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... Perceptions of Teaching Left-Handed Students Submitted to the Faculty of the College of Health Sciences University of Indianapolis In partial fulfillment of the requirements for the degree Doctor of Health Science By: Molly Mink, MS, OTR/L Copyright December 8, 2022 By: Molly Mink, MS, OTR/L All rights reserved Approved by: Lisa Borrero, PhD Committee Chair ______________________________ Laura Santurri, PhD, MPH, CPH Committee Member ______________________________ Joshua Skuller, PhD, OTR/L, BCP, ATP Committee Member ______________________________ Accepted by: Laura Santurri, PhD, MPH, CPH Director, DHSc Program Chair, Interprofessional Health & Aging Studies University of Indianapolis ______________________________ Stephanie Kelly, PT, PhD Dean, College of Health Sciences University of Indianapolis ______________________________ PERCEPTIONS OF TEACHING LEFT-HANDED STUDENTS Perceptions of Teaching Left-Handed Students Molly E. Mink Department of Interprofessional Health & Aging Studies, University of Indianapolis 1 PERCEPTIONS OF TEACHING LEFT-HANDED STUDENTS 2 Abstract Introduction: Kindergarten and first-grade teachers provide the first formal fine motor skills training many students will receive. They are often the first to teach handwriting to students, and they are also the first to notice a difference in students handwriting and fine motor abilities. There is a dearth of evidence regarding how teachers perceive their role in fine motor and handwriting development and, specifically, how teachers perceive their role in teaching lefthanded students. Purpose: This qualitative study explored the perceptions and experiences of kindergarten and first-grade teachers and their work with left-handed students. This study explored themes among this group of teachers and their experiences teaching fine motor skills to left-handed students. Method: Semi-structured interviews of kindergarten and first-grade teachers were conducted to facilitate an exploration of how teachers understand their experiences with left-handed students. A basic interpretive approach was used, and a convenience sample of 8 participant interviews took place. Teachers were recruited from elementary schools in a school district in the Southeastern U.S. Results: During data analysis, four major themes emerged: formal training in fine motor skills, barriers to teaching fine motor skills, individual needs assessment, and teaching styles related to handedness. These themes illustrate the experiences of each participant. Discussion: The data collected in this study aid in identifying gaps in teachers knowledge about fine motor skills instruction and a lack of needed resources to differentiate instruction for left-handed students. Keywords: left-handed, fine motor, elementary education, left preference PERCEPTIONS OF TEACHING LEFT-HANDED STUDENTS 3 Acknowledgements I want to take this opportunity to express my gratitude to the people who have supported and inspired me during this process. Thank you to my family, who have bolstered my confidence when I needed it and demonstrated an abundance of understanding when my work on this project consumed my time. To my daughter, Adelaide, your support and pride in me make me a better person and helped me to push through the times when I felt stuck on this journey. Ryan, your unwavering belief in me and my abilities has boosted my belief in myself. For that, I am eternally grateful. To the original doctor in my family, my mom, Gayle Mink, thank you for blazing the way and encouraging me to take on this project and see it through to the end. I am eternally grateful for the grace and support I have found in my entire doctoral committee. To my content expert, Dr. Joshua Skuller, thank you for sparking my interest in school-based occupational therapy and providing your incredible insight and expertise. Your contributions have continually encouraged me to ask questions of myself and dig a little deeper. Dr. Laura Santurri, my analysis expert, you have been an invaluable support during this endeavor. Thank you for always being willing to brainstorm, offer guidance, and give me grace when I was overwhelmed. You continually provided a fresh perspective and helped me overcome this research's obstacles. Finally, to my committee chair, Dr. Lisa Borrero, thank you for agreeing to lead me down this path. Your encouragement, kindness, and expertise in the research process have made overcoming the difficulties that have emerged in this process more accessible. I am exceedingly thankful for all of you and your belief in this project, your time, energy, and compassion. PERCEPTIONS OF TEACHING LEFT-HANDED STUDENTS 4 Table of Contents Title Page.1 Abstract....2 Acknowledgments3 List of Tables.......7 List of Appendices...8 Chapter 1: Introduction....9 Problem Statement.10 Purpose Statement..10 Research Questions....10 Significance of the Study...11 Chapter 2: Literature Review.11 Foundational Skills for Handwriting.....12 Bilateral Coordination....12 Midline Crossing....13 Strength and Control..14 Visual Perception...14 Teaching Handwriting...15 Hand Preference and Lateralization...15 Handwriting Programs...16 History of Left-Handedness...18 Forced Handedness....18 Classroom Tools19 PERCEPTIONS OF TEACHING LEFT-HANDED STUDENTS 5 Grasp Pattern Differences..20 Supporting Left-Handed Students..20 Chapter 3: Method.22 Study Design..22 Participants.23 Setting....23 Procedures..24 Recruitment....24 Informed Consent...25 Data Collection..26 Data Management and Analysis27 Rigor/Trustworthiness...29 Chapter 3: Results..30 Formal Training in Fine Motor Skills30 Barriers to Teaching Fine Motor Skills.....32 Individual Needs Assessment36 Teaching Style as Relates to Handedness..37 Chapter 4: Discussion40 Formal Training in Fine Motor Skills40 Barriers to Teaching Fine Motor Skills.....41 Individual Needs Assessment ...42 Teaching Style as Relates to Handedness..43 Limitations.43 PERCEPTIONS OF TEACHING LEFT-HANDED STUDENTS 6 Implication for Practice and Future Research44 Conclusion.45 References..46 PERCEPTIONS OF TEACHING LEFT-HANDED STUDENTS 7 List of Tables Table 1: Participant Demographics55 Table 2: Theme Table56 PERCEPTIONS OF TEACHING LEFT-HANDED STUDENTS 8 List of Appendices Appendix A: Interview Guide57 Appendix B: Informed Consent ....60 Appendix C: Recruitment Flier..63 Appendix D: University of Indianapolis Institutional Review Board Notification of Approval...64 PERCEPTIONS OF TEACHING LEFT-HANDED STUDENTS 9 The Perceptions of Teaching Left-Handed Students Left-handed people have made up a small portion of the population throughout history and have been seen as abnormal or defective (Allen, 1945). In school, left-handed children were often forced to use their right hand to write and perform other motor tasks, which led to decreased motor skills acquisition (Allen, 1945). Today, children are generally allowed to develop a hand preference naturally and without outside interference. However, differences remain in how the left and right-handed students acquire gross and fine motor skills (Giagazoglou et al., 2001; Scharoun & Bryden, 2014). Several issues face left-handed students when developing and utilizing fine motor skills. Mirrored writing or letter reversing is often seen in left-handed students (Fischer, 2017) and can make writing illegible. Additionally, using an awkward grip and hand position is often associated with left-handed writers and can significantly impact speed, legibility, and ease of writing (Park, 2013). Delayed or poor motor skills at a young age can directly affect writing and cutting skills during school years (Huffman & Fortenberry, 2011). Elementary school teachers help children transition to an educational setting and acquire the fundamental skills they will use throughout their academic lives (Arslan, 2012). Given that children arrive at school with varying needs, kindergarten and first-grade teachers must accommodate these differences in their teaching approaches (Case-Smith et al., 2011; Donica et al., 2013). Within this array of differences, left-handed students may pose unique challenges for teachers in helping these students develop fine motor skills (Giagazoglou et al., 2001; Hawkyard et al., 2014). PERCEPTIONS OF TEACHING LEFT-HANDED STUDENTS 10 Problem Statement Current literature reflects a need for more information on how teachers are trained to instruct left-handed students and how they perceive their ability to deal with issues of the lefthanded student regarding handwriting instruction (Hawkyard et al., 2014). Teachers thoughts, feelings, and actions regarding their left-handed students may be vital to understanding how lefthanded students first observe and then learn some basic motor skills needed to succeed in school. Hawkyard et al. (2014) explored the role of teachers in teaching handwriting to left-handed students; however, this research is one of the only pieces of literature that does so. Additional research must be conducted to further explore teachers perceptions of instructing left-handed students. Purpose Statement This study intended to explore the perceptions of kindergarten and first-grade teachers about teaching left-handed students. Specifically, this study focused on teacher perceptions about the needs of left-handed students, what supports teachers believe they have and need to accommodate left-handed students, and what facilitators and barriers exist in teaching lefthanded students. Research Questions This study addressed the following research questions: How do kindergarten and first grade teachers perceive and experience the teaching of left-handed students? o How do teachers perceive the needs of left-handed students? o What supports do teachers believe they have or need to accommodate left-handed students? PERCEPTIONS OF TEACHING LEFT-HANDED STUDENTS o 11 What do teachers perceive to be the institutional facilitators and barriers that affect the learning process of left-handed students? Significance of the Study The findings of this study will contribute to knowledge about teachers' experiences working with left-handed students. It will provide a basis for addressing the needs of left-handed students and the staff working with them and examining educational standards and teaching strategies for potential changes. By exploring teachers' perceptions and the methods they use when teaching left-handed children, the results of this study may also inform how occupational therapists (OT) in the school system help teachers understand motor skills development for lefthanded students. Literature Review Students spend between 37 and 60 percent of their school day engaged in fine motor activities (Caramia et al., 2020). The skills needed for writing and cutting begin developing early and develop over time and with practice (Huffman & Fortenberry, 2011). Basic fine motor skills include grasping patterns, bilateral coordination, crossing midline, developing strength and motor control, and visual perception skills (Cardoso & Magalhaes, 2009; Cermak & Ayers, 1984; Cermak et al., 1980; Huffman & Fortenberry, 2011). Fine motor skill development is critical in preparing children for handwriting and cutting once they enter school (Caramia et al., 2020). Without a good foundation in all of these areas, students may struggle to develop good handwriting and cutting skills (Lust & Donica, 2011). PERCEPTIONS OF TEACHING LEFT-HANDED STUDENTS 12 Foundational Skills for Handwriting Bilateral Coordination Bilateral coordination, or the ability to use both hands or feet together to perform motor tasks, is crucial in developing motor skills. Writing and cutting skills are impacted when students lack well-developed bilateral coordination skills (Cardoso & Magalhes, 2009). Some literature found a positive correlation between bilateral coordination and academic achievement (Pacheco et al., 2016). Bilateral coordination begins developing with the appearance of the symmetrical tonic neck reflex (STNR) around four months of age (Mulligan, 2014). It is this primitive reflex that begins to help children assume a quadrapod stance, balancing on hands and knees (Mulligan, 2014). During this time of crawling and scooting, children begin to use both sides of the body together. As children develop and grow, the motor movements requiring bilateral coordination become more complex (Mulligan, 2014). The evolution of bilateral coordination also contributes to hand preference development in children (Coryell & Michel, 1978). As children use their hands together in more functional ways, they also use one hand more frequently for tasks such as reaching or initial movements when crawling (Coryell & Michel, 1978; Mulligan, 2014). This use of one hand begins lateralization of the movements of the body. Lateralization refers to the localization of a function to one side of the body (Merriam-Webster, n.d.). Lateralization in the brain means that one hemisphere is responsible for controlling activity in the body. Left-handed people are typically less lateralized in their motor movements than right-handed people, meaning they tend to perform activities with both hands (i.e., throw with their right hand but catch with their left) (Rousson et al., 2009). Some literature suggests that left-handed individuals are not as successful in motor tasks with their dominant hand as right-handed individuals (Rousson et al., 2009). PERCEPTIONS OF TEACHING LEFT-HANDED STUDENTS 13 However, other literature does not support this conclusion and hypothesizes that left-handedness is associated with a lack of motor coordination because the action looks different when done with the left hand (Tan, 1985). Furthermore, a lack of tools for left-handed people may be to blame for this appearance of motor coordination deficits (Freitas et al., 2014). Midline Crossing The body's midline is the invisible line that divides the body into left and right halves (Cermak et al., 1980). Crossing the midline to complete tasks on the contralateral side of the body is a skill needed for many fine motor tasks (Cermak & Ayers, 1984; Cermak et al., 1980). Additionally, midline crossing is related to spatial awareness and can directly impact handwriting (Cermak et al., 1980). Handwriting requires significant kinesthetic awareness, and poor handwriting can result from a child's inability to know where their limbs are in space (Cermak et al., 1980). Cermak and Ayers (1984) postulate that being able to cross midline directly relates to bilateral integration and a child's ability to manipulate objects on the contralateral side even when the ipsilateral hand is in use. One of the critical indicators of handwriting readiness is the ability of both sides of the body to work in conjunction and for the individual to cross the midline to write across their paper without needing to switch hands (Lust & Donica, 2011). Stilwell (1987) found that most children had established midline crossing by the age of 2. In addition, she described the postural compensation in which children will participate to avoid crossing midline when writing (Stilwell, 1987). Children will sometimes turn or adjust their bodies to allow them to avoid reaching across to the contralateral side when participating in a fine motor task (Stilwell, 1987). Other times students have been known to change hands when writing to avoid crossing midline (Stilwell, 1987). This inability to cross PERCEPTIONS OF TEACHING LEFT-HANDED STUDENTS 14 midline spontaneously can lead to a lack of strength in one dominant hand. It may also reduce the ability to make letters appropriately and consistently. Strength and Control Skills that develop later but are essential for handwriting and cutting are strength and motor control (Alaniz et al., 2015; Cornhill & Case-Smith, 1996). Students may begin learning to form letters, but without the necessary strength and motor control to make accurate marks, their writing will not progress past the large, cumbersome writing of a preschool or kindergarten student. As a writer develops their skills, they will need to progress from the large motor movements of the arm and wrist to more controlled motor movements of the small muscles of the hand (Huffman & Fortenberry, 2011). This progression requires control and strength in the hand's small intrinsic muscles (Alaniz et al., 2015; Huffman & Fortenberry, 2011). As the demands for writing increase, students will need these foundational skills to keep up with the demand of writing through multiple grade levels (Caramia et al., 2020). Visual Perception Visual perception (how the brain processes the visual information it receives) works in conjunction with visual motor skills to allow people to complete motor tasks (Brown et al., 2008). Visual perception consists of several different areas, including but not limited to figureground, spatial relations, visual closure, form constancy, and hand-eye coordination (Brown et al., 2008). As such, it is a complex ability and develops over time and with practice (Brown et al., 2008; Toglia, 1989). Visual perception is closely tied to writing and can significantly impact a child's ability to understand how letters are formed and how to accurately space when writing (Chang & Yu, 2017). All of the components of visual perception, such as figure-ground and form constancy, work together to allow a student to differentiate between background and figure and PERCEPTIONS OF TEACHING LEFT-HANDED STUDENTS 15 then to identify the figure even when it is a different size or in a different orientation (Brown et al., 2008; Merriam-Webster, n.d.). Form constancy helps a child identify letters even when they are bigger or smaller, placed with other letters, or at an unusual angle (Tseng & Chow, 2000). In order to be able to recall a letter they want to write, a student will need to be able to utilize their visual memory (Tseng & Chow, 2000). Spacing and letter placement are other critical components of legible writing (Tseng & Chow, 2000). Suppose students lack the visual perception skill of spatial relations. In that case, they may not be able to place letters on the lines appropriately or space correctly between letters and words, making their writing illegible (Tseng & Chow, 2000). These components come into play in writing and allow a student to identify letters and know how the components of that letter come together to make the whole (Brown et al., 2008; Lust & Donica, 2011). Teaching Handwriting Hand Preference and Lateralization When students are young, a lack of lateralization may lead to left-handed students switching between hands when completing writing tasks. A lack of lateralization may impact their ability to develop the strength, proper grip, and fine motor manipulation needed for writing at the same pace as others who have shown strong lateralization (Scharoun & Bryden, 2014). Children who do not show strong hand dominance when writing may fail to consistently build the strength needed to keep up when writing and cutting in school (Case-Smith et al., 2011; Tan, 1985). Developmentally, children obtain the ability to produce prewriting strokes in a sequence. They can develop the first of these strokes at two, and the last and most complex prewriting shapes are obtained around five years of age (Faugno, 2019). The development of these prewriting shapes sets the stage for children to be able to produce letters. Without proper PERCEPTIONS OF TEACHING LEFT-HANDED STUDENTS 16 attainment of these foundational skills, writing can be laborious and difficult for children (Faugno, 2019). Several studies discuss the need to attain these foundational motor skills to develop the fine motor skills needed for writing (Lust & Donica, 2011; Stilwell, 1987; Wang et al., 2011). Students are regularly expected to be able to write their names prior to starting kindergarten (Faugno, 2019). However, based on normal childhood development, some students are still working to obtain prewriting shapes by the beginning of kindergarten (Faugno, 2019). This discrepancy in what is developmentally appropriate for students and the standard in kindergarten may also lead to difficulties in learning the foundational skills for writing and cutting (Faugno, 2019). Handwriting Programs Several programs exist to help children learn letter formation and spacing, including Handwriting Without Tears, Write Start, Write Direction, and Loops and Other Groups (Engel et al., 2018; Thompson, 2003). Each of these programs addresses letter formation differently, and all are curriculum-based handwriting tools that aim to improve a student's handwriting legibility and fluency (Engel et al., 2018). Handwriting Without Tears addresses left-handed students' needs by being cognizant of how they place the letter models in their workbooks so that lefthanded writers do not cover them with their hands when writing (Cassidy, 2018). Handwriting without Tears and Loops and Other Groups both use a kinesthetic approach to handwriting and incorporate a multi-sensory approach to writing, leading to greater retention of letter formation for students (Lust & Donica, 2011; Thompson, 2003). Left-handed people tend to complete some parts of letter formation, such as horizontal line-making, with a right-to-left motion (Cole, 1939; Suitner et al., 2015). Most curriculum-based programs show specific ways of forming letters and do not account for this difference in formation for left-handed writers. PERCEPTIONS OF TEACHING LEFT-HANDED STUDENTS 17 Many states within the United States no longer require handwriting to be taught as part of the common core standards (Davis, 2018). As many as 45 states no longer require teachers to teach handwriting specifically (Davis, 2018). Cantin and Hubert (2019) found that 57% of teachers interviewed teach handwriting to their students. 77% of the kindergarten teachers interviewed focused on handwriting; by third grade, most teachers did not specifically teach handwriting (Cantin & Hubert, 2019). The expectation is that children will enter school at five years old, already having a foundational knowledge of letter formation. As was noted before, the development of the final prewriting strokes can occur as late as six years of age. This gap in what is expected or explicitly taught in schools and what is developmentally appropriate could leave many students struggling with writing. While the literature suggests a need for handwriting programs and interventions (CaseSmith et al., 2011; Edwards, 2003; Wenze & Wenze, 2004), limited research exists about how handwriting programs, specifically programs for left-handed students, benefit teachers and students. Left-handed students would benefit from handwriting programs focused on specific challenges facing these students, including letter reversing (Fischer, 2016). Letter reversing is not exclusively a trait of left-handed students; however, a disproportionate number of left-handed children reverse numbers and letters (Fischer, 2016). In part, left-handed students have increased difficulty with letter formation due to the left-to-right writing direction (Fischer, 2016; Smetacek, 1992). Additionally, there is literature dedicated to discussing the hand and wrist positioning of the left-handed person (Park, 2013). Owing to the nature of writing from left to right as a lefthanded person, many students will adopt an awkward grasp and wrist position when writing, which leads to poor writing speed and illegible writing (Smith, & Reed, 1961; Todor, 1980; Park, 2013) PERCEPTIONS OF TEACHING LEFT-HANDED STUDENTS 18 History of Left-Handedness In the past, left-handedness was seen as a defect and was associated with disorders such as intellectual disability, attention deficit and hyperactivity disorder (ADHD), and other learning disabilities (Rousson et al., 2009; Tan, 1985). Because of this association, one common practice was to force children to use their right hand, despite indications that they preferred the left (McManus et al., 2010). As many as eighty percent of left-handed people educated in the first part of the 1900s report being encouraged to use their right hand for writing (Searleman & Porac, 2001). One researcher in the 1920s developed an experiment to formalize this switch to using the right hand and reported that making a switch to the right hand could be done without "emotional upset" (Morsh, 1930). Several methods were used into the mid-20th century to induce a person to switch hands, and some people report coercion, pressure, and threats as means of encouraging this switch (Searleman & Porac, 2001). Because the practice of pressuring students to use their right hand continued so far into the 20th century, it is unsurprising that so little literature exists surrounding the teaching of handwriting to left-handed students. Forced Handedness Within the historical literature about left-handedness, there exists a theme of encouraging left-handed persons to switch to using the right hand (Morsh, 1930; Porac, 1996; Porac & Buller, 1990; Searless & Porac, 2001). In Morsh's study, he reported that one could solve the "problem" of what to do with a left-handed student using the correct methodology. Morsh (1930) says that students will not lose the habit of writing with the left hand but will develop skills with the right hand that are equal to or surpass those of the left hand. Searless and Porac (2001) found that many left-handed adults fell into one of three categories. Left-handed adults had either never been encouraged to switch to the left hand, had been encouraged to switch and had been PERCEPTIONS OF TEACHING LEFT-HANDED STUDENTS 19 unsuccessful, or had been encouraged to switch and had been successful. They concluded that people who strongly preferred the left hand could not switch to the right hand for activities or had never been encouraged to switch (Searleman & Porac, 2001). They also suggest that people who could switch to using their right hand may have initially had a predisposition to right lateralization (Porac, 1996; Porac & Buller, 1990; Searleman & Porac, 2001). The documented pressure to switch to using the right hand, combined with the lack of literature surrounding how left-handed children develop fine motor skills, indicates a need for further data to address this issue. Classroom Tools Many of the tools used in the classroom accommodate right-handed users (Coren & Halpern, 1991). Things such as scissors, writing desks, spiral notebooks, and several other commonly used tools pose challenges for left-handed students (Coren & Halpern, 1991; Aggleton et al., 1993). While these may seem like small barriers to classroom facilitation, these can cause problems for young children trying to develop fine motor skills (Coren & Halpern, 1991). Issues such as wrist placement when writing, awkward scissor grasp, and poor coordination when performing fine motor tasks can sometimes be attributed to a lack of tools designed for left-handed users (Coren & Halpern, 1991; Aggleton et al., 1993). While some tools exist, such as left-handed scissors and left-side writing desks, these may only sometimes be available to students (Aggleton et al., 1993; Coren & Halpern, 1991). Furthermore, many students will learn to modify their tasks to use right-handed tools (Aggleton et al., 1993; Coren & Halpern, 1991). Mitchell et al. (2012) reported several different grasps for cutting. They emphasized the importance of different types of scissors used when cutting because this PERCEPTIONS OF TEACHING LEFT-HANDED STUDENTS 20 impacted how they were used (Mitchell et al., 2012). In practice, this can be important to teachers and occupational therapists in selecting tools they use with each student. Grasp Pattern Differences Grasp patterns in writing vary between people, and a growing amount of research suggests that there are several different functional grasp patterns (Schwellnus et al., 2012). Schwellnus et al. (2012) found no significant difference in legibility and speed among students with differing functional grasp patterns. The researchers did find that when students did not use a traditionally functional grasp pattern, they had difficulty with legibility and speed of writing (Schwellnus et al., 2012). There is also a body of literature that suggests that children who struggle with developing and utilizing a functional grasp pattern or who use a grasp that requires more work to be done by the wrist and arm than the fingers result in slower and less legible handwriting (Schwellnus et al., 2012). Teachers often have the task of helping children develop appropriate grasp patterns for writing when they enter kindergarten (Schwellnus et al., 2012). Some differences exist in how left-handed children may need to hold a pencil to be successful in writing. Due to the nature of writing left to right, left-handed writers must adjust their grip to see the end of the pencil and the writing they are completing (Cole, 1939; Suitner et al., 2015). Without specific training in how best to hold a pencil when writing with the left hand, students may begin to adopt awkward grasps on their pencil and may crook their wrists or slant their paper to accommodate (Park, 2013). Supporting Left-Handed Students While there is a diversity of literature on teaching handwriting in the classroom, there needs to be more current information on how teachers address left-handed students when teaching complex motor skills, such as writing and cutting (Hawkyard et al., 2014). In this PERCEPTIONS OF TEACHING LEFT-HANDED STUDENTS 21 literature, there are discussions of the outcomes of teaching handwriting and the extent to which handwriting programs benefit students. Edwards (2003) explored the benefits of direct instruction in handwriting with kindergarten and first-grade students. The author found that letter form knowledge plays a significant role in how well children can motorically produce a letter, spell, and communicate through written work. Although there is no consensus within the research as to what type of program for handwriting works best, such as a multi-sensory approach (Case-Smith et al., 2011) or intense practice (Howe et al., 2012), the evidence suggests that direct instruction in handwriting and a multimodal handwriting instruction does improve speed and legibility in writing (Case-Smith et al., 2011; Howe et al., 2012). The literature demonstrates a need for increased emphasis on handwriting and other motor skills development directed at left-handed students. A gap in the literature exists in how best to support this population. Hawkyard et al. (2014) explored the difficulties faced by lefthanded students and the perception of teachers concerning handwriting and left-handed teaching students. The students and teachers indicated several areas of concern. Students self-reported being slower when writing and not as neat as their right-handed counterparts. They also indicated fatigue when writing. They discussed a need for more access to equipment specifically for lefthanded students, such as pencil grips and left-handed scissors. Teachers indicated a need for support in instructing left-handed students and feeling that left-handed students needed additional help when learning to write. The study by Hawkyard et al. (2014) is one of the only studies to examine the lived experiences of left-handed students and teachers navigating this phenomenon. However, current literature needs to fully explore the experiences of kindergarten and first-grade public school teachers in the United States and how their training and experiences have prepared them for working with left-handed students. PERCEPTIONS OF TEACHING LEFT-HANDED STUDENTS 22 Overall, there is a clear difference in how left and right-handed students perform fine motor tasks (Gabbard et al., 1995; Giagazoglou et al., 2001). For example, left and right-handed students show significant differences in the speed at which they perform motor tasks and their ability to form letters in the appropriate direction (Gabbard et al., 1995; Giagazoglou et al., 2001). The literature does not say whether these differences in left and right-handed performance stem from an innate difference or a difference in training. A further understanding of teachers' experiences is needed to fill in the gaps in the research about best practices for teaching left-handed students. Gaining an understanding of their experiences and perceptions about how left-handed students function in the classroom, how they perceive the way left-handed students are being taught, and their thoughts about barriers and facilitators to teaching these students could provide key insights into developing strategies to support teachers in the classroom and provide a more well-rounded educational experience for these students. Method Study Design Researchers in this study used a qualitative basic interpretive approach. This specific methodology facilitated an exploration of how teachers understand their experiences with lefthanded students, specifically while teaching them fine motor skills (Merriam, 2002). The researcher collected data by conducting semi-structured interviews meant to elicit both rich descriptions of experiences and the ways in which participants perceive their teaching and teaching philosophy (Creswell & Poth, 2018). The researcher obtained approval from the Institutional Review Board of the University of Indianapolis (Appendix D) before proceeding with study activities. PERCEPTIONS OF TEACHING LEFT-HANDED STUDENTS 23 Participants Given that a basic interpretive study seeks to understand participants' breadth of experience, smaller sample sizes of 3 to 15 are deemed appropriate (Creswell & Poth, 2018). To obtain varying perspectives from participants of different teaching backgrounds and who have been teaching for various lengths of time, the researcher utilized the concept of information power (Malterud et al., 2015) to determine sample size. According to Malterud et al. (2015), several factors should be assessed to decide the sample size. For this study, the broad study aim, lack of an established theory, and use of cross-case analysis indicate a need for a larger sample size (Malterud et al., 2015). However, the sample was very specific and only included elementary school teachers; this, coupled with the likely strong quality of dialogue, would indicate a smaller sample size (Malterud et al., 2015). Taking this into account, a convenience sample of 8 participants was selected for this study. The researcher assessed needed changes to the sample size throughout the study (Creswell & Poth, 2018; Maltrud et al., 2015). The inclusion criteria for this study included public school teachers who self-reported having experience instructing left-handed students and who currently teach or within the last year taught kindergarten and first grade. Teachers experience helped determine their appropriateness for the study. Those with more time teaching students with disabilities than with typically developing students were excluded from the study. Setting Participants were primarily recruited from among nine elementary schools in a district that serves roughly 12,000 students from rural and suburban settings. The district is located in the Southeastern U.S. and is among 120 other county school districts in the state. The district PERCEPTIONS OF TEACHING LEFT-HANDED STUDENTS 24 ranks high in academic achievement and on college readiness assessments. The school district serves a growing number of students eligible for special education. Procedures Recruitment The researcher obtained permission to conduct the study as well as permission to obtain email addresses for elementary school teachers from the school system by first providing information about the study to the schools attorney. The school districts policy is to get a release from the districts attorney prior to any recruitment of staff, and the researcher obtained a letter of cooperation from the district. During the second semester of the 2020-2021 school year, the researcher placed recruitment fliers (Appendix C) in the school mailboxes of each of the kindergarten and first grade teachers. The fliers included language stating that the study intended to explore teachers perceptions about teaching fine motor skills to left-handed students. The fliers also stated that the interviews would take place virtually, mentioned that participants would receive a 20-dollar gift card incentive upon completion of the initial interview and included the researchers contact information. Interested teachers were instructed to contact the researcher via phone or email to express interest and learn more. When a teacher made contact to express interest in the study, the researcher answered questions about the study and obtained initial consent via email for participation. During that initial exchange the researcher also screened participants for eligibility, explained the studys purpose, reviewed methods to protect confidentiality, and discussed expectations of participants. The researcher also discussed the duration of participant involvement, including member checking, and how long the initial interview could be expected to last. A virtual or phone interview was then scheduled at the participants convenience. After the recruitment conversation, and prior to the interview, the PERCEPTIONS OF TEACHING LEFT-HANDED STUDENTS 25 researcher emailed a study information sheet to the participant. This study information sheet addressed study details, such as voluntary participation, confidentiality, and potential risks and benefits of participation. The researcher also used snowball sampling by asking current participants if they could recommend other teachers that may meet the studys inclusion criteria. The researcher used group emails, visits to each school, and social media to recruit participants. The researcher asked principals at each school to send out information about the study via email to the teaching staff. The researcher is a pediatric occupational therapist who works in the school system. She specializes in remediation of fine motor skills in school-aged children. She is associated with teachers through working with students in their classrooms. The researcher attempted to recruit participants with whom she was not familiar by recruiting from multiple schools within the district. However, several of the participants were teachers with whom the researcher worked directly. In order to combat bias in the study, the researcher coded the data alongside another member of the committee, conducted member checking, and explored other data sources, through literature review, to triangulate the findings. Informed Consent Informed consent (Appendix B) was sent to participants during the initial recruitment correspondence with the participant and was reviewed immediately before the interview began. At the time of the interview, the researcher reviewed key components of the study information sheet (previously sent to the participant), specifically regarding the study aim, risks and benefits of participating, the right to withdraw at any time, and methods to protect participant confidentiality. It was also explained that an incentive, in the form of a $20 gift card, would be offered to all participants at the conclusion of the initial interview. The researcher also answered PERCEPTIONS OF TEACHING LEFT-HANDED STUDENTS 26 questions the participant had about the study, then asked the participant to provide verbal consent to participate. By following this process, the researcher took steps to identify any questions or concerns the participants had about the study and ensured that fully informed consent took place (Dranseika et al., 2016). Data Collection Data collection consisted of one in-depth, virtual interview with each participant. Prior to each interview, the researcher discussed the aims of the study, provided time for the participant to ask questions, and provided information about the follow-up check-in. Informed consent was also re-established verbally. Additionally, permission to record the interview was verbally obtained, and each participant was informed that if at any time they wished to stop the interview or decline to answer a question, they could do so without repercussion. One interview took place on the phone; all others took place virtually using Google Meet. All interviews were audio recorded using Voice Memos on the researchers password-protected computer. Initial interviews ranged in length from 21 minutes to 76 minutes. The researcher kept a field journal during the interviews to make note of significant information received from the participants and to engage in reflexivity by identifying thoughts, perceptions, and preconceived notions of the researcher. Each interview followed a semi-structured interview guide (Appendix A). The interview started out with more focused questions to obtain background information and any other information that the participant deemed relevant to their experience. From there, the questions became broader as the interview progressed. As the questions were asked by the researcher, new topics arose that were explored through the use of probing and follow-up questions. In this manner, the researcher deviated from the interview guide to follow new lines of PERCEPTIONS OF TEACHING LEFT-HANDED STUDENTS 27 discovery as they presented themselves. However, the researcher returned to the guide in order to maintain consistency among interviews. Interview questions were open-ended and included questions about behavior and experience, as well as opinion questions. The interviewer stopped throughout the interview to do perspective checking in order to make sure understanding by the researcher was achieved. The interview was concluded when the researcher had asked all prepared questions, and any questions arising from the final prepared question were answered by the participant. Data Management & Analysis Audio recordings were transcribed verbatim using Temi transcribing software and were checked for accuracy by the researcher. To maintain confidentiality, audio recordings and notes were de-identified by assigning a participant identification number and kept on a passwordprotected computer in the possession of the researcher. Notations written during the interviews were paired with the transcriptions. Dedoose (version 9.0.62), a qualitative data analysis software, was used to analyze and store the data. The Dedoose software also allowed the researcher to form an audit trail, including thoughts, perceptions, and preconceived notions of the researcher, in order to improve rigor within the study (Creswell & Poth, 2018). The researcher began coding the data by listening to the audio recordings while reading through transcriptions, stopping and re-listening as needed (Creswell & Poth, 2018). Coding was done in Dedoose and did not contain any identifying information from participants. A first round of listening and reading was performed to allow the researcher to establish an overall understanding of the interview. A second round allowed the researcher to perform within-case coding (Creswell & Poth, 2018). PERCEPTIONS OF TEACHING LEFT-HANDED STUDENTS 28 At the conclusion of each interview, the within-case coding process took place and the researcher assigned a code to specific portions of the interview that pertained directly to the research question. Key words and phrases were used to identify the data that related to the research question and sub-questions (Glser, & Laudel, 2013). The researcher put codes from individual interviews into a codebook within Dedoose and included individual codes, their descriptions, and representative quotes from the data. Establishing a codebook for each interview allowed for easier cross-case coding and theme development. The researcher worked directly with the analysis expert to establish initial codes from one interview. After this process was carried out, the researcher used initial codes to continue coding the remaining interviews. Both the researcher and the analysis expert worked independently to identify codes and individual interview themes (Creswell & Poth, 2018). Once coding was completed for all interviews, the researcher worked with the analysis expert to begin to categorize codes and look for themes in the data (Creswell & Poth, 2018). The researcher developed themes by reading through coded interviews and looking at categorized codes and logging patterns (Creswell & Poth, 2018). A third analysis allowed the researcher to check within interview themes and compare them to the researchers initial perceptions. The researcher kept detailed notes in Dedoose during the coding process (Creswell & Poth, 2018). The meaning of the interviews was further clarified through member checking, during which the primary researcher followed up with participants via email and through social media messaging by sending them their individual themes with a request that they respond via email to ensure that the researcher correctly interpreted their experiences (Doyle, 2007). Member checking took place with participants, allowing them to provide feedback on how their interview PERCEPTIONS OF TEACHING LEFT-HANDED STUDENTS 29 was interpreted. Five participants responded to member checking attempts. One participant asked that the researcher add an observation to her understanding of the participants experiences. To identify overarching themes in the data, cross-case comparisons were made (Creswell & Poth, 2018). To this end, the full codebook within Dedoose was analyzed to compare themes drawn from each interview. The Dedoose softwares analysis features and collaboration with the analysis expert were utilized to move from individual to overarching themes within the coding. A master theme table was developed from the codebook to include overarching themes evident in multiple interviews (Creswell & Poth, 2018). Rigor/Trustworthiness To increase the confirmability of a study, researcher can identify ways to reduce bias in the research process (Henderson & Rheault, 2004). For example, in the present study, to identify and neutralize bias as much as possible, the researcher conducted reflexive analysis by sharing the researchers background and utilization of a field journal within Dedoose (Fischer, 2009). Several tools were put into place to ensure rigor and trustworthiness in data analysis and management. The use of a two-researcher evaluation, where the researcher will code and then the analysis expert will code the same data to form an initial codebook, maintained consistency during the coding process. The researcher also kept detailed descriptions of methods and created a digitized copy of the field journal to retrace the researchers steps when drawing conclusions about the data (Creswell & Poth, 2018). The use of an audit trail within the Dedoose software allowed the researcher to track the coding process and see how conclusions were drawn (Creswell & Poth, 2018). To establish credibility in research, definitions of themes and codes are straightforward and reflect the participants realities, which were established through member checking. PERCEPTIONS OF TEACHING LEFT-HANDED STUDENTS 30 Henderson and Rheault (2004) indicate that studies where the experiences described by the participants are relatable have more credibility. The researcher demonstrated reflexivity by providing the researchers background knowledge and investment in the research, and by maintaining a field journal to identify biases (Creswell & Poth, 2018). Results Eight participants completed the study (see Table 1). All participants were women elementary school teachers either currently teaching kindergarten or first grade or who taught one of these grades within the last two years. All participants taught most of the time in the general education setting, teaching typically-developing students. One participant spent the last few years as an instructional assistant in a kindergarten classroom while maintaining her teaching certification. Two participants reported having a left-handed child and one participant reported being left-handed. During these in-depth interviews, participants provided keen insights into their general perceptions of teaching fine motor skills and teaching style. While analyzing the data, four themes (see Table 2) became apparent and tied together the participants' experiences. All participants discussed their formal training in fine motor skills, barriers to teaching fine motor skills, individual needs assessment, and teaching styles related to handedness. These themes contain various influencing ideas that participants discussed in different aspects of their teaching experience. Formal Training in Fine Motor Skills Despite their various backgrounds and time since graduating from college, the participants all reported that their formal education had not prepared them to teach students fine motor skills. Participant Five wished the college program would offer more informationalso, PERCEPTIONS OF TEACHING LEFT-HANDED STUDENTS 31 emphasize that it is not all right-handed kids" concerning teaching fine motor skills to lefthanded students. They all reported feeling that they lacked motor skills training, and several indicated they had been self-taught or learned through trial and error with students. Participant Seven stated: Over the years, I have just gathered from, you know, from [the occupational therapist], and from other teachers, and interventionists, just skillsto build those fine motor skills, especially if kids come in and have never really held a pencil and used scissors. Many reported learning ways to teach fine motor skills through other teachers, internet searches, and working with an occupational therapist in their school. Ive sought out myself information just out of interest and knowing that thats not a strength of mine, stated Participant Three. Participant Eight reported, I have some practice papers that I have acquired from other teachers over the years where they practice cutting straight lines and then they have to stop, and one is curved. Participants reported that their formal training tended to focus more on academics (writing, reading, and math) despite fine motor skills development being foundational for elementary school children. Participant Five also discussed her concern with not having been formally trained to address fine motor skills and her experience that, if left to their own devices: They [students] are either going to use the skills they learned, which may not have been correct, to begin withor they took upon themselves to figure it outand then sometimes it is really hard to get them to correct those skills and do it the right way so that it doesn't cause deficiency later on. Participants also discussed the continuing education and professional development (PD) they had received in the school system. Only one participant noted attending a PD course supporting fine PERCEPTIONS OF TEACHING LEFT-HANDED STUDENTS 32 motor skills development, which was offered at her school by the occupational therapist. Many participants communicated that PD courses would be an excellent way to inform practicing teachers about fine motor strategies for left-handed students. I feel like professional developments, or even like a handout or something. You can look it up, and I have tried to look up stuff before, but Im never sure what is like the correct thing to actually teach, stated Participant Six. Other participants said a list of resources they could use when they had a lefthanded student would be the best way to provide them with this information. Participant One said, "Maybe some links to articles or websites would be great. Videos, you know, like YouTube videos or whatever, that would show us what we need to know." Some participants, like Participant Two, said they felt their college education classes should address it: I think first they need to have something in like college when you talk about it [lefthanded fine motor skills development]. Cause we do talk about left-handed brains and right-handed brains, and that sort of stuff could kind of go along with it. Participants believed discussion in their education classes, especially for teachers going into elementary education, would be beneficial. Participant Eight discussed her feelings about her formal education and fine motor skills training: College did not prepare me at all for teaching fine motor. We can't even blame it that I'm not a preschool certification cause I am certified K [kindergarten]. So, you can't blame it on that because, at any point, anyone with my degree could be teaching K. Barriers to Teaching Fine Motor Skills Across all interviews, participants described the barriers to teaching fine motor skills. An overarching theme in participant perceptions was the difficulty in finding the balance between PERCEPTIONS OF TEACHING LEFT-HANDED STUDENTS 33 what is part of the mandated curriculum and what is needed in the classroom to make students successful. Participant Six reported: [at the beginning of the year] I had like 20 minutes where I could do the letter formation, letter review. But now that weve gotten into like all the other stuff, it's been cut down to like five or ten minutes, and then some days it's like, oh, we might not have time for this. Participants reported spending 5 to 20 minutes across the day teaching fine motor skills to their students. Participant Two reported that "because it was not in our curriculum that, I would slide it in there, when asked about when and how long they spend on teaching fine motor skills. Participant Four reported, "I did it because I chose to; I wasn't required to. In discussing finding time to address fine motor skills with their students, Participant Five said, "Not enough, not enough. And every year, we talk about it. Participant Three expressed, "I feel like this might be a weakness in the K [kindergarten], one [first grade] program. Overall, most participants wished there was more time during the school day to develop fine motor skills. However, two participants reported that they spent a lot of time teaching fine motor skills in the classroom. Both participants reported spending 20-30 minutes a day teaching handwriting and cutting at the beginning of the year. Participant One stated, at the beginning of the yearit can be more because we have beginning year, we have activities that require cutting. we have, glue stick college, and scissor diplomas, and things like that. Many participants noted that the academic demands in reading and writing for kindergarten and first-grade students have increased over the years. Based on participant report, the emphasis appears to be on writing composition, and the goal was to have paragraphs out of K [kindergarteners] by the end of the year. Participant Five stated, "so much academic is being pushed on 'em right now and "they can barely write a sentence, and you're wanting them to PERCEPTIONS OF TEACHING LEFT-HANDED STUDENTS 34 write a paragraph. A significant focus on writing composition instead of mechanics appeared to be the experience of most participants. Many noted that with this as the end-of-the-year expectation, they had to move into teaching these higher skills quickly and had less time to spend on handwriting and cutting skills. I feel like weve moved to academics and that you only address the kids that are, I guess, deficient in that area," said Participant Three. Participant Eight said, "before common core [current teaching standards], I felt like I had more time in my day to work on fine motor skills. Some schools and teaching teams have implemented phonics programs and other global curriculum-based programs to help teach handwriting alongside reading instruction. Several participants noted that this was a way they found to teach the fundamentals of handwriting in their limited time. Participant Three described the program they use, Successful Start, The writing component is embedded in it. So, its a subtle way, but its like when youre teaching them sounds and letters and what they look like in a book, youre also teaching them how to write it too. Participant One discussed Handwriting Heroes as a program they use to teach the shape and formation of letters. Another integrated program that includes verbal directions for teaching letter formation was discussed by Participant Six as the Lucy Caulkins Phonics Program. And so she has like a path of movement for handwriting. Six out of eight participants indicated that they used an integrated or stand-alone program to teach letter formation. The participants noted cutting skills and handwriting instruction for left-handed students less often. One participant discussed awareness of resources from Handwriting Without Tears for left-handed students. Most participants described minimal knowledge of how to obtain resources for left-handed students for handwriting skills. Despite a statement from Participant Eight, I think they have a little bit harder time cutting," and Participant Seven, what I have noticed this PERCEPTIONS OF TEACHING LEFT-HANDED STUDENTS 35 year is just with cuttingit just seems so awkward to them, few participants noted using any specific strategy or techniques for addressing cutting skills with left-handed students. Many stated they would model using a thumbs-up technique and place the scissors in their hands to show them how to perform the activity. Participant One reported, "there are a few videos that I've used, tips to show kids, and there's a song, when asked about teaching cutting skills in general to her class. Most participants also noted that they did not have left-handed scissors in the classroom. Participant Four reported that "the only thing I've ever come across was one pair of scissors when discussing what available tools she had in her classroom for left-handed students. Students typically bring their school supplies, but participants did not report whether left-handed students brought left-handed scissors. Participant Eight said, I dont even know if parents of lefties are aware that they make left-handed scissors. Two participants noted that they had purchased left-handed scissors for students if needed. Overall, most participants were unaware of tools available for left-handed students or did not know how to obtain tools for their left-handed students. Another barrier reported by several participants was the change in foundational skills in incoming kindergarteners and first-grade students. Some of this change was related to the COVID-19 pandemic and the long periods when students received instruction at home. Participant Two discussed the impact of the pandemic: "you have kindergartners who haven't had a full year in school yet that are going to be in first grade without an aide [classroom paraprofessional]." Participant Six said this of the effects of at-home learning on fine motor skills, "the whole class does seem more behind in that area. They seem more like at the preschool level. Another identified contributor to this change was this move fromkids coloringwhich has now been replaced with iPads and gaming. Participant Two attributed this PERCEPTIONS OF TEACHING LEFT-HANDED STUDENTS 36 change in foundational skills to technology and her feeling that students do not get as much time doing activities with their hands and building hand strength and endurance. Participant One said, a lot of kids come in anymorewithout very good hand gripor like hand strength. Individual Needs Assessment Nearly all participants in this study discussed using individual needs assessment to determine each students strengths and weaknesses. Participant Five stated, when discussing individual needs assessment, "I approach each child differently because each of them learns in a different way." Participants had different ways of completing this task, but all indicated that it was an ongoing part of their job. Many reported that they structure their classrooms to allow them to work with students in small groups or a one-on-one setting several times throughout the day to meet students academic needs. Participant Four stated: I did like group work, like small groups with them. I would try to make sure that I had activities that specifically used those skills in some way, [letter] shape, or form. So, some groups might be writing the sentences. Some groups might be cutting the sentences out and pasting them down, whatever was appropriate for that level or what they needed. Participants used this time to address academic goals and assist students who were struggling with other tasks, such as writing and cutting. Several participants indicated that these small group settings were the only time they could focus on teaching fine motor skills instead of letter formation or phonics programs that may include several different skills. These small group sessions are teacher-implemented and highlight the value the participants' place on fine motor skills development. Participant Six reported: I think in kindergarten, just with fine motor skills, I'm just trying to help them hold a pencil the correct way. And then just making sure that they have enough strength to, like, PERCEPTIONS OF TEACHING LEFT-HANDED STUDENTS 37 use scissors and glue, which is kind of hard. I think because curriculum doesn't always allow that, but I think I try to incorporate that in like morning work and fun activities as much as possible. Most participants reported using these groups to address fine motor skills if a student struggled with some part of handwriting or cutting. In addition to using small-group instruction, participants also noted that they would modify writing or cutting tasks for some students during whole-group instruction. Participant Two stated that "it's a lot of differentiation at the beginning of the yearlike with cuttingyou might give them a smaller one or precut part of it out. Participants also pointed to this use of differentiation and meeting the students at their developmental level when discussing the needs of left-handed students. Most participants indicated that they only differentiate their way of teaching left-handed students if the student seems to be having difficulty with the task. When discussing why she does not change her approach for left-handed students, Participant Four said, "I don't think I adjust a lot because I don't know what to do." However, several participants expressed that left-handed students are "a little more time intensive and that they spent more one-on-one time with some of their lefthanded students because they may need to be modeling it, the left-handed way. Participant One discussed one element that makes left-handed students more time intensive: I think that's one thing is left-handers aren't always left-handed cutters. So, after you have to kind of determine what's what, which is really hard when they're young, because they don't know other than just to show you which one it feels right. Teaching Style as Relates to Handedness For left-handed students, participants reported using a variety of adaptations and strategies that have helped address the needs of these students. Participants reported adapting PERCEPTIONS OF TEACHING LEFT-HANDED STUDENTS 38 how they teach finger spacing for between word spacing when working with their left-handed students. Participant Two noted that she changed where her students sat if she had a left-handed student to ensure they were not bumping elbows with the student next to them: If you put two kids side by side and one's left, and one's right, that is going to either annoying the person to the left bumping in, or they don't have to put the kids like that. I prefer to put them on the end so that they have that whole table to themselves. Participant Three reported, "I get side by side so they can see its in my left handthe orientation is really important when discussing modeling with her left hand for cutting tasks. Participants also reported helping students adjust their wrists when using dry-erase boards because left-handed students sometimes erase what they have written when using their left hand. Participant Four also noted that she had moved some students from writing in a spiral notebook or binder to loose-leaf paper, so they do not hit their hands on the binding. I think sometimes adjusting what they use is needed. A regular notebook is not necessarily effective for them. Participant Two reported another strategy she used to help a struggling left-handed student, I remember one kid not getting it. And so there was a left-handed fifth grader that I had had before, and they came down and kind of modeled. Overall, the participants reported a wide variety of ways that they changed or shifted their teaching style to meet their left-handed students' needs. Most reports of these accommodations came from participants who had been teaching for some time. The participants reported receiving fine motor strategies from other teachers during group meetings or asking questions when they had a struggling student. Participant Six reported, I reach out to the kindergarten team a lot with those kinds of questions. Others indicated that they seek out the occupational therapist for help with fine motor strategies or for students who PERCEPTIONS OF TEACHING LEFT-HANDED STUDENTS 39 struggle with performing these fine motor tasks at the level. Participant Four said, I have no idea. If I had a question, Id probably try to find an occupational therapist." Though many participants reported doing a lot of their own research to find strategies for fine motor skills, only a few noted searching out strategies for left-handed students. Several participants discussed needing help finding resources. Participant Eight summed up some of her colleagues' feelings with this statement I feel like theres not enough information out there. A few common characteristics emerged when discussing teaching style and experiences with left-handed students. Participant Five said that left-handed students "come up with some of the most interesting ways to hold their tools. Participant Three noted that they have a creative side to them. Yeah, they think differently. Several participants discussed that their left-handed students seemed to move at a slower pace with fine motor skills, and what they see the most is their [students] fear of falling behind, said Participant Five. Participants who identified this as a characteristic of left-handed students said they try to encourage them to take their time and move at their own pace. Participants reported that left-handed students were more likely to get frustrated with fine motor skills than right-handed students. They may have trouble keeping up because using the available tools is more difficult than it is for their right-handed peers. Participant Three reported, "[Students get] frustrated because they aren't successful compared to their peers." Participant Four stated, when discussing using dry-erase boards in the classroom, "I do see the left-handed kiddos getting frustrated sometimes with the smearing aspect or the erasing aspect. So they are a little more hesitant or frustrated. Participant Eight described another struggle she sees with her left-handed students when writing: A trouble that, over the years, my lefties have had during writing workshop, and sentence writing is we start out the year with, you know, the thicker Popsicle sticks the kids use as PERCEPTIONS OF TEACHING LEFT-HANDED STUDENTS 40 their spacers. Now for the right-hand kids, that works great and helps them. Right. But for the lefties, it confuses them more because they like the Popsicle stick kind of gets in the way of them. So I need some spacing help for my left kids. Many participants reported similar formal education, experiences with teaching fine motor skills, and barriers they perceived to teaching these skills. Participants' experiences with left-handed students and their strategies did vary. However, all participants indicated that they could use more support in this area and additional resources to help them address the needs of their left-handed students. Participants also had similar ideas of providing resources and support to allow them to feel more confident when teaching this population of students. Discussion Formal Training in Fine Motor Skills This study sought to better understand the experiences and perceptions of kindergarten and first-grade teachers in teaching fine motor skills to left-handed students. From eight teacher interviews, the researcher discovered that teachers felt they had not received enough formal education to teach their students fine motor skills. None of the teachers reported spending time on fine motor skills during their college courses, and only one teacher had professional development in this area after entering the teaching field. This lack of formal education in this area and the pressure to address an abundance of academic standards left teachers feeling like they needed more support in fine motor skills instruction. Like teachers in this study, Donica et al. (2012) reported stress related to an imbalance between requirements and resources, noting that they did not feel they had time to devote solely to handwriting instruction. This study's findings are similar to those of Cantin and Hubert (2019) and Case-Smith et al. (2011), where teachers reported being unsure of best practices for teaching handwriting skills. In the current PERCEPTIONS OF TEACHING LEFT-HANDED STUDENTS 41 study, teachers reported using various handwriting curriculum programs, which varied from year to year, even within the same school. This lack of continuity of instruction may lead to difficulty for students and teachers. Teachers in this study discussed how they obtained information about teaching their students fine motor skills and identified several resources, including other teachers, internet searches, and collaboration with the occupational therapist in their building. Teachers felt they had to independently seek out information on this topic and continued to express concern about getting the most current and accurate information about teaching fine motor skills. When discussing resources available for teaching their left-handed students, the responses became much briefer. Teachers reported needing to learn how to differentiate their teaching specifically for left-handed students. Barriers to Teaching Fine Motor Skills Teachers in this study identified several characteristics of their left-handed students, such as struggling with spacing, pencil grasp, and wrist position, consistent with previous studies focused on left-handed students (Smith, & Reed, 1961; Park, 2013). Several teachers reported wanting to know what tools existed for their left-handed students. Teachers that did identify tools they had in their classrooms, such as left-handed scissors, reported purchasing these tools themselves. Teachers in this study reported a decrease in foundational fine motor skills in incoming kindergarten students both prior to and after non-traditional instruction related to the COVID-19 pandemic. Most teachers cited the pandemic, lack of in-person instruction, and increased technology use by students as their explanations for this decrease. Watts & Pattnaik (2022) also found that teachers reported a decrease in fine motor skills following the return to in-person PERCEPTIONS OF TEACHING LEFT-HANDED STUDENTS 42 instruction after the COVID-19 pandemic. Teachers in that study noted that incoming kindergartners had delayed fine motor skills compared to the previous years' incoming kindergarteners. Several teachers in this study felt that over the past 5 to 8 years, students spent more time playing video games and using technology instead of engaging in hands-on play activities. Along the same line of thinking, students learning at home during the pandemic would have had more screen time and less time using pencil, paper, or scissors. However, Bedford et al. (2016) found that not only is there no evidence to suggest that early use of touch screen devices inhibits fine motor skills development, but there may be a positive correlation between the two. These authors found that children were more likely to show finger isolation and related dexterity due to children's strong preference for touchscreen devices (Bedford et al., 2016). Individual Needs Assessment Assessing students' needs and creating a plan to support students in areas of relative weakness or strength appears to be the most common teaching philosophy among all teachers in this study. For example, previous studies have found that teaching fine motor skills in small group settings produces better outcomes for learning these skills than in whole-class instruction (Case-Smith et al., 2011; Case-Smith et al., 2014). Accordingly, all eight teachers described how they assess students' individual needs at the beginning and throughout the year to ensure they provide small group instruction as needed. During these small group experiences, teachers address areas of need with their students. Many described these as opportunities to model fine motor skills and used interventions for handwriting and cutting deficits. Teachers also indicated that they use one-on-one instruction to address fine motor skills with left-handed students. Teachers in this study pointed to modeling as one of their most valuable tools when working on fine motor skills. This use of demonstration and direct teaching of skills to left-handed students PERCEPTIONS OF TEACHING LEFT-HANDED STUDENTS 43 aligns with a study by Hawkyard et al. (2014). Teachers in the current study who taught kindergarten reported having a teaching assistant in their class who could work directly with students who might be struggling or who might need a different approach to engage in the classroom activity. Teaching Style as Relates to Handedness All teachers reported feeling they could use more education and support to work on fine motor skills with left-handed students. Among the participants of this study, those who appeared to feel the most prepared to address left-handed student needs were teachers with a lot of teaching experience, a left-handed teacher, and two teachers with left-handed children of their own. Only when exposed to the needs of left-handed people through direct work or personal circumstances are many teachers aware of the needs of left-handed students. Hawkyard et al. (2014) reported that left-handed students prefer to angle their paper differently when writing and are more inclined to use a pencil grip as an assistive device for writing. However, to differentiate instruction properly, teachers need the tools and resources so they are not simply guessing at best practices. Limitations This study is subject to several limitations. The researcher conducted the study within a single school district in the Southeastern U.S. Therefore, the study results may not be transferable to other school districts and research. All participants identified as Caucasian women, demonstrating limited diversity among the participants. Another limitation of this study is that three participants did not respond to member-checking attempts. The researcher used email and social media for communication with participants. Member checking was done to PERCEPTIONS OF TEACHING LEFT-HANDED STUDENTS 44 confirm the accuracy of the researcher's interpretation, therefore, three members not participating in member checking limited the study. Implication for Practice and Future Research All participants mentioned using the occupational therapist and the OT's knowledge as a resource for learning to teach fine motor skills. While occupational therapists intervene when there appears to be an underlying issue that impacts handwriting, such as visual perceptual motor deficits or physical deficits, they also have the training to support teachers and advocate for students. According to Asher (2006) and Donica (2012), teachers may need to provide more direct instruction and be more specific in teaching handwriting. It may be the role of the occupational therapy department in a school district to advocate for consistent direct handwriting instruction for all students. Additionally, occupational therapists can support left-handed students' interest by encouraging school systems to provide specific writing instruction for lefthanded students and encouraging training for elementary school teachers in fine motor development and strategies for differentiating teaching for left and right-handed students. Further research could focus on the experiences of left-handed students and their perceptions of the instruction they received related to handwriting and cutting during the kindergarten and first-grade years. In addition, the research could explore best practices for teaching fine motor skills to left-handed students. As discussed earlier, lateralization in the brain can correlate with how strong a person's hand and foot preferences are. By exploring this, more researchers may determine if there is a correlation between the strength of hand preference and fundamental fine motor skills development. PERCEPTIONS OF TEACHING LEFT-HANDED STUDENTS 45 Conclusion Teachers face a myriad of challenges in the current educational system. While it is difficult to change or fix many of the barriers facing teachers, access to knowledge should not be one of them. Teachers in this study wanted to help the children with whom they work. They wanted to know the best practices for teaching fine motor skills, and they wanted to know how to support a left-handed student. However, with all the expectations placed on teachers to produce good mathematicians and readers, it is easy to believe teachers feel less knowledgeable about fine motor skills, especially for left-handed students. Occupational therapists are in an excellent position to support and encourage school districts to define how teachers address fine motor skills and provide them with resources to feel knowledgeable about teaching these foundational skills. PERCEPTIONS OF TEACHING LEFT-HANDED STUDENTS 46 References Aggleton, J. P., Kentridge, R. W., & Neave, N. J. (1993). Evidence for longevity differences between left handed and right handed men: an archival study of cricketers. Journal of Epidemiology & Community Health, 47(3), 206209. https://doi.org/10.1136/jech.47.3.206 Alaniz, M. L., Galit, E., Necesito, C. I., & Rosario, E. R. (2015). Hand strength, handwriting, and functional skills in children with autism. American Journal of Occupational Therapy, 69(4). https://doi.org/10.5014/ajot.2015.016022 Allen, T. H. (1945). Left handed writing instruction manual: Prepared for use in the school, clinic or home. Warren H. Gardner. 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(1990). Overt attempts to change hand preference: A study of group and individual characteristics. Canadian Journal of Psychology/Revue Canadienne De Psychologie, 44(4), 512521. https://doi.org/10.1037/h0084268 Rousson, V., Gasser, T., Caflisch, J., & Jenni, O. G. (2009). Neuromotor performance of normally developing left-handed children and adolescents. Human Movement Science, 28(6), 809817. https://doi.org/10.1016/j.humov.2009.06.001 PERCEPTIONS OF TEACHING LEFT-HANDED STUDENTS 53 Scharoun, S. M., & Bryden, P. J. (2014). Hand preference, performance abilities, and hand selection in children. Frontiers in Psychology, 5. https://doi.org/10.3389/fpsyg.2014.00082 Schwellnus, H., Carnahan, H., Kushki, A., Polatajko, H., Missiuna, C., & Chau, T. (2012). Effect of pencil grasp on the speed and legibility of handwriting in children. American Journal of Occupational Therapy, 66(6), 718726. https://doi.org/10.5014/ajot.2012.004515 Searleman, A., & Porac, C. (2001). 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Laterality and motor skills in four-year-olds. Child Development, 56(1), 119. https://doi.org/10.2307/1130179 PERCEPTIONS OF TEACHING LEFT-HANDED STUDENTS 54 Thompson, S. (2003). The Write Stuff Developing Fine Motor Skills & Handwriting in Students. Handy Learning Seminars. Sanford; Florida. Todor, J. I. (1980). Sequential motor ability of left-handed inverted and non-inverted writers. Acta Psychologica, 44(2), 165173. https://doi.org/10.1016/00016918(80)90065-7 Toglia, J. P. (1989). Visual perception of objects: An approach to assessment and intervention. American Journal of Occupational Therapy, 43(9), 587595. https://doi.org/10.5014/ajot.43.9.587 Tseng, M. H., & Chow, S. M. K. (2000). Perceptual-motor function of school-age children with slow handwriting speed. American Journal of Occupational Therapy, 54(1), 8388. https://doi.org/10.5014/ajot.54.1.83 Wang, T., Howe, T., Hinojosa, J., & Weinberg, S. (2011). Relationship between postural control and fine motor skills in preterm infants at 6 and 12 months adjusted age. American Journal of Occupational Therapy, 65(6), 695701. https://doi.org/10.5014/ajot.2011.001503 Watts, R., & Pattnaik, J. (2022). Perspectives of parents and teachers on the impact of the COVID-19 pandemic on childrens socio-emotional well-being. Early Childhood Education Journal. https://doi.org/10.1007/s10643-022-01405-3 Wenze, G. T., & Wenze, N. (2004). Helping left-handed children adapt to school expectations. Childhood Education, 81(1), 2531. https://doi.org/10.1080/00094056.2004.10521288 PERCEPTIONS OF TEACHING LEFT-HANDED STUDENTS 55 Table 1 Participant Demographics Participant Total Years Teaching Years Teaching K-1 Dominant Hand 1 10 5 Left 2 27 13 Right 3 15 9 Right 4 8 2 Right 5 11 11 Right 6 6 5 Right 7 21 20 Right 8 15 8 Right PERCEPTIONS OF TEACHING LEFT-HANDED STUDENTS 56 Table 2 Theme Table Theme Formal Training in Fine Motor Skills Barriers to Teaching Fine Motor Skills Individual Needs Assessment Teaching Styles as Relates to Handedness Quotations College did not prepare me at all for teaching fine motor. I dont feel like I have as much time to help my kids with fine motor development. "I approach each child differently because each of them learns in a different way." I do think they are a little more time intensive. I feel like professional developments or even like a handout or somethingIve tried to look up stuff before, but Im never sure what is like the correct way to teach them. just the last five years, Ive noticed, students not ever [having used] scissors or holding pencils or crayons. "Well, with the left-handed, it would require some more direct one-on-one." I dont think I adjust a lot because I dont know what to do. PERCEPTIONS OF TEACHING LEFT-HANDED STUDENTS 57 Appendix A Interview Guide Introduction Statement First, I would like to thank you for taking time to speak with me. The purpose of this interview is to explore primary school teachers perceptions and experiences of teaching motor skills to left-handed students. The interview will last approximately (insert time range). You may skip any question(s) that youd prefer not to answer, and you may stop the interview at any time. All of the information that you provide will be kept confidential. Do you have any questions before we get started? As I mentioned before, I am going to audio record our interview. Are you ok with me starting the recording? Interview Questions 1. How long have you been teaching? a. What grade levels have you taught? b. What grade level have you taught for the longest amount of time? 2. What is your teaching philosophy when you approach teaching fine motor skills? 3. What is it like for you to teach fine motor skills to a diverse group of students? a. How do you feel your formal training helped prepare you for teaching fine motor skills to this age group? 4. Can you tell me some general information about how you go about teaching fine motor skills, specifically cutting and handwriting, to your students? a. How much time would you say you spend a week working on these skills with all of your students? b. What special measures do you take when students are struggling with these skills? PERCEPTIONS OF TEACHING LEFT-HANDED STUDENTS 58 5. What do you think are the greatest needs of left-handed students? 6. What is it like for you to teach fine motor skills to left-handed students? a. What kinds of left-handed equipment do you have available to you or do you seek out to help your left-handed students be successful with writing and cutting skills? b. How do you go about teaching use of left-handed equipment to your students? 7. What differences and similarities do you see in how your left and right-handed students approach writing and cutting? a. How do you differentiate your teaching style when helping right and left-handed students? b. What challenges do you see left-handed students facing in the classroom when learning to write and cut? 8. What specific considerations do you typically have to keep in mind when teaching writing and cutting to left-handed students? a. What strategies have you learned while working with left-handed students on writing and cutting? b. What do you perceive are the greatest institutional facilitators for you when teaching left-handed students? c. What do you perceive are the greatest institutional barriers for you when teaching left-handed students? d. What resources have you utilized to help you when working with left-handed students? 9. What steps do you think could be taken on a broader scale to make sure teachers feel prepared to teach handwriting and cutting to students who are left-handed? PERCEPTIONS OF TEACHING LEFT-HANDED STUDENTS 59 a. How would this information be best distributed to teachers so that they can fully synthesize and utilize this information? 10. Are there any other teachers whose perspective you think would be valuable to this study or who you think would be interested in participating? 11. Is there anything else you would like to share? PERCEPTIONS OF TEACHING LEFT-HANDED STUDENTS 60 Appendix B Informed Consent Department of Interprofessional Health & Aging Studies, University of Indianapolis KEY INFORMATION FOR POTENTIAL RESEARCH PARTICIPANTS This research study is being completed to explore the experiences of teachers regarding how they teach fine motor skills to left-handed kindergarten and first grade students. The outcome of this research may impact how OTs in the school system work with teachers to support their teaching of this student group. Participation is completely voluntary, and consent can be withdrawn at any point in the research process. Participation in the research process will consist of two interviews over the course of three months, specifically one hour-long virtual interview which will be audio recorded and then one follow-up interview (via phone or email) to discuss the main themes drawn from the original interview. Participants will not directly benefit from participation and no risks or discomforts have been identified for potential participants. CONSENT TO PARTICIPATE IN RESEARCH STUDY The Perceptions of Teaching Left-Handed Students Study Principal Investigator (PI): Lisa Borrero, PhD. UIndy Email: borrerol@uindy.edu UIndy Telephone: (317)791-5944| Student Investigator: Molly Mink, MS, OTR/L UIndy Email: minkm@uindy.edu Phone Number: (502) 938-1389 Molly Mink, Master of Occupational Therapy; Dr. Lisa Borrero, PhD in Health Behavior from the Department of Interprofessional Health & Aging Studies at the University of Indianapolis (UIndy) are conducting a research study. You were selected as a possible participant in this study because you have self-identified as a kindergarten or first grade teacher who would like to share your experiences of teaching lefthanded students. Your participation in this research study is voluntary. Why is this study being done? This study will explore the perceptions and experiences of kindergarten and first grade teachers and their work with left-handed students. This study will explore themes among this group of teachers and their experiences teaching fine motor skills to their left-handed students. What will happen if I take part in this research study? If you volunteer to participate in this study, the researcher will ask you to do the following: Participate in a one to one and a half hour virtual interview which will be audio recorded. PERCEPTIONS OF TEACHING LEFT-HANDED STUDENTS o 61 Interview questions will be open ended and will allow for a semi structured discussion of the participants experiences and feelings. Participate in a follow up interview on the phone or through email to discuss the interviewers understanding of the main themes of the original interview. How long will I be in the research study? Participation will consist of two interviews (one full and one follow-up) over the course of 3 months. Are there any potential risks or discomforts that I can expect from this study? Because email will be used to recruit participants, set up virtual meetings, and communicate with participants it is possible that a loss of privacy related to name and email address could occur during the study. Are there any potential benefits if I participate? You will not directly benefit from your participation in the study. The results of the research may impact how occupational therapists in this school system work with teachers and provide training for teaching left-handed students. Will I be paid for participating? A $20 gift card will be offered for participation at the conclusion of the first interview. Will information about me and my participation be kept confidential? The results of this study may be published in a scholarly book or journal, presented at professional conferences, or used for teaching purposes. However, only aggregate data will be used. Personal identifiers will not be used in any publication, presentation, or teaching materials. What are my rights if I take part in this study? You can choose whether you want to be in this study, and you may withdraw your consent and discontinue participation at any time. Whatever decision you make, there will be no penalty to you, and no loss of benefits to which you were otherwise entitled. You may refuse to answer any question/s that you do not want to answer and remain in the study. Who can I contact if I have questions about this study? The Research Team: If you have any questions, comments, or concerns about the research, you can talk to the one of the researchers. Please contact: Molly Mink, 502-938-1389, minkm@uindy.edu Lisa Borrero, 317-791-5944, borrerol@uindy.edu PERCEPTIONS OF TEACHING LEFT-HANDED STUDENTS 62 The Director of the Human Research Protections Program (HRPP): If you have questions about your rights as a research participant, or you have concerns or suggestions and you want to talk to someone other than the researchers, you may contact the Director of the Human Research Protections Program, by either emailing hrpp@uindy.edu or calling 1 (317) 781-5774 or 1 (800) 232-8634 ext. 5774. You will be given a copy of this information to keep for your records. You do not need to sign this, or any other document to indicate your consent. Participation in the interview and follow up interview indicate that you are willing to participate. PERCEPTIONS OF TEACHING LEFT-HANDED STUDENTS 63 Appendix C Recruitment Flier Volunteers Needed for Research Study on Teaching Writing to Left-Handed Students. Seeking teachers who have primarily taught kindergarten and first grade to discuss their experiences teaching left-handed students. You May Qualify If You You are currently teaching K or 1st grade Have taught K or 1st grade in the last 2 years Have an interest in sharing your experiences teaching writing and cutting to lefthanded students Participation Involves Location: All interviews will be conducted virtually All participants will be offered a $20 gift card. 1 to 1 hour interview Brief follow up interview (by phone or email) to discuss interviewers perceptions of original interview FOR MORE INFORMATION Please contact Molly Mink at 502-938-1389, email minkm@uindy.edu or molly.mink@oldham.kyschools.us This research project has been approved by the University of Indianapolis Institutional Review Board (IRB). Approval date 4/26/2021. Approval number 01412. PERCEPTIONS OF TEACHING LEFT-HANDED STUDENTS 64 Appendix D University of Indianapolis Institutional Review Board Notification of Approval Human Research Protections Program (HRPP) 800/232-8634 x5774 1400 East Hanna Ave Sease, Room 201L Indianapolis, IN 46227 1 (317) 781-5774 http://irb.uindy.edu hrpp@uindy.edu April 28, 2021 NOTIFICATION OF EXEMPTION DETERMINATION Study Number: 01412 Study Title: The Perceptions of Teaching Left-Handed Students Exemption Determination Date: April 26, 2021 Principal Investigator: Lisa Borrero, Ph.D. Gerontology The above-referenced protocol has been reviewed in accordance with the US Department of Health & Human Services (DHHS), Office for Human Research Protections (OHRP) regulations, specifically 45 CFR 46.104. Based on these criteria, this study is exempt from IRB Review. This exemption is valid unless changes in the project may impact the eligibility for exemption under the federal regulations. If you need to make any changes to the study, please contact the HRPP office hrpp@uindy.edu for guidance on whether additional review is required. Please submit all personnel changes through IRBManager as a Modification of Approved Protocol. Upon completion of your study, please submit a closure report through the IRBManager system. Yvonne Wakeford, Ph.D. Director: Human Research Protections Program (HRRP) HRPP Jan 2019  ...

