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... VIRTUAL REALITY (VR) IN BURN REHABILITATION 1 Virtual Reality (VR) in Burn Rehabilitation: The Impact of Training Protocols on Rehabilitation Staff Comfortability, Confidence, & Satisfaction in VR Treatments A nonhumans subject 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 DCE advisor: Dr. Alissia Garabrant, OTD, M.S., OTR VIRTUAL REALITY (VR) IN BURN REHABILITATION 3 ABSTRACT Purpose/Methods/Results/Conclusion/FuturePractice Purpose: To train/educate burn rehabilitation staff (RN/NP, OT, PT, tech, assistants) to be more comfortable and satisfied with VR treatment use. Methods: Training protocols & pre/post questionnaires were conducted with burn rehab staff for program development & training education. Burn rehabilitation included inpatient, outpatient, and OR staff. Results: 21 participants were included in the study. VR was applied using two & three-dimensional videos and applications. The findings demonstrated increased comfortability and satisfaction of staff post-training & program development. Few side effects were reported. Conclusion: Burn rehabilitation staff is hesitant to use VR in this setting due to lack of experience or knowledge of VR. However, VR can increase staff comfortability and satisfaction, once they are appropriately educated & trained. Thus, increasing the use of VR in a burn unit setting has been proven to be a beneficial treatment option for patients. Future Practice: VR can be utilized within other departments in a hospital setting. (i.e. dementia, dialysis, ORs, anxiety, other mental health disorders). INTRODUCTION Adult patients with severe burns frequently experience high levels of pain, anxiety, and decreased overall range of motion (ROM). Federal surveys show an annual estimate of 489,000 burn injuries receiving medical treatment in the United States (NHAMCS, 2017). Acute burns are commonly unpredictable and may have devastating consequences that impact the physical, psychological health, and well-being of patients (Jain, Khadilkar, & Sousa, 2017). The most common psychological problems faced by this population include but are not limited to delirium, fear, anxiety, stress disorders (acute and post-traumatic), depression, substance use disorder, decreased motivation, feelings of helplessness/hopelessness, and suicidal ideation (Hoffman et. al., 2019; Jain et. al., 2017; Furness et. al., 2019; Tarrant et. al., 2018). Acute physical & psychological issues may progress to chronic morbidities, if not resolved or addressed during the acute phase of recovery (Atzori et. al., 2018; Jain et. al., 2017). These chronic morbidities are better mitigated with pain management treatment interventions. Virtual reality (VR) is one VIRTUAL REALITY (VR) IN BURN REHABILITATION 4 non-pharmacological treatment approach that has shown good promise. However, VR is not commonly used across burn centers in the United States. Thus, the aim of this study was to create training protocols for VR treatments in a burn clinic setting. These training protocols were used to improve the rehabilitation staffs comfortability, confidence, and satisfaction when utilizing VR devices with patients. Review of Literature Multidisciplinary rehabilitation therapy is vital to the successful recovery of patients with severe burn injuries. In a burn clinic, the multiple disciplines can involve areas such as occupational therapy (OT), physical therapy (PT), nursing, various technicians, and assistants. Disciplines such as OT and PT typically begin patient rehabilitation early in the acute phase of hospitalization followed by continued treatment in outpatient services. Both phases of recovery involve conventional OT interventions such as therapeutic activity, therapeutic exercises, therapeutic positioning, splinting, self-care activities of daily living (ADLs), sensory needs, and scar management (Jeschke et. al., 2020). Active patient participation in therapeutic interventions has been shown to have a significant impact on the prevention of common morbidities like scar contractures and deformities (Jeschke et. al., 2020). Therapeutic exercise may involve active exercises, active-assisted ROM, passive ROM, stretching, and strengthening of affected muscles, joints, or skin. (AOTA, 2020). These OT therapeutic interventions help improve healing skin elasticity and sensation, maintain functional movement and ROM, as well as promote overall functional strength, endurance, and activity toleration (Hoffman et. al., 2020; Aghajanzade et. al., 2019; Atzori et. al., 2018; Carrougher et. al. 2009). Additionally, studies have shown that pain, anxiety, and decreased ROM reduce overall patient functional outcomes, reducing motivation and participation in therapeutic interventions (Bermo et. al., 2020; Navarro-Haro et. al., 2019). VIRTUAL REALITY (VR) IN BURN REHABILITATION 5 Thus, patients' motivation and participation in rehabilitation are critical for improving their overall recovery, functional outcomes, and better quality of life. Creating stronger pain control techniques is a national and international priority for medical professionals. This is vitally important to the adults experiencing extreme pain levels as a result of severe burn wounds during therapeutic treatment, debridement, and dressing changes (Keefe, Main, and George, 2018). Pain, psychological effects, and impaired mobility are common barriers to recovery from burn injuries (Jeschke et. al., 2020; Semas, 2017; Schneider et. al., 2009). Like acute inpatient burn rehabilitation centers, burn units within hospital settings typically treat pain and anxiety using pharmacological and non-pharmacological approaches. Acceptable levels of pain in burn injuries often fail with pharmacological methods due to the severity of pain experienced by patients (Bermo et. al., 2020; Spiegel et. al., 2019). Pharmacological methods are typically supplemented with nonpharmacological treatment interventions to help manage acceptable levels of analgesia as well as decrease opioid dependency. Non-pharmacological approaches can include but are not limited to VR, distraction, embodiment, relaxation, mindfulness, diaphragmatic breathing, cognitive-behavioral therapy (CBT), biofeedback, hypnosis or hypnotherapy, music therapy, pet therapy, exposure therapy, and attentional bias to help address pain and target various psychological issues (i.e. stress, anxiety, etc.) (Hoffman et. al, 2019; Matamala-Gomez et. al., 2019; Navarro-Haro et. al., 2019; Gupta, Scott, & Dukewich, 2018; Tarrant et. al., 2018). VR is one non-pharmacological intervention that has been shown to be an effective tool to treat pain and anxiety for hospitalized patients across a multitude of medical settings and environments (Hoffman et. al., 2020; Bermo et. al., 2020; Furness et. al., 2019; Atzori et. al., 2018; Khadra et. al., 2018; Scapin et. al., 2018). VIRTUAL REALITY (VR) IN BURN REHABILITATION 6 Burn centers could implement VR as a viable non-pharmacological treatment in conjunction with pain management protocols. Virtual reality (VR) used as an intervention to address pain in conjunction with passive range of motion (PROM) stretching has been shown as an effective analgesic in postburn injuries (Soltani et. al., 2018; Carrougher et. al., 2009). However, many nonpharmacological treatments like VR are either not being utilized or are unavailable for pain control for adult patients with acute burns (Ziolkowski et. al., 2021). This may be due to concerns with time to train, lack of comfortability, technological difficulties, lack of funding, or a lack of knowledge about VR in general. Currently, there is a lapse in research discussing why VR is not being utilized in burn clinics. Pain is a huge barrier that can result in traumatic experiences or phobias. Patients have often refused medical treatments and recommendations due to their previously experienced trauma or phobias involving severe pain (Garca-Palacios et. al., 2007). Thus, any non-pharmacological intervention that has shown to be effective within this population should be strongly considered by involved medical professionals. The VR protocols utilized in this study follow concepts of gate control theory. For this study, VR will be defined as a computer-generated simulation that immerses the user in a virtual environment using stimuli like visual, auditory, and tactile feedback (Semas, 2017; Virtual_Reality, 2021). VR technology utilizes various stimuli via distraction and gate control theory which can impact a persons bodily functions and performance skills like awareness, attention, and perception (Matamala-Gomez et. al., 2019). The idea behind these two concepts is that VR can help distract users from attending to their pain by giving them an alternative to focusing their attention on (Gould & Dyer, 2014). Additionally, the bodys awareness and VIRTUAL REALITY (VR) IN BURN REHABILITATION 7 perception of pain require attention as there are limitations on how much information a human brain can process or be aware of at one time (Kahneman, 1973). Researchers have shown that VR technology has been successful at decreasing pain during debridements and dressing changes (Hoffman et. al., 2011; Griggs et. al., 2017; Gupta et. al. 2018; Matamala-Gomez et. al., 2019; Spiegel et. al., 2019). However, pain is not the only burn-related factor impacting patients with burn injuries. Anxiety is another common burn-related factor that can negatively impact patients. Burn-related anxiety is known to be associated with physical rehabilitation and increases as rehabilitation progresses for burn victims (Jain et. al., 2017). Anxiety can transition from an initial acute symptom into a more detrimental long-term anxiety disorder if left untreated. VR intervention research has shown success for the treatment of a variety of acute and chronic anxiety-related conditions such as phobias, post-traumatic stress events/disorder, and generalized anxiety disorder (Schwartz et. al., 2020; Navarro-Haro et. al., 2019; Oing & Prescott, 2018; Tarrant et. al., 2018; Jain et. al., 2017). VR interventions work at decreasing overall anxiety through an interactive or immersive experience. These interventions involve the distraction of a burn victims perception of presence. Immersion is described as quantifiable and an objective description of what VR technology can provide to a particular participant. Whereas presence involves the psychological state of consciousness and subjective experience of said participant (Slater & Wilbur, 1997). The type of VR equipment and software applications are vital to consider as they may impact a burn victims overall experience of presence or immersion. Equipment variations can include different sets of hardware: headsets, goggles, controllers, monitors, computers, and screening devices (Atzori et. al., 2018; Navarro-Haro et.al., 2019; Maani et. al., 2011; Hoffman et. al., 2000; Hoffman et. al., 2020). A review of VR VIRTUAL REALITY (VR) IN BURN REHABILITATION 8 equipment utilized has shown to be highly variable across research studies (Hoffman et. al., 2011; Gupta et. al. 2018; Matamala-Gomez et. al., 2019; Spiegel et. al., 2019). The current trends in VR technology are quickly evolving and improving which can pose difficulty for replications of studies or interventions. For example, older technology would require space for a headset, controllers, cameras for hand tracking, computer, keyboard, and mouse all with cords. The new technology involves wireless goggles, controllers, and hand tracking which does not require controller use (Hoffman et. al., 2020). Additionally, the costs of VR equipment have dramatically dropped with the reduction of overall required equipment. Previously, the expensive costs of VR equipment impacted the acclimation and implementation within a burn clinic setting. However, the costs of VR technology have improved over time. Atzori et. al. (2018) found a drop in costs for VR technology from $35,600 to $800 in 2016/2017. The continued lowered costs have improved the overall accessibility and viability for VR technology used in burn setting therapeutic treatments. However, these VR equipment costs are not all-encompassing. Software and programming are required to be created or purchased as well. There is a broad range of software applications that can be used in burn injury settings. Software applications used in various research studies include but are not limited to the following: SnowWorld, SpiderWorld, Quake, MindfulRiverWorld, uniquely developed hypnotherapy programs, watching a table mountain sunset, reindeer racing in Norway, scuba diving at a coral reef, swimming with dolphins, exploring a space station, exploring Amsterdam, riding roller coasters or motocross, or playing soccer (Hoffman et. al., 2001; Konstantatos et. al., 2009; Morris, Louw, & Grimmer-Somers, 2009; Ford et. al., 2018; Furness et. al., 2019). The majority of these software programs have been developed by previous researchers to meet the VIRTUAL REALITY (VR) IN BURN REHABILITATION 9 needs of patients with severe burns. While it is wonderful to meet the needs of these clients, certain software applications may not be appropriate and generalizable to every patient population or burn clinic setting. This causes difficulties for replication studies or ensuring appropriate use across burn clinics. Additionally, other facilities may not be able to gain access to the software or have the necessary funds to purchase causing an accessibility issue. Thus, a goal of this study was to utilize easily accessible and affordable software for medical practitioners and patients alike. The highly variable nature of burn injuries can make research difficult within an acute care setting. Past studies have had relatively small sample sizes that involve a variety of populations including pediatrics, adolescents, and adults (Carrougher et. al., 2009; Ford et. al., 2018; Furness et. al., 2019; Hoffman et. al., 2000, 2001, 2011, 2019, 2020; Maani et. al., 2011; Morris et. al., 2009). It is important to appropriately assess and compare various populations, as this may impact the generalizability of research and the overall effectiveness of VR treatments. This can be difficult to complete as standardized VR training protocols are nonexistent. Burn rehabilitation staff may not have an appropriate comfortability level with VR devices to properly ensure the effectiveness of VR treatment interventions, especially without training. The focus of this study was to create training protocols to build the overall comfortability, confidence, and satisfaction of rehabilitation staff utilizing VR devices with patients. METHODS & MATERIALS A team of OT professionals guided the program development of VR training protocols in 2021. The team completed the program development using an experimental quantitative approach to explore the impact of VR training on staff member comfortability and satisfaction. Data was limited to this site and thus deemed non-generalizable. VIRTUAL REALITY (VR) IN BURN REHABILITATION 10 Study participants were recruited and enrolled from the Level 1 trauma burn center located at Sidney & Lois Eskenazi Health hospital in Indianapolis, Indiana. Eligible participants included the burn rehabilitation staff of registered nurses (RN), nurse practitioners (NP), physical therapists (PT), physical therapy assistants (PTA), occupational therapists (OT), and various care technicians. Once trained, burn rehabilitation staff demonstrated the use of VR with appropriate patients. Data were collected from staff, transcribed, and anonymized. Staff members were given a number within the data to ensure anonymity and were included on a voluntary basis. Inclusion criteria for participants were burn rehabilitation staff working on Eskenazis burn unit. The disciplines involved are listed above. Exclusionary criteria for participants included declining or being unable to participate in training due to time restraints. Staff members were educated on appropriate inclusion criteria for patients as follows: 18 years or older; patient admitted to the Burn Service (acute inpatient burn rehabilitation and outpatient burn clinic patients); anticipated length of stay >24 hours. Staff members were educated on the following appropriate exclusionary criteria: the presence of open wounds to face/head/neck that may interfere with VR headset, history of seizures, severe visual or auditory impairments, active delirium, delusions, psychotic disorders, physical disorders (i.e. disequilibrium, vertigo), extensive past medical history of eye/head injury or active traumatic brain injury, extensive history or excessive susceptibility to motion sickness or dizziness, patients who reported feeling excessively anxious or feelings of discomfort while utilizing VR goggles, Richmond Agitation and Sedation Scale of -3 or lower, active nausea or vomiting, or not wanting to participate or unable to consent to participation. Patients were not excluded from participation VIRTUAL REALITY (VR) IN BURN REHABILITATION 11 based on pain levels experienced during therapy. Participation was voluntary and reimbursement for study participation was not provided. Patients were not considered participants in this study, however, patients were included in the training procedures for staff. These patients included varying levels of total burned surface areas (TBSA), conditions, and required postburn injury physical and occupational therapy services. Therapy consisted of dressing changes, debridements, operating room laser treatments, and ROM exercises during their acute hospital stay or outpatient appointment. Informed verbal consent was gathered from patients on a strictly voluntary basis from study participants. Patients were allowed to discontinue at any time. VR DEVICE This study utilized the Oculus Quest 2 (Menlo Park, California) virtual reality device, purchased for $300 while utilizing free applications for this study. This included two handheld controllers and a headset with wireless capabilities. Researchers in this study utilized the Oculus Quest 2 due to the following reasons: commercially available for consumers or businesses, widely used, relatively inexpensive, wireless capabilities, good accessibility, ease of use, easy to clean/sanitize, and offers an acceptable patient experience. Researchers utilized VR equipment accessories to include the following: silicone face covers, disposable eye mask sanitary covers, oculus elite strap ($50 purchase), and blue-light filter lens protectors. For further specifications, see appendix A. Components of the VR device were contained within a traditional washbasin and included the following: headset, two controllers, a spray cleaner, laminated ruler, laminated cheat sheet, and laminated handouts. The laminated handouts included screenshot examples for patients to choose from. VR APPLICATIONS VIRTUAL REALITY (VR) IN BURN REHABILITATION 12 Only free applications were utilized in this study. This allowed greater accessibility for researchers and patients alike. The majority of patients participating were experiencing VR for the first time. Thus, it was pertinent to keep the VR experience as user-friendly, engaging, and as easy as possible. The applications utilized in this study included YouTube VR and First Steps. YouTube VR included a wide variety of two and three-dimensional videos with the primary purpose being relaxation, meditation, stress relief, guided imagery, distraction, embodiment, mindfulness, and diaphragmatic or deep breathing. The video environments included but were not limited to the following: A) an overhead view of mountains, B) traveling through a forest or nature, C) viewing an aquarium exhibit, D) being on a beach, E) seeing ocean wildlife, F) traveling through snow and icebergs in Antarctica, or G) a hodgepodge video of various environments. These options were presented on laminated handouts before the use of the device which can be reviewed in appendix B. Additionally, the videos had a variety of formats based on how immersive an experience a patient wanted. Formats ranged from a movie theater-style setting with a screen in front of you to watch a more immersive 360-degree range of view. For example, the 360-degree video could allow the user to look in any direction and feel immersed in a forest setting or standing at the edge of an ocean beach. These introductory videos would be described as passive experiences. This ensured patients to have a less demanding and stimulating experience which allowed them to become better acclimated and receptive to the VR experience. First Steps was another free application utilized in this study. This application provided a more immersive and active experience than YouTube VR. However, patients were required to be able to have the cognitive and physical function to utilize the two Oculus controllers. Additionally, this app was only used if it did not impact the patients current treatment. This application allowed patients to engage in a more hands-on approach. Step-by-step instructions VIRTUAL REALITY (VR) IN BURN REHABILITATION 13 were provided throughout the program. Within the virtual environment, patients were instructed to select various highlighted buttons. Then patients were guided to perform various actions such as grabbing or dropping objects. This experience utilized the non-pharmacological method of distraction during a patients routine therapeutic interventions (i.e. dressing changes, stretching, and ROM exercises). The application allowed users to perform the following actions: picking up objects, throwing or dropping objects, throwing virtual paper airplanes, using a ping pong ball and paddle, firing off rockets, flying a remote control blimp, hitting a speed bag, and shooting virtual lasers. VR TRAINING PROTOCOLS & OUTCOME MEASURES The evaluation team conducted pre/post questionnaires and surveys to record the program outcomes and determine the effectiveness of training protocols. The training protocols instructed to the burn rehabilitation staff were conducted in progressive phases. Training protocols addressed staff comfortability and satisfaction with VR (see appendix C). Informed consent and the purpose of the study were explained to staff members before continuing with the training. Staff was provided and encouraged to use pain and anxiety scales prior to and after using VR with a patient (see appendix D). The pre questionnaire was used to assess initial staff comfortability and satisfaction. This asked the following two questions on a 0-10 scale described as follows: A) How comfortable or confident would you feel using VR equipment with one of your patients? Why/Why not?, B) Do you feel this sort of intervention will be beneficial (0-10; 0 being not helpful at all; 10 being very helpful)? Why or Why not?. Training expectations were provided with a step-by-step instruction guide to review (see appendix E). However, staff was not required to read/review this document due to time constraints and variability between staff schedules. Alternatively, in-person one-on-one training and group training were conducted by the VIRTUAL REALITY (VR) IN BURN REHABILITATION 14 researchers as instructors to demonstrate performing placement, cleaning & sanitization, navigation, and set-up of the Virtual Reality (VR) device to staff members. Performing in-person training provided opportunities for staff members to become better acclimated to the VR device. A step-by-step laminated cheat sheet was also provided as a future tool for staff members to utilize (see appendix F). Staff members would then progress to the next phase of training involving hands-on performance steps and measures (see appendix G). They would then demonstrate placement, cleaning & sanitization, and navigation of the VR device to an instructor. A post questionnaire was then given to staff members to reassess their comfortability and satisfaction levels. This asked five questions, two of which were the same as the pre questionnaire listed previously above. The remaining questions gauged the level of difficulty required to operate the VR device, if the staff member would consider using it again, and overall comments. Staff members then proceeded to complete a pre-screen questionnaire with their patients to introduce and explain the purpose of VR and answer any questions from their patients (see appendix H). The final phase involved the staff with an instructor present, utilizing the VR device with their patient. Training times and types varied greatly throughout the study due to the required daily tasks staff members needed to complete. VR CLEANING & SANITIZATION All pieces of equipment utilized in this study were properly cleaned and sanitized after each use. Cleaning and sanitization protocols were in agreement with Eskenazi Healths BioMed, Environmental Services, Infection Control Department, and Centers for Disease Control (CDC) guidelines. Recommendations and instructions for cleaning protocols were provided by Oculus. An instructional sheet was created by the researchers to help guide Eskenazi staff (see appendix I). The VR device was cleaned and sanitized in two ways. First, a Hyperfect 256 cleaner is VIRTUAL REALITY (VR) IN BURN REHABILITATION 15 required over other cleaners. This hospital-grade disinfectant has been shown to destroy the COVID-19 virus within ten minutes. Oculus and the manufacturer recommended and supported this cleaner as well. Alcohol, bleach, or hydrogen peroxide-based cleaning products have been shown to damage and void the warranty on this device. Secondly, ultraviolet (UV) light disinfection was utilized for deeper clean in-between use. The boekel scientific model 234100 UV device was utilized for the light disinfection. Oculus and the manufacturer approved the UV disinfectant parameters for the VR device. RESULTS The purpose of this program development was to evaluate the impact of training protocols on burn rehabilitation staff comfortability, confidence, and satisfaction in VR treatments. The program development team achieved this purpose using an experimental quantitative approach. Training protocol results were indicated as significant (p < .05) showing improvement in both comfortability and satisfaction of burn rehabilitation staff members with VR devices. A total of 21 burn rehabilitation staff members were included in this study. Specifically, 12 RNs, 2 PTs, 2 care technicians, 3 students, 1 OT, and 1 NP. Seventeen members had improved levels of comfortability after the VR training. Additionally, 8 members of the 21 had improved levels of satisfaction after training. Overall, the majority of staff members reported high levels of satisfaction. Although they had a reasonable understanding of the beneficial impact of VR prior to training, this improved with education. The comfortability and satisfaction levels are present in Table 1. VIRTUAL REALITY (VR) IN BURN REHABILITATION TABLE 1. DISCUSSION The purpose of this program development was to determine the impact of training protocols on rehabilitation staff comfortability, confidence, and satisfaction in VR Treatments. This was met through controlled methods of experimental study collecting data from the burn rehabilitation staff. Results showed that the burn rehabilitation staff benefited from increased training. Further, the results demonstrate that outcomes of improved satisfaction and comfortability support the training received. There were several challenges encountered when developing a new VR program and training protocols. Of the aforementioned challenges, technological barriers, time restraints, practitioner competency, infectious control, VR unsafe stereotypes, safety and security, and patient/staff member interest were impeding factors. Additionally, there are factors future 16 VIRTUAL REALITY (VR) IN BURN REHABILITATION 17 practitioners should address before attempting to utilize VR technology. Practitioners should address overall cost, staff competency, patient interest, time restraints for therapy or staff training, quality of VR equipment, reliability of equipment, and carryover upon patient discharge. The findings related to burn rehabilitation staff comfortability and satisfaction demonstrate a need for training protocols to help improve pain management procedures and decrease the overall burden of pain and anxiety that patients often exhibit with severe burns. Medical professionals can encounter difficulties to truly empathize with a patient; VR may help bridge this gap by providing an experience involving both the health professionals and the patient. Guided learning and relearning of functional movement is an integral part of the pain, the rehabilitation process, and a necessary component of rehabilitation for patients with severe burns. VR experiences may be one way to help promote improved motor learning during rehabilitation. This study of VR training was completed with pre/post measurements. With continued measurements or training sessions, staff could maximize their comfortability and overall effectiveness of VR with their patients. Although this is a non-generalizable study, staff within burn units would benefit from increased training over non-familiar pain management procedures like VR to help lighten the dependency of pharmacological pain management procedures. This program development suggests exploration of other VR applications to determine overall efficiency and effectiveness. VR will be required to be assessed as a viable non-pharmacological treatment approach as technology continues to develop and evolve. Overall, more development and research are needed for the use of VR for patients with severe burn injuries. In the future, practitioners utilizing VR programs should investigate VIRTUAL REALITY (VR) IN BURN REHABILITATION 18 software applications, use with hospital staff, likelihood staff would use VR, other areas VR can be implemented, other settings and conditions for VR utilization, and possibly the creation of new job opportunities to help supplement the challenges experienced with VR. Software development is constantly evolving where researchers are either creating new programs or utilizing existing ones. It is pertinent that the efficiency and effectiveness are assessed of whichever program will be used. Additionally, the hardware of VR should be properly assessed. Head and arm mounts for the VR could be utilized with currently existing hospital equipment (i.e. overhead or ceiling transfer lifts) to help reduce the weight or strain of the device on patients. VR is currently being researched in other settings and conditions like patients with dementia, trauma, phantom limb pain, dialysis treatments, childbirth, chronic pain, and disabling conditions. VR could be utilized to help medical practitioners better learn empathy with patients of specific conditions, prior to surgery or OR procedures like laser treatments, or measuring real-time range of motion VR tracking technology. Lastly, VR technology has low-cost options where equipment is made out of cardboard. This provides a potential and functional avenue to measure or improve compliance with outpatient home exercise programs (HEP). For example, instead of patients having to perform 3 upper extremity exercises, patients could complete 10 minutes of VR. Adherence and long-term functionality would need to be researched and assessed for HEP application. Another potential use for VR would be for relaxation or stress relief for hospital staff to help reduce burnout. However, this has yet to be researched and explored. Overall, this training protocol was successful and would benefit from improved applications, generalizable data, and an annual training refresher course to ensure competency of VR use. The training could benefit from improvements of more proficient use with more immersive VR experiences. VR use has a huge impact on the OT profession as OTs can be the VIRTUAL REALITY (VR) IN BURN REHABILITATION 19 subject matter experts. New generations are becoming more adept with technology use showing promise and functional use within this demographic. Lastly, OT practitioners can play an action-oriented role in education, practice, and research with the functional use of VR. VIRTUAL REALITY (VR) IN BURN REHABILITATION 20 REFERENCES American Occupational Therapy Association. (2020). Occupational therapy practice framework: Domain and process (4th ed.). 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Annals of burns and fire disasters, 30(1), 3034. VIRTUAL REALITY (VR) IN BURN REHABILITATION 23 Jeschke, M. G., van Baar, M. E., Choudhry, M. A., Chung, K. K., Gibran, N. S., & Logsetty, S. (2020). Burn injury. Nature reviews. Disease primers, 6(1), 11. https://doi.org/10.1038/s41572-020-0145-5 Kahneman, D. (1973). Attention and Effort. Englewood Cliffs, NJ: Prentice-Hall. Keefe, F. J., Main, C. J., and George, S. Z. (2018). Advancing psychologically informed practice for patients with persistent musculoskeletal pain: Promise, pitfalls, and solutions. Phys. Ther. 98, 398407. doi: 10.1093/ptj/pzy024 Khadra, C., Ballard, A., Dry, J., Paquin, D., Fortin, J. S., Perreault, I., ... & LeMay, S. (2018). Projector-based virtual reality dome environment for procedural pain and anxiety in young children with burn injuries: a pilot study. Journal of pain research, 11, 343. Konstantatos, A. H., Angliss, M., Costello, V., Cleland, H., & Stafrace, S. (2009). Predicting the effectiveness of virtual reality relaxation on pain and anxiety when added to PCA morphine in patients having burns dressings changes. Burns : journal of the International Society for Burn Injuries, 35(4), 491499. https://doi.org/10.1016/j.burns.2008.08.017 Maani, C. V., Hoffman, H. G., Morrow, M., Maiers, A., Gaylord, K., McGhee, L. L., & DeSocio, P. A. (2011). Virtual reality pain control during burn wound debridement of combat-related burn injuries using robot-like arm mounted VR goggles. The Journal of trauma, 71(1 Suppl), S125S130. https://doi.org/10.1097/TA.0b013e31822192e2 Matamala-Gomez, M., Donegan, T., Bottiroli, S., Sandrini, G., Sanchez-Vives, M. V., & Tassorelli, C. (2019). Immersive virtual reality and virtual embodiment for pain relief. Frontiers in human neuroscience, 13, 279. VIRTUAL REALITY (VR) IN BURN REHABILITATION 24 Morris, L. D., Louw, Q. A., & Grimmer-Somers, K. (2009). The effectiveness of virtual reality on reducing pain and anxiety in burn injury patients: a systematic review. The Clinical journal of pain, 25(9), 815-826. National Hospital Ambulatory Medical Care Survey (NHAMCS): 2017 Emergency Department Summary Tables (accessed on April 22, 2021, at https://www.cdc.gov/nchs/data/nhamcs/web_tables/2017_ed_web_tables-508.pdf) Navarro-Haro, M. V., Modrego-Alarcn, M., Hoffman, H. G., Lpez-Montoyo, A., Navarro-Gil, M., Montero-Marin, J., Garca-Palacios, A., Borao, L., & Garca-Campayo, J. (2019). Evaluation of a Mindfulness-Based Intervention With and Without Virtual Reality Dialectical Behavior Therapy Mindfulness Skills Training for the Treatment of Generalized Anxiety Disorder in Primary Care: A Pilot Study. Frontiers in psychology, 10, 55. https://doi.org/10.3389/fpsyg.2019.00055 Oing, T., & Prescott, J. (2018). Implementations of virtual reality for anxiety-related disorders: systematic review. JMIR Serious Games, 6(4), e10965. Scapin, S., Echevarria-Guanilo Maria Elena, Boeira Fuculo Junior, P. R., Goncalves Natalia, Rocha Patricia Kuerten, & Coimbra, R. (2018). Virtual reality in the treatment of burn patients: a systematic review. Burns, 44(6), 14031416. https://doi.org/10.1016/j.burns.2017.11.002 Schneider, J. C., Bassi, S., & Ryan, C. M. (2009). Barriers impacting employment after burn injury. Journal of burn care & research : official publication of the American Burn Association, 30(2), 294300. https://doi.org/10.1097/BCR.0b013e318198a2c2 Schwartz, H. J., Fagan, S., Craft-Coffman, B., Truelove, C. A., & Mullins, R. F. (2020). 124 virtual reality for reducing pain and perioperative anxiety in pediatric burn patients. VIRTUAL REALITY (VR) IN BURN REHABILITATION 25 Journal of Burn Care & Research, 41(Supplement_1), 84. https://doi.org/10.1093/jbcr/iraa024.127 Semas, M. (2017). Effectiveness of virtual reality-based pain control as compared to standard pain management in children with acute burns: a meta-analysis. California State University, Fresno. College of Health and Human Services. Department of Physical Therapy. Doctorate in physical therapy evidence-based projects, cohort 3, spring 2017 (dissertation). Slater, M., & Wilbur, S. (1997). A framework for immersive virtual environments (FIVE): Speculations on the role of presence in virtual environments. Presence: Teleoperators & Virtual Environments, 6(6), 603-616. Soltani, M., Drever, S. A., Hoffman, H. G., Sharar, S. R., Wiechman, S. A., Jensen, M. P., & Patterson, D. R. (2018). Virtual reality analgesia for burn joint flexibility: A randomized controlled trial. Rehabilitation psychology, 63(4), 487494. https://doi.org/10.1037/rep0000239 Spiegel, B., Fuller, G., Lopez, M., Dupuy, T., Noah, B., Howard, A., ... & Danovitch, I. (2019). Virtual reality for management of pain in hospitalized patients: a randomized comparative effectiveness trial. PloS one, 14(8), e0219115. Tarrant, J., Viczko, J., & Cope, H. (2018). Virtual reality for anxiety reduction demonstrated by Quantitative EEG: A pilot study. Frontiers in psychology, 9, 1280. Virtual_Reality. (2021). In Oxford Online Dictionary. Retrieved from https://en.oxforddictionaries.com/definition/virtual_reality Ziolkowski, N., DAbbondanza, J., Rehou, S., & Shahrohki, S. (2021). 110 Pain Medication Prescription Patterns and the American Burn Association 2020 Guidelines on the VIRTUAL REALITY (VR) IN BURN REHABILITATION Management of Acute Pain in the Adult Burn Patient. Journal of Burn Care & Research, 42(Supplement_1). https://doi.org/10.1093/jbcr/irab032.114 26 VIRTUAL REALITY (VR) IN BURN REHABILITATION 27 APPENDIX A Oculus Quest 2 (Virtual Reality Device) Specifications as follows: A) Product Dimensions: 191.5 mm x 102 mm x 142.5 mm (strap folded in), 191.5 mm x102 mm x 295.5 mm (strap fully opened up); B) Product Weight:503g; C) Tracking: Supports 6 degrees of freedom head and hand tracking through integrated Oculus Insight technology; D) Storage:64GB or 256GB; E) Display Panel:Fast-switch LCD; F) Display Resolution: 18321920 per eye; Single Fast-Switch LCD; G) Display Refresh: 7 2Hz at launch; 90Hz support to come; H) Default SDK Color Space: Rec.2020 gamut, 2.2 gammas, D65 white point; I) SoC:Qualcomm Snapdragon XR2 Platform; J) Audio: Integrated speakers and microphone; also compatible with 3.5mm headphones; K) RAM: 6 GB; L) Battery Life:2-3 hours based on the content youre using on Quest 2; M) Charge Time: Quest 2 will charge to a full battery in about 2.5 hours; N) IPD: Adjustable IPD with three settings for 58, 63 and 68mm; O) Playspace:Stationary or Roomscale supported. Roomscale requires a minimum of 6.5feet x 6.5 feet of obstruction-free floor space. VIRTUAL REALITY (VR) IN BURN REHABILITATION 28 APPENDIX B What ENVIRONMENT would you like to try today? MOUNTAIN (SCREEN) - (7 HOUR 4K DRONE FILM: "Earth from Above" + Music by Nature Relaxation (Ambient AppleTV Style)) NATURE/FOREST (360) - (Virtual Nature Relaxation - VR 360 5K Video - Creek Canyon Trail, BC, Canada) ~ 40:58 VIRTUAL REALITY (VR) IN BURN REHABILITATION AQUARIUM (SCREEN) - SEA Aquarium Singapore Walking Tour ~ 32:11 BEACH WALK (SCREEN) - Tropical Island Walk | Ocean Beach Nature | Motu Tane | Bora Bora, French Polynesia | 4K Travel ~ 1 HOUR 29 VIRTUAL REALITY (VR) IN BURN REHABILITATION OCEAN LIFE (SCREEN)- (Beautiful (Underwater Sea Footage) Relaxing Sleep Music Meditation Music, Stress Relief Music) ~ 11 HOURS SNOW (360)- (Antarctica. Frozen world. Scenic Relaxation 360 Film in 5K) - 11 MIN HODGEPODGE (360)- (15 Unbelievable Places that Actually Exist) - 17 MIN 30 VIRTUAL REALITY (VR) IN BURN REHABILITATION 31 VIRTUAL REALITY (VR) IN BURN REHABILITATION 32 APPENDIX C Pre-Staff Questionnaire - Treatment Session Thank you for participating in my virtual reality (VR) program. I hope you find it helpful in reducing the pain and anxiety of our patients. I will be sending out emails with copies of related virtual reality resources at a later date. If you have any further questions, please feel free to contact me (Jeffrey T. Moore, OTS ~ J.T. the O.T.) at moorejt@uindy.edu or Laura K. Griffard at laura.griffard@eskenazihealth.edu. I enjoyed working with all of you :)! 1. How comfortable or confident would you feel using VR equipment with one of your patients? (circle one) Not Confident At All 0 1 2 Extremely Confident 3 4 5 6 7 8 9 10 Why/Why not?__________________________________________________________ 2. Do you feel this sort of intervention will be beneficial (0-10; 0 being not helpful at all; 10 being very helpful)? Why or Why not? _______________________________________________________________________ Post-Staff Questionnaire - Treatment Session 1. How comfortable or confident would you feel using VR equipment with one of your patients? (circle one) Not Confident At All 0 1 2 Extremely Confident 3 4 5 6 7 8 9 10 Why/Why not?__________________________________________________________ 2. How difficult was it to use the VR device? (0 being not difficult at all; 10 being extremely difficult) 0 1 2 3 4 5 6 7 8 9 10 3. Did you feel this sort of intervention was beneficial (0-10; 0 being not helpful at all; 10 being very helpful)? Why or Why not? _______________________________________________________________________ 4. Would you consider using VR again? Why or Why not? _______________________________________________________________________ 5. Overall Comment(s): _______________________________________________________________________ VIRTUAL REALITY (VR) IN BURN REHABILITATION APPENDIX D PAIN & ANXIETY SCALES 33 VIRTUAL REALITY (VR) IN BURN REHABILITATION 34 APPENDIX E VIRTUAL REALITY INSTRUCTIONAL HANDOUT A step-by-step guide POWER-ON the device a. Push & Hold the button on the RIGHT side for approximately 3 seconds to turn on the device. The button is below the headband. There is also a dot next to the power button that will light up once the device is turned on. VOLUME CONTROL a. + and - switch on the BOTTOM of the facial interface. b. Be sure to preset this prior to fitting the device for the user. LENS SPACING a. * Measure interpupillary distance (IPD) of user before VR use. The lens can be shifted horizontally left/right to 1, 2, or 3 settings (shown below). * IPD Range 61 mm or Smaller 61 mm - 66 mm 66mm or Larger Lens Spacing Setting 1 (narrowest, 58 mm) 2 (middle, 63mm) 3 (widest, 68mm) VIRTUAL REALITY (VR) IN BURN REHABILITATION Setting 1 Setting 2 Setting 3 35 VIRTUAL REALITY (VR) IN BURN REHABILITATION CONTROLLER LAYOUT Fig. A a. Each controller is labeled with L for Left and R for Right. i. Straps are located on their respective sides. (I.E. if the straps are on the right, this is the right controller). b. Grab the RIGHT controller. The straps should be on the OUTSIDE of your fingers as shown below (Fig. B). Fig. B c. Place user THUMB on the THUMBSTICK. d. Place the user's INDEX finger on the TOP or TRIGGER button (see Fig. A for location). e. Place the user's MIDDLE finger on the SIDE or GRIP button. f. Straps should rest on or near BACK KNUCKLES (see Fig. B). g. After fitting the RIGHT controller, you will be able to aim your controller and select options. In order to SELECT an option, you will need to press the 36 VIRTUAL REALITY (VR) IN BURN REHABILITATION 37 TRIGGER button labeled below (Fig. C). Fig. C ***Your index finger is your trigger finger. Think about it like a computer mouse, your index finger is your CLICKER or TRIGGER finger.*** HEADSET a. Now you are ready to put on the headset. b. Before placing the headset on a patient, we need to set up the VR device first. c. Make sure the environment is free of obstacles and the user should be seated or in an elevated supine position. VIRTUAL REALITY (VR) IN BURN REHABILITATION 38 d. Ensure the VR device is LENGTHENED before putting it on. For placement, see the following instructions: i. There is a large, round button on the back of the headband. This button allows users to stretch the headband back and fit the unit over a variety of head sizes. ii. Twisting LEFT or COUNTER-CLOCKWISE will LOOSEN or LENGTHEN the headband. iii. Twisting RIGHT or CLOCKWISE will TIGHTEN the headband. VIRTUAL REALITY (VR) IN BURN REHABILITATION b. Position Headset over users eyes. c. Slide the strap around the BACK of the users head, and ADJUST so that the headset fits SNUG and comfortably on the user. (Pic A to B) ***Turn button Clockwise to tighten*** A --------------------------------------> B 39 VIRTUAL REALITY (VR) IN BURN REHABILITATION i. 40 NOTE: You may need to gently ELEVATE or LOWER the back strap of the headset for the best fit. (see directly below) ii. The headband should rest slightly elevated on the back AND/OR top of the user's head. d. Make sure that the user can see the screen CLEARLY; ensure the user is NOT experiencing BLURRINESS or DOUBLE VISION. e. At this point, you may need to ***orient your screen***. ********************SCREEN ORIENTATION******************** i. ii. To orient the screen for user, PRESS & HOLD the O oculus button on the RIGHT controller for 3 seconds The screen always adapts to the initial user. Thus, it is pertinent to reorient the screen when switching users and when setting up the device for patients. ***************************************************************************** VIRTUAL REALITY (VR) IN BURN REHABILITATION 41 LOG-ON a. You will see a round O for oculus appear on the screen. This is a loading screen. You may not see this if you press the power button and then place the device on yourself or another user. b. Next, you should see a login screen. c. CONTINUE & LOGIN with the appropriate Account Name & Password. NAVIGATION TO YOUTUBE VIDEOS a. You should see the main or home screen (space station). b. You should also see a black toolbar near the bottom of your screen. If you do not see this black bar, CLICK AND PRESS the O oculus button. VIRTUAL REALITY (VR) IN BURN REHABILITATION c. CLICK & SELECT on the button labeled as Apps d. The Apps window should now pop-up or appear on your screen. CLICK & OPEN the app labeled as YOUTUBE VR e. You should now see one of the following screens. 42 VIRTUAL REALITY (VR) IN BURN REHABILITATION f. SELECT the option labeled ACCOUNT in the circular toolbar near the top. 43 VIRTUAL REALITY (VR) IN BURN REHABILITATION g. You should see this screen now. h. SELECT the option labeled WATCH LATER. 44 VIRTUAL REALITY (VR) IN BURN REHABILITATION i. You should see this screen now. Select the desired video from this screen. 45 VIRTUAL REALITY (VR) IN BURN REHABILITATION APPENDIX F VR CHEATSHEET 46 VIRTUAL REALITY (VR) IN BURN REHABILITATION 47 APPENDIX G VR Training ~ Staff Checklist STANDARDS: Performing placement, cleaning & sanitization, navigation and set-up of a Virtual Reality (VR) device while abiding by appropriate safety protocols. CONDITIONS: Identify whether or not the use of a VR device is appropriate for your specific patient or environment. PERFORMANCE STEPS 1. Perform correct and safe placement of a VR device on a patient. a. Lens Placement The lens can be shifted LEFT or RIGHT to setting #1, 2, or 3 (1-3 shown underneath yellow tab by lens) b. Measure distance between users pupils (IPD) i. Setting #1 if Left of the pink line ii. Setting #2 if In-between 2 pink lines iii. Setting #3 if Right of the pink line c. Check to ensure the user is seated or in an elevated supine before activity d. LENGTHEN VR device by twisting a large, round button on the back of headset COUNTER-CLOCKWISE e. Position headset over users eyes f. Slide strap around back of users head and tighten device by twisting large, round button CLOCKWISE VIRTUAL REALITY (VR) IN BURN REHABILITATION 48 g. Assist placement of patients hands-on VR controllers i. Straps on BACK KNUCKLES ii. Thumb on Thumbstick iii. Index Finger on TOP or Trigger Button iv. Middle Finger on SIDE or Grip Button v. NOTE: Each controller is labeled L for Left and R for Right. Strapping will rest on the respective sides. 2. Perform cleaning & sanitization protocols of a VR device. NOTE: DO NOT use alcohol, bleach, OR hydrogen peroxide cleaning solutions on ANY piece of VR equipment. This will damage and void the warranty of the VR device (ESPECIALLY the lens). a. Use a green, microfiber cloth with HYPERFECT 256 cleaner to clean surfaces of the headset, controllers, head strap, lenses, & facial interface. i. Use a gentle circular motion to clean the device. b. Follow UV Light Disinfection Protocols listed on sheet in front of UV device. i. 2 minutes on EACH side SPECIAL NOTE: Be aware that there are magnetic lens covers protecting the lens. DO NOT REMOVE. The actual lens surface is sensitive to sanitization and cleaning. You simply need to do a quick/gentle clean for the top surface. 3. Perform navigation & set-up of an application on a VR device. a. Power on the device. i. Push & Hold the button on the RIGHT side for approximately 3 seconds to turn on the device. The button is below the headband. b. Volume Control i. + and - switch on the bottom of the facial interface. c. Log-On d. Screen Orientation i. To orient the screen for the user, PRESS & HOLD the O oculus button on the RIGHT controller e. Navigate from Home Screen to Desired App (i.e. first steps) i. Find black toolbar. ii. CLICK button labeled Apps iii. CLICK to open the desired app. VIRTUAL REALITY (VR) IN BURN REHABILITATION PERFORMANCE 49 GO NO-GO 1. Perform correct and safe placement of a VR device on a patient. ___ ___ 2. Perform cleaning & sanitization protocols of a VR device. ___ ___ 3. Perform navigation & set-up of an application on a VR device. ___ ___ MEASURES Evaluation Guidance: Score the employee GO if all the performance measures are passed. Score the employee NO GO if any performance measure is failed. If the employee scores NO GO, show what was done wrong and how to do it correctly. VIRTUAL REALITY (VR) IN BURN REHABILITATION 50 APPENDIX H Pre-Screen for Virtual Reality (VR) Are you interested in using VR? yes/no Have you used VR before? yes/no Have you ever gotten motion sickness like on a roller coaster or on a boat? yes/no When/how? Do you currently wear glasses or contact lenses? Yes Contact lens requires no adjustments Glasses, size/fitting may need to be adjusted History of double vision? Seizures? PTSD? Claustrophobia? If yes to any, do NOT use this VR device **If you do feel uncomfortable at any time, let me know, we will have you close your eyes, take a deep breath, and if you still feel uncomfortable, we will discontinue use of the VR.** FAQ: What is Virtual Reality (VR)? A computer-generated simulation that immerses you in a virtual environment with visual, auditory, and tactile (sense of touch) feedback Will I get motion sickness? Feel dizzy afterward? Headache? Very seldomly do people feel these kinds of symptoms with the type of VR we are using today. These symptoms are always mild if at all. We will prevent those by limiting the amount of time you spend in VR as well as what type of application or game we will utilize with the VR Will I have a seizure? No, it is highly unlikely that you will have a seizure unless you have a past history of them. If you do have a past history, it is recommended that you do NOT use a VR device. *** Measure interpupillary distance (IPD) of user before VR use. The lens can be shifted horizontally left/right to 1, 2, or 3 settings (shown underneath the yellow tab). *** IPD Range 61 mm or Smaller 61 mm - 66 mm 66mm or Larger VIRTUAL REALITY (VR) IN BURN REHABILITATION Lens Spacing Setting 1 (narrowest, 58 mm) 2 (middle, 63mm) 51 3 (widest, 68mm) Exclusion Criteria Presence of open wounds to face/head/neck that may interfere with VR headset History of seizures Severe visual or auditory impairments Active delirium, delusions, psychotic disorders, physical disorders (i.e. disequilibrium, vertigo, claustrophobia, PTSD) Extensive past medical history of eye/head injury or active traumatic brain injury Extensive history or excessive susceptibility to motion sickness or dizziness Patients who reported feeling excessively anxious or feelings of discomfort while utilizing VR goggles Richmond Agitation and Sedation Scale of -3 or lower Active nausea or vomiting Not wanting to participate or unable to consent to participation VIRTUAL REALITY (VR) IN BURN REHABILITATION 52 APPENDIX I CLEANING & SANITIZATION OF PRODUCTS - (Oculus Support) QUICK - CLEAN DO NOT use alcohol, bleach, OR hydrogen peroxide cleaning solutions on ANY VR equipment. This WILL damage and VOID the warranty of the device (particularly the lens). Headset, Controllers, Lenses, & Facial Interface 1. GENTLY use a microfiber cloth (green) with HYPERFECT 256 cleaner to clean surfaces of the headset, controllers, head strap (elite strap), lenses, & facial interface. 2. BE CAREFUL of the small circular sensors on the front of the headset. Use gentle circular motions to clean these. SPECIAL NOTE: Be aware that there are magnetic lens covers protecting the lens. DO NOT REMOVE. The actual lens surface is sensitive to sanitization and cleaning. You simply need to do a quick/gentle clean for the top surface. UV Light Disinfection ~ ALL ITEMS ~ Follow UV Light Disinfection Protocols listed on 1/2 sheet in front of UV device. 2 minutes EACH side VIRTUAL REALITY (VR) IN BURN REHABILITATION 53 DEEP- CLEAN Before cleaning, REMOVE all components of the VR device including the silicone facial cover, strapping, and the magnetic lens cover only. Materials Needed Green Microfiber Cloth(s) HyperFect 256 A plastic card (like a credit card or ID) Q-tips Facial Foam Cover Gently remove the facial cover from the VR device. This simply snaps in/out of the device and should not require much force. Once removed, Use a microfiber cloth (green) with HYPERFECT 256 cleaner to clean the inside and outside of the cover. Silicone cover Use a microfiber cloth (green) with HYPERFECT 256 cleaner to clean the inside and outside of the cover. Controllers This component may be the one most likely to be dirty as there are contours along each of the controllers. Gently wipe with a microfiber cloth and hyperfect to get general surfaces. Followed by covering your plastic card with a microfiber towel with disinfectant, and go over the seams to remove dirt/debris. Lens SAFETY NOTE: The actual lens itself on the VR device does not need to be cleaned. There is a protective/magnetic cover then simply snaps into place. Remove magnetic lens cover and Use a microfiber cloth (green) with HYPERFECT 256 cleaner to clean inside and outside of the lens cover. The actual lens on the headset device. Use a DRY microfiber cloth (green) to wipe in a circular motion to remove any dust. VIRTUAL REALITY (VR) IN BURN REHABILITATION 54 Elite Strap SAFETY NOTE: the side straps are extremely sensitive and susceptible to breaking if placed/removed incorrectly. I highly recommend you watch a video for removing the elite strap before attempting to do this. Once the elite strap is removed, Use a microfiber cloth (green) with HYPERFECT 256 cleaner to clean all surfaces. Headset Once all components are removed from the VR device. Use a microfiber cloth (green) with HYPERFECT 256 cleaner to clean all surfaces of the headset. BE CAREFUL of the small circular sensors on the front of the headset. Use gentle circular motions to clean these. Here is a good HOW-TO video for a deep clean. https://www.youtube.com/watch?v=g0p1qwR-m98 Elite Strap Placement/Removal Video https://www.youtube.com/watch?v=cfqvJgNyTUU  ...

