith, 2015). In a study on the wellbeing of refugees, researchers found refugees who were dependent on others to complete daily activities had a sense of hopelessness (Baird, 2012). Little experience with modern conveniences and undeveloped daily skills contribute to the difficulties refugees face during resettlement. 6 During the integration and acculturation process, some refugees face unexpected difficulties. Mayne et al. (2016) found refugees often had preconceived ideas about what their life would be like in the new country. These ideas came from experiences of other refugees and barriers to engagement in occupations in their native country (Mayne et al., 2016). However, often refugees experienced a mismatch between their expectations and the reality of their new life (Mayne et al., 2016). Refugees coming into a new country have expectations of how life will look. They may expect to receive good healthcare, acquire a job using their skills, and develop new social connections. Even though these goals are not impossible, and refugees reach them, many face a harsh reality upon entering their new country. Refugees may struggle with access to healthcare (Huot et al., 2016). Many refugees must take jobs well below their skill level and have limited access to education (Smith, 2015). Frustration and loss of purpose often coincide with a persons inability to work within their skill set and have a meaningful job (Smith, 2015). Many refugees and asylum seekers expressed a lack of control and choice in their situations (Smith, 2015). This lack of self-efficacy led to participants feeling like rubbish (Smith, 2015, p. 617). These unexpected barriers can influence the mental health and quality of life for refugees. Guiding Models Based on the information found in this literature review, the development of occupation-based modules to address the acquisition of specific life skills would benefit the refugees well-being and participation in daily activities. The guiding models for this program were the Ecology of Human Performance (EHP) model and the Quality of Life (QoL) model. The Quality-of-Life model contains three sub-domains: being, belonging, and becoming (Renwick, n.d.). Being includes the physical being, psychological being, and spiritual being (Renwick, n.d.). The belonging sub-domain 7 includes physical belonging such as home or community connection, a feeling of social belonging with friends and co-workers, and community belonging such as health and social services (Renwick, n.d.). The becoming sub-domain includes practical becoming such as domestic activities or paid work, leisure becoming, and growth becoming such as improving knowledge and skills (Renwick, n.d.). In the EHP model, the person construct includes their sensorimotor, cognitive, and psychological skills and abilities (Cole & Tufano, 2008). The context in the EHP model includes physical, social, cultural, and temporal contexts (Cole & Tufano, 2008). In the EHP model, the performance range defines what tasks are available to the individual based on their skills, abilities, and context (Cole & Tufano, 2008). The being subdomain of the QoL model and the person construct of the EHP model include life skills the refugees have carried over from their native country, coping skills, personal values, self-esteem, and spiritual beliefs (Cole & Tufano, 2008; Renwick, n.d.). New housing, new relationships with other refugees and with other members of the community, and access to healthcare are all contained in the context construct of the EHP and the belonging sub-domain of the QoL model (Cole & Tufano, 2008; Renwick, n.d.). Tasks such as going to work, going to school, taking care of the home, taking care of children, or participating in leisure activities are contained in the becoming sub-domain of the QoL model and the performance range of the EHP model (Cole & Tufano, 2008; Renwick, n.d.). The current program aims to address occupational deprivation through occupation-based modules to facilitate learning necessary life skills. Many refugees learn about the culture of the US as it relates to daily activities, but they struggle with the skills to carry out these daily activities. Materials and Methods 8 Setting and Needs Assessment The Human Research Protection Program at the University of Indianapolis determined this study was exempt due to not being human subject research. The study took place with Catholic Charities of Indianapolis Refugee and Immigration Services (CCI RIS). I completed a needs assessment with CCI RIS staff to determine strengths and opportunities for improvement within the program. I discussed job roles and responsibilities with each staff member to determine the fit of an occupational therapy capstone project. I reviewed their curriculum and resources for Cultural Orientation, an acculturation class given to the refugees. At the time of this project, CCI RIS staff were in the process of restructuring their Cultural Orientation process and developing a mentor program for volunteers from the community. After this review, staff members and I determined a need for resources to teach refugees life skills in their home environment. I conducted semi-structured interviews with three refugee families to determine their perspectives on learning new life skills. Each family had recently gone through the cultural orientation class. Information gathered from the interviews and the needs assessment was used to create the kits. Based on the needs assessment and the areas focused on during the Cultural