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A Light in the Darkness: Exploring the Experiences of African American Women Living with Depression Submitted to the Faculty of the College of Health Sciences University of Indianapolis In partial fulfillment of the requirements for the degree Doctor of Health Science By: Deborah Pinkett Hammond, LCSW Copyright December 8th, 2022 By: Deborah Pinkett Hammond, LCSW All rights reserved Approved by: Lisa Borrero, PhD Committee Chair ______________________________ Laura Santurri, PhD, MPH, CPH Committee Member ______________________________ Lynn Shaw, EdD, LCSW, LCAC, ACSW Committee Member ______________________________ Accepted by: Laura Santurri, PhD, MPH, CPH Director, DHSc Program Chair, Interprofessional Health & Aging Studies University of Indianapolis ______________________________ Stephanie Kelly, PT, PhD Dean, College of Health Sciences University of Indianapolis ______________________________ AFRICAN AMERICAN WOMEN & DEPRESSION A Light in the Darkness: Exploring the Experiences of African American Women Living with Depression Deborah P. Hammond Department of Interprofessional Health & Aging Studies, University of Indianapolis Author Note I have no known conflict of interest to disclose. Correspondence concerning this article should be addressed to Deborah Hammond, University of Indianapolis, 1400 E. Hanna Avenue, Indianapolis, IN 46227. Email dhammond@uindy.edu 1 AFRICAN AMERICAN WOMEN & DEPRESSION 2 Abstract Background: Older African American women underutilize mental health services to treat their depression. There are limited qualitative studies on older African American women living with depression, so it is essential to hear their stories and understand this population's low rate of mental health treatment. Objective: This qualitative study used hermeneutic phenomenological analysis to explore and understand the experience of older African American women living with depression. The study also explored how stigma, culture, and religious beliefs play a role in their view on depression and mental health treatment. Method: The researcher used purposive sampling to recruit eleven participants from senior centers and churches that met the study's inclusion criteria. The study's eleven participants ranged from 50 to 70 years old. The researcher analyzed the data from semi-structured interviews to develop a deeper understanding of the participants' experiences living with depression Results: Four major themes resulted from the data, including difficulty in daily functioning, coping strategies, barriers to treatment, and impact of culture, religion, and stigma. Stigma was the predominant factor underlying participants' experiences living with depression and seeking mental health treatment. Discussion: Participants described mistrust and a lack of understanding when they sought treatment for their depression. The low rate of treatment can be improved when mental health clinicians address barriers to accessing treatment and incorporate cultural discussions in their treatment approaches. A strong support system, practicing holistic interventions, and positive connections to mental health clinicians emerged as effective methods to cope with depression. Keywords: African American women, depression. mental health treatment AFRICAN AMERICAN WOMEN & DEPRESSION 3 Acknowledgements I would like to thank everyone who supported me in my journey. A special thanks to my family, friends, and colleagues for their support. I am grateful to my second coder for this study, Valorie James. My amazing sisters, Brenda Little and Paula Barclay, my incredible nieces Sienna and Saffron Little and my wonderful husband Rudolph Hammond. My parents, Paul, and Eloise Pinkett, may you continue to rest in power. I will always love you for the many lessons you taught me to never give up, and you can achieve your goals. Finally, to my ancestors whose shoulders I stand on and the legacy of tenacity and perseverance I called on many times during this journey. I would like to thank my committee members. Dr. Lisa Borrero, Dr. Laura Santurri, and Dr. Lynn Shaw. Your support and belief that I could complete this doctoral program means a lot. I am grateful for your guidance and direction in my classes and during the writing of this dissertation. When I decided on my topic, you encouraged me from the beginning to the end. I am grateful to all the African American women living with depression who trusted me to share their stories. Your willingness to come forward and share your experiences opens the door for the next person to break the silence and not suffer alone. Hopefully, more African American women will seek help and find that light in the darkness because of your courage. Thank you, Deborah Hammond AFRICAN AMERICAN WOMEN & DEPRESSION 4 Table of Contents Title Page ........................................................................................................................................1 Abstract....................................................................................................................................2 Acknowledgment.............................................................................................................................3 Chapter 1: Introduction ...................................................................................................................7 Problem Statement ..............................................................................................................7 Purpose Statement ...............................................................................................................8 Research Questions .............................................................................................................8 Significance of the Study 8 Definition of Terms.9 Chapter 2: Literature Review .........................................................................................................9 Attitudes and Beliefs About Depression........................................................................10 Stigma.............10 Cultural Factors and Experiences .12 Attitudes and Beliefs About Treatments for Depression ................................................. 14 Religions .............................................................................................................. 14 Coping Strategies ..................................................................................................15 Chapter 3: Method ....................................................................................................................... 17 Study Design .....................................................................................................................17 Participants ....................................................................................................................... 17 Procedures .........................................................................................................................18 Sampling and Recruitment ................................................................................... 18 Informed Consent ................................................................................................. 19 AFRICAN AMERICAN WOMEN & DEPRESSION 5 Data Collection .... 21 Data Management & Analysis ............................................................................. 22 Rigor/ Trustworthiness ......................................................................22 Chapter 4: Results......................................................................................................................... 24 Difficulty in Daily Functioning ... 25 Physical and Emotional Changes . 25 Challenges of Health Conditions . 27 Response to Life Stresses ............. 28 Impact of Generational Trauma 29 Coping Strategies for Depression 30 Practicing Holistic Interventions ..30 Connection to Mental Health Providers ... 32 Interactions with Non-Mental Health Providers....33 Barriers to Mental Health Treatment .. 35 Internalized Beliefs ...35 Systemic Disparities...36 Impact of Culture, Religion, Stigma..37 Black Family and Community Responses ......38 Black Church Responses ...39 Recommendations from Participants .....41 Chapter 5: Discussion and Conclusion ........................................................................................42 Stressful Life Events......................................................................................................... 42 Negative Interactions with Helping Professionals ........................................................... 43 AFRICAN AMERICAN WOMEN & DEPRESSION 6 Holistic Methods and Interventions.................................................................................. 44 Positive Interactions with Mental Health Clinicians........................................................ 44 Impact of Barriers to Treatment........................................................................................ 45 Impact of Culture, Religion, and Stigma...46 Limitations 48 Implications and Future Research..48 Conclusions .......................................................................................................................51 References......................................................................................................................................53 Table 1 Participant Characteristics ...............................................................................................59 Table 2 Themes and Subordinate Theme Frequency....................................................................60 Appendices ...................................................................................................................................61 Appendix A: Interview Guide .........................................................................................62 Appendix B: Eligibility Screening Questions .64 Appendix C: Study Information Sheet.............................................................................65 Appendix D: Recruitment Flyer ...68 AFRICAN AMERICAN WOMEN & DEPRESSION 7 Exploring the Experiences of African American Women Living with Depression Depression is among older adults' most common and underrecognized mental health illnesses (Federal Interagency Forum on Aging Related Statistics, 2016). According to Ward and Brown (2015), African Americans report a higher incidence of persistent depression connected to their depressive symptoms. African Americans also seek treatment for their depression at a lower rate, 39.75%, compared to Caucasians at 54.1% (Gonzalez et al., 2010). Depression among African American women varies in age groups 50 and older. For example, in a study by Baldwin-Clark et al. (2016). Participants in the 80 to 89 age group were 80% less likely to have felt depressed in the last year compared to those in the 50 to 59 age group ). (p.314.) This is particularly significant because, despite this reality, older African American women underutilize mental health services (Ward et al., 2014). Numerous risk factors can contribute to depression in African American women, including lower socioeconomic status and institutionalized racism (Holden et al.,2013). In addition, unhappiness with day-to-day life, difficulties at work, and poor physical health are additional factors connected to depression in African American women. (Holden et al.,2013). Problem Statement As limited studies focus on depression and mental health treatment for older African American men and women (Conner et al., 2010; Pickett et al., 2013; Ward & Brown, 2015), it is essential to understand the perspectives of this population on depression and how they cope. Among the few studies that have examined this topic, Gatlin et al. (2012) stated that stigma, treatment preferences, and a strong religious foundation may impact beliefs about depression among African Americans 55 and older. A later study found that among African Americans 60 and older, stigma contributed to not seeking mental health treatment and a belief that seeking AFRICAN AMERICAN WOMEN & DEPRESSION 8 treatment is a sign of weakness (Sirey et al., 2014). Research has shown that multiple factors, including race and gender, can impact how older African American women experience depression (Clark et al., 2016). Due to the limited qualitative studies explicitly focusing on African American older adult women living with depression, there is a need to hear the voices of this population. Purpose Statement This study explored the experiences of African American women ages 45 to 75 living with depression. Of specific focus were the perceptions of treatment and the role of stigma, culture, and religious beliefs. Research Question This study addressed the following primary and two sub-questions: First, what are the experiences of African American women ages 45-75 living with depression? o What perceptions and beliefs among African American women ages 45-75 about mental health treatment for depression? o How do stigma, culture, and religious beliefs affect their view on depression and mental health treatment? Significance of the Study Results of this study may provide clinicians with information that can be used to address barriers in engaging this priority population through effective services. Specifically, mental health providers may benefit from increased knowledge about depression in African American older adult women and create effectively tailored intervention methods for clinical practice. This study may also benefit African Americans and the communities in which they live by AFRICAN AMERICAN WOMEN & DEPRESSION 9 underscoring the need for high-quality mental health care for depression in underserved populations. Definition of Terms African American: A person who self-identifies as Black or African American Depression: Meeting the Diagnostic and Statistical Manual of Mental Health Disorders, 5th Edition [LB9] (DSMV) criteria for major depression (APA, 2013) Mental Health Treatment: Psychotherapy by a licensed mental health provider (Mental Health America, n.d.) Literature Review Zurlo & Burch (2013) projected that depression in older adults can result in debilitating consequences, and the incidence of depression will increase from 3.8 million older adults to 6.6 million in 2025. However, despite the negative impact of depression on older adults' lives, older African Americans are underrepresented in research and studies on depression despite the negative impact on their lives. (Pickett et al., 2013; Sohail et al., 2014). In addition, untreated depression can lead to disabilities and chronic health conditions for older African Americans (Conner et al., 2010). African Americans were diagnosed with schizophrenia versus mood disorders more often than Caucasians with the same symptoms (Mental Health America, n.d.). Medication and therapy were also presented less to African Americans as a treatment option than the mainstream population (Mental Health America, n.d.). According to Mental Health America n.d., African Americans who screened positive for depression and stated they were willing to seek treatment for depression faced challenges when seeking treatment. Mistrust of the health care system, faith-seeking help behaviors, and a lack of African American mental health providers contributed AFRICAN AMERICAN WOMEN & DEPRESSION 10 to the low rate of mental health treatment for depression among African Americans (Mental Health America, n.d.). According to current literature, there is an urgent need for mental health providers to address the needs of older adults with depression. However, there were limited studies on the disparities in health care for treating depression in older African Americans (Zurlo & Burch, 2013). Older African American women who experienced depressive symptoms or were diagnosed with depression have low rates of mental health treatment (Ward et al., 2014). Economic status, racism, and lack of quality healthcare place African American women in lower socioeconomic urban neighborhoods at higher risk for depression (Carr et al., 2013). Examination of the literature identified existing gaps in research on the individual and societal factors that impact older African American women living with depression and their utilization of mental health treatment. A current gap in research exists on the lived experiences of the target population of African American women aged 45 to 75 living with depression. A literature search for the targeted population yielded 22 articles, including four qualitative studies of African American women 45 and older with depression. Attitudes and Beliefs Towards Depression Stigma Older African American women reported stigma as one factor contributing to their view about depression (Connor et al., 2010). In one study of African American men and women, negative stereotypes and hurtful comments because of their depression occurred during their interactions with others (Connor et al., 2010). Because of their diagnosis, participants also felt isolated and stigmatized in the African American community. Participants stated that the fear of not being accepted by the public because of a depression diagnosis contributed to their AFRICAN AMERICAN WOMEN & DEPRESSION 11 internalized feelings of stigmatization (Connor et al., 2010). The public stigma of living with a mental illness can result in an internalization of negative beliefs and a reluctance to seek treatment (Keller et al., 2016). Correspondingly, stigma about mental illness contributes to the rate at which African American adults seek mental health treatment (Connor et al., 2010). For example, in one study of adults 60 and older, African American men and women had similar depression scores compared to older Caucasian men and women. (Connor et al., 2010). However, less than one-third of older African Americans had seen a mental health treatment provider for depression compared to older adult Caucasian men and women (Connor et al., 2010). In addition, there were racial differences regarding seeking mental health treatment for depression. Only 56% of older African Americans were comfortable receiving treatment from a mental health provider of a different racial background versus 80.5% of Caucasians (Connor et al., 2010). Older African Americans in the study reported more internalized stigma than older Caucasian participants (Connor et al., 2010). Older African Americans in the study worried about the stigma of having a mental illness and how they would be perceived negatively by their neighbors and other community members (Connor et al., 2010). Internalized stigma also negatively influenced African American participants' attitudes about seeking mental health treatment (Campbell et al., 2016; Carr et al., 2013; Connor et al., 2010; Connor et al., 2014). Anticipated stigma, a public stigma that focuses on the opinions of the person's family and friends, impacts older African Americans' view of depression (Sirey et al., 2014). In one study of adults 60 and older, older African American men and women reported a higher rate of anticipated stigma for depression, 68% versus 53% for older Caucasian men and women (Sirey et al., 2014). Being concerned about how people close to them viewed their depression impacted AFRICAN AMERICAN WOMEN & DEPRESSION 12 older African Americans' willingness to discuss their depression with primary care practitioners. This lack of discussion about depression can lead to fewer referrals for mental health treatment for older adult African participants (Sirey et al., 2014). Public stigma can lead to self-stigma for women living with depression. With self-stigma, a person with a mental illness becomes aware of the public's negative stereotypes, agrees with them, and internalizes those negative feelings (Corrigan et al., 2010). In one study, African American, Latina, and Caucasian women aged 18 to 50 stated they experienced fear and shame from negative societal beliefs about depression. They would also keep their depressive symptoms and diagnosis of depression from family, friends, and healthcare providers (Oakley et al., 2011). Self-stigma can limit older adult women's ability to engage with healthcare professionals for resources to treat their depression (Watson & Hunter, 2015). African American women's perception that society and other social factors were the cause of their depression made them feel less self-stigmatization than Caucasian or Latina participants (Oakley et al., 2011). Older African American women 60 and older living with depression stated that societal factors, culture, and life events contributed to their depressive symptoms and diagnosis of depression (Ward et al., 2014). Cultural Factors and Experiences Depression is a topic rarely discussed in the African American community. However, a few studies revealed how African Americans understand depression. Participants expressed that they were unaware they were experiencing symptoms of depression (Connor et al., 2010; Connor et al., 2014; Gitlin et al., 2012). Instead, they attributed their symptoms to being tired, caretaking stress, sadness due to a death in the family, and relationship problems with friends and family AFRICAN AMERICAN WOMEN & DEPRESSION 13 members. Participants also described physical symptoms of having headaches and body aches from normal aging or not sleeping because of their physical conditions (Connor et al., 2010). Additionally, the language used to describe depressive symptoms may be different for older African Americans. Participants discussed sadness and stress to describe depressive symptoms, but participants were unclear on the possible connection to a mental health condition. (Connor et al., 2010, p 9). Akinyemi et al. (2018) found that a lack of awareness of the clinical definition of depression can lead to a misunderstanding of the signs and symptoms of depression. Examples cited included African American participants 51years of age and older using terms such as "feeling down" or "blue" instead of the term "sadness." Instead of stating they felt a sense of unworthiness, participants described feeling "unclear," "let down," or "funky." Poor concentration was described as "narrow-minded" and "thinking negatively" (p. 4.). African American women living with depression also faced unique challenges. Few studies focused on the impact of racism and gender on African American women diagnosed with depression (Baldwin-Clark et al., 2016; Carr et al., 2013). In one study of African American women and men aged 55 and older, participants stated that their experience with racism and discrimination caused their depression (Connor et al., 2010). African Americans described stress from racism as a contributing factor to depression. African American women discussed community racism and discrimination leading to a lack of jobs, housing, and educational resources as stressors contributing to their symptoms of major depression. Participants ranged from ages 37 to 80, and 18% reported major depressive symptoms (Russell et al., 2018). Coping with racism and oppression was also connected to depressive symptoms in African American women (Carr et al., 2013; Greer, 2011). In Connors et al. (2010), participants also stated they were not seeking mental health treatment for their depression due to how healthcare AFRICAN AMERICAN WOMEN & DEPRESSION 14 professionals had mistreated African Americans. The lack of trust in the healthcare system, the inability to discuss personal problems with health professionals, and the continued impact of racism as a cause for depression were also reasons for not seeking mental health services for depression in previous studies (Byers et al., 2012; Keller et al., 2014; Ward et al., 2014). Other research suggests that older African American women have specific beliefs about factors contributing to their depression. In one study, African American women aged 60 and older stated difficulties experienced by poverty, feelings of disempowerment, and traumatic events from childhood as the reasons for feeling depressed in adulthood (Ward et al., 2014). Many women believed their life experiences caused their depression and did not seek treatment. In a study of African American women aged 18 to 82, 49% reported depressive symptoms, and participants viewed the concepts of strength and resilience in the African American culture as managing depressive symptoms (Holden et al., 2013). Holden et al. connected low resilience and high depressive symptoms to chronic health conditions, lack of medical insurance, no college education, and unemployment. Cultural views of African American women as superwomen and the impact of social factors, including education, health conditions, employment, and socioeconomic status, should be further explored to determine effective interventions for depression treatment (Woods-Giscomb, 2010). Attitudes and Beliefs About Treatment for Depression Religion Previous studies discussed several perceptions and beliefs of older African American women about mental illness and depression related to religion (Akinyemi et al., 2018; Chatter et al., 2015; Connors et al., 2010; Ward, 2014; Wharton et al., 2016). In one study of older adult African American women, their religious beliefs and traditions set the framework for their view AFRICAN AMERICAN WOMEN & DEPRESSION 15 on depression. Depression was viewed based on adverse life circumstances. Relying on God for help was believed to be an effective treatment method (Connors et al., 2010). Attendance at religious services and support from church members, family, and clergy were important for managing depression for African American men and women aged 55 and older (Chatters et al., 2015). Positive interaction and social support from the church were indicators of successfully managing emotional distress and depressive symptoms (Chatters et al., 2015). Ward et al. (2014) suggested that older African American women believed there was no need to seek professional treatment for depression; instead, they sought help from church leaders. Keeping themselves busy with prayer and bible study helped manage depression symptoms. The reliance on prayer and the church is a central theme in older adult African American men and women's views on depression. In one study of African American men and women aged 50 and older, participants stated they would only seek professional help for depression after praying or talking with the clergy, pastors, or church staff (Wharton et al., 2016). Women in the study cited the importance of spirituality and connecting with God to help with their depression versus going to a mental health professional. For participants seeking services, a mental health provider's approach to depression that included spirituality and the whole person was an important factor in engaging older African Americans in services (Wharton et al., 2016). Coping Strategies The limited research focusing on this population has shown that older African Americans utilize specific coping strategies to manage depression. These strategies include informal support systems, self-help, family members, religion, spirituality, and community involvement (Connors et al., 2010; Connors et al., 2014; Ward et al., 2014; Watson & Hunter, AFRICAN AMERICAN WOMEN & DEPRESSION 16 2015). In addition, barriers to seeking mental health services included poor quality health services, inaccessible health services, lack of health care insurance, poverty, racism, discrimination by health and social service systems, and a lack of culturally sensitive mental health providers (Connors et al., 2010; Connors et al., 2014; Ward et al., 2014; Watson & Hunter, 2015). Managing depression based on cultural and religious beliefs was one strategy older African American women used to cope with depressive symptoms. In one study of African American men and women aged 55 and older, women were less likely to seek treatment from a doctor than men (Gitlin et al., 2012). Instead, women in the study relied on faith, spirituality, and practicing cognitive interventions. As cited in previous studies, stigma and cultural barriers did not appear to deter treatment. Further research on culture and stigma is necessary to engage older adult African Americans in treatment for depression. Positive interactions with family and friends and community involvement also helped older African Americans manage depression. In one study of African American men and women aged 30-60, a culturally adapted community-based intervention model for depression utilized a support group psychoeducational model with participants versus a traditional individual psychotherapy counseling model. This intervention decreased symptoms of depression with a high rate of completion by the participants (Ward & Brown, 2015). Therefore, research may be needed to determine if older African Americans would engage in mental health services for depression if a culturally adapted counseling model were offered as an option. Older African American women living with depression encounter many barriers when seeking treatment for depression. This study utilized an in-depth exploration of how they viewed their life while living with depression. AFRICAN AMERICAN WOMEN & DEPRESSION 17 Method Study Design This study used a hermeneutic phenomenological methodology. This approach emphasizes the importance of an individuals culture, social, and political context when interpreting their experience with a particular phenomenon (Wojnar & Swanson, 2007). Before participant recruitment, the researcher obtained approval for the study from the University of Indianapolis Institutional Review Board (IRB). Participants Participants eligible for inclusion in this study were women between the ages of 45 and 75 who have a diagnosis of clinical depression from a mental health provider or have experienced symptoms of depression, self-identify as Black or African American, and reside in a non-institutionalized setting. The IRB originally approved the study with an inclusion criterion of ages 50 to 64 with a diagnosis of clinical depression. The amended IRB protocol expanded the inclusion criteria to those ages 45 to 75 who experienced symptoms of depression. This change allowed for a more significant number of participants living with depression to share their experiences. Participants in the study contacted people they felt met the inclusion criteria in a method of recruitment called snowball sampling, which resulted in additional participants for the study. English was the language for all study activities. Exclusion criteria included individuals who do not read or speak English and reside in a nursing home or institutionalized setting. The researcher interviewed 11 participants for this study, and recruitment was ended when information power was determined. That is, information power allowed the researcher to determine the number of participants needed based on the study aim, sample specificity, theoretical background, quality of dialogue, and analysis strategy (Malterud et al., 2016). AFRICAN AMERICAN WOMEN & DEPRESSION 18 Procedures Sampling and Recruitment Purposeful sampling was used for this study, as it allows for selecting cases representing stories of participants living with the phenomenon without the researcher having prior knowledge of the outcomes (Patton, 1990). To begin recruiting, the researcher contacted senior directors at eight Department of Senior Services Centers located in African American neighborhoods in Chicago, Illinois. Given that African Americans have a low participation rate in mental health research (Campbell & Mowbray, 2016), religious denominations within the African American community, including the United Church of Christ, United Methodist, and Apostolic Church, were chosen for recruitment. Unfortunately, the initial outreach resulted in only two participants. Therefore, the researcher expanded the outreach to include two professional organizations, the National Congress of Black Women and the National Association of Negro Business and Professional Women. In addition, the researcher contacted administrators for two social media groups, FinishedD/Finished Ed and Black Women Ph.D., to post the flyer for recruitment. The researcher phoned or emailed the program director of the senior centers, the contact person for church ministries, and the administrators for the social media websites. During the conversations with each contact person, details on the study were provided, including the title and purpose of the study, confidentiality, inclusion criteria, study protocol, site locations, and contact information for the researcher. In addition, information was provided on the incentive of a $20 gift card available for each participant that completed the interview process. The information discussed was included in the recruitment flyer (Appendix D). The researcher asked the contact person to post the flyer to recruit members for the study. The researcher visited five AFRICAN AMERICAN WOMEN & DEPRESSION 19 senior centers to bring flyers to post on the information board and answer any questions regarding the study in person. The flyer directed anyone interested in the study to contact the researcher by email or phone. The researcher responded to each email and phone call within 48 hours of the inquiry. During the phone call, the researcher discussed information on the flyer, answered questions, and confirmed participant eligibility by asking questions related to the inclusion criteria (Appendix A). The researcher also informed participants of the studys aim, risks, and benefits and obtained verbal consent to schedule an interview for all eleven participants that qualified for the study. The researcher emailed the participants a copy of the study information sheet and scheduled the interview during the phone call. In addition, the researcher emailed the link for the Zoom videoconferencing, including the date and time for their HIPPA-compliant interview. Participants received a reminder email or call 24 hours before their scheduled interview. The researcher did not conduct Face to Face interviews for this study. Of the eleven interviews, eight were conducted through videoconferencing, and three were conducted via phone call. The interviews ranged in length from 45 -75 minutes. Informed Consent At the beginning of the interview session, the researcher reviewed the study information sheet with each participant (Appendix C). The researcher reminded the participants of the purpose of the study, including risks and benefits. In addition, the researcher discussed the anticipated length of interviews. Moreover, the right to withdraw from the study at any time. The researcher answered any participant's questions before the audio-recorded semi-structured interview. The researcher informed the participants of her profession as a licensed clinical social worker and reiterated that the researcher was a researcher during the interview and study. In AFRICAN AMERICAN WOMEN & DEPRESSION 20 addition, the researcher discussed the confidentiality of the interview and how data would be maintained and destroyed three years after the study concluded. Demographic information, including marital status, work status, and education level, were collected at the end of the interview. Methods to ensure confidentiality, including collecting any data not necessary for the study, removing any personal identifiers, and permanently destroying any noticeable personal identifiers and contact information. Audio recordings, transcriptions, and notes were stored using Dedoose (Version 8.3.35), and only authorized persons had access to the files. Data Collection Interviews were 45 to 75 minutes long, and based on participants' stories of living with depression. A semi-structured interview guide, developed by the researcher, included eleven questions (see Appendix B). The questions were open-ended and designed to gather in-depth information from participants on their perceptions and beliefs about living with depression and seeking mental health treatment. In addition, the researcher asked follow-up and probing questions were asked throughout the interviews based on the participants responses. Participants were very open to sharing their stories about living with depression. Participants provided additional information on why they wanted to participate in the study and the geographical area where they resided. This information was not part of the semi-structured questions. Participants felt comfortable sharing their location to highlight the lack of affordable mental health services or the limited number of culturally diverse therapists in their area. Describing the challenges they faced and continue to face was very emotional for some of the participants. The researcher was sensitive to the needs of each participant and paused during moments of the interview to allow the participant time to regroup and continue when they were AFRICAN AMERICAN WOMEN & DEPRESSION 21 ready to proceed. The researcher reminded participants that they could stop the interview at any time or not answer a question. The researcher concluded by thanking each participant, explaining how their data will be stored, and how to reach the researcher for any questions by providing my contact information. In addition, the researcher informed participants that they would be contacted later for additional information or clarification during the process of member checking. Finally, they would receive an email on the emerging themes to ensure the themes captured their experiences and information captured from the interviews. Data Management & Analysis Participant interviews were audio-recorded and transcribed using the speech-to-text transcription, Temi. The researcher uploaded each transcript and corrected any misspelled words before downloading the final version on the researcher's secure, password-protected Google drive. Participants' pauses and use of slang were not changed during the transcription. Each transcript was coded with a number and pseudonym to protect the confidentiality of the participant. Next, the data analysis software, Dedoose (Version 8.3.35), was used to store each audio recording, transcripts, and researchers' field notes. According to Wojnar & Swanson (2007), interpretive phenomenological data analysis consists of specific steps: 1. Data immersion took place with the researcher reading and re-reading the participants description of living with depression. 2. Significant words and phrases from the interview data related to the research question were extracted and assigned a code. AFRICAN AMERICAN WOMEN & DEPRESSION 22 3. A secondary coder with experience in clinical therapy with Africa American women reviewed the transcripts to independently develop codes and highlight the significant phrases and concepts. The researcher and secondary coder met on the phone and in person to discuss similarities and differences in codes. Next, the researcher and secondary coder agreed on the codes after the discussions. The next step was categorizing codes in a codebook and developing initial themes. Finally analyzing the data culminating in the development of overarching themes to characterize the participants experiences in the study. The researcher coded by hand and then used Dedoose for the final coding and theme analysis. The researcher implemented member checking by emailing each participant a copy of their initial themes to ensure their experiences were accurately captured. Next the researcher contacted the participant by phone or email to discuss any clarifications, additions, and changes. Participants commented on the accuracy of the researcher's interpretations of their stories and the initial themes as presented. Of the eleven interviews conducted, nine responded to provide feedback on the themes. Next, the primary researcher and secondary coder met in person and on the phone to discuss any changes in initial themes from the participants' feedback. Finally, they made changes to create the final list of overarching themes for the study. Rigor/Trustworthiness The researcher implemented components of the Rosalind Franklin Qualitative Research Instrument based on the Guba Model of Trustworthiness to ensure rigor and trustworthiness for this study (Henderson & Renault, 2004). The models components are credibility, transferability, dependability, and conformability (Henderson & Renault, 2004). AFRICAN AMERICAN WOMEN & DEPRESSION 23 The researcher used member checking and reflexivity to establish credibility. Establishing credibility occurs when the researchers themes and interpretation align with the participants views and stories during the data analysis phase (Henderson & Renault, 2004). Reflexivity was used to address any researcher bias that may occur during the data collection process. To this end, the researcher continued to utilize the technique of memoing to record opinions and feelings about the study in a journal (Birk et al., 2008). Memoing was used for the researcher to practice self-reflection on the process and recognize any assumptions and personal biases they have throughout the process. The researcher minimized bias by using field notes to describe any thoughts and feelings experienced during the interview process. Field notes and memoing are techniques used in qualitative research to help the researcher analyze what is going on and to support the data used in the research (Birks et al., 2008). The researcher disclosed the professional background as a licensed clinical social worker to participants at the beginning of the study. In addition, the researcher monitored any biases with reflexivity and memoing. Transparency was essential to identify to the participants that the researcher was not in the role of a therapist during the research study. Transferability was supported by employing various methods. Transferability is the ability to generalize results. Screening procedures established whether potential participants have a diagnosis of clinical depression from a mental health provider or experienced symptoms of depression, self-identify as Black/African American females, are between the ages of 45 to 75, and are community-dwelling residents living in a non-institutionalized setting. Replicating the study with a similar sample size reflects dependability (Henderson & Renault, 2004). The researcher has provided a detailed description of the data collection and data analysis procedure. The researcher has established an audit trail procedure for the study. An audit AFRICAN AMERICAN WOMEN & DEPRESSION 24 trail involves creating specific documentation that includes a log of all the procedures followed throughout the study (Creswell & Poth, 2018). The researcher kept a tracking log from the beginning of the study to detail each step and decision. Conformability efforts reduce researcher bias and ensure neutrality (Henderson & Renault, 2004). Reflexivity and memoing techniques addressed conformability. The researcher followed all guidelines established by the Institutional Review Board at the University of Indianapolis. Results The purpose of this study was to explore the experiences of African American women ages 45 to 75 living with depression, with a specific focus on their perceptions of treatment and the role of stigma, culture, and religious beliefs. Eleven participants completed the study. Table 1 describes the characteristics and demographics of the participants. Participants were assigned an identification number for confidentiality and to protect their privacy. Participants were all African American women residing in non-institutionalized settings. The participants' ages ranged from 50 to 70 years old. The education of the majority of participants was college-level. Participants were married, divorced, widowed, or never married. Some participants were unemployed, worked full-time, or retired. Of the eleven participants, five reported a diagnosis of depression, and six non diagnosed, but they experienced symptoms of depression. The five participants diagnosed with depression received their diagnosis from their primary care physician, a psychiatrist, or a licensed clinical therapist. The interview questions did not require participants to state where they resided, but they disclosed this information during the interview. Locations in the US included states in the Midwest, South, Southwest, and Northwest regions. Four significant themes resulted from the data. The four major themes are difficulty in daily functioning, coping strategies, barriers to treatment, and the impact of culture, religion, and AFRICAN AMERICAN WOMEN & DEPRESSION 25 stigma. For each theme, stigma was the predominant factor impacting how participants experienced living with depression and seeking mental health treatment. In addition, each theme had subthemes that further described participants' experiences. Table 2 provides quotes from the participants and list of themes and subthemes that resulted from the data. The researchers used pseudonyms to refer to the participants to protect their confidentiality. Difficulty in Daily Functioning The first theme, difficulty in daily functioning, describes each participant's ability to complete routine day-to-day tasks that allow them to function daily. The subthemes that emerged are experiencing physical and emotional changes, challenges due to health conditions, responses to life stressors, and the impact of generational trauma. Physical and Emotional Changes Participant described various behaviors and feelings to reflect their physical and emotional changes. Participants experienced physical and emotional changes that made it challenging to function daily. All eleven participants described some physical, behavioral, or emotional changes that impacted their day-to-day living, and ability to enjoy healthy relationships, attend school, or maintain employment. When asked how depression affected her day-to-day, Ms. C responded, My symptoms I've had um, included um, um crying, withdrawals um, being withdrawn um, being evil, being uh angry, not eating, losing weight, weight gain um, anxiety attack. I wasn't focused, um, mood swing, um, and just emotional instability. Another participant, Ms. D, stated, AFRICAN AMERICAN WOMEN & DEPRESSION 26 I eat when I'm not hungry, sleep a lot all day. I like being in the dark, you know, no light, just, just leave me in the dark. Uh, I cry for no reason. Um, just feeling down, you know, even when the sun is shining beautifully. I just don't feel like doing anything no energy. Besides relationships with family and friends, school and work were challenging. Participants struggled with engaging in everyday activities, including studying for classes, and functioning on their job. For example, Ms. D stated, "It's just kind of depressing. I wanna to go to school, but I don't have the energy." Ms. F also described her lack of sleep and having to wake up in the morning for work. I wake up every morning around three o'clock, three fifteen. Okay. I go back to sleep, and things that go through my mind are things I need to get ready to do on my job or worry about what's going to happen that day, and I'm like, why? I can't sleep all the way through. The language used to describe their depressive symptoms or diagnosis of depression was different for each participant. Participants were not always clear when they had been diagnosed and by whom and wondered if they were experiencing depression. Other participants were able to indicate when their depression started clearly and their diagnosis. According to Ms. G I've never had any diagnosis of depression; however, the symptoms of being isolated and feeling um withdrawn and sometimes um, feeling the need of just crying, just outbursts of crying. I've had those types of symptoms, maybe since I was a teenager. It's manageable depression, I have no energy, have lack of interest sometimes, lack of sleep, lack of concentration many times, and I come home to an empty, empty apartment. Participants were also made aware of their depression after visits to the doctor. For example, Ms. K commented, "My PCP diagnosed me, but it took a long time to figure out." AFRICAN AMERICAN WOMEN & DEPRESSION 27 Challenges of Health Conditions Some participants discussed health conditions or injuries that limited their mental or physical ability. For example, two participants described symptoms of postpartum depression. Their behavioral or physical changes occurred during a screening for depression and follow-up visits with their primary care physician. Ms. H stated, "The onset was when we moved. My daughter was less than six months old, so now that I think about it, I wonder if it was postpartum depression. I felt a wave of heaviness and, um, difficulty feeling happy." Ms. A described physical challenges after the birth of her child. It was 19 years ago when I gave birth to my son, um, that pregnancy wreaked havoc on my body, so I was at that point with postpartum depression. There was just a whole plethora of things that happened, um, health-wise, during my pregnancy, and I did end up on bed rest, so that prompted and spurred the initial diagnosis. Chronic health conditions, including diabetes, neuropathy, and injuries, exacerbated the depression experienced by participants. When asked if medical conditions impacted her depression, Ms. D responded, I have diabetes, and then you know, neuropathy in my leg from where the diabetes has damaged my body so bad, so I have several issues that add on to the depression. I think if I could walk, that would kind a free my mind but having issues with my leg and stuff, I can't do that. Participants who experienced ongoing depression throughout their lifespan described worsening symptoms of depression. Due to recent injuries or current medical diagnosis. Ms. G. stated, I fell and hurt myself and had a concussion I think that's when it finally escalated a little more. I had to go through low brain activity, no brain activity something like that for AFRICAN AMERICAN WOMEN & DEPRESSION 28 quite some time. The fact that no one came to see about me, um, really made me a little more depressed. Ms. J commented, "I'm diabetic and recently got diagnosed with stroke symptoms and my heart keeps beating hard and I don't understand why. Response to Life Stressors Life stressors were also a factor in how participants experienced their depression. Many of the participants shared stories of their childhood, pregnancies, marriages, work, and the impact on their relationships with family and friends. Participants described the events as occurring throughout their life causing stress, anxiety, and depression. Their responses to life events made it difficult to function each day. According to Ms. I, I was initially diagnosed with depression um while going through a divorce. I've never been depressed before. I wasn't sure what was happening, but I was you know, lethargic didn't want to get out of it um, had no appetite, lost quite a bit of weight, um and just isolated myself. Grief, loss, and death of close family members and children occurred during their lifespans. Ms. J commented, "I have a lot of anxiety, difficulty sleeping, sometimes both overeating, and not eating, not wanting to do anything, no energy. Started when my parents passed, the doctor diagnosed me with anxiety and some depression." Ms. K commented that when she got older, depressive symptoms occurred periodically, including during the death of a friend. I've had lots of losses, each time it's because of a death, lost a very dear friend and that brought up memories, first symptoms were death of my babies. Lost babies when I was pregnant 17, 21, 25, and 30. Last one doctor said it was a postpartum depression and that AFRICAN AMERICAN WOMEN & DEPRESSION 29 was normal. When I was a teenager, I was admitted to a mental institution several times, suicide attempts. Impact of Generational Trauma Generational trauma can impact individuals due to thoughts and feelings about a traumatic event that remains unresolved. Participants described family alcoholism, childhood abuse, and sexual misconduct when asked about factors that contribute to their depression. Ms. B stated, I was in high school, and I didn't t really know I was changing I didn't know I was going through mood changes. I wasn't aware that I was withdrawn, and I didn't know my appetite changed. So, the first bout of depression was when a pastor uh who was very beloved to my mother and my family um um hit on me in the church a few times and then he tried stalking me and that made me very, very nervous, and scared. Ms., I described her mother, who struggled with alcoholism made it difficult to share her own depressive symptoms and to look to her mom for support. My mom drank so her alcoholism affected me. It affected our relationship, and I had trouble when she stopped even just like forgiving and just trying to move on cuz we would never, she would never acknowledge that there was even a problem. Emotional and physical abuse was also part of the childhood for Ms. K Growing up, my father was alcoholic. So that's another reason why, uh, I didn't have very many friends because we moved a lot and you know, he was abusive and mm-hmm everything. So. Okay. Um, that could be a part of the depression. Um, people don't think that things affect their children. AFRICAN AMERICAN WOMEN & DEPRESSION 30 All eleven participants discussed the stigma connected to the challenges of daily functioning while living with symptoms of depression. Ms. B. commented: I have not been diagnosed with depression. Sometimes I feel I'm not myself, um not wanting to interact with other people, crying a lot, feeling like I got the blues, always angry. Just feeling like it's a cloudy day outside. I don't talk about it there's a lot of stigmas. Regardless of the societal stigma of living with depression, some participants were able to share their depression and find support from spouses, mothers, and sisters that were open and understanding. Ms. A described the support she receives from her husband. So specifically, with this, my husband is my go-to, you know communicator as far as if I'm not talking as much as I normally. do Am I seeming sad or withdrawn. He is well versed in medications I'm taking. Ms., I identified her sister as someone she could share her feelings about her struggles with depression. "My sister as you know in the trenches with me. So, she was the only person that I could really talk to and just be vulnerable with and open up to." Ms. B opened up to her mother about her continuing bouts with depression, My mom decided to take the kids off my hands. I left her house and went home and lay across the bed and couldn't move, I didn't' move for 24 hours. My doctor, they rook me out on a stretcher they said I had a panic attack, so it's been those things I dealt with a panic attack through the depression Coping Strategies for Depression The second theme described how each participant coped from day-to-day while living with symptoms of depression or a diagnosis. The strategies they described are categorized into AFRICAN AMERICAN WOMEN & DEPRESSION 31 three subthemes, practicing holistic interventions, personal connections with mental health providers, and experiences interacting with non-mental health providers. Practicing Holistic Interventions Holistic interventions were described as nontraditional methods of healing to treat their depression. The most effective methods mentioned were daily prayer, meditation, healthy diet, exercise, yoga, journaling, sister circles, prayer groups, and one-on-one listening sessions with supportive family, friends, coworkers, and clergy. When asked to describe ways to manage living with depression Ms. A responded, I have to take a very, very, proactive stance in self-care and making sure that I am being completely tuned into my mental health. I manage through a holistic health package medicinal intervention, diet, exercise. Adequate or above average amounts of physical activity, meditation, and prayer to stay balanced. Ms. B also focused on exercise as her coping strategy. "Working out, I'm a different person when I don't work out." Faith, hope, purpose, and the power of prayer were tools mentioned by eight of the participants. Ms. F. stated "Learning to start my day in meditation and prayer has really helped and I find strength in the Lord and the word of God. "Searching for some light and hope were key elements for Ms. D " I'll try to come out of my room. I'll try to get on the phone and call a friend and just talk just get out of that mood just to move that dark cloud to shine a light, a little light in that dark spot, open up my curtain and turn on some music. Some encouragement from friends and family and the feeling that they needed more than their holistic methods to continue to cope led some participants to seek out professionals and nonprofessionals for mental health treatment. AFRICAN AMERICAN WOMEN & DEPRESSION 32 Connections to Mental Health Providers Participants were asked their thoughts about using individual therapy with a professional mental health provider to treat their depression. Six of the eleven participants had sought therapy from someone they defined as a professional mental health provider. All six of the participants stated they had a positive interaction with at least one professional who provided their treatment. For example, Ms. I. stated, "I'm an advocate for therapy. I had a positive experience; she was an LMFT. I always looked for someone who was black. From a cultural standpoint, they could relate to things that I would experience or wanna talk about." Ethnicity of the therapist was also a factor in receiving treatment for Ms. G.Ms. G stated I totally agree with individual therapy they have lots of counselors to help with this, and when I went in to see mine, she was extremely helpful she was someone with an LCSW or doctorate. I went to a very, nice Caucasian lady. I would want an African American therapist, so I don't have to explain things to them if I was to go back to therapy. The participants who did not seek therapy from a professional also described who they felt were professionals that could treat their depression or any other mental illness. Education, experience, and licensure were related categories for this group to seek therapy. Ms. D. stated, "I would love it if I would like to get a doctor with a PhD and that has some studies in mental health and depression and someone who is trained." Specific types of support such as a peer support group proved helpful to one participant that did not attend individual therapy. The connection to the person leading the group and individuals sharing their experiences was beneficial in helping her cope with depressive symptoms. Ms. F. stated, AFRICAN AMERICAN WOMEN & DEPRESSION 33 I went to a group with a coworker with a lot of ladies we were just sitting there talking about our situations and what we were going through. That's what we need nowadays to be in a group to talk things out to make you feel better. Interactions with Non-Mental Health Providers Participants also described their interactions with non-mental health providers whom they sought to cope with their depression. The list of people who were considered non-mental health providers included nontrained clergy, primary care physicians, and social workers without special training in mental health. Two of the participants described interactions with pastors to help cope with their depression. One of the participants that was diagnosed with depression mentioned her negative interaction with a pastor prior to her deciding to attend professional individual therapy. According to Ms. I., I had a bad experience with a pastor. When I was going through my divorce and went to talk to the pastor about what I was going through, and he tried to hit on me. Personally, that left a bad taste in my mouth, and I feel like a pastor may come from the perspective of the Bible and instead of life experiences. Another participant, Ms. B described how her depressive symptoms started when her pastor stalked her when she was a teenager, as an adult, she participated in therapy and felt comfortable speaking to another pastor about her depression and life challenges. Although the two participants had negative interactions with clergy, three other participants mentioned pastors w they felt were helpful. They considered the pastors as progressive and part of denominations who believed in the science and treatment of depression through therapy and evidence-based practices. AFRICAN AMERICAN WOMEN & DEPRESSION 34 Non-credentialed social workers and primary care physicians untrained in mental health were mentioned by six participants when they gave an example of professionals that should not treat their depression. Ms. D. commented that the medical social worker with a master's degree at her dialysis center was not qualified to treat her depression. Ms. D. stated, They got to have that background, that mental health background, right? If they don't have any mental health background, you just talking. I can go to my social worker at dialysis to just talk to her, but she doesn't have that mental health background and she's not going to understand what I'm talking about when I say, that I am depressed. Participants also discussed annual depression screenings conducted by primary care physicians. These screenings can allow patients to discuss depressive symptoms with a professional and explore treatment interventions. Despite the purpose of the screenings, three participants described less than positive interactions when talking about their depressive symptoms with a primary care physician. Ms. K. stated, "The doctor asked me if I felt comfortable going on medication for my depression and I told him I don't need no medication for depression I coped with it all my life. I need someone to listen to me." Ms. H. commented, "I remember him saying that I was making too much of it and he looked at my chart and said you are overacting and over thinking. I said I don't think that's the case it was shocking." In the case of Ms. B., she sought out her friends who were doctors to discuss her depression after her interaction with her primary care physician. According to Ms. B., In the past I saw a doctor and I saw counselors, particularly in the past two years. Now, I've spoken with my doctor friends on various occasions when I've gotten to my weak points. In the past, I don't even think I knew that there were people, uh, in that profession that I could go to. I don't know if my doctor asked me the right question and, uh, that's AFRICAN AMERICAN WOMEN & DEPRESSION 35 when I realized that I was going through a lot or I just finally felt comfortable enough to tell her, so I was talking to her about it, and she told me to read a self-help book. I just didn't know that I knew anything about therapy then, you know. Barriers to Mental Health Treatment The third theme reflected barriers participants described to seeking or obtaining professional mental health treatment to treat depression or any mental health challenges. The two subthemes are internalized beliefs and systemic disparities. Internalized Beliefs Participants discussed their thoughts and feelings they have internalized due to their personal experiences of living with depression. Some participants also offered their perceptions and observations of the beliefs family and friends shared about barriers that exist regarding mental health treatment. The interviews expressed common themes of suffering in silence, the need to stay strong, and not knowing who they could seek out for help for fear of being judged. Ms. A. stated, I don't prescribe to the just sit and pray and it's going to go away. Culturally I know we as African Americans sometime prescribe to the you don't need mental health interventions, don't you take medicine, you don't need therapy. We are very reluctant to talk about these types of issues. Ms. D. also commented on cultural beliefs in the Black community as barriers to treatment, I think that as far as cultural in the, in the Black community, we don't talk about it and we should, within our family, we, we don't talk about it, you know, we talk about all other kind of stuff and things and you know, relationships, but we don't talk about depression. Like it doesn't happen to Black people. Yes, it does. AFRICAN AMERICAN WOMEN & DEPRESSION 36 Participants also had different feelings about what depression was and how they should respond before seeking any type of mental health intervention Ms. E. stated, "I'm not really depressed, just isolated due to COVID." The stigma of being diagnosed, and the belief that what happens in the family stays in the family were themes mentioned by participants as barriers to seeking help. According to Ms. G. "I have not gone to a doctor and said 'Hey, I'm depressed.' I don't want to be treated because I don't want that diagnosis. I don't want to be diagnosed as depressed. I know I have the symptoms." Ms. C. stated "The biggest belief is that you should snap out of it your own self, you should be able to just muddle through it. I have not sought it out, I feel like I'm pushing through." Ms. H. described the stigma contributing to African Americans not seeking treatment for depression or any mental illness. She stated, Black people are less likely to get treatment for it because there is a stigma attached to it. I don't ever remember growing up and hearing anybody in my family say I'm being treated for depression. I think our older senior African American hide mental health issues in the same way they hide um sexual predators within the family. It's one of those dirty secrets we don't really talk about but everyone in the family knows it happened and not understanding if you expose it and bring it to light you can heal it. Systemic Disparities Some participants described systemic barriers that occurred when they sought out mental health treatment for their depression. The barriers included: a lack of affordable therapy, lack of insurance coverage, inaccessible services located in their community, a limited number of licensed mental health providers, and a lack of Black therapists. According to Ms. A., AFRICAN AMERICAN WOMEN & DEPRESSION 37 I found that switch in medical care, the availability of licensed counselors, or their accessibility changed. I know it depends on where you are located, it's a regional thing. That's a big barrier when you're already depressed and your anxious and you keep reaching out to a therapist constantly, and they're not answering, or they're all booked up, or they don't take your insurance. So, availability, accessibility, um insurance, and compatibility culturally. Two participants stated they wanted a mental health provider with specific qualifications to treat their depression, Ms. D. stated, "I'm in the State of Louisiana and right now around here in my small town, we don't have any psychiatrists or psychologists that can help." Ms. C. commented "Um I haven't sought anything out, but I know the barriers are many. Many years ago, when I was in school, I sought out therapy, I wanted a Christian counselor and that was hard to find. So Christian and insurance can be a barrier." All participants did not experience systemic barriers. Four participants could access individual therapy through employee assistance programs (EAP), or health insurance provided by their employer. Two participants could access affordable therapy at community mental health centers on a sliding fee scale. Impact of Culture, Religion, Stigma The fourth theme, the impact of culture, race, and stigma included two sub themes. The two subthemes were about perceptions and beliefs regarding the responses to depression within the Black family and community and regarding the responses of Black churches. This theme also aligns with the subtheme of internalized beliefs under barriers to treatment. Both subthemes had various positive and negative responses, and stigma was a predominant factor discussed in both. Responses of Black Family and Community AFRICAN AMERICAN WOMEN & DEPRESSION 38 The researcher asked participants how they believed their depression impacted their relationships with their family and friends. Two participants stated they could be open to family members, share their experiences, and be selective in whom they chose to confide. Ms. H. stated, "I shared mostly with my sister no judgment there." Ms. A.'s support system included her husband, close family members, and friends. Ms. A. also commented on the cultural response of Black families and the concept of being a strong Black woman: I'm a firm believer that it stems from the resilience and the strength that we always had to show, and we have always had to exhibit and that you know due to the effects of slavery and that we have had that ingrained in us that we have to preserve. Six participants described not having support from family members and a cultural response of "don't talk about your problems or mental health" that still exists, especially in the older generation. For example, Ms. G. did not feel she could share her depression with her children or family members. She stated, "They have a lot going on and I'm the strong one in the family and I don't want to burden them." Ms. F. described negative comments by her brother when she had conversations with him about her struggles. "He always has something to say that makes me feel bad, so I just stopped saying anything." There were also comments about friends and family members who self-medicate as a response to their depression. Ms. J described someone she knows who she feels is living with depression," He loves to drink; he comes home, and his coping mechanism is to drink. He won't get medication for himself, but you know, if he's not drinking, he's very, I call it trigger happy." Diet pills were another medication for coping. Ms. D. described her friend's depression and small size. AFRICAN AMERICAN WOMEN & DEPRESSION 39 She ain't nothing but a buck, but she's always on some type of diet. I'm like, what are you doing, you're not big. But in her mind in her state, she just can't see it, but I can't get her to see it, I can't. I can't and I have tried to get her to, to talk to somebody to see somebody, but her thing is that I'm okay. Baby, you're not okay if every time I turn around you on a diet and steady losing weight like this, but she doesn't see it taking all those diet pills. I'm afraid for her. According to Ms. H. there is a generational difference for younger Black women regarding sharing their depression. "They are more open to talking about their mental health and affirm each other. They will come to church and say I saw my therapist this week like it's no big deal." Responses of the Black Church Participants were forthcoming in describing their experiences with pastors and church members and how they respond to mental illness. Some participants who stated they were members of what they saw as progressive churches and denominations felt supported in their efforts to cope with their depression. Ms. H. described her pastor's message, "It's a treatable disease seek professional help. If you had diabetes, you would get that treated." The church established a mental health ministry, support groups, and education on mental health. Ms. A's church denomination taught their congregation about the science behind mental health. Ms. A. stated, The church that I am a member of United Church of Christ is a wise congregation, which is one that is trained. And, um, I forget what the acronym stands for, but it's trained and, um, assigned that we are advocates for mental health and that we accept and welcome transparency where that is concerned, um, because it needs to be treated. AFRICAN AMERICAN WOMEN & DEPRESSION 40 Two participants described a response from their pastors or congregation that were not supportive of their struggles with depression. Lack of confidentiality, limited privacy, and mistrust were concerns listed by participants. Ms. F. described her interaction with the church, I'm gonna tell you what's going on and then suddenly either you going to find a sermon or preach about what I just told you or somebody that's in the church gonna know about it or whatever. So, I just tell myself, I don't wanna go, I'd rather talk to the minister, at another church. The minister I talk to is not affiliated with my church, she's at her own church. So, I feel if she is talking at her church, I don't know about it. Ms. D. described her feelings of mistrust for pastors that are "jackleg preachers not trained in mental health