... Establishing an Occupation-Based Dance Program in the Inpatient Psychiatric Setting Kayla Mitchell, OTS 04/22/2021 A doctoral 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 DCE advisor: Taylor McGann, MS, OTR, OTD A Doctoral Capstone Project Entitled Establishing an Occupation-Based Dance Program in the Inpatient Psychiatric Setting Submitted to the School of Occupational Therapy at University of Indianapolis in partial fulfillment for the requirements of the Doctor of Occupational Therapy degree. By Kayla Mitchell, OTS Approved by: Taylor McGann, OTS, OTR, OTD DCE Advisor (1st Reader) 2nd Reader Date 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: OCCUPATION-BASED DANCE PROGRAM 1 Establishing an Occupation-Based Dance Program in the Inpatient Psychiatric Setting Kayla Mitchell, OTS & Taylor McGann, MS, OTR, OTD University of Indianapolis OCCUPATION-BASED DANCE PROGRAM 2 Abstract Participation in occupation-based care is often associated with recovery in mental illness (Lipskaya-Velikovsky, Krupa, Silvan-Kosovich, & Kotler, 2020). Dance can be promising occupation-based therapeutic tool to implement in the psychiatric setting, due to its many physical and mental health benefits (Hackney & Earhart, 2010). The aim of this doctoral capstone experience was to create an occupation-based dance program to help improve healthrelated quality of life for individuals in the inpatient psychiatric setting. Six individuals participated in a biweekly 45 minute dance group over the course of six weeks. The group consisted of an educational session, main activity, and sharing component, with weekly themes incorporated based on the aspects of the needs assessment and literature. The results indicate favorable effects, specifically in the domains of emotional expression and leisure interests, and overall group enjoyment and satisfaction. Furthermore, the patients perceived the dance group as an enjoyable and likable experience, indicating its perceived sustainability for future programming. OCCUPATION-BASED DANCE PROGRAM 3 Establishing an Occupation-Based Dance Program According to the National Institute on Mental Health, mental illness is a common condition among U.S. adults, with one in five currently affected (2019). Major depressive disorder (MDD) and bipolar disorder (BP) are leading causes of disability (WHO, 2012), and 40 million people in the United States experience an anxiety disorder in one year (SAMHSA, 2015). In the United States, 1% to 2% of the population has obsessive-compulsive disorder (OCD), and 2.5 million American adults have schizophrenia (Treatment Advocacy Center, 2009). Despite the prevalence of mental health disorders, less than half of those affected currently seek treatment (NIH, 2019), which can cause challenges relating to many areas of their daily lives, including cognition (Chen et al., 2016), physical capacity (Kaltsatou et al., 2015), and quality of life (Kaltsatou et al., 2015). Occupational therapists assist individuals with mental illness by developing the skills necessary for productive living through a client-centered perspective (Gibson, DAmico, Jaffe, & Arbesman, 2011). This can include various life roles and responsibilities, often incorporating the community integration of ADLs and IADLs (leisure, social participation, job skills, educational resources, etc.) to meet goals necessary for meaningful discharge (Gibson, DAmico, Jaffe, & Arbesman, 2011). Research shows occupation-based intervention is an effective method to help cope with mental health conditions, as it increases overall life satisfaction and performance, strengthens clients self-motivation for change, and allows for an opportunity for self-reflection when facing difficult situations (Schindler, 2010). Challenges exist when incorporating occupation-based care in inpatient settings, as the structured environment can be constricting for clients to participate in meaningful occupations (Brown et al., 2011; Davidson et al., 2016; Jackman, 2016, as cited in Lipskaya-Velikovsky, Krupa, Silvan-Kosovich, I., & Kotler, 2020) OCCUPATION-BASED DANCE PROGRAM 4 and hospital staff is not always aware of the important role of daily occupation (Davidson et al., 2016; Jackman, 2016, as cited in Lipskaya-Velikovsky, Krupa, Silvan-Kosovich, I., & Kotler, 2020). It is important to address these barriers, as occupation-based care can enhance life and improve satisfaction and daily functioning for individuals with mental illness (Schindler, 2010). A unique way to incorporate occupation into mental health practice is implementing a dance-based intervention. Dance is an effective method to help cope with mental health challenges, as it influences both physical well-being (Kaltsatou et al., 2015) and mental wellbeing because it is linked to increased emotional processing (Duberg, Mller, & Sunvisson, 2016), body awareness (Danielsson, & Rosberg, 2015), and self-esteem (Kaltsatou et al., 2015). Additionally, it provides opportunity for community integration (Rosselli, Kimbrough, & Crutcher, 2018), healthy lifestyle promotion (weight loss, physical activity, etc.) (Runenko, Razina, Shelekhova, & Mushkabarov, 2018), and maintaining cognitive health (ThgersenNtoumani et al., 2018). When dance is employed from an occupation-based perspective, the outcome can influence independence in functional life skills, including the incorporation of stress management, coping skills, and self-awareness of thoughts and feelings (Barton, 2011). The purpose of my DCE project was to establish an occupation-based dance/movement group for individuals with mental illness to increase their physical and mental well-being for a safe and meaningful discharge into the community. The Model of Human Occupation (MOHO) is an appropriate model to guide my DCE project because it focuses on how the person and the environment contribute to a persons motivation and occupational performance (Cole & Tufano, 2008). Additionally, MOHO is a widely used theory in mental health practice, with the vast majority of therapists reporting it contributes to occupation-based practice and client satisfaction (Lee et al., 2012). In a descriptive study analyzing the impact of using MOHO in mental health OCCUPATION-BASED DANCE PROGRAM 5 practice, 60% of participants reported that using the MOHO improved their therapy outcome moderately to greatly (Lee et al., 2012). The MOHO improved their professional identity, increased other staff members' understanding of occupational therapy services, and contributed to OT services' unique value to clients (Lee et al., 2012). In a qualitative study by Cole (2010), the MOHO facilitated an understanding of the nature of physical activity participation for mental illness. It helped the researchers investigate the perceived barriers and support that individuals with mental illness face when participating in physical activity (Cole, 2010). The different areas of the MOHO (volition, habituation, environment, and performance capacity) support my project and are beneficial guidelines for formulating thoughts on how to structure the program, specifically volition, because it addresses how emotional and cognitive factors, such as fear or motivation, affect a persons ability to participate (Cole, 2010). This model will be utilized to create a program that is client-centered and guide the identification of the motivational barriers that may occur for participation in the program. The objective of this literature review is to analyze the themes related to dance intervention in mental health practice and the associated motivating factors guided by the MOHO along with the goals of the DCE project. Literature Review Physical Well-Being Research shows that exercise has profound impacts on physical health (Browne, Mihas, & Penn, 2016), by reducing the risk of chronic diseases such as cardiovascular disease and preventing conditions like obesity and high blood pressure (Bassuk and Manson 2005; Richardson et al., 2005). Individuals with mental illness are likely more sedentary than those who do not have a mental illness, causing them to gain weight and face health-related OCCUPATION-BASED DANCE PROGRAM 6 consequences like obesity (Browne, Mihas, & Penn, 2016). Motivation plays a significant role in exercise participation, especially since those with mental illness face many barriers, including decreased enjoyment in physical activity and co-morbidities (Browne, Mihas, & Penn, 2016). Dance is different from typical forms of exercise such as running and cycling because it offers a sense of community, pleasant experience, and emotional expression not found in other types of exercise (Duberg, Mller, & Sunvisson, 2016). In a study examining the effects of an 8-month dance program on individuals with schizophrenia, favorable effects were seen in functional capacity, with the 6-minute walk test, Berg Balance Test, and sit-to-stand test, all showing improvements (Kaltsatou et al., 2015). Along with these tests, dance increased flexibility, balance, and lower limb strength due to the movements in dance involving aspects of all three (Kaltsatou et al., 2015). Weight loss is also a potential result of engaging in dance programs, with one study finding fat mass decreasing 20% in a 9-month program and a 24.5% increase in physical capacity for individuals who are obese or overweight (Runenko, Razina, Shelekhova, & Mushkabarov, 2018). Individuals with severe mental illness increased their range of motion and mobility from participating in a movement and mindfulness group, leading to improved physical abilities for other daily tasks (Barton, 2011). Thus, dance is a contributing factor to increasing physical well-being in those with mental illness due to its many health-related benefits, such as increased motivation, functional capacity, flexibility, balance, strength, and weight loss. Quality of Life According to the World Health Organization (1998), quality of life (QOL) is a broad term that encompasses an individuals perception of their position in life within the context of their culture and value system in which they live in relation to goals, standards, and concerns. Many OCCUPATION-BASED DANCE PROGRAM 7 research studies explore the potential positive relationships between dance intervention and an individuals quality of life. In a study exploring the experiences of an 8-week dance program on health-related quality of life, the general mood for participation improved, specifically for feelings of depression and stressful feelings (Olga, Georgios, Ioannis, Dimitrios, & Maria, 2018). The psychological domain of quality of life significantly improved in participants during a 12week study on the effects of praise dance (Chung, Wong, Chen, & Chung, 2016). The results of an 8-month Greek traditional dance program on individuals with schizophrenia had significant improvements in QOL, specifically in life enjoyment and satisfaction (Kaltsatou et al., 2015). In an experimental study on the effects of a 16-week Zumba dance group on sedentary women, results demonstrated significant changes in the health-related QOL, specifically vitality, mental health, and physical functioning (Barranco-Ruiz, Paz-Viteri, & Villa-Gonzlez, 2020). Major increases in several subscales of QoL (activities of daily living, emotional wellbeing, and cognition) were seen in a group examining QOL in individuals with Parkinsons disease who participated in a dance program (Kalyani et al., 2019). These studies indicate dance as beneficial in improving psychological well-being, which is essential when establishing programming for mental health, as quality of life affects all areas of life (Olga, Georgios, Ioannis, Dimitrios, & Maria, 2018). Cognition Cognition includes the domains of memory, attention and processing speed, language, executive functioning, and learning (Chen et al., 2016). Cognitive impairment is commonly seen in individuals with mental illness and is one of the core features of some conditions, such as schizophrenia (Chen et al., 2016). In a study exploring the effects of an aerobic dance program on individuals with schizophrenia, participants significantly improved on many cognitive OCCUPATION-BASED DANCE PROGRAM 8 assessments, including verbal fluency, immediate recall, learning, and psychomotor speed (Chen et al., 2016). Participants with memory impairments in a study on social dance described it as a positive way to improve their cognitive function, especially since the class structure and level of challenge appealed to their interest (Thgersen-Ntoumani, Papathomas, Foster, Quested, & Ntoumanis, 2018). In a quasi-experimental study examining the effects of dance for individuals with Parkinsons disease, executive function showed significant improvement, along with improvements in episodic memory (Kalyani et al., 2019). In another experimental study, hip-hop dancers demonstrated faster judgment in deciphering images than non-hip-hop dancers (Bonny, Lindberg, & Pacampara, 2017). Older adults that participated in a six-month dance program demonstrated brain structure changes in areas associated with executive functioning, visuomotor integration, and action imitation, all of which are essential for many daily functioning motor activities (Rektorova et al., 2020). No matter the type of dance or population, cognitive improvements are seen across studies, indicating its ability to demonstrate effects. Social Participation Individuals with psychiatric disorders often develop symptoms in late adolescence or adulthood, which affects their ability to complete high school and any post-secondary education (Mowbray et al., 2005). This can cause them to have gaps in basic education and knowledge, along with a lack of understanding of the interpersonal skills needed to succeed in their occupational roles, such as student or employee (Gutman, Kerner, Zombek, Dulek, & Ramsey, 2009). A widely known benefit of dance is its ability to connect with others and increase motivation to participate through community and social benefits. Adults with memory impairments describe dance as a way to initiate social interaction while promoting physical OCCUPATION-BASED DANCE PROGRAM 9 activity (Thgersen-Ntoumani et al., 2018). In a quasi-experimental study on health-related quality of life for primary school students, dance improved quality of life by giving students meaningful social experiences that contributed to their overall health (Olga et al., 2018). Participants in a dance program for girls with internalizing problems stated that dance caused them to experience a social community, leading to feelings of support and togetherness (Duberg, Mller, & Sunvisson, 2016). In a qualitative study on the effectiveness of a movement and mindfulness group for individuals with severe mental illness, staff described interpersonal interactions as the most significant change among participants (Barton, 2011). The entire group displayed pro-social behaviors including increased social bonds among group members and improved participation in other social activities (Barton, 2011). Community-dwelling adults who participated in regular square dancing likely engaged in other social activities, such as volunteering and visiting friends, than those who did not regularly participate (Liao, S. Chen, Chen, & Yung-Jen Yang, 2019). Hence, dance beneficially connects others, all while creating a sense of community and social support, aspects that are important in all mental health conditions. Emotional Expression Along with the above themes, dance increases emotional expression and the ability to detect others' emotions more effectively (Bojner Horwitz, Lennartsson, Theorell, & Ullen, 2015). The theme of dance as emotional expression emerged in a study on a dance program for girls with internalizing issues. Participants connected dance with their emotions, rather than words, leading to better recognition and understanding of their emotions (Duberg, Mller, & Sunvisson, 2016). In addition, the increased body awareness from dance embodied them to feel multiple emotions, including happiness, sadness, freedom, and power (Duberg, Mller, & Sunvisson, OCCUPATION-BASED DANCE PROGRAM 10 2016). This emotional recognition increased awareness of various mental states, expanding their understanding of positive and negative everyday emotions, leading to direct implications to everyday life (Duberg, Mller, & Sunvisson, 2016). Individuals with severe mental illness involved in a 20-week movement and mindfulness group described movement as a way to identify and shift emotional states. In addition, they noted that it improved their ability to share thoughts and feelings, reduce stress, and invoke positive personal feelings (Barton, 2011). Emotional stability increased 20% in overweight or obese women after participating in a dance therapy program, along with greater self-confidence and general mood (Runenko, Razina, Shelekhova, & Mushkabarov, 2018). Older adults with memory impairments linked dance as a way to feel nostalgia, which evokes positive emotional memories (Thgersen-Ntoumani et al., 2018). These studies and more demonstrate the power of dance for emotional capability and expression, adding to its importance for mental health. In conclusion, the main themes that emerged from the investigation of the benefits of dance for mental health include physical well-being, quality of life, cognition, and emotional expression. The goal of my DCE was to employ strategies mentioned in the above studies, for individuals with mental illness. Through the perspective of occupational performance limitation and the motivational barriers recognized in MOHO, the program was created to be clientcentered in order to achieve these goals. Dance/movement is an incredible tool to increase awareness, embody recognition, and facilitate occupational wellness, and I aimed to share this with others. Method Program Implementation OCCUPATION-BASED DANCE PROGRAM 11 The program took place at a co-ed adult unit at an inpatient psychiatric hospital in the Midwest. A needs assessment was sent to the interdisciplinary team (recreational therapy, nursing, psychology, social work, transitional care staff, dietetics, chaplain, psychiatry) via Qualtrics to determine the needs of the population served (see Appendix A). Thematic analysis was used to examine the data and determine common themes. Topic areas reported that need to be addressed more frequently were categorized as personal and social development and included coping skills, communication skills, and community integration. Groups that patients benefited from/enjoyed the most had the following themes: hands-on activities, physical activity, and leisure interests. The greatest barriers reported for patient participation were motivation, attention span, and communication skills. Based on the needs assessment results, I designed a program that included the needed topic areas and combined the aspects of the group that patients benefited from the most. The group is called Expressive Dance and included the goals of increasing knowledge of using dance as a coping mechanism, increasing awareness of personal/social development topics, and increasing overall health-related quality of life. Dance was an appropriate group activity as it encompassed the needed themes of coping skills (Barton, 2011), communication, and community (Rosselli, Kimbrough, & Crutcher, 2018), all while being a motivating factor due to its aspects of enjoyable physical activity and leisure interest (Kaltsatou et al., 2015). The program's curriculum was specifically designed to meet the needs of the population and was approved by the director of recreational therapy. Participants were recruited from four-weeks of screening, evaluation, and observation of current groups offered to determine the program's best fit individuals. Additionally, participants were suggested and approved for the group by the treatment team via verbal and electronic communication. OCCUPATION-BASED DANCE PROGRAM 12 Program Description Six adults participated in the program. The dance program was led in a group format by myself (an occupational therapy doctoral student) and a recreational therapy assistant. The program was conducted two days a week for six weeks, with a total of 12 sessions. Each session lasted 45 minutes, with 10 minutes spent on the education of the topic, 30 minutes on the weeks activity, and five minutes left to share and discuss the session. The educational section focused on the different areas of health-related quality of life (physical, emotional, mental, social functioning), other related topics, and a different theme each week. This allowed participants the opportunity to understand the purpose behind each session. The activity section allowed for movement exploration and interactive leisure activities to encourage the program's motivation and participation. Lastly, the sharing section allowed for debriefing and time to reflect on the days session. Outcome Measures Participants were evaluated at the beginning and at the end of the six-week program in the form of a 14 question 5-point Likert scale pre-test and post-test survey. The pre-test survey addressed the topics to be addressed in the program to assess participants baseline knowledge on the topic areas (HRQOL, emotional expression, physical activity, future goals, social skills, cultural expression, leisure activities, dancing). See Appendix B to view the pre-test and post-test survey. The post-test survey addressed the same topics to assess areas of improvement, along with questions/statements to address what they liked/disliked about the program. Results Six participants completed the pre-test, and four participants completed the post-test (two participants were discharged during the group). See Figure 1 for each question's results from the OCCUPATION-BASED DANCE PROGRAM 13 pre/post-test and Figure 2 for the corresponding themes to each question. The post-test results indicate slight improvements in the themes of emotional expression (pre-test median: 4.15; posttest median: 4.25) and leisure interests (pre-test median: 4.05; post-test median: 4.13). The themes of physical well-being (pre-test median: 3.8; post-test median: 3.8) and coping skills (pre-test median: 4.5; post-test median: 4.5) had no change between the pre-test and post-test. The themes of social well-being (pre-test median: 3.9; post-test median: 3.5), personal development (pre-test median: 4.33; post-test median: 4.13), and cultural expression (pre-test median: 4.4; post-test median: 4.0) had a slight decrease between the pre-test and post-test. The two participants who wrote scores of 1 on two questions from the pre-test improved on the post-test, with the first improving from 1 to 3 and the other from 1 to 4. All participants affirmed they learned something from the group (median score: 4.25) from the statement I learned something from participating in this group. Participants also indicated they enjoyed the group (median score: 4.25) from the statement I enjoyed participating in this group. 100% of the participants confirmed program enjoyment with verbal question prompts. This included the following statements: I really enjoyed this group and dancing, You were a good teacher, I thought the last week was very fun, and I looked forward to this group. Several patients indicated they plan on using dance as a leisure activity and/or coping skill in the future. The participants also expressed the group was meaningful to them with the following statements: It got me off the unit, and I enjoyed coming here," and It was a good group, and gave me something to do other than sit around. Discussion The purpose of this doctoral capstone experience was to create an occupation-based dance group to help improve health-related quality of life for individuals in the inpatient OCCUPATION-BASED DANCE PROGRAM 14 psychiatric setting. To my knowledge, this was the first dance group created at this hospital and one of the few dance groups in the literature with an occupation-based focus. This program's favorable effects indicate that dance can be a beneficial intervention for patients with mental illness and enhance the finding that dance/movement can be implemented with other forms of therapy for a positive result (Kaltsatou et al., 2015). This project's main findings indicate improvements in the domains of emotional expression and leisure interests and overall group enjoyment and satisfaction. For emotional expression, specific improvements were seen in an awareness of emotions and identifying methods to cope with emotions. This was implemented by education on emotions and specific dance programming that allowed participants to express and identify their emotions in the past, present, and future. The literature aligns with this finding, including reports of acceptance of emotions from dance in an eight-month dance program (Duberg, Mller, & Sunvisson, 2016), reports of increased emotional stability in a nine-month dance therapy program (Runenko, Razina, Shelekhova, & Mushkabarov, 2018), and improved emotional well-being in a twelveweek dance group (Kalyani et al., 2019). In contrast, a study on dance fitness classes on women found no change in the emotional role of health-related quality of life; however, significant improvements were seen in the mental health dimension, which may indicate improved emotional expression was involved (Barranco-Ruiz, Paz-Viteri, & Villa-Gonzlez, 2020). Residents in inpatient psychiatric settings often have difficulty engaging and choosing meaningful leisure activities, with more time spent on unfulfilling leisure pursuits such as sleeping or watching television (Murphy & Shiel, 2019). The theme of leisure interests improved in this group, specifically with participants verbalizing leisure activities they can participate in (playing cards, walking, group sports, etc.) and identifying dance as a leisure interest to pursue in OCCUPATION-BASED DANCE PROGRAM 15 the future. Education and handouts on locations to participate in community dance, solo dance, and other related topics were provided to promote engagement in meaningful leisure occupations. This application is seen in other dance programs, as participants reported using dance/movement techniques on their own, including watching videos and practicing, after participating in a movement/mindfulness program for individuals with severe mental illness (Barton, 2011). Similarly, after participating in a 12-week dance workshop, older adults reported it to be a fulfilling leisure activity, leading the authors to conclude that leisure programming needs to be implemented in this population more often to improve quality of life (Miotto Nadolny et al., 2020). Adult females in a study exploring world dance as a therapeutic tool described dance as a way to confirm their careers and provide meaning to their lives as professional artists (Ali, Cushey, & Siddiqui, 2017). Objectively, the overall theme of group enjoyment and satisfaction is the most important to emerge from this program. Individuals in psychiatric hospitals often experience exclusion from meaningful occupations or do not reach their full potential in occupation, making it difficult to engage in their habits and routines (Murphy & Shiel, 2019). By providing them with an enjoyable group, they may experience a sense of belonging and enjoyment not found in other daily activities. Similarly, adults with severe mental illness in a dance/movement study reported overall liking, deeming it an enjoyable process and way to integrate themselves into other offered leisure opportunities (Barton, 2011). In a study on dance intervention in a rehabilitation hospital setting, participants reported enjoyability, confidence, and overall liking of the group, consistent with this group (Demers & McKinley, 2015). This aspect of the group is particularly important in the program's sustainability, as it may increase the likelihood other professionals will implement the program in the future or repeat aspects in related groups. OCCUPATION-BASED DANCE PROGRAM 16 Limitations The group was limited by sample size and attrition rate, mostly due to discharges in the inpatient acute psychiatric setting. Additionally, the group was limited by medical and personal reasons that often caused difficulties in group attendance. Staffing schedules and low staffing for patient escorts were limiting in ensuring the group's start and end time. All participants were chosen and selected by careful observation and selection from the treatment team, which may have contributed to the positive experience reported by all the participants. Also, since the group sessions typically consisted of six or fewer participants, they all received individualized attention that could have contributed to their liking of the group. A group with a larger sample size may provide less liking due to less personalized attention. Further studies should explore the benefits of dance intervention in a large population size in another psychiatric hospital, to determine if results are similar. Future studies could explore other avenues of dance intervention such as new styles or different themes or implementing it with other expressive forms of art, such as drumming, acting, or spoken word. Additionally, the program can be adjusted to fit different populations' needs, including youth, adolescents, and individuals in an outpatient psychiatric setting. Conclusion Dance is a promising therapeutic tool to implement in the psychiatric setting to aid in the care of individuals with mental illness. This project supports the idea that dance can be a feasible, enjoyable, and beneficial intervention for group programming. The results suggest that it can improve health-related quality of life, specifically emotional expression, application to leisure, and overall life enjoyment. The dance exercises and weekly themes can be adapted to fit the clients' needs with various psychological and physiological impairments, aiding in OCCUPATION-BASED DANCE PROGRAM 17 application of client-centered goals. Furthermore, the patients perceived the dance group as an enjoyable and likable experience, indicating its perceived sustainability for future programming. OCCUPATION-BASED DANCE PROGRAM 18 References Ali, S., Cushey, K., & Siddiqui, A. (2017). Diversity and dance: Exploring the therapeutic implications of world dance. Journal of Creativity in Mental Health, 12(1), 3147. https://doi.org/10.1080/15401383.2016.1203855 Barranco-Ruiz, Y., Paz-Viteri, S., & Villa-Gonzlez, E. (2020). Dance fitness classes improve the Health-Related quality of life in sedentary women. International Journal of Environmental Research and Public Health, 17(11). https://doi.org/10.3390/ijerph17113771 Barton, E. J. (2011). Movement and mindfulness: A formative evaluation of a dance/movement and yoga therapy program with participants experiencing severe mental illness. American Journal of Dance Therapy, 33(2), 157181. https://doi.org/10.1007/s10465-011-9121-7 Bassuk, S. S., & Manson, J. E. (2005). Epidemiological evidence for the role of physical activity in reducing risk of type 2 diabetes and cardiovascular disease. Journal of Applied Physiology, 99(3), 11931204. Bojner Horwitz, E., Lennartsson, A. K., Theorell, T. P., & Ullen, F. (2015). Engagement in dance is associated with emotional competence in interplay with others. Frontiers in Psychology, 6, 1096. doi:10.3389/fpsyg.2015.01096 Bonny, J. W., Lindberg, J. C., & Pacampara, M. C. (2017). Hip hop dance experience linked to sociocognitive ability. 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W., DAmico, M., Jaffe, L., & Arbesman, M. (2011). Occupational therapy interventions for recovery in the areas of community integration and normative life roles OCCUPATION-BASED DANCE PROGRAM 20 for adults with serious mental illness: A systematic review. American Journal of Occupational Therapy, 65, 247256. doi: 10.5014/ajot.2011.001297 Gutman, S. A., Kerner, R., Zombek, I., Dulek, J., & Ramsey, C. A. (2009). Supported education for adults with psychiatric disabilities: Effectiveness of an occupational therapy program. American Journal of Occupational Therapy, 63, 245254 Jing Liao, Sanmei Chen, Sha Chen, & Yung-Jen Yang. (2019). Personal and social environmental correlates of square dancing habits in Chinese middle-aged and older adults living in communities. Journal of Aging & Physical Activity, 27(5), 696702. Kaltsatou, A., Kouidi, E., Fountoulakis, K., Sipka, C., Theochari, V., Kandylis, D., & Deligiannis, A. (2015). Effects of exercise training with traditional dancing on functional capacity and quality of life in patients with schizophrenia: A randomized controlled study. Clinical Rehabilitation, 29(9), 882891. doi:10.1177/0269215514564085 Kalyani, H. H. N., Sullivan, K. A., Moyle, G., Brauer, S., Jeffrey, E. R., & Kerr, G. K. (2019). Impacts of dance on cognition, psychological symptoms and quality of life in Parkinsons disease. NeuroRehabilitation, 45(2), 273283. https://doi.org/10.3233/NRE-192788 Lipskaya-Velikovsky, L., Krupa, T., Silvan-Kosovich, I., & Kotler, M. (2020). Occupationfocused intervention for in-patient mental health settings: Pilot study of effectiveness. Journal of Psychiatric Research, 125, 4551. https://doi.org/10.1016/j.jpsychires.2020.03.004 Miotto Nadolny, A., Trilo, M., da Rosa Fernandes, J., Passos Pinheiro, C. S., Ziemer Kusma, S., & Marquine Raymundo, T. (2020). 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Retrieved from https://www.nimh.nih.gov/health/statistics/mental-illness.shtml Olga, T., Georgios, L., Ioannis, G., Dimitrios, C., & Maria, K. (2018). The positive effects of a combined program of creative dance and BrainDance on health-related quality of life as perceived by primary school students. Physical Culture & Sport. Studies & Research, 79(1), 4252. doi: 10.2478/pcssr-2018-0019 Rektorova, I., Klobusiakova, P., Balazova, Z., Kropacova, S., Sejnoha Minsterova, A., Grmela, R., Skotakova, A., & Rektor, I. (2020). Brain structure changes in nondemented seniors after six-month dance-exercise intervention. Acta Neurologica Scandinavica, 141(1), 90 97. https://doi.org/10.1111/ane.13181 Richardson, C. R., Faulkner, G., McDevitt, J., Skrinar, G. S., Hutchinson, D. S., & Piette, J. D. (2005). Integrating physical activity into mental health services for persons with serious mental illness. Psychiatric Services, 56(3), 324333. doi:10.1007/s10597-015-9896-y OCCUPATION-BASED DANCE PROGRAM 22 Rosselli, A. C., Kimbrough, S., & Crutcher, T. (2018). Experiencing Sense of Community in Dance Fitness. TAHPERD Journal, 86(3), 814. Runenko, S. D., Razina, A. O., Shelekhova, T. Y., & Mushkabarov, N. N. (2018). Efficiency of dance therapy for weight loss and improvement of the psychological and physiological state in overweight or obese young women. Journal of Physical Education & Sport, 18(2), 902913. doi: 10.7752/jpes.2018.02134 Schindler VP. (2010). A client-centered, occupation-based occupational therapy programme for adults with psychiatric diagnoses. Occupational Therapy International, 17(3), 105112. https://doi.org/10.1002/oti.291 Substance Abuse and Mental Health Services Administration. (2015). Mental Disorders: Anxiety Disorder. Retrieved from http://www.samhsa.gov/disorders/mental Thgersen-Ntoumani, C., Papathomas, A., Foster, J., Quested, E., & Ntoumanis, N. (2018). Shall We Dance? Older adults perspectives on the feasibility of a dance intervention for cognitive function. Journal Of Aging And Physical Activity, 26(4), 553560. doi:10.1123/japa.2017-0203 Treatment Advocacy Center. (2009). Schizophrenia Fact Sheet. Retrieved from www.treatmentadvocacycenter.org/problem/consequences-of-nontreatment/schizophrenia WHOQOL Group. (1998). The World Health Organization Quality of Life Assessment (WHOQOL): Development and general psychometric properties. Social Science & Medicine, 46, 1569-1585. World Health Organization (2012). Depression fact sheet no. 269. New York: NY: Author. Retrieved from http://www.who.int.mediacentre/factsheets/fs369/en/ OCCUPATION-BASED DANCE PROGRAM 23 Appendix A The purpose of the following questions is to address the needs of the adult population at this facility. Results will aid in the development of an occupational therapy doctoral capstone project. Results will be anonymous. Thank you for taking the time to complete this survey. Needs Assessment 1. Which topic areas are covered most consistently within the groups here? 2. Which skills or topic areas, if any, need to be addressed more frequently during group sessions? 3. Which topic areas do patients tend to benefit from/enjoy the most during group sessions? 4. Occupational therapists often help people with the following activities/skills. From the list below, check the topics, if any, patients would benefit from receiving further instruction on at or before discharge (Select All That Apply). ___ Health and Wellness ___ ADLs (activities of daily living) ___ Money Management ___ Stress Management ___ Social Skills ___ Cognitive Skills ___ Physical Mobility ___ Meaningful Relationships ___ Following Routines ___ Sensory Regulation ___ Home Management ___ Job Skills ___ Leisure/Hobbies ___ Goal Setting ___ Community Integration OCCUPATION-BASED DANCE PROGRAM 24 5. From the list below, select any areas that you believe are the greatest challenge(s) for patients to overcome when completing groups and/or daily tasks (Select All That Apply). ___ Attention Span ___ Social Skills ___ Time Management ___ Memory ___ Self-Confidence ___ Communication Skills ___ Behavior Regulation ___ Emotional Expression ___ Motivation ___ Physical Abilities ___ Stress Management ___ Decision Making Other: ________ 6. Please list any other group topics not mentioned above that you believe would help increase the quality of life and treatment success within the adult population. Appendix B OCCUPATION-BASED DANCE PROGRAM Question/Statement 25 Strongl y Disagre e Disagre e Undecided Agree 1 I know what health-related quality of life is 1 2 3 4 2 I am aware of my emotions 1 2 3 4 3 I know ways to cope with my emotions 1 2 3 4 4 I enjoy participating in physical activity 1 2 3 4 5 I understand the benefits of participating in physical activity 1 2 3 4 6 I can learn from my past 1 2 3 4 7 I have goals for my future 1 2 3 4 8 I like to work with others 1 2 3 4 9 Being on a team is important to me 1 2 3 4 10 I am aware of my own culture 1 2 3 4 11 I think it is important to learn about the culture of others 1 2 3 4 12 I know leisure activities that I can participate in 1 2 3 4 13 I enjoy dancing 1 2 3 4 14 I can use dance as a coping skill 1 2 3 4 15 Participating in this group improved my overall healthrelated quality of life 1 2 3 4 16 I learned something from participating in this group 1 2 3 4 17 I enjoyed participating in this group 1 2 3 4 Note. Questions 15-17 are only included in the post-test. Strongly Agree 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 OCCUPATION-BASED DANCE PROGRAM 26 Figure 1 Pre/post-test Results Question/Statement Median Response Median Response Pre-test Post-test 4.2 4.25 4.3 4.5 4 4 3.6 4 4 4 4.3 4.25 4.5 4 4.2 3.25 3.6 3.75 4.5 4 4.3 4 3.6 4 4.5 4.25 4.5 4.5 1 I know what health-related quality of life is 2 I am aware of my emotions 3 I know ways to cope with my emotions 4 I enjoy participating in physical activity 5 I know the benefits of participating in physical activity 6 I can learn from my past 7 I have goals for my future 8 I like to work with others 9 Being on a team is important to me 10 I am aware of my own culture 11 I think it is important to learn about the culture of others 12 I know leisure activities that I can participate in 13 I enjoy dancing 14 I can use dance as a coping skill 15 Participating in this group improved my overall health-related ---------quality of life 3.75 OCCUPATION-BASED DANCE PROGRAM 27 16 I learned something from participating in this group ---------- 17 I enjoyed participating in this group ----------- Figure 2 The Themes of the Pre/Post Test Questions Theme Questions Corresponding Personal Development 1, 6, 7 Emotional Expression 2, 3 Physical Well-being 4, 5 Social Well-being 8, 9 Cultural Expression 10, 11 Leisure Interests 12, 13 Coping Skills 14 Overall thoughts (post-test only) 15, 16, 17 4.25 4.25  ...