Orientation class, I developed seven occupationbased kits to improve the daily life skills of refugees. The seven kits address areas of occupation mentioned during the Cultural Orientation classes but provide an opportunity to go further in-depth and teach refugees hands-on skills. This approach to occupational therapys role in refugee resettlement has been done previously (Lunden, 2012). Development of Kits I designed the kits to be used by a volunteer to give CCI RIS staff time to focus on other needs. Seven kits covered topics including Hygiene, Laundry, Cleaning, 9 Cooking, Home Safety, Medications, and Money Management. Pictures of the kits are contained in Appendix A. Each kit contains step-by-step instructions to guide volunteers through the process of working with refugees using the kit. Appendix B includes an example of these instructions. The instructions include a description of occupational deprivation and the importance of engaging in meaningful activities. The initial questions allowed refugees to discuss their experiences with the occupation and the significance of the occupation in their native culture compared to the importance of the occupation in American culture. Each instruction sheet contains hands-on activities, Suggested Topics, a Rights and Responsibilities section, and an optional community outing to facilitate the refugee becoming familiar with their new community. See Appendix B for an example of the instructions sheet. Previously refugees had indicated they enjoyed community outings (Crandall & Smith, 2015). I also designed two handouts to be given to the clients. The two handouts from each kit were included in the Quick Learner Guide, given to each refugee family upon arriving in the USA. This was done to ensure the pages would be kept all together and would be available for use at any time. In previous life skills programs, refugees indicated they were likely to forget information without handouts (Crandall & Smith, 2015). The first handout includes common English terms related to the occupation. Previous researchers have shown refugees are more motivated to learn English when linked with meaningful activities (Werge-Olsen & Vik, 2012). The second handout contains a summary of the information taught during the module. Although these handouts are in English, they have pictures and as few words as possible to improve understanding. Outcome Measures Staff completed a short survey before the kits were created to assess the baseline perceptions of resources to teach life skills and refugees abilities to complete activities 10 of daily living. Staff filled out the survey again after a presentation on using the kits to assess changes in perception of resources to improve occupational performance. I created the Likert-style survey with eight questions about the current Cultural Orientation resources and the ability of refugees to complete occupations after Cultural Orientation class. Staff members ranked their agreement to each statement from one to five with five indicating the greatest level of agreement. The statements assessed staffs perception of topics such as the ability to teach expectations and skills for daily activities and the ability for refugees to retain and implement the learning. One statement assessed staffs perception of the resources available for volunteers to teach refugees daily skills. The survey is included in Appendix C. I averaged the scores for each statement and the overall average from three completed questionnaires. The same staff members filled out the same questionnaire after a training on the kits. I compared the average scores before and after the training. An increase in the score would indicate an improved perception of the effectiveness of Cultural Orientation materials to teach life skills. I determined a successful outcome would be an increase of at least one point for each statement. I used the Goal Attainment Scale (GAS) to determine the effectiveness of each kit (Ottenbacher & Cusick, 1990). The GAS provided a measurement of the refugees learning during the session through eight learning checks specific to each kit. An example of learning checks and the GAS are included at the end of the outline in Appendix B I determined a successful outcome would be a GAS score of 0 or higher for each session. Results Two refugee families completed each kit to test the effectiveness. Both families were originally from Myanmar and fled to Malaysia. The families spoke varying levels of English; however, I did not use live translation with either family. With the first 11 family, I used Google Translate and with the second family, I did not use translation of any kind. Each session occurred in the familys home, at a time convenient for them. I completed one kit per week with each family, to ensure they were not overwhelmed with information. Each session began with a discussion and included the various activities on the outline. At the end of the session, each refugee family completed the learning checks and received a GAS score. The scores from the implementation of each kit are included in Table 1. I calculated the T score from all the individual scores using the formula included in the GAS manual (Turner-Stokes, 2009). The GAS T score was 81.23. Each session lasted roughly an hour to an hour and a half. Three staff members completed the survey before and after the implementation of the kits. The scores for each question are summarized in Table 2. The survey was designed to assess staffs perception of the effectiveness