and only want money." Her experiences showed the ways participants described culture, religious beliefs, and stigma influencing Black women living with depression and seeking professional mental health treatment, I hear hurtful comments on mental health. We say, you know, we need to take that to the Lord, which I understand that, but God also made psychologists for us, that was the purpose he knew what he was doing when he made them. We need that, we need, people we can go to when you can't talk to family. Cause a lot of us, you know, can't talk to family member or friends because we figure that they going, they gonna stand in judgment on, you know, she gotta be crazy, not necessarily you know having depression don't mean that your whacked don't mean that your crazy, it just something in your life is making you depressed. There's an unhappiness, there's a dark spot. Let me put it like that. There's a dark area in life that needs, that needs, some light shining on it. Recommendations from Participants AFRICAN AMERICAN WOMEN & DEPRESSION 41 During the conclusion of the interview questions, the participants were asked how mental health professionals can help someone living with depression. The participants responses can be categorized into several areas. The first recommendation from nine of the participants was to have mental health professionals constantly talk about mental illness to reduce the stigma related to a diagnosis so older adult women can recognize the signs and seek treatment. Ms. K. stated. "The age group that's in this study was never introduced to therapy. They don't have an awareness and don't know there's something wrong. It's that's stigma again." The second recommendation included asking Black churches to train clergy and their congregation on how to respond and to help people suffering from mental illnesses appropriately. Several participants suggested clergy training includes recognizing depression and making referrals to mental health professionals. They also noted that congregations should support congregants who are mentally ill with encouragement through sermons, mental health ministries, and educational workshops. Ms. C. stated, "Once we get back in the church offer some type of workshops on mental health, don't make people feel bad if they answer the questionnaires saying that they are going through something." Ms. G. also agreed with ways churches can help reduce stigma and help increase participation in therapy, "I definitely think religious organizations should offer some type of support groups on managing depression and anxiety too. The pastor should be there too as a resource, and they can provide transportation if you need therapy." The third recommendation was to increase participation in therapy for older adults by adding holistic methods such as groups and sister support circles, Ms. K. stated, The first thing they want to do is give you pills and dope you up and your still not reality. Talk and listen first, and hear positive stories, my therapist told me to get up and do something different and see what works. AFRICAN AMERICAN WOMEN & DEPRESSION 42 The individual interview results demonstrated similarities and differences in the lived experiences of each participant. The impact of culture. Religion and stigma are evident in each of their stories as they attempt to manage their depression through various coping. Discussion and Conclusion This hermeneutical phenomenological study aimed to explore the experiences of African American women ages 45 to75 living with depression. Of specific focus was their experiences living with depression and the role of stigma, culture, and religious beliefs in mental health treatment. Participants shared intimate stories of living with symptoms of depression and the impact on their relationships with family and friends and their ability to work and attend school. The lived experiences of each participant in this study allowed the researcher to uncover themes and subthemes as they emerged throughout the interview process. The study's predominant themes were the impact of stressful life events, negative interactions with helping professionals, and the stigma experienced by the participants. A strong support system, practicing holistic interventions, and positive connections to mental health clinicians emerged as effective methods to cope with depression. Stressful Life Events Stressful life events (SEL) either in childhood or current are the most significant environmental risk factors for developing depression (Holden et al., 2013, p. 2). Many women in a study by Ward et al. (2015) had not sought treatment for their depression and believed the depression was normal based on their experience. African American women aged 60 and older described difficulties experienced by poverty, feelings of disempowerment, and traumatic events from childhood as the reasons for feeling depressed in adulthood (Ward et al., 2015). In our study, 45% of the participants did not seek mental health treatment for their depression. AFRICAN AMERICAN WOMEN & DEPRESSION 43 The impact of stressful life events on the participant's ability to function daily with depression was a key finding in our study. Participants identified life stressors, including divorce, isolation from family, postpartum depression with medical complications, inability to parent their children, and strained relationships with parents due to generational trauma. The connection between the participants' chronic health conditions and depression was a subtheme in the current study. Four participants described difficulty managing chronic medical conditions, including diabetes, heart conditions, obesity, and neuropathy, as debilitating and causing prolonged depression. The subtheme of chronic medical conditions as a life stressor that contributes to depression was also supported in the literature. For example, Holden et al. (2013) reported that low resilience and high depressive symptoms were connected to chronic health conditions, lack of medical insurance, no college education, and unemployment. Negative Interactions with Helping Professionals Participants in the current study shared interactions with helping professionals, including doctors untrained in mental health, that negatively impacted their ability to discuss symptoms and ask for help. This finding is similar to a study by Keller et al. (2016) where women stated that the primary care setting was not a place, they felt comfortable discussing their symptoms of depression. Some participants described interactions with clergy who were untrained and made disparaging remarks or sexual advances toward them that were inappropriate. Although some participants felt clergy, doctors, and social workers were not supportive and misunderstood their depression, it is essential to note that this was not the experience of everyone in the study. The researcher further explores the finding of positive and negative interactions with nonclinical helping professionals for participants in this study in the section on culture, religion, and stigma. AFRICAN AMERICAN WOMEN & DEPRESSION 44 Holistic Methods and Interventions Participants described holistic interventions, including prayer, meditation, journaling, and sister circles, as beneficial in coping with depression. This finding is significant due to the limited qualitative studies on the effectiveness of treating depression, specifically in older African American women, using many nontraditional methods. Therefore, exploring the effectiveness of holistic methods to cope with depression is recommended for further study. The finding of the power of prayer aligned with studies identifying the reliance on God for support as an effective treatment method (Connors et al., 2010). Another study showed that attending religious services and support from church members, family, and clergy were essential for managing depression for African American men and women aged 55 and older (Chatters et al., 2015). The mention of attendance at religious services is vital since two participants in our study mentioned that during the pandemic, they felt more isolated and lonelier due to churches being closed for in-person worship and activities. Positive Interactions with Mental Health Clinicians A notable finding from the results of the current study shows that participants who sought out and participated in therapy with a licensed clinical therapist had positive experiences. Participants described therapists who were nonjudgmental, professional, caring, and helpful and improved their lives in managing depression. Being open and objective and providing guidance and direction were also traits participants described they desired in a therapist. These findings are significant when clinicians attempt to engage older African American women in treatment so they can feel comfortable sharing their experiences in a supportive setting. Some participants described the race of the therapist and a cultural connection as factors in seeking and remaining in treatment. Two participants commented that it was essential to connect with someone that AFRICAN AMERICAN WOMEN & DEPRESSION 45 looked like them, understood them culturally, and did not have to explain their life experiences during therapy. Even though having an African American therapist was mentioned by some of the participants, one participant described how she benefited from sessions with a Caucasian therapist. These findings are similar to a systemic meta-analytical review of studies on mental health treatment. For example, Cabral and Smith found, "Across 81 studies of individuals' perceptions of therapists, the average effect size was 0.32, indicating a tendency to perceive therapists of one's race/ethnicity somewhat more positively than other therapists" (2011, p. 537). Impact of Barriers to Treatment Three significant findings on barriers to mental health treatment resulted from the findings. One is the cultural concept of African American women as superwomen who are strong and can manage depression independently. This concept also leads to internalized feelings of the stigma that one is weak when speaking up and asking for help. Nelson et al. (2020) studied African Americans seeking treatment for depression and noted three themes for participants in her study. African American participants mask or ignore pain, show an inability to ask for help, and demonstrate a lack of self-care. Woods-Giscombe (2010) recommended that health providers become aware of the superwoman concept and provide counseling and health education as part of their treatment approaches. Participants in this study also stated that some of their friends and family suffering from mental chose negative coping strategies, including denial and self-medication. The friends and family members remained silent and did not seek individual therapy. Secondly, some participants reported systemic barriers, including lack of insurance, high cost of therapy, and the limited number of professional therapists in their community. These AFRICAN AMERICAN WOMEN & DEPRESSION 46 findings aligned with the current literature showing that barriers to seeking mental health services included poor quality health services, inaccessible health services, lack of health care insurance, poverty, racism, discrimination by health and social service systems, and a lack of culturally sensitive mental health providers (Connors et al., 2010; Connors et al., 2014; Ward et al., 2014; Watson & Hunter, 2015). Thirdly, stigma was the most significant barrier many participants cited. Several participants expressed wanting help for their depression, but the negative view of their family, friends, and community on mental illness influenced their decisions to suffer in silence. The current literature also supported this finding with the concept of anticipated stigma, a type of public stigma that focuses on the opinions of the person's family and friends. Anticipated stigma impacted older African Americans' view of depression (Sirey et al., 2014). In one study of adults 60 and older, older African American men and women reported a higher rate of anticipated stigma for depression, 68% versus 53% for older Caucasian men and women (Sirey et al., 2014). In addition, a lack of awareness and discussion about depression led to fewer referrals for mental health treatment for older adult African participants (Sirey et al., 2014). Impact of Culture, Religion, and Stigma Many participants commented on how their family traditions, culture, and religious views impacted their beliefs about depression. One participant noted that she had never heard anyone in her family talk about mental illness or discuss going to see a therapist. A typical response from some families was "what goes on in this house stays in this house" and "just pray, and God will provide." Other participants felt a strong support system, including family, friends, and community, was crucial in managing depression. The participants were able to find support from husbands, sisters, friends, and clergy, who encouraged them to seek professional help. AFRICAN AMERICAN WOMEN & DEPRESSION 47 Another common theme included a need for the African American community and churches to embrace depression as a treatable disease and provide safe spaces for education on mental illness. There was a difference in how some participants openly talked with their children about mental illness versus no discussions with their parents growing up. For younger generations of African American women, this openness is very encouraging to reduce the stigma of living with depression. However, a stigma still exists within some families and religious denominations, especially for older African American women who cannot openly share their struggles living with depression. The theme of religion and the church as an integral part of treating depression was evident in the literature. For example, Ward et al. (2014) suggested that older African American women believed there was no need to seek professional treatment for depression; instead, they sought help from the clergy. In another study of African American men and women aged 50 and older, participants stated they would only seek professional help for depression after praying or talking with the clergy, pastors, or church staff (Wharton et al., 2016). Interestingly, this researchers findings did not entirely support the literature showing older African American women seek out their pastors first. Participants who had adverse reactions or views of the clergy were reluctant to include the clergy and churches in their care or divulge their diagnosis of depression. Even though negative interactions occurred within the church, participants could utilize prayer, the Bible, and prayer circles in combination with professional therapy to manage their depression. Limitations This study had two fundamental limitations. First, the researcher conducting the study and interviews for each participant was a licensed clinical social worker. In order to recognize AFRICAN AMERICAN WOMEN & DEPRESSION 48 and address any researcher bias, each participant was informed prior to the interview that the researcher was a licensed clinical social worker. Furthermore, the researcher stated that her clinical role was unrelated to the study, and participants could ask questions or express concerns about mental health professionals. In order to document and process any feelings, concerns, or impressions during data collection, the researcher completed memoing after each interview. As a second method to mitigate bias, a second researcher, a licensed clinical social worker, helped review the codes, themes, and subthemes based on the interviews. The second limitation was the method of interviewing. Though face-to-face was the preferred method of interviewing, all interviews were conducted electronically via a web conferencing format or on the telephone due to contact limitations of the COVID-19 pandemic. For three interviews, limited internet connection and poor phone reception were two issues encountered and quickly resolved. The study included a COVID-19 protocol for face-to-face meetings, but participants chose web conferencing or telephone for several reasons. Two participants stated they felt more comfortable with web conferencing due to being at an elevated risk for COVID-19. Also, some participants were located outside the Chicago area and could not travel to participate in face-to-face interviews Implications and Future Research There are several implications for future research based on this study's findings. All the participants mentioned several roles they continued to maintain as they coped with their depression. Participants were raising extended family members, caretakers for their grandchildren, working past retirement age, volunteering in their community, or supporting their church through service and leadership positions. This study showed that, despite the struggles and challenges of living with depression, the participants stressed the importance of being AFRICAN AMERICAN WOMEN & DEPRESSION 49 successful in their responsibilities. This finding is significant for African American women managing multiple roles with limited support. As a result, they may experience additional stress in their lives, leading to symptoms of depression. According to Baldwin-Clark et al. (2015), "Age, physical health, and marital status as an aspect of social support were significant predictors of whether or not an older African American woman had ever had depression and whether or not she felt depressed in the past year" (p. 8). Further studies are needed to determine how the multiple roles held by older African American women may impact their depressive symptoms and the chronic medical conditions mentioned by the participants. Another implication for further research involves using holistic intervention methods to treat depression. Participants commented on the effectiveness of prayer, yoga, meditation, journaling, and sister support circles. Participants felt empowered and connected to their cultural roots when they engaged in prayer, exercise, and spiritual music to cope with depression. Participants practiced holistic methods during counseling sessions with their therapists. Participants felt comfortable continuing to practice the techniques, such as grounding and breathing exercises, on their own. Clergy and social workers can be trained as mental health advocates to promote the benefits of holistic interventions that may complement professional therapy. Clergy and social worker can play a significant role in reducing the stigma of mental illness as mental health advocates. Their responsibilities include creating support groups, providing space for sharing success stories, raising awareness, preaching on depression, and forming mental health ministries to help reduce the stigma. A partnership between social workers and the clergy can help provide mental health educational seminars at the church. In addition, low-cost counseling, and transportation by volunteers for older dualistic attend therapy sessions. AFRICAN AMERICAN WOMEN & DEPRESSION 50 In summary, mental health clinicians can implement the findings from this study to increase the rate of participation in mental health treatment for older Adult African American women living with depression. These implications include but are not limited to the following: Medical conditions and injuries contributed to a decreased quality of life for participants struggling with depression. Unresolved trauma and continual life stressors may result in depressive symptoms and negatively impact day-to-day functioning. Interaction with helping professionals, including doctors untrained in mental health, may negatively impact a discussion of symptoms and seeking treatment for depression. Individual therapy with a licensed mental health professional may be a positive experience when the provider specializes in treating depression. Holistic interventions, and cultural practices including prayer, meditation, journaling, and sister circles, were beneficial in treating depression. Support from family and friends was a critical factor in effectively managing depression. Short-term individual sessions with an EAP provider were an additional positive resource for the treatment of depression. Stigma from family, friends, and the community impacted the ability to manage depression and seek professional help. There were generational differences among middle-aged and older Adult African American women taught to remain strong and not seek professional help for depression. AFRICAN AMERICAN WOMEN & DEPRESSION 51 Religious institutions in the Black community, including churches and pastors, may contribute to the negative stereotypes of living with a mental illness. Creating partnerships, mental health training, and targeted outreach to Black churches were critical in helping to reduce the stigma of living with depression and encouraging participation in mental health treatment. The cost of therapy, lack of insurance, unavailable services, and a limited number of African American therapists were barriers to seeking treatment. Conclusions Older African American women underutilize professional mental health services to treat their depressive symptoms. While participants in this study experienced challenges managing their symptoms of depression and expressed a desire to participate in therapy, locating low-cost, community-based, professional mental health therapy from an African American therapist remained out of reach in some communities. Also, despite numerous mental health campaigns aimed at reducing the stigma of depression, family traditions, cultural norms, and religious practices still maintained the concept of being a strong Black woman who has to suffer in silence. To normalize seeking professional mental health therapy for depression, doctors, clergy, and social service providers that frequently interact with the target population should build relationships and listen to older African American women when they are expressing their symptoms of depression. Participants described mistrust and a lack of understanding when they sought treatment for their depression. The low rate of treatment can be improved when providers commit to understanding the systemic barriers to accessing treatment. Increasing public awareness to address living with a mental illness and attending specialized training on recognizing and AFRICAN AMERICAN WOMEN & DEPRESSION 52 responding to depression in older African American women are ways health providers can begin to address the stigma surrounding mental illness. In addition, they are building a referral network of community-based African American therapists that emphasize holistic methods as a treatment option for depression. AFRICAN AMERICAN WOMEN & DEPRESSION 53 References Akinyemi, E., Watkins, D. C., Kavanagh, J., Johnson-Lawrence, V., Lynn, S., & Kales, H. C. (2017). A qualitative comparison of DSM depression criteria to language used by older church-going African Americans. Aging & Mental Health, 22(9), 11551161. https://doi.org/10.1080/13607863.2017.1337717 American Psychiatric Association (2013). 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Current Translational Geriatrics and Experimental Gerontology Reports, 2(1), 2430. https://doi.org/10.1007/s13670-012-0036-z 58 AFRICAN AMERICAN WOMEN & DEPRESSION 59 Table 1 Participant Characteristics Participant ID Age Marital Status Work Status Education Level Diagnosed w/Depression 001 Ms. A 50 Married Fulltime Doctorate Yes 002 Ms. B 65 Divorced Unemployed Masters No 003 Ms. C 69 Divorced Retired Bachelors No 004 Ms. D 59 Single Unemployed Some College No 005 Ms. E 70 Divorced Retired Masters No 006 Ms. F 68 Widowed Fulltime Some College No 007 Ms. G 57 Single Fulltime Masters No 008 Ms. H 61 Married Fulltime Masters Yes 009 Ms. I 56 Divorced Fulltime Some College Yes 010 Ms. J 50 Married Unemployed Doctorate Yes 011 Ms. K 69 Married Retired Doctorate Yes AFRICAN AMERICAN WOMEN & DEPRESSION 60 Table 2 Theme Table Theme Sub Theme Difficulty in Daily Functioning Physical and It takes all the joy out of your life. It sucks the Emotional Changes life out of you thats what its doing to me. Ms. Challenges of Health D. Conditions Response to Life Stressors Impact of Generational Trauma Coping Strategies for Dealing with Depression Practicing Holistic Interventions Connections to Mental Health Providers Interactions with Non mental Health Providers Barriers to Mental Health Treatment Internal Beliefs Systemic Disparities Impact of Culture, Religion. and Stigma Responses of the Black Family and Community Responses of the Black Church Participant Quotes Its a team family approach to my mental wellness. Ms. A. Someone with at least a masters degree, I cant run down all the letters and qualifications, but they have to be compassionate and judgmental. Ms. H. I may need to talk to someone pick up the phone and just talk but wait you going to charge me if its a $1, $5 I dont need that that makes it worse everything is a cost. Ms. G. Mental health period is a stigma. Ms. C. Whatever happens in the house stays in the house. Ms. J. . AFRICAN AMERICAN WOMEN & DEPRESSION 61 Appendix A Interview Guide Thank you for agreeing to be interviewed today. My name is Deborah Hammond, and I will be conducting this interview today. I am a doctoral student at the University of Indianapolis Doctor of Health Science program. As we discussed before, the purpose of this study is to better understand what it is like to live with a diagnosis of depression. The questions that I will ask you today are about your experiences living with depression and your treatment for depression. The interview will take about 60 to 75 minutes, and everything you say will be confidential. You may stop the interview at any time without consequences. If we come to a question you prefer not to answer just let me know. Do you have any questions before we start? Also, as we have discussed I will be audio recording the interview today to capture everything that you tell me. Is it okay if I start the audio recording now? Okay the audio recorder is on now. 1. Can you tell me about your initial diagnosis of depression? a) How did you first find out about your diagnosis of depression? b) Describe your day-to-day life of living with depression? c) Tell me about how living with depression affects your relationships with family and friends? d) Describe how living with depression affects your ability to work or attend school? e) Can you give me any other examples of how living with depressions has affected areas of your life? 2. Can you share with me your beliefs about what causes depression? a) Tell me about any cultural or religious beliefs you have about regarding depression? b) Can you describe any factors that may influence your beliefs about depression? AFRICAN AMERICAN WOMEN & DEPRESSION 62 3. Describe coping strategies you have used to manage living with depression? a) Share with me why you chose those specific coping strategies? b) Can you give me an example of how the coping strategies did or did not help manage your depression and why? 4. Describe how people you know deal with mental health issues? a) Do they seek professional help? b) Do they deal with mental health in other ways? 5. What are thoughts about using individual, professional therapy to treat depression? 6. Can you give me some examples of professional mental health therapists? 7. Tell me about any barriers you have faced to seeking individual therapy with a professional mental health therapist to treat your depression? a) Describe how you felt when you faced these barriers? b) Can you give me an example of steps you took to overcome any barriers? 8. Can you tell me about your experiences with a professional mental health therapist for your depression? a) If you participated in individual therapy, how did you feel about your interaction with the professional mental health therapist? b) Can you describe your conversations with the professional mental health therapist? c) If you decided against seeking individual therapy for your depression, can you explain why? 9. What are some ways mental health professionals can help someone living with depression? 10. Is there anything else you would like to share? AFRICAN AMERICAN WOMEN & DEPRESSION 63 Thank you again for taking the time to participate in my research study. Again, all information is confidential, and copies of this audio recording will be stored in a password protected computer. The audio recordings will be transcribed, and copies of the recordings and transcriptions will be destroyed at the conclusion of this research study. I will write down my contact information (Deborah Hammond hammonddp@uindy.edu). Feel free to contact me if you have any questions regarding this study. AFRICAN AMERICAN WOMEN & DEPRESSION 64 Appendix B Eligibility Screening Questions Hello, my name is Deborah Hammond and I want to thank you for your interest in participating in my research study on exploring the experiences of African American women aged 50 to 64 living with depression. I am going to ask questions to determine your eligibility for the research. 1. Do you self-identify as Black or African American? Yes No 2. Do you self-identify as female? Yes No 3. Please provide me with your current age. 4. Have you been diagnosed with depression currently or in the past by a mental health professional? Yes No If yes, when were you diagnosed and what was the professional title of the mental health professional that diagnosed, you? AFRICAN AMERICAN WOMEN & DEPRESSION Appendix C Study Information Sheet 65 AFRICAN AMERICAN WOMEN & DEPRESSION 66 AFRICAN AMERICAN WOMEN & DEPRESSION 67 AFRICAN AMERICAN WOMEN & DEPRESSION Appendix D Recruitment Flyer 68  ...

... Perception of Role-Emerging Level II Fieldwork Submitted to the Faculty of the College of Health Sciences University of Indianapolis In partial fulfillment of the requirements for the degree Doctor of Health Science By: Tracy L. Bentley-Root, MS, OTR/L Copyright December 7, 2022 By: Tracy L. Bentley-Root, MS, OTR/L All rights reserved Approved by: Lisa Borrero, PhD, FAGHE Committee Chair ___________________________ Elizabeth Stith, DHSc, OTR/L, BCG Committee Member ___________________________ Theresa A. Vallone, EdD, MS, OTR/L Committee Member ___________________________ Accepted by: Laura Santurri, PhD, MPH, CPH ___________________________ Director, DHSc Program Chair, Interprofessional Health & Aging Studies University of Indianapolis Stephanie Kelly, PT, PhD Dean, College of Health Sciences University of Indianapolis ___________________________ PERCEPTION OF ROLE-EMERGING Perception of Role-Emerging Level II Fieldwork Tracy Bentley-Root Department of Interprofessional Health & Aging Studies, University of Indianapolis 1 PERCEPTION OF ROLE-EMERGING 2 Abstract Background: Academic fieldwork coordinators (AFWC) in occupational therapy (OT) programs are challenged to find placements. Reasons for this challenge include changes in reimbursement, workload and productivity demands, and restrictions imposed in response to the pandemic. OT programs have pursued settings where OT is not currently provided to meet the growing need for level II placements. Research has investigated the students' perceptions of role-emerging placement (REP) but has not until now investigated the supervision provided by the other professions in addition to the Accreditation Council of Occupational Therapy Education (ACOTE) requirement of eight hours of supervision by an occupational therapist. Research has not been conducted into non-occupational therapy (non-OT) supervisors' perception of REP. Purpose: This study aimed to investigate the experiences of non-OT supervisors, including perceived opportunities and challenges, and supervisory practices utilized by the non-OT supervisor. Method: The researcher used a basic interpretive qualitative approach using individual semi-structured interviews. After Institutional Review Board (IRB) approval, criterion sampling was used to identify participants from established REP with D'Youville University. The interviews were transcribed verbatim and analyzed thematically. Results: Information power was achieved after four participants completed the interview process. Three themes emerged which elucidated the participant's perceptions of REP. The themes were: requirements for student success; benefits; and opportunities for further partnerships. Discussion: The significance of this research will be its potential to identify the benefits of role-emerging placements facilitating the profession's ability to respond to an ever-changing healthcare arena. Keywords: role-emerging placement, level II fieldwork PERCEPTION OF ROLE-EMERGING 3 Acknowledgments Many people have contributed to the successful completion of this research. I wish to acknowledge my committee members; Dr. Lisa Borrero, Dr. Elizabeth Stith, and Dr. Theresa Vallone. Their guidance and expertise were instrumental in the completion of this research. I will be forever grateful. To the role-emerging level II fieldwork sites, thank you for partnering with occupational therapy to meet the needs of underserved populations. To my friends and colleagues, I appreciate your efforts to keep me moving forward. To my sons, Aiden and Aaron, for keeping me grounded. And most importantly, to my dear husband, Rich, I would not have been able to complete this research without his constant support and encouragement. PERCEPTION OF ROLE-EMERGING 4 Table of Contents Title Page.........................................................................................................................................1 Abstract............................................................................................................................................2 Acknowledgments............................................................................................................................3 Table of Contents.............................................................................................................................4 Chapter 1: Introduction....................................................................................................................6 Problem Statement...............................................................................................................8 Purpose Statement................................................................................................................8 Research Questions..............................................................................................................9 Significance of the Study.....................................................................................................9 Definition of Terms..............................................................................................................9 Chapter 2: Literature Review.........................................................................................................10 Role-Emerging Placements................................................................................................11 Justification for Using REP and Requirements to Conduct a REP....................................11 Benefits and Challenges to Students Completing a REP...................................................13 Perceptions from the FWEd, AFWC, and Community Representatives...........................15 Chapter 3: Method.........................................................................................................................17 Study Design......................................................................................................................17 Participants.........................................................................................................................17 Setting................................................................................................................................18 Procedures..........................................................................................................................18 Rigor/Trustworthiness........................................................................................................23 Chapter 4: Results..........................................................................................................................24 PERCEPTION OF ROLE-EMERGING 5 Theme 1: Requirements for Student Success.....................................................................25 Theme 2: Benefits..............................................................................................................32 Theme 3: Opportunities for Further Partnerships..............................................................38 Chapter 5: Discussion and Conclusion..........................................................................................40 Theme 1: Requirements for Student Success.....................................................................41 Theme 2: Benefits..............................................................................................................44 Theme 3: Opportunities for Further Partnerships..............................................................47 Limitations.........................................................................................................................48 Implications for Practice and Future Research..................................................................49 Conclusion.........................................................................................................................50 References......................................................................................................................................51 Table 1: Content Requirements and Standards of Didactic Knowledge........................................60 Table 2: Domain and Process........................................................................................................62 Table 3: Participant and Site Characteristics.................................................................................64 Table 4: Interview Themes, Definitions, and Sub-Themes...........................................................65 Appendix A: Email to FWEd Prior to Contacting Non-OT Supervisor........................................66 Appendix B: Recruitment Email to the Non-OT Supervisor.........................................................67 Appendix C: Interview Guide........................................................................................................69 Appendix D: Follow-Up to Recruitment Email.............................................................................73 Appendix E: Study Information Sheet...........................................................................................74 PERCEPTION OF ROLE-EMERGING 6 Perception of Role-Emerging Level II Fieldwork Across the United States, occupational therapy academic fieldwork coordinators (AFWC) are challenged to secure level II fieldwork sites for their students. The level II fieldwork allows students to practice with clients across the lifespan in a supported environment. This experience is vital to the development of entry-level occupational therapists and is supported through curriculum design highlighting the use of meaningful, purposeful occupations and the profession's domain and process (American Occupational Therapy Association [AOTA], 2012; AOTA, 2020). The typical level II fieldwork occurs over a 12-week period, during which the occupational therapy student learns entry-level skills alongside an occupational therapist fieldwork educator (FWEd). This level II fieldwork occurs after the student completes the didactic portion of the curriculum (Accreditation Council of Occupational Therapy Education [ACOTE], 2021). The AFWCs are challenged most recently by a shortage of fieldwork placements due to the growth of accredited occupational therapy programs, perceived barriers to hosting students, and the recent COVID pandemic, which have limited opportunities in traditional occupational therapy placements (AOTA, n.d.; ACOTE, 2021; Varland et al., 2017). In addition, specific to this study, New York State has the highest number of occupational therapy schools, further adding to the volume of students needing fieldwork placements (ACOTE, n.d.-a). One potential avenue to identify new settings for fieldwork is via role-emerging placement (REP). The REP occurs in setting(s) where an occupational therapist is not or has never been employed (Linnane & Warren, 2017). Community-based sites that address an individual, group, or population's health and wellness would meet a REP's requirements (AOTA, n.d.). To meet ACOTE accreditation standards, at least two professionals must supervise students PERCEPTION OF ROLE-EMERGING 7 in a REP. The non-occupational therapy (non-OT) supervisor is a professional associated with the site responsible for the student's primary supervision during the fieldwork. The second supervisor is a regulated occupational therapist who is required to directly supervise the student for a minimum of eight hours per week and is available for consultation when the student is with the other supervisor (ACOTE, 2020; AOTA, 2012). The occupational therapist serves as the FWEd in the REP. The FWEd supervising the REP will have at least three years of full-time experience or equivalent experience before acting as the FWEd. This FWEd supervises the student under a contractual agreement with the academic program (ACOTE, 2020). The ACOTE Standards, allowing occupational therapy programs to place students in a REP, results in increased sites where OT programs can develop partnerships to fulfill the level II fieldwork requirement and expand the profession's scope of practice into community-based sites. Participation in the REP has also been beneficial for the students. Specifically, the REP has been shown to provide students with a variety of learning experiences, has the potential to expand the OT profession, and can address fieldwork placement shortages (Bossers et al., 1997; Cooper & Raine, 2009; Dancza et al., 2013). Studies investigating the student's experience after completing the placement have found growth in areas such as critical thinking, application of OT theory, and ability to collaborate (Clarke et al., 2015b; Dancza et al.,2013; Kaelin & Dancza, 2019; Mattila & Dolhi, 2016; Overton et al., 2009; Syed & Duncan 2019). Gat and Ratzon (2014) conducted a study in Israel and found that role-emerging, community-based fieldwork students scored higher in their perceived personal responsibility, cultural competence, and overall personal skills than their cohort who completed a more traditional placement with an onsite FWEd. Also, students' self-efficacy improved after completing the REP (Gat & Ratzon, 2014), a phenomenon supported by other studies (Golos & Tekuzener, 2019; Mattila, 2019; PERCEPTION OF ROLE-EMERGING 8 Mattila et al., 2018). Although research has been conducted in Australia, Ireland, Britain, Israel, and Canada, limited research has been carried out in the United States concerning the utilization of and experiences with role-emerging occupational therapy fieldwork placements (Lau & Ravenek, 2019; Mattila, 2019; Mattila et al., 2018; Mattila & Dolhi, 2016). Limited comparative studies have been conducted on students' perceptions before and after the REP. Additionally, to this date, the role of the non-OT supervisor has not been investigated. In the seminal work of Bossers et al. (1997), it was recommended to investigate the role and perception of fieldwork educators and non-occupational therapy supervisors. Additional studies have identified the gap in the literature regarding REP fieldwork opportunities and the perceptions of the non-occupational therapy supervisor (Clarke et al., 2014a; Wilburn et al., 2016). Problem Statement To date, of the studies conducted in the United States, most research investigating roleemerging fieldwork has been conducted after students completed the fieldwork (Lau & Ravenek, 2019). However, no studies have investigated the non-occupational therapy supervisors' perceptions of the role-emerging placement. Investigating these perceptions can further the OT profession, identify the non-OT supervisors' perceived enablers and barriers to successful student supervision in REP fieldwork, identify supervisory strategies currently being utilized, and assist the AFWC in curricular design to further support all involved with the REP. Therefore, to meet the fieldwork needs of occupational therapy students and make supportive changes in the curricula, the AFWC would benefit from understanding the non-OT supervisors' perceptions of the role-emerging placement. Purpose Statement PERCEPTION OF ROLE-EMERGING 9 A basic interpretive study will aim to understand the non-OT supervisor's perceptions of the role-emerging level II fieldwork placement. Research Questions How do non-OT supervisors perceive the role-emerging level II fieldwork placement? o What are the perceived opportunities? o What are the perceived challenges? o What supervisory practices are utilized by the non-OT supervisor? Significance of the Study The research findings and themes may identify potential new role-emerging placements that further the OT profession, ensuring the profession's evolution as occupational therapy practitioners respond to an ever-changing healthcare arena. Investigating the perceptions of the non-OT supervisor, the AFWC, and the supervising OTR can promote preparation to support the student and the REP. Gaining this knowledge about how the non-OT supervisors approach supervision and understanding their perceived potential opportunities and barriers will assist curricular development for the role-emerging setting. Definition of Terms Role-emerging practice setting: Role-emerging placements (REP) occur in settings where no occupational therapist is employed (Linnane & Warren, 2017). Level II fieldwork: "level II fieldwork provides an in-depth experience in delivering occupational therapy services to clients, focusing on the application of evidence-based purposeful and meaningful occupations, administration, and management of occupational therapy services" (AOTA, 2012, para. 4). PERCEPTION OF ROLE-EMERGING 10 Literature Review Fieldwork placements are vital components of every occupational therapy student's learning experience and are fundamental to curricular program design (AOTA, 2018; Mattila, 2019). Specifically, level II fieldwork allows students to apply the theory and techniques acquired through didactic and level I fieldwork exposure (AOTA, 2018, ACOTE, 2020). Didactic knowledge was described by ACOTE (2020) in section B standards. It included the following content requirements: foundational content requirements, occupational therapy theoretical perspectives, basic tenets of occupational therapy, referral, screening, evaluation, and intervention plan, context of service delivery, leadership, and management of occupational therapy services, scholarship, and professional ethics, values, and responsibilities (see Table 1). The level II experience allows the student to carry out professional responsibilities, including evidence-based, purposeful, and meaningful occupations, and conduct administrative and managerial duties under an occupational therapy professional (ACOTE, 2020). Through experiential learning, the student applies academic knowledge, develops clinical skills, and has the opportunity to determine what area of practice they are going to pursue (Mattila & Dolhi, 2016). Experiential learning allows the students to practice from the profession's framework, specifically the domain and process of occupational therapy. According to AOTA (2020), the domain identifies the "profession's purview and the areas in which its members have an established body of knowledge and expertise" (p. 4). The process includes the actions occupational therapy practitioners engage in when providing services that are "client-centered and focused on engagement in occupations" (p. 4). Aspects of the domain include occupations, contexts, performance patterns, performance skills, and client factors (see Table 2). The process further describes how occupational therapy practitioners apply the domain PERCEPTION OF ROLE-EMERGING 11 (e.g., evaluation, intervention, outcomessee Table 2) to support a client's engagement, participation, and health (AOTA, 2020). Traditionally, the supervision of the student is provided by a licensed and credentialed occupational therapist with a minimum of one year of practice experience (ACOTE, 2020). Per ACOTE (2020), FWEd is used when the occupational therapist functions as a student supervisor. Role-Emerging Placements Provisions exist for fieldwork placements where OT services do not exist (ACOTE, 2018). The literature defines these settings as role-emerging placement or nontraditional (Lau & Ravenek, 2019). For this study, REP will be the term used to identify this fieldwork type. Examples of REP areas found in the United States (U.S.) include prisons, primary care in underserved rural areas, at-risk youth shelters, homeless veterans' programs, psychosocial clubhouses, after-school programs, community outreach for individuals with intellectual disabilities, and long-term structured residences (Mattila, 2019; Mattila & Dolhi, 2016; Precin et al., 2018; Provident & Joyce-Gaguzis, 2005). Recently, there has been a shift to providing occupational therapy students with fieldwork opportunities in REPs (Syed & Duncan, 2019). To achieve AOTA's Vision 2025, academic programs must prepare students for emerging practice areas and meet the needs of diverse settings and populations (AOTA, 2019a). Justification for Using REP and Requirements to Conduct a REP The cause of this shift is multifaceted. In the U.S., there are currently 461 ACOTEaccredited programs, 98 programs in the candidate phase, and 112 programs in the application phase (ACOTE, n.d.-b). Given the potential for a nearly 50% growth rate in occupational therapy programs, there will be a significant need for additional fieldwork placements. According to the PERCEPTION OF ROLE-EMERGING 12 U.S. Department of Labor (2021), the 2019-2029 job outlook for occupational therapy practitioners is anticipated to be 16%, which is much faster growth than in other professions. A REP is possible when the site does not have an established occupational therapy service. In these situations, the student will be supervised by a site staff member (i.e., the nonOT supervisor) with an offsite FWEd (Fitzgerald et al., 2017). ACOTE (2018) further clarifies that the FWEd must have at least three years of full-time experience in occupational therapy. The offsite FWEd is also known as the long-arm supervisor (Warren et al., 2016). Fieldwork Educators' Perspective From the traditional FWEds' perspective, workload and productivity demands have been identified as reasons they do not host fieldwork students (Evenson et al., 2015; Ozelie et al., 2015). According to Varland et al. (2017), a cross-sectional survey of 500 FWEds found the following to be reasons that negatively affected their ability to host fieldwork students: job responsibilities, size of caseload, productivity standards, not working a full-time schedule, and fear of having to fail a student. Globally, there is also a shortage of placements across nursing and allied health professions (Taylor et al., 2016), and the COVID-19 pandemic has augmented the staffing crisis (Robinson et al., 2021). Given this information, there is a growing demand for placements but a decrease in available traditional opportunities. To address this gap between the need for and availability of placements, REPs are being established by academic programs. National Regulatory Changes and the COVID-19 Pandemic Additionally, the COVID-19 pandemic has caused unprecedented economic and medical challenges for the U.S. health care system, mainly affecting the small, independent, and rural systems that usually run on lean budgets (Khullar et al., 2020; Sokol & Pataccini, 2020). The effects of the COVID-19 pandemic may add to the previously mentioned reasons why FWEds PERCEPTION OF ROLE-EMERGING 13 and their employers choose not to host fieldwork students. The pandemic caused many fieldwork settings to cancel placements due to budgetary concerns and personal protective equipment (PPE) shortages, causing an accumulation of students requiring placements to satisfy ACOTE accreditation standards. The pandemic occurred nearly synchronously with U.S. health care regulatory changes. The changes shifted reimbursement from fee-for-service to value-based (i.e., Patient-Driven Payment Model and Patient-Driven Groupings Model; AOTA, 2019b; Bogenrief, 2020). Instead of being reimbursed based on the amount of therapy service, the new models determine payment based on the patient's characteristics (i.e., primary diagnosis, functional impairment, and the presence of comorbidities) (Bogenrief, 2020). Some providers have attempted to reduce costs by reducing the frequency of OT services. These changes have spurred a shift toward prevention, wellness, and recovery, supporting occupational therapy's move away from the medical model (Metzler, 2019). Given these identified hurdles, role-emerging placements are a way the AFWCs can procure fieldwork placements in areas where the number of students exceeds the number of available and willing FWEds and employers. Benefits and Challenges to Students Completing a REP Level II fieldwork generally provides experiential learning, enabling students to apply academic knowledge, develop clinical skills, and determine what practice area they will pursue (Mattila & Dolhi, 2016). Studies have elucidated the benefits and challenges students experienced during the REP. Benefits for Students The REP setting is known to provide students with a varied learning experience, offer the opportunity to expand the OT profession, and address the placement shortage (Bossers et al., PERCEPTION OF ROLE-EMERGING 14 1997; Cooper & Raine, 2009; Dancza et al., 2013; Overton et al., 2009). Literature examining the REP is growing, with the primary focus on the student experience upon completion of the placement. For example, recent studies have demonstrated that students develop the following skills while on their REP: critical thinking (Dancza et al.,2013; Mattila & Dolhi, 2016; Nielsen et al., 2020; Syed & Duncan, 2019) application of theory to a unique setting (Dancza et al.,2013; Kaelin & Dancza, 2019; Syed & Duncan, 2019) collaboration with those who may not understand their roles (Clarke et al., 2015a; Dancza et al.,2013; Syed & Duncan, 2019) advocacy for OT in the non-occupational therapy setting (Clarke et al., 2015b; Dancza et al.,2013; Syed & Duncan, 2019) organization and independent practice (Dancza et al.,2013; Syed & Duncan, 2019) practice in a more client-centered way (Clarke et al., 2014b; Kaelin & Dancza, 2019; Syed & Duncan, 2019) Studies conducted before and after the REP identified similar skill development and noted additional benefits, positive experiences, and perceptions of the placement. For instance, students' self-efficacy, described as a person's belief in their ability to perform and complete a task or situation (Bandura, 1977), was reported to improve throughout the REP (Gat & Ratzon, 2014; Golos & Tekuzener, 2019; Mattila et al., 2018; Mattila, 2019). In a study by Kaelin and Dancza (2019), students identified learning threshold concepts (i.e., client-centeredness, occupation, and applying OT theory) unique to OT while on their REP. Challenges for Students PERCEPTION OF ROLE-EMERGING 15 Upon completing the REP, it is essential to note that students have also identified challenges, negative experiences, and perceptions. Similar themes of fear and anxiety were reported in several studies. Mattila & Dolhi (2016) noted that participants reported fear and anxiety about the unknown. This fear was noted in themes surrounding the setting and the population (i.e., an at-risk youth shelter) (Mattila & Dolhi, 2016). Students identified uncertainty when applying knowledge because they could not emulate their FWEd (Kaelin & Dancza, 2019). Students noted various emotional extremes, from excitement, satisfaction, fulfillment, and tiredness (Dancza et al., 2013; Clarke et al., 2015a). Finally, students noted a sense of being thrown into the placement (Clarke et al., 2014a; Clarke et al., 2015a). In response to a limited understanding of the strategies used by students, Clarke et al. (2019) conducted an interpretative phenomenological analysis study of five students upon completion of their REP. They found two themes that described strategies used by the students. The students identified "drawing on inner resources," which included students investing themselves in the placement and use of the reflective practice to "make sense of the experience" (p. 23). The students also identified "being part of the team," which included the students' perceived level of support, the supervisory relationship, frequency of supervision, and learning through engagement with the clients (Clarke et al., 2019, p. 24). Given these findings, it is clear that supervision and support for the student completing the REP are vital. This support is provided through the combination of the individuals on-site at the REP, the FWEd, and the AFWC. Perceptions from the FWEd, AFWC, and Community Representatives A recent study investigating FWEds' experiences acting as long-arm supervisors identified enabling activities such as developing rapport with the site, using a peer or paired PERCEPTION OF ROLE-EMERGING 16 student supervision model, and professional gains from serving as the FWEd (Warren et al., 2016). Also identified in this study were challenges for FWEds, including providing supervision in unfamiliar settings, underestimating the time commitment, and managing the students' ideas and emotions during the placement (Warren et al., 2016). The enabling activities were necessary for the long-arm supervisor to meet the demands of this FWEd role. Wilburn et al. (2016) surveyed 44 AFWCs regarding their experiences in emerging practice areas in a related study. Perceptions shared by the AFWCs were noted that students on fieldwork in emerging practice areas demonstrated improved professional behaviors, gained abilities to collaborate interprofessionally, and attained a more refined ability to define and apply occupational therapy principles (Wilburn et al., 2016). According to van Rensburg et al. (2019), perceptions from community partners when OT students complete service learning noted contributions to occupational justice, occupational enablement, and improved health and well-being for its members. The role of AFWCs and FWEds in developing and sustaining REPs is vital to the future of the occupational therapy profession (Lau & Ravenek, 2019; Wilburn et al., 2016). Recent literature suggests that academic programs must provide learning opportunities to reflect the themes identified by the fieldwork educator and the students (Clarke et al., 2014a; Clarke et al., 2019). Research examining REPs primarily focuses on student perceptions after completion of the fieldwork and perceptions of the AFWC and long-arm supervisors. However, there is a lack of research into the role of the non-OT supervisor (Clarke et al., 2014a; Wilburn et al., 2016). This study will fill a gap in the literature and support the AFWC and FWEds to develop curricula and support initiatives for all students and non-OT supervisors. It is also important to note that the REP is routinely not the first fieldwork opportunity chosen by the OT students or assigned by PERCEPTION OF ROLE-EMERGING 17 the AFWC, which could be due to the structure of the long-arm supervision. Further developing REP opportunities will enhance the available pool of fieldwork placements, support the non-OT supervisors, and reach areas where OT services are necessary but are currently lacking. Method Study Design This study utilized a basic interpretive qualitative approach. Merriam (2002) described the purpose of this approach was to understand how people interpret their experiences and apply meaning to those experiences. This approach is appropriate as the researcher seeks to investigate non-OT supervisors' perceptions of a REP and what meaning these supervisors attribute to the fieldwork. The researcher also examined the supervisors' understanding of the REP, identified supervisor perception of enablers and barriers to completing the REP, discovered possible curricular needs, and ascertained supervisors' interest in the REP. The researcher received Institutional Review Board (IRB) approval at D'Youville University before recruitment and data collection. Also, a reliance agreement was developed between D'Youville University IRB and the University of Indianapolis IRB. Participants Participants were non-OT supervisors who supervised students during REP level II fieldwork. Inclusion criteria required participating as a non-OT supervisor in a REP within the past five years within a two-hour drive from D'Youville University. The researcher is a faculty member at D'Youville University and recruited non-OT supervisors from previously established REPs that the university utilizes. Qualitative researchers seek to understand the meaning associated with the experiences of people who share a common phenomenon. For this study, the researcher determined the number PERCEPTION OF ROLE-EMERGING 18 of participants through the use of information power (Malterud et al., 2015). These recommendations work in concert to determine when higher information power is present (i.e., a smaller N) or when a larger sample size is required to answer the research questions. To have higher information power, it is recommended that the research conducted have a narrow study aim, the participants are highly specific to the study aim, an applied theory be used, a robust interview dialogue is captured, and an in-depth analysis of the interview is conducted (Malterud et al., 2015). Information power "is not intended as a checklist to calculate N but is meant as a recommendation of what to consider systematically about recruitment at different steps of the research process" (Malterud et al., 2015, p. 4). Setting The researcher conducted all activities on a small, private urban campus that serves 3,000 students and on-site at the REP. The researcher conducted all interviews on-site at the community-based REP. All activities were conducted in a private, distraction-free setting. Procedures Sampling and Recruitment Qualitative research utilizes purposeful sampling to select participants who can best inform the researcher about the focus of the research question (Creswell & Poth, 2018). Specifically, criterion sampling was used in this study and deemed appropriate as these supervisors are likely to reveal opportunities for program improvement in curriculum development and identification of potential REP settings (Patton, 1990). The researcher is a clinical assistant professor in the occupational therapy department and does not have contact with non-OT supervisors. PERCEPTION OF ROLE-EMERGING 19 Upon receiving IRB approval, the researcher initiated recruitment by contacting the involved AFWC and requesting contact information, such as email address and work telephone number, for the FWEd assigned to the REP and the non-OT supervisor. The researcher then contacted the FWEd by email (see Appendix A) to introduce the study as a courtesy before the researcher contacted the non-OT supervisors. This step was required as the FWEds have established a relationship with the REP and the non-OT supervisor. Upon receiving the fieldwork educators' permission to contact the non-OT supervisor, the researcher emailed the non-OT supervisors and included the FWEd in the carbon copy (see Appendix B). Including the FWEd in this initial email will let the non-OT supervisor know that the FWEd was aware of this recruitment request. The FWEd piloted the interview guide (see Appendix C) via practice interviews with two FWEd. This introductory email to the non-OT supervisors introduced the proposed study, including the purpose, inclusion criteria, potential benefits and risks, confidentiality, and the opportunity to respond with questions and identify their interest in participating. Participants were informed that each would receive a $25 gift card to compensate for their time upon data collection and analysis completion. The researcher allowed the non-OT supervisors to reply with questions for one week from the email. After one week, the researcher reminded those non-OT supervisors who did not respond to the initial email to query their interest in participating in the study (see Appendix D). Upon receiving non-OT supervisors' emails indicating their statement of interest, the researcher contacted them individually by telephone, reviewed the inclusion criteria, and scheduled the interview date, time, and location. Informed Consent PERCEPTION OF ROLE-EMERGING 20 Before completing the semi-structured interviews, each participant was provided a study information sheet (see Appendix E) to read via email and again at the beginning of the interview. This sheet included: the voluntary nature of the study, the ability to withdraw from the study at any point, the purpose of the study, procedures to be used in the collection of data, protection of confidentiality, the risks and benefits associated with participation in the study, and contact information for the researcher (Creswell & Poth, 2018). To prevent the collection of identifiable information via a signed form, verbal informed consent was obtained via audio consent at the time of the recorded interview. Before initiating the interview, the participants were offered the opportunity to ask questions and seek clarification regarding any study component. Data Collection Data were collected through face-to-face semi-structured interviews between the researcher and the participant. The interviews were audio recorded via a password-protected Voice Recorder application on an Android phone. The interviews were conducted in an empty classroom on the campus to protect participant privacy or in a private, distraction-free setting of the participants choosing. The researcher utilized a previously established semi-structured interview guide (see Appendix C) throughout the interview and engaged in unique probing and follow-up questions to allow the conversation about the topic to evolve organically. The interview guide was piloted with the REP FWEds before conducting the research interviews. After each interview, the researcher completed field notes to capture what was observed to augment the audio recording. The practice of triangulation with the field notes ensured the confirmability of the researcher and added to the credibility of the data collection process (Henderson & Rheault, 2004). After each interview, the researcher also completed memoing to recognize similar information for thematic development, jumping from raw data to descriptions PERCEPTION OF ROLE-EMERGING 21 of the research question and reflexivity (Birks et al., 2018; Satterlund, n.d.). As previously mentioned, the researcher utilized information power to determine when data collection would cease, and the sample size was then known (Malterud et al., 2015). As Malterud et al. (2015) explain, information power can help shape the size of the sample because "the more information the sample holds, relevant for the actual study, the lower number of participants is needed" (p. 7). Data Management & Analysis Data analysis began immediately after the first semi-structured interview, with the researcher completing field notes and memoing observations for possible interpretation. Field notes served as observational accounts of the interviews and aided in removing researcher bias from the study to ensure confirmability (Henderson & Rheault, 2004). As such, the researcher completed field notes immediately following each interview. Additionally, memoing captured the researcher's learning through the interview process and identified similar views and themes (Birks et al., 2018; Satterlund, n.d.). Next, the researcher transcribed interviews through Temi, a password-protected transcription service. Then the researcher conducted a detailed review of the transcription against the password-protected Voice Recorder audio recording on an Android phone. This reviewer then completed this line-by-line to ensure the accuracy of the data. Data Storage. After the researcher completed the detailed review of the transcription against the audio recording, the audio was saved as a password-protected MP3 stored locally. The transcriptions and audio files were then stored in Dedoose 9.0 , a data management and analysis application. The audio recording was then removed from Voice Recorder and Temi. Dedoose files were only accessible by the researcher, an analysis expert acting as a secondary coder, and the outside reviewer, as requested. The written material generated through field notes PERCEPTION OF ROLE-EMERGING 22 and memoing was housed in a locked storage box accessible only by the researcher. Participants and related study data (MP3, transcription, field notes, and memoing) were assigned a unique identification number to ensure confidentiality and de-identification. The next step was inductive coding of the data. Coding. The researcher engaged in coding and theme identification via a line-by-line reviewing process through immersion in the data, reviewing the transcripts over multiple sessions, and using memoing for interpretation and analysis (Marshall & Rossman, 2011; Stuckey, 2015). During the interviews, the researcher intended to capture the multiple views of the non-OT supervisors. The researcher utilized information power to determine when the amount of information gained develops new knowledge and answers the research question (Malterud et al., 2015). The data in the first cycle of the coding process identified single words, short phrases, and more extensive passages relevant to the research question (Saldana, 2013). A codebook was developed and included the organization of this coding process. The codebook contained a list of codes, code descriptions, and sample data to reference (Saldana, 2013). This codebook aided the researcher in maintaining organization throughout the multicycle coding process (Saldana, 2013). Descriptive codes were used when coding the field notes, and In Vivo coding was used when coding the transcriptions (Saldana, 2013). Descriptive codes summarize the main topic from an excerpt of a field note, and In Vivo codes are taken from the interview transcript and placed in quotation marks (Saldana, 2013). The multicycle coding process included the analysis expert acting as a secondary coder. The secondary coder was CITI trained and had expertise in qualitative research methods, evidenced by experience publishing qualitative studies and data analysis with applications such PERCEPTION OF ROLE-EMERGING 23 as Dedoose 8.1 . The secondary coder separately coded all interviews. The researcher and the secondary coder agreed on codes that most accurately capture the data furthering the codebook development. This data triangulation verified the results and ensured the study's credibility (Henderson & Rheault, 2004). The following coding phase involved again reviewing the data, identifying additional codes, and potentially reconfiguring the codes to immerse the researcher further in the data (Saldana, 2013). With immersion in the data, this potential reconfiguration elucidated additional themes. The coding cycle continued as the researcher identified categories that organized the codes into families of information with similar meanings, and then the categories further developed into broader themes (Saldana, 2013). The researcher then engaged in member checking to ensure the credibility of the data by providing the resulting themes to each participant, allowing the participant to clarify any item (Lincoln & Guba,1985). This process was completed by sharing the generated themes with each participant through email, with the researcher requesting correspondence to verify the results, including seeking clarification and corrections. All data, transcripts, and interpretations, generated during the coding process, contributed to an audit trail to demonstrate how coding, categories, and themes were developed (Stuckey, 2015). An external audit was conducted using an outside