... Multifaceted Ergonomics Program to Decrease Risk Factors of Work-Related Musculoskeletal Disorder. Laura E McKay, OTS 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: Alissia Garabrant, OTD, MS, OTR Susan Hardesty, MS, OTR ERGONOMICS PROGRAM TO DECREASE RISK FACTORS OF WMSD A Research Project Entitled Ergonomics Program to Decrease Risk Factors of Work-Related Musculoskeletal Disorder. 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 Names Titles 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 Date 2 ERGONOMICS PROGRAM TO DECREASE RISK FACTORS OF WMSD 3 Abstract Background: Nurses are at high risk for developing work-related musculoskeletal disorders (WMSDs). Ergonomics programs assist in decreasing risk factors associated with WMSDs. This study aimed to develop a multifaceted ergonomics interventions program to increase awareness of ergonomics interventions to reduce overall risk factors of WMSDs and increase occupational therapy referral to address ergonomics issues. Method: A two-part ergonomics program was created and implemented. Part one focused on nurses training on the use of the friction reduction slide sheet (FRS). In part two, the researcher developed educational material with a holistic approach. Portions of the Rapid Upper Limb Assessment (RULA) and a pre/post questionnaire were used to determine effectiveness. Result: Thirteen burn nurses participated in the program. The participants increased their awareness of WMSDs and identifying the risk factors. The participants used the FRS training and ergonomics techniques for adapting and modifying the environment to decrease risk. All participants felt the program provided adequate information and applied it to work routines. Conclusion: In conclusion, an occupational therapist-led, multifaceted ergonomics program helps nurses increase awareness of WMSDs, provides a comprehensive method for reducing risk factors in the workplace, and helps increase occupational therapy referrals to address ergonomics issues. Keywords: Occupational therapy, Work-related musculoskeletal disorder (WMSDs), Program Development, Nursing, Ergonomics Acknowledgment: I want to give thanks to my site mentor Susan Hardesty who helped me problem solve and connect with the key stakeholders in my study. I also want to thank my faculty mentor Alissia Garabrant for assistance in editing my final paper and presentation. ERGONOMICS PROGRAM TO DECREASE RISK FACTORS OF WMSD 4 Musculoskeletal injuries cause wear and tear on skeletal muscles and joints within the body (Kotejoshyer, Punnett, Dybel, & Buchholz, 2019). The lower back, knee, neck, and shoulder are the most common areas for injury (Kotejoshyer et al., 2019). Many activities within ones occupation can increase the risk for musculoskeletal injuries, especially those occupations that require manual lifting, repetitive movement, awkward postures, vibration, and variation of temperatures (Kotejoshyer et al., 2019). In addition to these physical risk factors, psychosocial risk factors such as negative work environment (Abd El-Rasol & Abd El Rahman, 2018), decreased social support (Stansfeld, Shipley, Head, Fuhrer & Kivimaki, 2013), increased stress (Fisher, 2017), and lack of leadership within the company (Westerlund et al., 2010) can increase the risk for injuries. Many jobs are at increased risk for work-related musculoskeletal disorders (WMSDs) due to their occupational demand; however, nurses have reported having the highest exposure to WMSDs due to their job (Ratzon, Bar-Niv, & Froom, 2016). Completing activities relating to bedside care, transferring, positioning, and assisting in activities of daily living (ADLs) are all demands of nursing (Darragh, Huddleston, & King, 2009; Mirmohammadi, Yazdahi, Estemadinejad, & Asgarinejad, 2015). These job demands lead to awkward positioning, heavy loads, and repetitive movements (Kotejoshyer et al., 2019). Mirmohammadi et al. (2015) stated that improper biomechanics led to nurses having increased neck and back pain. The results of increased WMSDs in the workplace are a vast financial and psychosocial burden on both the company and the employees (And El-Rasol & Abd El Rahman, 2018). Over three-fourths of worker compensation claims come from nursing staff and therapists within the healthcare system with WMSDs (Kotejoshyer et al., 2019). Not only do WMSDs cause physical strain on the individual, but they can also lead to an economic burden on the company due to increased sick leave and workers compensation insurance claims (Rasmussen, ERGONOMICS PROGRAM TO DECREASE RISK FACTORS OF WMSD 5 Holtermann, Bay, Sgaard, & Jrgensen, 2015). Nestorova and Mircheva (2018) reported that there are on average, in the United States, 17.6 workdays lost and cost above six billion U.S. dollars to treat injuries. Along with economic stress, researchers have established a connection between employees with WMSDs and decreased productivity and quality of work (Nestorova & Mircheva, 2018). Ultimately WMSDs have also led to nurses reporting a low quality of life at both work and home (Abd El-Rasol & Abd El Rahman, 2018). Due to the cost of claims, decrease productivity, decreased quality of work, and quality of life WMSDs have huge consequences for both nurses and their companies. The good news is that WMSDs are preventable with the appropriate policies and training (Marcum & Adams, 2017). To solve the problem of increased musculoskeletal injuries in hospitals, in the mid-late 2000s, the National Institute for Occupational Health and Safety (NIOSH) and Occupational Health and Safety Association (OSHA) created policies for safe patient handling (Abd El-Rasol & Abd El Rahman, 2018). Policies for safe-patient handling require the use of equipment for any lifts over 35 pounds due to the amount of force on the nurses lumbar spine (Waters, 2007). Research has shown a decrease in work-related injuries when a nurse uses mechanical lifts to transfer a patient (Scanlon, 2014). In 2006, Texas became one of the first states to implement a no manual lift policy, which meant that hospitals emphasized the use of mechanical lifts (Waters, 2007). To maintain compliance with these policies, companies can obtain new mechanical lifting equipment and develop programs centered on safe patient handling. Several researchers have developed ergonomics programs to implement patient handling policies. Haris and Haris (2019) came up with an educational program that used booklets on ergonomics guidelines to reduce risk factors. Another program focused on ergonomics for ERGONOMICS PROGRAM TO DECREASE RISK FACTORS OF WMSD 6 bedside nurses and concentrated on three things: diagnosing the problem, propose change through additional resources, and implement change through educational tools and resources (Scallon, 2014). Scallon educated and trained individuals on mechanical lift equipment to prevent heavy lifts. Other programs created a training course on ergonomics techniques, focusing on posture, body awareness, conditioning, and equipment modification (Kozak, Freitag, & Nienhaus, 2017). The purpose of these ergonomics programs was to incorporate safety while on the job and provide protection from WMSDs by using mechanical lifts and training programs. There is still a high prevalence of WMSDs among nursing staff despite the new policies implemented to prevent musculoskeletal injuries (Wiggermann, Zhou, & McGann, 2020). Factors such as requiring too much time and hassle, not enough training and comfort, availability of additional staff, and patients needs (i.e., bathroom urgency, cognition, weight, etc.) reduce the adherence to the policies put in place by hospitals (Kucera et al., 2019). Furthermore, program development relies on buy-in and investment from nurses, the program developers must consider the motivators for the nurses to provide a client-centered approach (Koppelaar, Knibbe, Midema, & Burdorf, 2011; Scallon, 2014). Thus, there is a need for a multifaceted ergonomics program to address all aspects. Another avenue of ergonomics intervention is with implementation through a trained occupational therapist. Occupational therapists provide a unique perspective that looks at the whole person, from their client factors to their everyday environment (Kotejoshyer et al., 2019). With a top-down approach that focuses on the occupations and activity demands, occupational therapists can develop individualized and meaningful ergonomic programs to meet the individuals needs (American Occupational Therapy Association [AOTA], 2014). With a holistic approach, an occupational therapist can examine physical, cognitive, and psychosocial factors ERGONOMICS PROGRAM TO DECREASE RISK FACTORS OF WMSD 7 relating to an individual need (AOTA, 2014). An occupational therapist can use this complex approach to develop an ergonomics program. For instance, Fisher (2017) used both a psychological and physical approach to understand different ergonomic behaviors and the effects of these musculoskeletal injuries on everyday life. The occupational therapist in this study adapted and modified the environment to help create an ergonomics intervention that decreased risk factors for WMSDs. Fisher examined discomfort through the lens of the person and their environment; observing cultural, personal, temporal, and virtual characteristics to determine the overall problem and to create a complete education and training program (Fisher, 2017). Occupational therapist focuses on all aspects of the occupation along with external and internal factors (Stansfeld et al., 2013). Education, training, and continuing competency are essential in ensuring safety and providing a good work environment for employees (Haris & Haris, 2019). Occupational therapist provide a comprehensive approach to addressing specific factors relating WMSDs. Although researchers have created several successful ergonomics programs, many hospitals do not have formal programs in place. Barriers to ergonomics programs include time, education, ease of use, and location of mechanical equipment, which prevented employees from adhering to safe patient handling guidelines (Water, Dick, Lowe, Werren, Parsons, 2012). Research has found that nurses want increased education and practice to feel more comfortable on ergonomics interventions before implementation into practice (Fisher 2016). Therefore, the purpose of this study was to create a multifaceted ergonomics intervention program for nurses. Through the creation of the multifaceted ergonomics intervention program, the researcher aimed to increase awareness of ergonomics interventions, reduce overall risk factors of WMSDs, and ERGONOMICS PROGRAM TO DECREASE RISK FACTORS OF WMSD 8 increase referrals to occupational therapy and ergonomic specialists to address ergonomics issues. Methods Procedure This study was a qualitative case study. It was reviewed by the Institutional Review Board of the University of Indianapolis and exempt status was granted. Participants signed a consent form to acknowledge that pictures would be taken for use in the Rapid Upper Limb Assessment (RULA). The study took place over 14 weeks. Throughout the first four weeks, the researcher observed the nurses and took pre-photos for the RULA to assess initial risk factors for WMSDs during a lateral transfer. A pre-questionnaire was given to the participants to provide demographics and pre-knowledge on ergonomics interventions. In the second four weeks, the researcher implemented part one of the program. Next, the researcher created PowerPoints, a video, and pamphlets to educate participants on ergonomic techniques. The researcher worked with the nursing educational coordinators to provide sustainability of the training and educational material throughout the hospital. In the last two weeks, the researcher provided a dissemination plan and measured the outcome. The effectiveness of the program was evaluated through a postquestionnaire and the Goal Attainment Scale (GAS). Participants The researcher recruited 13 nurses from the burn unit at Eskenazi Health, in Indianapolis Indiana through cluster sampling. Eskenazi Health is one of four levels one trauma centers in the state, which includes an extensive 15-bed burn unit. The burn unit hosts patients with a variety of levels of injuries, from patients with low to high total body surface area burns. Inclusion criteria consisted of a burn nurse at Eskenazi Health, a full-time employee, and having a high risk of ERGONOMICS PROGRAM TO DECREASE RISK FACTORS OF WMSD 9 developing WMSDs. Exclusion criteria consisted of a nurse not wanting to participate in the program. Program Development The researcher used the people-environment-occupational-performance model and biomechanical-rehabilitation frame of reference to create an ergonomics program. The five domains of occupational therapy occupations, client factors, performance patterns, performance skills, and context and environment, were used to identify and treat the overall problem resulting in an increased risk of musculoskeletal injuries. The program consisted of two parts: (1) training and implementation of friction reduction slide sheet (FRS), and (2) educational resources through PowerPoints, video, and handouts. Part one: FRS training FRS is a sheet that reduces the amount of force and excursion placed on the nurse who is laterally transferring a patient thus reducing the risk factors relating to musculoskeletal injuries (Zhou & Wiggermann, 2019). First, the researcher explained the product to the nurses including the benefits of use. The FRS is quick and easy to use, and low cost compared to the larger mechanical lifts and reduces the shear force on the patients sensitive skin (Zhou & Wiggerman, 2019). Next, the researcher completed one-on-one instruction on how to use the FRS. After the participant was instructed on how to use the FRS, a photo was taken for the RULA. Based on the results of the RULA, a risk factors observation sheet was provided to each participant on ergonomic adjustment for use of the FRS. After education on the use of the FRS, the researcher continued to observe several lateral transfers to ensure proper use of the FRS. ERGONOMICS PROGRAM TO DECREASE RISK FACTORS OF WMSD 10 Part two: Educational Resources Based on previous observations, the researcher created ergonomic resources for the nurses to go with the FRS training. Topics included ergonomic education on risk factors, bedside care, computer use, equipment use, and wellness. Resource material came from evidence-based research, through online research and the site mentor. Educational material format included PowerPoints, handouts, and a video. The researcher created video and PowerPoint instructions for the FRS for future hires and continuing competency. Participants received the educational resources by email and hard copy. The hard copies were placed in the locker rooms and breakrooms and handed out to participants. An additional pamphlet was created on simple ergonomic tips and things to remember while transferring a patient. The researcher used information from the educational resources to develop this final pamphlet. The pamphlet was laminated and hung in each of the 15 patient rooms, nurses station, locker rooms, and break rooms. Measures Pre-Questionnaire The pre-questionnaire was created based on components of Oswestry Lower Back Disability Questionnaire and Roland-Morris Disability Questionnaire (Fairbank, J.C.T., Couper, K., Davies, J.B., 1980; Roland & Morris, 1983) and the needs assessment (Hardesty, 2019). The basis of this questionnaire used the person-environment-occupational-performance model to examine the client factors, their environment, and their meaningful occupations. The participants received the questionnaire through an interview format. The two parts of the pre-questionnaire, examine demographics and knowledge of ergonomics. The first part asked the participants about their overall wellness, including any pain/strain or fatigue that affects their daily activities. The ERGONOMICS PROGRAM TO DECREASE RISK FACTORS OF WMSD 11 second part examined the participant's knowledge of ergonomics and the use of mechanical equipment. The questionnaire was a combination of yes/no and fill in the blank answers, see Figure 2 for the full survey. Post questionnaire The post questionnaire asked similar questions to part two of the pre-questionnaire. The purpose of the post-questionnaire was to determine the effectiveness of the program. Additional questions were taken, such as their favorite and least favorite ergonomics resources, for program evaluation. Figure 2 shows the post-questionnaire. Rapid Upper Limb Assessment The RULA assesses the number of risk factors for musculoskeletal injuries during one specific task (McAtamney & Corlett, 1993). The researcher took photos of the participants completing a lateral transfer, several times throughout the programs. The researcher then answered a series of questions about the picture taken. Based on these results the researcher made recommendations and educational material to improve posture and alignment during lateral transfers. The RULA was found to be reliable and valid when assessing workplace musculoskeletal injury risk factors (McAtamney & Corlett, 1993). Goal Attainment Scale To determine the effectiveness of the researchers program, the researcher analyzed the results given on the questionnaires. The GAS used a five-point scale (I.e., 2-,1-,0,1+,2+), with 2+ being very effective and 2- being least effective. The GAS assessed the three objectives of this study. The GAS is a valid tool to self-evaluate achievement of goals and objectives. ERGONOMICS PROGRAM TO DECREASE RISK FACTORS OF WMSD 12 Data Analysis Microsoft-Excel was used to store, analyze, and compare the qualitative data to determine the effectiveness of the program. Results Participants Thirteen participants completed the ergonomics interventions program; all but one participant was female. The researcher had one dropout during the program due to a FMLA leave. Five additional nurses participated in the training of the FRS. They did not complete the RULA or the rest of the program due to scheduling or not meeting the inclusion criteria. All nurses gave consent for their photographs for the RULA. The nurses reported working between eight to ten hours in direct patient care and two to four hours of computer use. Seven nurses reported taking at least one extra shift per week. The nurses reported having mild to moderate pain in different areas of the body. Six reported pain in the back, five in the lower extremities, one in the upper extremities, and one throughout the body. Six of the nurses communicated they have injuries that affect their ability to do their job. These injuries include overuse, fall-related injury, and stress fractures. Four of the nurses reported that the pain mildly affected their ability to complete activities of daily living and instrumental activities of daily living such as house management and leisure activities. Two nurses stated they used therapy to help treat the injuries or pain; one completed physical therapy for several months and the other consulted an occupational therapist. Participant Previous Knowledge on WMSD Most nurses on the burn unit had little experience or knowledge of ergonomics training. Nurses reported that lifting heavy patients, not using equipment, improper technique, not asking ERGONOMICS PROGRAM TO DECREASE RISK FACTORS OF WMSD 13 for help, and not planning the activity were all activities that could increase the risk of WMSDs. One nurse noted that using computers with incorrect posture causes musculoskeletal injuries. The nurses responses showed a basic understanding of the knowledge of occupational therapy and ergonomics. One nurse stated that occupational therapists educate and prevent injuries by improving tasks. Another mentioned that occupational therapy uses ergonomics to provide Exercises that enhance function and protect an individual while performing physical tasks." Four nurses reported they were unsure what occupational therapy and ergonomics are. Six nurses requested more information on ways to prevent injuries during their shift. Common Reported Themes of Pre-Questionnaire Patient handling is a hazardous part of a nurse's role. Ten nurses reported positioning and transferring their patients at least once per day. Eight of the nurses reported that transferring a patient can be moderate to very difficult. One nurse stated that the level of difficulty depended on the patient. Only three nurses reported using patient handling equipment throughout the day because it helped them move larger, dependent, or complex patients and assisted them in dressing changes. These nurses reported using lift sheets, the crank on the cardiac chair, FRS, gait belts, and ceiling lift. The nurses that stated they do not use the patient handling equipment reported a variety of reasons. These reasons included having patients who do not require help, time and convenience, shortage of lift sheets, not getting max and dependent patients out of bed, and too many medical lines. Implementation of Program There were 18 nurses who participated in the FRS training and 12 nurses completed both pre and post-RULA. The participant who dropped out of the program did not complete the FRS training. The researcher spent the first few weeks observing lateral transfers and the positioning ERGONOMICS PROGRAM TO DECREASE RISK FACTORS OF WMSD 14 of patients. The observation based on the RULA showed the nurses demonstrated awkward postures and poor body mechanics. See Table 1 for details. All nurses lifted over 22 pounds when not using a minimal friction transfer sheet. Notes: This table is based on observations using the RULA. See Appendix, Figure 1. The observation consisted of participants completing a lateral transfer or positioning a patient in bed, with an FRS. The red indicates a high-risk body position, the yellow indicates moderate risk body positioning and the green low-risk body positioning. In this table, there are 22 red boxes, 28 yellow boxes, and 54 green boxes. FRS training was completed over several weeks. All nurses received at least one observation and one training session. Several nurses reached out to the researcher to receive additional training. Different orientations of the FRS were trialed to decide the most effective placement for heavier patients. The researcher determined that placing the FRS longways between the patients shoulders and bottom was most effective. Over half of the nurses found the FRS to be useful and stated they would use it for any heavy or dependent patient. One nurse initially expressed they did not feel a difference, however ERGONOMICS PROGRAM TO DECREASE RISK FACTORS OF WMSD 15 after several months of using the FRS stated they felt a difference in their body position. One nurse stated it is a useful device but not on this unit. That nurse felt that the FRS would be useful at the emergency room department and when transferring in radiology. One patient reported that the FRS created a smooth transfer for them and that they did not feel the placement of the FRS. Another nurse reported they encourage other staff members to use the FRS. There were 12 participants that participated in the educational part of the program. Appendix, Figure 2 shows the five handouts and two PowerPoints. One nurse said she appreciated all the visuals and colors used to make the pamphlets. Several nurses reported liking the graphics and colors on the pamphlets because the visuals made it easier to read. Other nurses reported liking physical copies because they are easy to reference. Overall, the nurses found the computer ergonomics pamphlet to be most helpful. Using observations from the RULA, the effectiveness of the FRS and ergonomics educational program showed significant improvement. See Table 2 for more details. Overall, high-risk body positions went from 22 to eight, with the use of the FRS. Participants reduced their arm flexion, shoulder elevation, and twisting of the body with the use of the FRS and education. Twelve nurses raised their beds to their waist to improve their trunk flexion. All nurses reduced their load to under 22lbs due to the use of the FRS. However, despite education and training some nurses still had shoulder flexed, forearms supinated, and necks extended. The use of the FRS was determined to be beneficial in the reduction of WMSDs. ERGONOMICS PROGRAM TO DECREASE RISK FACTORS OF WMSD 16 Note: This table is based on observations using the RULA. See Appendix, Figure 1. The observation consisted of participants completing a lateral transfer or positioning a patient in bed, with an FRS. The red indicates a high-risk body position, the yellow indicates moderate risk body positioning and the green low-risk body positioning. In this table, there are eight red boxes, 24 yellow boxes, and 64 green boxes. Post participant knowledge The nurses listed lack of education, work demand, not using equipment, improper body mechanics, and fatigue as risk factors for developing WMSDs. One nurse stated they learned that the FRS reduced shear force on the patient during transfers and attributed their use of the FRS because it improved comfort for the patient. Another nurse reported that they learned the ideal height for a standing computer in a patients room. They admitted to never adjusting the computer in the past but stated that they have since started to adjust the computer. Other nurses reported adjusting their computer settings and stated they have never learned how to make those adjustments in the past. All nurses were able to describe components of occupational therapy. Four of the nurses described occupational therapy as a profession that adapts and modifies activities to prevent ERGONOMICS PROGRAM TO DECREASE RISK FACTORS OF WMSD 17 injuries. Similarly, another nurse reported that an occupational therapists job is to maximize performance through modifications. Finally, another nurse stated that occupational therapy addresses ADLs and mobility. The researcher provided the nurses with contact information and gave an example of how to request an individualized ergonomics assessment. Program Evaluation Based on the responses from the nurses participating in the program, they scored the program on average a 9/10. Only two nurses reported a reduction in pain throughout the program. The other participants reported the same or increasing in pain, fatigue, and strain. Two nurses reported an increase in pain, fatigue, and stress. Increased use of the FRS occurred throughout the program, the nurses reported using the FRS for lifting heavy patients and positioning in bed. Other nurses reported using the FRS to assist in the placement of an X-ray board and for turning patients. Overall feedback was positive and appreciative. Many nurses appreciated the teachings and recommendations. Another nurse stated that the material the researcher provided them applied to a registered nurse's everyday life. The nurses reported they preferred the individualized training of the FRS and physical copies of the pamphlet over the video and PowerPoints. One nurse enjoyed the video the best and reported would have liked more of the materials in video format. Additional feedback was given by the night nurses and part-time staff. One nurse reported I appreciate the time you took to train and educate the night nurses on ergonomics and safe patient handling Another nurse reported, I have only been here for a few days, so this is very helpful as I begin my journey here. Based on the feedback from the nurses the GAS determined the overall effectiveness in the ergonomics program. See appendix, Figure 2, for results of the GAS. ERGONOMICS PROGRAM TO DECREASE RISK FACTORS OF WMSD 18 Discussion Nurses have some of the highest risk factors for developing WMSDs (Ratzon et al., 2016). Nurses spend most of their days completing patient care, patient handling, and documentation on computers. This study aimed to develop an ergonomics interventions program to increase awareness of ergonomics interventions to reduce overall risk factors of WMSDs and increase occupational therapy referrals to address ergonomics issues. The researcher developed a comprehensive program based on the population's needs and incorporated all aspects of the participants to address the problem. The participants gave great feedback and stated that the information provided applied to a nurses everyday life. The program received minimal recommendations for improvement, and all expressed they would recommend other nurses to have this information. These results fall in line with Rasmussen et al.'s (2015) study, which found that a diverse approach to ergonomics interventions is what makes a good program. Rasmussen stated that it is important to incorporate different learning styles because each nurse is unique, and each nurse will respond to the materials differently (Rasmussen et al., 2015). The participants in this study reported experiencing pain, strain, and fatigue prior to implementation of the program. There was a moderate reduction in the intensity of pain with the program knowledge applied. Abd El-Rasol & Abd El Rhaman (2018) supported these findings and found that increased awareness of pain and intervention techniques helped nurses manage symptoms. This study found that the leading cause of injury was overtime, lack of education, patient handling, and equipment shortage. This finding is similar to two prior studies, which also reported stress levels, workload, understaffing (Sandyha et al. 2015), and patient handling (Kotejoshyer et al., 2019) as high-risk factors for nurses. ERGONOMICS PROGRAM TO DECREASE RISK FACTORS OF WMSD 19 The researcher used the educational material to provide awareness of risk factors and list modifications to prevent these risk factors on the unit. The development of the materials used a client-centered approach and involved several key stakeholders. The key stakeholders were nursing education coordinators, an occupational therapist, and the participants in the program. The participants appreciated the videos, pamphlets, and PowerPoints because they gave reasonable solutions to reduce risk factors, such as body mechanics, patient handling equipment, energy conservation techniques, and joint protection principles. For example, to improve a participants posture and energy conservation, a participant can use a stool during patient care activities. Another example is while transferring, positioning, and patient care; the participant could adjust the bed height to their waist to reduce lumbar flexion. After reading the educational materials, the participants ability to identify risk factors increased. The post-questionnaire results demonstrated that the participants understood that patient handling, awkward postures, and lack of education increased their risks of developing WMSDs. The participants reported ways to reduce risk factors, including computer adjustments, joint protection principles, and the FRS. Haris & Haris (2019) concurred that educational materials increased participants' knowledge of WMSDs significantly. By the end of the program, the participants were able to identify what occupational therapy was and understood the processes of making a referral for an individualized ergonomics assessment. A large portion of a participants day is patient handling thus training on mechanical equipment for safe patient handling is an important aspect of an ergonomics interventions program. The researcher educated the participants on NIOSHs lifting equation and recommendations, that individuals in the healthcare field should not lift over 35lbs due to the increased risk of developing WMSDs. Patient's weight, weight-bearing capacities, cognition, ERGONOMICS PROGRAM TO DECREASE RISK FACTORS OF WMSD 20 agitation level, and availability of additional staff members are all recommendations for the nurses to think about prior to lifting (Waters, 2007). The researcher provided information on the Bed Mobility Assessment Tool (BMAT), a valid tool that assists nurses in assessing mobility (Laine, 2016). The use of BMAT and recommendations from NIOSH helped the participants develop clinical reasoning skills with patient mobility and safe patient handling. The cost and ease of implementation are why this study used the FRS over other safe patient handling equipment, for training. Although the FRS does not reduce all forces placed on the handlers low back during repositioning and lateral transfers, the FRS creates a low coefficient number, which increases smoothness and ease of transfer (Wiggermann, Zhou & McGann, 2020). The FRS is a large and slippery sheet that allows for it to slide across other fabrics and provides a minimal force on the handlers lower back. The participants reported an increase in the use of patient handling equipment due to the use of the FRS on the unit. The participants liked how the FRS has easy placement, close storage to the patient, and is quick. The FRS in conjunction with educational materials makes it a great tool to use in the hospital setting due to the product's ability to travel with the patient and the quickness to set up. All participants reported a decreased exertion level with the FRS, compared to no lifting equipment. The RULA observations showed a reduction of poor body mechanics during bedpositioning and lateral transfers, see Tables 1 and 2. The FRS reduced the force on the participants lower back, based on an average patients weight, from above 22 pounds per person to below 22 pounds per person. With the coefficient value of the FRS being around 0.15, with two nurses assisting in a transfer, the force distributed between each nurse would be lower than 22 pounds for most patients (Jamar Health Product, Inc., 2016). Overall, there was a significant reduction in high hazardous positions and a moderate reduction in risk for moderate hazardous ERGONOMICS PROGRAM TO DECREASE RISK FACTORS OF WMSD 21 positions. With the participants new knowledge of ergonomics and the FRS, the participants were able to eliminate twisting, reduce forward trunk flexion, keep upper arms close to the body, and decrease extension of necks. The researcher used a client-centered approach and involved key stakeholders for the sustainability of the project. Doll (2009) stated that a good program must involve internal leadership to maintain the success of the program. The researcher provided all the educational materials to the nursing education coordinators to place on the hospital's web server. The nursing education coordinators will be able to use this information and provide an easy implementation in other areas of the hospital to decrease WMSDs. Strengths, Limitations, and Future Studies There were several strengths of the program. The program used a needs analysis through observations and a pre-questionnaire to determine preliminary knowledge of the participants. The participants provided feedback on what they would like to see, and the researcher used that information to develop the program. The researcher worked closely with the nursing education coordinators and an occupational therapist to provide client-centered materials. The researcher provided sustainability through having the educational materials placed on the hospitals web server. There were some limitations of this study. First, the researcher believes there were some cases of acquiescence and observation bias. The researcher had the participants rate program and provided recommendations for improvement of the program. Most of the participants reported the program to be 10/10, with no recommendations for improvement. The researcher believes this could be an acquiescence bias. Observation bias could be present when the researcher was completing the RULA with the FRS. The participants could have consciously ERGONOMICS PROGRAM TO DECREASE RISK FACTORS OF WMSD 22 changed their posture based on what they thought the researcher wanted them to do. Another limitation of the study was the RULAs ability to capture one position instead of multiple positions. The real-time pictures for the RULA made it hard to replicate the movement for the post RULA photos. The final limitation was the small sample size, cohort sampling limited the diversity of the participants and may have changed the results due to living similar experiences on the unit. Implications to Occupational Therapy The use of the FRS for bedside nurses as a safe method of transferring and positioning dependent patients An effective ergonomics intervention program outline with resources and training material for continued implementation throughout the hospital Advocating for occupational therapists to play a role in program development and policies for safe patient handling and ergonomic training for bedside nurses. Conclusion In conclusion, an occupational therapist-led, multifaceted ergonomics program helps nurses increase awareness of WMSDs, provides a comprehensive method for reducing risk factors in the workplace, and helps increase occupational therapy referrals to address ergonomics issues. With safe patient handling and ergonomics interventions, occupational therapists can help change the environment for bedside nurses to decrease risk factors for WMSDs during their workday. ERGONOMICS PROGRAM TO DECREASE RISK FACTORS OF WMSD 23 References Abd El-Rasol, Z.M. & Adb El Rahman, R.M. (2018). Effect of implementing body mechanics and ergonomic training on nurses low back pain and quality of nursing work life. Journal of Nursing and Health Sciences 7(3). http://iosrjournals.org/iosrjnhs/papers/vol7-issue3/Version-10/C0703102035.pdf American Occupational Therapy Association (AOTA). (2014). 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.2014.682006 Darragh, A. R., Huddleston, W., & King, P. (2009). Work-related musculoskeletal injuries and disorders among occupational and physical therapists. American Journal of Occupational Therapy, 63(3), 351-362. doi:10.5014/ajot.63.3.351 Doll, J. D. (2009). Introduction to program development for grant writing, In Program Development and Grant Writing in Occupational Therapy: Making the Connection: Making the Connection. Jones & Bartlett Publishers. Fairbank, J.C.T., Couper, J., & Davies, J.B. (1980). The Oswestry Lower Back Pain Questionnaire. Physiotherapy, 66, 271-273. https://pubmed.ncbi.nlm.nih.gov/6450426/ Fisher, T. (2017). Role of occupational therapy in preventing work-related musculoskeletal disorders with recycling workers: A pilot study. American Journal of Occupational Therapy, 71, 1-6. doi:10.5014/ ajot.2017.022871 Hardesty, S. (2019). Critical lift zone: Recognizing the need for safe patient handling equipment across the broader spectrum of patient weights [PowerPoint slides]. Eskenazi Health. ERGONOMICS PROGRAM TO DECREASE RISK FACTORS OF WMSD 24 Haris, A., & Haris, A. (2019). The effectiveness of the use of nurse safety booklets on nurse knowledge in ergonomic injury prevention in BIMA hospital. International Journal of Studies in Nursing, 4(2), 108. doi:10.20849/ijsn.v4i2.578 Jamar Health Products, Inc. (2016). Understanding coefficient of friction and why other slide sheet properties are also important. Patran Slide to Safety: Greendale, WI. https://patran.net/wp-content/uploads/2016/09/Understanding-Coefficient-of-Friction.pdf Koppelaar, E., Knibbe, J. J., Miedema, H. S., & Burdorf, A. (2011). Individual and organizational determinants of use of ergonomic devices in healthcare. Occupational and Environmental Medicine, 68(9), 659-665. doi:10.1136/oem.2010.055939 Kotejoshyer, R., Punnett, L., Dybel, G., & Buchholz, B. (2019). Claim costs, musculoskeletal health, and work exposure in physical therapists, occupational therapists, physical therapist assistants, and occupational therapist assistants: A comparison among long-term care jobs. Physical Therapy, 99(2), 183-193. doi:10.1093/ptj/pzy137 Kozak, A., Freitag, S., & Nienhaus, A. (2017). Evaluation of a training program to reduce stressful trunk postures in the nursing professions: A pilot study. Annals of Work Exposures and Health, 61(1), 22-32. https://doi.org/10.1093/annweh/wxw002 Kucera, K. L., Schoenfisch, A. L., McIlvaine, J., Becherer, L., James, T., Yeung, Y. L., Avent, S. & Lipscomb, H. J. (2019). Factors associated with lift equipment use during patient lifts and transfers by hospital nurses and nursing care assistants: A prospective observational cohort study. International journal of nursing studies, 91, 35-46. doi:10.1016/j.ijnurstu.2018.11.006 ERGONOMICS PROGRAM TO DECREASE RISK FACTORS OF WMSD 25 Laine, K. C. (2016). Educating nurses on the use of the bedside mobility assessment tool (BMAT) to create a culture of safety". Master's Projects and Capstones, 348. https://repository.usfca.edu/capstone/348 Marcum, J., & Adams, D. (2017). Workrelated musculoskeletal disorder surveillance using the Washington state workers compensation system: Recent declines and patterns by industry, 19992013. American Journal of Industrial Medicine, 60(5), 457-471. https://doi.org/10.1002/ajim.22708 McAtamney, L., & Corlett, E. N. (1993). RULA: a survey method for the investigation of workrelated upper limb disorders. Applied Ergonomics, 24(2), 91-99. doi:10.1016/00036870(93)90080-s Mirmohammadi, S., Yazdani, J., Etemadinejad, S., & Asgarinejad, H. (2015). A cross-sectional study on work-related musculoskeletal disorders and associated risk factors among hospital health care. Procedia Manufacturing, 3, 4528-4534. doi:10.1016/j.promfg.2015.07.468 Nestorova, V. D., & Mircheva, I. S. (2018). Work-related musculoskeletal disorders (WMSDs): risk factors, diagnosis, and prevention. Script Scientific Salutes Publica, 4, 15-21. http://journals.mu-varna.bg/index.php/sssp/article/view/5076 Rasmussen, C. D. N., Holtermann, A., Bay, H., Sgaard, K., & Jrgensen, M. B. (2015). A multifaceted workplace intervention for low back pain in nurses' aides: a pragmatic stepped wedge cluster randomized controlled trial. Pain, 156(9), 1786. doi:10.1097/j.pain.0000000000000234 Ratzon, N. Z., Bar-Niv, N. A., & Froom, P. (2016). The effect of a structured personalized ergonomic intervention program for hospital nurses with reported musculoskeletal pain: ERGONOMICS PROGRAM TO DECREASE RISK FACTORS OF WMSD 26 An assigned randomized control trial. Work, 54(2), 367-377. https://content.iospress.com/articles/work/wor2340 Roland, M.O., Morris, R. W. (1983). A study of the natural history of back pain. Part 1: Development of a reliable and sensitive measure of disability in low back pain. Spine, 8, 141-144. doi:10.1097/00007632-198303000-00004 Scanlon, M. (2014). Safe patient handling & no lift policy: Reducing the incidence of workrelated injuries among nursing staff. Masters Projects and Capstone. 78. https://repository.usfca.edu/capstone/78 Stansfeld, S. A., Shipley, M. J., Head, J., Fuhrer, R., & Kivimaki, M. (2013). Work characteristics and personal social support as determinants of subjective well-being. PloS one, 8(11). https://doi.org/10.1371/journal.pone.0081115 Waters, T. R. (2007). When is it safe to manually lift a patient?. The American Journal of Nursing, 107(8), 53-58. https://www.asphp.org/wpcontent/uploads/2011/05/When_Is_It_Safe_To_Manually_Lift_A_Patient.pdf Westerlund, H., Nyberg, A., Bernin, P., Hyde, M., Oxenstierna, G., Jppinen, P., Vaananen & Theorell, T. (2010). Managerial leadership is associated with employee stress, health, and sickness absence independently of the demand-control-support model. Work, 37(1), 7179. doi:10.3233/WOR-2010-1058 Wiggermann, N., Zhou, J., & McGann, N. (2020). Effect of Repositioning Aids and Patient Weight on Biomechanical Stresses When Repositioning Patients in Bed. Human Factors, 1-13. doi/full/10.1177/0018720819895850 Zhou*, J., & Wiggermann, N. (2019). Physical Stresses on Caregivers when Pulling Patients Up in Bed: Effect of Repositioning Aids and Patient Weight. In Proceedings of the Human ERGONOMICS PROGRAM TO DECREASE RISK FACTORS OF WMSD 27 Factors and Ergonomics Society Annual Meeting (Vol. 63, No. 1, pp. 1057-1061). Sage CA: Los Angeles, CA: SAGE Publications. doi/abs/10.1177/1071181319631222 ERGONOMICS PROGRAM TO DECREASE RISK FACTORS OF WMSD 28 Appendix Figure 1: RULA modifications Note: The RULA was modified to address the needs of this study (McAtamney & Corlett, 1993). The red indicates a high-risk body position, the yellow indicates a moderate risk body position and the green position. Figure 2: Program Website Notes: This website was created to store the educational and training materials for this program. It also has copies of the assessment tools used to determine effectiveness. See link: https://sites.google.com/uindy.edu/ergonomics-interventions/home  ...

... TRAUMA INFORMED CARE IN JUVENILE DETENTION 1 Trauma-Informed Care within Juvenile Detention: Educating Staff on a TBRI and Sensory Approach Paige E. McIntire University of Indianapolis Dr. Christine Kroll, OTD, MS, OTR, FAOTA July 2021 TRAUMA INFORMED CARE IN JUVENILE DETENTION 2 Abstract Literature: Trauma within the juvenile justice system is common, with a high prevalence of Adverse Childhood Experiences (ACEs) (Baglivio & Epps, 2016; Clements-Nolle & Waddington, 2018), resulting in neurological changes negatively impacting sensory processing of those who are a part of the juvenile justice system (Collin-Vezina et al., 2019; Fraser et al., 2017; Pickens, 2016; van der Kolk & MacFarlane, 2007; Wolff et al., 2017). A trauma-informed system would allow youth to develop healthy coping skills (Ford & Hawke, 2012; Pickens, 2016) as well as provide for a safer environment for staff members by providing them with appropriate tools to manage youth behavior. Purpose: The purpose of the study was to educate staff at a juvenile detention center on the impact of trauma on sensory processing and the benefits of sensory interventions to utilize with residents to facilitate trusting relationships and reduce the effect of trauma within the population. Methods: This study utilized a survey methodology to anonymously collect opinions and knowledge from staff members at Johnson County Juvenile Detention Center regarding trauma, sensory processing, and re-traumatization before and after a six-week educational series on the topics. Results: Participants demonstrated increased agreement and acceptance of the educational topics as well as stated that they have a better understanding of all topics after completion of the educational series. Discussion: Findings of the study support the need for educating detention center staff on sensory interventions, as well as show the benefit of occupational therapy for residents of the detention center. Keywords: juvenile justice, trauma, sensory processing, Trauma-Informed Care (TIC), TrustBased Relational Interventions (TBRI) TRAUMA INFORMED CARE IN JUVENILE DETENTION 3 Trauma-Informed Care within Juvenile Detention: Educating Staff on a TBRI and Sensory Approach The impact that childhood trauma can have on youth is multifaceted (Pickens, 2016). When children experience multiple types of trauma or various traumatic experiences during their developmental stages, they have experienced complex trauma (Rapp, 2016), the most experienced type of trauma for children (Parris et al., 2015). Complex trauma is defined as exposure to traumatic stressors at an age or in a context that compromises secure attachment with primary caregivers and the associated ability to self-regulate emotions (Rapp, 2016, p. 493) and can evolve into various forms. Complex trauma is perpetrated on children by a caregiver and includes emotional, physical, and sexual abuse, neglect, and witnessing domestic violence (Parris et al., 2015). Some forms of evolved complex trauma include post-traumatic stress disorder (PTSD), depression, addictive behaviors, and offending behaviors (Childs & Sullivan, 2013; DAndrea et al., 2012; Kilpatrick et al., 2003; Rapp, 2016; Thornberry et al., 2010). Trauma and Brain Development There is extensive literature demonstrating the negative impact that childhood trauma has on the developing brain. Cumulative and chronic trauma during early life disrupts multiple areas of development, including behavioral, biological, cognitive, emotional, neurological, and relational domains (Cloitre et al., 2009; Collin-Vezina et al., 2019; Courtois, 2004; van der Kolk et al., 2005). This disruption can persist into adolescence, and young adulthood and can manifest in many ways, such as sensory processing difficulties, decreased self-regulation, and increased violent behaviors (Dowdy et al., 2020), as well as difficulties with aggression, attachment, anxiety, depression, emotional regulation, and trusting others (Fraser et al., 2017; Ogden et al. TRAUMA INFORMED CARE IN JUVENILE DETENTION 4 2006, van der Kolk 2003). The neurological changes that occur because of trauma lead to the individual living in a constant state of arousal that puts that child on high alert to potential dangers in his or her surroundings (Pickens, 2016; van der Kolk & MacFarlane, 2007; Wolff et al., 2017), and that child remains constantly prepared for either fight, flight, or freeze (Parris et al., 2015). Living in a constant state of heightened arousal impacts impulsivity, concentration, and decision-making (Cook et al., 2005). Living in either a high or a low state of arousal for long periods makes it difficult for individuals to process sensory information, which leads to misinterpretation of everyday situations (Fraser et al., 2017). Researchers call this misinterpretation sensory processing and define it as a regulatory process vital to daily function as it allows a person to perceive, interpret, and appropriately react to the environment (Dowdy et al., 2020, p. 375). This change in sensory processing means that children who have experienced trauma and struggle to process their sensory information will respond more quickly, frequently, and harshly to perceived threats than children who have not experienced trauma (Pickens, 2016). When children become hyper or hypo-sensitive to non-threatening stimuli, they may be diagnosed with a sensory processing disorder. Serafini et al. (2016) define sensory processing disorder as difficulties in registering/modulating sensory information and organizing sensory input in order to carry out successful adaptive responses to situational demands (p. 40). Because there is a wide basis of evidence stating that children who have experienced trauma have sensory processing difficulties/disorders (LeBel et al., 2010; Parris et al., 2015; Ryan et al., 2017; Warner et al., 2013) and a wide basis of evidence stating that juveniles within the justice system have experienced high levels of trauma (Abram et al., 2004: Baetz et al., 2019; Ford et al., 2006; TRAUMA INFORMED CARE IN JUVENILE DETENTION 5 Kerig & Becker, 2010), it is likely to assume that many children who are a part of the justice system have difficulties with sensory processing and self-regulation. Trauma-Informed Care (TIC) To combat the traumatic experiences juveniles in detention have experienced as well as to address the associated sensory processing difficulties, Pickens (2016) proposes utilizing a trauma-informed system of care within detention facilities to reduce the effects of trauma for both the youths residing there and the staff who work in the facility. This system of care involves establishing an environment that can acknowledge the trauma that youth experienced before their incarceration and providing an environment that is both physically and psychologically safe for youth and staff members (Pickens, 2016). The goal of TIC care is to restore these individuals sense of safety as well as help professionals understand and recognize the effects that trauma has on an individuals behaviors, emotions, physical health, relationships, and sensory systems (National Association for State Mental Health Program Directors [NASMHPD], 2009). Specific to the juvenile justice system, infusing a TIC approach requires the education of all staff members to create buy-in and gives staff members alternatives to punitive approaches that could further perpetuate the trauma cycle (Ezell et al., 2018; Pickens, 2016). Rhoden et al. (2019) found that for TIC to be effective, it must include components of education, skillbuilding, and self-regulation for all parties involved. Staff education should include content related to child development, de-escalation skills, self-regulation skills, and self-care (Rapp, 2016). Rapp (2016) and Yatchmenoff et al. (2017) emphasize the importance of the physical space when discussing a successful trauma-informed model of care. Both state that the physical environment must be safe, warm, and nurturing, as well as brightly lit and full of natural light (Rapp, 2016; Yatchmenoff et al., 2017). Yatchmenoff et al. (2017) suggest that juveniles within TRAUMA INFORMED CARE IN JUVENILE DETENTION 6 the detention center play a role in this process, creating artwork and signage to display in the halls, common areas, and bathrooms. Trust-Based Relational Intervention While there are many models of TIC used in the justice system, this paper specifically focuses on Trust-Based Relational Intervention (TBRI). Researchers designed TBRI to use with all children with histories of trauma and in all caregiving environments with various adaptations (Purvis et al., 2013). As opposed to other TIC models, TBRI practitioners can train any nurturing caregiver in the TBRI principles (Purvis et al., 2013), meaning that TBRI is an appropriate model of TIC to implement within a juvenile detention center so long as education about the principles is provided to all staff. Practitioners founded TBRI on three main principles of empowerment, connection, and correction, giving attention to the physical, attachment, and behavioral needs of children of trauma (Purvis et al., 2013). These principles allow both the child and their caregiver to learn healthy interactions so that both parties can play an active role in the process of healing from trauma (Purvis et al., 2013). The empowering principle focuses on the physical needs of the child, with a focus on ensuring the child is safe but also feels safe (Purvis et al., 2013). This feeling of safety is created through smooth transitions for children both in daily life and across the timespan, the meeting of sensory needs, and adequate sleep and nutrition. By meeting the safety needs of children with trauma histories, the children can learn to trust others and develop healthy emotions and behaviors instead of relying on their typical fear-driven behaviors (Knight et al., 2004). The connecting principle focuses on the attachment needs of the child by giving voice to the children so that they can better self-regulate. This increase in regulation is done through training caregivers to be aware of signs of stress and anxiety, giving and seeking care, and attunement TRAUMA INFORMED CARE IN JUVENILE DETENTION 7 between child and caregiver. Activities to achieve this include bonding, physical touch, and playful engagement to create a foundation for trusting relationships. The connecting principle improves the relationship between child and caregiver to reverse the effect of stress, stressrelated behavior and improve psychosocial functioning (Fisher et al., 2006). The last principle, correcting, focuses on the behavioral needs of the child through proactive and responsive strategies (Purvis et al., 2013). The objective of this principle is to build the childs social competence (Miltenburg & Singer, 1999), which is a strategy based in cognitive behavioral therapy (CBT) (Purvis et al., 2013). Staff and caregivers implementing proactive behavioral training has long been shown to improve social problem-solving and conflict management skills (Webster-Stratton & Hammond, 1997). Proactive strategies include verbal reminders, behavioral reversals, role-playing, and demonstrations of appropriate behaviors and can result in a decrease of negative behaviors (Purvis et al., 2013). While over time, behaviors will reduce, it will take time, and caregivers will also have to engage in responsive strategies after a behavior has already occurred. Through the three principles of empowering, connecting, and correcting, TBRI assists caregivers in understanding trauma and its effects on youth, recognizing behaviors that result from trauma, and knowing how to help children regulate their behaviors in times of stress (Parris et al., 2014). Purvis and Cross (2007) found that children who attended a summer camp based on TBRI principles demonstrated significant decreases in aggressive behavior, attention problems, cortisol levels, depressive symptoms, negative mood, and thought problems as well as improvements in attachment behavior and interpersonal relationships. Parris et al. (2014) found that implementing the TBRI principles in a residential charter school resulted in decreased TRAUMA INFORMED CARE IN JUVENILE DETENTION 8 physical aggression, profanity, and restraint use, as well as students being more likely to discuss their problems with staff members. Occupational Therapy in Juvenile Justice Due to the history of trauma and its negative impacts on daily life functioning through PTSD and sensory processing, it seems only fitting that occupational therapy plays a role in evaluating and treating the individuals within the juvenile justice system. The practice of occupational therapy exists to enhance or enable participation in everyday life occupations, such as roles, habits, and routines in any given setting (American Occupational Therapy Association [AOTA], 2020). Occupational therapists in the juvenile justice setting can address both physical and mental health, education, and social relationships, as well as smaller aspects of the individuals such as emotional regulation, coping skills, and self-control (De Ruigh et al., 2019). Occupational therapists within the United States have designed interventions suitable to address a wide range of areas to support occupational functioning within the justice system (Munoz et al., 2016). Sensory Approach to Trauma Specific to trauma and its impacts on the brain, occupational therapists can play a role in the sensory needs of juvenile offenders. According to Dowdy et al. (2020), occupational therapists are well-positioned to meet this need due to their knowledge and training in sensory processing and client-centered care (AOTA, 2020; Schoen et al., 2018; Warner et al., 2013). Dowdy et al. (2020) also states that the sensory interventions for self-regulation used with patients with mental health diagnoses would apply to the individuals in a detention center due to their similarities with experienced trauma. In addition, sensory approaches are non-invasive, self-directed, and empowering, supporting a recovery-oriented and TIC practice (Scanlan & Novak, 2015). TRAUMA INFORMED CARE IN JUVENILE DETENTION 9 Within the sensorimotor frame, occupational therapists can address not only the occupation but also the person and environment. Specific to the person, occupational therapists can assist in developing individualized sensory diets (Fraser et al., 2017) and educate on mindfulness (Wolan et al., 2015) to assist with self-regulation and relaxation. Champagne and Stromberg (2004) define a sensory diet as the preferred sensorimotor experiences that help individuals function optimally within their environments (p.38), stating that developing a sensory diet includes identifying activities or experiences that help ground, calm, or center an individual. Using their skills and knowledge of sensory processing, occupational therapists can create safe and calming environments within juvenile detention centers. Skills learned in these safe and calm spaces increase self-awareness of sensory responses and facilitate regulated reactions to overwhelming sensory input (Champagne & Stromberg, 2004; Lebel & Champagne, 2010; LeBel et al., 2010). These spaces, often called sensory rooms, offer various sensory experiences to users, with activities both for calming and alerting each of the sensory systems (Champagne & Stromberg, 2004). Champagne and Sayer (2003) found that implementing a sensory room within a psychiatric unit had a positive impact on 89% of its users, which resulted in decreased use of seclusions and restraints within the facility. Specific examples of sensory equipment that can be included in a sensory room include aromatherapy, fidget toys, relaxing music/sounds, rocking chairs, weighted blankets or vests, crash cushions, and body socks (Koomar, 2009; Scanlan & Novak, 2015), all of which assist the individual to become more organized and regulated. Sensory-based interventions that address trauma and support self-regulation positively impact an individuals engagement and participation in occupations (Champagne et al., 2010), increasing coping skills, resiliency, and post-traumatic growth (McGreevy & Boland, 2020). Dowdy et al. (2020) found that 89% of youth who participated in occupational therapy services TRAUMA INFORMED CARE IN JUVENILE DETENTION 10 while in a correctional facility reported an improvement in their ability to recognize and appropriately cope with negative emotions rather than relying on their previous reactive responses to stress. Participants in the study also reported that occupational therapy served as a consistent and predictable space in which they could be themselves (Dowdy et al., 2020), demonstrating that participants had an increased sense of felt safety. Occupation-Based Model and Frame of Reference To fully and successfully address occupational performance within the juvenile justice population, practicing occupational therapists within this setting must use an appropriate model and frame of reference to guide evaluation and assessment. The Person-Environment-Occupation (PEO) model would be beneficial when looking at youth in the juvenile justice system, whether they be a part of juvenile detention, community corrections, or on probation. This model assumes that the person is dynamic and always developing based upon their environment and their occupations (Law et al., 1996). The focus of this model is the occupational performance fit, which is formed by the interaction of the person, the environment, and the occupation (Law et al., 1996). This performance fit can change as time goes on and be a better fit at various points in life. When this population is a part of the justice system, their occupational performance fit is small. Through proper occupational therapy interventions, including habilitation and rehabilitation, interventions can increase this fit and lead to a more successful occupational performance fit in their given environment. Both the applied behavioral and sensory integration frames of reference apply to evaluation and intervention within the juvenile justice population. The applied behavioral frame of reference would help to frame evaluation and intervention with this population, as it focuses on the modification of current behaviors, facilitating desired behaviors, and learning new TRAUMA INFORMED CARE IN JUVENILE DETENTION 11 occupational skills (Cole & Tufano, 2008). The applied behavioral frame of reference addresses undesired behaviors and maladaptive occupational performance and would be applicable to this population, as research shows that they tend to revert to prior functioning upon release (De Ruigh et al., 2019; Eggers et al., 2006; Hutcherson, 2012; Ristad, 2008). The sensory integration frame of reference applies to this population due to the neurological brain changes from experienced trauma, resulting in difficulties with sensory processing. The sensory integration frame of reference focuses on the ability of an individuals brain to organize sensory information and produce an adaptive response in relation to that information (Cole & Tufano, 2008). As previously mentioned, children in juvenile detention often have difficulty with their sensory processing (LeBel et al., 2010; Parris et al., 2015; Ryan et al., 2017; Warner et al, 2013), meaning that the sensory integration frame of reference would serve as an informative guide to providing appropriate intervention to assist in regulating the processing of sensory information for these individuals. In addition, a large aspect of the sensory integration frame of reference focuses on the processing patterns of individuals, which includes sensory-seeking, sensoryavoiding, sensory sensitive, and low registration behaviors (Cole & Tufano, 2008). Once the juvenile offenders gain a better understanding of their own sensory preferenes, they will be better equipped to self-regulate and respond appropriately to sensory input in the environments. The Current Study In line with the foundations of TIC and TBRI, the first step of this felt safety includes education of staff members at juvenile detention facilities on trauma and its impact on development to avoid re-traumatization. Denison et al. (2018) provided education to staff members at a residential treatment center on these topics with the goal of reducing restraints and seclusions. Denison et al. (2018) found that older staff members, staff members with more than TRAUMA INFORMED CARE IN JUVENILE DETENTION 12 four years of experience at the facility, and staff who had completed a college degree initially agreed more with the principles of TIC than younger staff members, those with less than four years of experience, and those without a college degree. After education on trauma, restraints/seclusions, and sensory interventions, Denison et al. (2018) found that staff members who have spent the most time in the setting are more open to