of the Cultural Orientation resources in teaching life skills. The average score prior to the implementation of the occupation-based kits was 3.23. After training on the use of the kits, the average score increased to 4.5, indicating staff perceived the occupation-based kits to be more effective for teaching refugees life skills than the previous resources. Throughout the implementation of the kits, the families were eager to learn and expressed gratitude for the information. One family consistently noted they were excited to work on their English skills, as I did not use translation with them. The refugees often stated they had some experience with the occupations covered in the kits. However, they completed them in a very different way than we do in America. For example, one participant described the process of washing clothes. They only used water and washed all clothes by hand at a stream. She was familiar with the concept of washing clothes but was unfamiliar with and unsure of how to use a washing machine. Another participant described the differences in American money versus the money 12 they had used in their second country. He continued to tell me they did not use money at all in his village in Myanmar. He had some experience managing money in his second country, but was unfamiliar with American money, especially coins. Finally, some of the participants described having very different experiences with medications. One participant told me about the natural remedies they used in Myanmar. Another told me about his experience in having to take a day-long walk to get to the nearest healthcare facility. Participants were able to share their experiences with various occupations during the sessions and describe their varying levels of familiarity with the given occupation. Staff also expressed excitement over the development of the kits. Both the Supervisor of Resettlement Services and the Supervisor of Outreach and Education stated the kits would be useful long-term for the site. Both expressed excitement about the development of the kits and the ability to provide increased services for clients. Staff were excited about the kits and indicated the inclusion of the beginning discussion was important. Staff members indicated refugees level of familiarity with many of the occupations depends on their experiences in their previous country. We discussed the importance of assessing what the refugee knows before completing the kit to ensure we are not teaching them something they already know. Discussion The importance of learning life skills early in the resettlement process has been identified in previous literature. Crandall and Smith (2015) found a life skills program was beneficial in creating a successful resettlement process. Suleman and Whiteford (2013) also found building life skills early in the resettlement process promoted successful resettlement and a smooth transition. Due to the COVID-19 pandemic, prior to the start of this project, all of the cultural orientation curricula had been moved to an 13 online format. During the initial interviews with clients, there seemed to be a disconnect between understanding how to complete occupations and achieving the skills necessary to physically complete the occupations. Several times I heard clients say they understood all the curriculum from the cultural orientation classes, but there were still things they were having difficulty doing. Previous researchers have also found a complex interaction between the knowledge refugees are given through acculturation classes and acquiring life skills in a new culture (Suleman & Whiteford, 2013). Thus, the kits were created to bridge the gap between classroom knowledge and usable skills. The GAS T score of 81.23 indicates the kits were effective in achieving the goals set. Because the GAS was based on specific learning checks for each kit to assess retention of information and skills, the T score indicates the kits were effective as a tool to teach refugees life skills and improve occupational performance. An example of one GAS is included at the end of the outline in Appendix B. Overall, there was little difference in the effectiveness between kits. Based on the scores in Table 1, the first use of the Cooking Kit and the second use of the Money Management kit were slightly less effective, as indicated by a lower GAS score. The first use of the Cooking kit was the first implementation of any kit and the decreased effectiveness was likely due to a learning curve in implementing the kits. The decrease in effectiveness with the second use of the Money Management kit was likely due to the language barrier and the complex nature of the American banking and credit system. In the future, the mentors will be able to continue a relationship with the clients beyond the timeframe of this project which may improve the mentors ability to each the skill. The mentors will be able to re-educate clients on difficult topics as needed. The increase in staff scores on the survey indicates staff perceived the kits as effective for teaching refugees life skills and improving occupational performance. The 14 average score on the survey increased by 1.3 points. Each question increased by at least one point, except for Question 7. Question 7 related to staff perception of refugees readiness to complete occupations independently after use of the kits. This result is consistent with some of the GAS scores. Certain occupations were more complex than others, such as Money Management. In these