reviewer who examined the data analysis process and attested to the confirmability and dependability of the study (Lincoln & Guba, 1985). The outside reviewer completed an external audit for triangulation which will ensure the confirmability and dependability of the research. This outside reviewer had expertise in qualitative research methods through a history of publishing qualitative studies and data analysis. After the analysis, the researcher created a table comprising the relevant themes identified during the coding process. PERCEPTION OF ROLE-EMERGING 24 Rigor/Trustworthiness Guba's Model of Trustworthiness guided the procedures, emphasizing the data collection and data analysis processes to ensure a quality study. Trustworthiness was achieved by applying the following strategies: credibility, confirmability, dependability, and transferability (Lincoln & Guba, 1985). Credibility and confirmability were achieved during data collection through reflexivity and member checking (Henderson & Rheault, 2004). The researcher mitigated bias using memoing (Henderson & Rheault, 2004). During data analysis, member checking was utilized to ensure a credible study (Henderson & Rheault, 2004). The researcher achieved dependability by following the detailed step-by-step process in the method section. Triangulation and an audit trail were implemented to ensure confirmability and dependability. The sample represents a larger population of non-OT supervisors for transferability. This transferability will occur through purposeful criterion sampling, data collection using open-ended questions, and analysis (Henderson & Rheault, 2004). This transferability further occurred through the researcher providing thick descriptions of the participant's responses and context with transparency in the methods. Results Information power was achieved after four participants completed the interview process, becoming evident by both the researcher and the secondary coder as the rich data was analyzed and answers to the research questions emerged. Specifically, four participants who served as non-OT supervisors for level II fieldwork students completed the current study, all meeting the inclusion criteria (see Table 3). The participants were all women: two with clinical bachelors degrees, one with a liberal arts bachelors degree, and one with a dentistry degree. The settings included an adult day program, a pediatric dentistry clinic, a social club for individuals with PERCEPTION OF ROLE-EMERGING 25 autism, and a social club for individuals with acquired head injuries. Via supervision and collaboration with occupational therapists who served as the FWEd, the occupational therapy students (OTS) provided occupational therapy services addressing the professions domain and process by targeting the occupational needs of the REP clientele. The delivery of the services was supervised by the non-OT supervisor, an on-site professional responsible for the day-to-day duties and obligations. Data analysis resulted in 33 codes used to categorize the participant interview data. Of the 33 codes, ten of the codes were parent codes. Five of the ten parent codes were further delineated into 19 child codes. Finally, three of the child codes were split into four grandchild codes. One code (n=1) was removed during the analysis due to participant-specific application. Based on the analysis of the hierarchical codes, three themes, and six sub-themes (see Table 4) emerged and aided in answering the research questions. Theme 1: Requirements for Student Success The first theme that resulted from the multicycle coding process was the requirements for student success. Each participant identified requirements for success in their setting, noting student attributes, including a need for didactic knowledge, the students own ability to use therapeutic use of self, and the non-OT supervisors supervision style. Didactic Knowledge A sub-theme that emerged related to requirements for student success in a REP was didactic knowledge. Participant 1 stated, from an adult day program: When [students] come, when they first start here, theyre a student-like a true student-with a ton of knowledge and skills. Students need this didactic knowledge to identify a need for and provide occupational therapy services within the professions domain and process (see Table 2). Participants PERCEPTION OF ROLE-EMERGING 26 acknowledge that strong didactic knowledge is critical in a setting where an occupational therapy practitioner is not providing service. This sub-theme includes examples of didactic knowledge, including the ACOTE requirements of foundational content within occupational therapy educational curricula; basic tenets of occupational therapy; referral, screening, evaluation, and intervention plan; and professional, ethics, values, and responsibilities and how this knowledge looks at the REP (see Table 1). Participant 2 stated from a pediatric dental clinic, [Students] do come with an amazing skill set... strong didactic skills in occupational therapy. Foundational Content Requirements. Specific participant examples include the occupational therapy students ability to identify performance skills and occupations, as evidenced by participant 2 at a pediatric dental clinic: Whether it be your textbook or what youve seen or what youve learned, you have a child who is having difficulty with their motor skills [for example] holding a toothbrush. All participants identified specific diagnoses for their REP and how the diagnoses affected the occupational therapy domain and process. Participant 4, at a social club, stated: TBI or brain injury... You dont think of motor vehicle, MS... or other neurological disorders. [And] just the knowledge of our population is huge. Additionally, all participants emphasized the need to acknowledge variability in diagnoses, presentation, and specific client factors. Participant 1, from an adult day program, stated: Whats startling to some students is that [some participants] dont have memory loss, but the two [participants] with particular frontotemporal dementia, they have pretty significant aphasia. One is nonverbal now. And he laughs whether he is happy, sad, angry... Understanding the different types of dementia. When I talk about the fine dance, its because they dont have memory loss when they communicate with you, and PERCEPTION OF ROLE-EMERGING 27 people might assume that theyre not understanding, but they truly do understand. They do know who their family [is] and where they used to work... thats another example of the different types of cognitive deficits and what the students need to be prepared for. Participant 3, from a social club, also noted that OT students need to understand the variability in diagnoses, presentation, and specific client factors: [Clients] diagnosed with [autism]... [students] need to learn the differences [in autism]. The students at the REP apply this foundational knowledge to the provision of OT services occurring at the REP. Basic Tenets of Occupational Therapy. All participants spoke to the basic tenets of OT, including the ACOTE standard addressing Safety of Self and Others. For example, participant 3, from a social club, commented on the opportunity to address the clients performance skills during social interaction, specifically sensory regulation: Safety. Thats a big one, safety. We also make sure that [the students are] aware of when [an] individual leaves an area, [the student should] go make sure you know where [the individual] is. If [the individual] is going in the sensory room, [the student] should hang out in the sensory room with. Participant 3, from a social club, also shared the students exposure to client factors, specifically cognition: If [the individual] is going out to that front door [and says], my mom texted shes here or my moms here now, [the student should] walk them out there and make sure they are getting in the correct car... I have one girl thats so high functioning [and] she got turned around. She [went] outside to look for her mother. She ended up behind the building. PERCEPTION OF ROLE-EMERGING 28 Another example from a pediatric dental clinic, during the occupational therapy process of completing an evaluation and providing interventions, also addresses the safety of self and others: To not only perform to the safety of the child, but also to [the dental hygienist's and the OT students] safety. Finally, participant 1 summarized the need to address the safety of self and others by stating, understanding what [clients] cant do, I guess, understanding safety enough [that the] students understand where their limits are [for both clients and students]. Study participants discussed the standard, Effects of Disease Process, which was noted by participant 1 and included how the client's ability to complete performance skills and occupations was affected by a disease process. If [the student is] supervising a small group activity, [and a participant] has to get up from the table, most of our participants are not independent ambulators, but theres a few that are, the students need to know that... or I have to approach [the participant] from this side [or] if [the student] sees [a participant] go get up without their device, [the student] would need to provide a reminder. Lastly, students reportedly need to have a firm understanding of Activity Analysis, which was affirmed in a quote by participant 2 at the pediatric dental clinic: [Students] ability to see whats happening. I love that when... a child will be coming in, could be upside down in the chair... how are we going to modify the activity thats going on? And participant 3, from a social club, stated: in the evaluations... how you handle different situations [with the individual]... planning your group to tailor [to]everyone in that group. These examples demonstrate the students opportunity to complete activity analysis during the OT process at the REP. Participant 3 further noted that this ensures activities are ...accessible to everyone. PERCEPTION OF ROLE-EMERGING 29 Referral, Screening, Evaluation, and Intervention Plan. These quotes are related directly to the OT process and further illustrate the sub-theme, didactic knowledge. For example, participant 4, at a social club, stated, So I feel like it takes a couple weeks of just straight, straight up, observing skills [and] the groups. From a pediatric dental clinic, participant 2 stated: You are going to be teaching [during an intervention]... [students] should know medical histories and medical conditions. [And students should know] swallowing skills [the performance skills necessary for the occupation of eating and swallowing] Participant 3, at a social club, stated: theyre here for weeks, [but on] day one [the students are] cooking [with the individuals]. Participant 1, at a social club, noted interventions that occur at the REP in this statement: As far as eating and making decisions about how to keep people safe during mealtime... level II students have actually gone and gotten adaptive equipment for us. These quotes emphasize the student's didactic knowledge in screening, evaluation, and intervention planning. Professional, Ethics, Values, and Responsibilities. Another example of didactic knowledge includes the ACOTE standards relating to professional, ethics, values, and responsibilities. Participant 2, at the pediatric dental clinic, noted the student's ability to advocate for social responsibility, equitable services, and sustainability: buying into the therapies that we [OT] provide and just how important receiving OT is. Therapeutic Use of Self is another ACOTE standard included in the examples of didactic knowledge, specifically in the content requirement, referral, screening, evaluation, and intervention plan, and was heavily discussed by all participants. Thus it was identified as the next sub-theme. Therapeutic Use of Self PERCEPTION OF ROLE-EMERGING 30 Therapeutic use of self requires an occupational therapy practitioner to understand clients as human beings at an interpersonal level and the ability to apply empathy and use of interpersonal knowledge and related skills to thoughtfully resolve evocative interpersonal events in practice (Taylor, 2020, p. 2). All participants identified the students need to utilize therapeutic use of self to be successful at their REP. For example, participant 4, from a social club, stated, I think, as always, until they build a rapport, you just see a night and day difference with facilitation skills. Participant 4 continued, just having a strong demeanor... putting yourself out there... the students have to put themselves out there... you gotta be able to ... introduce yourself... make an attempt to get to know the individual. At another social club, participant 3 emphasized this in the following: [the students] interact, and they [develop] a good peer-to-peer relationship. Participant 3 also stated: We have eight autistic individuals here. Each one is different. I want you [OT student] to pick up on the difference qualities and abilities ... and always remember if you worked with one, the next will be different, and how to approach them [use of interpersonal skills]. Additionally, to further illustrate the therapeutic use of self, participant 3 stated, in your field... any professional who will eventually be working with the developmentally or intellectually disabled... need to learn to interact... they wanna be able to pick up on the cues that that person is giving off. Participants identified skills required to meet individuals at the interpersonal level, including rapport building, observation, socializing, intervening, communicating, behavior management, listening, objectivity, and confidence in these stated skills. From an adult day program, participant 1 stated: PERCEPTION OF ROLE-EMERGING 31 I never look to the students to understand how to intervene [initially]. I more would need the students to understand how important it is to not intervene... if they havent worked with the participant before... They would need to know whether to back off and observe or just ask for help or if they should intervene. These skills were also illustrated in a quote from the pediatric dental clinic interview with participant 2: To be able to use their interpersonal skills to read the situation. And to elevate if it needs to elevate or to calm if it needs to calm. Participant 2 continued: I mean the skills that you bring to the table, not just here, but the phone calls to parents and teleconference and with parents. Participant 4 from a social club stated, So if you really wanna build rapports, you gotta make the effort and... be comfortable doing so... Thats like the number one in this setting. Participants emphasized that therapeutic use of self is necessary for a successful REP student placement. This need was supported during the interview at a social club with participant 3: to take the education and the background that they have to the benefit of the individual. But first and foremost, to be a friend. And also, in the quote from participant 1 at an adult day program: open and willing to bend and meet [the students] needs as long as the clients needs are being met. Developing a therapeutic use of self requires supervision while the OT students are at the REP. Supervisory Style The participants all noted the need for a supervision plan and process to be successful. This supervision was provided via a combination of the non-OT supervisor and the FWEd and can be described as collaborative, supportive, and often available immediately. For example, participant 1 stated, Were in this together. Participant 3 provided feedback in a direct matter of fact... friendly manner. Not in a supervisory manner, in a friendly manner. Participant 2 PERCEPTION OF ROLE-EMERGING 32 described how the supervision is provided collaboratively at the pediatric dental clinic and begins with meeting the occupational therapy school... the director, the students, [the patient, the dental resident, and hygienist]... So getting to know each others session before were even on the floor. Participant 2 illustrated how this occurs, We move in, we debrief, we listen, we talk, you know, we see another patient. Participant 4 speaks explicitly to this supervisory style provided at the social club in the following quotes: And then the open-door communication is something that I have with the students because there isnt somebody [FWEd] directly on site, so if you have a question come right now, well formulate an email. If I cant answer it [well] call... and well get an answer for you. Participant 4 continued: Its great that [FWEd] sits in personally or via Zoom for the assessments. She [FWEd] gives the best and most appropriate feedback...its great that we both observe, but... its better she [FWEd] does too. And is there every time at the moment she can say, lets maybe rephrase that to... and that part's great and helps them... feel supported. The supervisory style can be summarized with the following single-word quotes: accessible, direct, informal, and supportive. Theme 2: Benefits The second theme that resulted from the multicycle coding process was benefits. Each participant reported benefits from hosting level II students at the REP. The benefits noted were experienced by the student, the site, and the non-OT supervisor and were highlighted as subthemes. To the Student PERCEPTION OF ROLE-EMERGING 33 Throughout the interviews, benefits to the student were emphasized by the participants. As anticipated, the benefits included advocacy for OT, applying OT theory in a unique setting, working independently, and program development. Additionally, the participants noted that a REP is supportive and can meet specific student needs. Students have the opportunity to gain continued experience at a REP throughout portions of their required fieldwork placements (i.e., level I, level II, or advanced clinical placement), and the REP allows OTS to pursue other areas of interest. Participant 3 described the benefits experienced at the social club: I do see advocacy... between your students and where they could go out and... advocate for things. Participant 3 then gave examples of when past OTS advocated for clients to receive OT and related services, which continued post-graduation. Participant 4 provided the following as an example of advocacy for OT at the social club: students quite literally seeing barriers that they wouldnt otherwise see, like how to access the community, something as simple as going to the grocery store, managing money, different daily living skills in place here. We have such great opportunities to really let folks know what an occupational therapist does, was witnessed at a pediatric dental clinic by participant 2. At the REP, students are afforded multiple opportunities to apply OT theory in a unique setting. Participant 4, at a social club, noted: that a student is having other opportunities that would not necessarily be at a traditional placement. Also, from a social club, participant 3 stated, building a relationship... were just different here. Examples of applying OT theory in a unique setting were provided by each of the participants and included from an adult day program, participant 1 noted: And when you have an OT [student] that comes here and is great with art and can work the somebody with a tremor or with CVA [cerebral vascular accident], PERCEPTION OF ROLE-EMERGING 34 with some vision loss and set them up the way they need to be set up. In the social club setting, participant 4 provided these examples: Even the goals are client-oriented. I sit one-on-one with participants when they start after 30 days. And then... two times a year to evaluate those goals. And its up to them what they wanna work on... I have people that quite literally come here with the only goal of I wanna come four times a month for [what] interests me. I have people that wanna come strictly for music... or social appropriateness... to talk in a social group setting. The socialization piece is always gonna be a goal here. Now we have a full-time evening program. Wonderful opportunities for future students... like intake assessments. Participation. Its a whole different realm that I dont feel students see all the time. So its great. In hopes that they buy in... this is a whole new world I wasn't aware of... I feel like we provide a unique takeaway... than another placement. Examples provided by participant 3 illustrate applying OT is a unique setting: we do advanced life skills, kitchen lifestyle... so theyre learning to prepare simple meals for themselves... So theyre a lot more higher functioning, but they do still need assistance. And thats what [the social club and the OTS] bring to a daytime program. Participant 2 provided the following comments regarding OT in a unique setting: The skills that you bring to the table, not just [in the clinic], but the phone calls to parents and the teleconference and... toothbrushing there [at the patients home] and then recreating it here, the green room created-they created for us [for sensory regulation], the social stories [for behavior management]. It is bountiful, you know, everything that has occurred. PERCEPTION OF ROLE-EMERGING 35 Students were also able to work independently when on their REP. Participant 3 stated at the social club, [students] jump [in]... its like, theyve always been here. Like they were made for that role. Theyre very good at what they do. And I think theyre going to be very successful, and theyre going to be an asset to the community. Participant 3 stated that students need very little direction. Participant 4 stated, its the individual [and] their opportunity to work independently during the REP at the social club. As summarized, the student's ability to work independently at the adult day program, participant 1 described this benefit with [Students] own observations and interventions from start to finish not because somebody else said we have a problem over here and identify it. Finally, students benefitted while on the REP from exposure to program development. Participant 1 described program development that students have been involved in: The printed information we have for staff training for exercise programs has come from level II students whove compiled yoga programs, gardening programs with grading challenges... its incredible... the encyclopedia we have from two students, theyre going to make sure that we have copies of all of that for our second site. Participant 4 noted the following opportunity for program planning: [develop] a group where... its for seven weeks, but then maybe we can run it again two months down the road. Well run it again, still keeps on paying... moving forward. There were unanticipated student benefits identified during the multicycle coding process. The interviews identified that the REP is supportive and can meet specific student needs. Participant 1 stated: We worked that [accommodations for her medical condition] out. We worked out her hours and how she would cue me if she was having a hard time [with her medical PERCEPTION OF ROLE-EMERGING 36 condition]... Its a really supportive environment here, and I think she shined, and I think it was great to get this under her belt... open and willing to bend and meet the needs as long as the clients needs are being met. Participant 4 provided another example of this benefit and stated, we [FWEd, the non-OT supervisor, and OTS] do a week-to-week check-in... to sit down and say this is the week were running our group. And close the next week. How do we think it went? The students also have the opportunity to gain continued experience at a REP throughout their fieldwork experience, from level I to level II or from level II to an advanced clinical placement required as part of the community practice course that follows the successful completion of level II fieldwork. This benefit was illustrated in a quote from the interview with participant 3, so thats another opportunity for, for students as well as, and you know, across just specifically to the level II, which is what this study is focusing on, for from the level I perspective [and] from the community practice perspective. Finally, the REP allows OTS to pursue other areas of interest. One example is an OTS with previous nursing experience who developed a manual on transfer training at the adult day program. Participant 1 provided the following example: A student was very outgoing and strong. And so, I set up situations where she would take the lead. And she, in particular, is one that Im thinking grew like exponentially while she was here... if I can identify things with the students, whether its a skill... we look at that early on and make sure theyre polished. Participant 1 continued: Natural abilities in certain areas... Ive really been pushing the idea that I want the students to develop on those areas while theyre here... I think they'd get the most out of PERCEPTION OF ROLE-EMERGING 37 this placement if they can dig deeper in areas that theyre interested in [or] are very skilled. To the Site The participants noted multiple instances of benefits to the site and the sites clients, including program planning, the client's benefit from evidence-based practice, and improved client quality of life. Participant 4 noted that the students develop programs and run groups that continue beyond their placement, stating, [students initiate a] group where its for seven weeks, but then maybe we can run it again two months down the road, leave it, leave it for us [to run after the student completed the REP]. Participant 3 stated, DYouville has helped us with the placement of students [to] advance to where we are today. There are very few programs [for our individuals]... but theres no social, so we base everything on social, but then we need hands-on. This hands-on refers to the students use of evidence-based practice. Participants provided additional examples of evidence-based practice. Participant 2 spoke about the students creating a sensory regulation room and using social stories: occupational therapists can get the evidence-based terminology and theories... we say so that we [pediatric dental clinic staff] can help. Participant 1 also noted evidence-based practice when working with home safety evaluations, with techniques to improve self-feeding and fall prevention. Participant 1 reported improvements in the clients quality of life using compensatory strategies and recommendations for adaptations, stating, the biggest role of the students [and the FWEd was] doing home visits... you need a handle to get into the tub, so that has been improved quality of life for our participants. Im so grateful for that. A statement from participant 2 summarized the benefits to the site as patient satisfaction and resident and student learning... the flow of the clinic... Very quickly on we realized it [occupational therapy on site] could be a help. PERCEPTION OF ROLE-EMERGING 38 To the Non-OT Supervisor Benefits to the non-OT supervisor were also identified. As a result of the interview with participant 1, the non-OT supervisor noted the benefits of program planning for business development and stated, All of the [programs and support materials] we have from two students, theyre going to make sure that we have copies of all of that for our second site. Participant 2 stated, I think it made it more exciting. Were all about interprofessional collaborating and we understood right away that this [REP] was gonna be groundbreaking or trailblazing. Participant 2 also noted benefits to the non-OT supervisor at the pediatric dental clinic from hosting the REP: Thats when I get fascinated... when we have our debriefing... but listen to connect how occupational therapy can connect the textbook with what we just saw... and label the behavior and, you know, move on. Maybe now we need sedation. [No,] maybe we need to take a break and have them [dental patient] come back. An occupational therapist can... get evidence-based terminology and theories... Maybe we dont have to go to the operating room. Maybe what we can try is a weighted blanket. Maybe we can try [a] change in the lighting or the atmosphere or massages or the smell... Occupational therapy brings so many more tools into the operatory [location of dental chair]... but its gonna take some time for everybody to realize that. I get the pleasure of seeing that... and now I have, have to get that out to everybody else. When queried, no participants noted barriers to hosting the level II students. A quote from Participant 3 illustrated this finding: quite honestly, I dont see any [barriers]. Theme 3: Opportunities for Further Partnerships PERCEPTION OF ROLE-EMERGING 39 The third theme that resulted from the multicycle coding process was opportunities for further partnerships. Each participant reported opportunities at their REP for continued partnerships with D'Youville. Specifically to the needs of the community, participant 3 from a social club stated: We love having the students here. We would love more of them. We would love to run a daytime program with DYouville.... Theres a need right now because the day hab [daytime habilitation programs] and different things are so short-staffed that everyones losing their services, adult, the adults, the ones that have aged out. Filling an unmet need in the community was also noted by participant 1, who stated, opportunities... Im looking to open up a second site because we have a waiting list all the time. Participant 4 from the social club stated, We just feel theres such a need for an OT in this setting. The participants identified a need for additional activities with the university to further these partnerships. Continuation of program planning was noted by participant 4, who stated: [adding] to previous program planning... not starting from scratch. Participant 3 stated, we would like to partner on a higher level with DYouville... we dont have nonprofit experience... but we work hard, and we know whats needed ... we dont have the insight that a university does. Examples included conducting needs assessments, running an organization, and further program development, specifically telehealth, to reach [clients] in their homes. Participant 4 stated, I hope somebody comes back in five years because our program has grown so much through DYouville. I cant wait to see what were gonna do together... I am so excited. PERCEPTION OF ROLE-EMERGING 40 Discussion and Conclusion "Occupational therapy has an important and expanding role in non-traditional settings and emerging practice areas outside of the healthcare system" (American Occupational Therapy Foundation [AOTF], n.d.). However, limited research has been conducted investigating roleemerging fieldwork, with the majority of research being conducted with students after they completed the fieldwork (Lau & Ravenek, 2019). To date, one study focused on psychosocial settings investigating "non-OT professionals' views regarding the profession of OT and their perceptions of OT" (Fanelli & Nadeau, 2022, p. 112). It is important to emphasize that the study focused on the psychosocial setting where level I and II fieldwork occurred for occupational therapy assistant students and occupational therapy students. It is also important to note that both the Fanelli and Nadeau (2022) study and this current study occurred nearly simultaneously, highlighting the need for research into REP and the non-OT supervisor. Therefore to add to the newly burgeoning area of REP, the purpose of this basic interpretive study was to investigate the non-OT supervisor's perceptions of the role-emerging level II fieldwork specific to the non-OT supervisor's perceived opportunities, perceived challenges, and supervisory practices. The findings of this study will further enhance the studys significance to the occupational therapy profession. The significance of this study includes the opportunity to identify new REP fieldwork placements which have the potential to further the reach of the occupational therapy profession. This study is also significant as it suggests strategies to enhance student preparation before the REP and ways to promote curricular development at the educational institution. The multicycle coding process revealed the following three themes: requirements for student success, benefits of participating in the REP, and opportunities for further partnerships. Through this discussion, the PERCEPTION OF ROLE-EMERGING 41 themes and related sub-themes will be expanded upon to answer the research questions from the non-OT supervisors' perspective. Theme 1: Requirements for Student Success Each participant identified that a student must possess strong didactic knowledge to be successful in the REP. For this study, didactic knowledge was defined through the ACOTE content requirements and related standards of foundational content requirements; basic tenets of occupational therapy; referral, screening, evaluation, and intervention plan; and professional, ethics, values, and responsibilities (see Table 4). Although this current study investigated the non-OT supervisors perceptions of the REP, this study's findings were similar to previous studies investigating the students' perceptions of the REP. Several previous studies highlighted the need to practice in a more client-centered way (Clarke et al., 2014b; Fanelli & Nadeau, 2022; Kaelin & Dancza, 2019; Syed & Duncan, 2019). Practicing in a more client-centered way requires the student to possess a deep understanding of the foundational content requirements. The ability to apply this foundational knowledge across the lifespan was identified by Syed and Duncan (2019) through an online survey of 88 occupational therapists who completed a REP fieldwork. The survey identified the following skills directly tied to the ability to apply foundational knowledge: clientcentered/therapeutic relationship, knowledge integration, and cultural sensitivity (Syed & Duncan, 2019). This study supports the findings from previous studies that strong didactic knowledge is one key to success in a REP; however, it further refines the broad representation of didactic knowledge to include foundational content requirements as defined by ACOTE (2020). This study celebrates the input of the non-OT supervisor because these findings, similar to data PERCEPTION OF ROLE-EMERGING 42 from other stakeholders in REP, strengthen the value and need for strong foundational content requirements for students to be successful at the REP. Additional ACOTE (2020) standards referenced by participants include the need for strong didactic knowledge related to the referral, screening, evaluation, and intervention plan. The ability to apply theory in a unique setting was identified by Kaelin and Dancza (2019) and is congruent with findings from this study of the non-OT supervisors' perceptions. After completing a school-based REP, 13 students were interviewed via semi-structured focus groups, and the results identified their need to apply OT theory in practice (Kaelin & Dancza, 2019). This identified need for strong didactic knowledge was also found in a study by Clarke et al. (2015b), noting that students leaned on their understanding of familiar models of practice and assessment tools to know how to advocate for the profession. This ability to advocate for the profession was emphasized in this current study and is consistent with ACOTE (2020) standards related to professional, ethics, values, and responsibilities. This finding was also identified in a study conducted by Dancza et al. (2013), which noted that students "appreciate being given the opportunity to use the occupational therapy process to frame their practice, taking time to complete observations and using these to justify their interventions" (p. 432). A finding unique to this study was regarding the non-OT supervisors' emphasis on the students' strong didactic knowledge regarding the basic tenets of occupational therapy. The participants noted the need for students to possess enhanced abilities to practice safely, both for themselves and others, to understand the effects of a disease on occupational performance, and to analyze activities for continued engagement in occupations. A possible reason for this finding is PERCEPTION OF ROLE-EMERGING 43 that this current study captured a day-to-day view of what was required for student success from the non-OT supervisor's perspective. Enhanced ability for the therapeutic use of self was also identified as a requirement for student success at the REP. The participants described it as "rapport building," "facilitation skills," "putting yourself out there," "ability to develop a peer-to-peer relationship," "learning to interact... pick up on cues," and "interpersonal skills." The recent study by Fanelli and Nadeau (2022) noted similar findings from the non-OT professionals who described "specific qualities that they felt were common among OT practitioners" (p. 116). In the previously discussed study of five students who completed a REP, Clark et al. (2019) noted that they identified how they learned through therapeutic interactions with clients. The participants in this current study also identified the support of both the non-OT supervisor and the FWEd as vital to students' success at a REP. Supervisory styles described by the participants included a collaboration between the non-OT supervisor and the FWEd, and the non-OT supervisor's style was often informal between the non-OT supervisor and the student. This sub-theme has not been identified in the literature due to the limited research into the role of the non-OT supervisor. Thus, this current study emphasizes the value of knowing and preparing the triad of partners (non-OT supervisor, FWEd, and student) in the REP. This first theme and sub-themes directly related to the purpose statement and research questions. As non-OT supervisors, the participants shared their perceptions on what was required for student success in the REP. These findings present an opportunity to the institution for future curricular development and enhancement of didactic knowledge to support students on the REP. This study's unique findings specific to the basic tenets of occupational therapy suggest that students need to possess enhanced skills in activity analysis to be successful at the REP. This PERCEPTION OF ROLE-EMERGING 44 finding includes the ability to identify how occupational performance should be addressed at the REP safely and that students be able to complete activity analysis independently. In addition to activity analysis, therapeutic use of self was identified as an explicit sub-theme requirement for student success. Enhancing a student's ability to develop and utilize therapeutic use of self before and while completing fieldwork requirements will ensure the student's success at the REP and solidify the profession's role at the REP. The therapeutic use of self is integral to occupational therapy practice and is used in all client interactions (AOTA, 2020). Identifying the preferred supervisory styles of the non-OT supervisor and that a strong collaboration is required between the non-OT supervisor and the FWEd is also an opportunity for institutional programming to support and nurture the non-OT supervisor during the REP. This support will better ensure future student success at the REP and has the likely potential to realize the benefits of the REP for many stakeholders. Theme 2: Benefits In the current study, the participants identified the benefits of hosting level II OT students at the REP. These benefits were afforded to the students, the REP site, and the non-OT supervisor. As anticipated, the participants identified benefits to the students in the following areas: advocacy for OT, working independently, applying OT theory in a unique setting, and program development. It is important to note that these benefits were in addition to the benefits of a traditional level II fieldwork placement. As previously discussed, the studies conducted by Clarke et al. (2015b), Dancza et al. (2013), and Syed and Duncan (2019) identified that the REP fieldwork provided students the opportunity to develop advocacy skills and work independently. Similarly, in the Clarke et al. (2015b) study, students noted an increased responsibility to represent the profession as they acted autonomously. The participants in this current study PERCEPTION OF ROLE-EMERGING 45 reported multiple opportunities where the students advocated for the profession and worked independently. Examples include identifying community barriers to participation in instrumental activities of daily living (IADL), advocating for the occupational therapy profession with other healthcare providers, and advocating for continued OT services after completing the REP fieldwork. Participants in this study also identified that the students benefitted from applying OT theory in a unique setting. The potential reason for this is the nature of the non-traditional REP setting. The represented settings included an adult day program, a pediatric dental clinic, and two social clubs. A study by Dancza et al. (2013) noted that students needed to rely on OT theory and process to justify their interventions. According to Danzca et al. (2013), the students' REP experience was either a school-based setting, a community education organization, or a homeless organization. The benefit of having the opportunity to apply theory to the OT process has been identified in this current study and supports the same findings from other studies, all of which were conducted in a wide variety of settings. In this current study, the participants noted that the students were also provided the opportunity for program development. This finding echoed the recent study by Fanelli and Nadeau (2022), where non-OT professionals identified that students created programs for their REP. Examples of program development completed by students on their REP level II placement included: the creation of group protocols, the creation of a sensory regulation room, the development of social stories, and enhancing staff training manuals. This current study identified unique benefits to the student completing the REP. Examples of this noted by the participants included the ability to adjust the REP to meet the specific needs of the students, such as addressing medical concerns, supervision frequency, and PERCEPTION OF ROLE-EMERGING 46 the opportunity to pursue other interests at the REP. Finally, a newly identified benefit of the REP provides the student the opportunity to follow the REP throughout their fieldwork experience, from level I to level II or from level II to an advanced clinical placement required as part of the community practice course that follows the successful completion of level II fieldwork. This finding also expands on the first theme, which identified the need for strong didactic knowledge to be successful at the REP. Participants noted multiple benefits realized by the REP as a result of hosting the level II students. Examples include the site's clientele benefitting from evidence-based OT practice improving the client's quality of life, enhanced program planning, improved patient satisfaction, enhanced workflow, and the opportunity to learn from other disciplines. These findings were consistent in the literature. A study investigating eight community partners' perceptions of service learning provided by OT students found that the clientele realized enhanced confidence and dignity and enhanced occupational participation, which led to an improved quality of life (van Rensburg et al., 2019). Fanelli and Nadeau (2022) also identified that the site benefits from hosting the OT students, specifically noting that the "students enhanced their programs, increased productivity of their staff, complemented other disciplines, and provided them with a new perspective and a fresh set of eyes" (p. 116). It is also important to know that the pediatric dental clinic from this current study has since hired an occupational therapist to develop further the program initiated through the REP fieldwork experience. Finally, the participants noted the benefits they personally received while acting as the non-OT supervisor. These benefits included the opportunity for future business development and to be part of ground-breaking interprofessional delivery of services. These findings echo the recent findings from the Fanelli and Nadeau (2022) study, which noted that the non-OT PERCEPTION OF ROLE-EMERGING 47 professionals desire further interactions with the OT profession as this partnership enhanced their current programs and professional practice. It is important to note that the participants in the present study did not identify any barriers to hosting level II REP students. This second theme and sub-themes are related to the purpose statement and research questions. As non-OT supervisors, the participants shared their perceptions of benefits gained by the student, the REP site, and the non-OT supervisor. These findings again speak to the significance of the study identifying opportunities for curricular development for the student and opportunities for business development and interprofessional service delivery for the non-OT supervisor. For the students, the focus should include enhancing didactic knowledge for applying OT theory and advocacy skills, developing strategies for practicing more independently compared to traditional level II fieldwork, and strengthening skills in program planning skills. The findings specific to the non-OT supervisors' perceived benefits and lack of barriers to hosting the level II students present an exciting opportunity to advance the OT profession and to reach, yet to be served, non-traditional settings ensuring the continued provision of occupational therapy. This opportunity will require the development of education by the academic institution for the non-OT supervisor on the OT scope of practice and supervisory styles. It is important to be cognizant that participants' responses in this study were highly favorable and did not identify any challenges to hosting level II students. This finding leads to the final identified theme of opportunities for further partnerships. Theme 3: Opportunities for Further Partnerships Participants identified multiple opportunities for further partnerships. These opportunities included meeting unmet needs in the community with a forecast for more interprofessional investment in service delivery. Participants also acknowledged the support from the academic PERCEPTION OF ROLE-EMERGING 48 institution for activities such as grant writing and continued program enhancement. The opportunity for further partnerships was also noted in the Fanelli and Nadeau (2022) study, as the non-OT professionals wanted to continue the relationship and have OT practitioners at the site. Three sites included in the Fanelli and Nadeau (2022) study have since hired OT practitioners to develop OT programs at their REP. One of the current study's settings also shares this finding, as the site has employed an OT to develop further the program initiated by the level II OT students. Limitations Investigating potential reasons why the non-OT supervisors did not identify any perceived challenges leads to identifying limitations in this study. The first limitation of this study is the potential for coercion. Although the researcher has never been involved with any of the interviewed non-OT supervisors or their respective REP, she is identified as a representative of the academic institution. The non-OT supervisors identified the hope for continued partnerships with the institution, which could affect their willingness to identify challenges to supervising level II OT students at their REP. Further, to protect the supervisory collaboration established between the FWEd and the non-OT supervisor, the researcher included the FWEd in the initial recruitment letter. This professional courtesy inadvertently may have also been coercive. There is also a potential for researcher bias as the researcher is a passionate occupational therapist. To counteract the potential researcher bias and coercion, extensive practices were followed to ensure the study's trustworthiness and rigor. These practices included field notes and memoing for confirmability and reflexivity (Henderson & Rheault, 2004). A secondary coder completed independent coding of all interviews, and a codebook was developed. These activities are an example of data triangulation which also speaks to the study's credibility (Henderson & Rheault, 2004). Member checking was conducted to further the study's credibility PERCEPTION OF ROLE-EMERGING 49 (Lincoln & Guba, 1985). And finally, the audit trail was reviewed by an outside reviewer who verified that the researcher and the secondary reviewer followed the process described in the methods section. Implications for Practice and Future Research The findings of this study focus on the perceptions of the non-OT supervisor at the REP and have implications for future occupational therapy fieldwork practices and research into the REP. Despite the stated limitations, this study presents several opportunities for stakeholders involved with the REP. For the AFWC, understanding what is required for student success on the REP will aid in curricular development, and this should include strategies for preparing students of all ability levels for the demands and expectations of fieldwork. The participants identified positive outcomes from hosting the level II students, but the academic institution should be aware of the student's abilities and needs before the assignment and selection of the REP fieldwork. The academic institution has the opportunity to develop community partners for all levels of fieldwork, including the capstone requirement. This opportunity will allow for largescale projects to be developed and followed through by occupational therapy faculty involved with the fieldwork (i.e., the AFWC and FWEd), encouraging threading the REP throughout the OT curriculum. This opportunity will also ensure that the occupational therapy program and other disciplines at the academic institution can further develop robust fieldwork experiences that benefit all stakeholders, including the community served by the REP. Developing community partners such as a REP will provide additional data for research at the institution. The first opportunity would be to add to the growing research on REP, including the effectiveness of OT in the REP and how OT addresses occupational performance within community health models (AOTF, n.d.). Additional research is warranted in other areas PERCEPTION OF ROLE-EMERGING 50 related to the REP, including the effectiveness of developed programming focused on student success and the effectiveness of programming focused on the non-OT supervisor's supervisory practices, the long-term effects of hosting OT students on outcomes measured at the REP, and sustainability practices between the institution and the REP. This future research will aid REP development in the United States as the need to develop emerging practice areas to meet the needs of diverse settings and populations were included in AOTA's Vision 2025 (AOTA, 2019a). Conclusion This study aimed to understand the non-OT supervisor's perceptions of the REP level II OT fieldwork placement. The research questions focused on perceived opportunity, perceived challenges, and supervisory styles. Three themes emerged and spoke to what was required for a student to be successful at the REP, what benefits are afforded to those who participate in the REP (i.e., the student, the site, and the non-OT supervisor), and the potential for continued partnerships. Participant responses were overtly positive, which could have been due to the researcher being identified as a university representative. However, the interviews provided rich, detailed information addressing specific requirements for student success, including strong didactic knowledge, keen use of therapeutic use of self, and the collaborative supervision offered by the FWEd and the non-OT supervisor. It is important to note that rigor and trustworthiness were maintained through several evidence-based processes. This current study adds to the seminal research conducted by Fanelli and Nadeau (2022) on the REP focusing on non-OT professionals and other studies on the REP. Additional research is necessary into using the REP as the occupational therapy profession adapts to the ever-changing healthcare arena (AOTF, n.d.). PERCEPTION OF ROLE-EMERGING 51 References Accreditation Council of Occupational Therapy Education. (n.d.-a). NY school directory. https://acoteonline.org/schools/?cn-cat-in%5B%5D=&cn-cat-in%5B%5D=&cn-catin%5B%5D=&cn-region=NY Accreditation Council for Occupational Therapy Education. (n.d.-b). Schools. https://acoteonline.org/all-schools/ Accreditation Council for Occupational Therapy Education. (2020, August). 2018 Accreditation council for occupational therapy education: Standards and interpretive guide. https://acoteonline.org/accreditation-explained/standards/ Accreditation Council of Occupational Therapy Education. (2021). Annual data report. https://acoteonline.org/2021-annual-reports/ American Occupational Therapy Association. (n.d.). COVID-19 FAQs for educators and students. Retrieved June 10, 2021, from https://www.aota.org/Practice/HealthWellness/COVID19/educators-students-faq.aspx American Occupational Therapy Association. (2012). Fieldwork level II and occupational therapy students: A position paper. American Journal of Occupational Therapy, 66(6), s75-s77. https://doi.org/10.5014/ajot.2012.66S75 American Occupational Therapy Association. (2018). Fieldwork level II and occupational therapy students. 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Merriam (Ed.), Qualitative research in practice: Examples for discussion and analysis. (pp. 3739). Jossey-Bass. Metzler, C. (2019). The future is now: How occupational therapy can thrive. American Occupational Therapy Association. https://www.aota.org/PublicationsNews/otp/Archive/2019/capital-report-pdpm.aspx Nielsen, S., Klug, M., & Fox, L. (2020). Impact of nontraditional level I fieldwork on critical thinking. American Journal of Occupational Therapy, 74(3), 1-7. Overton, A., Clark, M., & Thomas, Y. (2009) A review of non-traditional occupational therapy practice placement education: A focus on role-emerging and project placements. British Journal of Occupational Therapy, 72(7), 294301. Ozelie, R., Hansen, P., Liguzinski, J., Saylor, A., & Woodcock, E. (2018). Occupational therapy level II fieldwork impact on clinicians: A preliminary time study. Occupational Therapy in Health Care, 32(1), 6171. https://doi.org/10.1080/07380577.2017.1421800 Patton, M. (1990). 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Occupational Therapy in Health Care, 31(3), 238254. https://doi.org/10.1080/07380577.2017.1328631 Warren, A., Dancza, K., McKay, E., Taylor, A., Moran, M., Copley, J., & Rodgers, S. (2016). Supervising role emerging placements: A CPD opportunity that supports innovation in practice. World Federation of Occupational Therapists Bulletin, 72(1), 35-37. https://dx.doi.org/10.1080/14473828.2016.1160992 Wilburn, V. G., DeCleene Huber, K. E., Gahimer, J., Beitman, C., & Moore, E. S. (2016). Perceptions of academic fieldwork coordinators regarding the value of fieldwork in PERCEPTION OF ROLE-EMERGING emerging areas of practice. The Open Journal of Occupational Therapy, 4(4), 117. https://doi.org/10.15453/2168-6408.1185 59 PERCEPTION OF ROLE-EMERGING 60 Table 1 Content Requirements and Standards of Didactic Knowledge Component Foundational Content Requirements Definition Program content must be based on a broad foundation in the liberal arts and sciences. A strong foundation in the biological, physical, social, and behavioral sciences supports an understanding of occupation across the lifespan (ACOTE, 2020, pp. 24-25). Occupational Therapy Theoretical Perspectives Current and relevant interprofessional perspectives including rehabilitation, disability, and developmental as well as person/population-environment-occupation models, theories and frameworks of practice (ACOTE, 2020, p.26). Basic Tenets of Occupational Therapy Coursework must facilitate development of the performance criteria listed and include: OT History, Philosophical Base, Theory, and Sociopolitical Climate; Interaction of Occupation and Activity; Distinct Nature of Occupation; Balancing Areas of Occupation, Role in Promotion of Health, and Prevention; Effects of Disease Processes; Activity Analysis; and Safety of Self and Others (ACOTE, 2020, pp. 26-27). Referral, Screening, Evaluation, and Intervention Plan The process of referral, screening, evaluation, and diagnosis as related to occupational performance and participation must be client-centered; culturally relevant; and based on theoretical perspectives, models of practice, frames of reference, and available evidence. The process of formulation and implementation of the therapeutic intervention plan to facilitate occupational performance and participation must be clientcentered and culturally relevant; reflective of current and emerging occupational therapy practice; based on available evidence; and based on theoretical perspectives, models of practice, and frames of reference. These processes must consider the needs of persons, groups, and populations (ACOTE, 2020, p. 28). Context of Service Delivery, Leadership, and Management of Occupational Therapy Services Context of service delivery includes knowledge and understanding of the various contexts, such as professional, social, cultural, political, economic, and ecological, in which occupational therapy services are provided. Management and leadership skills of occupational therapy services include the application of principles of management and systems in the provision of occupational therapy services to persons, groups, populations, and organizations (ACOTE, 2020, p. 34). PERCEPTION OF ROLE-EMERGING 61 Scholarship Promotion of science and scholarly endeavors will serve to describe and interpret the scope of the profession, build research capacity, establish new knowledge, and interpret and apply this knowledge to practice (ACOTE, 2020, p.36). Professional, Ethics, Values, and Responsibilities Professional ethics, values, and responsibilities include an understanding and appreciation of ethics and values of the profession of occupational therapy. Professional behaviors include the ability to advocate for social responsibility and equitable services to support health equity and address social determinants of health; commit to engaging in lifelong learning; and evaluate the outcome of services, which include client engagement, judicious health care utilization, and population health (ACOTE, 2020, p. 38). PERCEPTION OF ROLE-EMERGING 62 Table 2 Domain and Process Domain Occupation Definition Everyday personalized activities that people do as individuals, in families, and with communities to occupy time and bring meaning and purpose to life. Occupations can involve the execution of multiple activities for completion and can result in various outcomes. The broad range of occupations is categorized as activities of daily living, instrumental activities of daily living, health management, rest and sleep, education, work, play, leisure, and social participation (AOTA, 2020, p. 79). Context Construct that constitutes the complete makeup of a persons life as well as the common and divergent factors that characterize groups and populations. Context includes environmental factors and personal factors (AOTA, 2020, p. 76). Performance Patterns Habits, routines, roles, and rituals that may be associated with different lifestyles and used in the process of engaging in occupations or activities. These patterns are influenced by context and time and can support or hinder occupational performance (AOTA, 2020, p. 80). Performance Skills Observable, goal-directed actions that result in a clients quality of performing desired occupations. Skills are supported by the context in which the performance occurred and by underlying client factors (Fisher & Marterella, 2019, as cited in AOTA, 2018, p. 80). Client Factors Specific capacities, characteristics, or beliefs that reside within the person and that influence performance in occupations. Client factors include values, beliefs, and spirituality; body functions; and body structures (AOTA, 2020, p.75). Process Evaluation The comprehensive process of obtaining and interpreting the data necessary to understand the person, system, or situation. . . Evaluation requires synthesis of all data obtained, analytic interpretation of that data, reflective clinical reasoning, and consideration of occupational performance and contextual factors (Hinojosa et al., 2014, p. 3, as cited in AOTA, 2020, p.76). PERCEPTION OF ROLE-EMERGING Intervention Process and skilled actions taken by occupational therapy practitioners in collaboration with the client to facilitate engagement in occupation related to health and participation. The intervention process includes the plan, implementation, and review (AOTA, 2015c. p. 2, as cited in AOTA, 2020, p.78). Outcome Result clients can achieve through the occupational therapy process (AOTA, 2020, p.80). 63 PERCEPTION OF ROLE-EMERGING 64 Table 3 Participant and Site Characteristics Identification Code Profession Highest Degree Earned Bachelors Gender Setting 1 Social Worker 2 Contract Established for REP 2020 Woman Adult Day Program Dentist Doctorate Woman Pediatric Dental Clinic 2020 3 Retired Bachelors Woman Social Club 2020 4 Recreational Therapist Bachelors Woman Social Club 2020 PERCEPTION OF ROLE-EMERGING 65 Table 4 Interview Themes, Definitions, and Sub-Themes Theme Requirements for Student Success Definition Non-OT supervisors identified skills and knowledge that students should possess to be successful at their REP. Sub-Theme Didactic Knowledge Therapeutic Use of Self Supervisory Style Benefits Non-OT supervisors reported benefits from hosting level II students at the REP. To the Student To the Site To the Non-OT Supervisor Opportunities for further partnerships Non-OT supervisors reported opportunities at their REP for continued partnerships with D'Youville. PERCEPTION OF ROLE-EMERGING 66 Appendix A Email to FWEd Prior to Contacting Non-OT Supervisor SUBJECT: Request to contact the non-OT supervisor at _______________ (name of facility) Message: Dear Dr. __________, As you may know, my doctoral research focuses on investigating the perceptions of the role-emerging practice (REP) non-OT supervisor. I am contacting you at this time out of courtesy as you have established a working relationship with ___________ (name of the non-OT supervisor). You will be included in the carbon copy of the recruitment email. Your cooperation and support of my research will benefit the D'Youville students, you as the FWEd, the REP, and our profession. Would you please let me know if you have any questions or concerns? Regards, Tracy Bentley-Root, MS, OTR/L PERCEPTION OF ROLE-EMERGING 67 Appendix B Recruitment Email to the Non-OT Supervisor SUBJECT: Request to interview for doctoral research Cc: Dr. ________ (FWEd assigned to the REP) Message: Dear __________, This email intends to seek your cooperation and recruit you to participate in my doctoral research investigating the perceptions of role emerging practice (REP) non-occupational therapy (non-OT) supervisors. As a faculty member at D'Youville, gaining knowledge into your perceptions of this role will be invaluable to you, as the non-OT supervisor, to the students, to the college, to the fieldwork educator (Dr. _________), and the occupational therapy profession as practitioners respond to an ever-changing healthcare arena. A basic interpretive study will aim to understand the non-OT supervisor's perceptions of the role-emerging level II fieldwork placement. Your participation is being sought as you meet the inclusion criteria of supervising a D'Youville level II student within the past five years and are located within a two-hour drive from the campus. There are no known risks associated with this study. The audio-recorded interview should take approximately 45 minutes, and all information discussed in the interview will remain confidential, meaning your name will not be associated with the research findings. All data collected will be de-identified and secured, with access only provided to the researchers. PERCEPTION OF ROLE-EMERGING 68 If you wish to participate and complete the interview, you will be offered a $25 gift card. I am happy to discuss your potential participation further and answer any questions. Feel free to email me. If I do not receive an email, a follow-up email will be sent in one week. Sincerely, Tracy Bentley-Root, MS, OTR/L PERCEPTION OF ROLE-EMERGING 69 Appendix C Interview Guide Introductory Paragraph Thank you for agreeing to be interviewed for this study. Completing the study is necessary to fulfill the DHSc dissertation requirement from the University of Indianapolis. The resulting research findings will be disseminated, at a minimum, via DHSc Doctoral Defense Days. The purpose of the study is to understand the non-occupational therapy (OT) supervisors' perceptions of a role-emerging Level II fieldwork. The questions that you will be asked today will focus on your perceptions of the role-emerging placement (REP), including the opportunities and challenges of the REP and the supervisory practices utilized during this fieldwork. Participation in this study does not carry any known risks. The anticipated expected benefits from participation in the study are for current and future students who choose a REP by identifying new fieldwork opportunities and furthering the occupational therapy profession in response to the ever-changing healthcare arena. Additionally, the research findings and identified themes will aid the academic fieldwork coordinator (AFWC) in guiding curricular development for the students, fieldwork educators, and non-OT supervisors during the REP fieldwork. The interview should take approximately 45 minutes, and all information shared during the interview will remain confidential. Your name will not be associated with the research findings. You can stop the interview at any time to clarify or ask a question. Please know that you can also skip any question that you are not comfortable answering and that you may withdraw from this study without affecting your relationship with the occupational therapy PERCEPTION OF ROLE-EMERGING 70 department, the researcher, or the academic institution. Do you have any questions before we begin this interview? If this is acceptable, this interview will be recorded. This recording will capture everything that is said and allow for review. Do I have your permission to start the recording? Interview Questions and Prompts General Prompts Tell me more How did that affect you? What are some examples of How did make you feel about it? What did you think about? Interview Questions 1. What comes to mind when you think of a REP? 2. When presented with the option of supervising a REP, what were your first thoughts? a. That is interesting. Would you please tell me more about this first impression? b. How did the first impression affect your decision to supervise a student for a REP? 3. Tell me more about your take on the purpose of a REP fieldwork site. a. What opportunities do you believe are present in the REP that may not be found during a traditional fieldwork placement where occupational therapy services are already offered? i. Specific prompts for this questionprobe for information on critical thinking, theory application in a unique setting, collaborate with other professions, OT advocacy, work independently, practice in a more client-centered way, etc. PERCEPTION OF ROLE-EMERGING 71 b. What barriers do you believe are present in the REP that may not be found during a traditional fieldwork placement? i. Specific prompts for this questionprobe for information on fear and anxiety, the uncertainty of their knowledge, handling the unexpected emotions, being in a setting without OT, etc. 4. What skills do you think are needed in the REP? a. Why do you think __________ (skill) will be necessary? 5. What special knowledge do you believe is/will be necessary for this REP? a. Why do you believe this knowledge is/will be necessary? 6. Can you describe what a successful placement looks like to you? a. How do you plan to prepare for a successful outcome? 7. Can you describe your supervisory style? a. How do you plan to provide feedback to the student? i. Specific prompts for this questionprobe for information on their understanding of feedback (i.e., immediate, etc.), their plan if the student does not modify their behavior, etc. Background Demographics 1. What is your profession? 2. What is your highest degree earned? 3. In terms of gender, how do you identify? Wrap-Up Would you like to share anything else regarding the REP or your participation in this interview? If you have questions, please do not hesitate to contact us via email. PERCEPTION OF ROLE-EMERGING I appreciate your cooperation. Thank you! Tracy Bentley-Root bentleyroott@uindy.edu 72 PERCEPTION OF ROLE-EMERGING 73 Appendix D Follow-up to Recruitment Email SUBJECT: Request to interview for doctoral research Cc: Dr. ________ (FWEd assigned to the REP) Message: Dear __________, This follow-up email intends to seek your participation with my doctoral research investigating the perceptions of the role emerging practice (REP) non-OT supervisor. The interview should take approximately 45 minutes and can be completed at your location or on the D'Youville campus. The benefits of this research are tremendous and can further the REP by providing curricular support to you as the non-OT supervisor. If you have additional questions or concerns, please email or contact me via my cell at (716) 868-9927. If you agree to participate in this study, I will contact you via email to set a date and time within the next two weeks. Thank you for your time, Tracy Bentley-Root, MS, OTR/L PERCEPTION OF ROLE-EMERGING 74 Appendix E STUDY INFORMATION SHEET The purpose of this form is to assure you are given enough information to make an informed decision as to whether you will agree to be a subject in research Study Title: Perception of Role-Emerging Level II Fieldwork Length of participation: 45 minutes Name and credentials of Study Investigator: Tracy Bentley-Root, MS, OTR/L Address of Study Investigator: D'Youville, 320 Porter Avenue, Buffalo, NY 14201 Phone number of Study Investigator: 716 828 8134 The purpose of the study is to understand the non-occupational therapy (OT) supervisors' perceptions of a role-emerging Level II fieldwork. The questions that you will be asked will focus on your perceptions of the role-emerging placement (REP), including opportunities and challenges of the REP and the supervisory practices utilized during this fieldwork. Participation in this study does not carry any known risks. The anticipated expected benefits from participation in the study are for current and future students who choose a REP by identifying new fieldwork opportunities and furthering the occupational therapy profession in response to the ever-changing healthcare arena. Additionally, the research findings and identified themes will aid the academic fieldwork coordinator (AFWC) in guiding curricular development for the students, fieldwork educators, and non-OT supervisors during the REP fieldwork. The interview should take approximately 45 minutes, and all information shared during the interview will remain confidential via password protection software and locked storage box. Your name will not be associated with the research findings. You can stop the interview at any time to clarify or ask a question. Please know that you can also skip any question that you are not comfortable answering and that you may withdraw from this study without affecting your PERCEPTION OF ROLE-EMERGING 75 relationship with the occupational therapy department, the researcher, or the academic institution. Upon completion of the data collection and analysis, you will receive a $25 gift card to compensate you for your time. If you choose to participate in this research, please reply to this email. Upon receiving non-OT supervisors' emails indicating their statement of interest, the researcher will contact you individually by telephone, review the inclusion criteria, and schedule the interview date, time, and location.  ...