alternative strategies, such as sensory interventions, in place of restraints/seclusions, also finding increased acceptance and understanding of TIC and sensory interventions across the population. This study supports the teaching of TIC and sensory interventions within juvenile justice settings, indicating that these strategies can impact the individuals within the setting as previously mentioned and on the staff members at the facility. Through educating staff at juvenile detention centers on the impact of trauma, sensory processing, and proper sensory interventions, occupational therapists can play a role in increasing safety within the detention center and increasing self-regulation, coping skills, and executive functioning of the children who spend time within the facility. Ideally, staff members will have a more positive attitude towards sensory strategies and the reduction of restraints/seclusions once they have a better understanding of the neurobiology that underlies behavior (Barkowski, 2016). The purpose of the current project is to educate staff members at Johnson County Juvenile Detention Center on trauma, its impact on brain functioning, and how sensory interventions can assist in behavioral management as well as to assess change in their view and use of TIC before and after education on the topic. Methods This study utilized survey methodology to anonymously collect opinions from the staff at Johnson County Juvenile Detention regarding knowledge and opinion about trauma-informed TRAUMA INFORMED CARE IN JUVENILE DETENTION 13 care, sensory strategies, and the use of restraints and seclusions within the facility both before and after a six-week educational series on the topics. Researchers created the survey from components of surveys by Abdoh et al. (2017), Denison et al. (2018), King et al. (2019), and Multnomah County Defending Childhood (2016) to address all relevant demographics and questions relevant to the previously mentioned topics. Researchers omitted some questions from each of the original surveys due to a lack of relevance to the current research. Participants The participants for this study consisted of 19 staff members at Johnson County Juvenile Detention. Researchers made the survey available to all 32 staff members via paper or online format, with a response rate of 59.4%. Of these participants, eight were female, nine were male, and two preferred not to disclose their gender identity. All participants had a minimum of a high school diploma, with seven participants holding a bachelors degree and an additional six participants having some post-high school education. shows responses for the highest levels of education for participants. Table 1 Highest level of education Level of Education n Percentage High School 4 21.1 Trade School 1 5.2 Some college 4 21.1 Associates degree 1 5.2 Bachelors degree 7 36.8 TRAUMA INFORMED CARE IN JUVENILE DETENTION Prefer not to answer 2 14 10.5 Note. n= Total participants with highest level of education. Respondents between 40 to 59 years of age accounted for 42% of the sample size. Four participants ranged between 20 and 29 years of age, two participants ranging between 30 and 39 years of age, and two participants ranging between 60 and 69 years of age. Three participants preferred not to say their age. Length of time working at the detention center ranged from less than 6 months to more than 20 years, with the highest representation from those who have worked at the facility for more than 20 years (26.3%), with an additional 15.8% working at the facility for both 3-5 years and 5-10 years. Three participants (15.8%) had worked at the facility for less than three years, while two participants (10.5%) had worked there between 10 and 20 years. Three participants (15.8%) preferred not to disclose the length of time they had worked at the facility. A majority of participants (73.75) had no previous experience working in the justice system, while 36.8% of participants did have previous experience working with children who had experienced trauma. Two participants preferred not to disclose their previous work experience in relation to working in the justice system or with children who had experienced trauma. Procedures The researchers submitted the proposed project to the Institutional Review Board at the University of Indianapolis, with the proposed study not requiring approval from the board. Researchers formed the sample through convenience sampling of all staff members at the facility. All digital communication with participants was completed via email through the Juvenile Detention Director, where the researchers did not have direct access to participant emails. TRAUMA INFORMED CARE IN JUVENILE DETENTION 15 Researchers initially provided paper surveys to all 32 staff members at the detention center, including youth care managers across all four work shifts, teachers, kitchen staff, and other administrative roles. Due to low response rates (12 of 32 participants), researchers sent an electronic form of the survey to participants via email, resulting in an additional seven participants. All responses from participants in this study remained anonymous to minimize the chance of researcher and participant bias. Each participant was asked a series of questions to create a unique identifying code that would assist researchers in matching pre-and post-surveys and ensure no participant completed both the paper and electronic forms of the survey. Researchers collected data for the pre-survey between April 20, 2021, and May 1, 2021, via paper survey and between April 28, 2021, and May 1, 2021, using an online survey created on Google Forms. Researchers verbally reminded staff members to complete the survey through informal discussions at the site. Researchers provided participants with the post-survey beginning on June 7, 2020, until June 25, 2020. The post-survey was provided in both paper and electronic forms for ease of completion by all willing participants. Twenty completed the postsurvey, two on paper and 18 through the online format, with only eight of the same participants from the pre-survey. The first part of the pre-survey asked participants five questions, such as what is the first letter of your mothers name? so that each participant could create a unique identification code consisting of letters and numbers to ensure anonymity during the pre-and post-surveys. The second part of the survey asked questions about demographics and their previous work experiences relevant to the justice system and children who have experienced trauma. The next part of the survey asked participants to respond to 30 statements relating to their knowledge about impacts of trauma, re-traumatization, and knowledge and opinions of TBRI and sensory TRAUMA INFORMED CARE IN JUVENILE DETENTION 16 interventions using a Likert scale ranging from strongly disagree to strongly agree. An optional prompt was provided for participants to share feedback regarding the survey or their personal opinions/experiences with the topic and ask questions regarding the topics on the survey. The complete survey can be found in Appendix A. The post-survey contained identical sections for creating the identification code, as well as the 30 statements about their knowledge about impacts of trauma, re-traumatization, and knowledge and opinions of TBRI and sensory interventions. An additional seven Likert scale statements were added to assess participants feelings about knowledge gained from the educational series. Lastly, researchers asked four open-ended questions about the impact of the educational series and how they plan to utilize the information provided. The post-survey can be found in Appendix B. Researchers provided the educational material for the program to participants via an online presentation as well as in PowerPoint format with a voice-over component. Table 2 shows the title of each weeks educational module, when it was sent to participants, and how many participants completed each educational component. After each weeks education, researchers asked participants to complete a small post-education survey of two to three questions to track the number of participants completing each weeks education. Questions on the post-education survey consisted of knowledge assessment questions as well as an open-ended prompt for feedback from participants. Table 2 Educational Topics Title Trauma and Sensory Processing Sensory Processing and the Sensory Systems Sensory Interventions The Sensory Room Date 4/28/21 5/5/21 5/12/21 5/19/21 n 20 22 23 23 TRAUMA INFORMED CARE IN JUVENILE DETENTION The R's of Trauma-Informed Care 5/26/21 Staff Self-Care 6/2/21 Note. n= number of participants each weeks educational component 17 20 20 Sensory Room In addition to providing an educational component to staff members at the detention center about the use of sensory interventions and a sensory room, the researchers also engaged in creating a sensory room and sensory paths for residents of the center. The sensory paths were designed using TBRI principles of relation and connection and were placed in two spaces in the detention center and one space in the accompanying probation office. One of the detention paths was placed in the hall, between the classroom and gym, while the other was designed to serve as a regulation tool as residents go up the stairs and into the courtroom. The space for the sensory room was located between two pods that previously served as a storage space for equipment. Researchers allowed residents to assist in painting an underwater mural scene on one of the walls in the room. Prior to the residents assisting in painting, the researcher outlined various underwater creatures on the wall to assist in breaking down painting tasks for the residents. Researchers allowed each resident to engage in painting the wall for a 30-minute time period, pulling one resident from their cell at a time. All residents were offered the opportunity to paint before allowing residents to engage in additional painting time. All but one resident stated that they would like to paint the room. The researcher was present with each resident as they painted, and the detention center provided all supplies for painting the room. Painting the room occurred over seven evenings and included 18 detention residents. Residents ranged in age from 14 to 18, with 15 boys and three girls engaging in the painting tasks. Results TRAUMA INFORMED CARE IN JUVENILE DETENTION 18 Of the 30 statements on the pre-survey, a majority of participants either agreed or disagreed in some capacity on 23 statements. Figure 1 shows the remaining seven statements that did not achieve a majority of responses in either agreement or disagreement. There was minimal agreement for two statements, with each of the Likert options being chosen at least once by a participant. Those statements were, I believe that all residents should be treated the same, regardless of the individual resident and their behavior and A resident who already received a punishment (such as catwalk) should not be permitted to engage in recreation time. While a majority of participants disagreed with the statement Giving options to an out-of-control resident can be dangerous, 10.6% of participants agreed, and 36.8% of participants were neutral. For the statement Exposure to trauma is common, a majority of participants (57.9%) agreed, but two participants disagreed in some capacity, while 31.6% were neutral. Figure 1 TRAUMA INFORMED CARE IN JUVENILE DETENTION 19 Non-Majority Agreement/Disagreement Statements Strongly disagree Disagree Neutral Agree Strongly Agree # of participants 14 12 10 8 6 4 2 0 Classroom Giving a resident For an individual disruptions an ultimatum who becomes and/or behavior can effectively quiet and problems are resolve an withdrawn is related to escalating response to trauma. situation. stress, engaging in physical activity can be helpful. I believe that all Once a resident's residents should behavior be treated the escalates past a same, regardless certain point, of the individual there is no resident and choice but to their behavior. restrain and/or seclude them. Engaging in an A resident who activity such as already received basketball or a punishment rapping can (such as catwlak) improve selfshould not be regulation skills. permitted to engage in recreation time. Statement Nine of the 30 statements on the pre-survey had an average level of agreement of 3.9 or higher on a five-point Likert scale, while five statements had an average level of disagreement of 2.4 or less. The remaining statements had an average level of agreement equaling a neutral response. Additional information regarding percentages of participants in agreement or disagreement and averages for each statement can be found in Appendix C. In week one of the educational component, researchers focused on basic definitions and statistics of trauma with the juvenile justice population, including ACEs, as well as giving a basic introduction into sensory processing and the importance of coping and resilience within the population. After completing week one, participants completed two post-education questions. When asked what drew them to working within the juvenile justice system, nine participants (45%) mentioned helping others, whether that be the juveniles themselves or their families. An additional three participants stated that their personal histories made them want to work with the TRAUMA INFORMED CARE IN JUVENILE DETENTION 20 juvenile offender population. Three respondents stated that there was no reason behind pursuing their job, and they were not sure why they worked within this setting. One participant specifically stated, I ended up here by chance but have learned to enjoy what I do. When asked what surprised them from the first week of education, 35% of participants stated that none of the information was surprising. In contrast, three stated that they were surprised about the high prevalence of trauma that staff experienced during childhood. The second weeks education focused on sensory systems and sensory processing styles. Participants learned about the eight sensory systems, hyper- and hypo-responsiveness, and the four sensory processing styles. Figure 2 and Figure 3 show the participants self-believed sensory processing styles and if they have experienced situations where sensory interventions would have been beneficial. Figure 2 Staff Sensory Processing Style Figure 3 Perceived Sensory Intervention Benefits Have you experienced a situation within the detention center where a sensory intervention would have been beneficial? Staff Sensory Processing Style Sensory Sensitive Sensory Avoiding Low Registration 3 2 15 10 10 6 5 0 Yes No Maybe Researchers focused specifically on preparatory and sensory interventions during week three of the educational series, which included a video on what it feels like to have sensory processing difficulties. After watching the video, 39.1% of respondents used words like stress, anxious, or overwhelmed to describe how they felt while watching the video. Four participants TRAUMA INFORMED CARE IN JUVENILE DETENTION 21 stated that the video made them feel more educated or informed about the experiences of those within the juvenile justice system. A large part of the preparatory interventions included the importance of offering choices to residents of the detention center. After the education, 69.6% stated that they were comfortable or extremely comfortable offering choices to residents, with only three participants stating that they were uncomfortable or extremely uncomfortable. The sensory interventions included research supporting the use of music and physical activity as sensory modulation and TIC activities to help reduce stress and anxiety in residents. Figure 4 shows what participants use to deal with their own stress or anxiety. Figure 4 Staff Coping Strategies Figure 5 Liklihood of Reccommending Sensory Room What do you use to help deal with your stress or anxiety? How likely are you to recommend a resident use the sensory room? Extremely Likely Music 2 2 Physical Activity Both Neither 16 3 Likely Neutral Unlikely Extremely Unlikely 0 2 4 6 8 10 Week four focused on creating the sensory room at the detention center, including why it would be beneficial and what sensory interventions and tools would be included. Figure 5 shows how likely participants stated they would recommend that a resident use the sensory room. Participants also described items they would enjoy having in a sensory room or relaxation space designed specifically for them. Nine participants stated they would enjoy having access to music or calming sounds, and three mentioned exercise or physical activity options. Additional options mentioned include smells and comfy seating, with four participants noting each item. Lastly, in the optional comment box, two participants stated that they were concerned about residents 12 TRAUMA INFORMED CARE IN JUVENILE DETENTION 22 manipulating or taking advantage of the sensory room, also stating that the room would be good for some residents. However, they would like to see detailed policies placed in the facility handbook about using the space. The focus of week five was on general trauma-informed care and how to implement the concept more easily into daily interactions within the detention center. When asked what the most difficult part of trauma-informed care was, five participants mentioned having difficulty with the punitive versus rehabilitative approaches, not knowing when to use which approach. One participant specifically stated that the most difficult part was how to hold kids accountable for their actions when sometimes their actions are a result of their trauma. Four participants stated that being empathetic and relating to residents was the most difficult part due to not having the same lived experiences. One participant, a shift leader, stated the following: I think time is our biggest challenge in detention. The responsibility of keeping everyone safe and making sure tasks get completed is daunting with only a few people to do it. Its very difficult to give individual attention and sometimes impossible when we are trying to get basic needs met. Being a supervisor its hard for me to help a resident process through what they are feeling when Im constantly getting interrupted or pulled away to the next situation. I think this leads to frustration for both parties. Prioritizing leaves some residents at the bottom of the list which can make them feel their issue is not worthy of time. Supervisors are sandwiched between resident and Youth Care Managers and there is never enough time for both. Researchers also asked how participants build connections with residents. Nine participants stated that they simply listen to what the residents have to say, while an additional four TRAUMA INFORMED CARE IN JUVENILE DETENTION 23 participants state that they engage the resident in conversation about preferred topics. Other strategies included playing games with residents, rewarding good behavior, and overall respect. The last part of the educational series focused on the staff and the importance of self-care and overall wellness. Of the 20 participants that completed the education, half stated that their go-to self-care activity involves some type of exercise or physical activity, with three participants specifically mentioned taking a walk. Four participants stated that their go-to self-care activity involved music, and one participant mentioned weekly therapy sessions. Seventy-five percent (15) of the participants stated that they had tried at least one of the mindfulness activities explained throughout the education, including mindful breathing, tai chi, yoga, body scan, guided imagery, affirmations, and meditation. After completing the six-week educational series, participants once again reached a majority of either agreement or disagreement for 23 of the 30 statements. Of the seven remaining statements without a majority, only three were the same statements from the pre-survey. These statements were Classroom disruptions and/or behavior problems are related to trauma Giving a resident an ultimatum can effectively resolve an escalating situation and A resident who already received a punishment (such as catwalk) should not be permitted to engage in recreation time. Three of the 30 statements received at least one participant answering with each of the five Likert options, two of which still received a majority decision in agreement or disagreement. Four statements had 90% or more of participants in agreement. For 14 of the statements, participants reached an average level of agreement of 3.9 or higher. Appendix C shows this in more detail, along with percentages and averages for all 30 statements on the postsurvey. TRAUMA INFORMED CARE IN JUVENILE DETENTION 24 Overall, participants showed increased agreement on 13 of the statements when looking at pre-and post- outcomes. Of these 13 statements, four statements were regarding their knowledge of the impact of trauma, six were regarding their knowledge and opinions of TBRI and sensory interventions, and the remaining three were related to re-traumatization. For five of these statements, none of the participants stated that they disagree in any fashion after the education. Despite minimal overall changes in response, no participant stated that they agreed with two of the statements they previously agreed with on the pre-survey. These statements were Residents can use higher level thinking (such as cause and effect) when they become upset, and Restraints and/or seclusions are the more effective way to control behavior. For an additional two statements, participants stated that they now strongly agree with the statement, as opposed to simply agreeing. The statement with the most change from the pre to post-survey was, Residents can benefit from routines and rituals to support them during transitions or difficult time periods. Prior to education, 21.1% of participants strongly agreed with this statement, as opposed to half who strongly agreed after education, with an additional 40% agreeing. Only two participants responded to this statement with neutral. Participants varied in their responses, with at least one participant choosing each of the Likert options for eight of the statements, two about knowledge of the impact of trauma, two about knowledge and opinions of TBRI and sensory processing, and four about re-traumatization. Of the 20 participants who completed the post-survey, only eight were the same participants who completed the pre-survey. When looking at these eight participants for pre-post survey changes specifically, they more strongly agreed with or had higher levels of agreement with six statements. Of these six statements, two were coded in each category of knowledge TRAUMA INFORMED CARE IN JUVENILE DETENTION 25 about the impact of trauma, knowledge, and opinions of TBRI and sensory interventions, and retraumatization. All eight participants stated that they agreed in some capacity with the following statements: Residents can benefit from routines and rituals to support them during transitions or difficult time periods, and Residents can benefit from opportunities for helpful participation, such as leadership or a designated job. Participants responded with each of the Likert scale options for two statements, meaning that all responses had a least one participant agreeing at that level. The statements with the most change in agreement from pre-survey to post-survey for these eight individuals were Re-traumatization can occur in both the community and in institutional settings, and Constant stress can impact a persons ability to make new memories. Eighty-seven and a half percent of participants agreed in some capacity with each of these statements on the post-survey, with an average level of agreement of 4.4 out of 5. See Appendix D for answer percentages on all items for the eight participants completing both the pre-and post-surveys. Along with the post-survey statements, participants also responded to seven statements regarding their gained knowledge about the topics presented during the educational series. A majority of participants agreed with all statements, except for I have a stronger belief in and support of trauma-informed care (TBRI), with 45% of participants agreeing in some way and 10% of participants disagreeing in some way. The most strongly agreed with statement was I have a better understanding on the impact of trauma, with 70% of participants stating that they agree or strongly agree. However, at least one participant disagreed with three of the seven statements. Table 3 shows percentages for all responses. Table 3 Statements about Gained Knowledge TRAUMA INFORMED CARE IN JUVENILE DETENTION Statement Strongly Disagree (1) 26 Disagree (2) Agree (4) Strongly Agree (5) 30 55 15 35 50 15 10 35 40 15 5.3 36.8 47.4 10.5 45 40 15 30 40 30 45 25 20 I have a better understanding of the impact of trauma I have a better understanding of sensory processing I have a better understanding of sensory interventions to use with residents during stressful times I have a better understanding of why residents would benefit from a sensory/calm down room I have a better understanding of trauma-informed care (TBRI) I have a better understanding of why it's important to take good care of myself I have a stronger belief in and support of trauma-informed care (TBRI) 5 5 Neutral (3) Sensory Room Feedback During the time spent painting the sensory room, residents engaged in conversation, discussing a wide variety of topics. Topics brought up by multiple residents include discussing their time spent at a residential treatment center, their parents going to jail/prison or doing drugs, their desire to get a job or go back to school upon release, their previous self-harm or suicide attempts, and their relationships with their parents. One resident specifically discussed how during his time in detention, his father was also going to jail and was to serve a long sentence. Other residents mentioned how they grew up in a broken household, witnessing or experiencing abuse, and seeing their parents do drugs. Multiple residents stated that they enjoyed their time painting and were surprised at their painting abilities. Discussion TRAUMA INFORMED CARE IN JUVENILE DETENTION 27 Ezell et al. (2018) and Pickens (2016) stated that to fully implement a TIC approach into the justice system, the staff members would have to buy into the principles and practices of TIC, specifically TBRI for the given setting. In line with this, after completing the six-week education, 55% of participants stated that they had a better understanding of TBRI and 45% of participants stated that they had a stronger belief in and support of the practices relevant to their facility. An additional 45% of participants felt neutral regarding a stronger belief in and support of TBRI, with the possibility that some of these participants had already bought into the principles and did not require any additional education or buy in to implement practices into their daily interactions with residents. The implemented education included all components of education suggested by Rhoden (2019), including education, skill-building, and self-regulation for all parties. Educational components addressed trauma, its impact on development, and sensory processes, with a majority of participants stating that they have a better understanding of all mentioned topics. Along with this, participants were given skill-building opportunities through examples of both proactive and reactive strategies of interaction with residents that support felt safety and build connections in line with TBRI. Self-regulation was addressed with participants by providing sensory interventions to utilize with residents or for themselves during high times of stress. The current education also included education relating to self-care, as supported by Rapp (2016) with the idea that those who work with this population must first take care of themselves to take of individuals with such high amounts of trauma. In accordance with this idea, 70% of participants stated that they now have a better understanding of the importance of self-care. The post-survey results also support Barkowski's (2016) findings. Staff report a better understanding of the neurobiology related to trauma and have more positive attitudes towards TRAUMA INFORMED CARE IN JUVENILE DETENTION 28 sensory interventions and the sensory processing approach. Findings of the current study also support that participants are more open to alternative strategies, as found by Denison et al. (2018), with one participant explicitly stating, I am much more open to alternative types of consequences when asked about the impact of the education. An additional participant stated, I will not be so quick to judge things and how things will be impacted on a kid, with other participants stated they now have increases levels of awareness and more perspective into the experiences of these individuals. Overall, participants agreed more strongly with 14 statements after being educated on the topics, six of which related specifically to sensory processing, which falls within the scope of practice of an occupational therapist within this setting. In addition, the statement with the most change in agreement from pre- to post-survey relates to routines and rituals, which are occupations (AOTA, 2020) and supports the notion of occupational therapy working with the residents at the facility in order to create more defined routines and rituals in line with a TIC approach. Additionally, as Yatchmenoff et al. (2017) suggested, residents at the facility were involved in the painting and creation of a sensory room within the detention center. Residents who participated reported feeling less stressed and more relaxed after working on the painting, suggesting that the activity helped with self-regulation, as Champagne et al. (2010) explained. One participant stated that painting let my stress out without breaking something or hurting others or myself and aided with his anxiety. Painting in the sensory space had additional benefits for residents, such as giving them hope for a better future and making them feel good about doing something that could help others in the future. For example, one resident stated, Painting made me feel like there is still stuff in the world that I can do, and It made me feel confident that I still have a good life ahead of me. TRAUMA INFORMED CARE IN JUVENILE DETENTION 29 While not explicitly stating that they felt safe, these residents could be honest and vulnerable due to feeling safe within the space, which supports the findings of Dowdy et al. (2020), where residents reported that OT was a consistent and predictable space in which they could be themselves. The current study's findings suggest that educating staff members at juvenile detentions centers on trauma, sensory processing, and the use of restraints and seclusions can benefit both staff and residents. Through this education, staff can gain an increased knowledge about alternative practices that may assist in creating stronger bonds with residents and result in fewer exhibited behaviors. In contrast, residents will benefit from being offered alternative methods to meet their sensory needs and cope with their stress and anxiety. These findings suggest that occupational therapy is deserving of a role within the justice system to assist with implementing TIC and implementing sensory interventions within the setting. Limitations Limitations of the current study include a small sample size with little participant retention between pre and post-survey due to high turnover rate at the facility. 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Effects of therapeutic interventions for foster children on behavioral problems, caregiver attachment, and stress regulatory neural systems. Annals of New York Academy of Sciences, 1094, 215-225. https://doi.org/10.1196/annals.1376.023 Ford, J. D., Chapman, J., Mack, J. M., & Pearson, G. (2006). Pathways from traumatic child victimization to delinquency: Implication for juvenile and permanency court proceedings and decisions. Juvenile and Family Court Journal, 57(1). https://doi.org/10.1111/j.17556988.2006.tb00111.x 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), 199-216. https://doi.org/10.1080/0164212X.2016.1265475 Hutcherson, D. T. (2012). The connection between time in prison and future criminal earnings. The Prison Journal, 92(3), 315-335. http://dx.doi.org/10.1177/0032885512448607 Kerig, P.K. & Becker, S. P. (2010). From internalizing to externalizing: Theoretical models of the processes linking PTSD to juvenile delinquency. In S. J. Egan (Ed.), Posttraumatic stress disorder (PTSD): Causes, symptoms, and treatment (pp. 37-79). Nova Science. Kilpatrick, D. G., Ruggiero, K. J., Acierno, R., Saunders, B. E., Resnick, H. S., & Best, C. L. (2003). Violence and risk of PTSD, major depression, substance abuse/dependence, and comorbidity: Results from the National Survey of Adolescents. Journal of Consulting and Clinical Psychology, 71(4), 692-700. https://doi.org/10.1037/0022-006x.71.4.692 King, S., Chen, K.-L. D., & Chokshi, B. (2019). Becoming trauma informed: Validating a tool to assess health professionals knowledge, attitude, and practice. Pediatric Quality and Safety, 9(4), 1-6. https://doi.org/10.1097/pq9.0000000000000215 TRAUMA INFORMED CARE IN JUVENILE DETENTION 34 Knight, D. C., Smith, C. N., Cheng, D. T., Stein, E. A., & Helmstetter, F. J. (2004). Amygdala and hippocampal activity during acquisition and extinction of human fear conditioning. Cognitive, Affective, and Behavioral Neuroscience, 4(3), 317-325. https://doi.org/10.3758/cabn.4.3.317 Koomar, J. (2009). Trauma and attachment-informed sensory integration assessment and intervention. Special Interest Section Quarterly, Sensory Integrations, 32, 1-4. Law, M., Copper, B., Strong, S., Stewart, D., Rigby, P., & Letts, L. (1996). The personenvironment-occupation model: A transactive approach to occupational performance. Canadian Journal of Occupational Therapy, 63(1), 9-23. https://doi.org/10.1177%2F000841749606300103 LeBel, J. & Champagne, T. (2010). Integrating sensory and trauma-informed intervention: A Massachusetts state initiative part 2. Special Interest Section Quarterly, Mental Health, 33, 1-4. LeBel, J., Champagne, T., Stromber, N., & Coyle, R. (2010). Integrating sensory and traumainformed interventions: A Massachusetts state initiative, part 1. Mental Health Special Interest Section Quarterly, 33(1), 1-4. Retrieved from http://tnoys.org/wpcontent/uploads/IntSensTICPart1.pdf McGreevy, S. & Boland, P. (2020). Sensory-based interventions with adult and adolescent trauma survivors: An integrative review of the occupational therapy literature. Irish Journal of Occupational Therapy, 48(1), 31-54. http://dx.doi.org/10.1108/IJOT-10-20190014 Miltenburg, R. & Singer, E. (1999). Culturally mediated learning and the development of selfregulation by survivors of child abuse: A Vygotskian approach to the support of survivors TRAUMA INFORMED CARE IN JUVENILE DETENTION 35 of child abuse. Human Development, 42(1), 1-17. https://psycnet.apa.org/doi/10.1159/000022604 Multnomah County Defending Childhood. (2016). Trauma informed practices self assessment for SUN instructors and partners. https://www.georgefox.edu/counselingtraining/tri/SUN-staff-self-assessment1.pdf Munoz, J. P., Moreton, E. M., & Sitterly, A. M. (2016). The scope of practice of occupational therapy in U.S. criminal justice settings. Occupational Therapy International, 23(3), 241254. https://doi.org/10.1002/oti.1427 National Association of State Mental Health Program Directors. (2009). National executive training institute: A training curriculum for the reduction of seclusion and restraints (7th ed.). Ogden, P., Pain, C., & Fisher, J. (2006). A sensorimotor approach to the treatment of trauma and dissociation. The Psychiatry Clinics of North America, 29(1), 263-279. https://doi.org/10.1016/j.psc.2005.10.012 Parris, S. R., Dozier, M., Parvis, K.B., Whitney, C., Grisham, A., & Cross, D. R. (2015). Implementing trust-based relational intervention in a charter school at a residential facility for at-risk youth. Contemporary School Psychology, 19, 157-164. http://dx.doi.org/10.1007/s40688-014-0033-7 Pickens, I. (2016). Laying the groundwork: Conceptualizing a trauma-informed system of care in juvenile detention. Journal of Infant, Child, and Adolescent Psychotherapy, 15(3), 220230. https://doi.org/10.1080/15289168.2016.1214452 TRAUMA INFORMED CARE IN JUVENILE DETENTION 36 Purvis, K. B & Cross, D. R. (2007). The Hope Connection: A therapeutic summer day camp for adopted and at-risk children with special socio-emotional needs. Adoption & Fostering, 31(4), 38-48. http://dx.doi.org/10.1177/030857590703100406 Purvis, K. B., Cross, D. R., Danserreau, D. F., & Parris, S. R. (2013). Trust-based relational intervention (TBRI): A systematic approach to complex developmental trauma. Child & Youth Services, 34(4), 360-386. https://dx.doi.org/10.1080%2F0145935X.2013.859906 Rapp, L. (2016). Delinquent-victim youth- Adapting a trauma-informed approach for the juvenile justice system. Journal of Evidence-Informed Social Work, 13(5), 492-497. https://doi.org/10.1080/23761407.2016.1166844 Rhoden, M. A., Macgowan, M. J., & Huang, H. (2019). A systematic review of psychological trauma interventions for juvenile offenders. Research of Social Work Practice, 29(8), 892-909. https://doi.org/10.1177%2F1049731518806578 Ristad, R. N. (2008). A stark examination of prison culture, and prison ministry. Journal of Theology, 47(3), 292-303. https://doi.org/10.1111/j.1540-6385.2008.00403.x Ryan, K., Lane, S. J., & Powers, D. (2017). A multidisciplinary model for treating complex trauma in early childhood. International Journal of Play Therapy, 26(2), 111-123. https://psycnet.apa.org/doi/10.1037/pla0000044 Scanlan, J.N. & Novak, T.(2015). Sensory approaches in mental health: A scoping review. Australian Occupational Therapy Journal, 62(5), 277-285. https://doi.org/10.1111/14401630.12224 Schoen, S. A., Miller, L. J., & Flanagan, J. (2018). A retrospective pre-post treatment study of occupational therapy intervention for children with sensory processing challenges. The TRAUMA INFORMED CARE IN JUVENILE DETENTION 37 Open Journal of Occupational Therapy, 6(1), 1-14. https://doi.org/DOI:%2010.15453/2168-6408.1367 Serafini, G., Gonda, X., Pompili, M., Rihmer, Z., Amore, M., & Engel-Yeger, B. (2016). The relationship between sensory processing patterns, alexithymia, traumatic childhood experiences, and quality of life among patients with unipolar and bipolar disorders. Child Abuse and Neglect, 62, 39-50. https://doi.org/10.1016/j.chiabu.2016.09.013 Thornberry, T. P., Henry, K. L., Ireland, T. O., & Smith, C. A. (2010). The causal impact of childhood-limited maltreatment and adolescent maltreatment on early adult adjustment. Journal of Adolescent Health, 46(4), 359-365. https://doi.org/10.1016/j.jadohealth.2009.09.011 van der Kolk, B. A. (2003). The neurobiology of childhood trauma and abuse. Child and Adolescent Psychiatry Clinics of North America, 12(2), 293-317. https://doi.org/10.1016/s1056-4993(03)00003-8 van der Kolk, B. A., & MacFarlane, A. C. (Eds.). (2007). Traumatic stress: The effects of overwhelming experience on mind, body, and society. New York, NY: Guilford Press. van der Kolk, B. A., Roth, S., Pelcovitz, D., Sunday, S., & Spinazzola, J. (2005). Disorders of extreme stress: The empirical foundation of a complex adaptation to trauma. Journal of Traumatic Stress, 18(5), 389-399. https://doi.org/10.1002/jts.20047 Warner, E., Koomar, J., Lary, B., & Cook, A. (2013). Can the body change the score? Application of sensory modulation principles in the treatment of traumatized adolescents in residential settings. Journal of Family Violence, 28(7), 729-738. https://doi.org/10.1007/s10896-013-9535-8 TRAUMA INFORMED CARE IN JUVENILE DETENTION 38 Webster-Stratton, C. & Hammond, M. (1997). Treating children with early-onset conduct problems: A comparison of child and parent training interventions. Journal of Consulting and Clinical Psychology, 65(1), 93-109. https://doi.org/10.1037//0022-006x.65.1.93 Wolan, T., Delaney, M. A., & Weller, A. (2015). Group work with children who have experienced trauma using a sensorimotor framework. Children Australia, 40, 205-208. https://doi.org/10.1017/cha.2015.16 Wolff, K. T., Baglivio, M. T., & Piquero, A. R. (2017). The relationship between adverse childhood experiences and recidivism in a sample of juvenile offenders in communitybased treatment. International Journal of Offender Therapy and Comparative Criminology, 61(11), 1210-1242. https://doi.org/10.1177/0306624x15613992 Yatchmenoff, D. K., Sundborg, S. A., & Davis, M. A. (2017). Implementing trauma-informed care: Recommendations on the process. Advances in Social Work, 18(1), 167-185. https://doi.org/10.18060/21311 TRAUMA INFORMED CARE IN JUVENILE DETENTION 39 Appendix A Pre-Survey Hello, As mentioned via email, I will be implementing an educational series regarding trauma within the juvenile detention center. Before the educational series begins, I am conducting an anonymous survey to assess your current knowledge and opinions regarding trauma and its associated factors within the detention center. You will complete an additional survey at the end of the educational series. The survey consists of 3 parts. The initial part of the survey is to create a unique identification code to ensure anonymity. The following part will ask demographic information, while the last part of the survey consists of 30 statements. There is an additional prompt at the end of the survey regarding questions you may have or topics you would like to see covered. Each survey will take approximately 15-20 minutes to complete. Your identity will remain anonymous throughout both surveys. You are free to quit the survey at any point without penalty. You are free to omit answers on any question you feel uncomfortable answering. Your participation and answers on this survey will in no way impact your employment status at Johnson County Juvenile Detention and will not be shared with any of your fellow Youth Care Managers. If you have any questions, please feel free to contact Paige McIntire at the contact information below. Once you have completed the survey, please place it inside of an enveloped and seal the envelope. Please then place your sealed envelope into the basket for collection. Please do not write your name on the survey or the envelope. Please only complete this survey if you are 18 years of age or older. Please tear off the cover page of this survey and keep it for your records. Thank you for your participation. Sincerely, Paige McIntire Paige McIntire, Occupational Therapy Student Department of Occupational Therapy University of Indianapolis, Indianapolis, Indiana 46227 (317) 642-7685 mcintirep@uindy.edu TRAUMA INFORMED CARE IN JUVENILE DETENTION 40 Pre survey Please answer all identification questions. These questions will assist you in creating a code to ensure anonymity while taking the survey. This code will be used on both the pre- and posteducational surveys. What is the first letter of your mothers name? ________ Example: Jennifer (J) What is the second number of your current age? ________ Example: 24 years old (4) What are the last 2 digits of your cell phone number? _________ Example: 798-9862 (62) What is the first letter of the month you were born in? _____________ Example: August (A) What is the first letter of your middle name? ________ Example: Marie (M) Your identification code: _______________________ Example: J462AM Demographics: Please circle your answer, choosing only one answer per question. 1. What is your preferred gender identity? a. Female b. Male c. My preferred gender is not listed here d. Prefer not to answer 2. What is your age range? a. Less than 20 years b. 20-29 years c. 30-39 years d. 40-49 years e. 50-59 years f. 60-69 years g. 70+ h. Prefer not to answer 3. What is the highest degree or level of education you have completed? a. Some high school b. High school c. Trade school d. Some college e. Associate degree f. Bachelors Degree g. Masters Degree h. Ph.D. or higher TRAUMA INFORMED CARE IN JUVENILE DETENTION 41 i. Prefer not to say 4. How long have you worked at Johnson County Juvenile Detention? a. Less than 6 months b. 6 months-1 year c. 1-3 years d. 3-5 years e. 5-10 years f. 10-20 years g. More than 20 years h. Prefer not to answer 5. Before working at Johnson County Juvenile Detention, did you have experience working within the justice system? a. Yes b. No c. Prefer not to answer 6. Before working at Johnson County Juvenile Detention, did you have experience working with children who have experienced trauma? a. Yes b. No c. Prefer not to answer Statements: Please respond to the following statements using a scale of 1 (Strongly Disagree) to 5 (Strongly Agree). Circle the number that best describes how you feel about each statement. 1 2 3 4 5 Statement Strongly Disagree Disagree Neutral Agree Strongly Agree Substance use can be indicative of past traumatic experiences or adverse child experiences (ACEs). * 1 2 3 4 5 There is a connection between mental health and past traumatic experiences or adverse child experiences (ACEs). * 1 2 3 4 5 Listening to music can make a persons body feel calmer. 1 2 3 4 5 TRAUMA INFORMED CARE IN JUVENILE DETENTION Giving options to an out-ofcontrol individual can be dangerous. 42 1 2 3 4 5 Statement Strongly Disagree Disagree Neutral Agree Strongly Agree Residents can use higher level thinking (such as cause and effect) when they become upset. 1 2 3 4 5 Re-traumatization can occur in both the community and in institutional settings. * 1 2 3 4 5 Re-traumatization can occur unintentionally. * 1 2 3 4 5 Classroom disruptions and/or behavior problems are related to trauma.  1 2 3 4 5 1 2 3 4 5 Distrusting behavior is indicative of past traumatic experiences or adverse childhood experiences (ACEs). * 1 2 3 4 5 Stress can negatively impact residents cognitive and physical abilities.  1 2 3 4 5 Giving a resident an ultimatum can effectively resolve an escalating situation. 1 2 3 4 5 Residents can benefit from routines and rituals to support them during 1 2 3 4 5 For many residents, there are no alternatives to restraints and/or seclusions. TRAUMA INFORMED CARE IN JUVENILE DETENTION 43 transitions or difficult time periods.  Strongly Disagree Disagree Neutral Agree Strongly Agree Residents can benefit from opportunities for helpful participation, such as leadership or a designated job.  1 2 3 4 5 Trauma affects physical, emotional, and mental wellbeing. * 1 2 3 4 5 For an individual who becomes quiet and withdrawn in response to stress, engaging in physical activity can be helpful. 1 2 3 4 5 1 2 3 4 5 Focusing on a residents negative actions is an effective approach to resolving a situation. * 1 2 3 4 5 Choosing an activity to do when a resident becomes upset can directly impact their ability to regulate their behavior. 1 2 3 4 5 Statement I believe that all residents should be treated the same, regardless of the individual resident and their behavior. * TRAUMA INFORMED CARE IN JUVENILE DETENTION 44 Experiences in the detention center can be a trigger for residents who have experienced trauma.  1 2 3 4 5 Statement Strongly Disagree Disagree Neutral Agree Strongly Agree Getting involved in a strenuous physical activity makes a persons body feel calmer. 1 2 3 4 5 Individuals are in control of their actions when they are upset. 1 2 3 4 5 Once a residents behavior escalates past a certain point, there is no choice but to restrain and/or seclude them. 1 2 3 4 5 Engaging in an activity such as basketball or rapping can improve self-regulation skills. 1 2 3 4 5 Exposure to trauma is common. * 1 2 3 4 5 Making decisions that consider both logic and emotion can be improved through physical activity. 1 2 3 4 5 Constant stress can impact a persons ability to make new memories. 1 2 3 4 5 TRAUMA INFORMED CARE IN JUVENILE DETENTION 45 A resident who already received a punishment (such as catwalk) should not be permitted to engage in recreation time. 1 2 3 4 5 Statement Strongly Disagree Disagree Neutral Agree Strongly Agree Offering choices to a resident and respecting their decisions is an effective way to resolve a situation. * 1 2 3 4 5 Restraints and/or seclusions are the most effective way to control behavior. 1 2 3 4 5 Survey statements adapted from Abdoh et al. (2017), Denison et al. (2018), and Multnomah County Defending Childhood (2016). signifies verbatim statements from original source; * signifies statements from Abdoh et al. (2017); signifies statements from Denison et al. (2018); signifies statements from Multnomah County Defending Childhood (2016) Please share any questions you would like addressed regarding trauma-informed care, sensory interventions, or occupational therapy: TRAUMA INFORMED CARE IN JUVENILE DETENTION 46 Appendix B Post-Survey Hello, I am conducting an anonymous survey to assess your current knowledge and opinions regarding trauma and its associated factors within the detention center. This survey is to be completed after completing the 6-week educational series on the topic. The survey will take approximately 15-20 minutes to complete. Your identity will remain anonymous. You are free to quit the survey at any point without penalty. You are free to omit answers on any question you feel uncomfortable answering. Your participation and answers on this survey will in no way impact your employment status at Johnson County Juvenile Detention and will not be shared with any of your fellow staff members. If you have any questions, please feel free to contact Paige McIntire at the contact information below. Once you have completed the survey, please place it inside of an enveloped and seal the envelope. Please then place your sealed envelope into the basket for collection. Please do not write your name on the survey or the envelope. Please only complete this survey if you are 18 years of age or older. Please tear off the cover page of this survey and keep it for your records. Thank you for your participation. Sincerely, Paige McIntire Paige McIntire, Occupational Therapy Student Department of Occupational Therapy University of Indianapolis, Indianapolis, Indiana 46227 (317) 642-7685 mcintirep@uindy.edu TRAUMA INFORMED CARE IN JUVENILE DETENTION 47 Post survey Please answer all identification questions. These questions will assist you in creating a code to ensure anonymity while taking the survey. This code will be used on both the pre- and posteducational surveys. What is the first letter of your mothers name? ________ Example: Jennifer (J) What is the second number of your current age? ________ Example: 24 years old (4) What are the last 2 digits of your cell phone number? _________ Example: 798-9862 (62) What is the first letter of the month you were born in? _____________ Example: August (A) What is the first letter of your middle name? ________ Example: Marie (M) Your identification code: _______________________ Example: J462AM Statements: Please respond to the following statements using a scale of 1 (Strongly Disagree) to 5 (Strongly Agree). Circle the number that best describes how you feel about each statement. 1 2 3 4 5 Statement Strongly Disagree Disagree Neutral Agree Strongly Agree Substance use can be indicative of past traumatic experiences or adverse child experiences (ACEs). * 1 2 3 4 5 There is a connection between mental health and past traumatic experiences or adverse child experiences (ACEs). * 1 2 3 4 5 Listening to music can make a persons body feel calmer. 1 2 3 4 5 Giving options to an out-ofcontrol individual can be dangerous. 1 2 3 4 5 TRAUMA INFORMED CARE IN JUVENILE DETENTION 48 Statement Strongly Disagree Disagree Neutral Agree Strongly Agree Residents can use higher level thinking (such as cause and effect) when they become upset. 1 2 3 4 5 Re-traumatization can occur in both the community and in institutional settings. * 1 2 3 4 5 Re-traumatization can occur unintentionally. * 1 2 3 4 5 Classroom disruptions and/or behavior problems are related to trauma.  1 2 3 4 5 1 2 3 4 5 Distrusting behavior is indicative of past traumatic experiences or adverse childhood experiences (ACEs). * 1 2 3 4 5 Stress can negatively impact residents cognitive and physical abilities.  1 2 3 4 5 Giving a resident an ultimatum can effectively resolve an escalating situation. 1 2 3 4 5 Residents can benefit from routines and rituals to support them during transitions or difficult time periods.  1 2 3 4 5 For many residents, there are no alternatives to restraints and/or seclusions. TRAUMA INFORMED CARE IN JUVENILE DETENTION 49 Strongly Disagree Disagree Neutral Agree Strongly Agree Residents can benefit from opportunities for helpful participation, such as leadership or a designated job.  1 2 3 4 5 Trauma affects physical, emotional, and mental wellbeing. * 1 2 3 4 5 For an individual who becomes quiet and withdrawn in response to stress, engaging in physical activity can be helpful. 1 2 3 4 5 1 2 3 4 5 Focusing on a residents negative actions is an effective approach to resolving a situation. * 1 2 3 4 5 Choosing an activity to do when a resident becomes upset can directly impact their ability to regulate their behavior. 1 2 3 4 5 Experiences in the detention center can be a trigger for residents who have experienced trauma.  1 2 3 4 5 Statement I believe that all residents should be treated the same, regardless of the individual resident and their behavior. * TRAUMA INFORMED CARE IN JUVENILE DETENTION 50 Strongly Disagree Disagree Neutral Agree Strongly Agree Getting involved in a strenuous physical activity makes a persons body feel calmer. 1 2 3 4 5 Individuals are in control of their actions when they are upset. 1 2 3 4 5 Once a residents behavior escalates past a certain point, there is no choice but to restrain and/or seclude them. 1 2 3 4 5 Engaging in an activity such as basketball or rapping can improve self-regulation skills. 1 2 3 4 5 Exposure to trauma is common. * 1 2 3 4 5 Making decisions that consider both logic and emotion can be improved through physical activity. 1 2 3 4 5 Constant stress can impact a persons ability to make new memories. 1 2 3 4 5 A resident who already received a punishment (such as catwalk) should not be permitted to engage in recreation time. 1 2 3 4 5 Statement TRAUMA INFORMED CARE IN JUVENILE DETENTION 51 Statement Strongly Disagree Disagree Neutral Agree Strongly Agree Offering choices to a resident and respecting their decisions is an effective way to resolve a situation. * 1 2 3 4 5 Restraints and/or seclusions are the most effective way to control behavior. 1 2 3 4 5 Survey statements adapted from Abdoh et al. (2017), Denison et al. (2018), and Multnomah County Defending Childhood (2016). signifies verbatim statements from original source; * signifies statements from Abdoh et al. (2017); signifies statements from Denison et al. (2018); signifies statements from Multnomah County Defending Childhood (2016) Statements: Please respond to the following statements using a scale of 1 (Strongly Disagree) to 5 (Strongly Agree). Circle the number that best describes how you feel about each statement. Each of the statements will begin with the following phrase: After this education, I 1 2 3 4 5 Statement Strongly Disagree Disagree Neutral Agree Strongly Agree have a better understanding of the impact of trauma. 1 2 3 4 5 have a better understanding of sensory processing 1 2 3 4 5 1 2 3 4 5 have a better understanding of sensory interventions to use with TRAUMA INFORMED CARE IN JUVENILE DETENTION 52 residents during stressful times Strongly Disagree Disagree Neutral Agree Strongly Agree have a better understanding of why residents would benefit from a sensory/calm down room. 1 2 3 4 5 have a better understanding of traumainformed care (TBRI) 1 2 3 4 5 have a better understanding of why its important to take good care of myself 1 2 3 4 5 have a stronger belief in and support of traumainformed care (TBRI). 1 2 3 4 5 Statement Please answer the following questions. Feel free to use the the back of this page or a blank piece of paper as additional space if needed. Be sure to include the additional paper in the envelope with the survey. Describe the impact this educational series had on the way you think about the residents that you work with. TRAUMA INFORMED CARE IN JUVENILE DETENTION How have you used (or plan to use) the information you learned in this educational series? Is there an example of a time when you saw physical activity impact a residents behavior? Please describe. Describe how you plan to maintain your own regulation during times of high stress when working with residents. Please list any other feedback below. Thank you! 53 TRAUMA INFORMED CARE IN JUVENILE DETENTION 54 Appendix C Pre-Post Survey Results for all Participants Strongly Disagree (1) Statement Substance use can be indicative of past traumatic experiences or adverse child experiences (ACEs). There is a connection between mental health and past traumatic experiences or adverse child experiences (ACEs). Listening to music can make a persons body feel calmer. Pre Residents can use higher level thinking (such as cause and effect) when they become upset. Neutral (3) Agree (4) Average Strongly Degree of Agree (5) Agreement 15.8 42.1 42.1 4.3 Post 5 15 45 35 4.1 Pre 5.3 21.1 31.6 42.1 4.1 Post 5 10 35 50 4.3 21.1 57.9 21.1 4 5 5 45 45 4.3 Pre Post Giving options to an out-of-control individual can be dangerous. Disagree (2) Pre 5.3 47.4 36.8 5.3 5.3 2.6 Post 5 25 60 5 5 2.8 Pre 10.5 63.2 15.8 10.5 Post 25 50 25 2.3 2 TRAUMA INFORMED CARE IN JUVENILE DETENTION Re-traumatization can occur in both the community and in institutional settings. Re-traumatization can occur unintentionally. Classroom disruptions and/or behavior problems are related to trauma. For many residents, there are no alternatives to restraints and/or seclusions. Distrusting behavior is indicative of past traumatic experiences or adverse childhood experiences (ACEs). Stress can negatively impact residents cognitive and physical abilities. 55 Pre 15.8 73.7 10.5 3.9 Post 15 45 40 4.25 Pre 15.8 63.2 21.1 4.1 Post 15 45 40 4.24 26.3 63.2 10.5 Pre 2.8 Post 5 10 65 15 Pre 11.8 41.2 41.2 5.9 2.4 Post 5 50 35 10 2.5 5.3 42.1 42.1 10.5 3.6 Post 35 40 25 3.9 Pre 5.3 68.4 26.3 4.2 Post 15 40 45 4.3 Pre 5 3.05 TRAUMA INFORMED CARE IN JUVENILE DETENTION Giving a resident an ultimatum can effectively resolve an escalating situation. Residents can benefit from routines and rituals to support them during transitions or difficult time periods. Residents can benefit from opportunities for helpful participation, such as leadership or a designated job. Trauma affects physical, emotional, and mental wellbeing. For an individual who becomes quiet and withdrawn in response to stress, engaging in physical activity can be helpful. I believe that all residents should be treated the 56 Pre 10.5 26.3 42.1 21.1 2.7 Post 15 15 35 35 2.9 Pre 15.8 63.2 21.1 4.1 Post 10 40 50 4.4 Pre 5.3 73.7 21.1 4.2 Post 5 70 25 4.2 Pre 10.5 47.4 42.1 4.3 Post 20 30 50 4.3 52.6 26.3 40 40 20 3.8 10.5 10.5 15.8 2.5 21.1 Pre Post Pre 26.3 36.8 3.1 TRAUMA INFORMED CARE IN JUVENILE DETENTION same, regardless of the individual resident and their behavior. Focusing on a residents negative actions is an effective approach to resolving a situation. Choosing an activity to do when a resident becomes upset can directly impact their ability to regulate their behavior. Experiences in the detention center can be a trigger for residents who have experienced trauma. Getting involved in a strenuous physical activity makes a persons body feel calmer. Individuals are in control of their actions when they are upset. 57 Post 35 35 10 5 Pre 15.8 52.6 26.3 5.3 Post 20 40 30 5 Pre 5.3 42.1 52.6 Post 10 45 25 20 3.6 Pre 21.1 73.7 5.3 3.8 Post 20 50 30 4.1 5.6 33.3 50 11.1 3.7 5 3.4 Pre Post 5 5 40 45 Pre 21.1 47.4 21.1 10.5 Post 20 35 30 10 15 2.3 2.2 5 2.4 3.5 2.2 5 2.5 TRAUMA INFORMED CARE IN JUVENILE DETENTION Once a residents behavior escalates past a certain point, there is no choice but to restrain and/or seclude them. Engaging in an activity such as basketball or rapping can improve selfregulation skills. Exposure to trauma is common. Making decisions that consider both logic and emotion can be improved through physical activity. Constant stress can impact a persons ability to make new memories. A resident who already received a punishment (such as catwalk) should not be permitted to engage in recreation time. 58 15.8 36.8 42.1 5.3 3.4 5 30 45 25 3.8 5.3 52.6 36.8 5.3 3.4 25 60 15 3.9 5.3 31.6 47.4 10.5 3.5 Post 5 45 30 20 3.7 Pre 5.3 36.8 52.6 5.3 3.6 31.6 47.4 21.1 3.9 22.2 55.6 11.1 3.7 20 45 35 4.2 Pre Post 5 Pre Post Pre 5.3 Post 11.1 Pre Post Pre 10.5 26.3 36.8 15.8 10.5 2.9 Post 10 15 50 10 15 3.1 TRAUMA INFORMED CARE IN JUVENILE DETENTION Offering choices to a resident and respecting their decisions is an effective way to resolve a situation. Restraints and/or seclusions are the most effective way to control behavior. 59 Pre 26.3 73.7 Post 35 45 5.3 Pre 31.6 47.4 15.8 Post 25 50 25 3.7 20 3.9 1.9 2 TRAUMA INFORMED CARE IN JUVENILE DETENTION 60 Appendix D Pre-Post Survey Results for Eight Participants Strongly Disagree (1) Statement Substance use can be indicative of past traumatic experiences or adverse child experiences (ACEs). There is a connection between mental health and past traumatic experiences or adverse child experiences (ACEs). Listening to music can make a persons body feel calmer. Re-traumatization can occur in both the Agree (4) Strongly Agree (5) Average Degree of Agreement 12.5 25 62.5 4.5 Post 12.5 75 12.5 4 Pre 12.5 25 62.5 4.5 Post 12.5 50 37.5 4.3 75 25 4.3 50 37.5 4.1 Pre 12.5 Pre 12.5 Post Residents can use higher level thinking (such as cause and effect) when they become upset. Neutral (3) Pre Post Giving options to an out-of-control individual can be dangerous. Disagree (2) Pre Post Pre 12.5 50 25 25 75 62.5 12.5 75 25 12.5 12.5 2.4 2.8 12.5 2.3 2.3 75 12.5 4 TRAUMA INFORMED CARE IN JUVENILE DETENTION 61 community and in institutional settings. Re-traumatization can occur unintentionally. Classroom disruptions and/or behavior problems are related to trauma. Post 12.5 37.5 50 4.4 Pre 12.5 50 37.5 4.3 Post 12.5 37.5 50 4.4 75 12.5 3 87.5 12.5 3.1 37.5 37.5 12.5 2.5 62.5 25 12.5 2.5 Pre 37.5 37.5 25 3.9 Post 37.5 50 12.5 3.8 62.5 37.5 4.4 12.5 50 37.5 4.3 12.5 Pre Post For many residents, there are no alternatives to restraints and/or seclusions. Distrusting behavior is indicative of past traumatic experiences or adverse childhood experiences (ACEs). Stress can negatively impact residents cognitive and physical abilities. Pre Post 12.5 Pre Post Giving a resident an ultimatum can effectively resolve an escalating situation. Pre 37.5 37.5 25 2.9 Post 25 50 25 3 TRAUMA INFORMED CARE IN JUVENILE DETENTION Residents can benefit from routines and rituals to support them during transitions or difficult time periods. Residents can benefit from opportunities for helpful participation, such as leadership or a designated job. Trauma affects physical, emotional, and mental well-being. For an individual who becomes quiet and withdrawn in response to stress, engaging in physical activity can be helpful. I believe that all residents should be treated the same, regardless of the individual resident and their behavior. Focusing on a residents negative actions is an effective approach to resolving a situation. Choosing an activity to do when a resident becomes upset can 62 12.5 62.5 25 4.1 Post 62.5 37.5 4.4 Pre 87.5 12.5 4.1 Post 87.5 12.5 4.1 Pre Pre 12.5 50 37.5 4.3 Post 25 37.5 37.5 4.1 62.5 25 37.5 50 12.5 3.8 12.5 Pre Post 3.1 Pre 25 37.5 12.5 12.5 12.5 2.5 Post 25 37.5 12.5 12.5 12.5 2.5 Pre 25 50 25 2 62.5 37.5 2.4 Post Pre 37.5 62.5 3.6 TRAUMA INFORMED CARE IN JUVENILE DETENTION directly impact their ability to regulate their behavior. Experiences in the detention center can be a trigger for residents who have experienced trauma. Getting involved in a strenuous physical activity makes a persons body feel calmer. Individuals are in control of their actions when they are upset. Once a residents behavior escalates past a certain point, there is no choice but to restrain and/or seclude them. Engaging in an activity such as basketball or rapping can improve selfregulation skills. Exposure to trauma is common. 63 12.5 62.5 25 Pre 12.5 75 12.5 4 Post 25 62.5 12.5 3.9 Pre 37.5 37.5 25 3.9 Post 62.5 37.5 3.4 50 25 12.5 2.4 Post 50 37.5 12.5 2.6 Pre 12.5 37.5 37.5 12.5 3.5 Post 12.5 12.5 50 25 3.9 Pre 50 37.5 12.5 3.6 Post 12.5 87.5 Pre 12.5 62.5 25 4.1 Post 37.5 37.5 25 3.9 Post Pre 12.5 3.1 3.9 TRAUMA INFORMED CARE IN JUVENILE DETENTION Making decisions that consider both logic and emotion can be improved through physical activity. Constant stress can impact a persons ability to make new memories. A resident who already received a punishment (such as catwalk) should not be permitted to engage in recreation time. Offering choices to a resident and respecting their decisions is an effective way to resolve a situation. Restraints and/or seclusions are the most effective way to control behavior. 64 Pre 50 37.5 12.5 3.6 Post 37.5 37.5 25 3.8 Pre 25 50 25 4 Post 12.5 37.5 50 4.4 Pre 12.5 37.5 25 12.5 12.5 2.8 Post 12.5 12.5 50 12.5 12.5 3 Pre 12.5 87.5 Post 37.5 50 3.9 12.5 3.8 Pre 37.5 50 12.5 1.8 Post 25 75 25 2.3  ...