cases, refugees may not be ready to complete the occupation independently after one educational session. As previously mentioned, this will be addressed in the future by the continued relationship with the mentors. While the concept of many occupations is consistent across cultures, the reality of the skills required to complete the occupations in a new culture differs. In the current project, the participants had a least some experience with more of the occupations. We had many discussions about how occupations were done in their home country and how they are done in America. Suleman and Whiteford (2013) found occupations can seem straightforward when you know the culture and the language, but chaotic when you are transitioning to a new life. An important aspect of the project was the ability to build therapeutic relationships with the clients. After spending one to two hours a week with them for seven weeks, they felt more comfortable asking questions about things outside of the occupation we were working on that day. Having someone to learn from and feel comfortable with can decrease the chaos of adjusting to a new culture. I recommend the organization continues to have a consistent mentor complete the kits with each family to facilitate the same kind of trusting relationship. Overall, the clients were eager to learn and share their experiences. They enjoyed being able to practice their English skills. Werge-Olsen and Vik (2012) found activity or occupations could be used as tools to improve language skills. Through the 15 implementation of the kits, the family who spoke less English became more comfortable practicing English words and were able to communicate better without the use of translation. They demonstrated increased confidence in attempting to pronounce the English words each week. The family who spoke more English continued to learn new words in the context of various occupations. Occupational therapists can bring a unique perspective to refugee resettlement. The value of the occupational perspective is in facilitating a smooth and healthy occupational transition for refugees (Suleman & Whiteford, 2013). Occupational therapists in any setting have a role to play in ensuring all people have the right to participate in occupations that promote fulfilment and satisfaction congruent with their cultures and beliefs, allowing them to flourish (Winlaw, 2017, pg. 19). The process of resettlement can be stressful and full of highs and lows. By bringing a mindset of participation and empowerment and building therapeutic relationships, occupational therapists can work alongside refugees to help improve the process of acquiring new life skills in a new culture. This can improve wellbeing, social connectedness, and cultural understanding (Suleman & Whiteford, 2013). Limitations There were a few limitations to the implementation of this project. The primary limitation was the impact of both the COVID-19 pandemic and various political factors on the number of refugees coming into the United States at the time. Due to the decrease in refugees being resettled during the creation and implementation of this project, there were few refugee families resettled in the appropriate time frame to complete the kits. Both families who participated in the project were from Myanmar. Having a variety of backgrounds would have been beneficial to ensure the kits are 16 effective for all refugees. However as previously described, uncontrollable factors limited the variety of refugees being resettled. Implications for OT Practice The success of this project along with the previous literature indicates occupational therapists have a role to play in refugee resettlement. Implications for practice include increased participation in this emerging area of practice. Even though most people working in the resettlement process have a social work background, occupational therapists can provide a unique perspective and can bring skills in activity analysis, teach life skills, and facilitate a healthy transition to new occupations. Occupational therapists should be willing to step up to the challenge and advocate for our role in this setting. Acknowledgments The authors would like to thank the participants for their eagerness to learn, their willingness to share their experiences, and the joy they brought to each session. They would also like to thank Michele Schrougham and Beth Carney at Catholic Charities of Indianapolis Refugee and Immigrant Services for their guidance, support, and encouragement throughout the project. Declaration of Interest Statement The authors have no known financial or personal conflicts of interest that could have influenced this paper. 17 References American Occupational Therapy Association. (2020). Occupational therapy practice framework: Domain and process (4th ed.). American Journal of Occupational Therapy, 74(Suppl. 2), S1-S87. Baird, M. (2012). Well-being in refugee women experiencing cultural transition. Advances in Nursing Science. 