... HOW WELL DO CARDIOVASCULAR NURSES ESTIMATE THEIR CVD RISK AND THEIR LIKELIHOOD OF RECOMMENDING EXERCISE TO THEIR PATIENTS? Submitted to the Faculty of the College of Health Sciences University of Indianapolis In partial fulfillment of the requirements for the degree Doctor of Health Science By: Tina A. Schmidt-McNulty, MS, CES, RN Copyright 12/08/2022 By: Tina A. Schmidt-McNulty, MS, CES, RN All rights reserved Approved by: Heidi H. Ewen, PhD, FGSA, FAGHE Committee Chair ________________________ Elizabeth S. Moore, PhD Committee Member ________________________ Diane Smith, DNP, RN, CNML, CNE Committee Member ________________________ Accepted by: Lisa Borrero, PhD, FAGHE Dissertation Coordinator, DHSc Program University of Indianapolis ________________________ Stephanie Kelly, PT, PhD Dean, College of Health Sciences University of Indianapolis ________________________ CARDIOVASCULAR NURSES PHYSICAL ACTIVITY BEHAVIOR PRACTICES How Well Do Cardiovascular Nurses Estimate Their CVD Risk and Their Likelihood of Recommending Exercise to Their Patients? Tina Schmidt-McNulty Department of Health and Aging Studies, University of Indianapolis 1 CARDIOVASCULAR NURSES PHYSICAL ACTIVITY BEHAVIOR PRACTICES 2 Abstract Cardiovascular nurses are influential healthcare providers who provide patient education and counseling on cardiovascular risk factor reduction and positive lifestyle habits (Fair et al., 2009). However, nurses may not always engage in the appropriate level of physical activity central to decreasing cardiovascular disease (CVD) risk and related other health conditions (Priano et al., 2018; Wilkerson et al., 2019). This cross-sectional quantitative study investigated cardiovascular nurses relationships and differences of CVD to self-reported knowledge of CVD, intentions to change behavior, and perceived benefits of physical activity to their exercise habits and individual characteristics. The possibility that nurses recommended physical activity to their patients based on the relationship of the health belief factors was also explored. An online survey was distributed through social media platforms emphasizing a convenience sample of full-time, part-time, and PRN nurses working in various United States cardiac units. The final sample size consisted of 62 participants. Results showed that 26% of nurses who participated met the criteria for high risk of CVD. There were no significant differences between those at low risk of CVD and those at high risk of CVD on knowledge about cardiovascular disease and benefits and intentions to change behavior based on the ABCD Risk Questionnaire. Additionally, there were no differences in perceived barriers to exercise and current exercise habits. Only 8 out of 62 nurses met the recommended weekly physical activity guidelines of 150 minutes of moderate physical activity. Nurses with higher knowledge scores and higher scores on the BBAQ Lack of Skill questionnaire were more likely to recommend physical activity to patients; however, this was not statistically significant. Cardiovascular nurses are critical in patient care, education, and prevention. The health of cardiovascular nurses is just as important as the health of their patients. In this sample, no significant differences were found between risk factor groups concerning CVD CARDIOVASCULAR NURSES PHYSICAL ACTIVITY BEHAVIOR PRACTICES 3 knowledge, intentions to change behavior, barriers to exercise, and current activity habits. However, nurses with 6-10 years of experience scored higher on the ABCD Knowledge subscale and the BBAQ Lack of Skill tended to recommend exercise to patients. Nurses need to take accountability for their health through positive lifestyle habits to become better role models for patients and increase their effectiveness in health counseling, particularly by encouraging regular physical activity. Keywords: Cardiovascular nurses, Cardiovascular risk factors, barriers to exercise, physical activity CARDIOVASCULAR NURSES PHYSICAL ACTIVITY BEHAVIOR PRACTICES 4 Acknowledgments My journey through the DHSc program has been a challenging yet rewarding experience, and I could not have done this alone. First, I would like to take the opportunity to thank those who have supported me along the way especially my husband, John, my two children, Casey and Cavin, and my mom, Connie Schmidt. Thank you for being my main support system and motivation especially when times were challenging. I also would like to thank my colleagues at University of Illinois Chicago, especially Dr. Columb-Lilly, Amy Jandek and Michelle Adams for their constant support and reassurance especially with my research. I am grateful to be surrounded by such an inspiring group of people on a daily basis. I appreciate you sharing your expertise and words of encouragement along the way. The support I received was priceless. Next, I would like to thank my committee members, Dr. Heidi Ewen, Dr. Elizabeth Moore, and Dr. Diane Smith. Thank you for your guidance, expertise, and sharing your knowledge on this project. Finally, I would like to dedicate this dissertation to my late father, Corky Schmidt. He unfortunately passed during my DHSc journey but inspired me to continue my education. I look forward to honoring his legacy by educating and inspiring others to make healthy lifestyle choices to improve their personal health and live life to the fullest. With my deepest gratitude, Tina Schmidt-McNulty CARDIOVASCULAR NURSES PHYSICAL ACTIVITY BEHAVIOR PRACTICES 5 Table of Contents Title Page . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 Abstract . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 Acknowledgements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 Chapter 1: Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 Background . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 Problem Statement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 Purpose Statement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 Significance of Study . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 Chapter 2: Literature Review . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 Health of Nurses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 Cardiovascular Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 Physical Activity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 Perceived Cardiovascular Disease Risk . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 Research in the United States . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16 Chapter 3: Method . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 Study Design . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 Participants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 Data . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18 Instruments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18 AHA/ACSM Health/Fitness Facility Pre-Participation Screening Questionnaire . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18 ABCD Risk Questionnaire . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 CARDIOVASCULAR NURSES PHYSICAL ACTIVITY BEHAVIOR PRACTICES Rapid Assessment of Physical Activity . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 20 Barriers to Being Active . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21 Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21 Recruitment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21 Informed Consent . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22 Data Collection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22 Data Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23 Data Analysis Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23 Chapter 4: Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26 Research Question 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27 Research Question 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28 Research Question 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28 Research Question 4 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30 Chapter 5: Discussion and Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31 Limitations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37 Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44 Appendices . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64 Appendix A: Online Survey Questionnaire . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65 Appendix B: Standardized Assessments and Questionnaires . . . . . . . . . . . . . . . . . 91 AHA/ACSM Health/Fitness Facility Pre-participation Screening Questionnaire . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 92 The ABCD Risk Questionnaire and Scoring Guide . . . . . . . . . . . . . . . . . . . 94 CARDIOVASCULAR NURSES PHYSICAL ACTIVITY BEHAVIOR PRACTICES Rapid Assessment of Physical Activity . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 97 Barriers to Being Active Quiz . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 101 List of Tables . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Table 1: Sample Baseline Characteristics (n=62) . . . . . . . . . . . . . . . . . . . . . . . Table 2: Descriptive Statistics for Outcome Measures: RAPA1, ABCD Risk 56 56 Questionnaire, and BBAQ (n=62) . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58 Table 3: Comparison of ABCD Risk Questionnaire Scale Scores Between Nurses with High CVD Risk and Nurses with Low CVD Risk (n=61) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Table 4: 59 Comparison of Barriers to Being Active Questionnaire Subscale Scores Between Nurses with High CVD and Low CVD Risk (n=61) ....................................................... Table 5: Comparison of RAPA1 Categories Between Nurses with a High CVD Risk and Nurses with a Low CVD Risk (n=62) . . . . . . . . . . . . Table 6: 60 61 Hierarchical Logistic Regression Analysis on Recommendations of Physical Activity to Patients Based upon the Health Belief Model . . 62 CARDIOVASCULAR NURSES PHYSICAL ACTIVITY BEHAVIOR PRACTICES 8 How Well Do Cardiovascular Nurses Estimate Their CVD Risk and Their Likelihood of Recommending Exercise to Their Patients? Florence Nightingale, a visionary pioneer in nursing, understood the need to prevent disease and promote health (Olshansky, 2010). She advocated that to care for patients adequately, nurses needed to practice self-care (Kelly et al., 2016). Present day, nurses' personal health-care may be compromised due to work schedules, family obligations, fatigue, and other stressors of their jobs, resulting in poorer health behaviors (Willis et al., 2019). Individuals poor health behaviors can lead to many adverse health outcomes, including cardiovascular disease (CVD) and its complications (Jahromi et al., 2017). CVD is the leading cause of death in the United States (U.S.); however, it can be prevented and controlled by instilling positive lifestyle changes such as regular physical activity (Riegel et al., 2017). Research supports that nurses have evidence-based knowledge of current CVD risk reduction and prevention practices such as physical activity (Woringer et al., 2017). Despite knowing the benefits of physical activity, nurses often do not adhere to the recommended physical activity guidelines, which may contribute to the high prevalence of diseases such as obesity, hypertension, and lipid disorders (Avraham et al., 2020; Gould et al., 2019; Ross et al., 2017). Nurses are educated on the signs and symptoms of CVD, associated risk factors, and the interventions developed to promote healthy lifestyle behaviors; however, they may be unaware of their own risk of CVD and may not engage in activities that may lower their risk (Woringer et al., 2017). Problem Statement Researchers have reported that many nurses fail to adhere to recommended physical activity guidelines and may not engage in positive health behaviors (Priano et al., 2018; CARDIOVASCULAR NURSES PHYSICAL ACTIVITY BEHAVIOR PRACTICES 9 Wilkerson et al., 2019). The personal lifestyle practices of nurses may influence the quality of care they provide their patients (Avraham et al., 2020; Blake et al., 2017; Keele, 2019; Priano et al., 2018). Findings show that nurses who practice healthy lifestyle behaviors are more likely to recommend preventative health behaviors to patients under their supervision (Priano et al., 2018; Ross et al., 2019). Healthy lifestyle behaviors are essential for cardiovascular nurses who are responsible for patient education related to awareness of cardiovascular disease risk factors, including physical activity habits (Fair, 2009). Nurses provide post-intervention risk factor modification education and counseling when patients have a cardiovascular intervention such as coronary angioplasty, stent placement, or coronary artery bypass surgery. It has been reported that patients find they can relate and have better compliance with behavior change when it is recommended by nurses whom they perceive to practice regular healthy behaviors (Heidke et al., 2020; Kelly et al., 2016). In addition, it has been found that patients tend to disregard advice on health promotion education practices and question the credibility of nurses who demonstrate poor lifestyle behaviors (Heidke et al., 2020; Kelly et al., 2016; Marchiondo, 2014; Willis et al., 2019). Thus, nurses who exercise positive self-care practices may be better role models and advocates for the health promotion behaviors of their patients (Ross et al., 2019). Evidence suggests that nurses may not be aware of their own risk of CVD, which may influence their personal health behaviors and perceptions (Deasy et al., 2016; Gujral et al., 2020). Lack of awareness about their risk of CVD may help account for the fact that only 3% or less of nurses reported that they practiced healthy lifestyles such as regular exercise and maintained a healthy weight, as reported in the Nurses Health Study (Priano et al., 2018). Lack of physical activity may be attributed to barriers such as lack of time, lack of energy due to stress, and other CARDIOVASCULAR NURSES PHYSICAL ACTIVITY BEHAVIOR PRACTICES 10 excessive responsibilities which may place risk on their personal health and lives (Priano et al., 2018; Waksmaska et al., 2018). Currently, there is a need to assess cardiovascular nurses, who work in U.S. cardiovascular units, their knowledge of CVD and its risk factors, and their physical activity habits (Fair et al., 2009; Gujral et al., 2020; Imes & Lewis, 2014). Few studies have investigated the physical activity lifestyle practices and personal risk factors, both actual and perceived, among cardiovascular nurses in the U.S. (Fair et al., 2009; Gujral et al., 2020). Investigating individual activity practices will provide insight into potential barriers to maintaining these habits with the potential of improving nurses' cardiovascular health. Most healthcare professionals realize that CVD risk factors play a significant role in overall health; however, their perceived risk for CVD can affect self-health related behaviors, including regular physical activity promotion habits (Huijg et al., 2015; Imes & Lewis, 2014). Nursing programs emphasize health promotion and lifestyle behavior which may lead to several positive health outcomes, including knowledge and self-management of illness. However, evidence confirms that health knowledge may not influence practical health promotion practices or personal health behaviors by nurses (Deasy et al., 2016; Kemppainen et al., 2012). Early research in the U.S. suggested that nurses knowledge concerning CVD risk reduction and prevention was inadequate (Wu et al., 2011). In addition, personal perception of heart disease risk can be a significant predictor in personal health promotion lifestyle habits and influence preventative behaviors (Gujral et al., 2020). Few studies have investigated the physical activity lifestyle practices and perception of personal CVD risk factors among cardiovascular nurses in the U.S. (Fair et al., 2009; Gujral et al., 2020). Investigating CVD risk knowledge, individual exercise habits, and beliefs will provide insight into potential challenges for maintaining these habits to improve nurses' cardiovascular health. CARDIOVASCULAR NURSES PHYSICAL ACTIVITY BEHAVIOR PRACTICES 11 Health Belief Model This study was guided by the Health Belief Model (HBM), a theoretical model that can predict health behaviors (Champion & Skinner, 2008; Becker, 1974). The hypothesis of the HBM is based on demographics, health knowledge, personal experiences, and the individual perceived benefits and barriers to behavior change which may prompt individual behaviors (McKenzie et al., 2017). An individuals willingness to change their health behavior is influenced by their perception of risk, disease severity, potential benefits, and barriers to behavior change, known collectively as health beliefs that are influenced by modifying factors such as individual characteristics (Glanz et al., 2015; Gujral et al., 2020). Based on the HBM, recognizing factors that affect nurses approach to health might help to understand how likely nurses are to participate in regular physical activity and recommend this habit to their patients. Purpose Statement The purpose of this study was to investigate differences and relationships among cardiovascular nurses self-reported risk of CVD, knowledge about CVD, perceived benefits and intention to change behavior, beliefs of perceived barriers to physical exercise, and their characteristics and exercise habits. The relationships among the health belief factors and the likelihood that nurses recommended physical activity to their patients were also explored. To address the study purpose, the following research questions were explored: 1. Do nurses with a self-reported high risk of CVD have greater knowledge of CVD, as measured with the ABCD Knowledge subscale, compared to nurses with a self-reported low risk of CVD? CARDIOVASCULAR NURSES PHYSICAL ACTIVITY BEHAVIOR PRACTICES 12 2. Do nurses who self-report a high risk of CVD perceive greater benefits and intention to change behavior, as measured with the ABCD Risk Questionnaire, compared to nurses who have a self-reported low risk of CVD? 3. Do nurses who have a self-reported high risk of CVD have different beliefs about barriers to exercise, as measured with the Barriers to Being Active Questionnaire (BBAQ), and their exercise habits, as measured with the Rapid Assessment of Physical Activity (RAPA) 1, compared to nurses who have self-reported low risks of CVD? 4. Can factors, including cardiovascular nurses CVD risk, knowledge of CVD, health beliefs, and individual characteristics, predict how likely they recommend physical activity to their patients? Significance Results from this study may contribute to encouraging nurses, specifically cardiovascular nurses, to increase awareness of CVD risk, and improve their physical activity habits with the hope of recommending positive lifestyle changes to their patients. An accurate personal CVD risk perception may also influence disease-preventive and lifestyle decisions (Gujral et al., 2020). With healthy lifestyle education as a significant part of post-care for patients who have had a cardiovascular intervention, some primary healthcare providers state they encounter several barriers to physical activity promotion, including lack of time, lack of knowledge, and personal efficacy on this topic (Dickins & Braun, 2017; Huijg et al., 2015; Lobelo & Garcia de Quevedo, 2014). A better understanding of the relationship between cardiovascular nurses, their CVD risk, current exercise habits, and beliefs and barriers towards physical activity practices may help with intervention development to promote active lifestyles not only amongst nurses but also to improve their patient education practices. CARDIOVASCULAR NURSES PHYSICAL ACTIVITY BEHAVIOR PRACTICES 13 Literature Review The World Health Organization (WHO) and the American Heart Association (AHA) both recognize nurses as imperative for playing a supportive role in reducing death and disability from cardiovascular disease (Kilicli et al., 2019). Cardiovascular nurses care for patients across the lifespan who may have had a cardiovascular event, cardiac interventions, or other heart-related problems under the care of the cardiologist (Lin et al., 2017). These types of nurses tend to work on cardiology hospital units such as Intermediate Care Units, Cardiovascular Units, Cath Labs, and Cardiac Rehabilitation. Along with providing care for patients, these nurses emphasize risk factor education such as eating a healthy diet, performing regular physical activity, management of risk factors (blood pressure, lipids, diabetes, weight control), smoking cessation practices, medication information, and follow-up care (Lin et al., 2017). Health of Nurses Nursing is a demanding and stressful profession. Often, nurses tend to work long hours, have variable shifts, and experience high-stress levels due to a nursing shortage at hospitals (Jahromi et al., 2017; Roskoden et al., 2017; Ross et al., 2019). Evidence supports that due to the demands of their profession, nurses tend to have a weak health profile resulting in an elevated poor health outcomes risk. One of the health risks nurses face is CVD which includes obesity, smoking, hypertension, high cholesterol, and diabetes (Jahromi et al., 2017; Priano et al., 2018; Reed et al., 2018; Wills et al., 2019). Several studies also have mentioned that obesity and elevated body mass index (BMI) seem to be of the highest prevalence among nurses in the U.S. and worldwide, thus increasing the risk for CVD (Blake et al., 2017; Reed & Prince, 2018; Ross et al., 2019; Wills et al., 2019). However, minor lifestyle changes can be introduced to reduce CVD prevalence, even if there is a genetic tendency (Jahromi et al., 2017). CARDIOVASCULAR NURSES PHYSICAL ACTIVITY BEHAVIOR PRACTICES 14 Cardiovascular Disease CVD is the leading global cause of death (Reed et al., 2018; Riegel et al., 2017). Several risk factors can be modified through positive changes in lifestyle habits such as improving physical activity, which can target conditions such as elevated BMI, hypertension, dyslipidemia, and glucose levels (American College of Sports Medicine [ACSM], 2018). Nurses are knowledgeable of this risk, but several choose not to lead a healthy lifestyle, which can eventually have consequences that affect the risk for CVD and other chronic diseases (Blake et al., 2017; Darch et al., 2019; Keele, 2019; Priano et al., 2018; Ross et al., 2019). The demands of the nursing profession may also cause health complications including CVD and affect the quality and quantity of their work (Jahromi et al., 2017). One research study highlighted a group of nurses from Iran who specialized in heart disorder prevention and found that the nurses had a history of obesity, hypertension, and lipid disorders (Jahromi et al., 2017). Another study discovered that telemetry nurses were more likely to participate in more health-promoting behaviors than critical care nurses (Ross et al., 2019). Scientific evidence supports that healthy lifestyle changes and regular physical activity can reduce the risk of CVD, heart attack, stroke, and other chronic conditions (Keele, 2019; Riegel et al., 2017). Physical Activity There is substantial evidence in support of regular physical activity towards the management and prevention of several chronic and non-communicable diseases and the decrease of all-cause mortality (ACSM, 2018; Lobelo et al., 2014; Reed et al., 2018; Roskoden et al., 2017; Ross et al., 2017; Ross et al., 2019; Wilkerson et al., 2019). Both the AHA and ACSM encourage 150 minutes of moderate physical activity weekly (ACSM, 2018; AHA, 2016). However, nurses, one of the largest professional groups in the healthcare workforce, often report CARDIOVASCULAR NURSES PHYSICAL ACTIVITY BEHAVIOR PRACTICES 15 suboptimal health behaviors, including low levels of physical activity (Neall et al., 2016; Priano et al., 2018; Reed et al., 2018; Roskoden et al., 2017; Ross et al., 2019). Even though the nursing profession may be demanding physically, especially concerning direct patient care, and may require lifting patients, work-related activity levels surrounding patient care are still not considered as taxing as regular physical activity (Ross et al., 2019; Wilkerson et al., 2019). Researchers investigating the inadequate physical activity levels of hospital nurses in the U.S. have found that this practice may not only place them at an increased risk of CVD, but also may adversely impact health counseling, patient education, and credibility (Deasy et al., 2016; Heidke et al., 2020; Neall et al., 2016). Nurses who do not consistently practice good physical activity habits may also be at higher risk for musculoskeletal injuries (Wilkerson et al., 2019). Most studies have found that nurses report having inadequate levels of physical activity, and research reveals that nurses are amongst the lowest levels concerning engagement in regular physical exercise when compared to other professional groups (Al-Tannir et al., 2017; Priano et al., 2018; Ross et al., 2019). However, nurses who exercise regularly are more likely to promote the physical activity benefits to their patients (Darch et al., 2019; Priano et al., 2018; Ross et al., 2019). Perceived Cardiovascular Disease Risk Nurses are knowledgeable about the prevention of CVD (Lin et al., 2017; Wu et al., 2011). They are aware of CVD; however, they frequently do not accurately perceive their own CVD risk (Gujral et al., 2020; Webster & Heeley, 2010). Often, personal perceptions tend to be towards inappropriate optimism with an inclination to underestimate CVD risk (Gujral et al., 2020; Webster & Heeley, 2010). Research also supports that those with a genetic predisposition or family history risk of CVD tend to have a higher perceived risk of developing CVD (Claassen CARDIOVASCULAR NURSES PHYSICAL ACTIVITY BEHAVIOR PRACTICES 16 et al., 2012; Imes & Lewis, 2014). Perceptions of a disease may impact health promotion actions and intent to engage in preventative behaviors (Gujral et al., 2020; Imes & Lewis, 2014; Webster & Heeley, 2010). Research in the United States Cardiovascular nurses provide preventative and maintenance education to patients, both pre- and post-treatment or surgery (Lin et al., 2017). However, the demands of the nursing profession may cause personal health complications, including CVD, and affect the quality and quantity of their work (Jahromi et al., 2017). Scientific evidence supports that healthy lifestyle changes not only can reduce the risk of CVD, heart attack, stroke, and other chronic conditions, but regular physical activity can also play a vital role in preventing heart attacks (Keele, 2019; Riegel et al., 2017). There is currently limited research concentrating on cardiovascular nurses' healthpromoting behaviors, their physical activity practices, and perceived versus the actual risk of CVD on health promotion practices emphasizing the personal physical activity habits of cardiovascular nurses in the U.S. (Blake et al., 2017; Gujral et al., 2020; Jahromi et al., 2017; Priano et al., 2018). Information and knowledge are provided to nurses through their education which supports physical and mental well-being and health. However, there currently is limited research concerning the prevention of CVD in nurses through health belief model (HBM)-based educational programs (Amraei et al., 2020; Wu et al., 2011). Nevertheless, nurses have an individualistic approach to effective health promotion practices that are often not transferred to their lifestyles (Darch et al., 2019; Kemppainen et al., 2012). The HBM is often used concerning health behaviors and is integral to nursing practice (Chen et al., 2018). This also suggests that the likelihood that individuals will change a health behavior is related to their perception of the CARDIOVASCULAR NURSES PHYSICAL ACTIVITY BEHAVIOR PRACTICES 17 benefits and barriers of the change. The HBM established that promoting long-term changes of lifestyle behaviors, self-efficacy is essential and barriers need to be reduced (Glanz et al., 2015). Situational influences, personal beliefs, restrictions, and benefits in the nursing profession can persuade attitudes toward their health promotion practices (Glanz et al., 2015; Hosseini et al., 2013). The HBM may help explain cardiovascular nurses' perceived barriers and the relationship between personal health beliefs and their actions (Chen et al., 2018). Method Study Design This non-experimental study, using a cross-sectional design, investigated cardiovascular nurses self-perceived cardiovascular disease risk factors, attitudes, and perceived barriers toward physical activity and their promotion of a healthy lifestyle by recommending physical activity to their patients. Before data collection, the study was reviewed and approved by the University of Indianapolis Human Research Protections Program (protocol #01450, dated 6/4/2021, see Appendix A), and permissions were received from site administrators. Participants A convenience sample of full-time, part-time, and PRN nurses who consistently worked in the U.S. on cardiovascular units, such as the Intermediate Care Unit (IMCU), Cardiovascular Unit (CVU), Cardiac Catheterization Lab (Cath Lab), and Cardiac Rehabilitation (CR) was recruited. An exclusion criterion was being a float or registry nurse working in one of the cardiovascular units at the time of the survey. An a priori sample size estimate was conducted using G*Power software (Faul et al., 2009). Based on conducting multiple linear regression using the following parameters: fixed model, R2 deviation from zero, a medium effect size, 0.80 CARDIOVASCULAR NURSES PHYSICAL ACTIVITY BEHAVIOR PRACTICES 18 power, five predictors, and a significance level of .05, it was estimated that a minimum sample size of 92 responses was needed. Data Data were collected via an online survey using Qualtrics (Qualtrics, Provo, UT), an online survey platform. The survey consisted of three sections: demographics, cardiovascular risks, and current physical activity, and one question on health promotion (see Appendix A). Demographic data collected included: age (years), gender (male, female), marital status (single, married, divorced, separated, widowed), employment status (part-time, full-time, PRN), the highest level of nursing degree achieved (LPN, BSN, MSN, DNP), and years as a licensed nurse (0-5, 6-10, 11-15, 15+ years). The demographic section also inquired in which state of the U.S. the respondent was employed and in which cardiovascular unit (ICU, IMCU, CVU, Cath lab, CR, other cardiovascular units) they were working at the time of the survey. Respondents selfreported current body weight, height, and health status information, including current cardiovascular disease risk and physical activity habits, using the modified AHA/ACSM Health/Fitness Facility Preparticipation Screening Questionnaire (see Appendix B). Perceived cardiovascular disease health risks were measured with the ABCD Risk Questionnaire (see Appendix B). Physical activity habits were operationalized as the score received on the Rapid Assessment of Physical Activity (RAPA) Questionnaire (see Appendix B), and the Barriers to Being Active Quiz (BBAQ) (see Appendix B) was used to investigate potential obstacles to physical activity practices. To determine health promotion, a single question was asked about whether cardiovascular nurses recommended physical activity to their patients. Instruments AHA/ACSM Health/Fitness Facility Pre-Participation Screening Questionnaire CARDIOVASCULAR NURSES PHYSICAL ACTIVITY BEHAVIOR PRACTICES 19 The AHA/ACSM preparticipation screening questionnaire was used to determine the risk of cardiovascular disease and identify individuals who may be at an elevated risk for exerciserelated sudden cardiac death and acute myocardial infarction (Balady et al., 1998). The multidimensionality of this questionnaire supports internal consistency measures (Whitfield et al., 2014). Responses to each screening item are presented in a checklist in a yes, no format and coded as 1 or 0; the item responses were summed and averaged using the Statistical Package for Social Sciences (SPSS) software version 24.0 to compute the score. Scores of two or higher were considered high risk, while those with one or less were considered low risk of having CVD. This self-reported scale is within the public domain and is also used to assess the safety of participating in physical activity (Balady et al., 1998). ABCD Risk Questionnaire The ABCD Risk Questionnaire examines self-reported awareness of CVD risk and is available in an 85-item, 65-item, and 26-item version questionnaire (Woringer et al., 2017; Appendix B). The 26-item version was chosen for this study due to topic specificity and the length the of survey. The 26-item questionnaire subscales of Perceived Risk of Heart Attack/Stroke (Cronbachs = .85) and Perceived Benefits and Intentions to Change subscales (Cronbachs = .82) have high internal consistency (Martos et al., 2020; Woringer, 2017). The knowledge subscale was unable to be assessed for reliability (alpha) or structure (factor analysis) due to the dichotomous response choices and resultant singularity in the statistical matrix (Woringer, 2017). However, a positive, significant relationship was found between perceived and predicted CVD risk (r = .22) using the 26-item questionnaire (Woringer et al., 2017). The 26-item questionnaire consists of three subscales: 1) Knowledge of having a heart attack or stroke consists of 8 true (1) or false (0) items with summed scores ranging from 0 CARDIOVASCULAR NURSES PHYSICAL ACTIVITY BEHAVIOR PRACTICES 20 to 8; 2) Perceived Risk of Heart Attack/Stroke consists of 8 items measured on a 5-point Likert scale with a summed score ranging from 7 to 28; 3) Perceived Benefits and Intention to Change behavior which consists of 6 items measured on a 5-point Likert scale and summed scores ranging from 6 to 24. One question was reverse-coded and added to the summed score per the scoring instructions. Another question was eliminated in this category since it was related to nutrition habits. For each subscale, a higher average score indicates greater knowledge concerning heart attack or stroke, a greater perception of risk for heart attack or stroke, and greater perceived benefits of exercise and readiness for change. This scale is available through the public domain, licensed under Creative Commons Attribution 4.0 International License. Rapid Assessment of Physical Activity The RAPA questionnaire (see Appendix B) measures sedentary to vigorous physical activity habits (Lobelo et al., 2014; Topolski et al., 2006). Only the RAPA 1 Questionnaire was used in this study. The RAPA 1 is a 7-item assessment based on the Centers for Disease Control and Prevention (CDC) guidelines which recommend 30 minutes or more of moderate physical activity on every or most days of the week (Topolski et al., 2006). The RAPA 1 scale consists of seven yes or no items, yes = 1 and no = 0, that are summed for 1 to 7 points based on physical activity habits. Responses of the seven items are summed then placed into one of the following five categories based on the summered score: 1 = sedentary, 2 = under-active, 3 = under-active regular (light activities), 4 or 5 = under-active (regular) and 6 or 7 = active (Topolski et al., 2006). The RAPA has been shown to have good sensitivity, specificity, and both positive and negative predictive values (Topolski et al., 2006; Vega-Lpez et al., 2014) along with acceptable test-retest reliability (0.65, p < 0.01) (Lobelo et al., 2014; Vega-Lpez et al., 2014). Studies have also reported adequate concurrent and criterion-referenced validity assessed against concurrent CARDIOVASCULAR NURSES PHYSICAL ACTIVITY BEHAVIOR PRACTICES 21 accelerometer use (Lobelo et al., 2014). The RAPA 1 is available publicly and is open access, however, registration to use this instrument is required for research, personal use or clinical practice (University of Washington Research Center, 2006). Barriers to Being Active Quiz The BBAQ (see Appendix B) is a 21-item questionnaire that measures common reasons for not exercising. Questions are answered using a 4-point Likert scale to indicate agreement with the statement and to assess truth in the barrier statements (0 = very unlikely through 3 = very likely) (Kulavic et al., 2013). The scale consists of seven subscales of perceived barriers with three items per barrier (Kulavic et al., 2013). The seven perceived barrier subscales are: 1) Lack of Time, 2) Social Influences, 3) Lack of Energy, 4) Lack of Willpower, 5) Fear of Injury, 6) Lack of Skill, and 7) Lack of Resources (Kulavic et al., 2013; Sawchuk et al., 2011; U.S. Department of Health and Human Services, 1999). This instrument has been found to have good internal consistency (Cronbachs = .85) (Kulavic et al., 2013; Sawchuk et al., 2011). The subscales are scored by summing responses to the three questions for a possible total subscale score of 0-9 (Kulavic et al., 2013). A subscale score of five or greater indicates a physical activity barrier to overcome (Kulavic et al., 2013). The BBAQ measure is available for public access (U.S. Department of Health and Human Services, 1999; Zalewski et al., 2014). Procedures Recruitment The primary investigator (T. S.-M.) and study principal investigator (H. H. E.) are members of online nursing and healthcare administration social media interest groups on Facebook, Instagram, Twitter, and Reddit that allowed posts to solicit participation in research studies. Moderators of each nursing group on the various social media platforms were contacted CARDIOVASCULAR NURSES PHYSICAL ACTIVITY BEHAVIOR PRACTICES 22 about the study. The IRB (see Appendix A) and social media group moderators generated and approved an informative post with information about the study. In addition to information about the study, moderators were provided with links to the survey and IRB approval forms. The post was then made available to site users for approximately two months. Reposts were made every two weeks throughout the study period. Informed Consent Nurses interested in participating in the study followed the link to the online survey. The first page of the survey was the informed consent form (see Appendix A). To complete the survey, potential participants had to read the document and indicate their consent by clicking agree. Failure to provide consent did not allow the potential participant to continue, and they were directed to an exit page. Participants were also given the option to decline any question they were uncomfortable answering. Data Collection The survey was disseminated, and responses were collected through Qualtrics. The survey was available for two months beginning July 9, 2021, and reminders were reposted every two weeks on social media platforms. At the end of the study, participants were offered the opportunity to enter a raffle for a restaurant gift card to incentivize participation in the study. Participants who were interested in the raffle were provided the option, and to protect their anonymity, their raffle entry was not associated with their survey responses. If they clicked yes, they were directed to a separate form where they entered their name and email address. Participants who decided to not participate in the raffle, submitted their data and exited the study survey. Data from the raffle form was downloaded in an Excel file. Using a random number CARDIOVASCULAR NURSES PHYSICAL ACTIVITY BEHAVIOR PRACTICES 23 selection program, four winners were selected and the Excel file was deleted after the winners were notified. Data Management The initial posted survey resulted in over 230 responses. After the close of the survey, data were exported from Qualtrics into an Excel file. Upon examining the data, it was found that many replies were computer-generated (spambots); therefore, the protocol was revised to lessen the risk of spambots. An amendment to the IRB proposal included the addition of a captcha prompt after the consent agreement, which was reviewed and approved by the University of Indianapolis IRB. Once the revised survey was approved, the survey was reopened, and the link was posted to the social media groups. After the close of the survey, data were downloaded from Qualtrics by the primary investigator in an Excel file format. Data were reviewed by the primary investigator and the study principal investigator to eliminate false data generated by robots. Several steps were taken to clean the data. First, responses from the same IP address were eliminated followed by cases with countries (not states or territories of the US). Next, any cases where open-ended responses were not written in English were removed. At the next step, any cases with identical responses to the open-ended questions were deleted. At this stage, the IP addresses were stripped from the final data file which was stored in a password-protected format. Once data were cleaned, calculations specific for each of the instruments was conducted for the remaining 62 responses. Data Analysis Plan Data were analyzed using IBM SPSS Statistics for Windows, Version 24.0 (IBM Corp., Armonk, NY). All comparisons were two-tailed and a significance level of less than .05 was considered statistically significant. To determine the normality of the data, Shapiro-Wilk test CARDIOVASCULAR NURSES PHYSICAL ACTIVITY BEHAVIOR PRACTICES 24 results and visual inspection of histograms, box plots, and Q-Q plots were used. When warranted, Levenes tests were used to test for homogeneity of variance. Descriptive statistics were conducted for the demographic variables and results for each of the outcome instruments. Nominal data are reported as frequencies and percentages. Ordinal and non-normally distributed interval and ratio data are reported as medians and interquartile ranges while normally distributed data are reported as means and standard deviations. Research Question 1 Do nurses who have a self-reported high risk of CVD have greater knowledge of CVD, as measured with the ABCD Knowledge subscale, compared to nurses with a self-reported low risk of CVD? Due to the data not being normally distributed, a Mann-Whitney U test was conducted to determine if there was a significant difference in CVD knowledge between nurses with a selfreported high risk of CVD compared to nurses with a self-reported low risk of CVD. Research Question 2 Do nurses who self-report a high risk of CVD perceive greater benefits and intention to change behavior, as measured with ABCD Risk Questionnaire, compared to nurses who have a self-reported low risk of CVD? Data were normally distributed and had equality of variance; therefore, an independent samples t-test was used to determine if there were differences in ABCD Perceived Benefits and Intentions to Change scores by CVD perceived risk. Independence of observations was honored between the risk factor groups and data reviewed for significant outliers. CARDIOVASCULAR NURSES PHYSICAL ACTIVITY BEHAVIOR PRACTICES 25 Research Question 3 Do nurses who have a self-reported high risk of CVD have different beliefs about barriers to exercise, as measured with the BBAQ, and their exercise habits as measured with the RAPA 1 compared to nurses who have self-reported low risks of CVD? Normality tests showed that data for two of the BBAQ subscales, Lack of Will Power and Lack of Resources, were normally distributed; while Lack of Time, Social Influence, Lack of Energy, Lack of Skill, and Fear of Injury were not normally distributed. However, based on visual inspection of histograms, box plots, and Q-Q plots it was determined that the data were normally distributed. In addition, equality of variance was present. Therefore, independent samples t-tests were used to compare all the BBAQ subscales to CVD risk categories. Finally, Pearson chi-square tests were used to compare CVD perceived risk categories to the five RAPA 1 physical activity levels (sedentary, under-active, under-active regular light activities, underactive regular, active). The Fisher-Freeman-Halton exact test showed the significance value of the test statistic was greater than alpha and therefore was used to determine results. Research Question 4 Can factors including cardiovascular nurses CVD risk, knowledge of CVD, health beliefs, and individual characteristics, predict how likely they are to recommend physical activity to their patients? A multinomial logistic regression was used to identify health belief factors that were predictive of recommendations for physical activity to their patients. Bivariate analyses, including correlation analyses, were used to determine which variables to add to the model given that the sample size was relatively small (n = 62). Measures of modifying factors included years as a nurse and knowledge of cardiovascular disease risk. Age was excluded because it was CARDIOVASCULAR NURSES PHYSICAL ACTIVITY BEHAVIOR PRACTICES 26 collinear with years as a nurse. Measures of health beliefs included the barriers to being active scores. Physical activity, as measured by RAPA 1, was not included in the model due to unequal sizes across the activity categories. Variables with correlation coefficients of .30 or greater and tests of differences with p values of .05 or less were added to the model. The regression analysis used hierarchical variable entry based on the Health Belief Model which posts that modifying factors (e.g., years as a nurse, ABCD Knowledge) and beliefs [e.g., and barriers to exercise (BBAQ)] were used to determine whether the nurses made recommendations of physical activity to their cardiac patients. The first model included the modifying factors, the second model consisted of both modifying and belief factors in predicting exercise recommendations. Results The initial survey yielded responses from 230 participants. The majority of the data collected was unusable due to computer-generated spam responses. The data cleaning process entailed reviewing the responses based upon inclusion criteria, beginning with the location. Cases were deleted if they were from outside the United States. The redundant cases that had open-ended responses that were identical or had originated from the same IP address were also removed. The data were thoroughly reviewed, and 62 entries were determined to be valid. The majority of the participants (n = 56) were located on the East coast (35.7%) and the West coast (33.9%) in areas of high population density with the remainder from the Midwest area, thus the majority of nurses worked in urban settings. The sample demographics showed a mean age of 41.8 years (standard deviation = 8.9), 53.2% of participants were female, and 95.2% worked full time. Most participants (51.6%) achieved a Masters of Science in Nursing (MSN) degree and 14.5% achieved the highest level of nursing education with a Doctor of Nursing Practice (DNP). In addition, the majority of nurses (30.6%) who participated in the study worked in a cardiac CARDIOVASCULAR NURSES PHYSICAL ACTIVITY BEHAVIOR PRACTICES 27 rehabilitation unit and were employed 11 to 15 years (41.9%). Table 1 presents the detailed demographic characteristics of the sample. Results showed that 74.2% of the group had one or fewer risk factors for CVD and 25.8% had two or more risk factors. The mean and median scores for physical activity habits, selfreported awareness of CVD risk (Knowledge, Perceived Risk of Heart Attack/Stroke, Benefits and Intention to Change), and barriers to being active are found in Table 2. Research Question 1 Do nurses who have a self-reported high risk of CVD have greater knowledge of CVD, as measured with the ABCD Knowledge subscale, compared to nurses with a self-reported low risk of CVD? A Mann-Whitney U test was used to determine whether there was a difference in ABCD Knowledge scores between nurses with a high and a low risk of CVD. The Mann-Whitney U test was used to compare the two independent groups because the data was not normally distributed. The Mann-Whitney U test, Z = -1.01, p = .314 indicated that the groups did not differ statistically at an alpha of .05 and the effect size (d = .26) showed a small effect. Thus, there were no statistically significant differences between the low-risk and high-risk groups on their knowledge of cardiovascular risks. A Mann-Whitney U test was also used to determine whether there was a difference in ABCD Perceived Risk of Heart Attack and Stroke subscale scores between nurses with a high and low risk of cardiovascular disease. Since data were not normally distributed, a MannWhitney U test was used to test for differences. The test (Z = -0.45, p = .651) results indicated that the groups did not differ statistically at an alpha of .05. The effect size (d = .11) showed a CARDIOVASCULAR NURSES PHYSICAL ACTIVITY BEHAVIOR PRACTICES 28 negligible effect. Therefore, nurses with either high or low risk of CVD do not differ in their perceived risk of heart attack or stroke scores. Research Question 2 Do nurses who self-report a high risk of CVD perceive greater benefits and intention to change behavior, as measured with ABCD Risk Questionnaire, compared to nurses who have a self-reported low risk of CVD? An independent samples t-test was used to determine if there was a difference in ABCD Perceived Benefits and Intentions to Change scores between nurses who had a high risk and low risk of CVD. The mean and standard deviation for the low-risk group was 18.59 (2.37) and 17.38 (3.76) for the high-risk group. The independent samples t-test, t(60) = 1.50, p = .139 showed that the groups did not differ statistically at an alpha level of .05. The 95% confidence interval of the mean difference between the groups ranged from -0.40 to 2.23. The Cohens effect size was large (d = 2.78). It is inferred that there was no statistically significant difference between the two risk factor groups on and their ABCD Perceived Benefits and Intentions to Change subscale scores; however the effect of the perceived benefits and intention of change may be relevant. Research Question 3 Do nurses who have a self-reported high risk of CVD have different beliefs about barriers to exercise, as measured with the BBAQ, and their exercise habits as measured with the RAPA 1 compared to nurses who have self-reported low risks of CVD? Shapiro-Wilk tests for normality showed that the BBAQ subscale categories of Lack of Willpower and Lack of Resources were normally distributed while BBAQ subscales Lack of Time, Social Influence, Lack of Energy, Fear of Injury, and Lack of Skill scores were not normally distributed. However, visual inspection of histograms, box plots, and Q-Q plots were CARDIOVASCULAR NURSES PHYSICAL ACTIVITY BEHAVIOR PRACTICES 29 used and indicated normal distribution for Lack of Energy and Fear of Injury. Levenes test for equality of variances revealed that Lack of Resources (p = .344), Lack of Energy (p = .289), and Fear of Injury (p = .902), did not differ significantly. Therefore, independent samples t-tests were conducted for these subscales producing p values that were greater than .05 indicating that the low-risk and high-risk groups did not differ statistically. Thus, there were no differences between the risk factor groups on these barriers to exercise. The Levenes test indicated there was a significant difference in variances for Lack of Willpower (p = .014); therefore, an independent samples t-test with correction for unequal variances was conducted which indicated there was not a significant difference (p = .796) in Lack of Willpower between the risk factor groups. Mann-Whitney U tests were used for the three non-normally distributed subscores: Lack of Time (Z = -0.85, p = .396), Social Influence (Z = 1.07, p = .286), and Lack of Skill (Z = -1.09, p = .275). Results produced p values greater than the alpha of .05 and had a small effect size respectively (d = 0.22, d = 0.28, d = 0.28) indicating that there were no differences between the low-risk and high-risk groups and they did not differ statistically (see Table 4). A Pearson chi-square test was used to compare physical activity habits groups (Active, Under-active regular, Under-active-light activities, Under-active, Sedentary) as measured by the RAPA 1, between the two CVD perceived risk groups for physical activity habits. The Sedentary group had 3 nurses (100%) that were in the CVD low risk group and none in the CVD high risk group for this category. The Under-active-light activities group comprised the largest group in the CVD low risk category with 17 out of 22 nurses (77.3%) while the largest group in the CVD high risk category was found in the Under-active-light group (5 out of 22) and Under-active regular group (5 out of 21) with 22.7% and 23.8% respectively. Only 8 out of 62 nurses (12.9%) CARDIOVASCULAR NURSES PHYSICAL ACTIVITY BEHAVIOR PRACTICES 30 were in the Active category (5 CVD low risk; 3 high risk) which met the recommended physical activity guidelines. The two-sided Fisher-Freeman-Halton exact test indicated there was not a statistically significant difference (p = .717) between RAPA 1 categories with risk factor groups at an alpha level of .05. The Cohens effect size is a very large effect (d = 1.29) based on the continuity correction statistic. The null hypothesis is accepted and it is inferred that there is no difference between RAPA 1 aerobic activity categories and risk factor groups. Research Question 4 Can factors including cardiovascular nurses CVD risk, knowledge of CVD, health beliefs, and individual characteristics, predict how likely they are to recommend physical activity to their patients? A binomial logistical regression was employed to identify factors that predicted whether or not cardiovascular nurses recommend exercise to CVD patients. Assumptions for logistical analysis were met. Observations in the dataset were independent of each other and there was no severe multicollinearity amongst variables. Years as a nurse, self-assessed CVD risk perceptions (ABCD Knowledge subscale), and barriers to exercise (as measured by the BBAQ Fear of Injury, Lack of Skill, Social Influence, and Lack of Energy subscales) were used as predictors. The regression analysis used hierarchical variable entry based on the HBM which posits that modifying factors (e.g., years as a nurse, knowledge of CVD risks) and beliefs (e.g., barriers to exercise) determine recommendations of physical activity. The first regression model included only one of the modifying factors: years as a nurse. Since this was a categorical variable in a logistic regression, the reference category was the last (15 or more years). Age was not included as a predictor because it was collinear with years as a nurse. The second model included two modifying factors: years as a nurse and knowledge about cardiovascular disease. The final model CARDIOVASCULAR NURSES PHYSICAL ACTIVITY BEHAVIOR PRACTICES 31 included modifying, health belief factors, and barriers to exercise as predictors of whether nurses recommended exercise to their cardiac patients. Results of the analysis are found in Table 6. Categories for years as a nurse were 0-5 years, 6-10 years, 11-15 years, and the 15+ years was the reference category for this test. ABCD Knowledge was used since the subscale assesses knowledge about perception of CVD risk. Model 1, which included Years as a Nurse, took five iterations to fit the line) and there also was not a significant improvement found over having no predictors in the model (p = .778). Years as a Nurse alone did not predict exercise recommendation; although not significant, it is interesting to note that those in the 6-10 year category were nearly two times as likely to recommend exercise to patients than nurses with 15 or more years of experience. Model 2 added ABCD Knowledge subscale scores. The second model also took five iterations to fit the line and none of the predictor variables were effective at predicting whether or not the nurses recommended exercise (p = .670). Although not significant, it is interesting to note that nurses who achieved higher ABCD Knowledge scores were almost twice as likely to recommend physical activity to patients. Model 3 added to the prior model four of the barriers to being active: Lack of Skill, Fear of Injury, Social Influence, and Lack of Energy subscale scores. There was a significant improvement in fitting the regression line with ABCD Knowledge (p = .027) and BBAQ Lack of Skill (p = .020). These were found to be significant predictors of recommendations for exercise. Those who had greater knowledge of cardiovascular risk were found to be almost three times as likely to recommend exercise to cardiac patients and more than twice as likely for those who scored higher on the BBAQ Lack of Skill subscale. Discussion The purpose of this study was to investigate the differences and relationships between cardiovascular nurses self-reported knowledge of CVD, risk of CVD, perceived benefits of CARDIOVASCULAR NURSES PHYSICAL ACTIVITY BEHAVIOR PRACTICES 32 regular exercise, intention to change behaviors, and perceived barriers to physical exercise to their characteristics and exercise habits. The relationships among the factors of the health belief model and the likelihood that nurses recommend physical activity to their patients were explored. Cardiovascular nurses were chosen as the target group since they have an essential role in patient counseling and education concerning cardiovascular risk factor reduction and positive lifestyle habits (Fair et al., 2009). Telemetry and medical-surgical nurses have reported a higher participation rate in health-promoting behaviors compared to other critical care nurses that could be influenced by workplace factors such as unit and job type (Ross et al., 2019). Depending on the unit and the hospital, most intensive care units have individual rooms that one nurse monitors. The nurses are responsible for an individual patient since most patients are in a critical state on this floor and may need 24-hour care. Telemetry and medical-surgical floors, on the contrary, tend to have a centrally located workstation where all patient rooms can be monitored (Thompson et al., 2012). Nurses on these floors can be responsible for 3-4 patients per shift, which would promote more overall activity to care for several patients. However, research has shown that nurses may not always engage in the appropriate level of physical activity that is crucial for decreasing the risk of CVD along with other health conditions (Priano et al., 2018; Wilkerson et al., 2019). The prevalence of CVD in nurses can lead to nurses having increased stress, fatigue, absenteeism, burnout, decreased quantity and quality of patient care, leave, or job change which can be critical in delivering patient prevention services (Bakhshi et al., 2015; Hojat et al., 2019). In addition, nurses health performance can significantly impact healthcare consumers (Hojat et al., 2019; Jahromi et al., 2017). It is expected that nurses who are aware of their risk factors and follow healthy lifestyle behaviors are more likely to recommend healthy behaviors to their CARDIOVASCULAR NURSES PHYSICAL ACTIVITY BEHAVIOR PRACTICES 33 patients and they are more effective in health counseling roles and physical activity promotion (Bakhshi et al., 2015; Esposito & Fitzpatrick, 2011; Fair