... Running Head: IMPACTS OF GROUP EXERCISE Developing a Group Exercise Program For Older Adults to Impact Social Participation Isabel Mazanowski University of Indianapolis IMPACTS OF GROUP EXERCISE Abstract Introduction: Social isolation and physical activity can impact the overall health of older adults. Researchers have found that there is a connection between social participation, loneliness, and activity levels in older adults. Thus, the purpose of this study is to examine whether a weekly group exercise program at Anytime Fitness can positively impact the social and mental health of older adults that are at risk for social isolation and loneliness.Method: Participants were seven men and nine women (Mean age 66.8) who participated in a seven-week group functional training program led by a Occupational Therapy Doctoral (OTD) Student. Participants completed pre- and post-assessment questionnaires that addressed social and mental health. Body fat percentage was measured prior and following the program to assess physical health. Results: There were positive changes between the pre- and post- assessment for 14 of the categories measuring social and mental health, however there were negative changes for three of the categories. There was one category that showed equally negative and positive changes. On average, participants improved in body fat percentage after the seven-weeks. All participants had positive feedback and reported high satisfaction toward the program. Discussion: Older adults benefit from a group exercise program because they are more motivated to regularly participate. A group exercise program can positively impact the social and mental health of older adults. Introduction As of 2018, around 49 million Americans were 65 years or older, and researchers predict the population size to grow to 98 million by 2060 (NCOA, 2018). The physical changes that accompany the aging process can lead to a decrease in endurance, dexterity, balance, and cardiovascular health for older adults can be combated with physical activity programs designed IMPACTS OF GROUP EXERCISE specifically for the older adult population (Bjorklund, 2014). Researchers have found that individuals with higher physical activity levels have lower mortality risks (Feldman et al., 2015). Despite the commonly known benefits of physical activity, an alarming majority of older adults do not meet the recommended amount of daily physical activity (McPhee, French, Jackson, Nazroo, Pendleton, & Degens, 2016). Individuals are motivated by social interaction and personal enjoyment to participate in sports or physical activities (Allender, Cowburn, & Foster, 2006). Older adults perception of their general health is strongly associated with their levels of social participation (Robins, Hill, Finch, Clemson, & Haines, 2018). Researchers have found that higher levels of social isolation and loneliness are correlated with decreased gait speed, and specifically loneliness is correlated with increased difficulty in performing activities of daily life (Shankar, McMunn, Demakakos, Hamer, & Steptoe, 2017). Health services that typically use a medical model approach can benefit from using the Lifespan Frame of Reference to address motivational drives for older adults (Cole & Tufano, 2008). Lifespan Frame of Reference focuses on how older adults cope with transitional roles, such as aging, death of a loved one, and retirement (Cole & Tufano, 2008). When older adults have a negative self-perception of aging and are unable to effectively transition through life, they have a higher risk for poor health and functional outcomes; intervening and addressing negative perceptions of aging can slow the decline in physical function (Sargent-Cox, Anstey, & Luszcz, 2012). Changing negative perceptions of aging can be done by providing support in transitional roles and facilitating older adults to participate in their environments at age-appropriate levels, such as physical activity (Cole & Tufano, 2008). Although older adults may understand the physical benefits of physical activity, health care practitioners need to focus on the areas outside the medical IMPACTS OF GROUP EXERCISE model, such as social participation and leisure activities which may motivate older adults to engage in the needed physical activity. (Cole & Tufano, 2008). Social Participation Social participation is a very important and meaningful occupation for older adults. Social support systems change for older adults throughout their lives for many reasons, such as retirement, illness, and deaths (Smith, Banting, Eime, OSullivan, Van Uffelen, 2017). A study identified the variables that distinguish lonely individuals, and the researchers found that lonely individuals reported having inadequate social systems, such as infrequent contact with friends, and reported having fewer supportive people in their lives (Wilson & Moulton, 2010). Socially isolated or lonely older adults are at higher risk for physical and mental conditions, such as chronic disease, falls, depression, cognitive decline, and mortality (Coyle & Dugan, 2012; Wilson & Moulton, 2010). Older adults perception of their general health is strongly associated with their levels of social isolation (Robins, Hill, Finch, Clemson, & Haines, 2018). Researchers have concluded that community-based interventions provide meaningful social participation for older adults (Smallfield & Molitor, 2018). When participating in group-based activities and when encouraged by health care providers, older adults are motivated to participate in physical activities and have higher self-efficacy for exercising (Mcphee, French, Jackson, Nazroo, Pendleton, & Degens, 2016). Researchers assessed social participation of physically active older adults and found by promoting the benefits of social participation in advance; the older adults were more likely to have higher levels of physical activity and a reduction of sedentary time (Kikuchi et al., 2017). Providing social participation benefits in the health services of older adults is essential to increase physical activity (Smith, Banting, Eime, OSullivan, Van Uffelen, 2017). Preferences for group programs, socializing with others, and encouragement and motivation from others were factors that researchers found IMPACTS OF GROUP EXERCISE promoted consistent participation in physical activity programs for older adults (Bethancourt, Rosenberg, Beatty, & Arterburn, 2014). Researchers found that to improve social participation, older adults biases towards fitness, fears toward abilities, and their identities must be addressed (Goll, Charlesworth, Scior, & Scott, 2015). Mental Health Social isolation impacts the mental health of individuals, but the two dimensions of isolation, subjective and objective, can have different effects on mental health. (Taylor, Taylor, Nguyen, & Chatters, 2016). Subjective isolation is commonly defined as loneliness and is the perception of whether or not someone feels isolated, whereas objective isolation is the quantifiable measure of social support, such as the size, type, frequency of contact, and amount of participation with their social network (Elder & Retrum, 2012). Researchers analyzed the different effects of subjective and objective isolation on the mental health of older adults and found that compared to objective isolation, subjective isolation from family and friends has higher correlations with an increase in depressive symptoms and psychological distress (Taylor, Taylor, Nguyen, & Chatters, 2016). Social participation plays a major role in cognitive functioning and successful aging (Bourassa, Memel, Woolverton, & Sbarra, 2017). When older adults participate in social activities, they are exposed to cognitively demanding environments; therefore, the social activities may act as a buffer for cognitive decline (Bourassa, Memel, Woolverton, & Sbarra, 2017). Bae, Ik, Ryu, & Heo (2017) conducted a study to analyze the impacts of physical activity on older adults and concluded that light exercise has a positive correlation with both the mental and physical health, overall well-being, and life satisfaction of older adults. Health Services IMPACTS OF GROUP EXERCISE Health care systems and government agencies are responsible for promoting physical activity but have not found a way for implementing regular exercise into the older adult population as a whole (McPhee, French, Jackson, Nazroo, Pendleton, & Degens, 2016). Older adults experience barriers that inhibit participation in physical activity programs. The barriers include feeling unfamiliar with the benefits of exercise, lack of motivating instructors, program criteria, unawareness about available programs, and programs not meeting the individuals goals and needs (Bethancourt, Rosenberg, Beatty, & Arterburn, 2014). By developing a physical activity program that incorporates social support for older adults, health care practitioners can improve physical activity in older adults (Smith, Banting, Eime, OSullivan, Van Uffelen, 2017). Health care practitioners need to increase older adults physical activity and exercise participation to a level that is beneficial for older adults (Taylor, 2014). Researchers found success in improving physical activity when health care practitioners provided older adults with detailed and individualized information for the adult to participate in exercise routinely (Taylor, 2014). There is a need in the healthcare system for practitioners to provide individualized recommendations about the type, amount, intensity, and frequency of physical activity to receive health benefits (Taylor, 2014). Researchers found that older adults desire to have health care professionals assist them with establishing a physical activity routine, setting realistic and age-appropriate goals, and tracking their progress (Bethancourt, Rosenberg, Beatty, & Arterburn, 2014). The older adult population needs greater support from the health care system and more client-centered, age-appropriate adjustments from practitioners to address physical activity programs for older adults (Bethancourt, Rosenberg, Beatty, & Arterburn, 2014). Researchers found that many older adults have negative thoughts associated with starting an exercise program, but they feel more positive about it once they have participated (Ruby, Dunn, IMPACTS OF GROUP EXERCISE Perrino, et al., 2011). Older adults are more likely to be motivated to participate in leisure exercise when they feel a sense of enjoyment related to the exercise (Haughton, Wyrwich, Brownson, Clark & Kreuter, 2006). Exercises and activities need to be age-appropriate and at a light intensity level for the older adults to receive benefits physically, mentally, and socially (Bae, Ik, Ryu, & Heo, 2017). By improving both the quality and quantity of social interaction for an older adult through an exercise program, the risk of depressive symptoms and psychological distress may decrease (Taylor, Taylor, Nguyen, & Chatters, 2016). Health care providers need to increase physical activity participation of older adults. Social isolation is correlated with poor health outcomes and it needs to be addressed for the growing older adult population. Addressing social isolation with group physical activity can help improve the aging process for older adults (Sargent-Cox, Anstey, & Luszcz, 2012). Social isolation and feelings of loneliness are under assessed conditions in older adults and are highly connected with poor overall health outcomes (Coyle & Dugan, 2012). With the pandemic of COVID-19, social isolation and loneliness are greater threats than ever before in the older adult population. Instead of the initial two weeks of quarantine, society has been faced with almost a year of social distancing and isolation, which intensifies social isolation and loneliness (Wang, Rabheru, Peisah, Reichman, & Ikeda, 2020). Due to limited interactions with friends and family, older adults have physical and mental health consequences that need to be addressed (Wang, Rabheru, Peisah, Reichman, & Ikeda, 2020; Panchal et al., 2020). Because of the correlation between physical activity and social isolation and loneliness, health professionals may be able to impact the mental and social health of older adults (Shankar, McMunn, Demakakos, Hamer, & Steptoe, 2017). A holistic health care practitioner with the resources and knowledge to provide client-centered services can influence older adults to regularly participate in physical activity by focusing on IMPACTS OF GROUP EXERCISE intrinsic motivation (Bethancourt, Rosenberg, Beatty, & Arterburn, 2014). Occupational therapists are qualified to provide client-centered interventions that implement routines of wellness into an individuals personal lifestyles in order to impact their social and mental health (Bethancourt, Rosenberg, Beatty, & Arterburn, 2014). By having an occupational therapy mindset, older adults client factors and environmental factors can be addressed in order to help them physically and mentally participate in a healthy exercise routine. Older adults are in need of exercise programs led by skilled health care professionals who can provide support, guidance, and follow-up appointments while conducting client-centered exercises (Bethancourt, Rosenberg, Beatty, & Arterburn, 2014). The purpose of this study is to examine whether a weekly group exercise program at Anytime Fitness can positively impact the social and mental health of older adults that are at risk for social isolation and loneliness. Needs assessments Methods The Occupational Therapy Doctoral (OTD) student (a certified personal trainer) met with the Anytime Fitness staff to converse about the needs at their club and their training program. Participants were recruited via word of mouth, club advertisement, social media, and Anytime Fitnesss communicating system. The recruiting information offered a free group exercise program for older adults led by an OTD student (a certified personal trainer) for seven weeks. Inclusion criteria consisted of being 60+ years of age, availability to complete pre- and post-interview, and the ability to participate 1x/week on average for the seven weeks. To obtain past medical history, physical activity level, and social and mental health information, a pre-assessment was conducted one to two weeks prior to the seven-week program beginning. Each initial interview lasted between IMPACTS OF GROUP EXERCISE 30 to 60 minutes. Details were documented via voice recording with verbal consent provided by interviewee. Results The Anytime Fitness owner and personal training manager expressed a need to expand their Ageless (50+ year old) program. The staff presented a desire to learn how to recruit older adults to the gym and clients in a training program that would benefit the older adults holistically. Members and clients of the club who were 60+ years old met with the OTD student to discuss their needs and desires from the club and a training program. All participants stated that they were interested in learning about challenging but age-appropriate exercises. Also, all older adult participants were looking for ways to incorporate a healthy exercise routine into their lives and how to improve their overall health. Program Methods Participants from Anytime Fitness were recruited by word of mouth, fliers, and social media advertising. There were 23 older adults (16 females and 7 males) who agreed to participate in the program. The ages of the participants ranged from 60 to 83 years old with the average age equaling 66.8 years. All participants ranged in physical activity level. Only 11 participants had been engaging weekly in physical activity in the club or in a personal training session and one participant regularly engaged in dance prior to the treatment. Ten participants reported not regularly engaging in physical activity inside or outside a gym. Only one participant was sedentary and required a rollator to mobilize. The group consisted of 16 retirees, five full-time workers, and two part-time workers. Marital status of the participants consisted of 14 married, five widowed, three divorced, and one single individual. IMPACTS OF GROUP EXERCISE All individuals participated in a group exercise program that focused on full-body functional training that incorporated mobility, stability, strength, and endurance (Refer Appendix A). The program design followed Anytime Fitness Ageless Program, which was developed by Dr. Dan Ritchie and Dr. Cody Sipe who co-founded the Functional Aging Institute in 2013 (Functional Aging Institute, 2013). FAI training programs focus on exercises that provide functional longevity by involving strength, aerobic health, balance, agility, mental acuity, and coordination for older adults (Functional Aging Institute, 2013). Group, circuit training provides a fun and social environment for older adults who have a wide range of functional and health levels (Sipe, nd). The hour-long sessions were formatted to include three to five minutes to socialize, five to 10 minutes of balance exercises, 30 40 minutes of functional exercises, and five to 10 minutes of cool down. The OTD student sought out participant feedback in regard to difficulty of exercises, music, format of workouts, and social factors. All participants completed an exit interview, which involved filling out a questionnaire consisting of the items from the initial questionnaire and questions in regard to program satisfaction and perceived social impacts. Results The program lasted seven weeks with three sessions a week (Monday, Wednesday, and Friday from noon to one oclock). Participants were required to attend at least one session per week. The program was located at the fitness club, Anytime Fitness Indianapolis/Fishers, and occurred on the purple functional training turf (18 ft x 37 ft). Every group session focused on full-body functional training, allowed for socializing before, during, and after every gathering, and incorporated balance training (Refer Appendix A).The training intensity was adjusted based on feedback from participants and each individuals physical fitness. Participants were encouraged to take frequent, necessary breaks and to modify exercises as needed and instructed. The certified IMPACTS OF GROUP EXERCISE trainer (the doctoral occupational therapy student) moved around the purple turf frequently checking on participants, modifying exercises, and adjusting exercise form. Feedback in regard to difficulty of exercises, music preferences, format of workouts, and social factors were sought out in order to enhance the experience for all participants. The group sizes varied as a result of participants weekly availability and drop-out over the course of the seven-week program. There were 16 remaining participants out of the original 23 participants at the end of the seven-week program. There were seven men and nine women participants at the end of the seven week program. The attrition rate occurred due to scheduling conflicts, injuries that occurred outside of the program, and concerns in regard to COVID protocol. Participants who were unable to attend one session per week were excluded from data gathering, but still welcomed to participate in the sessions. On average, participants attended 13.65 out of the 21 sessions throughout the seven-week program, which was equivalent to 1.95 sessions per week. Number of sessions attended by participants ranged from 7 to 21 sessions. Outcome Measures Methods Subjective and objective information was gathered from participants by the OTD student during pre- and post-assessment meetings. Pre-assessment meetings lasted from 30-60 minutes, which included education of the purpose behind the project, measuring body fat percentage, gathering written objective information, and asking open-ended questions to gather subjective information. Post-assessment meetings lasted 20-45 minutes in order to collect written objective information, reassess body fat percentage, and gather subjective program satisfaction reports. Data was analyzed using Google Forms. A Google Form was developed to mimic the questions asked on the questionnaire. After written and recorded information was obtained from participants, the IMPACTS OF GROUP EXERCISE occupational therapy student entered the information into the Google Form. The Google Form provided summary results for the pre-assessment and the post-assessment. The pre- and post-assessments were compared in order to analyze the changes in group results after completing the seven-week program. Social Health, Loneliness, Mental Health The questionnaire used for the pre- and post-assessments was influenced by mental health, social health, and quality of life scales found in literature. The social health aspect of the questionnaire was developed from questions on Friendship scale (Hawthorne, 2006), indicators from the NSHAP study (Cornwell & Waite, 2009), DeJong Gierveld Loneliness Scale (Gierveld & Tilburg, 2006), the Perceived Support Network Inventory (PSNI) (Oritt, Paul, & Behrman, 1985) and other measures of social isolation validated by researchers (Zavaleta et al., 2017). The mental health portion of the questionnaire was influenced by Patient Health Questionnaire (PHQ-9) (Kroenke et al., 2001) and Severity Measure for Generalized Anxiety Disorder (Lebeau et al., 2012). The first seven questions used a Likert scale of Every day, Most days, Few days, or Never. Five questions used a Liker scale of Very satisfied, Fairly satisfied, Not very satisfied, Not at all satisfied, or Dont know/No answer. The last seven questions used a Likert scale of Never, Occasionally, Half of the time, Most of the time, or All of the time. The questions used for qualitative measurements are as listed: 1. I feel lonely 2. I find it easy to make new friends 3. How often in the previous 4 weeks have you spent time with family 4. How often in the last 2 weeks have you met face to face with friends or family outside of your household IMPACTS OF GROUP EXERCISE 5. I often feel rejected 6. I miss having people around 7. I experience a general sense of emptiness 8. How satisfied or unsatisfied are you with your life overall 9. How satisfied or unsatisfied are you with your friends 10. How satisfied or unsatisfied are you with your family 11. How satisfied or unsatisfied are you with your neighborhood/town/community 12. How satisfied or unsatisfied are you with your spouse or partner 13. In the past 14 days, I have felt tense muscles, felt on edge or restless, or had trouble relaxing or trouble sleeping 14. In the past 14 days, I have avoided or did not approach or enter situations about which I worry 15. In the past 14 days, I have left situations early or participated only minimally due to worries 16. In the past 14 days, I have felt anxious worried or nervous 17. In the past 14 days, I have had little interest or pleasure in doing things 18. In the past 14 days, I have felt down, depressed, or hopeless 19. In the past 14 days, I have had trouble falling or staying asleep or sleeping too much Subjective Program Satisfaction. Program satisfaction was assessed through motivational interviewing and acquiring qualitative and subjective information from the participants during conversation. The interviewer obtained information by asking open ended questions. IMPACTS OF GROUP EXERCISE Tell me your thoughts toward the program. How did this program impact your social life? How satisfied were you with the program? What did you enjoy about the group program? What did you not enjoy about the group program? What would you change about the program? How were your relationships with the others in the program? What benefits did you gain from this group? Socially, mentally, and physically? Results Pre-assessment and post-assessment data were analyzed only for the participants that were able to attend at least one session a week. There were 16 participants who completed both the preand post- assessment. Quantitative Results By the completion of the seven-week program, there was an average total loss of 0.61% body fat percentage by the group of participants. There were positive changes in how participants responded to the items: I find it easy to make new friends (Figures 3 & 4), How often in the last 2 weeks have you met face to face with friends or family outside of your household (Figures 7 & 8), I often feel rejected (Figures 9 & 10), I miss having people around (Figures 11 & 12), I experience a general sense of emptiness (Figures 13 & 14), How satisfied or unsatisfied are you with your life overall (Figures 15 & 16), How satisfied or unsatisfied are you with your friends (Figures 17 & 18), How satisfied or unsatisfied are you with your neighborhood/town/community (Figures 21 & 22), How satisfied or unsatisfied are you with your spouse or partner (Figures 23 & 24), In the past 14 days, I have had little interest or pleasure in doing things (Figures 33 & 34), IMPACTS OF GROUP EXERCISE In the past 14 days, I have felt down, depressed, or hopeless (Figures 35 & 36), and In the past 14 days, I have trouble falling or staying asleep or sleeping too (Figures 37 & 38). There were notable changes between pre and post test for the following items: In the past 14 days, I have avoided or did not approach or enter situations about which I worry (Figures 27 & 28) and In the past 14 days, I have left situations early or participated only minimally due to worries (Figures 29 & 30). There were changes in all items of the objective measures, except for the item In the past 14 days, I have felt anxious, worried, or nervous (Figures 31 & 32), which stayed consistent between pre- and post- assessment. Although there were positive changes in most items, there was a negative change for the following items: I feel lonely (Figures 1 & 2), How often in the previous 4 weeks have you spent time with family (Figures 5 & 6), and How satisfied or unsatisfied are you with your family (Figures 19 & 20). There were both negative and positive changes in the item In the past 14 days, I have felt tense muscles, felt on edge or restless, or had trouble relaxing or trouble sleeping (Figures 25 & 26). Subjective Results Pre-Assessment. At the initial assessment, 10 out of the 16 participants mentioned feeling isolated due to loss of a partner, moving, COVID-19 circumstances, or their lifestyle. Four participants mentioned they wished to have friends that participated in more physically active hobbies or leisure activities. Two participants reported being very satisfied with their life and friendships overall at the time of the initial assessment owing it to their outgoing personalities and optimistic outlooks. Five participants expressed great excitement toward participating in a group exercise program, however the remaining 11 participants seemed indifferent to a group setting. Four individuals stated a desire to engage in more hobbies and leisure activities with their significant IMPACTS OF GROUP EXERCISE others. Eight of the 16 participants were hesitant toward the exercise programs age appropriateness and impacts of past medical conditions. Post-Assessment. All participants reported loving or enjoying the group exercise program. Every individual commented on either their shock at their lack of balance, the comradery while working on balance in a group, or the benefits of the balance exercises. Of the 16 participants, 13 participants specifically mentioned how encouraging working on balance was together because it affirmed that they were not the only one struggling. Two participants stated they had a hard time remembering the names of the individuals in the program and suggested there to be more time for group introductions during the sessions. Besides the date and time of the program, there were no suggested changes to the format of the program. Three participants mentioned they did not develop close friendships with other participants outside of the hour sessions, however they did enjoy seeing them weekly and at other times while at the club. Three participants mentioned a positive experience about running into each other at a store during an off day from the group sessions. Four participants commented on how beneficial and positive it was to regularly engage with a group of similarly aged individuals outside of their norm, such as churches or workplaces. The three couples who participated mentioned the satisfaction of engaging in the program with their spouse because it allowed them to regularly partake in an activity with each other. Two participants reported sleeping better at night on the days they participated in the group sessions. Discussion Previous research indicates the older adults are at risk for both social isolation and for participating minimally in physical activity, which are both highly correlated to poor health outcomes (McPhee et al., 2016; Coyle & Dugan, 2012). Community and group-based programs can provide meaningful social experiences and motivate older adults to participate in physical activities IMPACTS OF GROUP EXERCISE (Smallfield & Molitor, 2018; Mcphee et al., 2016). An area that needs further intervention is learning how to intertwin social participation with physical activity more appropriately for older adults, thus the purpose of this project. The information gathered from this project lined up with research in literature. For example, the participants reported enjoying the program because they were engaging in an activity with a group of similarly aged adults (Mcphee et al., 2016). Also, the participants stated they specifically enjoyed exercises, such as the balance training, because they were able to see that they were not the only person struggling, which helped them have a better perception of their own aging (Sargent-Cox, Anstey, & Luszcz, 2012). Similar to the findings of Haughton et al., (2006), most participants stated they were more motivated to attend every session because it gave them an activity to do outside of the home and they looked forward to participating with the same group of people. All participants reported the program exceeding their expectations whether they were initially excited before the first sessions or had no expectations at all, which lines up with researchers findings that older adults tend to feel more positive toward an exercise program after participating (Ruby, et al., 2011). Because the barriers, such as unfamiliarity with exercises, lack of personal instructors, program availability, and not addressing goals and needs, were tackled throughout the seven-week program, the participants reported the program as being age appropriate and engaging (Bethancourt, Rosenberg, Beatty, & Arterburn, 2014). Interestingly, there were noticeable improvements in most quantitative outcomes along with the subjective outcomes. Although the older adults verbally reported positive benefits from participating in the program, the subjective outcome item I feel lonely showed a negative change at the end of the program; however, other subjective isolation measurements demonstrated positive changes (Taylor, Taylor, IMPACTS OF GROUP EXERCISE Nguyen, & Chatters, 2016). In the future, this item can be broken down into smaller sections, for example, but not limited to, I feel lonely because I wish I had more friends, I feel lonely when I spend too much time by myself, or I feel lonely because I wish I had more things to do during the week. Another way to dissect that item further, instead of looking at the average changes of each item, each participants data of the items could be individually analyzed for changes. Even though there was a negative change on the item I feel lonely, all of the participants verbally reported during the motivational at the post-assessment that the program was a very meaningful and beneficial experience. Overall, all participants that committed to attending the sessions at least once a week reported and demonstrated positive social health, mental health, and physiological benefits. As predicted, there were many limitations that existed. First, participants were all made aware of the purpose of the project and could have engaged and interacted at high levels due to their biases. Second, limitation was that the quantitative outcomes may have been skewed due to the fact that COVID restrictions were loosening up because of the increase of vaccinations among the population, which would impact overall social and mental health. A third limitation is that the program occurred during the COVID pandemic, which has impacted many peoples social, mental, and physical health. Lastly, only the participants who committed to attending a session at least once a week were interviewed at the end, so the individuals who dropped out or attended less than once a week were not measured. This fact could impact the generalizability to all older adults. Despite the limitations, the findings from this project demonstrated how a group-based exercise program can benefit older adults both physically and mentally. Although the participants did not develop deep friendships after seven-weeks, the weekly social interactions motivated the older adults to engage in more physical activity. Older adults may benefit from the extra source of IMPACTS OF GROUP EXERCISE motivation to engage in physical activity, while fitness facilities may benefit from gaining a larger client population to serve. There are many reasons why this project is beneficial to the field of occupational therapy. One reason is that this demonstrated how a group-based program can impact the social health of older adults and provide meaningful social participation regularly. A program like this one can produce positive health outcomes for older adults such as increased activity tolerance, improved strength, and lower body fat percentages that can aid with better occupational performance. Occupational therapists can provide engaging, group-based balance training in exercise programs for older adults that can improve their functional mobility and balance at home and in their communities. Lastly, this is important for occupational therapy as a field because physical activity and exercise are hobbies and leisure activities that can either directly add meaning to ones life or aid with performance of meaningful activities that add purpose to ones life. Occupational therapists can help develop exercise programs in communal living spaces, nursing facilities, and fitness facilities that will benefit older adults physically, mentally, and socially. IMPACTS OF GROUP EXERCISE References Allender, S., Cowburn, G., & Foster, C. (2006). Understanding participation in sport and physical activity among children and adults: a review of qualitative studies. Health education research, 21(6), 826-835 Bae, W., Ik, S., Ryu, J., & Heo, J. (2017). Physical activity levels and well-being in older adults. Psychological Reports, 120(2), 192-205. doi:10.1177/0033294116688892 Bethancourt, H., Rosenberg, D. E., Beatty, T., & Arterburn, D. E. (2014). Barriers to and facilitators of physical activity program use among older adults. Clinical medicine & research, 12(1-2), 10-20. Bjorklund, B.R. (2014). Journey of adulthood (8th ed.). New York, NY: Pearson. ISBN: 9780205970759 Bourassa, K. J., Memel, M., Woolverton, C., & Sbarra, D. A. (2017). Social participation predicts cognitive functioning in aging adults over time: comparison with physical health, depression, and physical activity. Aging & mental health, 21(2), 133-146. Cole, M.B., & Tufano, R. (2008). Applied theories in occupational therapy: A practical approach. Thorofare, NJ: SLACK, Inc. Coyle, C. E., & Dugan, E. (2012). Social isolation, loneliness and health among older adults. Journal of aging and health, 24(8), 1346-1363. Cornwell, E. Y., & Waite, L. J. (2009). Measuring social isolation among older adults using multiple indicators from the NSHAP study. Journals of Gerontology Series B: Psychological Sciences and Social Sciences, 64(suppl_1), i38-i46. https://doi-org.ezproxy.uindy.edu/10.1093/geronb/gbp037 Elder, K. & Retrum, J. (2012). AARP foundation isolation framework report. Retrieved from IMPACTS OF GROUP EXERCISE aarpfoundation.org Feldman, D. I., Al-Mallah, M. H., Keteyian, S. J., Brawner, C. A., Feldman, T., Blumenthal, R. S., & Blaha, M. J. (2015). No evidence of an upper threshold for mortality benefit at high levels of cardiorespiratory fitness. Journal of the American College of Cardiology, 65(6), 629-630 Functional Aging Institute (2013). The Functional Aging Institute. Retrieved from https://functionalaginginstitute.com/about/ Gierveld, J. D. J., & Tilburg, T. V. (2006). A 6-item scale for overall, emotional, and social loneliness: Confirmatory tests on survey data. Research on aging, 28(5), 582-598. https://doi.org/10.1177/0164027506289723 Goll, J. C., Charlesworth, G., Scior, K., & Stott, J. (2015). Barriers to social participation among lonely older adults: the influence of social fears and identity. PloS one, 10(2). Haughton McNeill, L., Wyrwich, K. W., Brownson, R. C., Clark, E. M., & Kreuter, M. W. (2006). Individual, social environmental, and physical environmental influences on physical activity among black and white adults: a structural equation analysis. Annals of Behavioral Medicine, 31(1), 36-44. Hawthorne, G. (2006). Measuring social isolation in older adults: development and initial validation of the friendship scale. Social Indicators Research, 77(3), 521548. Hwang, T. J., Rabheru, K., Peisah, C., Reichman, W., & Ikeda, M. (2020). Loneliness and social isolation during the COVID-19 pandemic. International psychogeriatrics, 32(10), 12171220. https://doi.org/10.1017/S1041610220000988 Kikuchi, H., Inoue, S., Fukushima, N., Takamiya, T., Odagiri, Y., Ohya, Y., Amagasa, S., Oka, IMPACTS OF GROUP EXERCISE K., & Owen, N. (2017). Social participation among older adults not engaged in full- or part-time work is associated with more physical activity and less sedentary time. Geriatrics & Gerontology International, 17(11), 1921-1927. https://doi.org/10.1111/ggi.12995 Kroenke, K., Spitzer, R. L., & Williams, J. B. (2001). The PHQ-9: validity of a brief depression severity measure. Journal of general internal medicine, 16(9), 606613. https://doi.org/10.1046/j.1525-1497.2001.016009606.x Lebeau, R. T., Glenn, D. E., Hanover, L. N., BeesdoBaum, K., Wittchen, H. U., & Craske, M. G. (2012). A dimensional approach to measuring anxiety for DSM5. International Journal of Methods in Psychiatric Research, 21(4), 258-272. McPhee, J. S., French, D. P., Jackson, D., Nazroo, J., Pendleton, N., & Degens, H. (2016). Physical activity in older age: perspectives for healthy ageing and frailty. Biogerontology, 17(3), 567-580. National Council of Aging. (2018). Healthy Aging Fact Sheet. Arlington, VA: Retrieved from https://www.ncoa.org Oritt, E.J., Paul, S.C., Behrman, J.A. (1985). The perceived support network inventory. American Journal of Community Psychology. 13(5): 565-582. https://doi.org/10.1007/BF00923268 Panchal, N., Kamal, R., Orgera, K., Cox, C., Garfield, R., Hamel, L., & Chidambaram, P. (2020). The implications of COVID-19 for mental health and substance use. Kaiser family foundation. Robins, L. M., Hill, K. D., Finch, C., Clemson, L., & Haines, T. (2018). The association between physical activity and social isolation in community-dwelling older adults. Aging & mental health, 22(2), 175-182. IMPACTS OF GROUP EXERCISE Ruby, M. B., Dunn, E. W., Perrino, A., Gillis, R., & Viel, S. (2011). The invisible benefits of exercise. Health Psychology, 30(1), 67. Shankar, A., McMunn, A., Demakakos, P., Hamer, M., & Steptoe, A. (2017). Social isolation and loneliness: Prospective associations with functional status in older adults. Health psychology, 36(2), 179. Sipe, C (nd). Functional Circuits for Aging Clients [PowerPoint slides]. Smallfield, S., & Molitor, W. L. (2018). Occupational therapy interventions supporting social participation and leisure engagement for community-dwelling older: A systematic review. American Journal of Occupational Therapy, 72(4), 7204190020p1-7204190020p8. Smith, G. L., Banting, L., Eime, R., OSullivan, G., & Van Uffelen, J.G. (2017). The association between social support and physical activity in older adults: a systematic review. International Journal of Behavioral Nutrition and Physical Activity, 14(1), 56. Spitzer, R. L., Kroenke, K., Williams, J. B., & Lwe, B. (2006). A brief measure for assessing generalized anxiety disorder: the GAD-7. Archives of Internal Medicine, 166(10), 1092-1097. https://doi:10.1001/archinte.166.10.1092 Taylor, D. (2014). Physical activity is medicine for older adults. Postgraduate medical journal, 90(1059), 26-32. Taylor, H. O., Taylor, R. J., Nguyen, A. W., & Chatters, L. M. (2016). Social isolation, depression, and psychological distress among older adults. Journal of Aging and Health, 118. doi: 10.1177/0898264316673511 Wilson, C., & Moulton, B. (2010). Loneliness among older adults: A national survey of adults 45+. Washington, DC: AARP. Retrieved from https://assets.aarp.org/rgcenter/general/loneliness_2010.pdf IMPACTS OF GROUP EXERCISE Zavaleta, D., Samuel, K., & Mills, C. T. (2017). Measures of social isolation. Social Indicators Research, 131(1), 367-391. https://doi.org/10.1007/s11205-016-1252-2 IMPACTS OF GROUP EXERCISE Appendix A Workout Template Week 1 Day 1 Warmup/Balance Introduction with names and 1 fact about self SL standing w/ changing arm positions (each leg) Heel to toe standing (both legs leading) Circuit 1: Half of group 20 seconds on, 20 seconds off (6x) Bodyweight TRX rows Step Ups Circuit 2: Half of group 20 seconds on, 20 seconds off (6x) Bear Hug Medicine Ball Squats Alternating OHP Circuit 3: Full Group 30 seconds (3x each station) TRX push ups Lateral step ups Forward press Cool Down Triceps stretch Inner thigh stretch Hamstring stretch Oblique Stretch IMPACTS OF GROUP EXERCISE Week 1 Day 2 Warmup/Balance Name with place they were born or grew up Lateral stepping with single leg standing Forward and backward heel to toe walking *complete group circuit 3x, switch to next circuit and complete 3x - 30 seconds each* Group circuit: 1 TRX lunges Squat press unilateral Straight arm band pulls Oblique twist with ball Group circuit: 2 TRX flutters Banded lateral walks DB boxing KB DL Cool Down Arm circles Opening chest Hamstring stretch Week 1 Day 3 Warmup/Balance Alt knee to elbow standing crunches IMPACTS OF GROUP EXERCISE Alt overhead reach to standing crunch Heel to toe standing (both legs) Lunge standing (both legs) 1 large group circuit (20 sec, 20 seconds rest) 6x Small banded squats (reg or with chair) Bent over rows with large bands Forward reach with DB rotation SA planks TRX with shoulder abduction Single Leg step ups Cool Down Floor stretch Glutes Abductors Back Hamstrings Shoulder circles Week 2 Day 2 Warmup/Balance Split squat stance bring toe closer to heel every 15 seconds, changing head orientation (both legs) You Go, I Go Squats (1, 2, 3, , 8 reps) Circuit 1: 6 minutes (30 seconds each time) Squats with knee drive (modified with TRX) IMPACTS OF GROUP EXERCISE OHP with small bands above wrists Circuit 2: 6 minutes Rolling Weighted ball in squat KB farmers carry (resting on shoulders) Circuit 3: 6 minutes Shoulder tap planks (floor or bench) Band bicep curls Reviewing Form: squats and lunges Cool Down: Hamstrings Neck Shoulders Adductors Week 2 Day 2 Warmup/Balance Review names Windmill stretch Partner oblique twist ball passes Calf raises Eyes closed narrow stance Eyes closed narrow stance with alternating heel lifts Group Circuit - at your own pace Brace squat IMPACTS OF GROUP EXERCISE TRX rows Supine chest press Alt step ups Plank leg raises Stretching Cross body arm stretch Forearms Calves Week 2 Day 3 Warmup/Balance Tight rope walking on turf Floor and Standing Pelvic tilts In Your Own Space Circuit - Need 1 or 2 KB/DB Wood chops (10e) Curls (10) Side to side squats (10) SA rows (10e) Overhead Ext (10) Torso Twists (10e) Rev lunge with knee drive (10e) SA OHP (10e) Stretching Hamstring IMPACTS OF GROUP EXERCISE Forward reach Backward circles Week 3 Day 1 Warmup/Balance SL stances SL abduction 15 toe raises 15 arm circles forward, backward, OH reaches Group circuit (30 seconds on, 15 sec off - 3x) (20 sec, 15 - 1x) TRX Y pulls TRX rev lunges squat and press backward weighted arm circles KB sumo squats cable bicep curls Sphinx back extension side box runs Cool Down Tricep Rear delt Backward circles Chest opening - hands behind back 3x overhead reach to toe touch IMPACTS OF GROUP EXERCISE Week 3 Day 2 Warmup/Balance Internal/external shoulder rotation with 1 DB (3x, 10 reps) Split squat stance bringing toe closer to heel Superset Circuit - Switch with partners every 30 seconds 1. Swiss ball back extension 1. Squat and vertical toss 2. Straight arm raise overhead 2. Large banded squat 3. Bent over wallball bounce 3. Cable side to side steps 4. Tubing bent over rear delt row 4. Glute Bridge with abduction Cool Down Hip flexor in standing Oblique Cross body shoulder stretch Forward reach with arm circles Week 3 Day 3 Warmup/balance Tightrope walking Arm circles forward, backward, OHP At your own pace circuit IMPACTS OF GROUP EXERCISE Forward box runs Deadbugs Split squat oblique twists TRX push ups Squat and press Inward/outward bicep curls Cool Down IT stretch Hamstring Torso/oblique Week 4 Day 1 Warmup/Balance Marches Soldier toe touches High knees Under knee claps Shifting left to right with alt arm raises At Your Own Pace Circuit 1 (9 minutes) TRX MTN climbers (10e) Lat lunges (10e) tricep kickbacks (10e) At Your Own Pace Circuit 2 (9 minutes) TRX bicep curls (10) IMPACTS OF GROUP EXERCISE Hip mobility squat (10) Wood chops (10e) At Your Own Pace Circuit 3 (9 minutes) Slider Rev Lunges (10e) Around the world (10) Shoulder tap planks (10e) Cool Down Neck stretches Cross body shoulder Inner thigh and hamstring stretch Week 4 Day 2 Warmup/Balance SL standing - open and closed eyes TRX group rotating (30 sec, 2x) rows push ups In Your Own Space Circuit 1 (8 minutes) Overhead tricep ext Lat shoulder raise Weighted squat In Your Own Space Circuit 2 (8 minutes) Curl and press Bird dogs IMPACTS OF GROUP EXERCISE Straight leg DL In Your Own Space Circuit 3 (8 minutes) High knee Banded side to side steps DB boxing Week 4 Day 3 Warmup/Balance Eyes occluded standing SL standing Squats High knees Jumping jacks Straight leg toe touch At your Own Pace Circuit (10e) Ladders Squat ball rolls OHP w/ large band Lateral shoulder circles TRX rollouts Plank leg raises Chair hamstring walks Cool Down Hamstring stretch IMPACTS OF GROUP EXERCISE Cross body shoulder IT band Week 5 Day 1 Warmup/Balance Toe presses Alt SL toe presses High knees Soldier reaches Groups of 3 squatting ball passes At your own pace circuits by equipment Bands SL DL Hip Abduction Standing chest flies TRX Flutters Rows DBs Curl and press X squats Cool Down Seated stretching Straight back sitting IMPACTS OF GROUP EXERCISE Week 5 Day 2 Warmup/Balance Tightrope walking with 2 dumbbells Partner standing toe taps At your own pace circuit 1 (8min) DB boxing KB Figure 8s Tricep kickbacks At your own pace circuit 2 (8min) Side to side squats OHP Bicep curls At your own pace circuit 2 (8min) Forward press Weighted butt kicks Weighted jumping jacks Cooldown External rotation Backward circles Inner thighs Week 5 Day 3 Warmup/balance SL standing with other foot in front, lateral, behind IMPACTS OF GROUP EXERCISE Heel to toe stance 20 jumping jacks At own pace circuit (30 minutes) Ropes Alt kicking bosu ball SA cable row Ladders TRX bicep curls Seated hip abduction with bands Cool Down Low back stretch Standing oblique stretch Wide stance inner thighs and hamstrings Week 6 Day 1 Warmup/Balance Group partner ball passes (3-4 people) SL passes At Your Own Pace Circuit (10-15 reps each) Plate drives Plate curls SL side steps with bands Chair hamstring walks Banded rows IMPACTS OF GROUP EXERCISE Cool Down Hamstring Abductors Cross body shoulder Week 6 Day 2 Warmup/balance Ropes Ladders Back to back partner passes SL standing with different UB orientations At your own pace Cable forward reach Step ups Static lat lunges TRX chin up Side to side OHP SA OH extension Cool down Stretching outdoors Chest Calves Quads Week 6 Day 3 IMPACTS OF GROUP EXERCISE Warmup/Balance external rotation elbows up and down OH raises toe touch hamstring stretch standing oblique crunch Circuit (30 minutes) toe taps seated swiss ball ohp straight arm band pull downs bear hug squats lateral banded walks straight arms oblique twists Cool Down DB bicep curls DB tricep kick backs anchored back stretch Week 7 Day 1 Warmup/Balance Tight rope walking with DB forward backward grapevine tip toes IMPACTS OF GROUP EXERCISE At your own pace circuit (10-20 reps) Cable underhand row Lateral step ups Banded DL Banded jumping jacks Split squat unilateral OHP TRX bicep curls DB Bent Over Extensions Cool Down Standing hip flexor stretch Anchored low back stretch Week 7 Day 2 Warmup/Balance Alt marching Group ball passing - heels raised, one legged At Own Pace Circuit (10-20 reps) Calf raises on step (TRX) Rear delt straight arm pulls Small banded overhead reach Mtn climbers Swinging lunges/steps Unilateral elevated squat Cool Down IMPACTS OF GROUP EXERCISE Neck Upper back Shoulders Hamstrings Week 7 Day 3 Warmup/Balance SL standing Alt SL hops At your own pace circuit (5-15 reps) Ladders Ropes Wall ball bounces Toe taps TRX push ups Wood chops Cool Down Hands and knees stretching Hip flexor stretch Thoracic stretch Triceps IMPACTS OF GROUP EXERCISE Appendix B Pre-Assessment Questionnaire IMPACTS OF GROUP EXERCISE IMPACTS OF GROUP EXERCISE IMPACTS OF GROUP EXERCISE Appendix C IMPACTS OF GROUP EXERCISE Post-Assessment Questionnaire IMPACTS OF GROUP EXERCISE IMPACTS OF GROUP EXERCISE IMPACTS OF GROUP EXERCISE IMPACTS OF GROUP EXERCISE IMPACTS OF GROUP EXERCISE IMPACTS OF GROUP EXERCISE  ...