35(3), 249-63. https://doi.org/10.1097/ANS.0b013e31826260c0 Blankvoort, N., Arslan, M., Tonoyan, A., Damour, A., & Mpabanzi, L. (2018). A new you: A collaborative exploration of occupational therapy's role with refugees. World Federation of Occupational Therapy Bulletin, 74(2), 92-98. https://doi.org/10.1080/14473828.2018.1526560 Cole, M.B., & Tufano, R. (2008). Applied theories in occupational therapy: A practical approach. Thorofare, NJ: SLACK, Inc. Crandall, J. & Smith, Y. (2015). The life skills program: Occupational therapy among resettled refugees in an urban context. OT Practice 20(22), 18-20. Huot, S., Kelly, E., & Park, S. J. (2016). Occupational experiences of forced migrants: A scoping review. Australian Occupational Therapy Journal, 63(3), 186-205. https://doi.org/10.1111/1440-1630.12261 Huot, S. & Veronis, L. (2018). Examining the role of minority community spaces for enabling migrants performance of intersectional identities through occupation. Journal of Occupational Science, 25(1), 37-60. https://doi.org/10.1080/14427591.2017.1379427 Indiana State Department of Health. (n.d.). Community at Large. https://www.in.gov/isdh/24672.htm 18 Kjrsti Raanaas, R., rstavik Aase, S., & Huot, S. (2019). Finding meaningful occupation in refugees resettlement: A study of amateur choir singing in Norway. Journal of Occupational Science, 26(1), 66-76. https://doi.org/10.1080/14427591.2018.1537884 Lunden, E. (2012). Refugee resettlement through the lens of occupational therapy. [Unpublished Masters thesis. University of Puget Sound, Tacoma.] Mayne, J., Lowrie, D., & Wilson, J. (2016). Occupational experiences of refugees and asylum seekers resettling in Australia: A narrative review. OTJR: Occupation, Participation, and Health, 36(4), 204-215. https://doi.org/10.1177/1539449216668648 McCarthy, K., Cantrell, J., Daine, J., Keagan Banuelos, K., & Chan, A. (2020). Transition in occupations of refugees during resettlement. The Open Journal of Occupational Therapy 8(4), 1-15. https://doi.org/10.15453/2168-6408.1714 Ottenbacher, K. J. & Cusick, A. (1990). Goal attainment scaling as a method of clinical service evaluation. American Journal of Occupational Therapy, 44(6), 519-525. https://doi.org/10.5014/ajot.44.6.519 Refugee Processing Center. (2020). FY 2020 arrivals by state and nationality. https://www.wrapsnet.org/archives/ Refugee Processing Center. (2019). FY 2019 arrivals by state and nationality. https://www.wrapsnet.org/archives/ Renwick, R. (n.d.). Quality of life model. http://sites.utoronto.ca/qol/qol_model.htm Smith, H. (2015). An exploration of the meaning of occupation to people who seek asylum in the United Kingdom. British Journal of Occupational Therapy, 78(19), 614-621. https://doi.org/10.1177/0308022615591174 19 Suleman, A. & Whiteford, G. (2013) Understanding occupational transitions in forced migration: The importance of life skills in early refugee resettlement. Journal of Occupational Science, 20(2), 201-210. https://doi.org/10.1080/14427591.2012.755908 Thornton, M. & Spalding, N. (2018). An exploration of asylum seeker and refugee experiences of activity: A literature review. World Federation of Occupational Therapists Bulletin, 74(2), 114-122. https://doi.org/10.1080/14473828.2018.1539282 Trimboli, C., Rivas-Quarneti, N., Blankvoort, N., Roosen, I., Algrado, S., & Whiteford, G. (2019). The current and future contribution of occupational therapy and occupational science to transforming the situation of forced migrants: Critical perspectives from a think tank. Journal of Occupational Science, 26(3), 323328. https://doi.org/10.1080/14427591.2019.1604408 Trimboli, C. & Taylor, J. (2016). Addressing the occupational needs of refugees and asylum seekers. Australian Occupational Therapy Journal, 63(6), 434-437. https://doi.org/10.1111/1440-1630.12349 Turner-Stokes L. (2009). Goal attainment scaling (GAS) in rehabilitation: A practical guide. Clinical Rehabilitation, 23(4), 362-70. https://doi.org/10.1177/0269215508101742 United Nations Higher Commission for Refugees. (2020, June 18). Figures at a glance. Retrieved January 29, 2021 from https://www.unhcr.org/en-us/figures-at-aglance.html Werge-Olsen, I. & Vik, K. (2012). Activity as a tool in language training for immigrants and refugees. Scandinavian Journal of Occupational Therapy, 19(6), 530-41. https://doi.org/10.3109/11038128.2012.661455 20 Whiteford G. (2000). Occupational deprivation: Global challenge in the new millennium. British Journal of Occupational Therapy, 63(5), 200-204. http://doi.org/10.1177/030802260006300503 Winlaw, K. (2017). Making the connection: Why refugees and asylum seekers need occupational therapy services. Occupational Therapy NOW, 19(4), 18-19. https://www.caot.ca/document/5748/Making%20the%20connection%20Why%2 0 refugees%20and%20asylum%20seekers.pdf 21 Table 1. GAS Scores for Occupation Based Kits Kit Name GAS Score Cooking 1+ Cooking 2+ Home Safety 2+ Medications 2+ Home Safety 2+ Money Management 2+ Medications 2+ Laundry 2+ Money Management 1+ Laundry 2+ Cleaning 2+ Hygiene 2+ Cleaning 2+ Hygiene 2+ 22 Table 2. Average Scores for Staff Outcome Measure Prior to development of kits After development of and training on kits Question 1 3.7 4.7 Question 2 3.0 4.7 Question 3 3.5 4.7 Question 4 3.2 4.7 Question 5 2.8 4.2 Question 6 2.8 4.2 Question 7 3.7 4.6 Question 8 3.2 4.3 23 Appendix A Hygiene Kit Laundry Kit Cleaning Kit Cooking Kit 24 Home Safety Kit Medication Kit Money Management Kit 25 Appendix B Cooking Module As refugees begin to integrate into a new culture, they must learn about new places, new habits, cultural practices, and people. This process can be overwhelming and difficult. This can lead to refugees not being able to participate in daily activities that Americans take for granted. This is called occupational deprivation. By teaching refugees needed life skills, we can help them be able to participate in the activities we do on a daily basis. As the refugees have begun their resettlement process and the process of learning about their new country, we refer to them as Learners. CORE