et al., 2009; Priano et al., 2018; Ross et al., 2019; van Hell-Cromwijk et al., 2021). Patients are also more likely to accept education on health topics, including physical activity, from nurses who engage in self-health promotion practices (Esposito & Fitzpatrick, 2011; Lobelo & Garcia de Quevedo, 2014; Neall et al., 2015). In this study, the participants were middle-aged, mid-career, underactive female nurses working in urban settings who perceived they were knowledgeable about CVD. This sample information does complement the finding that nursing education programs provide knowledge about health promotion, disease prevention, patient education, and lifestyle behaviors. Nurses, in general, are expected to have an awareness-based knowledge of CVD recommendations, prevention, and treatment which was assessed in this study with the ABCD Knowledge subscale (Wu et al., 2011). However, adequate knowledge comes with increasing accountability (Hall, 2005). The personal health practices of many nurses may not reflect this knowledge and be less than optimal (Darch et al., 2019; Deasy et al., 2016; Kiamco-Millman & Pinto-Zipp, 2013). Results from this study showed that 8 out of 62 nurses actually met the recommended physical activity requirements. Job type, type of unit, workplace environment, shift work, attitudes, fatigue, awareness of guidelines, and perceived barriers have also been found to influence physical activity habits and eating a healthy diet (Gould et al., 2019; Letvak, 2013; Priano et al., 2018; Ross et al., 2019). In addition, hospital-based nurses were found to be more physically active if they had higher self-efficacy, fewer barriers, positive perceptions of personal health, and believed in physical activity's perceived benefits (Ross et al., 2019). Researchers have reported that those with an accurate personal risk perception of getting CVD may influence their intent to participate in healthy lifestyle behaviors (Alwan et al., 2009; CARDIOVASCULAR NURSES PHYSICAL ACTIVITY BEHAVIOR PRACTICES 34 Gujral et al., 2020; Imes & Lewis, 2014). A positive relationship has been found between those with a known family history of CVD and perceived risk. However, the intent to engage in healthrelated behavior change to decrease the risk of CVD does not always reflect accurate personal perceptions of disease risk (Gujral et al., 2020; Imes & Lewis, 2014). The mental portrayal of an illness threat based on existing beliefs and knowledge can influence motivation to engage in behavior change (Claassen et al., 2012). The current study found no differences concerning knowledge, perceived risk of heart attack or stroke, and perceived benefits and intentions to change regardless of the risk factors identified by the AHA/ACSM preparticipation screening questionnaire. Scores indicated that nurses perceived that they were knowledgeable about topics related to a heart attack or stroke and believed they were more likely to be at risk. Scores also showed perceived benefits and readiness to change in support of exercise behaviors for heart health (Woringer et al., 2017). In support of this finding, research on cardiovascular nurses found them to be more knowledgeable on the topic of CVD risk factor reduction than surgical and medical nurses (Ding et al., 2016). In addition, in another study by Khan et al. (2012), most nurses in the sample reported they knew about identifying cardiovascular diseases. However, more than half reported they personally lacked discipline for making healthy behavior choices. Results from this study supported the finding that nurses in this sample demonstrated knowledge of risk factors. However, most of the nurses did not meet the recommended physical activity requirement of 150 minutes per week of moderate physical activity. Physical activity results from this study showed that nurses engage in some light to moderate physical activities every week, but less than the recommended 30 minutes a day (Ross et al., 2019; Topolski et al., 2006). This is less than the recommended physical activity guidelines of 150 minutes of moderate physical activity weekly encouraged by both the AHA CARDIOVASCULAR NURSES PHYSICAL ACTIVITY BEHAVIOR PRACTICES 35 and ACSM (AHA, 2016; ACSM, 2018). This outcome is consistent with findings that confirm that nurses report low physical activity levels when objectively measured (Avraham et al., 2020; Duignan & Duignan, 2017; Gould et al., 2019; Reed & Prince, 2018; Woringer et al., 2017; van Hell-Cromwijk et al., 2021). Nurses with highly physically demanding jobs that include direct patient care have been found to engage in less leisure-time physical activity which was supported by the findings in this study (McCarthy et al., 2018; Wilkerson et al., 2019). Furthermore, nurses often overestimate the physical activity they perform throughout the day and may not engage in additional exercise after work (Essen & Brown, 2020). Research has shown that nurses can walk several miles a day on their shift. However, occupational physical activity levels are largely low level and not continuous as recommended by AHA and ACSM to contribute to positive health effects (McCarthy et al., 2018; Reed & Prince, 2018; Ross et al., 2019). Research confirms that nurses with fewer perceived barriers are more likely to be physically active (Ross et al., 2019). The current survey results showed no significant difference between risk factor groups and activity barrier categories. However, this sample identified a lack of energy as a barrier to regular physical activity. This finding is consistent with the fact that nurses are often required to work long or rotating hours, experience high job stress and fatigue, and may have other responsibilities at home and competing outside demands that contribute to this barrier (Gould et al., 2019; Letvak, 2013; Priano et al., 2018; Ross et al., 2019). There are few research studies found evaluating nurses, specifically cardiovascular nurses, that assess barriers to physical activity. Still, some research supports that lack of energy, social influence, fear of injury, and lack of skill tend to be common barriers to healthy living (AlTannir et al., 2017; Duignan & Duignan, 2017; Huijg et al., 2015; Kemppainen et al., 2012; Priano et al., 2018; Ross et al., 2017 Ross et al., 2019; Wilkerson et al., 2019). Thus, these CARDIOVASCULAR NURSES PHYSICAL ACTIVITY BEHAVIOR PRACTICES 36 barriers were included in the predictive model as health belief factors that may influence physical activity recommendations for cardiac patients. Years as a nurse was a category for the regression analysis to investigate if nurses with more experience were more likely to recommend physical activity to patients. As mentioned previously, age was found to be collinear with years of experience. Current study results demonstrated no significant relationship between how long the individuals had been nurses and their likelihood of recommending exercise to patients. In a study by Thacker et al. (2016), researchers found that older nurses, 50 years of age and older, tended to be more concerned with their own health; however, no significant correlations were found between years in practice and Health-Promoting Lifestyle Profile II scores. In another study by Bakhski et al. (2015), researchers found that clinical practice length contributed to professional barriers relating to personal physical activity habits. Physical activity generally declines with age, and older nurses may feel challenged by the physical demands of their job (McCarthy et al., 2018; Piazza et al., 2001). This finding was supported and remained unchanged when other variables were added to the model in the current study. When the knowledge variable was added, nurses were more likely to recommend physical activity to patients if they scored higher on the ACBD Knowledge questionnaire. Studies indicate that nurses, including cardiovascular nurses, have the knowledge regarding CVD risk and prevention needed for patient education and counseling (Ding et al., 2016; Kiamco-Millman & Pinto-Zipp, 2013), nurses also gain knowledge from practice, scientific articles, and additional continuing education (Durlak, 2018). The nursing profession is constantly evolving, and needs continuous professional development (Hall, 2005). Nurses should be responsible for their education. Personal interest and lack of knowledge on continuing education topics such as updated physical activity guidelines, should be self-directed by not only the nurse but also CARDIOVASCULAR NURSES PHYSICAL ACTIVITY BEHAVIOR PRACTICES 37 encouraged by unit managers. Finally, when the four barriers to being active (lack of energy, social influence, fear of injury, and lack of skill) were added to the model, nurses with higher knowledge scores and higher scores on the exercise barrier, lack of skill, were more likely to recommend exercise to cardiac patients. This result emphasizes that nurses in this sample perceive themselves as knowledgeable about health-promoting activities such as regular physical activity and other risk factors. In addition, findings support that nurses who have knowledge of physical activity guidelines and frequently practiced physical activity were more likely to counsel patients on this behavior (Bakhshi et al., 2015; Esposito & Fitzpatrick, 2011; Lin et al., 2017; Ross et al., 2019; van Hell-Cromwijk et al., 2021; Wilkerson et al., 2019). Nurses received information on CVD, treatment, and physical activity guidelines in their formal education; however, they may be lacking in updated CVD information regarding these topics. Nonetheless, they know the significance and health benefits of physical activity in CVD prevention (Duignan & Duignan, 2017; Huijg et al., 2015; van Hell-Cromwijk et al., 2021). Taking action to stay updated on current guidelines, specifically physical activity recommendations, can benefit nurses personally and professionally. Sources that support physical activity guidelines, such as the AHA and WHO, regularly update their information and make their recommendations easily accessible to everyone. The AHA has an entire library of brochures that are downloadable and available for the public. Limitations This study was initially intended to target cardiovascular nurses in a local hospital with three unique demographic locations. However, due to the COVID pandemic, hospital administration approval was challenging, and the investigators decided to pursue responses from cardiovascular nurses via social media. Following IRB and social media host approval, the initial CARDIOVASCULAR NURSES PHYSICAL ACTIVITY BEHAVIOR PRACTICES 38 survey was posted without a captcha to generate extraneous responses. The irrelevant computer responses were repeats of some participant responses, and others were random answers to the survey questions. These responses would not have reflected the samples responses and were eliminated. The survey was then modified and re-approved, and results were screened according to the study criteria for data analysis. The sample size was also smaller than the estimated a priori minimal sample size of 92 participants, which was needed to find a significant effect at a power level of .80. This also controls for type I and type II errors to support the hypothesis that nurses do recommend physical activity to their patients (Kang, 2021). A post hoc power analysis using the achieved effect size, .05 alpha, and sample size of 62 nurses yielded a power of 0.30. Thus, it is highly likely that these results do not accurately reflect the views of this target group due to the small sample size. In addition, internal and external validity may also be compromised. Given that this was a cross-sectional study, there were threats to the internal validity. One threat that may have affected the results was the limited amount of time, two months, over which the information was collected from the survey. In addition, the results may not be generalizable to the targeted population since it included only nurses who worked on a cardiovascular unit in the U.S. and may not apply to all nurses. The survey link was also distributed via social media platforms with responses from nurses in various locations in the U.S. who may have different views. Findings can, however, have practical value to nurses in cardiovascular units, other units, and various clinical environments. This type of survey could also be conducted in a hospital as a social media platform to target this population. The survey was constructed to assess CVD risk factors, knowledge of CVD, physical activity habits, and barriers to being active using questionnaires to target these topics. Overall, CARDIOVASCULAR NURSES PHYSICAL ACTIVITY BEHAVIOR PRACTICES 39 with this sample, the survey evaluated ability of CVD, current exercise habits, beliefs, and barriers to being active, and if this sample promoted physical activity to their patients; however, there were few significant results. The initial survey included both height and weight as part of the demographics with the intent to assess this sample's BMI. The survey used a slider to estimate height in both feet and inches. Unfortunately, the height results were difficult to read and were not included in this study. Obesity and being overweight is an issue of concern among nurses, and the lack of data on this CVD risk factor limited the ability to assess the BMI of current the sample (Esposito & Fitzpatrick, 2011; Essen & Brown, 2020; Ross et al., 2019). Plus, with some research stating that telemetry nurses practice more health-promoting behaviors than others, evaluating BMI may have provided data to assess the potential CVD risk associated with obesity in this study sample (Ross et al., 2019). Result responses may have been influenced in this study due to self-reporting and selfperception of physical activity habits and risk factor assessment. Some studies have shown that nurses can overestimate the amount of exercise and rigor experienced during their workday (Essen & Brown, 2020). Participants may have a low perception of risk despite having a family history and other risk factors for CVD, which may limit their participation in health-related behaviors (Imes & Lewis, 2014). Furthermore, evidence also supports that some nurses may still not be aware of CVD prevention and recommended physical activity guidelines (Ding et al., 2016; Duignan & Duignan, 2017; Huijg et al. 2015; Kiamco-Millman & Pinto-Zipp, 2013; van Hell-Cromwijk et al., 2021). As expected, nurses aware of their risk factors are more likely to practice healthy lifestyle behaviors and may be more effective with patient counseling (Fair et al., 2009). Support of family and friends, personal attitudes, beliefs, and behaviors may impact personal and professional health promotion practices (Bakhski et al., 2015). Plus, those who CARDIOVASCULAR NURSES PHYSICAL ACTIVITY BEHAVIOR PRACTICES 40 found interest in this topic may also have been more likely to participate. Finally, the survey was distributed online, so questions or concerns could not be addressed in person if needed. Conclusion There are limited studies investigating CVD knowledge and physical activity practices among nurses, specifically telemetry nurses in the United States. In addition, nurses who work in cardiovascular units are often underrepresented in studies. Much of the CVD risk reduction education and counseling is provided by cardiovascular nurses, who are also likely to serve as behavior-change role models for patients (Fair et al., 2009). The nurses in this study did know about CVD; however, physical activity habits were below the recommended guidelines. This finding is consistent with the literature (Kiamco-Millman & Pinto-Zipp, 2013; Ross et al., 2019; Wilkerson et al., 2019). Literature also states that nurses consider health promotion necessary and fundamental to nursing care (Ding et al., 2016; Essen & Brown, 2020; van Hell-Cromwijk et al., 2021). Furthermore, self-care for good health is essential for nurses personal benefits and potentially positive effects that can be conveyed to their patients (Lobelo & Garcia de Quevedo, 2014). Patient interactions and interventions can positively influence physical activity habits and cardiovascular risk factors (Castro et al., 2017). However, personal obstacles, lack of time, outside commitments, lack of resources, organizational culture, fatigue, and lack of discipline may hinder healthy behavioral practices (Essen & Brown, 2020; Kemppainen et al., 2012; Khan et al., 2012; Ross et al., 2019). Studies have found that many nurses lack facilities such as access to a gym or resources that offer exercise and relaxation classes, but also can accommodate their work schedules (Ross et al., 2019). In addition, workplace environments including unit, job type, and social support can also influence personal health behaviors (Bakhski et al., 2015; Ross et al., CARDIOVASCULAR NURSES PHYSICAL ACTIVITY BEHAVIOR PRACTICES 41 2019). Regular physical activity decreases the risk of chronic disease and work absenteeism and increases work productivity allowing nurses to maintain a necessary level of health to provide quality patient care (Wilkerson et al., 2019). Cardiovascular disease continues to be a leading global cause of death, and the World Health Organization (WHO) supports strategies to reduce risk factors, develop care standards, and improve the quality of healthcare systems to care for patients with CVD (WHO, 2021). Hospitals can encourage screening, early diagnosis, and treatment/prevention for CVD for their nurses. Offering wellness programs to their employees to promote stress relief and personal health education along with potential incentives such as discounts on gym memberships and possible monetary rewards for healthy behavior changes can stimulate participation and bring attention to individual preventable health risk factors. In addition, continuing education on CVD awareness and the significance of regular physical activity can improve nurses knowledge, health, and well-being, which can be promoted to patients. With CVD remaining as the leading cause of death in the U.S., identifying risk factors, encouraging healthier lifestyles, and practicing regular physical activity can still help prevent most cardiovascular diseases (AHA, 2021). Reinforcing these lifesavers through education for both nurses and patients provides the means vital to the prevention of CVD. Future studies need to further evaluate CVD risk factors among different nursing units and the current physical activity practices of the staff. In addition, methods to educate nurses on improving awareness of the significance of regular physical activity and current guidelines may heighten awareness of CVD risk factor prevention, encourage healthier lifestyle practices, and generate patient education. Both AHA and CDC have materials available that could be used to update nurses knowledge regarding CVD for personal and professional reasons. The Health CARDIOVASCULAR NURSES PHYSICAL ACTIVITY BEHAVIOR PRACTICES 42 Observances Calendar can also be used for reference and to emphasize CVD topics such as heart month in February and employee health and fitness month in May (Healthgrades, 2022). During these months, nurses can further their knowledge on these topics while also educating their patients. Nurses, especially telemetry nurses, should take advantage of the teachable moments, possibly when taking blood pressures or other one-on-one patient interactions to provide counseling on CVD risk prevention and other healthy lifestyle interventions (Kiamco-Millman & Pinto-Zipp, 2013). Healthy nurses lead by example and can become role models for their patients and other healthcare professionals. Personal attitudes, behaviors, and beliefs concerning health promotion can be translated into professional practices (Bakhshi et al., 2015). When practicing health behaviors, nurses are more likely to promote these behaviors to patients. The patients, in turn, are more likely to be influenced and compliant with these behaviors (Esposito and Fitzpatrick, 2011; Lin et al., 2017; Lobelo & Garcia de Quevedo, 2014; Neall et al., 2016; Priano et al., 2018; Ross et al., 2019). The results of this study illustrate that perceived barriers to exercise affect nurses recommendations of exercise to their patients. Even though significant differences were not found between risk factor groups on knowledge, intentions to change behaviors, years as a nurse, and barriers to exercise, with the exception of lack of energy. Results demonstrated that the majority of nurses in this sample did not achieve recommended physical activity guidelines. In addition, nurses who scored higher in the ABCD Knowledge and those who had higher scores on the BBAQ Lack of Skill were more likely to recommend exercise to patients. Research supports that nurses perceive they have sufficient knowledge of physical activity but may lack the skill and knowledge concerning the physical activity guidelines to advise patients on this topic (van Hell-Cromwijk et al., 2021). Plus, as previously mentioned, those with personal experiences with CARDIOVASCULAR NURSES PHYSICAL ACTIVITY BEHAVIOR PRACTICES 43 physical activity are also more likely to have a positive attitude toward sharing health promotion topics with their patients (Kemppainen et al., 2012). Nurses are a vital component in healthcare, but self-care and healthy lifestyle choices, especially concerning exercise, have been found to be lacking consistent practice (Thacker et al, 2016). While there is the restriction of adequate power in this sample, it is important for future studies to consider these limitations as well. Future studies should investigate ways to improve nurses knowledge of current guidelines, engagement, and participation in adequate levels of physical activity. Improving awareness, providing resources and education can enhance nurses professional roles to make physical activity a core component of patient care. 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American Journal of Lifestyle Medicine, 10(1), 36-52. https://doi.org/10.1177/1559827613520120 Marchiondo, K. (2014). Stemming the obesity epidemic: Are nurses credible coaches? Medsurg Nursing, 23(3), 155-158. McCarthy, V. J. C., Wills, T., & Crowley, S. (2018). Nurses, age, job demands and physical activity at work and at leisure: A cross-sectional study. Applied Nursing Research, 40, 116-121. https://doi.org/10.1016/j.apnr.2018.01.010 McKenzie, J.F., Neiger, B.L., & Thackeray, R. (2017). Planning, implementing, & evaluating health promotion programs: A primer (7th ed.). Pearson Education, Inc. Martos, T., Csabai, M., Bagyura, Z., Ocsovszky, Z., Rafael, B., Sallay, V., & Merkely, B. (2020). Cardiovascular disease risk perception in a Hungarian community sample: Psychometric evaluation of the ABCD Risk Perception Questionnaire. BMJ Open, 10, e036028. https://doi.org/10.1136/bmjopen-2019-036028 CARDIOVASCULAR NURSES PHYSICAL ACTIVITY BEHAVIOR PRACTICES 51 Neall, R. A., Atherton, I. 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L., & Prince, S. A. (2018). Women's heart health: A focus on nurses' physical activity and sedentary behavior. Current Opinion in Cardiology, 33(5), 514-520. https://doi.org/10.1097/HCO0000000000000545 Reed, J. L., Prince, S. A., Pipe, A. L., Attallah, S., Adamo, K. B., Tulloch, H. E., Manuel, D., Mullen, K.-A., Fodor, G., & Reid, R. D. (2018). Influence of the workplace on physical activity and cardiometabolic health: Results of the multi-centre cross-sectional Champlain Nurses' study. International Journal of Nursing Studies, 81, 49-60. https://doi.org/10.1016/j.ijnurstu.2018.02.001 CARDIOVASCULAR NURSES PHYSICAL ACTIVITY BEHAVIOR PRACTICES 52 Riegel, B., Moser, D. K., Buck, H. G., Dickson, V. V., Dunbar, S. B., Lee, C. S., Lennie, T. A., Lindenfeld, J., Mitchell, J. E., TreatJacobson, D. J., Webber, D. E., & on behalf of the American Heart Association Council on Cardiovascular and Stroke Nursing; Council on Peripheral Vascular Disease; and Council on Quality of Care and Outcomes Research. (2017). Selfcare for the prevention and management of cardiovascular disease and stroke: A scientific statement for healthcare professionals from the American Heart Association. Journal of the American Heart Association, 6(9), e006997. https://doi.org/10.1161/JAHA.117.006997 Roskoden, F. C., Krger, J., Vogt, L. J., Grtner, S., Hannich, H. J., Steveling, A., Lerch, M. M., & Aghdassi, A. A. (2017). Physical activity, energy expenditure, nutritional habits, quality of sleep and stress levels in shift-working health care personnel. PLOS ONE, 12(1), 1-21. https://doi.org/10.1371/journal.pone.0169983 Ross, A., Bevans, M., Brooks, A. T., Gibbons, S., & Wallen, G. R. (2017). Nurses and healthpromoting behaviors: Knowledge may not translate into self-care. AORN Journal, 105(3), 267-275. https://doi.org/10.1016/j.aorn.2016.12.018 Ross, A., Touchton-Leonard, K., Perez, A., Webrien, L., Kazmi, N., & Gibbons, S. (2019). Factors that influence health-promoting self-care in registered nurses. Advances in Nursing Science, 42(4), 358-373. doi:10.1097/ANS.0000000000000274 Ross, A., Yang, L., Wehrlen, L., Perez, A., Farmer, N., & Bevans, M. (2019). Nurses and healthpromoting self-care: Do we practice what we preach? Journal of Nursing Magazine, 27(3), 599-608. https://doi.org/10.1111/jonm.12718 CARDIOVASCULAR NURSES PHYSICAL ACTIVITY BEHAVIOR PRACTICES 53 Sawchuk, C. N., Russo, J. E., Bogart, A., Charles, S., Goldberg, J., Forquera, R., Roy-Byrne, P., & Buchwald, D. (2011). Barriers and facilitators to walking and physical activity among American Indian elders. Preventing Chronic Disease, 8(3), 1-9. http://www.cdc.gov/pcd/issues/2011/may/10_0076.htm Thacker, K., Stavarski, D. H., Brancato, V., Flay, C., & Greenawald, D. (2016). An investigation into the health-promoting lifestyle practices of RNs. American Journal of Nursing, 116(4), 24-30. doi:10.1097/01.NAJ.0000482141.42919.b7 Thompson, D. R., Hamilton, D. K., Cadenhead, C. D., Swoboda, S. M., Schwindel, S. M., Anderson, D. C., Schmitz, E. V., St. Andre, A. C., Axon, D. C., Harrell, J. W., Harvey, M. A., Howard, A., Kaufman, D. C., & Petersen, C. (2012). Guidelines for intensive care unit design. Critical Care Medicine, 40(5), 1586-1600. doi:10.1097/CCM.0b013e3182413bb2 Topolski, T. D., LoGerfo, J., Patrick, D. L., Williams, B., Walwick, J., & Patrick, M. B. (2006). The rapid assessment of physical activity (RAPA) among older adults. Preventing Chronic Disease, 3(4), 1-8. http://www.cdc.gov/pcd/issues/2006/oct/06_0001.htm U.S. Department of Health and Human Services (1999). Barriers to Being Physically Active Quiz. http://www.cdc.gov/nccdphp/dnpa/physical/life/barriers_quiz.pdf University of Washington Health Promotion Research Center (2006). Rapid assessment of physical activity (RAPA). https://depts.washington.edu/hprc/resources/productstools/rapa/ CARDIOVASCULAR NURSES PHYSICAL ACTIVITY BEHAVIOR PRACTICES 54 van Hell-Cromwijk, M., Metzelthin, S. F., Schoonhoven, L., Verstraten, C., Kroeze, W., & de Man van Ginkel, J. M. (2021). Nurses perceptions of their role with respect to promoting physical activity in adult patients: A systematic review. Journal of Clinical Nursing, 30, 2540-2562. https://doi.org/10.1111/jocn.15747 Vega-Lpez, S., Chavez, A., Farr, K. J., & Ainsworth, B. E. (2014). Validity and reliability of two brief physical activity questionnaires among Spanish-speaking individuals of Mexican descent. Research Notes, 7(29). https://doi.org/10.1186/1756-0500-7-29 Waksmaska, W., Wo, H., & Bobiski, R. (2018). The occurrence of abnormal body weight values and selected eating habits and physical activity of nurses. Journal of Medical Science, 87(4), 179-187. https://doi.org/10.20883/jms.314 Webster, R., & Heeley, E. (2010). Perceptions of risk: Understanding cardiovascular disease. Risk Management and Healthcare Policy, 3, 49-60. https://doi.org/10.2147/RMHP.S8288 Whitfield, G. P., Pettee Gabriel, K. K., Rahbar, M. H., & Kohl III, H. W. (2014). Application of AHA/ACSM adult pre-participation screening checklist to a nationally representative sample of US adults aged 40 and older from NHANES 2001-2004. Circulation, 129(10), 1113-1120. https://doi.org/10.1161/CIRCULATIONAHA.113.004160 Wilkerson, A. H., Thomas, H. O., & Nahar, V. K. (2019). Correlates of physical activity behavior among nursing professionals: A systematic search and literature review. Journal of Health and Social Sciences, 4(2), 157-172. https://doi.org/10.19204/2019/crrl5 Wills, J., Kelly, M., & Frings, D. (2019). Nurses as role models in health promotion: Piloting the acceptability of social marketing campaign. Journal of Advanced Nursing, 75(2), 423431. https://doi.org/10.1111/jan.13874 CARDIOVASCULAR NURSES PHYSICAL ACTIVITY BEHAVIOR PRACTICES 55 Woringer, M., Nielsen, J. J., Zibarras, L., Evason, J., Kassianos, A. P., Harris, M., Majeed, A., & Soljak, M. (2017). Development of a questionnaire to evaluate patients' awareness of cardiovascular disease risk in England's National Health Service Health Check preventative cardiovascular programme. BMJ Open, 7(9), 1-10. https://doi.org/10.1136/bmjopen-2016-014413 World Health Organization (2021, June 11). Cardiovascular diseases (CVDs). https://www.who.int/en/news-room/fact-sheets/detail/cardiovascular-diseases-(cvds) Wu, Y., Deng, Y., & Zhang, Y. (2011). Knowledge, attitudes, and behaviors of nursing professionals and students in Beijing toward cardiovascular disease risk reduction. Research in Nursing & Health, 34, 228-240. https://doi.org/10.1002/nur.20431 Yu, E., Rimm, E., Qi, L., Rexrode, K., Albert, C. M., Sun, Q., Willett, W. C., Hu, F. B., Manson, J. E. (2016). Diet, lifestyle, biomarkers, genetic factors, and risk of cardiovascular disease in the Nurses Health Studies. American Journal of Public Health, 106, 1616-1623. doi:10.2105/AJPH.2016.303316 Zalewski, K., Alt, C., & Arvinen-Barrow, M. (2014). Identifying barriers to remaining physically active after rehabilitation: Differences in perception between physical therapists and older adult patients. Journal of Orthopaedic & Sports Physical Therapy, 44(6), 415-424. https://www.jospt.org/doi/10.2519/jospt.2014.5171 CARDIOVASCULAR NURSES PHYSICAL ACTIVITY BEHAVIOR PRACTICES Table 1 Sample Baseline Characteristics (N = 62) N % Male 28 45.2 Female 33 53.2 Single 12 19.4 Married 45 72.6 Separated 3 4.8 Divorced 1 1.6 Licensed Practical Nurse 5 8.1 Bachelor of Science in Nursing 15 24.2 Master of Science in Nursing 32 51.6 Doctor of Nursing Practice 9 14.5 Other 1 1.6 Intensive Care 5 8.1 Immediate Care 9 14.5 Cardiovascular 8 12.9 Catherization Lab 16 25.8 Cardiac Rehabilitation 19 30.6 Gender a Marital Status a Nursing Level Unit 56 CARDIOVASCULAR NURSES PHYSICAL ACTIVITY BEHAVIOR PRACTICES Other Cardiovascular 5 8.1 0-5 12 19.4 6-10 11 17.7 11-15 26 41.9 >15 13 21.0 Years as a Nurse Note. a N = 61. 57 CARDIOVASCULAR NURSES PHYSICAL ACTIVITY BEHAVIOR PRACTICES 58 Table 2 Descriptive Statistics for Outcome Measures: RAPA 1, ABCD Risk Questionnaire, and BBAQ (N = 62) Mdn (IQR) Minimum Maximum 3.00 (1.00) 1.00 7.00 7.00 (2.00) 4.00 8.00 12.00 32.00 18.00 (3.00) 8.00 24.00 Lack of Time 5.00 (2.00) 0.00 9.00 Social Influence 4.00 (3.00) 0.00 9.00 Lack of Energy 5.41 (1.68) b 2.00 9.00 Lack of Willpower 4.59 (2.40) b 0.00 9.00 Fear of Injury 3.85 (2.26) b 0.00 9.00 Lack of Skill 4.00 (3.00) 0.00 9.00 Lack of Resources 3.98 (1.99) b 0.00 9.00 RAPA 1 Score ABCD Risk Questionnaire Scores Knowledge Perceived Risk of Heart Attack/Stroke 22.18 (4.26) b Perceived Benefits and Intentions to Change BBAQ Subscale Scores a Note. RAPA 1 = Rapid Assessment of Physical Activity; ABCD = Attitudes and Beliefs about Cardiovascular Disease; BBAQ = Barriers to Being Active Questionnaire; IQR = interquartile range a N = 61. b Mean and standard deviation reported. CARDIOVASCULAR NURSES PHYSICAL ACTIVITY BEHAVIOR PRACTICES 59 Table 3 Comparison of ABCD Risk Questionnaire Scale Scores Between Nurses with High CVD Risk and Nurses with Low CVD Risk (N = 62) High Risk (n = 16) Low Risk (n = 46) Mdn 25%, 75% Mdn 25%, 75% Z p ES Knowledge 7.00 6.00, 7.00 6.50 5.00, 7.00 -1.01 .314 0.26 Perceived Risk of 21.50 18.25, 25.50 23.00 20.00, 25.00 -0.45 .651 0.11 M SD M SD t p ES 17.38 0.94 18.59 0.35 1.50 0.70 2.78 Heart Attack/Stroke Perceived Benefits and Intentions to Change Note. ES = effect size. CARDIOVASCULAR NURSES PHYSICAL ACTIVITY BEHAVIOR PRACTICES 60 Table 4 Comparison of Barriers to Being Active Questionnaire Subscale Scores between Nurses with High CVD Risk and Nurses with Low CVD Risk Among (N = 61) High Risk (n = 16) Low Risk (n = 45) M (SD) M (SD) t p ES Lack of Energy 5.56 (1.93) 5.36 (1.98) -0.42 .675 1.69 Lack of Willpower 4.75 (3.04) 4.53 (2.16) -0.26 .796 2.42 Fear of Injury 3.13 (2.47) 4.11 (2.15) -1.52 .135 2.23 Lack of Resources 3.38 (2.33) 4.20 (1.83) 1.44 1.55 1.97 Mdn (IQR) Mdn (IQR) Z p ES Lack of Time 5.50 (4) 5.00 (2) -0.84 .396 0.22 Social Influence 3.50 (4) 4.00 (2) -1.07 .286 0.28 Lack of Skill 3.00 (5) 5.00 (2) -1.09 .275 0.28 Note. CVD = cardiovascular disease; IQR = interquartile range; ES = effect size. CARDIOVASCULAR NURSES PHYSICAL ACTIVITY BEHAVIOR PRACTICES Table 5 Comparison of RAPA 1 Categories Between Nurses with a High CVD Risk and Nurses with a Low CVD Risk (N = 62) High Risk (n = 16) Low Risk (n = 46) N (%) N (%) p .717 Sedentary 3 (4.8) 0 Under-active 5 (8.1) 3 (4.8) Light Activities 17 (27.4) 5 (8.1) Under-active Regular 16 (25.8) 5 (8.1) 5 (8.1) 3 (4.8) Under-active Regular Active Note. RAPA 1 = Rapid Assessment of Physical Activity; CVD = cardiovascular disease. 61 CARDIOVASCULAR NURSES PHYSICAL ACTIVITY BEHAVIOR PRACTICES 62 Table 6 Hierarchical Logistic Regression Analysis on Recommendations of Physical Activity to Patients Based upon the Health Belief Model SE p OR 0 to 5 years -.63 1.03 .541 .53 6 to 10 years .59 1.31 .653 1.80 11 to 15 years -.17 .92 .850 .84 0 to 5 years -.99 1.18 .349 .37 6 to 10 years .13 1.39 .929 1.14 11 to 15 years -.05 .96 .867 .95 .41 .32 .197 1.51 0 to 5 years .12 1.65 .926 1.13 6 to 10 years -.43 1.95 .749 .65 Model 1: Modifying -2 Log Nagelkerke Likelihood R2 55.66 .03 Factors Characteristics Years as a Nurse a Model 2: Modifying 53.71 .08 Factors (All) Years as a Nurse a CVD Knowledge Model 3: Modifying and 37.42 .45 Belief Factors Years as a Nurse a CARDIOVASCULAR NURSES PHYSICAL ACTIVITY BEHAVIOR PRACTICES 11 to 15 years 63 .05 1.19 .829 1.05 1.09 .52 .027* 2.97 Lack of Skill .97 .43 .020* 2.65 Fear of Injury .19 .32 .594 1.21 Social Influence -.33 .41 .332 .72 Lack of Energy -.58 .35 .083 .56 CVD Knowledge Activity Barriers Note. SE = standard error; OR = odds ratio. CARDIOVASCULAR NURSES PHYSICAL ACTIVITY BEHAVIOR PRACTICES Appendix A Online Survey Questionnaire 64 CARDIOVASCULAR NURSES PHYSICAL ACTIVITY BEHAVIOR PRACTICES 65 Minimal Risk UIndy Study # 01450 Study Version: 1 Study Version Date: 6/4/2021 Informed Consent Form (ICF) Version: 1 ICF Version Date: 6/4/2021 INTERPROFESSIONAL HEALTH AND AGING STUDIES STUDY TITLE Cardiovascular Nurses Estimates of Their CVD Risk and Barriers to Exercise KEY INFORMATION FOR POTENTIAL RESEARCH PARTICIPANTS This survey targets nurses who work on cardiovascular units (CVU, IMCU, ICU, catheterization laboratory, and Cardiac Rehabilitation). This survey will be assessing personal cardiovascular risk factors and physical activity practices. Participant honesty is required, and participation is entirely voluntary. Consent is being sought for research purposes and there will be no personal identifiers utilized in this study. All information collected will remain confidential and secure with the investigator. The approximate survey completion time is 10-13 minutes. CONSENT TO PARTICIPATE IN RESEARCH STUDY Cardiovascular Nurses Estimates of Their CVD Risk and Barriers to Exercise CARDIOVASCULAR NURSES PHYSICAL ACTIVITY BEHAVIOR PRACTICES 66 Study Principal Investigator (PI): Heidi H. Ewen, PhD, FGSA, FAGHE ewenh@uindy.edu Co-Investigator: Tina Schmidt-McNulty, DHSc Candidate schmidtmcnultyt@uindy.edu UIndy Telephone: 317-791-4425 or 1-800-232-8634 x 4425 Why is this study being done? The purpose of this study is to investigate the perceived CVD risk factors of cardiovascular nurses and their beliefs in the value of physical activity practices. This study is being conducted for Ms. Schmidt-McNulty's doctoral dissertation. What will happen if I take part in this research study? If you volunteer to participate in this study, the researcher will ask you to do the following: Answer a survey concerning PRE-COVID lifestyle practices as honestly as possible. The survey will target nurses who work on cardiovascular units and have questions about cardiovascular risk factors, physical activity practices, and potential barriers. All responses will remain confidential and will not have any personal identifiers attached. How long will I be in the research study? Participation will take approximately 10-13 minutes. Are there any potential risks or discomforts that I can expect from this study? There are no anticipated risks or discomforts. Some questions may be personal in nature and cause feelings of embarrassment or discomfort. However, you may decline to answer any questions with which you are uncomfortable. Are there any potential benefits if I participate? You will not directly benefit from your participation in the research. However, your responses are valuable and may lead to benefits for the advancement of scientific knowledge and potential interventions or continuing education modules. Research interventions may be developed to CARDIOVASCULAR NURSES PHYSICAL ACTIVITY BEHAVIOR PRACTICES 67 encourage cardiovascular nurses self-health promotion habits to improve their physical activity habits and make positive lifestyle changes. Will information about me and my participation be kept confidential? This study results may be published in a scholarly book or journal, presented at professional conferences, or used for teaching purposes. However, only aggregate data will be used. Personal identifiers will not be used in any publication, presentation, or teaching materials. Will the data from my study be used in the future for other studies? It is possible that de-identified data from this study could be used for future research or shared with other researchers for use in studies without additional informed consent. De-identified means that any codes and personal information that could identify you will be removed before the data is shared. What are my rights if I take part in this study? You can choose whether or not you want to be in this study. Whatever decision you make, there will be no penalty to you and no loss of benefits to which you were otherwise entitled. You may refuse to answer any questions that you do not want to answer and still remain in the study. Who can I contact if I have questions about this study? The Research Team: If you have any questions, comments, or concerns about the research, you can talk to one of the researchers. Please contact: Heidi H. Ewen, Ph.D., FGSA, FAGHE Associate Professor, Interprofessional Health and Aging Studies University of Indianapolis, College of Health Sciences 1400 East Hanna Avenue, Indianapolis, IN 46227 Phone: (317) 791-4425 Email: ewenh@uindy.edu Tina Schmidt-McNulty, MS, CES, RN, DHSc Candidate Doctoral of Health Science Candidate, Interprofessional Health and Aging Studies Email: schmidtmcnultyt@uindy.edu CARDIOVASCULAR NURSES PHYSICAL ACTIVITY BEHAVIOR PRACTICES 68 The Director of the Human Research Protections Program (HRPP): If you have questions about your rights as a research participant, or you have concerns or suggestions and you want to talk to someone other than the researchers, you may contact the Director of the Human Research Protections Program, by either emailing hrpp@uindy.edu or calling 1 (317) 781-5774 or 1 (800) 232-8634 ext. 5774. Please read the informed consent in its entirety. If you agree with the information provided and would like to proceed with the survey, please choose "yes". If you do not agree or would not like to participate in the survey, please choose "no". Thank you for your time and consideration. We value your participation. Please read the informed consent in its entirety. If you agree with the information provided and would like to proceed with the survey, please choose "yes". If you do not agree or would not like to participate in the survey, please choose "no". Thank you for your time and consideration. We value your participation. Yes No Thank you for taking the time to read the information concerning the survey. We understand that your time is valuable and respect your decision to decline the survey at this time. Thank you for being a Healthcare Hero! CARDIOVASCULAR NURSES PHYSICAL ACTIVITY BEHAVIOR PRACTICES 69 Please verify that you are human. How old are you? (Please type age in years.) No An swer 8 Age in years What is your gender? Male Female Non-binary / third gender Prefer not to say What is your marital status? Single Married Separated 6 4 2 0 9 7 5 3 1 9 CARDIOVASCULAR NURSES PHYSICAL ACTIVITY BEHAVIOR PRACTICES Divorced Widowed From where did you learn about the study? Facebook Instagram Reddit Twitter Email Other Employment status: Full time Part time PRN Highest level of nursing achieved: LPN BSN MSN DNP 70 CARDIOVASCULAR NURSES PHYSICAL ACTIVITY BEHAVIOR PRACTICES Other Years as a licensed nurse: 0-5 years 6-10 years 11-15 years 15+ years In which country do you live? United States (Please enter which state.) Outside the United States (Canada, Mexico, etc.) On which unit do you work? ICU IMCU CVU Cath lab Cardiac rehab Other cardiovascular unit Other unit 71 CARDIOVASCULAR NURSES PHYSICAL ACTIVITY BEHAVIOR PRACTICES 72 This section has items asking about your personal health. How much do you weigh in pounds? (Ex. 145 lbs.) Decline Click to write Label 1 to A nswer 80 102 124 146 168 190 212 234 256 278 300 Weight in pounds How tall are you in feet and inches? Height in Feet Height in Inches This section contains a series of statements about cardiovascular disease risks. Please select either "true" or "false" in response. One of the main causes of heart attack and stroke is stress. True False Walking and gardening are considered types of exercise that can lower the risk of having a heart attack or stroke. CARDIOVASCULAR NURSES PHYSICAL ACTIVITY BEHAVIOR PRACTICES True False Moderately intense activity of 2.5 hours a week will reduce your chances of having a heart attack or stroke. True False People who have diabetes are at higher risk of having a heart attack or stroke. True False Managing your stress levels will help you to manage your blood pressure. True False Drinking high levels of alcohol can increase your cholesterol and triglyceride levels. True False 73 CARDIOVASCULAR NURSES PHYSICAL ACTIVITY BEHAVIOR PRACTICES HDL refers to "good" cholesterol, and LDL refers to "bad" cholesterol. True False A family history of heart disease is not a risk factor for high blood pressure. True False Please answer each item on a scale from strongly disagree to strongly agree. I feel I will suffer from a heart attack or stroke sometime during my life. Strongly disagree Disagree Agree Strongly agree Decline to answer 74 8/8/22, 4:38 PM Qualtrics Survey Software It is likely that I will suffer from a heart attack or stroke in the future. Strongly disagree Disagree Agree Strongly agree Decline to answer It is likely that I will have a heart attack or stroke some time during my life. Strongly disagree Disagree Agree Strongly agree Decline to answer There is a good chance that I will experience a heart attack or stroke in the next 10 years. Strongly disagree Disagree Agree Strongly agree Decline to answer My chances of suffering from a heart attack or stroke in the next 10 years are great. Strongly disagree Disagree 75/103 8/8/22, 4:38 PM Qualtrics Survey Software Agree Strongly agree Decline to answer It is likely I will have a heart attack or stroke because of my past and/or present behaviours. Strongly disagree Disagree Agree Strongly agree Decline to answer I am not worried that I might have a heart attack or stroke. Strongly disagree Disagree Agree Strongly agree Decline to answer https://uindy.co1.qualtrics.com/Q/EditSection/Blocks/Ajax/GetSurveyPrintPreview?ContextSurveyID =SV_8lb1Vll1AS0qSdo&ContextLibraryID=UR_d I am concerned about the likelihood of having a heart attack or stroke in the near future. Strongly disagree Disagree 76/103 8/8/22, 4:38 PM Qualtrics Survey Software Agree Strongly agree Decline to answer I am thinking about exercising at least 2.5 hours a week. Strongly disagree Disagree Agree Strongly agree Decline to answer I intend or want to exercise 2.5 hours a week. Strongly disagree Disagree Agree Strongly agree Decline to answer 77/103 8/8/22, 4:38 PM Qualtrics Survey Software When I exercise for at least 2.5 hours a week I am doing something good for the health of my heart. Strongly disagree Disagree Agree Strongly agree Decline to answer I am confident that I can maintain a healthy weight by exercising at least 2.5 hours a week within the next two months. Strongly disagree Disagree Agree Strongly agree Decline to answer I am not thinking about exercising for 2.5 hours a week. Strongly disagree Disagree Agree Strongly agree Decline to answer Increasing my exercise to at least 2.5 hours a week will decrease my chances of having a heart attack or stroke. Strongly disagree https://uindy.co1.qualtrics.com/Q/EditSection/Blocks/Ajax/GetSurveyPrintPreview?ContextSurveyID=SV_8lb1Vll1AS0qSdo&ContextLibraryID=UR_ 78/103 8/8/22, 4:38 PM Qualtrics Survey Software Disagree Agree Strongly agree Decline to answer Please check all that apply. You are a man older than 45 years. You are a woman older than 55 years. You smoke, or quit within the last 6 months. Your blood pressure is 140/90 mmHg or higher. You don't know your blood pressure. You take blood pressure medication. Your blood cholesterol level is > 200 mg/dL. You don't know your cholesterol level. You have a close blood relative who had a heart attack before the age of 55 (father or brother) or age 65 (mother or sister). You have a fasting plasma glucose greater than or equal to 126 mg/dL, known diabetes and/or an HbA1c greater than or equal to 6.5%. You have a known BMI greater than or equal to 30 kg/m2 or are more than 20 pounds overweight. You are physically inactive (i.e., you get <30 minutes of physical activity on at least 3 days per week.) None of the above are true. https://uindy.co1.qualtrics.com/Q/EditSection/Blocks/Ajax/GetSurveyPrintPreview?ContextSurveyID=SV_8lb1Vll1AS0qSdo&ContextLibraryID=UR_ 79/103 8/8/22, 4:38 PM Qualtrics Survey Software This section of questions concerns your physical activities. Please respond based upon your habits PRIOR to the COVID-19 pandemic. I rarely or never do any physical activities. Yes No Prefer not to answer I do some light or moderate physical activities, but not every week. (Light activity - heart beats slightly faster than normal; can talk and sing. Moderate activity - heart beats faster than normal; Can talk, but not sing.) Yes No Prefer not to answer I do some light physical activity every week. Light activities: Your heart beats slightly faster than normal; you can talk and sing. (i.e. walking leisurely, stretching, vacuuming or light yard work.) Yes No Prefer not to answer I do moderate physical activities every week, but less than 30 minutes a day or 5 days a week. https://uindy.co1.qualtrics.com/Q/EditSection/Blocks/Ajax/GetSurveyPrintPreview?ContextSurveyID=SV_8lb1Vll1AS0qSdo&ContextLibraryID=UR_ 80/103 8/8/22, 4:38 PM Qualtrics Survey Software Moderate activities: Your heart beats faster than normal; you can talk, but not sing. (i.e. Walking fast, aerobics class, strength training, swimming gently). Yes No Prefer not to answer I do vigorous physical activities every week, but less than 20 minutes a day or 3 days a week. Vigorous activities: Your heart rate increases a lot; you can't talk or your talking is broken up by large breaths. (i.e. stair machine, jogging or running, tennis, racquetball, pickleball or badminton). Yes No Prefer not to answer I do 30 minutes or more a day of moderate physical activities, 5 or more days a week. Yes No Prefer not to answer I do 20 minutes or more a day of vigorous physical activities, 3 or more days a week. Yes No Prefer not to answer https://uindy.co1.qualtrics.com/Q/EditSection/Blocks/Ajax/GetSurveyPrintPreview?ContextSurveyID=SV_8lb1Vll1AS0qSdo&ContextLibraryID=UR_ 81/103 8/8/22, 4:38 PM Qualtrics Survey Software I do activities to increase muscle strength, such as lifting weights or calisthenics, once a week or more. Yes No Prefer not to answer I do activities to improve flexibility, such as stretching or yoga, once a week or more. Yes No Prefer not to answer Beliefs and Barriers to Exercise How likely are you to say, my day is so busy now, I just don't think I can make the time to include physical activity in my regular schedule. Very likely Somewhat likely Somewhat unlikely Very unlikely Prefer not to answer How likely are you to say, none of my family members or friends like to do anything active, so I don't have a chance to exercise. Very likely Somewhat likely Somewhat unlikely https://uindy.co1.qualtrics.com/Q/EditSection/Blocks/Ajax/GetSurveyPrintPreview?ContextSurveyID=SV_8lb1Vll1AS0qSdo&ContextLibraryID=UR_ 82/103 8/8/22, 4:38 PM Qualtrics Survey Software Very unlikely Prefer not to answer How likely are you to say, I'm just too tired after work to get any exercise. Very likely Somewhat likely Somewhat unlikely Very unlikely Prefer not to answer How likely are you to say, I've been thinking about getting more exercise, but I just can't seem to get started. Very likely Somewhat likely Somewhat unlikely Unlikely Prefer not to answer How likely are you to say, I'm getting older so exercise can be risky. Very likely Somewhat likely Somewhat unlikely Unlikely Prefer not to answer https://uindy.co1.qualtrics.com/Q/EditSection/Blocks/Ajax/GetSurveyPrintPreview?ContextSurveyID=SV_8lb1Vll1AS0qSdo&ContextLibraryID=UR_ 83/103 8/8/22, 4:38 PM Qualtrics Survey Software How likely are you to say, I don't get enough exercise because I have never learned the skills for any sport. Very likely Somewhat likely Somewhat unlikely Unlikely Prefer not to answer How likely are you to say, I don't have access to jogging trails, swimming pools, bike paths, etc. Very likely Somewhat likely Somewhat unlikely Unlikely Prefer not to answer How likely are you to say, physical activity takes too much time away from other commitments - time, work, family, etc. Very likely Somewhat likely Somewhat unlikely Very unlikely Prefer not to answer How likely are you to say, I'm embarrassed about how I will look when I exercise with others. Very likely https://uindy.co1.qualtrics.com/Q/EditSection/Blocks/Ajax/GetSurveyPrintPreview?ContextSurveyID=SV_8lb1Vll1AS0qSdo&ContextLibraryID=UR_ 84/103 8/8/22, 4:38 PM Qualtrics Survey Software Somewhat likely Somewhat unlikely Very unlikely Prefer not to answer How likely are you to say, I don't get enough sleep as it is. I just couldn't get up early or stay up late to get some exercise. Very likely Somewhat likely Somewhat unlikely Very unlikely Prefer not to answer https://uindy.co1.qualtrics.com/Q/EditSection/Blocks/Ajax/GetSurveyPrintPreview?ContextSurveyID=SV_8lb1Vll1AS0qSdo&ContextLibraryID=UR_ 85/103 8/8/22, 4:38 PM Qualtrics Survey Software How likely are you to say, it's easier for me to find excuses not to exercise than to go out to do something. Very likely Somewhat likely Somewhat unlikely Very unlikely Prefer not to answer How likely are you to say, I know of too many people who have hurt themselves by overdoing it with exercise. Very likely Somewhat likely Somewhat unlikely Very unlikely Prefer not to answer How likely are you to say, I really can't see learning a new sport at my age. Very likely Somewhat likely Somewhat unlikely 8/8/22, 4:38 PM Qualtrics Survey Software How likely are you to say, it's just too expensive. You have to take a class or join a club or buy the right equipment. Very likely Somewhat likely Somewhat unlikely Very unlikely Prefer not to answer How likely are you to say, my free times during the day are too short to include exercise. Very likely Somewhat likely Somewhat unlikely Very unlikely Prefer not to answer How likely are you to say, my usual social activities with family and friends do not include physical activity. Very likely Somewhat likely Somewhat unlikely 8/8/22, 4:38 PM Qualtrics Survey Software How likely are you to say, I'm too tired during the week and I need the weekend to catch up on my rest. Very likely Somewhat likely Somewhat unlikely Very unlikely Prefer not to answer How likely are you to say, I want to get more exercise, but I just can't seem to make myself stick to anything. Very likely Somewhat likely Somewhat unlikely Very unlikely Prefer not to answer How likely are you to say, I'm afraid I might injury myself or have a heart attack. Very likely Somewhat likely Somewhat unlikely CARDIOVASCULAR NURSES PHYSICAL ACTIVITY BEHAVIOR PRACTICES How likely are you to say, I'm not good enough at any physical activity to make it fun. Very likely Somewhat likely Somewhat unlikely Very unlikely Prefer not to answer How likely are you to say, if we had exercise facilities and showers at work, then I would be more likely to exercise. Very likely Somewhat likely Somewhat unlikely Very unlikely Prefer not to answer Care for Cardiac Patients and Discharge Recommendations Do you encourage or recommend physical activity to the patients you care for? Always Often Sometimes 89 CARDIOVASCULAR NURSES PHYSICAL ACTIVITY BEHAVIOR PRACTICES Rarely Never What physical activity recommendations do you generally offer to patients? In which situation or condition would you NOT advocate exercise to patients? Are there any other questions you feel we should have asked on this survey, but did not? Powered by Qualtrics 90 CARDIOVASCULAR NURSES PHYSICAL ACTIVITY BEHAVIOR PRACTICES Appendix B Standardized Assessments and Questionnaires 91 CARDIOVASCULAR NURSES PHYSICAL ACTIVITY BEHAVIOR PRACTICES AHA/ACSM Health/Fitness Facility Pre-participation Screening Questionnaire 92 CARDIOVASCULAR NURSES PHYSICAL ACTIVITY BEHAVIOR PRACTICES 93 CARDIOVASCULAR NURSES PHYSICAL ACTIVITY BEHAVIOR PRACTICES The ABCD Risk Questionnaire and Scoring Guide The ABCD Risk Questionnaire and scoring guide Scale Knowledge Higher sum score = more knowledgeable / more correct about having a heart attack or stroke Items 1. 2. 3. Coding One of the main causes of heart attack and stroke is stress. Correct Answers: Walking and gardening are considered types of exercise that can lower the risk of having a heart attack or stroke. Q2-T Moderately intense activity of 2 hours a week will reduce your chances of having a heart attack or stroke. Q1-T Q3-T Q4-T Q5-T Q6-T 4. People who have diabetes are at higher risk of having a heart attack or stroke. Q7-T Q8-F Perceived Risk of Heart Attack/Stroke Higher sum score = higher perception of risk of having a heart attack or stroke 5. Managing your stress levels will help you to manage your blood pressure. 6. Drinking high levels of alcohol can increase your cholesterol and triglyceride levels. 7. HDL refers to good cholesterol, and LDL refers to bad cholesterol. 8. A family history of heart disease is not a risk factor for high blood pressure. 9. I feel I will suffer from a heart attack or stroke sometime during my life. T= True F= False Correct: Score = 1, Incorrect or Dont Know: Score = 0. 1=Strongly disagree; 2 = disagree; 3 = agree; 4 = strongly agree; N/A = 0 10. It is likely that I will suffer from a heart attack or stroke in the future. 1=Strongly disagree; 2 = disagree; 3 = agree; 4 = strongly agree; N/A = 0 11. It is likely that I will have a heart attack or stroke some time during my life. 1=Strongly disagree; 2 = disagree; 3 = agree; 4 = strongly agree; N/A = 0 12. There is a good chance I will experience a heart attack or stroke in the next 10 years. 1=Strongly disagree; 2 = disagree; 3 = agree; 4 = strongly agree; N/A = 0 94 CARDIOVASCULAR NURSES PHYSICAL ACTIVITY BEHAVIOR PRACTICES 13. My chances of suffering from a heart attack or stroke in the next 10 years are great. 1=Strongly disagree; 2 = disagree; 3 = agree; 4 = strongly agree; N/A = 0 14. It is likely I will have a heart attack or stroke because of my past and/or present behaviours. 1=Strongly disagree; 2 = disagree; 3 = agree; 4 = strongly agree; N/A = 0 15. I am not worried that I might have a heart attack or stroke. Reverse coded 4=Strongly disagree; 3 = disagree; 2 = agree; 1 = strongly agree; N/A = 0 Perceived Benefits and Intentions to Change 16. I am concerned about the likelihood of having a heart attack or stroke in the near future. 1=Strongly disagree; 2 = disagree; 3 = agree; 4 = strongly agree; N/A = 0 17. I am thinking about exercising at least 2 hours a week. 1=Strongly disagree; 2 = disagree; 3 = agree; 4 = strongly agree; N/A = 0 18. I intend or want to exercise at least 2 Higher average hours a week. score = Higher perceived benefits of diet and exercise 19. When I exercise for at least 2 hours a week and higher I am doing something good for the health perceived readiness of my heart. for change in regards to exercise 20. I am confident that I can maintain a healthy behaviour weight by exercising at least 2 hours a week within the next two months. 21. I am not thinking about exercising for 2 hours a week. 1=Strongly disagree; 2 = disagree; 3 = agree; 4 = strongly agree; N/A = 0 1=Strongly disagree; 2 = disagree; 3 = agree; 4 = strongly agree; N/A = 0 1=Strongly disagree; 2 = disagree; 3 = agree; 4 = strongly agree; N/A = 0 Reverse coded 4=Strongly disagree; 3 = disagree; 2 = agree; 1 = strongly agree; N/A = 0 22. When I eat at least five portions of fruit and vegetables a day I am doing something good for the health of my heart. 1=Strongly disagree; 2 = disagree; 3 = agree; 4 = strongly agree; N/A = 0 23. Increasing my exercise to at least 2 hours a week will decrease my chances of having a heart attack or stroke. 1=Strongly disagree; 2 = disagree; 3 = agree; 4 = strongly agree; N/A = 0 95 CARDIOVASCULAR NURSES PHYSICAL ACTIVITY BEHAVIOR PRACTICES Healthy Eating Intentions 24. I am confident that I can eat at least five portions of fruit and vegetables per day within the next two months. Higher average score = Higher perceived readiness 25. I am thinking about eating at least five for change with portions of fruit and vegetables a day. regard to health dietary behaviour 26. I am not thinking about eating at least five portions of fruit and vegetables a day. 1=Strongly disagree; 2 = disagree; 3 = agree; 4 = strongly agree; N/A = 0 1=Strongly disagree; 2 = disagree; 3 = agree; 4 = strongly agree; N/A = 0 Reverse coded 4=Strongly disagree; 3 = disagree; 2 = agree; 1 = strongly agree; N/A = 0 The Attitudes and Beliefs about Cardiovascular Disease (ABCD) Risk Questionnaire is licensed under the Creative Commons Attribution 4.0 International License. 96 CARDIOVASCULAR NURSES PHYSICAL ACTIVITY BEHAVIOR PRACTICES Rapid Assessment of Physical Activity 97 CARDIOVASCULAR NURSES PHYSICAL ACTIVITY BEHAVIOR PRACTICES 98 CARDIOVASCULAR NURSES PHYSICAL ACTIVITY BEHAVIOR PRACTICES 99 CARDIOVASCULAR NURSES PHYSICAL ACTIVITY BEHAVIOR PRACTICES 100 CARDIOVASCULAR NURSES PHYSICAL ACTIVITY BEHAVIOR PRACTICES Barriers to Being Active Quiz 101 CARDIOVASCULAR NURSES PHYSICAL ACTIVITY BEHAVIOR PRACTICES 102  ...