... 1 The Correlation Between Rehabilitation Intensity and Standardized Functional Performance Measures in Postacute Care Kroll 5 University of Indianapolis Dr. Christine Kroll, OTD, MS, Mary Grace Willis, BS, Elizabeth Gowen, BS, Colin Hauber, BS, Lauren Kelley, BS 2 Abstract Aims: This study aims to determine if a correlation exists between rehabilitation intensity, length of therapy, and standardized functional performance measures, derived from Section GG of the CARE Tool. Methods: This is a retrospective dataset analysis using descriptive and inferential statistical analysis for correlational research. The population is 943 Medicare Part A beneficiaries 65+ years of age sent to a SNF from an acute hospital stay with diagnoses of medically complex and total hip replacement. Results: Researchers used an ANOVA to determine if the change in assessment scores by levels could predict RI. Researchers found a significant correlation between the high levels of GSSC and RIOT, as well as a significant correlation between the high levels of GSMob and RIPT. Conclusions: Higher levels of therapy are correlated to increases in functional performance measure scores, indicating good support for higher levels of RI. Key Words: Medicare, Rehabilitation Intensity, Occupational Therapy, Physical Therapy, Functional Performance Measure, Section GG 3 Introduction Researchers discovered a limited amount of available research about the relationship between rehabilitation intensity volume compared to value of rehabilitation services in skilled nursing facilities. This gap in research is especially relevant due to changes in regulations that have impacted the amount of rehabilitation services provided within SNFs. With recent changes in Medicare regulation providing standardized data, further research is needed regarding the relationship between the rehabilitation intensity of occupational therapy (OT) and physical therapy (PT) services provided and the standardized functional performance measures across post-acute care settings. Healthcare reform in the United States began in 1965 with the passage of Medicare and began to increase steadily in 1997 with the passage of the Balanced Budget Act (BBA). An example of one of the changes in Medicare Part A reimbursement is the introduction of the Patient Driven Payment Model (PDPM) on October 1, 2019, as a replacement for the Resource Utilization Group Version IV (RUG-IV)1. The RUG reimbursement model used total rehabilitation minutes to determine reimbursement for clients receiving therapy services; whereas, the PDPM bases much of the reimbursement on client characteristics, including standardized functional performance measures. 2,3 Changes in reimbursement through the PDPM are in response to the Improving Medicare Post-Acute Care Transformation (IMPACT) Act of 2014. 4 Along with the changes in reimbursement due to the IMPACT Act, Centers for Medicare and Medicaid Services (CMS) created functional items and outcome performance measures that can be utilized by occupational therapists to justify that their services improve the health of clients in SNFs. 5 The Deficit Reduction Act (DRA) of 2005 focused on creating a standardized assessment to use in all postacute care settings, resulting in the Continuity Assessment Record 4 and Evaluation (CARE) tool. The PAC assessments include the Minimum Data Set (MDS) used in skilled nursing facilities (SNFs). The MDS requires healthcare providers to assess clinical conditions and submit standardized data. Since the CARE Tools development utilized item response theory (IRT) and Rasch analysis, each line item is reliable and valid and may be used independently of the entire item set. 6 Therefore, the self-care and mobility scales were taken from the CARE Tool and inserted into the PAC assessments, and named Section GG. The CARE Tool self-care and mobility items demonstrate how occupational therapists timing, intervention, and intensity add value for both the short and long-term health of clients in PAC. 7 This study used standardized functional performance measures from the self-care and mobility items included in Section GG. With the implementation of the PDPM, these standardized functional performance measures can directly impact reimbursement. Different post-acute care settings utilize the selfcare and mobility items in calculating the functional outcome measures for quality reporting programs within the comprehensive postacute care client assessments in the form of Section GG [Skilled Nursing Facilities (SNFs), Inpatient Rehabilitation Facilities (IRFs), Home Health (HH), and Long Term Care Hospitals (LTACH)]. The goal of including the standardized functional performance measures is to share meaningful client information between all four postacute care (PAC) settings by applying the Section GG items to each setting. The standardized functional outcome measures from Section GG are interdisciplinary; occupational therapy (OT), physical therapy (PT), and nursing are among the disciplines that may develop clients care plans by documenting data in the PAC assessments. However, the Center for Medicare and Medicaid Services (CMS) does not have specific regulations about who 5 is required to report this data. If occupational and physical therapists are not actively involved in the data collection process, there may be a lack of therapy input related to their services. Kroll and Fisher 8 found that correlating rehabilitation intensity with self-care and mobility items is possible when analyzing self-care and mobility data from the Section GG. In previous studies, researchers attempted to measure the correlation of self-care and mobility items with rehabilitation intensity using the Functional Independence Measure (FIM). 2, 9-12 The previous studies also reviewed data from PAC assessments; however, they lacked assessments with data sets standardized across the PAC settings. These studies commonly evaluate diagnostic categories to examine changes in types of medical populations. 2, 9-12 Researchers in this study used the diagnostic categories of medically complex and orthopedic hip to focus on differences in disparate types of clients by medical diagnostic groupings. OBrien & Zhang 3 found that among Medicare fee-for-service recipients in SNFs, higher-level rehabilitation intensity was associated with higher community discharge rates, while rates of hospitalizations and deaths increased when the level of rehabilitation intensity decreased. OBrien & Zhang 3 used discharge setting (community, hospitalization, permanent placement, and death) and length of therapy as reported on the MDS as their primary outcome measures. Understanding how rehabilitation intensity impacts standardized functional performance measures is vital to delivering effective, efficient care for our clients. The need to consider patients specific needs in determining their level of postacute care was further demonstrated by research by Hong et al. 13, finding that clients who have experienced a stroke and receive care at IRFs are associated with greater improvement in mobility and self-care, using the FIM mobility and self-care scales than clients who have experienced a stroke and receive care at SNFs. Another study by Rogers et al. 14 found that among patients with heart failure, pneumonia, or 6 acute myocardial infarction, the only specific service that demonstrated a decrease in readmission rates associated with an increase in spending was occupational therapy. Previous research investigated the relationship between functional outcomes and rehabilitation intensity in skilled nursing facilities (SNFs). 15 Researchers found the intensity of therapy services correlated with clients achieving higher scores on self-care items. The changes anticipated with the implementation of the PDPM may influence practitioners to focus more on client-centered care with reliable, functional status measurement. The PDPM influences the data relating to the relationship between functional outcome measures and rehabilitation intensity not found in Kroll and Fishers 15 original study. No standardized data across the postacute care (PAC) settings existed before the self-care and mobility items developed through the CARE tool. 6, 16-18 Cogan et al. 2 conducted research in which they found evidence to support a relationship between the length of therapy and therapy minutes on the outcome trajectory of individuals with hip replacements in IRFs and SNFs. Although Cogan et al. 2 completed their research prior to the implementation of the PDPM and did not utilize Section GG as an outcome measurement, their findings support this current studys design and reasoning. This current study can also explore any differences that the implementation of the PDPM and use of Section GG items may impact the relationship found in Cogan et al. 2 With this research, we plan to identify any potential relationship between the SNFs rehabilitation intensity and changes in the standardized functional performance measures derived from Section GG. This study used one year of data following the implementation of the PDPM, and the last six months were notably during the COVID-19 pandemic. Overall SNF admissions decreased after the onset of the COVID-19 pandemic in March of 2020. 19 Purpose Statement 7 The purpose of this paper is to identify possible relationships among the rehabilitation intensity the skilled nursing facility (SNF) provides, the standardized functional performance measures, and length of therapy (LOT) using the standardized data from Section GG. In addition, the influence of the following covariables is considered as well: medical diagnostic categories, change in reimbursement, and the COVID-19 pandemic. Methods Researchers obtained data from the electronic records of a rehabilitation therapy company that collects data from 90 SNFs in Indiana and Kentucky. The researchers obtained two separate sets of data; the first set was recorded between October 1st, 2019 to April 31st, 2020, and the second set of data was recorded from May 1st, 2020, to September 31st, 2020. Each section of data includes data for clients admitted and discharged within the frame of the dates in which data was collected. The data set included Section GG item scores for self-care and mobility recorded by occupational therapists and physical therapists. The data set does not include personal health information from the clients to ensure anonymity. Each participant has a client number assigned to them to assist with data organization but does not link back to any personal information. Researchers reformatted the data to per-column scores for each item from Section GG prior to transferring it to IBM SPSS Statistics 26 for analysis. Inclusion criteria for data is Medicare Part A beneficiaries over the age of 65 sent to a SNF directly from an acute hospital stay. Additionally, the data includes two diagnostic categories: total hip replacements and medically complex diagnoses. Exclusion criteria for data is Medicare Part A beneficiaries under 65 as those participants may create additional outliers to the data. Other payer systems such as Medicare Advantage were excluded as well because they may reimburse differently for SNF stays and might influence the provision of therapy services. 20 8 The researchers excluded incomplete or misreported client data such as scores outside of the 0-6 range, clients with duplicated scores, clients with less than 60 therapy minutes indicating only an evaluation was completed, or scores which were marked as 0 indicating that the item was not tested. Clients with a length of therapy over 100 days were also excluded due to Medicare only covering the first 100 days of stay. The original number of clients was 997 but was reduced to 943 after exclusions. Researchers included each of the 943 clients data in part or all of the analyses, but N values varied depending upon the recorded data available as shown in Table 1. The researchers ran descriptive and inferential analyses of the data. The researchers ran normality plots to assess the distribution of variables and used Log10 transfers to best normalize the distributions. The researchers created models using varying N values based upon the recorded demographics as shown in Table 1. The researchers ran an initial linear regression model using rehabilitation intensity (RI) of OT to predict change in self-care assessment scores and RI of PT to predict change in mobility assessment scores. The researchers used correlational, linearity, and post-hoc assessments to test the validity of the model. After completing the primary analysis, the researchers created categorical groups of the RI for OT, RI for PT, change in self-care assessment scores, and change in mobility assessment scores. The researchers created the groups using the 33, 67, and 100 percentiles of each variable to create a low, medium, and high category for each variable. The researchers borrowed the method from a previous article which used the categorical variables approach to determine correlations between length of stay and recovery outcomes. 2 The researchers used an analysis of variance (ANOVA) to look for correlations between the categorical groups to determine if RI of OT by low, medium, or high level could predict change in self-care assessment scores. The same was done with RI of PT and 9 change in mobility assessment scores. The researchers also reversed the process to determine if low, medium, or high level of change in assessment scores could predict RI level for OT and PT. Results The final collected data included 997 total clients. Researchers excluded 1 participant for having a length of treatment (LOT) over 100 days, indicating the reimbursement method was no longer Medicare Part A. Researchers excluded 1 participant because they had 0 minutes of OT and PT therapy. Researchers excluded 32 clients under the age of 65 and excluded 20 duplicates leaving a final total N of 943 clients. The average age of clients was 80.9 years with a standard deviation of 0.44 years. The data had 8 clients with no recorded age. The average LOT for OT clients was 23 days with a standard deviation of 16.2 days, and the average LOT for PT clients was 23.4 days with a standard deviation of 16.6 days. The data included 21 clients with no information about LOT as shown in Table 1. The average OT client received 854 total minutes of therapy with a standard deviation of 21 minutes, and the average PT client received 933 total minutes of therapy with a standard deviation of 22.5 minutes. Researchers calculated rehabilitation intensity (RI) by dividing the total minutes of therapy by the LOT. The rehabilitation intensity for OT clients (RIOT) and the rehabilitation intensity for PT clients (RIPT) was the primary independent variable for the analysis. Healthcare practitioners recorded results of the assessment tools during the first three days upon admission and the last three days before discharge; the dependent variable is the change between the scores at admission and discharge. The primary linear regression models test for the correlation between RIPT and change in mobility assessment scores and RIOT and change in self-care assessment scores. Average RIOT 40.53 minutes per day and average RIPT 43.50 minutes per day. 10 Researchers tested for normal distribution of the variables to determine if the proper assumption were met before running the regression models. The data for LOT, therapy minutes for OT, therapy minutes for PT, and RI was not normally distributed. The data was right skewed and had a strong positive skewness. Researchers corrected the data by transforming the data with Log10 transfers. The RI had the strongest positive skew and was not able to be corrected with Log10 transfers or inverse transfers. The subsequent variables RIOT and RIPT were not normally distributed due to the affect from RI. The variables did not meet the assumption of normal distribution to create a linear regression model. Researchers created the model to test other assumptions and determine the viability of the model. The first linear regression model created correlated RIOT and self-care assessment change in scores. RIOT was significantly correlated with change in self-care score with a p-value of 0.002. The RIOT variable was not significantly correlated with any other variables including gender, age, or diagnosis. The linearity of the model was significant but weakly correlated. The Durbin-Watson score was 2.016 which indicates the model is viable, but the R squared value was 0.069 which indicates a small amount of variance is explained by the model. None of the predictor variables had strong significance. The second model correlated RIPT and mobility assessment change in scores. RIPT was not significantly correlated to change in mobility score with a p-value of 0.107. The RIPT variable was not correlated with any other variables including gender, age, or diagnosis. The linearity of the model was not significant and had a curvilinear shape. The Durbin-Watson score was 1.884 which indicates the model is viable, but the R squared value was 0.089 which indicates a small amount of variance is explained by the model. The model failed the assumptions of linearity, correlation, and did not explain a large amount of variance. Researchers 11 recreated the model to include only clients with an ortho-hip diagnosis and the correlation score was not significant. After creating the models, researchers graphed the residuals for both models but did not have linearity and had weak correlation. The data did not meet standards of normality. The partial regression plots showed no significant correlation of variables for either model. Researchers created groups using the same analysis idea from Cogan et al. 2 The Rehab intensity for OT and PT were turned into three groups using the frequency function to separate the scores into equal thirds of low, medium and high scores using the 33rd, 67th and 100th percentiles as references for group start and end points. Researchers took the total change in score for the self-care assessment and divided by LOT to create the gain score self-care variable (GSSC). The same method was used to create the gain score mobility variable (GSMob). Then researchers created low, medium, and high groups for GSSC and GSMob by using their 33rd, 67th, and 100th percentiles. The low group is considered level 1; the medium group is considered level 2; and the high group is considered level 3. The researchers used an ANOVA to determine if change in assessment scores by low, medium, and high level could predict RI. The between groups p-value was 0.001 and was determined to be significant. Researchers used the Tamhane post-hoc test because the groups were not equivalent in size and determined significance between the groups. In the GSSC and RIOT ANOVA, levels 1 and 3, and 2 and 3 were determined significantly different, as shown in Table 2. In the GSMob and RIPT ANOVA, levels 1 and 3, and 2 and 3 were determined significantly different, as shown in Table 3. Researchers show the differences between RIOT level average minutes of therapy and GSSC level averages, and RIPT level average minutes of therapy and GSMob level averages in Table 4. The N value for GSSC, GSMob, RIOT, and RIPT 12 vary based upon available data for minutes of therapy collected and assessment tools administered as shown in Table 1. Discussion The purpose of this study was to address the need for further research regarding the relationship between the rehabilitation intensity of occupational therapy and physical therapy services provided and the standardized functional performance measures across post-acute care settings. Researchers found a significant correlation between the high levels of GSSC and RIOT, as seen in Table 2, as well as a significant correlation between the high levels of GSMob and RIPT, as seen in Table 3. The findings suggest that clients in GSSC and GSMob level 3, who had the highest change in functional performance measure scores per day, received the highest level of rehabilitation as shown in Table 4. The finding indicates that the highest level of therapy provided is correlated to larger gains in functional performance measure scores which indicates good support for both OT and PT interventions at the higher levels of rehabilitation intensity. The correlation between RI and functional performance score changes only existed at the highest levels of RI, which is why the correlation was not as significant in the linear regression that used the entire data set. The finding indicates a higher level of therapy intensity could lead to larger increases in functional performance measure scores. As shown in OBrien & Zhang3, 60 minutes or more of therapy a day is the threshold for greater outcomes with an increase in community discharges and a decrease in the risk of hospitalizations and death. During the initial analysis using linear regressions, the RI was not normally distributed, but the linear regressions were still completed. The linear regression for RIOT and self-care score changes was statistically significant, indicating that a correlation did exist; however, the 13 variance, post-hoc tests, and predictor variables were too inconclusive to deem the regression significant to the research findings. Under the PDPM, therapy provisions changed from set levels of therapy to a clientcentered care model that focuses on client outcomes. Research completed by CMS indicated a decline in the amount of therapy minutes provided after the implementation of the PDPM, going from an average of 91 minutes per client per day in 2019 to an average of 62 minutes per day in 2020. 21 During the research, findings indicated a small deviation of therapy minutes for both OT and PT across the 943 clients, even though our research suggests that high levels of RI indicate larger increases in function performance measure scores. The narrow window of therapy minutes from 27.63 minutes to 60.87 minutes for both OT and PT could be a result from the functional performance measures not being sensitive enough to the therapy provided. Another possible explanation for the reduction in therapy provision under the PDPM could be a decrease in therapy staffing, as the national total therapy staffing in SNFs decreased by 5.5% immediately after implementation of the PDPM. 22 Additional research should be conducted to assess the sensitivity of the measure to directly reflect the therapy provided. Cogen et al. 2 found that high and medium groups for therapy minutes received per length of stay were significantly correlated to better outcomes but only explained 1% of the variance under the regression model. The article also suggests that longer LOT for medium therapy groups would achieve similar results as high therapy groups with shorter LOT. Similar studies that were conducted collected and analyzed data on clients that were discharged from therapy. 3, 14 These studies also found that clients who received higher therapy minutes had increased discharge rates, further explaining why we chose this research. 3, 14 14 Additionally, the researchers collected the second set of data from 5/1/2020 to 9/31/2020 during the COVID-19 pandemic. The initial 6-month data set before the pandemic included 578 clients and the second data set included 365 clients from the same SNFs. There was a 38% decrease in client data provided. The dramatic change in client data and facility changes during the COVID-19 pandemic could be a limitation to the data analysis due to the sudden and comprehensive changes in the facilities. Another limitation of the study could be the diagnoses selected for data collection. The medically complex diagnosis comprised 81% of the data but does not directly state the reason the client is receiving therapy. The limited disparity between diagnostic categories could affect the comparison between medical diagnostic groupings. Additionally, IRFs have better discharge rates than SNFs for clients who had a stroke. 13 The data collection came exclusively from SNFs and might not be a reflection of RI and change in functional performance measure scores across PAC settings as a whole. Another limitation within the dataset was the lack of further demographic and comorbidity information on the clients. Researchers identified several areas for potential further research throughout this study, including a need for research investigating the difference in the variance of therapy minutes provided under the RUG system as opposed to therapy minutes provided under the PDPM. Another topic that requires further study is the sensitivity of the functional standardized performance measures from Section GG in relation to therapy minutes provided. This study identified a correlation between rehabilitation intensity and standardized functional performance measures, but further research is needed to identify missing variables that can helpfully explain the correlation. This study was also limited to exclusively SNFs; further research may benefit from a national Medicare reporting analysis that includes all PAC settings. 15 Conclusion Researchers found a significant correlation between the high levels of GSSC and RIOT, as well as a significant correlation between the high levels of GSMob and RIPT. The findings suggest that clients in GSSC and GSMob level 3, who had the highest change in functional performance measure scores per day, received the highest level of rehabilitation intensity. The finding indicates that the highest level of therapy provided is correlated to larger gains in functional performance measure scores which indicates good support for both OT and PT interventions at the higher levels of rehabilitation intensity. Further research is needed in order to quantify the findings of this study. Disclosure of Interest The authors report no conflict of interest. 16 References 1. The Medicare Patient-Driven Payment Model (PDPM): Changes to the skilled nursing facility payment system. https://www.asha.org/Practice/reimbursement/medicare/Medicare-Patient-DrivenPayment-Model/. 2. Cogan AM, Weaver JA, McHarg M, Leland NE, Davidson L, Mallinson T. Association of length of stay, recovery rate, and therapy time per day with functional outcomes after hip fracture surgery. JAMA Netw Open. 2020;3(1):e1919672. doi:10.1001/jamanetworkopen.2019.19672 3. OBrien SR, Zhang N. Association between therapy intensity and discharge outcomes in aged medicare skilled nursing facilities admissions. Arch Phys Med Rehabil. 2018;99(1):107115. doi:10.1016/j.apmr.2017.07.012 4. CMS adopts new SNF PPS Patient-Driven Payment Model (PDPM): Important highlights from the SNF PPS 2019 final rule. American Occupational Therapy Association. https://www.aota.org/Advocacy-Policy/Federal-RegAffairs/News/2018/CMS-SNF-PPS-Patient-Driven-Payment-Model.aspx. Accessed November 13, 2019. 5. Sandhu S, Furniss J, Metzler C. Using the new postacute care quality measures to demonstrate the value of occupational therapy. Am J Occup Ther. 2018;72(2):7202090010p1-7202090010p6. doi:10.5014/ajot.2018.722002 6. Gage B, Smith L, Ross J, Coots L, Kline T, Shamsuddin K, Deutsch A, Mallinson T, Reilly K, Abbate JH, Gage-Croll Z. The development and testing of the Continuity Assessment Record and Evaluation (CARE) item set: Final report on reliability testing 17 (RTI Project No. 0209853.004.002.008). Baltimore: Centers for Medicare & Medicaid Services, Office of Clinical Standards and Quality. Retrieved from https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/PostAcute-Care-Quality-Initiatives/CARE-Item-Set-and-B-CARE.html 7. DeJong G. Coming to terms with the IMPACT act of 2014. Am J Occup Ther. 2016;70(3):7003090010p1-7003090010p6. doi:10.5014/ajot.2016.703003 8. Kroll C, Fisher T. Justifying rehabilitation intensity through functional performance measures in postacute care. Am J Occup Ther. 2018;72(1):7201090010p17201090010p6. doi:10.5014/ajot.2018.721002 9. Cifu DX, Kreutzer JS, Kolakowsky-Hayner SA, Marwitz JH, Englander J. The relationship between therapy intensity and rehabilitative outcomes after traumatic brain injury: A multicenter analysis. Arch Phys Med Rehabil. 2003;84(10):14411448. doi:10.1016/S0003-9993(03)00272-7 10. Jette DU, Warren RL, Wirtalla C. The relation between therapy intensity and outcomes of rehabilitation in skilled nursing facilities. Arch Phys Med Rehabil. 2005;86(3):373379. doi:10.1016/j.apmr.2004.10.018 11. Joy Karges SS. A description of the outcomes, frequency, duration, and intensity of occupational, physical, and speech therapy in inpatient stroke rehabilitation. J Allied Health. 2009;38(1):10. 12. Thompson JN, Majumdar J, Sheldrick R, Morcos F. Acute neurorehabilitation versus treatment as usual. Br J Neurosurg. 2013;27(1):2429. doi:10.3109/02688697.2012.714818 18 13. Hong I, Goodwin JS, Reistetter TA, Kuo Y-F, Mallinson T, Karmarkar A, Lin Y-L, Ottenbacher KJ. Comparison of functional status improvements among patients with stroke receiving postacute care in inpatient rehabilitation vs skilled nursing facilities. JAMA Netw Open. 2019;2(12):e1916646. doi:10.1001/jamanetworkopen.2019.16646 14. Rogers AT, Bai G, Lavin RA, Anderson GF. Higher hospital spending on occupational therapy is associated with lower readmission rates. Med Care Res Rev. 2017;74(6):668 686. doi:10.1177/1077558716666981 15. Kroll C, Fisher T. The congressional mandate: Standardized post-acute care quality measures. Int J Ther Rehabil. 2019;26(8):110. doi:10.12968/ijtr.2019.0028 16. Jette A, Haley S. Contemporary measurement techniques for rehabilitation outcomes assessment. J Rehabil Med. 2005;37:339-345. doi:10.1080/16501970500302793 17. Li C-Y, Karmarkar A, Kuo Y-F, Mehta HB, Mallinson T, Haas A, Kumar A, Ottenbacher KJ. A comparison of three methods in categorizing functional status to predict hospital readmission across post-acute care. PLoS One. 2020;15(5):e0232017. doi:10.1371/journal.pone.0232017 18. Mallinson T, Deutsch A, Bateman J, Tseng H-Y, Manheim L, Almagor O, Heinemann AW. Comparison of discharge functional status after rehabilitation in skilled nursing, home health, and medical rehabilitation settings for patients after hip fracture repair. Arch Phys Med Rehabil. 2014;95(2):209217. doi:10.1016/j.apmr.2013.05.031 19. Barnett M, Hu L, Martin T, Grabowski D. Mortality, admissions, and patient census in 3 US cities during the COVID-19 pandemic. J Am Med Assoc. 2020;324(5):507-509. doi:10.1001/jama.2020.11642 19 20. Kumar A, Rahman M, Trivedi AN, Resnik L, Gozalo P, Mor V. Comparing post-acute rehabilitation use, length of stay, and outcomes experienced by Medicare fee-for-service and Medicare Advantage beneficiaries with hip fracture in the United States: A secondary analysis of administrative data. PLoS Med. 2018;15(6):114. doi:10.1371/journal.pmed.1002592 21. CMS confirms steep decline in therapy at nursing facilities. Center for Medicare Advocacy. May 6, 2021. Accessed December 6, 2021. https://medicareadvocacy.org/cms-confirms-steep-decline-in-therapy-at-nursingfacilities/ 22. Prusynski RA, Leland NE, Frogner BK, Leibbrand C, Mroz TM. Therapy staffing in skilled nursing facilities declined after implementation of the Patient-Driven Payment Model. J Am Med Dir Assoc. 2021;22(10):2201-2206. doi: 10.1016/j.jamda.2021.04.005  ...

... Safe Families for Children Doctoral Capstone Experience Kirby Jones, OTD 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 research advisor: Taylor McGann, MS, OTR, OTD, CEIM A Capstone Project Entitled Safe Families for Children Doctoral Capstone Experience 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 Kirby Jones, OTD 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 SFFC DCE 3 Abstract Topic: The purpose of this Doctoral Capstone Experience was to provide screening and education to individuals served at Safe Families for Children (SFFC) Central Indiana. Through trauma-informed care and interprofessional collaboration, occupational therapists can address behaviors related to exposure to trauma, impaired sensory processing, poor attachment, and delayed development. Occupational therapists working in this emerging practice area can increase access to services for individuals that may not qualify for traditional services. Method: Participants voluntarily requested services and attended educational sessions. I used the Occupational Therapy Referral Tool (OTRT) and Short Sensory Profile (SSP) to screen each child. Educational training sessions focused on the role of OT and the impact of sensory processing on behavior. I utilized a pre-post and satisfaction survey to assess caregiver and attendee education and satisfaction. Results: Four participants completed the OTRT; three of the four resulted in Recommended Referral. Five participants completed the SSP; three resulted in Probable Difference and two in Definite Difference. All families reported improved child behavior and understanding of sensory processing. Sixteen of 24 educational session attendees completed the surveys. All results improved from pre-to post-test with high satisfaction scores. Conclusions: Occupational therapists working in community programs can improve children and familys functioning. This DCE at SFFC can serve as a foundation for future occupational therapists establishing programming, education, or services for children in adoption, foster care, and voluntary programs. SFFC DCE 4 Safe Families for Children Doctoral Capstone Experience Introduction The American Occupational Therapy Association defined occupational therapy as therapeutic use of everyday activities with individuals or groups to improve participation in occupations, overall health, and quality of life (American Occupational Therapy Association [AOTA], 2014, p. S1). Working with children in the adoptive and foster care systems is an emerging practice area in occupational therapy (Lynch et al., 2017). Occupational therapists providing services to this population address client factors and skills that impact occupational performance, such as developmental milestones, self-regulation, sensory processing, mental health, routines and habits, and attachment with caregivers (Lynch et al., 2017). The purpose of my doctoral capstone experience (DCE) is to advocate for the role of occupational therapy in a community organization by developing programs that address the needs of the children and families served at Safe Families for Children. Safe Families for Children (SFFC) is a national nonprofit organization that utilizes volunteers to temporarily host at-risk children. At the same time, the biological parents secure safe housing, acquire a job, attend a rehabilitation program, or receive medical services (SFFC, 2020). This program is similar to the foster care system except without a government agency monitoring the family. SFFCs purpose is to prevent unsafe, abusive, or neglectful environments for the children and to reduce the number of children entering the foster and adoptive care system (SFFC, 2020). SFFC staff and volunteers provide high-quality support to the families and children. Still, additional occupational therapy services could further improve families and children's success by addressing problematic behaviors associated with exposure to trauma and sensory processing challenges. SFFC DCE 5 Literature Review Trauma refers to an event that an individual perceives as frightening, dangerous, or violent and threatens their physical body or life (National Child Traumatic Stress Network, n.d.). Parents that utilize SFFC services commonly struggle with homelessness, unemployment, domestic violence, incarceration, and drug use, which are all risk factors for exposure to trauma (SFFC, 2021). Many of these parents experienced trauma in their childhood, which may impact their decision making, parenting style, behavior, mental health, and attachment to their child, further emphasizing the need for trauma informed care services. SFFC is continually improving and implementing trauma-informed care (TIC), but additional programs focused on addressing the challenging behaviors associated with exposure to trauma could better assist volunteer host families, biological parents, and children. Children exposed to trauma often have increased social isolation, occupational deprivation, mental health conditions, delayed developmental skills, and behavioral changes such as flat affect, explosive anger, oppositional defiance, distracted attention, and negative self-talk (Crabill & Hanson, 2018; Fox & Kollodge, 2019; Fraser et al., 2019; Precin et al.,2010). These concerns negatively affect a childs ability to behave at home and in school appropriately, selfregulate their emotions, and complete simple daily occupations (Nesayan et al., 2018; Yochman & Pat-Horenczyk, 2019). Exposure to trauma impacts each individual differently, but a childs brain can be altered at the brainstem level due to exposure to trauma (Yochman & PatHorenczyk, 2019). This location in the brain is also where sensory processing occurs, leading to decreased self-regulation and increases the occurrence of sensory processing challenges (Crabill & Hanson, 2018; Fraser et al., 2019; Gurwticha, 2015; Simpson, 2016; May-Benson & Teasdale, 2019; Nesayan et al., 2018; Yochman & Pat-Horenczyk, 2019). SFFC DCE 6 Sensory processing is defined as how the brain perceives, organizes, and responds to sensations in the environment (Case-Smith & OBrien, 2015). Sensory input can come from tactile, olfactory, auditory, oral, gustatory, proprioceptive, vestibular, and interoceptive input (Case-Smith & OBrien, 2015). Sensory processing challenges impact individuals ability to appropriately respond to sensory stimuli, self-regulate, and functionally participate in meaningful occupations (Bailliard, 2015). Researchers describe sensory processing patterns in a variety of categories and classifications; essentially, hyperresponsive sensory processing causes individuals to feel intimidated or threatened by neutral sensory inputs, and hyporesponsive sensory processing causes individuals to require additional sensory input to feel regulated (Nesayan et al., 2018). Individuals who are hyperresponsive often present as easily stressed, anxious, or avoidant, whereas hyporesponsive individuals often present as hyperactive and easily distracted (Nesayan et al., 2018). Sensory processing challenges may receive a formal diagnosis, but many individuals exhibit problematic sensory behaviors without receiving a diagnosis or education on addressing their sensory needs (Bailliard, 2015; Case-Smith & OBrien, 2015; Yochman & PatHorenczyk, 2019). Caregivers may be unaware of how sensory behaviors are different than traditional childhood behaviors, and therefore how to appropriately provide the input the child needs versus utilizing traditional parenting methods to address a childs behaviors (Neseyan et al., 2018). Researchers found that problematic sensory behaviors are present in 51% of children exposed to trauma, compared to 8% of typically developing children (Yochman & Pat-Horencyzk, 2019). Behavioral challenges related to these issues increased the number of foster parents ending a foster placement (Crabill & Hanson, 2018). Miller-Kuhaneck and Watling (2018) reported foster parents desire to understand their childs sensory needs better, but do not feel current services SFFC DCE 7 and trainings are adequate. This reveals the need for improved education on and identification of exposure to trauma and presence of sensory behavior in children removed from their biological home. Occupational therapists are qualified to address the sensory processing challenges and problematic behaviors associated with exposure to trauma, along with traditional occupational areas of focus such as developmental delay, participation in play, parent child attachment, and engagement in occupations (Fraser et al., 2017, 2019). Occupational therapy theory guides high quality, evidence based therapeutic processes. Therapists working with this population relied on the sensory integration frame of reference to understand how individuals perceived sensory stimuli and influenced behavior (Case-Smith & OBrien, 2015). This bottom-up approach allowed therapists to focus on sensory modulation at the brainstem level with the use of regular and appropriate sensory exposure which improved a childs sensory processing, overall behavior, and self-regulation (Fraser et al., 2019). Therapists applied the Ecology of Human Performance (EHP) occupation-based model to consider the impact of a childs environmental context on their behaviors and task performance (Dunn et al., 1994; Fox & Kollodge, 2019). With the EHPs collaborative and interdisciplinary model, therapists viewed individuals performance and behaviors as dynamic, complex, and influenced by their environment (Dunn et al., 1994). The EHP model guided the development of the first occupational therapy-based screening tool for children in foster and adoptive care systems (Fox & Kollodge, 2019). The Occupational Therapy Referral Tool (OTRT) is a questionnaire that screens children in adoptive and foster care systems for developmental delay and need for occupational therapy services (Fox & Kollodge, 2019). Categories within the screening include psychosocial, cognitive, sensorimotor, functional performance of occupations, behaviors, social skills, physical abilities, SFFC DCE 8 and temporal development for children birth to 18 years old (Fox & Kollodge, 2019). The results of the OTRT determine major, minor, or no concern related to development, as well as the level of recommendation for referral to traditional occupational therapy services (Fox & Kollodge, 2019). With no occupational therapy-based, comprehensive standardized assessments for children in adoptive and foster care systems, this tool helps to initiate the evaluation of this populations unique variables of exposure to trauma, presence of sensory processing, developmental delay, and overall occupational performance. The Adverse Childhood Experiences (ACE) screening tool is the gold standard initial screening for determining the extent of childhood trauma (Schulman & Maul, 2019; Center for Disease Control and Prevention [CDC], 2020). Appropriately assessing exposure to trauma is an invaluable component of provided trauma-informed care and high quality of occupational therapy services to children that have been removed from their biological home (Crabill & Hanson, 2018). Due to the increase occurrence of sensory challenges in children with a history of trauma, it is also crucial for to occupational therapists to evaluate sensory processing to better understand the multiple factors impacting childrens performance (Yochman & Pat-Horenczyk, 2019). The Short Sensory Profile (SSP) questionnaire assesses sensory processing behaviors and determines the severity of sensory behaviors compared to typical behavior (McIntosh et al., 1999; Yochman & Pat-Horenczyk, 2019). Additional methods of evaluation, such as pre-post surveys and satisfaction ratings, are commonly utilized in community and group-based occupational therapy services (CDC, 2012; Whitman, n.d.). Satisfaction surveys and pre- and post-surveys provide evaluation of community programs and progress toward programs objectives (CDC, 2012; Whitman, n.d.). SFFC DCE 9 Evidence-based, occupational therapy interventions can simultaneously address exposure to trauma and sensory challenges of children in adoptive and foster care; improving the childs performance in age-related occupations, sensory processing, social participation, and overall function (Crabill & Hanson, 2018; Dunn et al., 2012; Fraser et al., 2017, 2019; Miller-Kuhaneck & Watling, 2018; Nesayan et al., 2018; Reynolds et al., 2017). Collaborative, family-based services focused on sensory education can: reduce negative behaviors related to exposure to trauma, improve the overall family dynamic, and increase childrens ability to self-regulate and complete age-appropriate occupations (Bailliard, 2015; Miller-Kuhaneck & Watling, 2018; Reynolds et al., 2017; Simpson, 2016; Yochman & Pat-Horenczyk, 2019). Occupational therapists working as consultants through community-based services can effectively address performance skills and performance patterns to improve childrens behaviors related to exposure to trauma and sensory processing, as well as overall participation in occupations (Crabill & Hanson, 2018; Dunn et al., 2012; Kugel et al., 2016; Precin, et al., 2010). Community-based occupational therapy services promoted awareness and education on the common challenges of children transitioning between caregivers, such as exposure to trauma and sensory challenges and improved childrens functional performance, quality of life, and caregiver confidence in addressing their childs needs (Crabill & Hanson, 2018; Fox & Kollodge, 2019). A sense of social support and understanding from others experiencing similar challenges was an added benefit of community-based programs (Precin et al., 2010). The literature review provided evidence-based information on the unique needs of children removed from their biological home and appropriate occupation therapy services. Safe Families for Children has supported families and children for decades, but occupational therapy services could further support the quality of life of the children and families served by providing SFFC DCE 10 trauma-informed sensory processing education and training. Through comprehensive screenings, caregiver education, and community programs, this doctoral capstone experience aims to improve childrens function in daily occupations, minimize the effects of trauma, and advocate for the role of occupational therapists at SFFC and related populations. Organizational Structure Methods The Central Indiana branch of Safe Families for Children (SFFC) includes the director, church engagement coordinator, two family coach supervisors, intake coordinator, and volunteer intake coordinator. The director oversees all organization components, establishes community partnerships, and pursues grant and fundraising opportunities. The church engagement coordinator facilitates the partnership between local church leadership and SFFC to recruit volunteers, provide support to host families, and financially support SFFC. The volunteer coordinator works to ensure all interested volunteers complete a thorough application process. Once approved volunteers are deemed a host family and can begin to host children. A parent requesting SFFCs services for their child to be temporarily hosted are referred to as a placing parent. The intake coordinator receives the request calls and arranges a placing parent, host families, and family coach. Family coaches serve as a mediator and resource for all individuals: ensuring the host familys needs are met and assisting the placing parent with making progress towards a more stable and safe life for their children. The family coach supervisors monitor all placements and support volunteer family coaches. Children served through SFFC Central Indiana range in all ages, cultures, abilities, and neighborhoods. Capstone Supervision Structure The church engagement coordinator also supervised this doctoral capstone experience. With a background in social work and three years of experience at the site, she was qualified to SFFC DCE 11 support my projects direction and give site-specific recommendations. We also met weekly with three social work interns to reflect and collaborate on our previous and upcoming week. Additional meetings with my supervisor were coordinated as needed to discuss specific components of my project. A professor at the University of Indianapolis with multiple years of experience in pediatrics and program development served as my faculty supervisor. Additionally, she supervised a DCE student last year at SFFC and was familiar with their organizational purpose and structure. Meetings with the faculty mentor occurred as needed to review course assignments and discuss my projects components specifically related to occupational therapy. Site Needs Assessment I completed preparatory courses and assignments, a thorough literature review, and a sitespecific needs assessment before and during the start of this DCE. Prior to beginning, I assessed the sites needs with my site supervisor and the SFFC Central Indiana director, which revealed themes of behavioral issues, exposure to trauma, and lack of parent and volunteer training and education. After the DCE began, I completed thirteen semi-structured interviews with key stakeholders to understand others perspectives of SFFC, experience with challenging behaviors, the potential value of parent education and training, and any other perceived needs or areas for improvement. The stakeholders included all staff members, specific volunteers with various volunteer positions and years of experience, and mothers who previously utilized SFFC services. My site supervisor recommended these individuals based on a history of timely communication, multiple experiences within SFFC, and openness to discussion. I voice recorded and transcribed each semi-structured interview to evaluate the responses. Key themes that emerged from these interviews included relationship with placing parents, personal growth and reflection, exposure SFFC DCE 12 to trauma and crises, differences in parenting, the definition of a successful hosting, challenging behaviors, and support for occupational therapy program within SFFC. Shadowing, supervision, staff meetings, and weekly Define, Evaluate, Articulate Learning (DEAL) model reflections aided in the creation and refinement of the project components. Shadowing each staff member increased my perspective of the role and responsibility within each part of the SFFC process. Supervision meetings with my site supervision and additional interns increased interdisciplinary discussion and reflection of project progression. Staff meetings allowed me to build rapport with staff members, promote an occupational therapy approach, and understand the ongoing changes of hostings. Weekly DEAL reflections and forum discussions with classmates also facilitated reflection on what I was learning, gain perspective from individuals outside of my site, and refine my project details. Project Components The traditional individual, group, and community-based occupational therapy services were not appropriate for this Doctoral Capstone Experience due to many placing parents being in crisis situations, complex family dynamics in hosting, and volunteer components of services at SFFC. Instead, two types of programming were implemented: informational training sessions to volunteers and parents and child-specific collaboration with placing parents and host parents. Additionally, I formally advocated for occupational therapys role within SFFC by creating electronic educational resources, videos, and instructional referral documents. Informal advocacy occurred through discussion at staff and intern meetings, during the