Objective/Indicator Covered: There are additional domestic life skills that facilitate independent living. Understanding basic safety considerations and use of appliances/ facilities will promote safety in the home Supplies Needed: Food storage Tupperware Saran wrap Dishwasher detergent Oven mitt Cookies or other easy to bake item Reminder Handouts Common English Terms Handout Beginning Discussion: Ask the Learner about his/her experiences with cooking and common kitchen appliances Ask the Learner if cooking is important or meaningful to them Discuss importance of cooking/kitchen safety in US culture Activities: Teach Learner how to use common kitchen appliances such as oven by baking cookies (or other easy to bake item) Teach Learner how to preheat oven, wait for it to preheat Oven Turn oven off when finished Use oven mitt to take items out of oven Close the oven door immediately after removing or testing food Dishwasher Teach Learner about dishwasher detergent Teach Learner about what can go in the dishwasher and what cant Look for dishwasher safe or microwave safe on dishes 26 Microwave What goes in the microwave and what does not go in the microwave Look for dishwasher safe or microwave safe on dishes Using included food flashcards, have the Learners put the food where they think it should be stored (cupboard, fridge, or freezer) Teach Learner about how to use food storage items Tupperware Saran wrap Suggested Topics: General nutrition (use MyPlate Handout) Oven vs stove top Where the oven is vs where the stove top is What dishes go in each Pots and pans on stove top Baking sheets, glass, ceramic dishes in oven Stove top safety Use burners on the back as much as possible. Never use a pot that is too small or big for the burner. Never leave a burner on that does not have a filled pot or pan on it. Do not leave an empty pan on a hot burner. Turn all pot and pan handles inwards. They can be pulled and knocked over when they are turned out. Keep oven mitts and other cloth and paper out of the way of the burners. Refrigerator vs freezer Refrigerator keeps items cold, freezer keeps items frozen Look for Keep refrigerated after opening on food items Expiration dates Find examples on various food items Risks of not storing food correctly Bugs Expired food Wasting food/money Rights and Responsibilities: You have the responsibility to keep your food stored correctly to prevent getting bugs You have the responsibility to use appliances safely Learner Homework: A New Place to Live and Home Safety lessons on SettleIn app Optional Community Outing: Take Learners to the grocery store to purchase food or to practice naming items in English Learning Check: Have the Learner demonstrate preheating the oven 27 Ask the Learner to name (or show you) one item that can not go in the oven Ask the Learner to name (or show you) one item that can not go in the microwave Ask the Learner to name (or show you) one item that can not go in the dishwasher Have the Learner show you how to place a pot on the stove top (handle in) Ask the Learner to name (or show you) one way to store food Have the Learner name (or show you) one food item that needs to be refrigerated Have the Learner name (or show you) one food item that can be stored in the cupboard Level of Expected Outcome (immediately after use of kit) Much More than Expected More than Expected Expected Outcome Less than Expected Much Less than Expected Rating Cooking 2+ Learner able to correctly answer/demonstrate 8 of 8 learning checks 1+ Learner able to correctly answer/demonstrate 6-7 of 8 learning checks 0 Learner able to correctly answer/demonstrate 4-5 of 8 learning checks 1- Learner able to correctly answer/demonstrate 2-3 of 8 learning checks 2- Learner able to correctly answer/demonstrate 0-1 of 8 learning checks 28 Appendix C Outcome Measure Please rate the extent to which you agree with each statement from 1 (Strongly Disagree) to 5 (Strongly Agree). 1. The current CO resources adequately cover information regarding expectations for activities of daily living (including hygiene) 1----------------2--------------3----------------4-----------------5 2. The current CO resources adequately teach skills necessary for activities of daily living (including hygiene) 1----------------2--------------3----------------4-----------------5 3. The current CO resources adequately cover information regarding expectations for instrumental activities of daily living (including cooking, home management, community mobility, and money management) 1----------------2--------------3----------------4-----------------5 4. The current CO resources adequately teach skills necessary for instrumental activities of daily living (including cooking, home management, community mobility, and money management) 1----------------2--------------3----------------4-----------------5 5. Refugees adequately retain information related to activities of daily living after CO. 1----------------2--------------3----------------4-----------------5 6. Refugees adequately retain information related to instrumental activities of daily living after CO. 1----------------2--------------3----------------4-----------------5 7. After the current cultural orientation, refugees are ready to complete activities of daily living and instrumental activities of daily living on their own. 1----------------2--------------3----------------4-----------------5 8. Volunteers have the tools to address these topics with refugees as needed 1----------------2--------------3----------------4-----------------5  ...