... An Intervention for Mental Health Issues in College-Student Athletes: A COVID-19 Pandemic Quantitative Study Submitted to the Faculty of the College of Health Sciences University of Indianapolis In partial fulfillment of the requirements for the degree Doctor of Health Science By: Erik Brown, MS, LAT, ATC, CES, PES Copyright May 19, 2022 By: Erik Brown, MS, LAT, ATC, CES, PES All rights reserved Approved by: Jessica Emlich Jochum, PhD, LAT, ATC Committee Chair ______________________________ Elizabeth S. Moore, PhD Committee Member ______________________________ Chelsi Day, PsyD Committee Member ______________________________ Accepted by: Laura Santurri, PhD, MPH, CPH Director, DHSc Program Chair, Interprofessional Health & Aging Studies University of Indianapolis ______________________________ Stephanie Kelly, PT, PhD Dean, College of Health Sciences University of Indianapolis ______________________________ INTERVENTION AND MENTAL HEALTH IN STUDENT-ATHLETES An Intervention for Mental Health Issues in College-Student Athletes: A COVID-19 Pandemic Quantitative Study Erik R. Brown University of Indianapolis 1 INTERVENTION AND MENTAL HEALTH IN STUDENT-ATHLETES 2 Abstract The COVID-19 pandemic has wreaked havoc internationally, domestically, and more specifically, it has significantly affected collegiate student-athletes, since the spring of 2020. The purpose of this study was to determine if a student-athlete focused mindfulness intervention could have an impact on mental health concerns during the COVID-19 pandemic return to sports in 36 Division I and Division II womens basketball student-athletes. A single group pretestposttest study design utilizing the DASS-21 and two mindfulness interventions was conducted between March 2021 and January 2022. Results showed that participants had significantly less stress post-intervention compared to pre-intervention, p = .019. Additionally, there was a statistically significant difference in stress change scores by psychologist history, p = .031. Those who had not seen a psychologist had significantly greater change (improvement) in stress scores than those who had a history of seeing a psychologist. In addition, there was a significant difference in change scores between students who were quarantined and those who were not quarantined, p = .042. Those who were quarantined had greater change (improvement) in their stress scores relative to those who were not quarantined. Future research should look at mental health interventions in conjunction with athletic performance, other genders and over the span of one basketball season. Additionally, following up with abnormal mental health screenings from pre-participation exams and implementing mindfulness interventions could be beneficial. Implications for mindfulness interventions should be carefully selected, administered, and can be used to help smaller institutions with limited mental health resources in stressful/ non-pandemic times. Keywords: mindfulness, COVID-19, pandemic, DASS-21, depression, anxiety, stress, student-athletes, womens basketball INTERVENTION AND MENTAL HEALTH IN STUDENT-ATHLETES 3 Acknowledgements I would like to express my thanks and gratitude for all those that have supported me along this long journey. I could have not done this without the support of my family, friends, athletic trainers, coaches, and colleagues. I would also like to thank my committee. Thank you to Dr. Jochum, Dr. Moore, and Dr. Day for your patience, understanding, and guidance throughout this process. INTERVENTION AND MENTAL HEALTH IN STUDENT-ATHLETES 4 Table of Contents Title Page ........................................................................................................................................ 1 Abstract ........................................................................................................................................... 2 Acknowledgements ......................................................................................................................... 3 Table of Contents ............................................................................................................................ 5 Chapter 1 Introduction .................................................................................................................... 8 Problem Statement ...................................................................................................................... 8 Purpose Statement ..................................................................................................................... 10 Significance of the Study .......................................................................................................... 10 Chapter 2: Literature Review ........................................................................................................ 11 Mental Health Issues ................................................................................................................. 11 Mindfulness Intervention .......................................................................................................... 13 Mindfulness and Athletes ......................................................................................................... 14 Mindfulness and Basketball Athletes........................................................................................ 15 Chapter 3: Method ........................................................................................................................ 17 Study Design ............................................................................................................................. 17 Participants ................................................................................................................................ 17 Data ........................................................................................................................................... 17 Instruments ................................................................................................................................ 18 Procedures ................................................................................................................................. 20 Recruitment ........................................................................................................................... 20 Informed Consent.................................................................................................................. 20 INTERVENTION AND MENTAL HEALTH IN STUDENT-ATHLETES 5 Data Collection ..................................................................................................................... 21 Intervention ........................................................................................................................... 22 Data Management ................................................................................................................. 23 Data Analysis ............................................................................................................................ 23 Chapter 4: Results ......................................................................................................................... 24 Pre-Intervention and Post-Intervention Comparisons By DASS-21 Subscales ........................ 26 Comparison of DASS-21 Subscale Change Scores by Student Demographics, Characteristics and COVID-19 History .................................................................................... 26 Correlations Between DASS-21 Subscale Change Scores and Age and Missing Playing Days ............................................................................................................................. 27 Chapter 5: Discussion and Conclusion ......................................................................................... 27 Demographics and COVID-19 History .................................................................................... 28 Pre-Intervention and Post-Intervention Comparisons ............................................................... 29 Comparisons of Severity Based on Subscale Scores ................................................................ 30 DASS-21 Subscale Change Scores ........................................................................................... 31 Limitations and Barriers to the Study ....................................................................................... 33 Recommendations for Future Research .................................................................................... 36 Conclusion ................................................................................................................................ 37 References ..................................................................................................................................... 39 INTERVENTION AND MENTAL HEALTH IN STUDENT-ATHLETES 6 List of Tables Table 1: Descriptive Statistics for Participant Demographics and COVID-19 History ............... 50 Table 2: Descriptive Statistics for Age and Missed Playing Days ............................................... 52 Table 3: Pre-Intervention and Post-Intervention Comparisons By DASS-21 Subscale Scores ... 53 Table 4: Comparison of Frequency and Percentage of Severity Categories for DASS-21 Subscales ................................................................................................................................. 54 Table 5: Comparison of Participant Demographics and COVID-19 History by DASS-21 Subscale Change Score ........................................................................................................... 55 Table 6: Correlations of Age and Missed Playing Days with DASS-21 Subscale Change Scores ...................................................................................................................................... 57 Table 7: Comparison of Participant Demographics and COVID-19 History Between Participants Who Completed the Study and Those Who Did Not Complete the Study..........58 Table 8: Comparison of Participant Age and Missed Playing Days Between Participants Who Completed the Study and Those Who Did Not Complete the Study..............................60 INTERVENTION AND MENTAL HEALTH IN STUDENT-ATHLETES 7 List of Appendices Appendix A: DASS-21 questionnaire..61 Appendix B: Email announcements.............63 Appendix C: Video screenshots...68 INTERVENTION AND MENTAL HEALTH IN STUDENT-ATHLETES 8 An Intervention for Mental Health Issues in College-Student Athletes: A COVID-19 Pandemic Quantitative Study Student-athletes are prone to stress due to the pressure of juggling academics, sports, and social demands (Shannon et al., 2019). They have to manage the pressure of academics while performing at a high-level in their sport (Moreland et al., 2018; Sherry & Zeller, 2014). Additionally, anxiety of performing at a high level can distress student-athletes (Mistretta et al., 2017). The demands and pressures faced by them can negatively affect their mental status. Depression has been noted to afflict around 20% of student-athletes (Sudano & Miles, 2017). Furthermore, student-athletes are more likely than non-athletes to be afflicted by substance abuse problems, eating and mood disorders, sleep disturbances, and even suicide ideation (Moreland et al., 2018; Sudano & Miles, 2017). Despite their increased risk of mental health issues, college student-athletes are unlikely to acknowledge or seek mental health treatment (Moreland et al., 2018; Sudano & Miles, 2017). Consequently, there are few programs in place at colleges and universities to address student-athlete mental health needs. There needs to be more mental health interventions for student-athletes and subsequently more buy-in from college administrators, coaches, and athletic trainers in providing student-athletes access to interventions. Problem Statement The National Athletic Trainers Association (NATA) recommends their constituents (athletic trainers) and stakeholders (coaches, administrators, mental health services, student affairs, and general counsel) recognize signs and symptoms of psychological problems among their athletes and refer those student-athletes to mental health services. They also need to construct and implement better educational plans, policies, and procedures than are currently available (Neal et al., 2013). Policies and procedures may include properly identifying and INTERVENTION AND MENTAL HEALTH IN STUDENT-ATHLETES 9 recognizing student-athletes with mental issues and appropriately referring these individuals to mental health services (Neal et al., 2013). In response to this, some athletic departments have implemented policies and procedures that require student-athletes (upon recommendation) to have mental health screenings as part of their pre-participation physical exams via their sports medicine staff (Kaminski, 2016; Kroshus, 2016; Moreland et al., 2018; Sudano et al., 2017). The National Collegiate Athletic Association (NCAA) notes the need to address mental health concerns as an intervention to address the whole person and have recommended increased hiring of sport mental health providers (Kaminski, 2016). Most student-athletes can, at minimum, seek mental health services at their institutions counseling center, but far fewer have access to specialists in athlete mental health. Help seeking behaviors in student-athletes are further complicated as some student-athletes may ignore or underreport their mental health concerns due to the stigma associated with such issues (Cox et al., 2017). The coronavirus pandemic (COVID-19) has disrupted college campuses and athletics (Sahu, 2020). In response to the pandemic, winter and spring 2020 championships were cancelled. During this time, student-athletes reported a variety of psychological dysfunction, disturbances, and/or distress (The University of North Texas Center for Sport Psychology and Performance Excellence, 2020). Upon return to sport during the pandemic, student-athletes may have suffered additional psychological distress due to their altered participation and training schedules in their respective sport. Because of the novel nature of COVID-19, it is unknown whether mental health interventions such as mindfulness could have positively impacted studentathletes mental health post-COVID-19 sports play restrictions and adjusted/altered schedules. INTERVENTION AND MENTAL HEALTH IN STUDENT-ATHLETES 10 Purpose Statement The purpose of this study was to determine if a student-athlete focused mindfulness intervention could have an impact on mental health concerns during the COVID-19 pandemic return to sports. Specifically, this study addressed the following research question: Does a mental health intervention improve self-reported mental health concerns in NCAA Division I and Division II womens basketball student-athletes during their COVID-19 pandemic return to sport related activity? To answer the research question, the following objective was addressed: To determine if a mindfulness intervention provided to womens basketball student-athletes during the COVID-19 pandemic return to sport related activity would improve mental health as measured with the Depression, Anxiety, and Stress Scale-21 (DASS-21) via subscale scores, subscale change scores, and severity based upon the DASS-21 subscale scores. Significance of the Study If it was found that a mindfulness intervention given to student-athletes during the COVID-19 pandemic can decrease their self-reported mental health concerns, it would provide a resource athletic department personnel could use to meet student-athlete mental health needs. Identifying mental health concerns and applying an intervention may not only improve college student-athletes mental health, but it may also result in better athletic performance. If a mindfulness intervention improves student-athlete mental health under an extremely difficult situation like the COVID-19 pandemic, then the intervention may also be effective in less stressful times. INTERVENTION AND MENTAL HEALTH IN STUDENT-ATHLETES 11 Literature Review Mental Health Issues It was suggested that when students returned to college campuses in the fall of 2020, after stay at home orders were lifted and COVID-19 sanctions were modified upon Centers for Disease Control (CDC) guidelines, there would be an increased need for counseling and mental health services (Sahu, 2020). A survey conducted in mid-July 2020 confirmed an increased prevalence of depression (Redden, 2020). There are many factors that could have resulted in an increase in depression among college students such as financial stress the COVID-19 pandemic placed on them. Students were faced with the closure of college campuses, leaving them to have to find housing, buy meals, and find resources needed to adapt to online learning. Stress was compounded with concerns of how long the pandemic would last and social injustices that were experienced by students of color with the discriminatory availability of treatment and vaccines for COVID-19 (Cao et al., 2020; Redden, 2020). All of the stresses related to COVID-19 left students vulnerable to mental health issues upon their return to campus. Unfortunately, many students (as of July 2020) reported difficulty accessing mental health care (Redden, 2020). Under usual circumstances, student-athletes face an inordinate amount of pressure and stressors related to balancing school, sport, and social life (Egan, 2019; Moreland et al., 2018; Ryan et al., 2018; Sherry & Zeller, 2014). It was supposed that stressors experienced by studentathletes would be further exacerbated when they return to sport after the COVID-19 mandatory hiatus in collegiate sports. With the need to address the repercussions of COVID-19, the importance of addressing mental health issues in college student-athletes continues to gain momentum (Hong et al., 2018). COVID-19 significantly disrupted college athletics and ultimately cancelled winter and spring 2020 championships. During this time student-athletes reported a variety of mental health concerns (depression, psychological distress, disordered INTERVENTION AND MENTAL HEALTH IN STUDENT-ATHLETES 12 eating, risky drinking, body dissatisfaction, sleep issues, and being dissatisfied with life) (The University of North Texas Center for Sport Psychology and Performance Excellence, 2020). Upon return to campus, students faced the cancelations or postponements of division or conference games and tournaments, which led to changes in their athletics routines such as practices, games, strength and conditioning sessions, and other countable related activities (CARAs). Andreato et al. (2020) noted that student-athletes might worry about their athletic performance when they return to school and could have an increase in tension and anxiety due to the routine change in their respective sport. Historically, student-athletes were thought to experience fewer mental health issues (Br & Markser, 2013). Lack of disclosure by student-athletes may have contributed to this myth (Br & Markser, 2013; Daniel 2018; Kaminski, 2016; Moreland et al., 2018). The stigma around having mental health issues and concerns about reactions of coaches and/or teammates may play a substantial role in why student-athletes tend to underreport mental health issues (Sudano & Miles, 2017). Mental health prevalence data for college student-athletes, specifically depression, shows continued need to investigate and understand their mental health concerns to more fully understand their needs and how to provide support (Cox et al., 2017). While underreported mental health issues have been a concern, student-athletes have begun opening up about mental health, which has allowed greater focus on effective interventions. Upwards of 33% of NCAA Division I student-athletes reported symptoms of depression and student-athletes across all divisions are just as likely to report depressive symptoms as their non-athlete peers (Cox, et al., 2017; Gorczynski et al., 2017). Female college basketball players report pressure to succeed athletically, while at the same time they also fear injury (Sherry & Zeller, 2014) and pain that follows an injury (Rizeanu & Bratu, 2018). Higher INTERVENTION AND MENTAL HEALTH IN STUDENT-ATHLETES 13 levels of depression and anxiety can lead to higher levels of pain perception. (Rizeanu & Bratu, 2018). Identification of anxiety and depression followed by early intervention can decrease perceived pain and help with future injury prevention (Rizeanu & Bratu, 2018). Because of the risks associated with playing sports, injuries, and other pressures on student-athletes, there is a need to focus on the mental health of this population. Research regarding student-athlete mental health has been ongoing for decades and it continues to gain interest. Previous and continued research sets the stage for exploration in college student-athletes and mental health interventions; specifically, an evidence-based, whole-person management intervention addressing depression, anxiety, and stress in college athletics. A specific whole-person management intervention that has gained traction recently is mindfulness. Mindfulness Intervention Mindfulness, developed by Jon Kabat-Zinn in 1979 for chronic pain patients, has been defined as a state of being nonjudgmentally aware in the present moment (Janssen et al., 2018; Sharma & Rush, 2014; Wielgosz et al., 2019). Mindfulness-based interventions (MBIs) train a person to be aware of moments and feelings, enhancing their ability to focus their attention and concentration on in the moment experience rather than allowing feelings and thoughts to take precedent (Rthlin et al., 2016). Mindfulness-based training is considered a whole person management intervention and is gaining momentum in managing mental health issues such as depression, anxiety, and stress and has been found to improve overall well-being (Shannon et al., 2019). In a recent study, Sampath et al. (2019) utilized the DASS-21 to identify depression, anxiety, stress and the Five Facet Mindfulness Questionnaire (FFMQ) to investigate if mindfulness improved the well-being of medical students. They found mindfulness was associated with significantly lower levels of depression and stress (Sampath, 2019). INTERVENTION AND MENTAL HEALTH IN STUDENT-ATHLETES 14 Mindfulness-based interventions can also help with other complex psychopathologies such as addictive behaviors, post-traumatic stress disorder (PTSD), and pain disorders (Gordon et al., 2015; Shonin et al., 2013). Mindfulness-based interventions have become more popular in recent years with over 75% of mental health practitioners utilizing this technique in the United Kingdom and over 2 million adults in the United States using mindfulness meditation in 2012 (Morone et al., 2017; Shonin et al., 2013). Mindfulness and Athletes Mindfulness techniques have been used with college student-athletes to teach them to focus their attention on feelings, sensations, thoughts, and emotions occurring in their body as they are happening (Chen et al., 2019; Mistretta et al., 2017; Rthlin et al., 2016). MBIs have been shown to reduce negative emotions, reduce perceived stress, reduce the potential for injury, increase flow, improve satisfaction with life, and reduce worry (Glass et al., 2019; Petterson & Olson, 2017). Mindfulness was initially introduced into athletics via an acceptance and commitment approach (Gardner & Moore, 2004). This approach targeted the development of nonjudgmental present-moment acceptance of present feelings and thoughts (Gardner & Moore, 2004). Since then, techniques used to train athletes in mindfulness have included yoga, various forms of meditation, workshops, mediators, and breathing exercises (Bhlmayer et al., 2017; Chen et al., 2019; Goodman et al., 2014; Rthlin, et al., 2016; Shannon et al., 2019). For example, yoga interventions have been shown to increase mindfulness and decrease stress (Goodman et.al, 2014). There are many reasons why mental health interventions are important to student-athletes and athletics in general. Athletes at all levels experience mental health concerns as a result of a stressful lifestyle, training loads, injuries, and competitions, which can affect athletic INTERVENTION AND MENTAL HEALTH IN STUDENT-ATHLETES 15 performance (Schinke et at, 2018). This supports the use of appropriate evidence-based psychological interventions pre-performance, during performance, and after performance (Schinke et al., 2018). Psychological skills training (self-talk, imagery, goal-setting, and arousal control) has led to an increase in athletic performance when implemented and sustained daily over the course of weeks while also being combined with additional mindfulness intervention programs such as Mindfulness-Acceptance-Commitment, Acceptance and Commitment Therapy, and Mindfulness-Based Stress Reduction (Rthlin et al., 2016). Interestingly, an internet-based mental health intervention can also be utilized in athletes to reduce stigma, increasing mental health literacy, and to improve relations with providers (Gulliver et al., 2012). Mental health interventions are not only beneficial to student-athletes; they can also benefit the stakeholders (coaches, administrators, sports medicine personnel) of athletic departments (Aaron et al., 2020). A mindfulness-based intervention can be implemented across an entire athletic department and ultimately strengthen an organization (Aaron et al., 2020). While student-athletes suffer from mental health issues at the same rates as their nonathlete peers with stressors related to the demands of academics, athletics, and/or their social lives, the COVID-19 pandemic has made these issues even more challenging to manage. Because of these stressors, mindfulness interventions may be more useful than ever before. Mindfulness and Basketball Athletes Mindfulness interventions have been shown to reduce anxiety, stress, and/or depression in basketball players (Burns, 2016; Dehghani et al., 2018; Rachbach, 2019; Vidic et al., 2016; Wolch et al., 2020). Mindfulness and meditation interventions can lead to performance enhancement, decrease in sport anxiety and experiential avoidance, and decreased stress (Burns, 2016; Dehghani et al., 2018; Vidic et al., 2016). Mindfulness-training programs can also improve INTERVENTION AND MENTAL HEALTH IN STUDENT-ATHLETES 16 mental resilience and emotional intelligence among amateur basketball players (Ajilchi et al., 2019). Specifically, on the basketball court, mindfulness-based interventions can be used to help with free-throws and shooting slumps (Rachbach, 2019; Wolch et al., 2020). Brief mindfulness interventions have actually lowered anxiety in high-pressure basketball situations, such as attempting a free-throw (Wolch et al., 2020). Also, a mindfulness-based intervention can assist Division I college mens basketball players when they experience situations like a shooting slump (Rachbach, 2019). Shooting slump is a term used in basketball to define deficits in athletic performance when issues pertaining to depression, stress, and anxiety go unmanaged i.e. mental clutter (Rachbach, 2019). The existing literature and gaps in the research provide support for the current study. Current literature has examined mental health, mindfulness interventions, mindfulness and student-athletes/athletes, and mindfulness and basketball student-athletes/athletes. Previous literature provides a foundation to support college student-athletes capacity to overcome mental health struggles given the appropriate environment, tools, and resources such as mindfulnessbased interventions in the team environment. The data has provided insight into the concerns of student-athletes and opportunity for continued research related to useful interventions, particularly in Division I mens basketball. No current literature exists using the DASS-21 assessment tool and MBIs in the identified study population of Division I and Division II womens college basketball during the COVID-19 pandemic. INTERVENTION AND MENTAL HEALTH IN STUDENT-ATHLETES 17 Method Study Design This was a quasi-experimental study using a single group pretest-posttest design to see if a mindfulness intervention would improve mental health issues (depression, anxiety, and/or stress) in Division I and Division II collegiate womens basketball players. Data for this study were collected online using Qualtrics (Qualtrics, Provo, UT), an online survey platform. The study took place from March 2021 to January 2022. Prior to data collection, the study was approved by the institutional review board at the University of Indianapolis. Participants Participants were NCAA Division I and Division II collegiate women basketball players. Inclusion criteria for this study were: undergraduate scholarship and non-scholarship women basketball student-athletes, those who had extra years of eligibility due to being redshirted, and graduate transfers (fifth year seniors). Participants who quit the team or were asked to not be a member of the team, and those who became academically ineligible during the study were removed from the study. Womens basketball student-athletes who played at a community college, junior college, or a college that was a member of the National Association of Intercollegiate Athletics (NAIA), NCAA Division III, were excluded. Student-athletes under 18 years of age were excluded from the study. An a priori sample size estimation was calculated using G*Power 3.1 (Faul et al., 2007). Based on conducting a paired t test, with the following parameters, two-tailed, effect size of 0.45, alpha of .05, and power of .80, the estimated minimum sample size required was 40. Data Data were collected online at two different time periods, pre-intervention and postintervention. Demographic data collected prior to the intervention included: age (years), race INTERVENTION AND MENTAL HEALTH IN STUDENT-ATHLETES 18 (American Indian, Native, Black or African American, Asian, Hispanic or Latino, Native Hawaiian, other Pacific Islander, White or Caucasian, other race, refused answer, unknown), and student classification (freshman, redshirt freshman, sophomore, redshirt sophomore, junior, redshirt junior, senior, redshirt senior, and graduate transfer). Data on injury history was also collected pre-intervention which included participation lost in sports during their college basketball career due to injury (yes or no), when injury occurred during their college basketball career (past or present and how long injury occurred during college (days/weeks/months). History of utilizing a psychologist and/or sports psychologist (yes or no), if yes, when (exact date and/or dates if they saw a mental health provider more than once) and for how long (days/weeks/months) was requested. A question asked if there was a mindfulness program at their school (yes, no, or unsure), if yes, a Likert-like scale of 0-5 was utilized with 0 = never used it, 1 = rarely used it, 2 = sometimes used it, 4 = used it often, and 5 = always used it. Finally, history of having COVID-19 (yes or no), quarantined due to COVID-19 (yes or no), if yes, how many times and for how long, selfisolated due to COVID-19 (yes or no), if yes, how many times and for how long, and when they returned to their sport (summer or fall of 2020). A question was asked if there was hospitalization due to COVID-19 and if so for how long. A question was also asked if the athlete had any long-term symptoms of COVID-19 (yes or no), and if yes, for how long. At both preintervention and post-intervention, DASS-21 scores were collected to measure the outcomes of anxiety, depression, and stress. Instruments For this study, the DASS-21 was used. The DASS-21 scale is self-report and was created to measure the negative emotional states of depression, anxiety, and stress (Psychology INTERVENTION AND MENTAL HEALTH IN STUDENT-ATHLETES 19 Foundation of Australia, 2018). The DASS-21 scale includes three subscales, depression, anxiety, and stress (Psychology Foundation of Australia, 2018). All three scales consist of 7 questions which are answered on a Likert-like scale of 0-3 with 0 = never and 3 = almost always. Responses to each scale are totaled giving each one a range of scores from 0-21 (Psychology Foundation of Australia, 2018). Score cut-off values are established for all three subscales with lower scores representing normal and higher scores designated as extremely severe. The DASS21 offers a web-based questionnaire, which is free to access, and can be administered in groups or individually (Psychology Foundation of Australia, 2018). The DASS-21 has strong internal consistency, Cronbachs alpha coefficients of .91 for depression, .80 - .84 for anxiety, and .88 - .90 for stress among both Malaysian students and U.S. adults has been reported (Manap et al., 2019; Sinclair et al., 2011). Another study (on collegeaged students) showed that total DASS-21 scores were highly correlated for measures of depression and anxiety than specific scores of depression and anxiety and also showed good coefficient omega estimates (.88 for depression, .83 for anxiety, .85 for stress) for measuring internal consistency of the DASS-21 (Osman et al., 2012). Glass et al. (2019) noted the DASS21 had acceptable to excellent construct validity, concurrent validity, and internal consistency for all three subscales on U.S. college students while Manap et al. (2019) denoted this tool as well established, easy to use, and reliable. Other studies established that the DASS-21 and the three subscales needed additional research to provided stronger psychometric properties and its clinical usage as compared to other established instruments (Osman et al., 2012 & Sinclair et al., 2011). INTERVENTION AND MENTAL HEALTH IN STUDENT-ATHLETES 20 Procedures Recruitment The primary investigator (E. B.) sent an email describing the study along with the link of the survey to the Athletic Directors (AD), womens basketball athletic trainers, and womens basketball coaches at member institutions of the Missouri Valley Conference (MVC), Ohio Valley Conference (OVC), Summit League, ASUN Conference, Southland Conference, Big Sky Conference, Metro Atlantic Athletic Conference (MAAC), Conference USA, Big Ten Conference, Western Athletic Conference (WAC), Horizon League (HL), PAC-12, MidAmerican Conference (MAC), Pennsylvania State Athletic Conference (PSAC), and the Mountain East Conference, from March 2021 through December 2021. The AD and/or womens basketball athletic trainers/coach sent the email describing the study along with the survey link to all womens basketball student-athletes at their respective institutions. The womens basketball student-athletes interested in participating in the study then clicked on the link that contained the survey and informed consent. Informed Consent The institutional review board informed consent form was used and collected as part of the pre-intervention and post-intervention data collection surveys. A hyperlink to the survey was provided in potential participants email and the AD, athletic trainer, coaches email. Possible participants could not proceed through the study without first acknowledging they agreed to be in the study. Potential participants had time to examine the implications their consent had upon them as individuals and could request a video conference with the primary researcher to ask any questions they may have before consenting. Participants were required to provide informed INTERVENTION AND MENTAL HEALTH IN STUDENT-ATHLETES 21 consent at both pre-intervention and post-intervention time periods. Those who did not agree to be in the study were taken to the end of the survey. Data Collection Data were collected at two separate time periods, pre-intervention and post-intervention through Qualtrics. Data collection started in March 2021 and was completed in January 2022. Prior to completing the pre-intervention survey, participants created a unique identification number that was used to link pre-intervention and post-intervention survey responses. The identification number was the first 3 letters of their fathers (or mothers) name and last 3 digits of their phone number (ex. DAR-768). Over 6 weeks, participants watched two different 3 to10-minute mindfulness videos. The pre-intervention survey was sent out one-week prior to the intervention and collected participant demographics and characteristics, and a baseline DASS-21. Participants had two weeks to complete the pre-intervention survey. An email reminder was sent out halfway into the process to both the participant and the athletic trainer, AD, or coach. After completing the preintervention survey, a link to the first intervention video was sent to participants from their AD, athletic trainer, or coach via email. Participants were then directed to the Google form with the video by clicking on the link. Participants had one week to watch the first video. An email reminder was sent out 48 hours prior to the deadline to watch the first video. One week after the deadline for watching the first video, the link became inactive and participants were provided, via email, a link to the second video. Participants were then directed to the Google form with the second video by clicking on the link. An email reminder was sent out 48 hours prior to the deadline to watch the second video. One week after the deadline for watching the second mindfulness video, participants had two weeks to complete the post- INTERVENTION AND MENTAL HEALTH IN STUDENT-ATHLETES 22 intervention survey. An email reminder was sent out halfway into this process to both the participant and the athletic trainer/coach. Participants had to provide informed consent to complete the post-intervention survey. Next, participants confirmed if they watched the entirety of both mindfulness videos. If they did not indicate they watched at least one of the videos in its entirety, they did not progress any further in the survey. Participants were removed from the study if they did not complete both the pre-intervention and post-intervention surveys or if they did not confirm they watched at least one of the mindfulness videos. Data on participants who did not complete the study were retained and only descriptive data were analyzed (Table 7 and 8). Intervention The intervention for this study was watching two online mindfulness videos. After completion of the demographics and baseline DASS-21, participants accessed and watched an online mindfulness video provided to them by the primary investigator. The content of the mindfulness video included a brief introduction to mindfulness and an explanation and demonstration of one technique that can be utilized (Chen et al., 2019). A second video was available to participants one week after the deadline to watch the first video. The second mindfulness video reviewed the technique from the previous video and an additional mindfulness technique was explained and demonstrated (Chen et al., 2019). The mindfulness videos were no longer than 3-10 minutes. These videos were taken from YouTube and are free and accessible to the public. The videos were chosen to represent information from the developer of the mindfulness concept (Jon Kabat-Zinn) and two common mindfulness techniques. The first video was taken from Stop, Breathe, and Think app and was accessible on YouTube (Meditation4 SelfHealth, n.d.). This was a 3-minute video on mindful breathing to relieve stress. One expert INTERVENTION AND MENTAL HEALTH IN STUDENT-ATHLETES 23 reviewer gave the app good reviews (Buckmaster, 2019). The second video was taken from the Calm app and was accessible on YouTube (Calm, 2016). This was a 10-minute video that focused on to Be Present. The Calm app is free and accessible to all Big Ten student-athletes, coaches, full-time members of the university athletic departments and the Big Ten Conference staff (Big Ten Conference, 2020). Data Management All precautions were made to try to ensure data collected would be anonymous and confidential and would remain so after the study ended. Data were and are currently secured privately on the primary researchers computer. Data from both the pre-intervention and postintervention surveys were exported from Qualtrics into two separate Microsoft Excel spreadsheets after the post-intervention survey had been closed. Pre-intervention and postintervention Excel files were combined into one file by linking participants unique identification number. Data were examined for errors and data manipulation was conducted (i.e., calculation of DASS-21 total scores). Data Analysis Data imported from the Excel spreadsheet were analyzed using IBM SPSS Statistics for Windows, Version 28.0 (IBM Corp., Armonk, NY). All comparisons were two-tailed and a significance level of less than .05 was considered statistically significant. Normality of data was determined using the Shapiro-Wilk test and visual inspection of histograms, Q-Q plots, and boxplots. Descriptive statistics was conducted to describe the sample and the outcome constructs (depression, anxiety, and stress). Nominal data (gender, race, student classification, injury history, psychologist/sport psychologist history, mindfulness program, COVID-19 history, and quarantine history) was reported as frequencies and percentages. For comparison purposes, due INTERVENTION AND MENTAL HEALTH IN STUDENT-ATHLETES 24 to limited responses in categories in three variables, race, student classification, and if there was a mindfulness program at their school did they use it, were collapsed. For race, the Other category was assigned to the African-American category; for student classification, the categories were collapsed into redshirt and non-redshirt. Because the majority of participants (77.8%) were unsure whether they had a mindfulness program, the variable wasnt used for comparisons. Interval and ratio data (age and three subscale DASS-21 scores) were reported as medians and minimum and maximum values. To determine if there was a change in the three subscale DASS-21 scores after participating in the mindfulness intervention, Wilcoxon signedranks tests were used due to the data not being normally distributed. Change scores were calculated by taking each of the three subscale DASS-21 post-scores minus the three subscale DASS-21 pre-scores. Comparison of DASS-21 subscale change scores was conducted by using Mann-Whitney U tests while comparison of severity based on DASS-21 subscale scores were conducted by utilizing marginal homogeneity tests. Correlations between DASS-21 subscale scores, age, and missed playing days were analyzed by using Spearman rho tests. Results A total of 106 student-athletes responded to the pre-intervention survey, 76 (70.4%) watched the first intervention video, 53 (49.1%) watched the second intervention video, 44 (40.7%) completed the post-intervention survey; however, only 36 (33.3%) completed the preintervention survey, one or both interventions, and the post-intervention survey. (Descriptive statistics are presented in Tables 1 and 2.) The median age was 20.5 years and the majority of the sample was African-American (52.8%), sophomores (30.6%), and had a history of injury (61.1%). Additionally, the majority of the sample had not utilized a psychologist (72.2%) and INTERVENTION AND MENTAL HEALTH IN STUDENT-ATHLETES 25 most were unsure if their school had a mindfulness program (77.8%). Finally, a majority did not have a history of testing positive for COVID-19 (55.6%); however, the majority had been quarantined (55.6%). The median number of days missed due to injury in their college basketball career was 10.5, days spent self-isolated due to being COVID-19 positive was 10, and the number of COVID-19 quarantine (due to being a close-contact to someone that was COVID-19 positive) days was 17.5. A total of 70 student-athletes did not complete the study (Comparisons between those who completed the study and those who did not complete the study are presented in Table 7 and 8). The majority of the sample was white (52.9%), freshmen (31.4), and had a history of injury (62.9%). Additionally, the majority had not utilized a psychologist (81.4%), while most also were unsure if their school had a mindfulness program (60%). Finally, a majority did have a history of testing positive for COVID-19 (52.9%) and the majority had been quarantined (81.4%). The median age was 20 years, number of days missed due to injury in their college basketball career was 42, days spent self-isolated due to being COVID-19 positive was 10, and the number of COVID-19 quarantine (due to being a close-contact to someone that was COVID19 positive) days was 14. Of note, there were 8.5% more African-Americans that completed the study than their white counterparts. 11% more sophomores completed the study while 14.6% more seniors dropped out of the study. Also, 9.2% more participants who completed the study had a history of utilizing a psychologist/sports psychologist while 17.8% more participants who completed study were unsure if their school had a mindfulness program. Interestingly, 25.9% more of participants who did not complete study had a history of quarantine and tested positive for COVID-19 (8.5%). Interestingly, those who completed the study missed 31.5 less days due to injury but INTERVENTION AND MENTAL HEALTH IN STUDENT-ATHLETES 26 were quarantined for 4 more days. The two-sided Fishers exact test indicated there was a statistically significant difference (p = .006) in quarantine history between those who completed the survey versus those who did not complete the survey. Finally, there was a significant difference in COVID-19 isolation days between those who completed the survey versus those who did not complete the survey, Mann-Whitney U test, Z = -2.12, p = .044. Pre-intervention and Post-intervention Comparisons By DASS-21 Subscales To determine if there was a change in depression, anxiety, and stress, after participating in a mindfulness intervention, pre- and post-intervention DASS-21 subscale scores were compared. Since data were not normally distributed, DASS-21 scores were compared using the non-parametric Wilcoxon signed-ranks test. As can be seen in Table 3, there was not a significant difference in depression and anxiety scores after participating in the intervention and effect sizes were weak for depression and negligible for anxiety. For stress, post-intervention scores were statistically significantly smaller compared to pre-intervention scores, signed-ranks test, Z = -2.34, p = .019, with a moderate effect size. To determine if there were differences in the level of severity between pre-intervention and post-intervention results, severity scores were compared using marginal homogeneity tests. As reported in Table 4, there was no significant change in severity based on depression (p = .537), anxiety (p = 1.000), and stress (p = .157) subscale scores. Comparison of DASS-21 Subscale Change Scores by Student Demographics, Characteristics and COVID-19 History Comparisons were made between student demographics and DASS-21 subscale change scores (Table 5). There was not a significant difference in change scores for most student demographics, student characteristics, and COVID-19 history results including: race, student INTERVENTION AND MENTAL HEALTH IN STUDENT-ATHLETES 27 classification, injury history, and COVID-19 occurrence. However, there was a statistically significant difference in stress change scores by psychologist history. Those who did not see a psychologist had significantly greater change (improvement) in stress scores than those who had a history of seeing a psychologist, Mann-Whitney U test, Z = -2.14, p = .032. In addition, there was a significant difference in change scores between students who were quarantined and those who were not quarantined. Those who were quarantined had greater change (improvement) in their stress scores relative to those who were not quarantined, Mann-Whitney U test, Z = -2.03, p = .043. Correlations Between DASS-21 Subscale Change Scores and Age and Missing Playing Days Correlations were calculated between age, injury history missed playing days, COVID-19 self-isolation days, COVID-19 quarantine days, and DASS-21 subscale change scores (Table 6). For depression subscale scores, correlations ranged from negligible (r = -.03) to weak (r = .28) with neither correlation reaching statistical significance. The correlations for anxiety subscale change scores also ranged from negligible (r = .02) to weak (r = .28) with neither correlation reaching statistical significance. For stress change scores, the correlations were negligible for age and COVID-19 change scores, r = -.02, r = .05, respectively. However, Spearman rho tests showed a statically significant weak positive correlation between injury history missed days and stress change scores, r = .32, p = .048. Discussion The COVID-19 pandemic wreaked havoc on college athletics and unfortunately new variants, such as Omicron, continued to postpone, cancel, and alter basketball practices and games into 2022 (The University of North Texas Center for Sport Psychology and Performance Excellence, 2020). Additionally, student-athletes were subjected to further disruptions such as INTERVENTION AND MENTAL HEALTH IN STUDENT-ATHLETES 28 relocated campus housing situations, virtual and/or altered academic courses, and quarantined and/or self-isolated due to exposure or having COVID-19 again (The University of North Texas Center for Sport Psychology and Performance Excellence, 2020). The stressors of studentathletes have now been compounded for a longer period of time with policies in place for vaccinated and unvaccinated individuals. Furthermore, unvaccinated student-athletes had to adhere to additional policies when they came in close contact with a positive individual and could have had to quarantine and face additional testing if they became symptomatic. Moreover, elapsed time since initial vaccine dose may have led to additional self-isolation despite previous infections. Due to these increased instances of quarantines, self-isolations, and detachment from their teams, there has been an additional call for mental health interventions to help combat mental health issues (Bullard, 2020). Because of all the added COVID-19 stressors, in conjunction with the already busy schedule that student-athlete have, there was a need to explore ways to reduce these and other mental health issues. In turn, this study surveyed NCAA Division I and Division II collegiate womens basketball players to explore whether a mindfulness intervention could improve their perceived depression, anxiety, and stress. Demographics and COVID-19 History Tables 1 and 2 explain the demographics, COVID-19 history, along with missed playing time either due to injury or due to COVID-19 (quarantined or self-isolation). The majority of participants in this study were Division 1 and Division II, African-American, sophomores that missed playing time due to injury and/or due to COVID-19 (quarantined or self-isolation). Of particular note, a majority did not utilize a psychologist/sports psychologist and were unsure if their institution had a mindfulness program. Specifically, the demographics of this study are homogenous in nature as were a couple other studies that also focused on female womens INTERVENTION AND MENTAL HEALTH IN STUDENT-ATHLETES 29 basketball players (Dehghani et al., 2018; Vidic et al., 2016). In 2019, the Institute for Diversity and Ethics in Sport (TIDES) released the 2019 College Racial and Gender Report Card, which showed that in 2020-2021, 40.6% of Division I women basketball student-athletes were African-American (Lapchick, 2021). Also, importantly a much larger study showed there was also a lack of counseling across the COVID-19 time points that reflected ongoing mental health issues in student-athletes (especially African-Americans) and the lack of resources available (The University of North Texas Center for Sport Psychology and Performance Excellence, 2020). Notably, the present study has similar percentages of African-Americans compared to all of Division I womens basketball, while also being the largest group with ongoing mental health issues. Our study also found similar findings in retrospect to utilization of a psychologist/sports psychologist and their awareness of a mindfulness program. Pre-Intervention and Post-Intervention Comparisons This study focused on womens basketball student-athletes and encompassed two seasons in a non-controlled environment. This non-controlled environment had many external factors that could have contributed to depression, anxiety, and stress, with the addition of COVID-19, and the many policies and procedures associated with the NCAA and the individual institutions. As seen in Table 2, the population missed playing time due to injuries and COVID-19 related quarantines and self-isolations. Pre-COVID-19, sports anxiety was alleviated in a mindfulnessbased intervention that primarily utilized womens basketball athletes (Dehghani et al., 2018). In a non-controlled environment, and pre-COVID, other female sports, like tennis, had an improvement in anxiety scores after a 4-week mindfulness intervention but not stress, which could have been attributed to a small sample size and non-randomization (Li, et al., 2019) while rowers reduced their stress after an 8-week mindfulness based intervention (Jones et al., 2020). INTERVENTION AND MENTAL HEALTH IN STUDENT-ATHLETES 30 These aforementioned pre-COVID-19 studies were highly influential in forming the hypothesis that mindfulness-based studies can alleviate stress or anxiety in student-athletes. This study utilized mindfulness intervention(s) to examine if there would be a change in DASS-21 subscale (depression, anxiety, and stress) scores. The results can be found in Table 3. As hypothesized, there was a significant difference in at least one subscale - namely, the stress subscale was notably lower. However, there was no significant reduction in either the depression subscale or the anxiety subscale. Interestingly, it is not uncommon for one or two of the subscales of the DASS-21 (depression, anxiety, and stress) to be reduced while also seeing little change in a third while using similar mindfulness-bases interventions and self-reporting tools. Programs such as yoga and meditation with other similar self-reporting tools improved mental health in regular students in as early as 6-weeks (Lemay, et al., 2019). This particular study utilized two internet/web-based applications to deliver the mindfulness-based interventions, which has been a supported distribution method (Hoffman & Gomez, 2017) and also was successful in reducing depression and anxiety (Gulliver, et al., 2012). Additionally, targeting specific mindfulness-based interventions could have helped with obtaining the results i.e. some interventions could specifically help with stress, anxiety, and/or depression (Shonin et al., 2013). Comparisons of Severity Based on Subscale Scores As noted in Table 4, there were no significant findings when looking at frequency and percentage for severity from pre-intervention and post-intervention based upon the DASS-21 subscale scores. The majority of the populations subscale scores would have been classified as normal while other severity scores varied from no change, improving, or worsening. Even as early as 2021, there were more noted mental health issues in college-students, especially females with suggestion of needing professional psychological therapy and counseling (Chen & Lucock, INTERVENTION AND MENTAL HEALTH IN STUDENT-ATHLETES 31 2022). As stated before, the Omicron variant, vaccination vs. non-vaccination policies and procedures were external variables that presented themselves during this study, which could have made scores worse. Additionally, not having the mental health resources/lack of knowledge about mental health resources could have also accounted for DASS-21 scores not improving in certain categories. For example, specifically looking at anxiety severity scores, five more subjects ended up normal post-intervention and seven improved to mild post-intervention but three more ended up severe post-intervention. Specifically, looking at stress severity scores, three more subjects ended up normal post-intervention while three improved in the moderate category and two improved in the moderate category while two unfortunately got worse in the mild category. Having more subjects that were not classified in the normal category along with having more interventions sessions could possibly improve abnormal severity scores. DASS-21 Subscale Change Scores Table 5 compares participant demographics, COVID-19 history, and the DASS-21 subscale change scores while Table 6 examined any correlations between age, missed playing time, and DASS-21 subscale change scores. Interestingly, those who were quarantined had improvement in their stress scores relative to those who were not quarantined, while those who did not see a psychologist had improvement in stress scores than those who had a history of seeing a psychologist. A constant theme revolving around scores getting worse is the fluidity of COVID-19 over the past two years regarding policies and procedures and the sheer number of days that participants were being subjected to quarantine. Table 2 shows that participants quarantined from 7 to 56 days. Being quarantined and isolated from others for as potentially long as 2.5 months could have devastating mental health repercussions on anyone. During these times, social media could be assumed as the primary means to pass the time. Interestingly, more INTERVENTION AND MENTAL HEALTH IN STUDENT-ATHLETES 32 exposure to social media led to worsening mental health in Chinese college students (Zhao & Zhao, 2020). Contrastingly, because of the potential of more than normal utilization of social media and completing our web-based mindfulness-based intervention could in fact have contributed to scores improving. This could be due to quarantined participants already being subjected to more social media i.e. on their device more and had the ability to pay attention to the intervention without distraction. Additionally, being quarantined over holidays and other special events could have decreased stress if they completed one intervention before they were quarantined. The worsening of mental health with little background of preexisting mental health issues were exacerbated over the pandemic i.e. previous traumas, lack of family and friend interactions, and decreased exercising could have all been a relevant factor for better scores while quarantined (Robillad et al., 2021). Scores worsened with participants not in quarantine. This might have been due that they were able to live a normal life, dealt with the everyday stressors of school, athletics, and socializing and maybe did not pay attention to the mindfulness intervention. Participants who never had a history of interactions with a psychologist/sports psychologist had better improvement in stress scores than those that did have an interaction with these mental health providers. The importance of both these mental health providers are without question in athletics. Those participants who never had access to a mental health counselor had improved stress change scores with the mindfulness-based interventions. The results indicate the importance of a mental health counselor and it evidently had better effects on those participants than our mindfulness-based interventions, thus there was no improvement. The importance of mindfulness-based interventions being directed by a mental health professional might have prevented those results we found. Due to the COVID-19 pandemic, mental health resources were stretched thin. Mental health professionals directing college programming e.g. mindfulness- INTERVENTION AND MENTAL HEALTH IN STUDENT-ATHLETES 33 based programming can not only be preventative and psychoeducational but also cost efficient and effective (Seppala et al., 2020). Table 6 shows a correlation between injury history, missed days, and stress change scores. COVID-19 and injuries can contribute to student-athletes missing practice and/or games. Table 2 indicated that participants have missed 2.5 days to near threequarters of a year due to injury. Mindfulness has been shown to not only improve mental health but to reduce injury and even facilitate recovery from injury (Anderson et al., 2021). Injuries were common following the COVID-19 pandemic shutdown of sports and throughout the past two years. One German soccer team saw an increase in muscular injuries returning from the COVID-19 pandemic shutdown in 2020 (Sheshardi et al., 2021). Domestically, Major League Baseball (MLB) saw the incidence rate of injuries twice the rate as compared to 2 seasons before (Platt et al., 2021). The NCAA is currently collecting its injury data over the COVID-19 pandemic via their injury surveillance program (Parsons et al., 2021). Limitations and Barriers to the Study The COVID-19 pandemic has affected two seasons for womens basketball studentathletes and the study looked at participants over the span of the 2020-2021 season, the summer of 2021, and the 2021-2022 season. Issues like the transfer portal, job turnover, athletes graduating, and sitting out and/or quitting the team all took place over the course of this study. The transfer portal gives student-athletes the opportunity to investigate leaving their current school and enrolling and playing at another institution. Prior to the pandemic, student-athletes had to sit out for a year if they transferred, unless they obtained a waiver. Recently, the NCAA gave immediate eligibility to those student-athletes who transfer, which increased the numbers of those that went into the portal (OBrien, 2021). Over the course of this study, many coaches, administrators, and athletic trainers found new jobs at other institutions, were fired, and/or found INTERVENTION AND MENTAL HEALTH IN STUDENT-ATHLETES 34 new jobs in different settings while due to increased demands of college athletics many did not have the time or energy to participate in any research studies. For all of these reasons, communication became difficult and ultimately there was a high dropout rate. Threats to internal validity are important and worth mentioning. The extreme dropout rate/mortality (as mentioned previously), history/length of the study, maturation, selection, (lack of homogeneity of sample) are types of threats to internal validity of this study (Creswell & Creswell, 2018). This was an underpowered study, which was calculated anecdotally and via clinician expertise to obtain the minimum sample of participants. A higher number of participants would have certainly yielded a greater body of data on which to base our assumptions and findings. Additionally, the study relied completely on the word of the participants regarding their participation that is, participants may have watched some, all, or none of the videos yet reported they watched the videos in their entirety. We did not differentiate if participants were either Division I or Division II womens basketball. There were ultimately a low number of Division II participants and there was no comparison between the two. This study did not utilize a control group. Due to the small sample size it would have been difficult to recruit and organize populations to put into two groups of equal and appropriate size. A metaanalysis of randomized and non-randomized control studies of a mindfulness intervention on regular college students confirmed they benefits to improving mental health (McConville et al., 2017) while another meta-analysis examined studies that did not have randomized controlled design, smaller samples, but still found mindfulness-based programs beneficial for mental health and especially stress (Sharma et al., 2014). Other mindfulness- based studies utilized control groups (Ajilchi et al., 2019; Dehghani et al., 2018; Galante et al., 2018; Glass et al., 2019; Goodman, 2014; Gulliver et al., 2012; Hoja & Jansen, 2019; Jones et al., 2020; Rothlin et al., INTERVENTION AND MENTAL HEALTH IN STUDENT-ATHLETES 35 2016; Seppala et al., 2020). Additionally, participants who self-select to be in the study, selfreporting answers, and the investigators deciding who completed the study brought bias to the study. The investigator emailed ADs, coaches, and athletic trainers with personal connections to gain a higher chance of getting student-athletes to fully participate in the study. Even though there was a high dropout rate, demographics were still collected on 70 participants (Table 7 and Table 8). While there were initially more white participants than African-Americans, 8.5% more African-American completed the study than their white counterparts. Also, those who dropped out missed more time due to injury (31.5 more days), tested positive for COVID-19 (8.5%) and also quarantined (25.9%). Also, to note there was some that reported that they utilized mindfulness programming at their institution (6 participants) but still a majority did not know if their school had a mindfulness program (60%). Seemingly, those who dropped out had worse outcomes related to injuries, tested positive for COVID-19, and quarantine history than their counterparts that completed the study. There was a significant difference in quarantine history and COVID-19 isolation days between those who completed the study and those who did not complete the study. Student-athletes who did not complete the study were significantly more likely to have been quarantined in comparison to those who completed the study (81.4% and 55.6%, respectively). It is possible that being quarantined and isolated led to decreased motivation which affected study follow through. It has been reported that those who were college students during the COVID-19 pandemic had a decrease in autonomous types of motivation (Corpus et al., 2022). A lack of motivation could have lessened their interest in the study and completing tasks that could be personally meaningful, like practicing mindfulness. INTERVENTION AND MENTAL HEALTH IN STUDENT-ATHLETES 36 Recommendations for Future Research Since the beginning of the pandemic in March of 2020, and as it continues to shift to an endemic phase in many parts of the world, the need to focus on the re-normalization of studentathletes lives has been and will continue to be of paramount importance. Pandemics and other stressful events in the world and in our country (i.e. wars, social events, etc.) may arise in the future, but the COVID-19 pandemic is unprecedented in many ways. The need for research directed at smaller colleges and with specific sports and genders including specific mindfulnessbased interventions would benefit those with limited medical and mental health staffs while also examining Division III, NAIA, and junior colleges. While our results saw many participants classified as normal as per the DASS-21, it would be beneficial to follow-up with the recommended pre-participation physical exams (Kaminski, 2016; Kroshus, 2016; Moreland et al., 2018; Sudano et al., 2017) and implement mindfulness-based interventions on those who have abnormal mental health screenings. This would provide more robust baseline data as well as aide in tracking data around changes to the clinical applicability of those who presented with more severe classifications on the DASS-21. Additionally, focusing on studies during the span of one season and being in-person to conduct all surveys and to supervise any web-based mindfulness-based interventions would help with alleviating participant dropouts, problems with maturation, and ensuring the participants complete the tasks associated with the study. Additionally, focusing on improving athletic performance may coincide with improved mental health. Future studies may add in measuring some type of athletics performance to see if there are changes with a mindfulness-based intervention during the course of an athletic season. INTERVENTION AND MENTAL HEALTH IN STUDENT-ATHLETES 37 Conclusion From March 2020 to March 2022, the COVID-19 pandemic has disrupted all of our lives and especially those that work and compete in collegiate athletics. The rise of the Omicron variant, vaccination status, additional chances of being self-isolated and/or quarantined, and the politicization of public health has contributed to more depression, anxiety, and stressors. The ever-evolving NCAA and institutional policies/procedures have contributed to the waning mental health of all student-athletes. The purpose of this study was to determine if a mindfulness intervention provided to womens basketball student-athletes during the COVID-19 pandemic return to sport related activity would improve mental health as measured with the DASS-21via subscale scores, subscale change scores, and severity based upon the DASS-21 subscale scores. The mindfulness videos were chosen to represent information from Jon Kabat-Zinn and 2 common mindfulness techniques. A mindfulness intervention was utilized and post- intervention stress subscale scores improved. Specifically, those that were quarantined had stress subscale scores improved while those that did not have a history of seeing a psychologist/sports psychologist also saw their stress subscale scores improve. There is a clear need for education on and implementation of mindfulness interventions not only because of the results of our study, but because of how the results can potentially translate to the improvement of mental health of student-athletes within the bigger picture of college athletics. While larger NCAA conferences have developed stronger initiatives for mental health such as Teammates for Mental Health (ACC, 2021) many smaller NCAA conferences and schools still have limited mental health resources. Unfortunately, we have seen an increase in not only mental health issues but self-harm in college athletics. Mindfulness interventions have the ability to help reduce mental health issues INTERVENTION AND MENTAL HEALTH IN STUDENT-ATHLETES 38 in womens basketball student-athletes and other student-athletes, not only during a pandemic, but also during normal, less stressful times. These mindfulness interventions should be carefully selected and implemented by medical and mental health professionals and not primarily used in place of counseling. All of those working in college athletics should be buying-in and promoting mindfulness interventions. By having all of the constituents and stakeholders in college athletics educated and successfully implementing mindfulness interventions, we can confidently prevent mental health issues also becoming a pandemic. INTERVENTION AND MENTAL HEALTH IN STUDENT-ATHLETES 39 References Aaron, C. M., Gearity, B. T., & Kuklick, C. R. (2020). Mindfulness in collegiate athletics: A case study at a division 1 university. Journal of Sport Behavior, 43(2), 147-175. ACC. (2021, November 29). ACC, Big Ten and Pac-12 announce alliance mental health initiative. https://theacc.com/news/2021/11/28/general-acc-big-ten-and-pac-12-announcealliance-mental-health-initiative.aspx Ajilchi, B., Amini, R. H., Ardakani, Z. P., Zadeh, M. 