training sessions, and when working with families. Informational Training Sessions SFFC DCE 13 The informational training sessions provided education on the role of occupational therapy, general sensory processing information, connection between exposure to trauma and sensory behaviors, the impact of sensory processing on behavior, how to begin identifying and addressing sensory needs, and additional occupational therapy services available to families. Three training sessions occurred for various populations at the site: family coach volunteers, host family volunteers, and past placing parents involved in an associated ministry program. Each session occurred over Zoom due to COVID-19 guidelines and to increase the ease of scheduling with individuals across central Indiana. The training sessions utilized a PowerPoint presentation, encouraged participation from attendees in order to promote learning, included time for questions and discussion, and ranged from 40 to 60 minutes total. I utilized a pre-and postmeasure to assess each participants progress toward the sessions objectives, and a satisfaction survey to determine satisfaction and suggested changes for future training sessions. The family coach training included seven participants; the host family training included eight participants; the past placing parent training included four past placing parents and five mentors attending the meeting. Child-Specific Collaboration Child-specific collaboration with placing parents and host parents occurred seven times throughout the capstone experience. This process is depicted in Figure 1. Collaboration with the child, host parent(s), and placing parent(s), social work interns, SFFC staff, and family coach volunteers improved the quality of the services, resources, and education provided. Pre- and post-surveys and a satisfaction survey were utilized with placing parents and host parents in order to determine progress toward objectives and satisfaction with the services provided. The OTRT, SSP, and ACE screening tools were utilized at the onset of the collaboration process to SFFC DCE 14 increase my understanding of the child, but not as an outcome measure for the impact of the program. Documentation was completed after all communication and interactions in order to log progress, updates, and plans for following visits. Each collaboration was highly client-centered and varied based on placing parents involvement, host family dynamics, and the childs performance and needs. Each step of the process was completed with respect to the individuals current availability and stressors. Complete Post-Survey and Satisfaction Survey with Host Parent(s) and Placing Parent(s) Initial Request for Consultation Approval from Placing Parent(s) Complete PreSurvey with Placing Parent(s) Follow-Up Education and Modifications Provide Education and Suggestions to Host Parent(s) and Placing Parent(s) Approval from Host Parent(s) Complete PreSurvey with Host Parent(s) Provide Results to Host Parent(s) and Placing Parent(s) Complete OTRT, SSP, and ACE with Placing Parent(s) Complete OTRT and SSP with Host Parent(s) Observe Child's Behavior and Interactions Figure 1: Child-Specific Collaboration Process Educational Resources The educational materials created for the sites website focused on occupational therapys scope of practice and value within SFFC, general sensory processing information, the connection of sensory processing and exposure to trauma, and general instructions for pursuing formal occupational therapy services. The resources were also referenced during my educational training sessions so that all hosting and placing parents can better understand the topics and receive appropriate services. A video covering these topics was integrated into the family coach SFFC DCE 15 and host family volunteer training materials. The PowerPoints from each training session was also uploaded to the website for all individuals to access, review, and utilize as needed. Results Child Specific Collaboration Results: Seven families utilized the occupational therapy programming offered through my DCE at SFFC, although each collaboration did not result in complete data collection, see Table 1. Caregivers may not have completed the screenings and surveys due to lack of interest from the caregiver, lack of time, or limited connection between the area of concern and screening topics. Participant numbers are consistent throughout all results, tables, and figures. Each participants area of need and education greatly varied, see Table 2. Participants 2 and 3 are the same individual with multiple caregiver scores due to multiple hostings during my DCE Table 1: Completion of Screenings Participant Gender Age 1 Female 9 2 Male 3 3 Male 3 4 Female 4 5 Male 11 6 Female 6 7 Male 14 OTRT Yes Yes Yes Yes No No No SSP Yes Yes Yes Yes Yes No No Pre Yes Yes Yes Yes Yes No No Post Yes Yes Yes No Yes No No Satisfaction Yes Yes Yes No Yes No No Table 2: Area of Concern and Education Participant Area of Concern 1 Behaviors, Mental Health 2 High Energy, Limited Speech 3 Limited functional play, poor sleep 4 Meltdown behaviors, poor focus 5 Frustration with school, poor focus 6 Defiance, poor behavior Education Focus Zones of Regulation, Sensory Strategies Heavy work, functional communication Sensory diet, sleep strategies Sensory diet, Zones of Regulation Sensory strategies for schoolwork Zones of Regulation SFFC DCE 7 16 Bedwetting Spinal Galant reflex integration OTRT The OTRT values and cut-off points are age-specific but generalize the need for occupational therapy regardless of age. Table 3 depicts each participants results. Figure 1 depicts the level of concern for all domains, and Figure 2 depicts the Level of Recommendation for skilled occupational therapy services based on the Overall score. These results indicated a minor delay in at least one domain and recommendation for occupational therapy services for 3 out of 4 participants. Table 3: OTRT Level of Concern Participant 1 Age 8.0-11.11 Person 21 Minor 65 Task 62 Minor 39 Context 31 Minor 27 Overall 114 Recommended 131 Figure 1: Level of Concern Major Minor No Concern 2 3.0-3.11 Minor 82 Minor 51 Minor 28 Recommended 161 3 3.0-3.11 None 85 Minor 79 Minor 38 Recommended 202 5 4-5.11 No No No No Concern Figure 2: Referral for OT Highly Recommended Recommended No Concerns SFFC DCE 17 SSP Table 4 depicts SSP results of each participant and a comparison of all responses for each domain is present in Figure 3. This comparison reveals no individual scored within Typical overall, but also that there is high variability in the sensory profiles of the individuals screened. Table 4: SSP Domain Scores Participant 1 2 3 4 5 Tactile Sensitivity Taste/Smell Sensitivity 17 13 D P 24 19 D T 35 19 T T 27 14 P P 28 18 P T Movement Sensitivity 13 T 15 T 15 T 7 D 15 T Under responsive/ Seeks Sensation 16 D 21 D 15 D 19 D 15 D Auditory Filtering 11 D 19 Low Energy/Weak 21 D 30 Visual Auditory 18 P 25 Sensitivity Total Score 109 D 153 Note: D = Definite, P = Probable, T = Typical D T 23 30 T T 20 16 P D 9 30 D T T 25 T 15 D 25 T P 162 P 118 D 140 P Figure 3: Comparison of SSP Domains Number of Occurences 5 4 3 2 1 0 Tactile Sensitivity Taste/Smell Sensitivity Movement Sensitivity Under responsive Definite Probable Auditory Filtering Typical Low Energy/Weak Visual Auditory Sensitivity Total Score SFFC DCE 18 Pre-Post and Satisfaction Survey The average pre-and post-results of the caregivers understanding of sensory processing and its relation to the child, see Figure 4. All values improved from pre- to post-survey. Figure 5 depicts the results of the pre-survey responses. This reveals a limited initial understanding of sensory processing and how it impacts childrens behavior. The averaged satisfaction survey scores, see Table 6, indicated agreement for Questions 1, 2, and 3 and disagreement on Question 4. The results for Question 4 may be lower than the other values due to poor wording. Upon reflection, Question 4 would have been more appropriate as an open-ended question and not satisfaction based. Figures 4 and 5 depict the questions in each survey. Figure 4: Average Pre-Post Survey Results 5-point Likert Scale 5 4 3 2 1 0 Question 1 Question 2 Pre Question 3 Question 4 Post 5-point LIkert Scale Figure 5: Pre-Survey Results 5 4 3 2 1 0 1 2 3 4 Question: Participant 1 Participant 2 Participant 3 Participant 4 Participant 5 SFFC DCE 19 Figure 6: Average Satisfaction Survey Results 5-point Likert scale 5 4 3 2 1 0 1 2 3 4 Question Figure 7 Figure 8 Pre-Post Survey for Parents 1. I have a general understanding of sensory processing and how it can impact a childs behavior 2. I have a general understanding of my child/my host childs sensory processing needs and how to address them. 3. I have a general understanding of how to incorporate appropriate sensory strategies and activities into daily life 4. I have a general understanding of how to adjust my childs sensory strategies and activities based on their changing sensory needs and behaviors. Satisfaction Survey for Parents 1. The education and resources provided were helpful and increased my understanding of sensory processing and childrens behavior 2. My child/host childs behaviors improved after completing sensory strategies and activities 3. I was involved in the decision-making process and helped give ideas/feedback on which sensory strategies would be helpful and realistic 4. I have suggestions that may improve the process of OT related services regarding sensory processing Educational Training Sessions The three educational training sessions occurred within 10 days of one another (Thursday, Saturday, Saturday) with little variability between presentation slides, presentation approach, and overall length. Twenty-four participants attended the sessions; 21 completed the SFFC DCE 20 pre/post and satisfaction survey, and 16 fully completed all surveys. Resulting in a response rate of 66.67%. I converted the description-based scale of each survey into a numerical-based Likert scale for data analysis. The values included Strongly disagree, too short as 1, Disagree, a little too short as 2, Neutral, just right as 3, Agree, a little too long as 4, Strongly agree, too long as 5. I averaged the responses for each question to compare learning between sessions and overall satisfaction. Figures 9 and 10 depict the questions in each survey for the training session. The average results of the pre-post surveys, as seen in Figure 11, indicated an increased understanding of each question. The average satisfaction survey results see Figure 12, indicated at least a score of 4 (agree) with the exception of Question 4, which asked if the length of the session was too short (1), a little too short (2), just right (3), a little too long (4), or too long (5). All participants ranked this question as 3 with no variance. The overall satisfaction value averaged to 4.0875 on a 5point scale with a standard deviation of 0.573. Figure 9 1. I have a general understanding of how occupational therapists can work with a child 2. I have a general understanding of sensory processing and how it can impact a child's behavior 3. I have a general understanding of how to identify a childs sensory processing needs. 4. I have a general understanding of how to incorporate appropriate sensory strategies and activities for my child. 5. I have a general understanding of additional OT services and how to pursue these services. Figure 10 1. The information provided was relevant and related to my experience with Safe Families for Children. 2. The education provided was clear and increased my understanding of sensory processing and childrens behavior. 3. The resources provided were helpful and increased my understanding of sensory processing and childrens behavior. 4. The training session was an appropriate length of time. 5. I feel additional trainings should be provided on this topic. SFFC DCE 21 Figure 12: Average Satisfaction Survey from Training Session Figure 11: Average Pre-Post Survey from Training Sessions 5 4 5 3 4 2 3 1 2 0 1 2 3 Pre 4 5 Post 1 0 1 2 3 4 5 I compared the pre-survey, post survey, and satisfaction surveys independent of one another, see Table 5, to assess all participants scores and not only the responses of fully collected data. The pre-survey comparison resulted in the difference for each question from 0.010.13 and the standard deviation of 0.01 to 0.11, revealing no significant difference in averages. The post-survey comparison resulted in the difference for each question from 0.03-0.10 and the standard deviation of 0.02 to 0.07, revealing no significant difference in averages. The satisfaction survey comparison resulted in a difference for each question from 0-0.19 with the standard deviation of 0-0.13, revealing no significant difference in averages. These results support that no significant differences existed in the full data set for each question compared to the fully collected data of all three survey components. Table 5: Comparison of Full Data and All Responses Pre (n=16) Pre ONLY (n=20) Difference (only - data) Std Dev 3.5625 3.8125 2.90625 3.40625 3.1875 3.7 3.85 3.075 3.425 3.3 0.1375 0.0375 0.16875 0.01875 0.1125 0.09722718241 0.02651650429 0.1193242693 0.01325825215 0.07954951288 Post (n=16) Post- ONLY (n-21) Difference (only - data) Std Dev 4.625 4.571428571 -0.05357142857 0.03788072042 SFFC DCE 22 4.625 4.21875 4.21875 4.25 4.523809524 4.119047619 4.166666667 4.285714286 -0.1011904762 -0.09970238095 -0.05208333333 0.03571428571 0.07155247191 0.07050022967 0.03682847819 0.02525381361 Satisfaction (n=16) Satisfaction ONLY(n=21) Difference (only - data) Std Dev 4.6875 4.375 4.375 3 4 4.571428571 4.333333333 4.380952381 3 3.80952381 -0.1160714286 -0.04166666667 0.005952380952 0 -0.1904761905 0.08207489424 0.02946278255 0.004208968936 0 0.1346870059 I did not implement changes to the presentation based on the participants recommendations to maintain consistency. Recommendations included the use of a case study, examples or visual demonstrations of how to work with children on sensory strategies, presenting the material slower based on the audiences demographic and assumed educational level, and general appreciation and support for the training. I did not formally assess advocacy efforts. Throughout the interviews with stakeholders and the educational training sessions, individuals reported an increase in understanding of occupational therapy and how an occupational therapist could work with families through SFFC. I recorded the final training session and uploaded it to the Central Indiana SFFC website for volunteers, families, and parents to review at their leisure. Additionally, I created and uploaded educational materials on occupational therapists role, the impact of trauma on behavior, the basis of sensory processing, how sensory processing impacts behavior, and information regarding formal occupational therapy services. At the completion of the DCE, I provided an inservice to the staff to review the results of the interviews, the child-specific collaboration, the training sessions, the educational materials, and future opportunities for OT students to provide programming and support at SFFC. Discussion SFFC DCE 23 This DCE aimed to establish occupational therapy-based services at Safe Families for Children to address the needs of children, families, and volunteers. Through child-specific collaborations and educational training sessions for volunteers, host families, and past placing parents, I reduced the occurrence of maladaptive behaviors, improved understanding of the impacts of sensory processing on behaviors, and increased awareness of occupational therapy. I continued advocacy efforts during staff meetings, meetings with families, and online resources. Child-Specific Collaboration Throughout the initial program of working with children and their families, I consistently identified a need for brief, targeted occupational therapy services versus traditional, ongoing services. The OTRT results varied for each child, although three of four children's scores resulted in an overall Recommended Need for Referral. These three children also scored within the None to Minor Level of Concern for developmental skills related to person, task, and contexts. These findings support my initial programs structure of brief, targeted education and intervention. The childrens scores did not qualify for Major Level of Concern or Highly Recommended Need for Referral, which would indicate a need for more intensive, formal services. Based on the SSP, each childs total score resulted in a Definitive or Probable Difference in sensory processing, revealing the prevalence of children's sensory challenges in SFFC. This finding supports the program approach of caregiver education on sensory-based education for improved function, behavior, attention, and development. The families served through my DCE program may not qualify for traditional OT services, but the education provided improved functioning in all families. These families typically would not receive services due to no formal diagnosis, minor delays in function and developmental skills, and the caregivers lack of awareness of occupational therapy. Through the SFFC DCE 24 implementation of community-based programming, these families could access appropriate and necessary occupational therapy education and services before behaviors or delays became more significant, which reduced the need for more extensive and costly traditional, ongoing intervention. The services improved their childs ability to perform occupations in play and school, addressed sensory processing impacts, and increased overall family quality of life. The Adverse Childhood Experience (ACE) tool was not utilized as planned during childspecific collaborations based on additional insight of trauma-informed care guidelines and recommendations (Adepoju, 2020; Oey et al., 2019; Oral et al., 2016; Raja et al., 2015). Researchers consistently emphasize the importance of providing referrals and support following a trauma screening, and this was not within the scope of my DCE or my abilities as a student with limited TIC training (Adepoju, 2020; Oey et al., 2016; Raja et al., 2015). Raja et al. (2015) reported the absolute final component of providing trauma-informed care should be the decision to screen individuals, but that practitioners of all levels of training can utilize trauma-informed approaches to reduce anxiety and build rapport. Oral et al. (2016) stated additional screenings for resiliency, access to support, and previous interventions for trauma need to be completed with trauma-specific screenings. Further, multiple trauma-specific screening and assessment tools have been identified through research and selection of a tool requires extensive review and education, which was not within the scope of this DCE. The decision to remove the ACE tool from my screenings was based upon the updated literature findings, limited duration of time spent with individuals, minimal training on trauma-informed care, and lack of referral sources to appropriate address exposure to trauma. In place of the ACE tool, I utilized universal precautions of trauma-informed care throughout my communication, interactions, and education. Educational Training Sessions SFFC DCE 25 The educational training sessions served families and volunteers of Safe Families for Children. This DCE component focused on increasing awareness of the role of occupational therapy, general concepts on sensory processing, and initial sensory strategies to promote utilization of the child-specific collaboration program. On average, participants understanding of the objectives improved from pre-to post-test, revealing perceived learning on the topic. Participants averaged a satisfaction rating between Agree and Strongly Agree, and all participants reported the 30-minute length of the training was Just Right. The results supported the approach, presentation, and content covered in the sessions. Open-ended recommendations from participants included the use of a case study and visual demonstrations of sensory strategies. Limitations and Future Studies The program design included multiple limitations that limit the strength and generalizability to other populations and organizations. The small number of participants in the child-specific collaboration limits the type of children screened, the focus of education provided, and the results and responses from caregivers about the programming. Additional participants need to be integrated into the program before the impact and efficacy can truly be evaluated. The variability in needs and education provided also limits this study's strength and the ability of future practitioners to replicate the program. Most families' crisis situation also impacted caregivers availability to address the behavioral, sensory, and developmental needs of their child. The educational sessions also had a limited number of participants and completed surveys, narrowing narrows the results, recommendations, and overall reflection on the sessions. As an OT DCE student, I was limited in the extent of education and intervention I can ethically provide to families. Certified and licensed occupational therapists with continuing SFFC DCE 26 education on sensory processing and the impact of trauma would provide more targeted and beneficial recommendations to families. Also, SFFC does not have an occupational therapist on staff, so I could not quickly discuss occupational therapy-related ideas or concerns with a site supervisor. My faculty mentor was available via email or video conferencing but was not fully aware of the dynamics and variables of the families I was working with through SFFC. All of these components weakened my DCE programming and the extent of services for families. Future studies need to utilize a certified and licensed OT so families can receive the highest level of education and services. Practitioners and students also need to work to consistently incorporate placing or biological parents into the child-specific collaboration. Future studies also need to include more participants in both programming components to evaluate the results and impacts better. Improved evaluation methods for both components would also strengthen the results and impact of the programming. Conclusion This DCE effectively created OT-based programming and advocated for the professions role in the emerging practice area of foster and adoptive care. Although the DCE had limited participants, practitioners and students can utilize them as a foundation for future programs and advocacy efforts. Occupational therapists are equipped to provide families and children in foster and adoptive care trauma-informed evaluation and education to improve child behavior, child occupational performance, and family quality of life. Implications for Practice Practitioners and students can support children and families' success through communitybased services, reducing the need for formal services. SFFC DCE 27 Safe Families for Children and similar populations in formal adoptive and foster care systems can benefit from brief and targeted occupational therapy screening and education. One-time, brief OT-based educational trainings increase attendees understanding of OT and sensory processing. SFFC DCE 28 References Adepoju, A. (2020). Implementation of Trauma Informed Care in a Primary Care Setting Using the Adverse Childhood Experience as a Screening Tool. (Publication No. 209). [Doctoral dissertation, University of Massachusetts Amherst]. ScholarWorks@UMass Amherst. American Occupational Therapy Association. (2014). Occupational therapy practice framework: Domain and process (3rd ed.). American Journal of Occupational Therapy, 68(Suppl. 1), S1-S48. Bailliard, A. L. (2015). Habits of the sensory system and mental health: Understanding sensory dissonance. American Journal of Occupational Therapy, 69(4), 6904250020p16904250020p8. http://dx.doi.org/10.5014/ajot.2015.014977 Case-Smith, J., & OBrien, J.C. (2015). Occupational therapy for children and adolescents. (7th ed.). Elsevier Mosby. 259-267. Center for Disease Control and Prevention. (2012). Introduction to program evaluation for public health programs: A self-study guide. https://www.cdc.gov/eval/guide/step3/index.htm Center for Disease Control and Prevention. (2020). Adverse Childhood Experiences (ACEs). https://www.cdc.gov/violenceprevention/aces/index.html Crabill, C., & Hanson, K. (2018). A guide for occupational therapists: Utilizing trauma-informed care to guide intervention for children in foster care (Publication No. 378). [Masters scholarly project, University of North Dakota] UND Scholarly Commons: Occupational Therapy Capstones. Dunn, W., Brown, C., & McGuigan, A. (1994). The ecology of human performance: A framework for considering the effect of context. American Journal of Occupational Therapy, 48(7), 595-607. SFFC DCE 29 Dunn, W., Cox, J., Foster, L., Mische-Lawson, L., & Tanquary, J. (2012). Impact of a contextual intervention on child participation and parent competence among children with autism spectrum disorders: A pretestposttest repeated-measures design. American Journal of Occupational Therapy, 66(5), 520-528. http://dx.doi.org/10.5014/ajot.2012.004119 Fox, A., & Kollodge, E. (2019). An Occupational Therapy Referral Screening Tool for Children in Adoptive and Foster Care Placements (Publication No. 418) [Masters scholarly project, University of North Dakota] UND Scholarly Commons: Occupational Therapy Capstones. 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), 199-216. https://doi.org/10.1080/0164212X.2016.1265475 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), 317-338. https://doi.org/10.1080/0164212X.2019.1652132 Kugel, J., Hemberger, C., Krpalek, D., & Javaherian-Dysinger, H. (2016). Occupational therapy wellness program: Youth and parent perspectives. 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Parental or teacher education and coaching to support function and participation of children and youth with sensory processing and sensory integration challenges: A systematic review. American Journal of Occupational Therapy, 72(1), 7201190030p1-7201190030p11. http://doi.org/10.5014/ajot.2018.029017 National Child Traumatic Stress Network. (n.d.) What is a traumatic event? https://www.nctsn.org/print/765 Nesayan, A., Gandomani, R. A., Movallali, G., & Dunn, W. (2018). The relationship between sensory processing patterns and behavioral patterns in children, Journal of Occupational Therapy, Schools, & Early Intervention, 11(2), 124-132, http://doi.org/10.1080/19411243.2018.1432447 Oey, E., Tunningley, J., Brayman, T., Brokamp, K., & Lynch, B. (2019). Learning together in a community of practice to address pediatric trauma. OT Practice 24(8). 21-25. SFFC DCE 31 Oral, R., Ramirez, M., Coohey, C., Nakada, S., Walz, A., Kuntz, A., Benoit, J., & Peek-Asa, C. (2016). Adverse childhood experiences and trauma informed care: the future of health care. Pediatric research, 79(1), 227-233. http://doi.org/10.1038/pr.2015.197 Precin, P., Timque, J., & Walsh, A. (2010). A role for occupational therapy in foster care. Occupational Therapy in Mental Health, 26(2), 151-175. http://doi.org/10.1080/01642121003736085 Raja, S., Hasnain, M., Hoersch, M., Gove-Yin, S., & Rajagopalan, C. (2015). Trauma informed care in medicine. Family & community health, 38(3), 216-226. http://doi.org/10.1097/FCH.0000000000000071 Reynolds, S., Glennon, T. J., Ausderau, K., Bendixen, R. M., Kuhaneck, H. M., Pfeiffer, B., Watling, R., Wilkinson, K., & Bodison, S. C. (2017). Using a multifaceted approach to working with children who have differences in sensory processing and integration. American Journal of Occupational Therapy, 71(2), 7102360010p17102360010p10. http://doi.org/10.5014/ajot.2017.019281 Safe Families for Children. (2021, January 28). Safe Families for Children: Family Coach Training. [Prezi slides]. Safe Families for Children. Safe Families for Children. (2020). About us. https://safe-families.org/about/ Schulman, M., & Maul, A. (2019). Screening for adverse childhood experiences and trauma [PDF file]. https://www.chcs.org/media/TA-Tool-Screening-for-ACEs-andTrauma_020619.pdf Simpson, D. (2016). Examining the lived experiences of families who have adopted children and received occupational therapy services (Publication No. 426) [Masters thesis, Eastern Kentucky University]. Encompass Online Theses and Dissertations. SFFC DCE Whitman, A. (n.d.). Section 4: Rating member satisfaction. https://ctb.ku.edu/en/table-ofcontents/evaluate/evaluate-community-initiatives/member-satisfaction/main Yochman, A., & Pat-Horenczyk, R. (2019). Sensory modulation in children exposed to continuous traumatic stress. Journal of Child & Adolescent Trauma, 1-10. http://doi.org/10.1007/s40653-019-00254-4 32  ...

... Running head: SUPPORTING PARENTS AND CAREGIVERS AFTER A PEDIATRIC BURN INJURY Supporting Parents and Caregivers After a Pediatric Burn Injury Molly Johnson University of Indianapolis Supporting Parents and Caregivers After a Pediatric Burn Injury 2 Supporting Parents and Caregivers After a Pediatric Burn Injury Abstract Objective: To improve readiness and competence of facilitators implementing a support group to support parents and caregivers with children with burn injuries. Method: Semi-structured interviews completed for needs assessment with occupational therapist, burn clinic nurse, parents of children with burn injuries, and a child with burn injuries to create a Parent Support Group Guide. Likert Scale used to determine changes in participants readiness and competence after reviewing a Parent Support Group Guide. Results: Both participants had a total eight-point change in readiness and competence for facilitating a parent support group for children with burn injuries after reviewing the Parent Support Group Guide. Conclusion: The Parent Support Group Guide can be used to improve readiness and competence for potential facilitators interested in implementing a parent and caregiver support group for children with burn injuries. Keywords: Burn injuries, pediatrics, parent support groups, trauma, recovery Introduction Supporting Parents and Caregivers After a Pediatric Burn Injury 3 Parents of children with burn injuries experience many challenges throughout their childs treatment. Parents of children who have experienced trauma are at risk for enduring posttraumatic stress symptoms (Bakker, Maertens, Van Son, & Van Loey, 2013; Egberts et al., 2019; McGary, Girdler, McDonald, Valentine, Wood, & Elliot, 2013; Parrish et al., 2019). Symptoms may include isolation, PTSD symptoms, blame, distrust, anxiety, hopelessness, and more (Egberts et al., 2019; Heath et al., 2018; Lernevall, Moi, Cleary, Kornhaber, & Dreyer, 2020). Due to the traumatic experience of pediatric traumatic burns, roles of being a parent/caregiver and well-being of the parents are impacted (Egberts et al., 2019). According to McGarry et al. (2013), almost one in every four-experience increased anxiety, and one in every five experienced PTSD symptoms. According to Heath et al. (2018), discussing shared experiences after a traumatic burn injury are beneficial for parents and families. Parent participants in research studies have stated that talking to somebody with a shared experience are beneficial (Heath et al., 2018). Providing an opportunity for parents to share experiences with others who have been in a similar situation can assist with coping throughout the burn injury recovery journey. Literature Review Caregiver Risk Factors Both emotional and physical isolation are common themes after a childs burn injury (Heath, Williamson, Williams, & Harcourt, 2018). According to Alisic et al. (2012), some parents experience difficulty with attentiveness to their childs needs after a trauma. Some parents experience negative feelings about themselves and the world after the trauma (Egberts et Supporting Parents and Caregivers After a Pediatric Burn Injury 4 al., 2019). Parents of children with burns experienced a myriad of emotions including fear, sadness, anger, self-blame, and shock (Egberts et al., 2019; Lernevall, Moi, Cleary, Kornhaber, & Dreyer, 2020). Around their children, some parents suppressed emotions around the child, although many children recognized their parents anxiety or emotions (Alisic et al., 2012). Other difficulties parents experience included the physical pain of the child, feeling hopeless, time spent away from other children, residual scars, the emotional trauma of the child, impending surgeries, employment instability, and reoccurring medical appointments (Rimmer et al., 2015). Parents also may have difficulty understanding and remembering health information from professionals due to psychological symptoms after their childs accident. Barriers and Facilitators for Support Participants in Heath et al, (2018) described barriers to support included life balance with work and family, putting their needs last, lack of resources, the distance for services, time, finances, guilt, and avoiding re-living pain from the event. Hiding emotions around others was a theme in the study conducted by Alisic et al. (2012) to shelter their child during recovery. Other parents from the study stated they felt they were unable to disguise feelings and emotions, leading to unhealthy coping strategies. Parents in this study also found difficulty with being responsive to their childs needs after the incident (Alisic et al., 2012). Only 21% of parents of children with visible scars from a burn injury engaged in some psychological therapy after returning home from the hospital (Rimmer et al., 2015). Some parents found support from their clinicians in both formal and informal settings. Clinicians recommended continuing with daily routines, which was helpful while recovering (Alisic et al., 2012). According to Heath et al. Supporting Parents and Caregivers After a Pediatric Burn Injury 5 (2018), participants stated that informal and formal support was presented or offered. Support is offered to most families, but it is not always utilized. Support Group Effectiveness Parents reported that discussing the burn injury with people who have had a similar situation was helpful (Phillips, Fussell, & Rumsey, 2007). Parents of children with burn injuries often experience physical and emotional isolation, One participant in Heath et al. (2018) study described their experience as I felt like I was the only person that felt like thisYou feel like youre the only person it has ever happened to. (p. 5). Similarly, participants in Heath et al. have been beneficial. In the same study, interviewers specified parents thoughts on peer support. Participants stated peer support would be beneficial or was beneficial for those who participated in peer support (Heath et al., 2018). Parents of children with burn injuries also determined that addressing psychosocial health online would also be beneficial (Heath, Williamson, Williams, & Harcourt, 2019). Model Every parent of a child with a burn injury has a unique experience. The Canadian Model of Occupational Performance CMOP focuses on how an individual defines their self-care, leisure, and productivity performance (Cole & Tufano, 2008). The model includes the prioritization of occupations for a specific client (Cole & Tufano, 2008). The client-centered CMOP can be used to encourage collaboration between the therapist and the client by focusing on occupations and roles that are meaningful to the client (Cole & Tufano, 2008). Support groups focus on a population of people, but each individual has a unique experience. The model Supporting Parents and Caregivers After a Pediatric Burn Injury 6 increases individuality within a group session allowing each participant to share their unique experience. Ikiugu, et al (2017) focused on occupational therapy and mental health which is a risk factor for caregivers following trauma, using the CMOP-E within a group session. The researchers used the model to encourage participants to engage in occupations and sharing experiences of occupation within a group. The CMOP-E framework in a group can encourage a variety of sharing and experiences for members (Ikiugu et al., 2017). For the population of caregivers, this model is appropriate as it addresses needs that are specific to an individual from their perspective. Needs for this population could range from mental or physical health, finances, education, and others (Kirk & Glendinning, 1999; Thwala, Ntinda, & Hlanze, 2015). For the burn injury support group for parents, the use of the CMOP-E model will allow each member to address their unique difficulties in each occupation that they find difficult. Through sharing experiences and education on resources within the group, members will be able to reevaluate how the support group has addressed their specific needs. Educating Professionals Professionals are interested in facilitating the support group for parents of children with disabilities to have a new experience (Kapur, 2018). To facilitate learning, adult learners benefit from reflection of the material they have learned (Kapur, 2018). Providing feedback and educating professionals on purposeful things are both principles of learning (Kapur, 2018). Professionals who are motivated with diverse experiences enhance learning (Kapur, 2018). There are multiple teaching and learning strategies but using more than one will be most effective (Kapur, 2018). Providing handouts facilitates independent learning by allowing time for learners Supporting Parents and Caregivers After a Pediatric Burn Injury 7 to pace themselves through the material (Collins, 2004). Using handouts for adult learners can provide structure for teaching material as well (McCall, Padron, & Andrews, 2018). Conclusion After a burn injury, all parents have different needs and struggles. Symptoms following the burn injury can include anxiety, guilt, PTSD symptoms, hopelessness, and more (Egberts et al., 2019; Heath et al., 2018; Lernevall, Moi, Cleary, Kornhaber, & Dreyer, 2020). Support is commonly offered to families but is not always utilized (Heath et al., 2018; Rimmer et al., 2015). Barriers to receiving support include life balance with work and family, putting their needs last, lack of resources, the distance for services, time, finances, guilt, and avoiding re-living pain from the event (Heath et al., 2018). Treatment for burn injuries can last years depending on the severity. Parents of children with burn injuries benefit from talking to others who share a similar experience (Heath et al., 2018; Phillips, Fussell, & Rumsey, 2007). Supporting families throughout the long treatment for burn injuries can decrease common symptoms experienced as a result of the trauma. Methods Project Development Information for the needs assessment was gathered through interviews with employees at Riley Hospital including staff occupational therapist and clinic nurse within the burn unit as well as two parents of children receiving care within the burn unit. Interviews were completed in participants' offices or therapy sessions with semi-structured format that allowed interviewees to add additional information they felt was important. Topics from the interviews included support Supporting Parents and Caregivers After a Pediatric Burn Injury 8 throughout burn injury recovery, resources, transition to home, and preferred topics for a support group for parents of children with burn injuries. Based on the interviews and information gathered from the needs assessment, including discussions with the site mentor, it was decided that the development of a parent support group facilitation guide would meet the needs of the site. Program Development In order to understand the population served within the burn unit clinic, both observations and interviews were completed. Additionally, the clinic staff provided this student with the current resources provided to the families and patients receiving care. These resources include information regarding burn injuries, recovery, and reintegration into community including a pediatric camp for children who have suffered from burns. Continued interviews with the occupational therapist in the burn clinic, a nurse in the burn clinic, and parents of children with disabilities assisted with the design of a parent support group guide for parents of children with burn injuries. The parent support group guide included information about facilitator skills, facilitator purpose, strategies for co-facilitation, preparation for meetings, the format of meetings, group rules, potential topics and prompts, conflict resolution management, and resources for managing group dynamics. The guide was reviewed by a burn clinic nurse and occupational therapist, two parents of children with burn injuries, a faculty mentor, and a social worker. Edits to the guide were made based on feedback. Program Implementation 9 Supporting Parents and Caregivers After a Pediatric Burn Injury The purpose of the parent support group guide is to provide a readily available resource for facilitators to use when implementing the support group. Participants completed a pretest. Next, participants were educated on the guide and provided a copy. Participants reviewed the guide at their leisure. Lastly, participants completed a posttest. The outcome measure provided feedback on readiness, comfort, and competence for potential facilitators. The occupational therapist and nurse in the burn clinic were interested in implementing the group. Outcome Measure A Likert scale was used to assess participants comfort and competence in facilitating a support group. Numeric values ranged from one-five Uncomfortable/unprepared represented a score value of one and Comfortable/prepared represented a score value of five. Changes in score from pre and posttest represented improvement with comfort, readiness, and competence for facilitating the parent support group using the guide. The outcome measure used is shown in Figure 1 below. Figure 1 Outcome Measure (Pre/Post-Test) Rank the following statements using the Likert Scale below. 1 Uncomfortable/ unprepared 2 Slightly uncomfortable and prepared 3 Neutral 4 Mostly comfortable and prepared 5 Comfortable and prepared Supporting Parents and Caregivers After a Pediatric Burn Injury 10 1. How would you rate your understanding of the role of a facilitator for the parent support group for burn injuries? 2. How comfortable are you facilitating a parent support group for children with burn injuries? 3. How comfortable are you discussing group rules and group expectations? 4. How comfortable are you intervening throughout the session to ensure everybody has an opportunity to share? 5. How comfortable are you providing appropriate topics and prompts to encourage participation in a group? 6. How comfortable are you intervening when a group member is being disruptive? Results Likert Scale Participants completed a pretest and posttest before and after reviewing the parent support group facilitation guide. The occupational therapy student interpreted the results from the Likert scale pre and posttest. Scores ranged from one to five points on the Likert scale, providing responses a numeric value. Uncomfortable/unprepared represented a score value of one and Comfortable/prepared represented a score value of five. Changes in score from pre and posttest represented improvement with comfort, readiness, and competence for facilitating the parent support group using the guide. Scores improved approximately 27% on average. 11 Supporting Parents and Caregivers After a Pediatric Burn Injury Two participants completed a pretest and posttest after reviewing the guide. The guide had 6 questions with a 5-point Likert scale for 30 possible points for the pre and posttest. Both participants scored a 16/30 on the pretest. Both participants scored a 24/30 on the posttest. Both participants had an 8-point difference for pre to posttest. For both participants, there was a 2point difference between the pretest and posttest for understanding the role of a facilitator for a parent support group for burn injuries for both participants. For both participants, the participants scored a 4 on all areas meaning the participants are mostly comfortable and prepared to facilitate a parent support group for burn injuries. Refer to Figure 3 for raw scores for each question on pre/posttest. Figure 2 30 Participant Pre and Posttest 25 20 15 10 5 0 Partcipant A Pretest Posttest Partcipant B 12 Supporting Parents and Caregivers After a Pediatric Burn Injury Figure 3 Likert Scores per Question 5 4 Likert Scale Score 3 A Pretest B Prestst A Posttest 2 B Posttest 1 0 1 2 3 4 Pre/Posttest Question Number 5 6 Discussion The purpose of this project was to provide a plan to support parents and caregivers of children with burn injuries. Creating a parent support group facilitation guide allowed potential support group facilitators to have a readily available resource in order to implement a support group when an opportunity arises. The outcome measure allowed potential facilitators to rate readiness and competence for facilitating a support group after reviewing the facilitation guide. With the 2 participants, both had an eight-point difference from pretest to posttest improving readiness and competence for facilitating a parent support group for children with burn injuries. Supporting Parents and Caregivers After a Pediatric Burn Injury 13 Participants scores improved for understanding the role of a facilitator, comfort with facilitating, comfort with establishing ground rules and expectations, comfort with intervening in sessions as appropriate, comfort with providing appropriate topics and prompts during sessions, and comfort with intervening when disruptions occur. Limitations were noted when interpreting the results. One limitation included only having two participants. Another limitation included both participants being employees at the same hospital. Also, data was self-reported from participants involving potential biases. Implications for Occupational Therapy Occupational Therapist should always consider parents, caregivers, and family when treating pediatric populations. Caregivers require education and support in regard to therapy for their child with burn injuries. Treatment for burn injuries is a time commitment for caregivers requiring scheduled stretching, scar massage, donning and doffing garments and orthoses, and more depending on location and severity of burn. Ensuring caregivers are educated and supported appropriately is important for carry-over at home. Providing a parent and caregiver support group creates a community to enhance support and a safe environment to share experiences. Through the Parent Support Group Guide, facilitators are more prepared and comfortable with the role of being a facilitator and able to intervene as appropriate. Facilitators also have increased understanding of topics and prompts for the specific population using the guide. Supporting Parents and Caregivers After a Pediatric Burn Injury 14 References Alisic, A., Boeije, H., Jogmans, M., & Kleber, R. (2012). Supporting children after single incident trauma: parents views. Clinical Pediatrics, 51(3) 274- 282. doi:10.1177/0009922811423309 Bakker, A., Maertens, K., Van Son, M., & Van Loey, N. (2013). Psychological consequences of pediatric burns from a child and family perspective: A review of the empirical literature. Clinical Psychology Review, 33(3), 361371. doi.org:10.1016/j.cpr.2012.12.006 Cole, M. & Tufano, R. (2008). Applied theories in occupational therapy: A practical approach. Thorofare, NJ: SLACK Incorporated. Collins, J. (2004). Educating techniques for lifelong learning: Principles of adult learning. RadioGraphics, 24(5). doi:10.1148/rg.245045020 Egberts, M., Engelhard, I., de Jong, A., Hofland, H., Geenen, R., & Van Loey, N. (2019). Parents memories and appraisals after pediatric burn injury: a qualitative study. European Journal of Psychotraumatology, 10(1), 111. doi:10.1080/20008198.2019.1615346 Frenkel, L. (2007). A support group for parents of burned children: A south African childrens hospital burns unit. Burns, 34(4), 565569. doi:10.1016/j.burns.2007.09.016 Heath, J., Williamson, H., Williams, L., & Harcourt, D. (2019). Supporting children with burns: Developing a UK parent-focused peer-informed website to support families of burn injured children. Patient Education and Counseling, 102(9), 17301735. doi.org:10.1016/j.pec.2019.04.003 Heath, J., Williamson, H., Williams, L., & Harcourt, D. (2018). Parent-perceived isolation and barriers to psychosocial support: a qualitative study to investigate how peer support might help parents of burn injured children. Scars, Burns & Healing, 4, 1-12. doi:10.1177/2059513118763801 Ikiugu, M., Nissen, R., Bellar, C., Maassen, A., & Van Peursem, K. (2017). Clinical effectiveness of occupational therapy in mental health: A meta-analysis. American Journal of Occupational Therapy, 71(5) doi:10.5014/ajot.2017.024588 Kapur, R. (2018). Facilitation of adult education programs and the adult learners. Retrieved from https://www.researchgate.net/publication/323771446_Facilitation_of_Adult_Education_ rograms_and_the_Adult_Learners Supporting Parents and Caregivers After a Pediatric Burn Injury 15 Lernevall, L., Moi, A., Cleary, M., Kornhaber, R., & Dreyer, P. (2020). Support needs of parents of hospitalized children with a burn injury: An integrative review. Burns: Journal of the International Society for Burn Injuries, 46(4), 771781. doi:10.1016/j.burns.2019.04.021 McCall, R,. Padron, K., & Andrews, C. (2018). Evidence-based instructional strategies for adult learners: A review of the literature. The Journal of the Louisiana Chapter of the ACRL, 4(4). McGarry, S., Girdler, S., McDonald, A., Valentine, J., Wood, F., & Elliott, C. (2013). Paediatric medical trauma: The impact on parents of burn survivors. Burns, 39(6), 11141121. doi:10.1016/j.burns.2013.01.009 Parrish, C., Shields, A., Morris, A., George, A., Reynolds, E., Borden, L., Hankinson, J., Ziegfeld, S., Stewart, D., & Ostrander, R. (2019). Parent distress following pediatric burn injuries. Journal of Burn Care &Research, 40(1), 7984. doi.org:10.1093/jbcr/iry048 Phillips C, Fussell A, & Rumsey N. (2007). Considerations for psychosocial support following burn injury a family perspective. Burns, 33(8), 986994. doi.org:10.1016/j.burns.2007.01.010 Rimmer, R., Bay, R., Alam, N., Sadler, I., Richey, K., Foster, K., Caruso, D., & Rosenberg, D. (2015). Measuring the burden of pediatric burn injury for parents and caregivers: informed burn center staff can help to lighten the load. Journal of Burn Care & Research, 36(3), 421427. doi:10.1097/BCR.0000000000000095 Thwala, S., Ntinda, K., & Hlanze, B. (2015). Lived experience of parents of children with disabilities in swaziland. Journal of Education and Training Studies, 3(4), 206-207. dio:10.11114/jets.v3i4.902  ...

... Running Head: OCCUPATION-BASED PROGRAMS FOR CANCER SURVIVORS 1 Use of Occupation-Based Programs to Decrease Distress and Increase Independence and Well-Being in Cancer Patients Thomas Jacocks, OTS 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: Beth Ann Walker, Ph.D., MS, OTR, FAOTA OCCUPATION-BASED PROGRAMS FOR CANCER SURVIVORS Design and Implementation of Virtual Occupation-Based Programs to Increase Health and Well-Being of Cancer Survivors Thomas Jacocks, OTS OTD 612: Doctoral Capstone Planning Dr. Beth Ann Walker University of Indianapolis 2 OCCUPATION-BASED PROGRAMS FOR CANCER SURVIVORS 3 ABSTRACT OBJECTIVE: Reintegrating back to ones life after a cancer diagnosis can be difficult for a lot of reasons. Cancer patients should receive an ample amount of services, support, and opportunities to re-engage in their previous lifestyles. Therefore, productive and occupationbased programs should be included in their rehabilitation and recovery process. Cancer Support Community (CSC) of Central Indiana has been providing programs for cancer patients for over 20 years, and there are many opportunities to add to the growing list of programs that are offered for this population. METHODS: To incorporate the varying needs of participants, a needs assessment was developed and a program survey was sent out to gauge interest in potential programs. Previous knowledge about programs, the population, and gaps in services assisted in creating a comprehensive list of potential programs for regular members. Ultimately, the feedback from the program survey and knowledge of occupational performance and independence spurred the creation of three occupation-based programs. RESULTS: The three occupation-based programs that were selected were Building Strength and Endurance Program, Home Organization and Downsizing Educational Series, and Cooking Class. These programs took place on a weekly to biweekly basis and lasted for one hour. The occupation-based programs appeared to be beneficial for cancer patients in terms of occupational engagement and independence. 10 out of 11 participants who completed the program evaluation survey reported the programs as Moderately to Extremely useful and informative for daily activities and overall well-being. CONCLUSION: Individuals served through the Cancer Support Community of Central Indiana may benefit from regular participation in occupation-based programming aimed to decrease distress levels in cancer patients and foster creativity in this period of their lives. OCCUPATION-BASED PROGRAMS FOR CANCER SURVIVORS 4 Use of Occupation-Based Programs to Decrease Distress and Increase Independence and Well-Being in Cancer Patients In 2020, there were an estimated 1,806,590 new cases of cancer within the United States and over 600,000 people died from the disease (National Cancer Institute, 2020). As of January 2019, there were an estimated 16.9 million cancer survivors with that number projected to increase to 22.2 million by 2030 (National Cancer Institute, 2020). Although there are several different treatments for cancer, the type of treatment received depends on the type of cancer and how advanced it is. The common treatment types are chemotherapy, immunotherapy, radiation therapy, hormone therapy, stem cell transplant, surgery, and targeted therapy (National Cancer Institute, 2020). These popular forms of treatment lead to widespread side effects including cancer-related fatigue, chemo-brain (memory or concentration problems), muscle weakness, appetite loss, pain, neuropathy, and endocrine, digestive, muscular immune, and nervous system deficiencies (National Cancer Institute, 2020; Sada et al., 2021). Cancer survivors often have difficulty maintaining adequate levels of physical activity, decreasing the fatigue and weakness associated with treatment and medication side effects, and maintaining independence during meaningful occupations (Sada et al., 2021; Sammut et al., 2016). Quality of Life The survival period of cancer survivors has continuously increased and with it the physical and psychological symptoms that negatively affect the quality of life (QoL) (Kim & Yoon, 2021). Since cancer survivors have, on average, a lower QoL compared to healthy individuals and other individuals with chronic diseases, continued focus and prioritization of QoL and health problems is crucial for this population (Kim & Yoon, 2021). The experience of a cancer diagnosis and its treatment diminishes an individuals physical capabilities and disrupts OCCUPATION-BASED PROGRAMS FOR CANCER SURVIVORS 5 the psychological, spiritual, and social well-being (Novakov et al., 2021). Adequate social support is essential when dealing with cancer diagnoses and various forms of oncological treatment (Huang & Hsu, 2013). Some studies have found that social support was related to better QoL and decreased symptoms of depression while elevating overall QoL (Huang & 2013). Independence Chemotherapy and radiation treatment in cancer patients causes cancer-related fatigue (CRF) which affects the level of independence during activities of daily living (ADLs) (Werdani, 2018). The complex nature of CRF and the heightened levels of dependence experienced by the patient leads to increased stress levels for both the patient and caregivers (Werdani, 2018). According to Diaz et al. (2008), 58.3% of patients experience limitations while performing self-care actions including bathing, dressing, or grooming. Cancer survivors perceive fatigue as the highest impacting symptom on daily living and report that it negatively affects their emotional and social areas as well (Diaz et al., 2008). Mental Health Cancer survivors have been found to experience mental, physical, and economic difficulties and social role confusion during treatment following the initial diagnosis (Edwards & Greeff, 2017). Cancer survivors may experience physical and cognitive impairments, anxiety, and fear of cancer recurrence even after the completion of recovery (Stanton & Bower, 2015). Around 50% of patients with cancer present great resilience at the time of diagnosis, treatment, and thereafter (Anderson et al., 2014). For the other half of individuals with cancer, they will be vulnerable to later distress after diagnosis and even through remission (Anderson et al., 2014). Regarding the timing and situation around psychiatric comorbidity, there can be substantial emotional, interpersonal, and financial costs for patients and economic barriers for healthcare OCCUPATION-BASED PROGRAMS FOR CANCER SURVIVORS 6 professionals and the health care system when depressive and anxiety symptoms or disorders are not treated (Anderson et al., 2014). Cancer-Related Fatigue Cancer-related fatigue (CRF) is highly prevalent among cancer survivors and may have long-term effects on physical activity and quality of life (Sada et al., 2021). Cancer-related fatigue is associated with deterioration in mobility performance, an increase in sedentary activities, increases in cumulative sedentary postures (longer sitting and lying postures and shorter standing posture), and a decrease in locomotion activities (lower step count and shorter longest unbroken walking bout) (Sada et al., 2021). Cancer-related fatigue can be caused by cancer itself or a side effect of chemotherapy, and its treatment is often neglected (Chidinma et al., 2017). Physical activity and an associated exercise program may help alleviate the barriers that CRF and other symptoms have on occupational performance during activities of daily living (Sada et al., 2021). Cancer-related fatigue is associated with adverse long-term effects and poorer survival outcomes for cancer survivors (Jones et al., 2016). Unfortunately, accurate assessment of CRF is regularly compromised by subjective screening tools, patient reporting bias, and variable evaluation by clinicians (Chidinma et al., 2017). Cancer-related fatigue is commonly assessed by self-report or clinical observation, which may limit timely diagnosis and management (Sada et al., 2021). The authors explored the current assessment and treatment of fatigue in patients with cancer through reviews and analysis of current pharmacological or non-pharmacological therapies for cancer-related fatigue (Nitipir et al., 2021). The complexity of cancer-related fatigue warrants individualized treatment and a multi-disciplinary approach (Nitipir et al., 2021). OCCUPATION-BASED PROGRAMS FOR CANCER SURVIVORS 7 A sedentary lifestyle can cause catabolic processes which lead to cancer-related fatigue. Therefore, muscle strength following rhythmic physical training can help manage fatigue (Nitipir et al., 2021). A randomized trial with 159 stage I-III breast carcinoma patients, with sleep or depressive disorders following their first cycle of treatment, were included in a 12-week exercise walking program (placebo cohort). At the end of the experimental period, fatigue, assessed by the Brief Fatigue Inventory, was significantly lower in patients who exercised for a longer time period (Nitipir et al., 2021). Physical Activity Baumann (2013) discussed how physical activity (PA) can reduce the loss of power, counteract cancer-related cachexia, reduce treatment-related side effects, and improve general performance. Baumann (2013) further stated that physical activity and controlled exercise therapy improve the quality of life, while also decreasing symptoms of fatigue, loss of function, and reducing the risk for more comorbidities. Physical activity played a large role in increased well-being and enjoyment in a large group of individuals with malignant tumors (Hh et al., 2018). Most of the participants confirmed that PA improved body awareness and provided a feeling that they were able to improve their coping skills and have peace of mind with their diagnosis (Hh et al., 2018). Although there was a decrease in physical activity and sport participation after diagnosis of cancer, participants who performed higher levels of PA and engagement in sports reported a higher quality of life scores than participants who did not meet adequate PA standards after diagnosis (Sammut et al., 2016). Individuals with a cancer diagnosis tend to slow down and decrease their engagement in physical activity. Several factors such as stress, depression, feeling sick, and side effects from the diagnosis or treatment strain activity levels (Hoffman, 2007). One of the best forms of recovery OCCUPATION-BASED PROGRAMS FOR CANCER SURVIVORS 8 for individuals with cancer is to start exercising as soon as possible given the clearance from doctors and capabilities of the individual (Hoffman, 2007). Benefits from exercise for cancer patients include an increased level of fitness, greater muscular strength, leaner body mass, less weight gain, improved mood, boost in self-confidence, and reduced fatigue (Hoffman, 2007). The two most recommended types of exercises for cancer patients are aerobic exercises and weight training, with flexibility and resistance training, also being important factors in regaining a healthy lifestyle (Hoffman, 2007). Benefits of a Healthy Diet Marmot et al. (2007) report evidence that a healthy diet that involves plant-based foods such as fruits and vegetables along with limited intake of high-calorie foods and red or processed meats can help prevent cancer. Cancer survivors need to maintain a balanced diet that includes the above foods in addition to lean proteins, whole grains, and low-fat dairy to manage cancerrelated side effects, daily energy levels, and prevention of recurrence or onset of other cancers and diseases (Marmot et al., 2007). A low-fat diet is beneficial for individuals with cancer due to the positive effect on hormones and the stimulation of growth in cancer cells later in life (Barnard, 2005). Diets rich in vegetables and fruits can also strengthen the white blood cells that seek out and attack cancer cells (Barnard, 2005). Furthermore, nutritional guidelines with specific energy and protein intakes should still be followed with or without a cancer diagnosis. While some patients maintain a strict diet, a majority use self-made or web-based diets to try and alleviate the symptoms of a cancer prognosis (Rinninella, 2020). Rinninella (2020) found a significant positive correlation between certain dietary patterns, especially western diet (WD) trends, and cancer progression. Additionally, high consumption of fiber seemed to be protective against cancer progression and OCCUPATION-BASED PROGRAMS FOR CANCER SURVIVORS 9 mortality (Rinninella, 2020). Cancer patients should continue to incorporate animal proteins such as fish, poultry, low-fat dairy products, and meat and decrease intake of saturated/trans fats, high-fat dairy products, and other WD trends (Rinninella, 2020). Home Modifications for Independence Re-organizing ones home to promote functionality and effectiveness will be a great way to get this population active and create an environment for independence. Home visits by an occupational therapist can prevent falls and can lead to changes in behaviors that enable individuals to live safely within the home and other environments (Cumming et al., 1999). Occupational therapists are equipped with the knowledge to assess homes for environmental hazards and provide home modifications that lead to independence and usefulness during daily activities (Cumming et al., 1999). Lien et al. (2015) note the importance of evaluating both objective and perceived indicators of person-environment (P-E) fit to administer housing modifications that support independence. Participant perceptions of accessibility and usability yielded various approaches that help to achieve performance and independence in daily activities (Lien et al., 2015). Similar to older adults, cancer patients need to simultaneously overcome physical barriers in ways that compensate for functional declines and decreases in environmental support (Lien et al., 2015). Meaning and Purpose A core element of combating these cancer-related effects is finding purpose and meaning during each activity. Cameron and Lively (2016) stressed the importance of finding meaning amidst a cancer diagnosis and eliciting creativity during times of stress and uncertainty. Interventions based around meaning for cancer patients provide techniques that help patients reorder their priorities, spend more time with family, experience more personal growth, and create OCCUPATION-BASED PROGRAMS FOR CANCER SURVIVORS 10 methods of coping with their traumatic loss or illness (Greenstein & Breitbart, 2000). For this population, their midlife or traumatic experience would be a cancer diagnosis. Coping plays an essential role in maintaining the well-being of patients with cancer (Harrop et al., 2017). Three broad domains were identified to categorize the core life concerns of participants; making sense of and managing one's illness, maintaining daily life and relationships, and confronting the future. Within these domains multiple coping themes were identified, which to varying degrees help to maintain patient well-being and quality of life (Harrop et al., 2017). This population can greatly benefit from meaningful and purposeful interventions targeted at redefining important aspects of their lives. Whether going through treatment or living as a survivor, these individuals deserve the best chance at independence and happiness regularly. Communication was vital in collaboratively creating common goals with the participants to prioritize meaningful occupations and activities. Guiding Model and Frame of Reference The Ecology of Human Performance (EHP) theoretical model was used to guide program development and measurement of outcomes. The Ecology of Human Performance model focuses on task performance and the relation to categories of activities of daily living (ADLs), leisure/play, and social participation (Cole & Tufano, 2008). The model depicts how an individual and his/her context affects their tasks and performance. Through this lens, clients can use their abilities and social support to manage barriers in their contexts. The inconsistency of the person, context, and tasks can lead to faulty performance which comes in the form of a lack of physical activity and engagement in meaningful daily occupations (Cole & Tufano, 2008). OCCUPATION-BASED PROGRAMS FOR CANCER SURVIVORS 11 According to the EHP, the client is the facilitator of change, meaning the client is the decision-maker during sessions (Cole & Tufano, 2008). The five specific intervention strategies of the EHP include: establish and restore, alter, adapt/modify, prevent, and create (Cole & Tufano, 2008). These strategies are targeted at the person, context, and task and how these are related and used during clients occupations. By using the EHP, clients will have assistance in providing environments, skills, contexts, support, and motivation that promote performance in the occupations of physical activity, cooking, and modifying/organizing living spaces. The first therapeutic intervention alternative is to establish or restore (remediate) the person's skills and abilities (Dunn et al., 1994). In this category, the occupational therapist identifies the person's skills and the barriers to performance and designs interventions that improve the person's skills and abilities (Dunn et al., 1994). One of the concerns for this population may be re-establishing the person's role in the family, which means it would be beneficial to work on coping skills or physical endurance to enable the person to perform tasks related to the family role. Additionally, cancer survivors may need more interventions related to physical and cognitive capabilities to adapt to the cancer-related side effects. Because of this, occupation-based programs fill the gap for remediating and restoring ones capabilities and performance in daily routines and tasks. Restorative approaches are common options chosen by therapists, particularly within the medical model, which considers what is wrong with the person and sets a plan to correct the problem. (Dunn et al., 1994). This concept is also essential for cancer survivors adapting to their new normal given the occupational limitations from a cancer diagnosis and treatment. OCCUPATION-BASED PROGRAMS FOR CANCER SURVIVORS 12 Cancer Support Community Cancer Support Community is a global non-profit network of 175 locations, including CSC and Gilda's Club centers, hospital and clinic partnerships, and satellite locations that deliver more than $50 million in free support and navigation services to patients and families (CSC, 2021). Cancer Support Community also conducts cutting-edge research on the emotional, psychological, and financial journey of cancer patients and advocates at all levels of government for policies to help individuals whose lives have been disrupted by cancer (CSC, 2021). For over 25 years, CSC of Central Indiana has provided education and wellness programs as well as support groups and events that coincide with the needs and goals of cancer survivors. All programs are free of charge and have been offered virtually since the COVID pandemic began. Cancer survivors are challenged with a multitude of physical, mental, and emotional side effects (Edwards & Greeff, 2017). These side effects impact cancer survivors independence and performance of daily activities and occupations (Diaz et al., 2008). Cancer Support Community is an organization that focuses on providing cancer survivors with psychosocial support that helps complement medical treatments and other therapies to help them grow and recover. The education programs offered through CSC aim to empower individuals affected by cancer with the essential knowledge to take an active role in their fight for recovery. The purpose of this DCE is to conduct a needs assessment for the individuals in this community and develop programs based off those needs. The goal of the programs is to improve cancer survivors participation and performance in daily activities while decreasing distress levels. OCCUPATION-BASED PROGRAMS FOR CANCER SURVIVORS 13 METHODS Participants This doctoral capstone project included individuals receiving services from the Cancer Support Community (CSC) of Central Indiana. Participants receiving services from this organization either had cancer and were currently undergoing treatment or were cancer survivors. Participants were recruited to CSC through health care professionals, brochures within hospitals and health centers, fellow cancer patients or survivors, and word of mouth. Members involved in this community joined voluntarily and were offered free services on their own time. Needs Assessment To determine programming needs, participants were emailed a survey link to decide programs for the next schedule. The next projected schedule consisted of the months of JuneJuly 2021. Nine programs were listed on the survey for participants to choose from. The nine programs on the list included Walking/Hiking Club, Cooking Class, Outdoor Games and Activities Group, Building Strength and Endurance Program, Peripheral Neuropathy Group, Golf program, Home Organization and Downsizing Educational Series, Game Night, and Finding Meaning and Purpose Educational Series. A total of 46 participants responded to the needs assessment survey with varying program results. The needs assessment program survey sent out is provided in appendix A. Project Materials and Procedures Based on the needs assessment, three separate five-week programs were selected to be implemented including Building Strength and Endurance program, Home Organization and Downsizing Educational Series, and Cooking Class. The Building Strength and Endurance program was offered weekly on Mondays, while the Home Organization and Downsizing OCCUPATION-BASED PROGRAMS FOR CANCER SURVIVORS 14 Educational Series and Cooking classes were offered biweekly on an alternating basis on Wednesdays. Programs were offered virtually for one hour through RingCentral, which is a video service correlated with Zoom. The author recorded attendance for each program throughout their 5-week duration. For participants who were unable to attend during the scheduled meeting times, a PDF summary of the meeting was sent out via email at the end of the program to the participants on the program contact list. It was important to set up growth-facilitating environments that fostered the acquisition and repetition of new skills for the adaptation to various cancer diagnoses and treatment side effects. As the individuals schedule and priorities change from the cancer-related effects and treatments, so does the mastery of skills and life roles. Ongoing communication between the author and the participants when creating the programs was essential for collaboratively setting goals for individuals and the population of CSC as a whole. The Building Strength and Endurance programs were based around three main concepts of strengthening exercises, aerobic exercises, and overall range of motion/movement. Table 1 outlines what occurred during each weekly session. Table 1 Week 1 Energy Conservation, Flexibility, and Balance Week 2 Aerobic Exercises Week 3 Strengthening Exercises Week 4 Balance and Isometric Exercises Week 5 Strengthening and Aerobic Exercises During after-care from cancer treatment, patients are encouraged to engage in homebased exercise programs to improve physical and mental recovery as well as psychosocial OCCUPATION-BASED PROGRAMS FOR CANCER SURVIVORS 15 stabilization (Baumann, 2013). Physically active patients experience psychosocial benefits in terms of a reduction in depression and anxiety (Baumann, 2013). There is evidence that shows that exercise is safe and beneficial for the quality of life and muscular and aerobic fitness for people with cancer during and after treatment (Segal et al., 2017). The Cooking Class revolved around three main concepts of health, energy, and capabilities. Two recipes were demonstrated during each Cooking Class session that occurred during three separate weeks. The recipes were taken from Cancer Support Communitys Recipe Gallery on their website (CSC, 2020). Table 2 outlines the recipes demonstrated during each session. Table 2 Session 1 Egg and Avocado Sandwich & No-Bake Energy Bites Session 2 Chicken Salad & Kiwi Green Smoothie Session 3 Turkey Meatballs w/ Butternut Squash Sauce & Mixed Berry and Yogurt Crepes There is evidence that a healthy diet that involves plant-based foods with a limited intake of high-calorie foods and red or processed meats, can help prevent cancer (Marmot et al., 2007). Balanced diets including lean proteins, fruits, vegetables, whole grains, and low-fat dairy are beneficial for managing cancer-related side effects, increasing daily energy levels, and helping to prevent recurrence or onset of other cancers and diseases (Marmot et al., 2007). In one study, researchers reported that cancer survivors have a positive outlook on eating healthy and make a change or attempt to change their diets following their cancer diagnosis (Beeken et al., 2016). Diet is an important modifiable factor in the lifestyle of cancer survivors and can promote longterm health (Beeken et al., 2016). OCCUPATION-BASED PROGRAMS FOR CANCER SURVIVORS 16 The foundation of the Home Organization and Downsizing Educational Series was to create a safe and functional home environment for cancer survivors at CSC. Within ones living space, there are several opportunities to promote efficiency and productivity during daily activities and tasks. Occupational therapists are equipped with the knowledge to assess homes for environmental hazards and provide home modifications that lead to independence and usefulness during daily activities (Cumming et al., 1999). Cancer patients need to simultaneously overcome physical barriers in ways that compensate for functional declines and decreases in environmental support (Lien, Steggell, and Iwarsson, 2015). Table 3 describes the weekly session for this program. Table 3 Session 1 Organization and decluttering of the bedroom, bathroom, closets/storage spaces, Session 2 Organization and efficiency of kitchen, living and family room, basements, and attics (if applicable) Session 3 Organization and decluttering of the garage and guest presentation on comprehensive storage space for pictures, movies, and other forms of media Measurement of Outcomes Each participant was contacted and the author administered the Distress Screening Tool (Distress Screener) before the beginning of the programs (Patient Planning Services, 2020). Buzaglo et al. (2020) found that the Cancer Support Source Distress Screening Tool was a reliable, and valid multi-dimensional tool that could screen individuals at risk for clinically significant levels of depression or anxiety. The Distress Screening tool allowed for more insight OCCUPATION-BASED PROGRAMS FOR CANCER SURVIVORS 17 into the limitations of the program participants and allowed the author to tailor the programs around improving upon these limitations. A total of 12 program participants completed the distress screener before the program's start date. Five of the twelve participants completed the distress screener after programs had begun. The Distress Screening Tool consisted of 16 questions regarding concerns about various emotions, situations, decisions, and stressors in their life during that particular day. The Distress Screening Tool used a Likert scale from 1-5 with 1 being Not at All concerned to 5 being Very Seriously concerned. The results were added up for a total distress score out of 80 points. A higher distress score represented a higher chance of depression and/or anxiety for the given participant. The second section consisted of demographic information and questions regarding the participants cancer diagnosis. The tool helped bring up conversations about barriers, capabilities, and other factors relating to the level of anticipated participation during each program. The Distress Screening Tool was also administered at the end of the program timeline to assess improvements or declines in distress levels and concerns at the time. A program evaluation survey was sent out at the end of the programs to collect responses of overall effectiveness and satisfaction of the offered programs. RESULTS Prior to programs starting, less than 30 participants were actively participating in overall programming at CSC. After the first week, 59 participants expressed interest in participating in the newly established programs. The number of participants who expressed interest, attended, or asked for follow-up information regarding program content increased each week. A total of 28 different participants attended one or all three of the offered programs during their 5-week duration. Five different participants attended at least one of the Building Strength and Endurance Program sessions. 14 different participants attended at least one of the Home Organization and OCCUPATION-BASED PROGRAMS FOR CANCER SURVIVORS 18 Downsizing Educational Series sessions. Nine different participants attended at least one of the Cooking Class sessions. Several other participants who were unable to make scheduled program times requested information from each session. Needs Assessment Program Evaluation A program evaluation survey was sent out via email to participants who attended and initially expressed interest in attending the occupation-based programs. The survey included seven questions regarding the attendance, usefulness, and overall effectiveness of the programs. A total of 11 out of 28 participants who attended at least one program, completed the program evaluation survey sent out at the cessation of the occupation-based programs. The 11 participants who completed the program evaluation survey reported the programs as OCCUPATION-BASED PROGRAMS FOR CANCER SURVIVORS 19 Moderately to Extremely effective and informative for use during daily activities and overall improvement in well-being. Participants mentioned the variation in program options and the emphasis on using the capabilities of participants with cancer to maximize program outcomes. For example, one participant said, All of the programs I attended were therapeutic and helpful. In response to the program evaluation survey, another participant stated You can really see that all of the programs were planned and constructed thinking about the cancer patient attendees. The Program Evaluation Survey is provided in appendix B. Distress Screener 10 of the 12 participants completed both the initial distress screener at the start of the programs and the final distress screener after the programs. Average distress scores dropped 2.1 points from the initial screening of 9.2 to the final screening of 7.1. Results are depicted in the graph below. Participants mentioned that the programs themselves were the reason for a decrease in concern given specific questions, therefore lowering their overall distress score. Due to the specificity of the occupation-based programs the author was only able to control certain factors from the distress screener such as exercise and physical activity, ability to complete daily tasks, support system, and safety measures. OCCUPATION-BASED PROGRAMS FOR CANCER SURVIVORS 20 DISCUSSION According to overall program evaluation and the common needs expressed by the population, occupation-based programs are essential in promoting the independence and wellbeing of members of this local cancer community. The programs increased participant attendance and engagement with other participants throughout their duration. Cancer Support Community should consider acquiring regular feedback and updates to their current and future programs to meet the varying needs and barriers of their participants. Offering occupation-based programs may increase the likelihood of participants gaining the necessary skills and strategies to improve their daily performance in activities and outlook on life. Participants were able to have consistent social participation and occupational engagement from the multiple weekly programs that were offered throughout the 5-week duration. The author had the opportunity to train and inform other CSC students and staff members on the preparation and effectiveness of certain programs. Since the author was directing other programs in addition to the established occupation-based programs, there was ample communication between other team members regarding program content and administration. Due to the lack of occupational therapy (OT) staff and knowledge of occupational science at CSC, a majority of participants gained more insight into the field of occupational therapy and applied this insight during the programs they attended. The participants applied this knowledge through utilizing the safety protocols and universal design strategies throughout their living spaces, practicing exercises and stretches to maximize motion and endurance during daily activities, and completed meal preparation with maximum efficiency that promoted increased energy throughout the day. Topics such as universal design, activities of daily living, meaningful engagement in occupations, independence, balance, and support were continuously brought up OCCUPATION-BASED PROGRAMS FOR CANCER SURVIVORS 21 and discussed throughout each program offered. Having programs that were chosen by participants who voluntarily attended each session made for increased motivation and meaningful participation. Limitations Although the occupation-based programs were beneficial for participants in terms of satisfaction, independence, and overall well-being, several barriers limit the future implementation and success of these programs. Cancer Support Community has several staff members who are clinical hospital coordinators, certified generalists in Oncology, and experienced in program development and operations but do not employ an Occupational Therapist within their team. Therefore, there is limited knowledge and experience in developing and leading occupation-based programs with no effective analysis of occupational performance or demands. Since the Central Indiana location is one of many Cancer Support Communities around the nation, the evaluation of programs only extends to the specific population at this location and limits the widespread use of occupation-based programming. Furthermore, since only three programs were selected out of the nine possible options, there may have been other programs that could have had even higher attendance or been more effective in meeting project goals. Implications for Practice The development of the various occupation-based programs appeared to be beneficial for cancer survivors. Participants were able to gain the necessary skills and creative thinking to combat constant distress and foster independence during daily activities. These occupation-based programs have a place in the treatment and rehabilitation of cancer survivors for their longlasting effects and functionality to varying lifestyles. Occupation-based programs prioritize the OCCUPATION-BASED PROGRAMS FOR CANCER SURVIVORS 22 importance of independence while allowing participants to engage in meaningful activities. The concept of this specific program development may promote the well-being and creativity of cancer survivors for years to come. Implications for Cancer Support Community Cancer Support Community has done a great job adapting program delivery to the changes in society from COVID-19. Programs have gone from in-person to virtual meetings and have changed the accessibility for participants a part of this community. The needs of cancer survivors are constantly changing and require creative and updated programming during each monthly schedule. Occupation-based programs, such as the ones in this doctoral capstone project, appeared to be effective for the population at the Cancer Support Community of Central Indiana. The continuation of these programs requires the administration from either an occupational therapy student or an occupational therapist to have the most opportunities for positive effects on the individuals enduring treatment or survivors who are looking to reintegrate themselves back into the community. Cancer Support Community of Central Indiana would benefit from hiring an occupational therapist on staff to administer interventions that would help promote growth and rehabilitation for this population. An occupational therapist on staff also means the effective administration and evaluation of the programs implemented throughout the doctoral capstone project. CONCLUSION Occupation-based programming appeared to be beneficial for the cancer survivors at Cancer Support Community of Central Indiana. These programs resulted in participants decreased distress levels on the Distress Screening tool, improved sense of independence during certain occupations, and resources for participants to find meaning and creativity in their lives. OCCUPATION-BASED PROGRAMS FOR CANCER SURVIVORS 23 Occupation-based programs should be incorporated into the regular schedule at Cancer Support Community for continued variation in programs, assistance in occupational independence, and prioritization of meaningful occupations. OCCUPATION-BASED PROGRAMS FOR CANCER SURVIVORS 24 References Andersen, B. L., DeRubeis, R. J., Berman, B. S., Gruman, J., Champion, V. L., Massie, M. J., Holland, J. C., Partridge, A. 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Nutrients, 12(8), 2345. https://doi.org/10.3390/nu12082345 Sada, Y. H., Poursina, O., Zhou, H., Workeneh, B. T., Maddali, S. V., & Najafi, B. (2021). Harnessing digital health to objectively assess cancer-related fatigue: The impact of fatigue on mobility performance. PLoS ONE, 16(2), 115. https://doi.org/10.1371/journal.pone.0246101 Sammut, L., Fraser, L. R., Ward, M. J., Singh, T., & Patel, N. N. (2016). Participation in sport and physical activity in head and neck cancer survivors: associations with quality of life. Clinical Otolaryngology, 41(3), 241248. https://doi.org/10.1111/coa.12506 Segal, R., Zwaal, C., Green, E., Tomasone, J. R., Loblaw, A., & Petrella, T. (2017). Exercise for people with cancer: A systematic review. Current Oncology, 24(4), 290315. MDPI AG. Retrieved from http://dx.doi.org/10.3747/co.24.3619 Spiegel, D., Bloom, J., & Yalom, I. (1981). Group support for patients with metastatic cancer. Archives of General Psychiatry, 38, 527-533. http://dx.doi.org/10.1001/archpsyc.1980.01780300039004 OCCUPATION-BASED PROGRAMS FOR CANCER SURVIVORS 29 Stanton, A.L., & Bower, J.E. (2015). Psychological adjustment in breast cancer survivors. Advances in Experimental Medicine and Biology; 862: 231-242. https://doi.org/10.1007/978-3-319-16366-6_15 Werdani, Y. D. W. (2018). Effect of cancer-related fatigue to the level of independence of cancer patients and caregiver stress level. Folia Medica Indonesiana, 54(2), 108112. https://doi.org/10.20473/fmi.v54i2.8859 OCCUPATION-BASED PROGRAMS FOR CANCER SURVIVORS 30 Appendix A. Needs Assessment/Program Interest Survey 1. Would you be interested in participating in any of the following programs? Check all that apply: a. Walking/Hiking Club b. Cooking Class c. Outdoor Games and Activities Group d. Building Strength and Endurance Program e. Peripheral Neuropathy Group f. Golf Training Program g. House Organization and Downsizing Educational Series h. Game Night i. Finding Meaning and Purpose Educational Series 2. How often would you like these programs to meet? a. Once a week b. Every other week c. One meeting 3. Would you be comfortable attending programs in person if they were offered? a. Yes b. No 4. Would you attend these programs if they were offered virtually? a. Yes b. No 5. We'd love to contact you when we start these programs. Please leave your name and email. OCCUPATION-BASED PROGRAMS FOR CANCER SURVIVORS 31 Appendix B. Program Evaluation Survey 1. Did you attend any of the programs led by Thomas? (Exercise, Cooking, or Home Organization) a. Yes b. No 2. Did you find the programs to be helpful, useful, or informative? a. Not at All b. Slightly c. Moderately d. Extremely 3. If you weren't able to attend any programs, did you view the summary/recap document sent after the end of each program? a. Yes b. No 4. Did you find the summary/recap documents to be helpful, useful or informative? a. Yes b. No 5. Did you learn more about the field of Occupational Therapy during any of the programs? a. Yes b. No 6. What was the best part/most beneficial aspect of the programs? a. Comment  ...

... Running head: CREATING COMMUNITY Creating Community: Occupational therapys role in program development for adults with Intellectual and/or Developmental Disabilities Madeline E. Hunter 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 mentor: Taylor McGann, OTR, MS, OTD 1 Running head: CREATING COMMUNITY 2 Abstract Adults with Intellectual and/or Developmental Disabilities (I/DD) experience a variety of barriers that impact their participation in social interactions and community engagement; however, there is a distinct lack of targeted programming for this population. As adults with I/DD are beginning to live independently within their communities well into old age, it is necessary to understand the unique needs of the I/DD population and explore potential interventions to better facilitate inclusivity and independence for this population. With training in developmental stages, transitions, and activity analysis, occupational therapists can educate, train, and prepare individuals with I/DD for independently engaging in meaningful activities within their communities. This Opinions in the Profession paper aims to inform members of the occupational therapy community of the role that occupational therapists have in developing social skills programs to facilitate independence among the I/DD population and share an example of the development and implementation of one program. The Creating Community program increased knowledge, participation, skills, and confidence among individuals with I/DD and highlights a need for continued research in various service delivery methods for occupationbased group programming. Keywords: intellectual disabilities, developmental disabilities, adults, participation, community Running head: CREATING COMMUNITY 3 Creating Community: Occupational therapys role in program development for adults with Intellectual and/or Developmental Disabilities With the recent increase in inclusive housing developments and communities for individuals with Intellectual and/or Developmental Disabilities (I/DD), it is necessary that the individuals planning and implementing these options understand the unique needs of people with I/DD, especially as it relates to social skills. However, research focusing on adults, especially those that have transitioned to living independently and are seeking employment, meaningful relationships, and overall self-sufficiency through community integration is scarce (Marcotte et al., 2020). As adults with I/DD are beginning to live independently well into old age, it is necessary to explore these interventions to understand their needs better and promote inclusivity and independence for all individuals. Literature review and paper position This opinion piece is informed by the completion of the occupational therapy doctoral capstone experience with a focus on program development for the I/DD population at the community level. The purpose of implementing a social skills program with a focus on community integration was to increase the overall inclusivity of adults with I/DD within communities and increase independence as they transition to long-term independent living. A thorough review of literature was completed to understand current legislation, established practice guidelines, and research related to social skills training and programs for communitydwelling adults with I/DD. Several programs exist for school-aged individuals with I/DD; however, there is a distinct lack of targeted programming for individuals with I/DD of working Running head: CREATING COMMUNITY 4 age living in noninstitutionalized housing. This paper provides one example of program development and implementation specifically for adults with I/DD. Since the deinstitutionalization of individuals with disabilities in the 1950s and 1960s, individuals with I/DD have sought out community-based housing and living opportunities that allow for participation in meaningful activities, relationships, and ultimately self-sufficiency (Friedman, 2019). However, the majority of individuals with I/DD continue to live with their parents and rely on family members for their care (NY Alliance, 2018). As parents of individuals with I/DD age, familial stress and anxiety surrounding the topics of death of caretakers and aging in place is extremely common (NY Alliance, 2018). Families must plan for the future with limited knowledge of their options, supports, and finances, making identifying the best fit for the individual with I/DD a challenge (NY Alliance, 2018). Due to this lack of resources and knowledge, individuals with I/DD and their families frequently struggle to identify and secure independent housing that facilitates participation in their desired and required daily tasks (NY Alliance, 2018). In established research, many adults with disabilities, including intellectual, chronic, and physical disabilities, that do make the transition to living independently face environmental, social, and financial barriers that prevent engagement in the activities that give them a sense of community and purpose (Angell et al., 2020). Based on interviews conducted with adults with disabilities such as I/DD, meaningful activities include giving back to their community through volunteer work, establishing friendships and romantic relationships, visiting local restaurants, sporting events, and movie theatres, attending religious services and concerts, and working (Angell et al., 2020). Overall community accessibility, including transportation, finances, and societal and individual perceptions of disability impacts community integration and participation Running head: CREATING COMMUNITY 5 for individuals with disabilities despite ADA (ADA; Pub. L. 103-336) implementation (Angell et al., 2020). Individuals with I/DD and their families must consider the supports in place for community integration and accessibility when choosing a home (Friedman, 2019), as these factors impact the overall inclusivity and well-being for individuals with I/DD. For individuals with I/DD and their family members, these supports often include financial waivers and subsidies, individualized service plans, transportation, reliable staff, and planned programming and activities (Friedman, 2019). Occupational Therapy Theory As part of a profession built on empowering individuals within their environments to facilitate meaningful participation in functional activities, occupational therapists have the potential to meet the long-term needs of individuals with I/DD and their families as they transition into independent living and face the challenges of community integration (AOTA, 2014). With extensive training in developmental stages and transitions, occupational therapists have the knowledge and skills to educate, train, and prepare individuals with I/DD for independently engaging in functional activity within their communities. Additionally, occupational therapists can provide consultative services to community organizations and their partners to reduce the environmental and societal barriers that individuals with I/DD face within their communities (Umeda et al., 2017). The Transactional Contextualism and Environmental Press components of the occupation-based Ecology of Human Performance (EHP) model appropriately explains how the environment affects ones occupational performance, and also conversely describes how an individuals performance affects their environment (Dunn, Brown, & McGuigan, 1994). Identifying an individuals desired or required tasks, skills, and abilities, and the environmental barriers impacting completion of function highlights this unique reaction Running head: CREATING COMMUNITY 6 between person, environment, and occupation. When addressing barriers to individuals with I/DD, it is essential to focus on barriers to a successful transition from living with parents and family members to living on their own. Considering the individuals physical, cultural, social, and temporal contexts allows therapists to address barriers limiting task performance appropriately, to support individuals with I/DD by limiting Environmental Press, and to educate community partners on the unique needs of individuals with I/DD. The EHP model can also guide intervention as therapists provide resources for meeting goals by establishing or restoring new skills through programming, adapting or modifying environments or tasks, preventing barriers, and creating new opportunities for successful occupational performance. New skills and additional knowledge allow individuals to overcome barriers limiting occupational engagement. Age-appropriate and productive goals can be set according to life stages and developmental milestones while aiding in the transition to independent living and identifying barriers to occupational engagement. Based on the nature of I/DD, individuals with I/DD are often not performing at an age-appropriate level when they transition into independent living. Still, they must learn to adapt to new environments and social situations to be self-sufficient. Utilizing the Lifespan/Developmental frame of reference to guide occupational therapy intervention allows therapists to set reasonable goals and objectives for intervention that help meet developmental milestones and expectations (Cole & Tufano, 2008). The needs of individuals with I/DD who are looking to transition to independent living consistently include the desire to have meaningful friendships and peer support within their community and an increase in overall independence (Friedman, 2019). Occupation-based program development and Running head: CREATING COMMUNITY 7 implementation can support individuals with I/DD by facilitating social interaction that develops and maintains friendships within future communities. A Social Skills and Community Integration Intervention Group for Adults with I/DD Participants Program participants were adults with various intellectual and developmental disabilities who were receiving supports from a nonprofit organization in Indianapolis, Indiana that provides residential supported living to adults with I/DD through the Medicaid Home-and-CommunityBased Service Waiver program (HCBS) under the Indiana Bureau of Developmental Disabilities Services (BDDS) (BDDS, 2020a; BDDS, 2020b). The social skills and community integration intervention program was developed and implemented as part of the programming available to individuals with I/DD through the nonprofit organization. The majority of individuals who participated in the program lived independently within the same apartment complex where programming was held; however, some participants were living independently or with family in the community not far from the complex. Participation in the social skills and community integration intervention program was voluntary, like all other programs offered by the nonprofit organization. Procedure A six-week group program was developed and conducted based on the societal needs of the I/DD population to improve and increase the social skills and community integration of adults with I/DD. The intervention group outcomes were evaluated throughout implementation and following the conclusion of week six using a pre- and post-program questionnaire and interviews. The program was then disseminated to the Executive Director and administration of the nonprofit organization so that the program could be utilized again. Running head: CREATING COMMUNITY 8 Needs assessment To fully understand the organizations programming needs and I/DD population, a thorough analysis of established programming was necessary. An informal assessment of the nonprofit organizations programming needs was conducted through faciliatory conversation and informal, face-to-face interviews with the organizations Executive Director, Community Program Director, Live in Support, and Staff Support Coordinator. Observation of the organizations current programming was also conducted, and field notes were taken throughout various programming sessions. Surveys were utilized to collect additional information about the lived experiences of the individuals with I/DD receiving supports from the nonprofit organization and the Life Skills coaches spending one-on-one time with the individuals with I/DD. Three different surveys were created and distributed: a version for individuals with I/DD living in the apartment complex, a version for individuals with I/DD living in the community and receiving supports from the nonprofit organization, and a version for the Life Skills coaches spending one-on-one time with the individuals with I/DD. These surveys were sent out via email and printed copies. Surveys were completed individually or with a Life Skills coach and were made up of 16-32 questions, with variation depending on which version of the survey was completed. Completion of surveys was voluntary. In total, 31 surveys were completed. Thematic Analysis Data collected through conversations, interviews, observations, and surveys were analyzed to determine the overall needs of the organization and the I/DD population, which guided the development and implementation of the group program. Specifically, thematic analysis was completed to understand the community participation and integration experiences Running head: CREATING COMMUNITY 9 of individuals with I/DD receiving support from the nonprofit organization. Survey questions and responses from people receiving support from the nonprofit organization analyzed included: 1. How often do you go out into the community (e.g., appointments, shopping, restaurants)? 2. What do you like about going out into the community? 3. What is hard about going out into the community? Survey questions and responses from the life skills coaches providing support to adults with I/DD included: 1. In your opinion, what are the biggest barriers to independence that the people you support experience? 2. What are the biggest barriers within the community that the people you support experience? 3. How often do you go out into the community with the people that you support? The thematic analysis process followed Vaismoradi et al.s (2016) method for theme construction beginning with a thorough review of data and identification of keywords, followed by creating codes and categories, and concluding with identification of the overall themes within the data (Vaismoradi et al., 2016). After reviewing and analyzing the data collected, the following themes and subthemes were identified: Desire to be in community with others, limited communication and social skills, decreased confidence in social situations, decreased initiation of social interactions, lack of access to the community, limited opportunity for community outings, and lack of knowledge of community resources. Four program objectives were set based on the results of the needs assessment and thematic analysis. Program objectives included: Running head: CREATING COMMUNITY 10 1. By April 2021, group members will demonstrate increased knowledge of resources available for accessing the community by identifying at least 1 way to interact within the Indianapolis community. 2. By April 2021, group members will demonstrate increased participation by identifying at least 1 way to maintain friendships. 3. By April 2021, group members will demonstrate increased social skills by identifying at least 1 way to initiate a social interaction or community outing. 4. By April 2021, group members will report increased confidence in their social interaction skills. Program Implementation A six-week group program, titled Creating Community, was developed and implemented based on the societal needs of the I/DD population following Coles (2018) Seven Steps for Group Leadership (Cole, 2018). Coles (2018) method for leading an occupation-based group facilitates group participation through occupational engagement and reflection (Cole, 2018). Coles (2018) seven steps include an introduction, activity, sharing, processing, generalizing, application, and summary (Cole, 2018), and were utilized throughout the six-week social group for individuals with I/DD to engage participants in activities and discussion that facilitate the growth of social skills and knowledge necessary for successful and confident community integration. Group sessions took place once a week for six weeks and were held using video conferencing technology. Each session lasted approximately 60 minutes. Sessions were planned and led based on the needs assessment outcomes and identified themes. Sessions are outlined in Table 1. Table 1 Creating Community Interventions Running head: CREATING COMMUNITY Session Session 1: Meet & Greet Session 2: Defining Community Session3: Interests & Community Activities Occupation- Intervention based Program Objectives Objectives The first session served as 1-4 an introduction to the social group. The focus of this session was to introduce the purpose of the group program, establish group expectations, explain the goals of the program, and build rapport between the group leader and participants. Group members assisted in establishing group expectations, guidelines, and goals. 11 Rationale Overall community accessibility, including transportation, finances, and societal and individual perceptions of disability impacts community integration and participation for individuals with disabilities despite ADA implementation (Angell et al., 2020). With this knowledge, individuals who are planning and facilitating independence-related training and activity can address the barriers to these meaningful activities to support individuals with I/DD and increase their overall participation and confidence related to community integration and social interaction. Objectives 2 Session educated group By introducing individuals with and 4 members on the different intellectual and developmental types of community and the disabilities to the many concepts benefits of being in of community, including physical community with others. spaces, relationships, and virtual The purpose of this session connections, we can create a sense was to explore the of belonging, empower individuals communities that group to increase participation in the members are a part of and communities they are currently a discuss opportunities to part of, and facilitate the creation expand these groups. of new communities (Wigfield et Group members spent time al., 2020). discussing what types of environments they like to be a part of, how they can create these types of environments with other people, and then as a group defined community. Objectives Session addressed interests By discussing interests, hobbies, 1, 2, and 4 and how group members and favorite activities in a group participate in community setting, individuals with activities that interest them. intellectual and developmental Group members spent time disabilities can discover shared Running head: CREATING COMMUNITY 12 discussing how they could create community with people who share the same interests as them, how they could start conversations with people based on interests, and how they can advocate for participating in activities that are meaningful to them in the future. interests with others and consider how they might initiate conversations or plans with those who share the same interests. Because this population has decreased social circles and social connections, it is important to organize social groups that are based on interests to facilitate social participation and occupational engagement (Johnson et al., 2019). Session 4: Planning an Outing Objectives 1-4 Session educated group members on the steps necessary for planning a meeting with friends and a community outing. Group members spent time identifying the information necessary for planning when making various plans, learned where to access this information, and practiced initiating social interactions through roleplay scenarios. To facilitate community participation and integration, we must first consider community mobility and challenges that adults with intellectual and developmental disabilities face due to executive functioning and working memory deficits. Planning, preparation, and practice can help individuals with disabilities feel more confident in their ability to participate in community activities and more motivated to engage within their communities (Kersten et al., 2020). Session 5: Virtual Community Objectives 1, 2 and 4 Session focused on exploring Zoom alternatives for creating virtual community as following the email invites, meeting IDs, and passcodes can be a difficult process. Group members were introduced to the concept of virtual community and challenged to identify the benefits of virtual community as well as ways that they can create virtual community in the future. Because barriers to using social media commonly experienced by adults with intellectual and developmental disabilities include, but are not limited to, safety concerns, difficulties caused by literacy and communication skills, understanding cyber-language, following cyber-etiquette, and accessibility, intervention should address internet safety education, specifically on the topics of etiquette, appropriate posting, profile security settings, and being assertive. By addressing the barriers related to technology use Running head: CREATING COMMUNITY Session 6: Staying in Touch Objectives 1-4 The final session served as a conclusion of the program. The focus of this session was to re-visit the overall goals of the group and summarize the skills learned throughout the program. Additional resources for community integration were provided based on the outcomes of the previous sessions, as the development of the social skills and knowledge necessary for successful community participation is an ongoing process. 13 and social networking, we can combat the social isolation and loneliness typically experienced by this population and limit the risk of individuals being bullied, exploited, and sexually harassed online when they seek or create virtual community (Caton & Chapman, 2016; Sallafranque-StLouis, & Normand, 2017). Social skills should be taught and practiced in a group setting and activities should give individuals the opportunities to use strategies for initiating and sustaining social interactions with others AOTA, 2017). By following these guidelines, adults with I/DD can continue to develop and refine their social skills, which can then increase social interaction and participation and decrease social isolation. Program Evaluation The social group program was evaluated using pre- and- post- program questionnaires and interviews to measure the effectiveness of the six-week intervention to meet the overall goals of the program. The pretest-posttest design has been used in the past to measure change overtime within a variety of populations and settings and is recognized as an appropriate method for the program evaluation portion of the program development process (Taylor, 2017). Additionally, interviews and other in-person outcomes measures give a voice to individuals participating who are often left out of the data collection process due to their disability, empowering them to participate in programs (Scaffa et al., 2010). The pre-and-post-program questionnaire was Running head: CREATING COMMUNITY 14 administered following the first and final sessions of the program to evaluate the knowledge, participation, skill, and confidence of participants. The questionnaire consisted of six open-ended and multiple-choice questions and was administered to eight participants following Session 1 and seven participants following Session 6. Questionnaires were administered in-person and over the phone to accommodate for the cognitive deficits of participants. Dissemination Following the conclusion of the six-week social group, the program was disseminated to the Executive Director and members of administration at the nonprofit organization where the program was implemented. Dissemination included a thorough review of the data collected during the initial needs assessment, a review of the program goals and objectives, a review of program interventions, a review of the program evaluation data, and a review of additional resources. The Executive Director was given curriculum and materials for an additional four weeks of the program. Curriculum resources included session outlines following Coles (2018) Seven Steps for Group Leadership and Writing a Group Protocol (Cole, 2018). Curriculum and resources were based on the skills developed in the first six weeks of the social group program and the additional interests and needs of the group members. An empty outline of Coles steps and protocol were also provided so that the Program Director could create additional sessions as the program continued. Results Following the final program session, individuals who attended three or more sessions completed the post-program questionnaire to measure the effectiveness of the six-week intervention. There is a difference of one individual between pre-and-post- program Running head: CREATING COMMUNITY 15 questionnaire data. Complete results from the pre-and-post-program questionnaire are reported in Table 2. Table 2 Creating Community Pre-and-Post-Program Questionnaire Results Question Occupation-based Pre-Program Program Objective Questionnaire Association Tell me what ways Objective 1: 100% of individuals you use to connect Knowledge of ways identified at least with your friends, to interact or connect one way to interact family, and other with others to be a within the people. (open-ended) community. Indianapolis area. Connection methods identified included 57% of individuals using the phone, identified more than social media, Zoom, one way to interact in-person within the conversations, and Indianapolis area. making plans with others. In the last six weeks, how often have you connected with other people? (open-ended) Objective 2: Participation and social interactions. Tell me what you know about how to make plans with a friend. (open-ended) Objective 3: Making plans with friends. Tell me what you know about how to plan a community outing. (open-ended) Objective 3: Planning an outing. Post-Program Questionnaire 100% of individuals identified at least one way to interact within the Indianapolis area. 71% of individuals identified more than one way to interact within the Indianapolis area. 50% of individuals reported connecting with others at least a few times a week in the last six weeks. Only three individuals reported connecting with others every day. 88% of individuals identified at least one way to make plans with a friend. 100% of individuals reported connecting with others at least a few times a week in the last six weeks. Five individuals reported connecting with others every day. 25% of individuals identified more than one way to make plans with a friend. 88% of individuals identified at least one way to plan a community outing. 57% of individuals identified more than one way to make plans with a friend. 100% of individuals identified at least one way to plan a community outing. 100% of individuals identified at least one way to make plans with a friend. Running head: CREATING COMMUNITY How confident do you feel in your ability to connect with other people? (multiple choice) How confident do you feel in your ability to plan and go on a community outing? (multiple choice) 13% of individuals identified more than one way to plan a community outing. Objective 4: 50% of individuals Confidence in ability reported feeling to connect with confident in their others. ability to connect with others. Objective 4: 50% of individuals Confidence in ability reported feeling to plan and go on a confident in their community outing. ability to plan and go on a community outing. No one reported feeling confident in their ability to do so without the help of a life skills coach. 16 86% of individuals identified more than one way to plan a community outing. 71% of individuals reported feeling confident in their ability to connect with others. 86% of individuals reported feeling confident in their ability to plan and go on a community outing. Three individuals shared experiences of planning and going on community outings with friends since the beginning of the Creating Community program. Conclusion and Implications for Practice The purpose of this Opinion in the Professions paper is to inform individuals developing programs and providing services for adults with I/DD of the role of occupational therapy in facilitating independence and provide one example of program development and implementation for adults with I/DD. A social skills program focusing on community integration was developed and implemented by an occupational therapy doctoral capstone student to increase the overall inclusivity of adults with I/DD living independently. As a result of program interventions, group members recognized more than one way to connect with others and initiated more social interactions with their peers. Group members also identified additional steps to take when making plans with friends, such as talking about their schedules and availability and were able to follow up with important questions to clarify their friends availability when practicing and Running head: CREATING COMMUNITY 17 applying these skills. Lastly, group members identified additional steps necessary for planning community outings such as arranging transportation and managing their money to cover the cost of their leisure activities. The overall confidence levels for making plans with friends and planning outings in the community of group members increased throughout the program as well. To continue to increase knowledge, participation, skills, and confidence for independently initiating and participating in social and community activities, occupation-based interventions for adults with I/DD should consider the use of technology to support this population. This is especially relevant as this population continues to age in place. Occupational therapists can support adults with I/DD across the lifespan by introducing adaptive technology to modify daily routines, provide visual supports, and provide remote services. Although the Creating Community program did not directly address assistive technology, group members did explore using technology as a way to expand their social circles and increase social participation. Most group members were familiar with using technology to connect with others, however, they struggled with accessing and navigating virtual community and required step-by-step instructions for completing these tasks. Because of this, additional education and practice are necessary, and as society continues to rely more on technology for participation in communication and other everyday occupations, such as work and leisure activities, occupational therapists should work with adults with I/DD so that they can be independent in these tasks and live fulfilling lives. Along these same lines, future programming for adults with I/DD should focus on developing working memory and executive processing skills with individuals as these deficits present as some of the greatest barriers to independence among this population. Implementation of the Creating Community program led to identifying these needs; however, continued research Running head: CREATING COMMUNITY 18 related to facilitating social and community autonomy is necessary to fully understand the bestpractice methods when teaching these skills. There is limited literature that details the benefits of occupational therapy-based social skills training for adults with disabilities. The American Occupational Therapy Association (AOTA) outlines opportunities for occupational therapy intervention and research when working with individuals with disabilities such as ASD (AOTA, 2017). A 2017 article, AOTA (2017) acknowledges group-based social skills training programs as an intervention strategy with strong research-supported evidence for improving social skills in individuals with ASD. AOTA included activity-based interventions, computer-based interventions, and focused interest interventions in the same article as intervention strategies requiring additional research in the future (AOTA, 2017). Although evidence is limited, positive outcomes in peer-led social skills intervention groups have been reported by occupational therapists when working with adolescents with ASD. When using these strategies, Tomchek et al. 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