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Sports Health, 9(3), 262-267. https://doi.org/10.1177/1941738116679127 The University of North Texas Center for Sport Psychology and Performance Excellence. (2020). Impact of COVID-19 on college student athletes' health, performance, and psychological well-being: An executive summary on baseline data. (Executive Summary). https://sportpsych.unt.edu/covid-and-college-student-athlete-health-and-wellbeing-study INTERVENTION AND MENTAL HEALTH IN STUDENT-ATHLETES 49 Vidic, Z., St. Martin, M., & Oxhandler, R. (2016). Mindfulness intervention with a U.S. NCAA division 1 basketball team: Impact on stress, athletic coping skills and perceptions of intervention. Sport Psychologist, 31(2), 1-37. https://doi.org/10.1123/tsp.2016-0077 Wielgosz, J., Goldberg, S. B., Kral, T. R., Dunne, J. D., & Davidson, R. J. (2019). Mindfulness meditation and psychopathology. Annual Review of Clinical Psychology, 15, 285-316. https://doi.org/10.1146-annurev-clinpsy-021815-093423 Wolch, N. L., Arthur-Cameselle, J. N., Keeler, L. A., & Suprak, D. N. (2020). The effects of a brief mindfulness intervention on basketball free-throw shooting performance under pressure. Journal of Applied Sport Psychology, 33(2): 1-31. https://doi.org/10.1080/10413200.2020.1720044 Zhao, N., & Zhou, G. (2020). Social media use and mental health during the COVID-19 pandemic: Moderator role of disaster stressor and mediator role of negative affect. Applied Psychology: Health and Well-Being, 12(4), 10191038. https://doi.org/10.1111/aphw.12226 INTERVENTION AND MENTAL HEALTH IN STUDENT-ATHLETES Table 1 Descriptive Statistics for Participant Demographics and COVID-19 History (N = 36) Demographics N (%) Race African-American 19 (52.8) White 16 (44.4) Other 1 (2.8) Student Classification Freshman Redshirt Freshman Sophomore 7 (19.4) 0 11 (30.6) Redshirt Sophomore 2 (5.6) Junior 7 (19.4) Redshirt Junior 2 (5.6) Senior 4 (11.1) Redshirt Senior 3 (8.3) Injury History Yes 22 (61.1) No 14 (38.9) Yes 10 (27.8) No 26 (72.2) Psychologist History 50 INTERVENTION AND MENTAL HEALTH IN STUDENT-ATHLETES Mindfulness Program No 3 (8.3) Never Used 4 (11.1) Rarely 1 (2.8) Unsure 28 (77.8) COVID-19 History Yes 16 (44.4) No 20 (55.6) Yes 20 (55.6) No 16 (44.4) Quarantine History 51 INTERVENTION AND MENTAL HEALTH IN STUDENT-ATHLETES Table 2 Descriptive Statistics for Age and Missed Playing Days (N = 36) Mdn (Min, Max) Age (years) Injury History Missed Days 20.5 (19, 23) 10.5 (2.5, 213) COVID-19 Self-Isolation Days 10.0 (7, 14) COVID-19 Quarantine Days 17.5 (7, 56) Note. Min = minimum; Max = maximum. 52 INTERVENTION AND MENTAL HEALTH IN STUDENT-ATHLETES 53 Table 3 Pre-Intervention and Post-Intervention Comparisons By DASS-21 Subscale Scores (N = 36) DASS-21 Subscale Pre-Intervention Post-Intervention Mdn (Min, Max) Mdn (Min, Max) p ES Depression 7.0 (0, 38) 4.0 (0, 30) .085 .42 Anxiety 8.0 (0, 28) 4.0 (0, 36) .922 .02 Stress 12.0 (0, 32) 7.0 (0, 24) .019 * .57 Note: DASS-21 = Depression, Anxiety and Stress Scale-21; Min = minimum; Max = maximum; ES = effect size. * p < .05. INTERVENTION AND MENTAL HEALTH IN STUDENT-ATHLETES 54 Table 4 Comparison of DASS-21 Subscales between Pre-intervention and Post-intervention (N = 36) Pre-Intervention Post-Intervention N (%) N (%) Depression p .537 Normal 22 (61.1) 24 (66.7) Mild 5 (13.9) 4 (11. 1) Moderate 4 (11.1) 4 (11.1) Severe 2 (5.6) 1 (2.8) Extremely Severe 3 (8.3) 3 (8.3) Anxiety 1.000 Normal 17 (47.2) 22 (61.1) Mild 8 (22.2) 1 (2.8) Moderate 7 (19.4) 6 (16.7) 0 (0) 3 (8.3) 4 (11.1) 4 (11.1) Severe Extremely Severe Stress .157 Normal 25 (69.4) 28 (77.8) Mild 2 (5.6)) 4 (11.1) Moderate 7 (19.4) 4 (11.1) Severe 2 (5.6) 0 (0) 0 (0) 0 (0) Extremely Severe Note. DASS-21 = Depression, Anxiety, and Stress Scale-21. INTERVENTION AND MENTAL HEALTH IN STUDENT-ATHLETES 55 Table 5 Comparison of Participant Demographics and COVID-19 History by DASS-21 Subscale Change Score a (N = 36) Depression Change Score Mdn (Min, Max) Race p Anxiety Change Score Mdn (Min, Max) .710 p Stress Change Score Mdn (Min, Max) .290 .207 African-American 0 (-18, 24) 1 (-10, 14) 5 (-10, 24) White 2 (-12, 22) 0 (-16, 8) 1 (-12, 16) Student Classification Non-redshirt Redshirt .089 .147 .161 0 (-18, 12) 0 (-16, 12) 3 (-12, 22) 4 (0, 24) 2 (-4, 14) 6 (-2, 24) Injury History .576 .883 .182 Yes 0 (-12, 34) 0 (-16, 14) 5 (-12, 24) No 2 (-18, 6) 0 (-10, 22) 0 (-10, 22) Psychologist History .174 p .319 .032* Yes 0 (-12, 2) 0 (-16, 2) -2 (-10, 16) No 3 (-18, 24) 1 (-10, 14) 6 (-12, 24) INTERVENTION AND MENTAL HEALTH IN STUDENT-ATHLETES COVID-19 Occurrence .375 56 .471 .836 Yes 3 (-18, 24) 2 (-10, 14) 4 (-12, 16) No 0 (-12, 22) 0 (-16, 12) 1 (-10, 24) Quarantine History .961 .305 .043* Yes 0 (-14, 24) 2 (-16, 14) 5 (-10, 24) No 2 (-18, 12) -1 (-10, 8) -1 (-12, 24) Note. DASS-21 = Depression, Anxiety, and Stress Scale-21; Min = minimum; Max = maximum. a Change score = post-intervention score minus pre-intervention score. Negative number means condition got worse. * p < .05. INTERVENTION AND MENTAL HEALTH IN STUDENT-ATHLETES 57 Table 6 Correlations of Age and Missed Playing Days with DASS-21 Subscale Change Scores a (N = 36) Depression Anxiety Stress Change Score Change Score Change Score r p r p r p Age (years) .11 .533 .17 .316 .05 .792 Injury History Missed Days .19 .272 .02 .911 .32 .048* COVID-19 Self-Isolation Days .28 .102 .22 .208 -.02 .917 COVID-19 Quarantine Days -.03 .886 .09 .587 .30 .077 Note. DASS-21 = Depression, Anxiety, and Stress Scale-21. a Change score = post-intervention score minus pre-intervention score. * p < .05. INTERVENTION AND MENTAL HEALTH IN STUDENT-ATHLETES 58 Table 7 Comparison of Participant Demographics and COVID-19 History Between Participants Who Completed the Study and Those Who Did Not Complete the Study Completed Study Did Not Complete Study N = 36 N = 70 N (%) N (%) Race p .420 African-American 19 (52.8) 31 (44.3) White 17 (47.2) 39 (55.7) Student Classification .377 Non-Redshirt 29 (80.6) 62 (88.6) Redshirt Athlete 7 (19.4) 8 (11.4) Injury History 1.000 Yes 22 (61.1) 44 (62.9) No 14 (38.9) 26 (37.1) Psychologist History .323 Yes 10 (27.8) 13 (18.6) No 26 (72.2) 57 (81.4) Mindfulness Program .304 No 3 (8.3) 3 (4.3) Never Used 4 (11.1) 17 (24.3) Rarely 1 (2.8) 1 (1.4) 0 (0) 2 (2.9) Sometimes INTERVENTION AND MENTAL HEALTH IN STUDENT-ATHLETES Often 0 (0) 2 (2.9) Always 0 (0) 2 (2.9) Unsure 28 (77.8) 42 (60.0) COVID-19 History .539 Yes 16 (44.4) 37 (52.9) No 20 (55.6) 33 (47.1) Quarantine History * p < .05. 59 .006* Yes 20 (55.6) 57 (81.4) No 16 (44.4) 13 (18.6) INTERVENTION AND MENTAL HEALTH IN STUDENT-ATHLETES 60 Table 8 Comparison of Participant Age and Missed Playing Days Between Participants Who Completed the Study and Those Who Did Not Complete the Study Completed Study Did Not Complete Study N = 36 N = 70 Mdn (Min, Max) Mdn (Min, Max) p 20.5 (19, 23) 20.0 (18, 24) .886 10.5 (2.5, 213) 42.0 (1, 395) .183 COVID-19 Self-Isolation Days 10.0 (7, 14) 10.0 (0, 19) .044* COVID-19 Quarantine Days 17.5 (7, 56) 14 (1, 60) .703 Age (years) Injury History Missed Days Note. Min = minimum; Max = maximum. * p < .05. INTERVENTION AND MENTAL HEALTH IN STUDENT-ATHLETES 61 Appendix A DASS21 Name: Date: Please read each statement and circle a number 0, 1, 2 or 3 which indicates how much the statement applied to you over the past week. There are no right or wrong answers. Do not spend too much time on any statement. The rating scale is as follows: 0 1 2 3 Did not apply to me at all Applied to me to some degree, or some of the time Applied to me to a considerable degree, or a good part of time Applied to me very much, or most of the time 1 I found it hard to wind down 0 1 2 3 2 I was aware of dryness of my mouth 0 1 2 3 3 I couldn't seem to experience any positive feeling at all 0 1 2 3 4 I experienced breathing difficulty (eg, excessively rapid breathing, breathlessness in the absence of physical exertion) 0 1 2 3 5 I found it difficult to work up the initiative to do things 0 1 2 3 6 I tended to over-react to situations 0 1 2 3 7 I experienced trembling (eg, in the hands) 0 1 2 3 8 I felt that I was using a lot of nervous energy 0 1 2 3 9 I was worried about situations in which I might panic and make a fool of myself 0 1 2 3 10 I felt that I had nothing to look forward to 0 1 2 3 11 I found myself getting agitated 0 1 2 3 12 I found it difficult to relax 0 1 2 3 13 I felt down-hearted and blue 0 1 2 3 14 I was intolerant of anything that kept me from getting on with what I was doing 0 1 2 3 15 I felt I was close to panic 0 1 2 3 16 I was unable to become enthusiastic about anything 0 1 2 3 17 I felt I wasn't worth much as a person 0 1 2 3 18 I felt that I was rather touchy 0 1 2 3 INTERVENTION AND MENTAL HEALTH IN STUDENT-ATHLETES 62 19 I was aware of the action of my heart in the absence of physical exertion (eg, sense of heart rate increase, heart missing a beat) 0 1 2 3 20 I felt scared without any good reason 0 1 2 3 21 I felt that life was meaningless 0 1 2 3 INTERVENTION AND MENTAL HEALTH IN STUDENT-ATHLETES 63 Appendix B Hello, You are receiving this email to send the link(s) to survey(s) and mindfulness intervention videos to your womens basketball student-athletes on an intervention for mental health issues in college-student athletes during the COVID-19 pandemic. My name is Erik Brown and I am a doctoral student at the University of Indianapolis and faculty in the Athletic Training Program at the University of Evansville. This doctoral research project is examining an intervention for mental health issues in college student-athletes during the COVID19 pandemic. This research study is being conducted by Jessica Jochum, PhD, ATC and Erik Brown, MS, ATC The purpose of this research study is to determine if a student-athlete focused mindfulness intervention can have an impact on mental health concerns during the COVID-19 pandemic return to sports. Specifically, this research study will address the following research question: Does a mental health intervention improve self-reported mental health concerns in NCAA Division 1 and Division 2 basketball student-athletes during their COVID-19 pandemic return to sport related activity? To answer the research question, the following objective will be addressed: To determine if a mindfulness intervention provided to basketball student-athletes during the COVID-19 pandemic return to sport related activity will improve mental health as measured with the Depression, Anxiety, and Stress Scale-21 (DASS-21). There are no risks of discomforts associated with this research study. By participating in this research study, student-athletes might improve their mental health and athletic performance, use an intervention that could be a resource for athletic department personnel, and use an intervention that could be effective in less stressful times. The first survey will take 10-15 minutes. After 2 weeks, participants will click on a link that will take them to a Qualtrics survey that contains a Google form survey that contains the first two videos. They will have 1 week to watch an explanation of mindfulness that is around 2 minutes in length and an intervention video that is around 3 minutes in length. After 1 week, the link for the second intervention will become active. They will click on the link that will take them to another Qualtrics survey that contains a Google form survey and they will re-watch the 1st intervention video watch the 2nd video that is around 10 minutes. After 1 week to complete this, they will have 2 weeks to complete the 10-15 minutes post-intervention survey. Survey questions will include demographics, information requesting information about injuries, utilizing a psychologist/sports psychologist, and COVID-19 information. Also, questions about depression, anxiety, and stress will be asked. Responses will be confidential and anonymous. Data will be stored and secured in a computer file and kept for a minimum of 3 years. Participation in this research study is voluntary and participants can withdrawal at any time. If you have any questions about this research study, you can contact the researcher below: INTERVENTION AND MENTAL HEALTH IN STUDENT-ATHLETES Erik Brown, MS, LAT, ATC, CES, PES Doctoral Student University of Indianapolis browne001@uindy.edu 812-630-5768 Here is the link to the informed consent and first survey: https://qfreeaccountssjc1.az1.qualtrics.com/jfe/form/SV_ewGT8gfJ1olffFP 64 INTERVENTION AND MENTAL HEALTH IN STUDENT-ATHLETES 65 Hello, You are receiving this email to send the link(s) to survey(s) and mindfulness intervention videos to your womens basketball student-athletes on an intervention for mental health issues in college-student athletes during the COVID-19 pandemic. Please click on the following link that will take participants to a Qualtrics survey that contains a Google form survey that contains the first two videos. Participants will have 1 week to watch an explanation of mindfulness that is around 2 minutes in length and an intervention video that is around 3 minutes in length. Here is the link to the second survey: https://qfreeaccountssjc1.az1.qualtrics.com/jfe/form/SV_dpbDGSosQBLpPb8 Thanks, Erik Brown, MS, LAT, ATC, CES, PES Doctoral Student University of Indianapolis browne001@uindy.edu 812-630-5768 INTERVENTION AND MENTAL HEALTH IN STUDENT-ATHLETES 66 Hello, You are receiving this email to send the link(s) to survey(s) and mindfulness intervention videos to your womens basketball student-athletes on an intervention for mental health issues in college-student athletes during the COVID-19 pandemic. Please click on the following link that will take participants to another Qualtrics survey that contains a Google form survey where participants will re-watch the 1st intervention video watch the 2nd video that is around 10 minutes. Here is the link to the third survey: https://qfreeaccountssjc1.az1.qualtrics.com/jfe/form/SV_ekzSB4bAkXnodPn Thanks, Erik Brown, MS, LAT, ATC, CES, PES Doctoral Student University of Indianapolis browne001@uindy.edu 812-630-5768 INTERVENTION AND MENTAL HEALTH IN STUDENT-ATHLETES 67 Hello, You are receiving this email to send the link(s) to survey(s) and mindfulness intervention videos to your womens basketball student-athletes on an intervention for mental health issues in college-student athletes during the COVID-19 pandemic. Please click on the following link that will take participants to the final survey. Participants will have 2 weeks to complete the 10-15 minutes post-intervention survey. Here is the link to the final survey: https://qfreeaccountssjc1.az1.qualtrics.com/jfe/form/SV_1GjoX6Xjl0sNmHX Thanks, Erik Brown, MS, LAT, ATC, CES, PES Doctoral Student University of Indianapolis browne001@uindy.edu 812-630-5768 INTERVENTION AND MENTAL HEALTH IN STUDENT-ATHLETES Appendix C 68 INTERVENTION AND MENTAL HEALTH IN STUDENT-ATHLETES 69 INTERVENTION AND MENTAL HEALTH IN STUDENT-ATHLETES 70  ...

... Dynamic Visual Acuity and Cervical Proprioception Following Adolescent Concussion Submitted to the Faculty of the College of Health Sciences University of Indianapolis In partial fulfillment of the requirements for the degree Doctor of Health Science By: Pam Cornwell, PT, DHSc, NCS Copyright June 30, 2022 By: Pam Cornwell, PT, DHSc, NCS All rights reserved Approved by: Stephanie Miller, PT, PhD, NCS Committee Chair ______________________________ Elizabeth S. Moore, PhD Committee Member ______________________________ Laura Morris, PT, NCS Committee Member ______________________________ Accepted by: Laura Santurri, PhD, MPH, CPH Director, DHSc Program Chair, Interprofessional Health & Aging Studies University of Indianapolis ______________________________ Stephanie Kelly, PT, PhD Dean, College of Health Sciences University of Indianapolis ______________________________ ADOLESCENT CONCUSSIONS 1 Dynamic Visual Acuity and Cervical Proprioception Following Adolescent Concussions Pam Cornwell Department of Health and Aging Studies, University of Indianapolis ADOLESCENT CONCUSSIONS 2 Abstract Prolonged dizziness is common among adolescents after a concussion. The source of dizziness can be multi-factorial involving the vestibular, ocular, or cervical sensorimotor pathways which make treatment challenging. Research has shown a high prevalence of abnormal Dynamic Visual Acuity (DVA) in adolescents following a concussion despite a lack of objective Vestibular Ocular Reflex impairments. The purpose of this study was to examine factors correlated with DVA and cervical proprioception in adolescents with dizziness after a concussion. This quantitative, non-experimental study used a correlational design and gathered data on 14 adolescents between 12 and 18 years of age referred to vestibular physical therapy after a concussion. Data were collected on participants characteristics and objective measures including DVA, Cervical Joint Position Error Test (JPET), Vestibular/ocular motor screening (VOMS), neck pain, and contact versus non-contact sports involvement. Using Pearson and Spearman rho, correlations among variables were examined. No associations were identified between DVA and Cervical JPET and most participants scored below clinical cut-offs. Negative moderate statistically significant correlations were found between DVA scores and the number of PT visits and between the average Cervical JPE measures and participants age. Mann-Whitney U and independent t tests were used to identify differences between participants' type of sport and with or without neck pain. Contact sport participation yielded a statistical difference for Cervical JPET but not DVA. No statistical differences were found between neck pain groups for primary variables. The results highlight the importance of a comprehensive evaluation following a concussion. Future research to better understand prolonged dizziness among adolescents after a concussion is necessary. ADOLESCENT CONCUSSIONS 3 Acknowledgements I would like to take this opportunity to express my immense appreciation for those people who have supported and encouraged me along this journey. First, I could not have completed this arduous task without the ongoing support of my family. To my husband, Steve, and two children, Julianna and Anderson, your love and understanding are beyond words. You never wavered from your belief in my ability to complete this endeavor. To my Mom and mentor, Nancy Hoffman, whose experience and wisdom in the process was invaluable. Next, I would like to thank my Northwestern team including Dr. Brian Babka and the Aurora Rehab staff. Dr. Babka encouraged and assisted me in recruiting individuals for the study. Also, my team at Aurora had my back and was keeping an eye out for any potential participant amidst the unprecedented times of COVID. Finally, I am extremely grateful for my entire doctoral committee of experts. To my content expert, Laura Morris, thank you for brainstorming with me and fostering the development of this idea. I feel incredibly honored to have had an opportunity to work with such an expert in my field. To my analysis expert, Dr. Elizabeth Moore, thank you so much for your patience, experience, dedication, and thoroughness. I learned a great deal from you about the entire research process. Lastly, to my committee chair, Dr. Stephanie Miller, thank you for your guidance, ongoing encouragement, and research expertise in the field of physical therapy. I am exceedingly grateful that you agreed to serve as my chair and had faith in my study even when the world around me seemed to be working against me and my efforts. ADOLESCENT CONCUSSIONS 4 Table of Contents Title page .........................................................................................................................................1 Abstract ............................................................................................................................................2 Acknowledgments............................................................................................................................3 Chapter 1: Introduction ....................................................................................................................9 Background ..........................................................................................................................9 Problem Statement .............................................................................................................10 Purpose Statement ..............................................................................................................10 Research Questions ............................................................................................................10 Significance of the Study ...................................................................................................11 Chapter 2: Literature Review .........................................................................................................11 Post-Concussion Dizziness ................................................................................................12 Vestibulo-Ocular, Cervical Impairments ..........................................................................13 Vestibular and Oculomotor Dysfunction in Concussion ..................................................14 Cervical Proprioception Impairment and Concussion ......................................................16 Vestibular and Cervical Rehabilitation Post-concussion ..................................................18 Chapter 3: Method .........................................................................................................................19 Study Design ......................................................................................................................19 Participants .........................................................................................................................19 Setting ................................................................................................................................20 Data ....................................................................................................................................20 Instruments .........................................................................................................................22 Procedures ..........................................................................................................................27 Data Analysis .....................................................................................................................30 ADOLESCENT CONCUSSIONS 5 Chapter 4: Results ..........................................................................................................................31 Research Question 1 ..........................................................................................................32 Research Question 2 ..........................................................................................................32 Chapter 5: Discussion and Conclusion ..........................................................................................33 Dynamic Visual Acuity Results .........................................................................................34 Cervical Proprioception Results ........................................................................................37 Clinical Application ...........................................................................................................40 Study Limitations and Implications for Future Research ..................................................41 Conclusion .........................................................................................................................42 References ......................................................................................................................................44 ADOLESCENT CONCUSSIONS 6 List of Tables Table 1: Descriptive Statistics for Participant Demographics and Injury Characteristics ............ 62 Table 2: Descriptive Statistics Age and Injury Characteristics .................................................... 63 Table 3: Descriptive Statistics for Outcome Variables ................................................................. 64 Table 4: Spearman Rho Correlations Between Outcome Variable Scores ................................... 66 Table 5: Correlations with Demographics and Participant Impairment Variables ....................... 68 Table 6: Comparison of Outcome Variables Between Non-Contact and Contact Groups ........... 69 Table 7: Comparison of Outcome Variables Between Neck Pain and No Neck Pain Groups ..... 70 ADOLESCENT CONCUSSIONS 7 List of Figures Figure 1: Participant Recruitment Flowchart ................................................................................ 71 ADOLESCENT CONCUSSIONS 8 List of Appendices Appendix A: Northwestern Memorial Healthcare Institutional Review Board Approval Notice .72 Appendix B: University of Indianapolis Institutional Review Board Notification of Approval ...75 Appendix C: IRB Yearly Check-in Notice ....................................................................................77 Appendix D: Vestibular/Ocular Motor Screen Scoring Sheet .......................................................78 Appendix E: Dizziness Handicap Inventory ..................................................................................80 Appendix F: Cervical Joint Position Error Target .........................................................................83 ADOLESCENT CONCUSSIONS 9 Dynamic Visual Acuity and Cervical Proprioception Following Adolescent Concussions An estimated 1.6 to 3.8 million people experience a concussion from a sport or recreational activities in the United States annually (Centers for Disease Control [CDC], 2017; Harmon et al., 2013). Children and adolescents make up a sizable portion of these injuries (CDC, 2011). Children and adolescents who have a concussion experience prolonged recovery and are at risk for repeat concussions with catastrophic injury (Harmon et al., 2013). Concussions can result in vestibular, oculomotor, and cervical dysfunctions which present as sensorimotor and functional impairments that have potential long-term ramifications (Harmon et al., 2013; Reneker et al., 2018; Zemek et al., 2013). Complaints of headache, dizziness, imbalance, and impaired vision are common among adolescents post-concussion and are associated with delayed recovery, (Alsalaheen et al., 2010; Kontos et al., 2017; Lau et al., 2011), reduced visual reaction times (Cochrane et al., 2017), and may negatively impact neurocognitive performance (Sinnott et al., 2019). A high prevalence of children with post-concussion dizziness present with abnormal dynamic visual acuity (DVA) (Zhou & Brodsky, 2015), which is defined as the ability to stabilize ones gaze while ones head is moving (Schubert et al., 2008). Dynamic visual acuity impairments result from changes in the vestibular ocular reflex (VOR) causing impaired gaze stability (Dannenbaum et al., 2005). However, VOR abnormalities and peripheral vestibular dysfunction among children, adolescents, and adults are limited after a concussion as determined with specialized objective tests (Alshehri et al., 2016; Christy et al., 2019; Cochrane et al, 2021; Zhou & Brodsky, 2015). Therefore, the pathology involved in impaired DVA requires further investigation to improve post-concussion treatment, facilitate a faster return to function, and reduce the risk for subsequent concussions. ADOLESCENT CONCUSSIONS 10 The clinical test for DVA measures gaze stability and involves movements of the head and neck; however, the underlying mechanism of DVA is unclear and not fully understood (Schubert et al, 2008). Aside from DVA impairments, researchers have found prolonged postconcussion headaches and dizziness to be associated with cervical spine impairments including cervical proprioception (Kennedy et al., 2019; Kennedy et al., 2017; Reneker et al., 2018; Schneider et al., 2018; Schneider et al., 2014). Furthermore, cervical proprioception impairments are present in a high percentage of children and adolescents following a concussion but are less frequently assessed (Tiwari et al., 2019). Cervical proprioception provides sensory input from the neck to assist in postural control and gaze stabilization (Leigh & Zee, 2006). Despite the overlap in cervical proprioception and gaze stabilization testing procedures, a direct association between abnormal DVA results and cervical proprioception has not been examined (Leigh & Zee, 2006). Understanding the associations between the vestibular, oculomotor, and cervical systems and their contribution to dizziness in adolescents following a concussion is important for optimizing the quality of their care. The purpose of the study was to examine factors correlated with impaired dynamic visual acuity and cervical proprioception in adolescents experiencing dizziness following a concussion. The main research questions are: 1. Is there a relationship between DVA and cervical proprioception impairment following a sports-related concussion for adolescents and youth (ages 12-18 years) presenting with dizziness to outpatient vestibular therapy? 2. What patient impairments are most closely related to DVA and cervical proprioception in adolescents with dizziness following a concussion? ADOLESCENT CONCUSSIONS 11 With concussions on the rise within the adolescent population (Zhang et al., 2016), greater use of vestibular physical therapy is necessary for facilitating their return to function because of prolonged dizziness and imbalance. Impaired DVA is a common abnormal finding during a functional assessment of the vestibular system. Recovery of visual acuity during functional dynamic activities is imperative for adolescents to return to learning and sport. Beyond the vestibular system, symptoms of dizziness may be due to disruption in the other two afferent sensory systems which include the cervical proprioception and oculomotor systems. Efficiently and effectively diagnosing the source of dizziness by the vestibular physical therapist is essential for optimal quality of care. Literature Review Concussions can result in significant and enduring impairments for children and adolescents (Bey & Ostick, 2009; Kapadia et al., 2019) and cross-sectional cohort studies show the incidence of concussions among adolescents to be increasing (Zhang et al., 2016). When examined prospectively, symptom resolution following adolescent sports-related concussions required an average of 21-28 days rather than the previously estimated 7-10 days with the greatest improvement occurring within the first 14 days (Henry et al., 2016). Furthermore, postconcussion symptoms were present in 11% of children (ages 6 to 18 years) after three months (Barlow et al., 2010). Headache, dizziness, imbalance, double vision, and a variety of cognitive impairment symptoms are common among adolescents post-concussion and are associated with impaired visual reaction times (Cochrane et al., 2017) and delayed recovery (Alsalaheen et al., 2010; Kontos et al., 2017; Lau et al., 2011; Master et al., 2016). However, the differentiation of underlying impairments causing post-concussive dizziness can be challenging especially among ADOLESCENT CONCUSSIONS 12 adolescent athletes because it depends primarily on subjective self-reporting of symptoms (Duhaime et al., 2012). Post-Concussion Dizziness Subjective dizziness has been identified through prospective studies to be one of the only early predictors of prolonged recovery following a sports-related concussion (Lau et al., 2011). Yet, adolescents often have difficulty describing their symptoms (Reneker et al., 2015) and sometimes delay in reporting their symptoms (Asken et al., 2016). The underlying impairments contributing to dizziness and imbalance are difficult to diagnose because they result from a complex sensory integration process involving the vestibular, vision, and somatosensory systems and involve complex motor execution required for eye and head coordination, postural stability, and mobility (Akin et al., 2017). Post-concussive dizziness can result from one or multiple factors influencing these three afferent systems which contribute to body awareness, position sense, and balance (Schneider et al., 2018). The vestibular system is composed of central and peripheral components and functions as a sensory and motor system. The semi-circular canals and otoliths of the vestibular system provide sensory information while the vestibular-ocular reflex (VOR) and vestibulospinal reflex (VSR) offer gaze stability and postural control during head movements (Vidal et al., 2012). Disruption of the afferent information from the cervical region can also contribute to symptoms of dizziness and imbalance (Kristjansson & Treleaven, 2009). Cervical proprioception is essential to balance and postural control because it sends sensory information to the brain about the orientation of the head on the body and directly connects via projections to the vestibular nuclei with the visual and vestibular systems for efficient and coordinated movements (Kristjansson & Treleaven, 2009). ADOLESCENT CONCUSSIONS 13 Vestibulo-Ocular, Cervical Impairments Retrospective and cross-sectional data indicate that a substantial proportion of children and adolescents experience vestibulo-ocular, cervical, or a combination of both impairments following a concussion (Ellis et al., 2015; Kennedy et al., 2017; Renecker et al., 2018; van der Walt et al., 2019). Furthermore, studies of adolescent athletes following a sport-related concussion revealed central dysfunction causing either vestibular or oculomotor impairments (Leung et al., 2018; Reneker et al., 2018). According to Corwin and colleagues (2015), 81% of pediatric and adolescent patients demonstrate an abnormal VOR or abnormal dynamic balance at the evaluation following a concussion, and as many as 90% of children who experience prolonged symptoms of dizziness or unsteadiness and have been found to present with one or more abnormal balance and vestibular finding (Zhou & Brodsky, 2015). The prevalence of vestibular, oculomotor, and cervical dysfunction following sportsrelated concussion highlights the importance of screening for risk factors and impairments before and immediately following a concussion to provide optimal, individualized care (Zuckerman et al., 2016). Research suggests that a comprehensive assessment, followed by physical rehabilitation including vestibular and oculomotor training can reduce vertigo and improve balance and gait, resulting in an earlier return to sport (Alsalaheen et al., 2010; Gottshall & Hoffer, 2010; Kontos et al., 2018; Schneider et al., 2014). Additionally, the Consensus Statement on Concussion in Sport (McCrory et al., 2017) and expert opinion (Gottshall, 2011; Gurley et al., 2013; Kapadia et al., 2019; Kontos et al., 2017) recommend physical rehabilitation to manage vestibular, oculomotor, and cervical impairments and facilitate earlier recovery and return to prior function (Broglio et al., 2015; Schneider et al., 2014). According to van der Walt et al. (2019), the majority of patients with persisting post-concussive symptoms are referred to ADOLESCENT CONCUSSIONS 14 physical therapy for treatment of the neck, vestibulo-ocular systems, or both. Therefore, therapists need to recognize the multiple systems involved in patients following a concussion and a variety of interventions to address them. Vestibular and Oculomotor Dysfunction in Concussion Researchers have developed and tested clinical assessment tools to measure symptoms (Chen et al., 2007) and identify vestibular and oculomotor impairments associated with vestibular disorders (Whitney et al., 1999), specifically following a concussion (Anzalone et al., 2016; Elbin et al., 2018; Mucha et al., 2014). A brief symptom provocation measure called the Vestibular/Ocular Motor Screen (VOMS) has demonstrated high internal consistency, Cronbach's alpha = .92 (Mucha et al., 2014), and the ability to predict the return to sport following a sports-related concussion with predictive probability area under the curve (AUC) of .89 (Anzalone et al., 2016; Mucha et al., 2014). The Visual motion sensitivity (VMS) (odds ratio [OR] = 3.37; p < .01) and VOR (OR = 3.89; p < .01) domains were the most predictive components of the VOMS (Mucha et al., 2014). The VOMS also identifies prospective changes for patients with concussions when comparing baseline scores to post-injury scores using the total score and change scoring methods (Elbin et al., 2018). Furthermore, Tomczyk and colleagues (2021) found the change score method may provide more clinical utility in identifying specific impairments for treatment planning among adolescents and young adults after a concussion. Beyond vestibulo-ocular and oculomotor screening, the Functional Gait Assessment (FGA) for assessing balance and gait dysfunction have been found to have acceptable interrater (intraclass correlation coefficient [ICC] = .84), intrarater reliability (ICC = .83), and internal consistency (Cronbachs alpha = .89) in patients with vestibular disorders (Wrisley et al., 2004). Concurrent validity of the FGA was also established with the Activities-specific Balance ADOLESCENT CONCUSSIONS 15 Confidence scale (ABC) (rs = .53; p < .001), Berg Balance Scale (rs = .84; p < .001); and Timed Up & Go test (rs = -.84; p < .001) for identifying fall risk (Wrisley & Kum, 2010). A high prevalence of children with dizziness post-concussion present with gaze stabilization and DVA abnormalities (Corwin et al., 2015; Zhou & Brodsky, 2015). Furthermore, a recent prospective cohort study found a significant positive correlation between concussive impacts and DVA impairments (Miyashita & Ullucci, 2020). However, DVA (i.e. reduced visual acuity with concurrent movements of the head and a functional measure of the VOR) is not impacted by exertion in athletes. Therefore, the DVA may provide a more rapid assessment of the balance system in athletes compared to other balance tools including the Balance Error Scoring System (BESS) which is impacted by the athletes fatigue level and may lead to inaccurate results (Patterson et al., 2017). Findings of retrospective and prospective repeated measure studies examining vestibular rehabilitation following concussion show improvements in DVA, target acquisition, and target following (Gottshall & Hoffer, 2010; Story et al., 2018), as well as in outcome measures including Dizziness Handicap Inventory (DHI), Post-Concussion Symptom Scale (PCSS), VOMS, ABC, and FGA (Alsalaheen et al., 2010). Significant improvements in children were found in postural control following vestibular rehabilitation as well (Storey et al., 2018). However, the underlying source of DVA abnormality in concussion is unclear and may rather involve the central sensory integration of vestibular and visual input as the abnormalities appear to exist even in the absence of objective peripheral vestibular impairments (Zhou & Brodsky, 2015). Researchers have found limited impairment of the VOR in adolescent and young adult athletes following a concussion with rotational chair, cervical myogenic potential (c-VEMP) (Christy et al., 2019), and video head impulse tests (vHIT; Alkathiry et al., 2019; Alshehri et al., ADOLESCENT CONCUSSIONS 16 2016). Furthermore, a recent study by Cochrane et al. (2021) found no significant difference between concussed and non-concussed children and adolescents in objective clinical testing of the peripheral vestibular function and VOR. Impaired gaze stability, which is often functionally measured with DVA, has implications for children and adolescent athletes on and off the field. Vestibular ocular reflex dysfunction has been linked to a prolonged recovery of academic activities such as reading, writing, and computer skills (Corwin et al., 2015). Additionally, DVA is essential for maintaining focus during rapid head movements which are necessary for sports activities to allow for quick responses (Broglio et al., 2015). Lastly, a retrospective study has shown impaired VOR function is associated with prolonged recovery and a greater likelihood of developing post-concussion syndrome (Ellis et al., 2015). Cervical Proprioception Impairment and Concussion Several researchers have explored the role of the cervical spine and impaired cervical proprioception in dizziness following sports-related concussion (Morin et al., 2016), and have found the cervical spine contributes to prolonged post-concussion symptoms such as headache and dizziness (Cheever et al., 2021; Kennedy et al., 2019; Kennedy et al., 2017; Reneker et al., 2018; Schneider et al., 2018; Schneider et al., 2014). Whiplash and concussion injuries can result in neck pain (Cooper et al., 2003) and impaired cervical proprioception due to the density and complexity of sensory receptors throughout the cervical spine (Ellis et al., 2015). Cheever and colleagues (2021) found an increase in cervical joint reposition error among athletes with a history of contact sports. This finding appears to support the idea that cervical proprioception impairments can be associated with concussions. The altered proprioception contributes to a mismatch of sensory information when integrating with sensory input from the visual and ADOLESCENT CONCUSSIONS 17 vestibular systems and contribute to the sensation of dizziness (Kristjansson & Treleaven, 2009). Furthermore, children and adolescents may be at greater risk for cervical impairments following a concussion due to reduced neck strength (Ellis et al., 2015; Tiwari et al., 2019), ligamentous laxity and sensorimotor systems which are not yet fully matured (Quatman-Yates et al., 2012). Findings from retrospective chart reviews and case studies suggested a majority of patients had a cervicogenic component of dizziness after concussion (Kennedy et al., 2017). However, most of these patients respond well to neuromuscular reeducation to improve cervical proprioception and sensorimotor integration (Hammerle et al., 2019; Saviola et al., 2016). Hynes and Dickey (2006) found a strong relationship between concussion and whiplash-associated disorder symptoms following a sports-related injury when prospectively examining 183 hockey players (ages 15-35 years). Researchers of a case-controlled, repeated measure study found no differences in the perception of dizziness and cervical proprioception among participants with whiplash-associated disorder and those with an acoustic neuroma (Treleaven et al., 2008). However, the researchers did find some differences between both groups and controls in postural stability and smooth pursuits with the neck in a rotated position (Treleaven et al., 2008). This would seem to indicate concurrent engagement of neck and vestibular systems suggesting impaired cervical proprioception and sensorimotor control of the neck may involve an afferent mismatch between the two systems. In contrast, cross-sectional and prospective cohort studies of young athletes revealed the history of a concussion combined with altered cervical proprioception was predictive of a future head and neck injury (Hides et al., 2017) while vestibular ocular reflex and balance measures were not significantly different between injured and uninjured athletes (Hides et al., 2017; Leung et al., 2018; Schneider et al., 2018). Vestibular and Cervical Rehabilitation Post-concussion ADOLESCENT CONCUSSIONS 18 The most rigorous experimental study to date investigating combined cervical and vestibular rehabilitation for treatment of concussion is a randomized controlled trial by Schneider and colleagues (2014). Study participants randomized to the intervention group received cervical and vestibular rehabilitation compared to a group that only received patient education. Seventythree percent of the intervention group returned to sport within eight weeks, compared to 7% of the group receiving only the education (Schneider et al., 2014). Although many adolescents with persisting post-concussive dizziness are referred for cervical and vestibular therapy (van der Walt et al., 2018); no research has been published to our knowledge that has examined the direct relationship between DVA and cervical proprioception impairments following a concussion. The existing literature provides some preliminary evidence that both the cervical sensorimotor system and the vestibular system play a role in postconcussion symptoms of dizziness. Researchers recognize a significant overlap between these balance subsystems, making diagnosis and optimization of treatment challenging for clinicians, which in turn can prolong symptoms and treatment for patients. Yet, the specific roles of the cervical spine and the vestibulo-ocular systems in prolonged post-concussive dizziness are lacking clarity, as research in this area is primarily preliminary (van der Walt et al., 2018). Due to the ease at which symptoms can be exacerbated during clinical testing, clinicians need to be efficient in their identification of impairments and provide targeted treatment (Christy, 2018). The specific relationship between cervical sensorimotor dysfunction and vestibular deficits, as well as other existing adolescent impairments following a concussion, requires further investigation to determine optimal prevention, screening, and treatment strategies. ADOLESCENT CONCUSSIONS 19 Method Study Design This was a quantitative non-experimental study using a correlational design. This design allowed the examination of relationships among variables (Cottrell & McKenzie, 2011) associated with adolescents following a sports-related concussion. The correlational design assisted in determining if certain participant characteristics contributed more than others to DVA following sports-related concussions. The data collection portion of the study took place from February 2021 through February 2022. The study was approved by the institutional review boards of Northwestern Medicine (Appendix A) and the University of Indianapolis (Appendix B) before participant recruitment. Participants A convenience sample was recruited from all physical therapy orders received by Northwestern Medicine West Region Rehabilitation department for patients with the diagnosis of a concussion. Convenience sampling with the use of homogeneity of sample and adherence to inclusion and exclusion criteria increased control for extraneous factors unable to be controlled by lack of randomization (Polit & Beck, 2014). Adolescents between 12-18 years of age who had sustained a concussion and were referred to outpatient physical therapy were eligible for recruitment. Exclusion criteria were adolescents who had a known neurological injury other than concussion, known neuro-ophthalmological condition, fractures, or musculoskeletal injuries other than of the cervical spine within the previous 6 months, and positive clinical tests indicating cervical instability. Sample Size ADOLESCENT CONCUSSIONS 20 An a priori sample size estimation was conducted to identify an appropriate sample size for statistical significance using G*Power 3 (Faul et al., 2007). The DVA test and cervical JPET measures were the variables used to calculate the sample size for a Pearsons r correlation. The estimated sample size was 29 as calculated for a moderate effect size, a significance level of .05, and the power set at .80. A moderate effect size was chosen due to a lack of research suggesting an appropriate effect size (Cottrell & McKenzie, 2011). However, the estimated sample size was not achieved due to numerous externally imposed obstacles including the COVID-19 pandemic, reduced adolescent sports during the period of recruitment, and increased workplace restrictions. A sample size of 14 participants was achieved. A post hoc calculation for power, G*Power 3 (Faul et al., 2007), based on the sample size and statistical significance of .05 indicated the power ranged from .12 to .09 for the correlations of DVA scores and cervical JPET measures. Setting The setting for this study was an outpatient physical therapy clinic associated with a large, suburban hospital system in Illinois. The primary researcher (P. C.) performed informed consent and assent as well as the testing at two locations depending on patient preference and referrals. The setting for recruitment and data collection was standardized to a private, outpatient clinic environment. Data Data were collected on the following continuous variables: participants age (in years), duration of time since concussion injury (in days), length of stay in physical therapy (number of visits and weeks seen in therapy), Cervical JPET results (measured in cm for each of six trials to the right and the left), and score on non-instrumented DVA, DHI score (0-100), VOMS total ADOLESCENT CONCUSSIONS 21 scores and change scores (0-40) for individual domains including VMS and HVOR, and NPRS score (0-10) when pain was present. Nominal variable collected included the participant's gender and contact versus noncontact sport involvement. Operationalization and Definition of Variables The operationalization and definitions for the following variables was used for this study. Cervical proprioception Within this study, cervical proprioception was defined as the sensory afferent input from the neck which integrates with vestibular and visual input to provides neuromuscular control of the cervical spine (Kristjansson & Treleaven, 2009) and was assessed by the cervical JPET (Swait et al., 2007). Contact sport For the purposes of this study, contact sports were identified according to the Family Practice Notebook (Moses, 2021). Contact sports included wrestling, hockey, football, and soccer. Dizziness For this study, dizziness was any subjective complaint of dizziness, vertigo, imbalance, or unsteadiness experienced by the participant since the concussion injury. Dizziness was measured according to the subjective perception of handicap related to the participants symptoms utilizing the DHI (Jacobson & Newman, 1990; Shirley Ryan AbilityLab, 2013). Dynamic visual acuity For this study, DVA was the ability to stabilize ones gaze while ones head is moving and was assessed by change in function from stable acuity compared to head motion acuity at 2 Hz measured as line differential (Dannenbaum et al., 2005) when reading an Early Treatment Diabetic Retinopathy Study (ETDRS) chart (Shamir et al.2016). ADOLESCENT CONCUSSIONS 22 Horizontal Vestibular Ocular Reflex (HVOR) For the purposes of this study, HVOR was defined as the participants' tolerance to horizontal head movement while maintaining a focal point on a target. A participant's HVOR was measured according to the HVOR subtest on the VOMS using the total symptom score (TSS) (Mucha et al., 2014) and total symptom change score methods (TSCS) (Elbin et al., 2018; Yorke et al., 2016). Neck pain Participants neck pain was defined as a subjective rating of his or her neck pain according to the NPRS and self-selecting a number between 0-10 representing their level of intensity (Herr et al., 2004). Oculomotor control Oculomotor control was defined as the ability to control one's eye movements and visually maintain focus on and change gaze to a target. Oculomotor control impairments included any subjective report of visual or perceptual complaints including double vision or blurred vision. Oculomotor control was screened according to the VOMS including the smooth pursuit, horizontal and vertical saccades, and near point convergence (NPC) (Mucha et al., 2014). Visual Motion Sensitivity (VMS) For the purpose of this study, VMS was defined as a participants' tolerance to visual motion and ability to utilize vision for inhibition of vestibular induced eye movements (Quintana et al., 2021). The participant's VMS was measured according to the VMS subtest on the VOMS using the total score method (Mucha et al., 2014) using the change score method (Elbin et al., 2018; Yorke et al., 2016). ADOLESCENT CONCUSSIONS 23 Instruments Instruments used within this protocol are all recommended performance and self-report outcome measures for the assessment of impairments following a concussion. Based on the subjective information, the patients history, and the time allotted for a typical evaluation, the combined performance measures are not always performed during the initial evaluation as they were within this protocol. Instead, often some of them are typically performed within a second or third visit with the physical therapist. The DHI is most often used as the primary self-report measure if a patient presents with dizziness and the NPRS is commonly used as a preferred pain rating scale for physical therapy and other healthcare professionals. In practice, the VOMS or similar oculomotor and vestibular ocular testing is performed and often includes the DVA during the first visit. Frequently, therapists do not have the time to administer the cervical JPET during the initial evaluation and defer to subsequent visits. Dynamic Visual Acuity Dynamic visual acuity was measured according to the non-instrumented test per the protocol described by Schneider et al. (2018) with the use of the ETDRS eye chart (Shamir et al., 2016) adapted from Dannenbaum et al. (2005). The DVA non-instrumented test was found to have excellent criterion validity as evidenced by a sensitivity (100%) and specificity (100%) with passive yaw plane testing when comparing children with bilateral vestibular hypofunction to normal developing children or adults (Rine & Braswell, 2003). Test-retest reliability and interrater/intrarater reliability were also found to be excellent with intraclass correlation coefficients (ICC) = .94 and .84 respectively (Rine & Braswell, 2003). Christy et al. (2014) found a minimal detectable change (MDC90) of 8 optotypes or approximately 1.6 lines for the DVA performed with children (6-12 years old). The DVA sensitivity is 88% and specificity is ADOLESCENT CONCUSSIONS 24 69% among children for predicting vestibular hypofunction with a cutoff score of 10 optotypes or 2 lines (Christy et al., 2014) Cervical Joint Position Error Test The cervical JPET test also described by some as the cervical relocation test was used to measure cervical proprioception and sensorimotor function by measuring the degree of joint position error (Reiley et al., 2017). The test was performed within this study as described by L'Heureux-Lebeau et al. (2014) utilizing the target developed by Landel (2019) and adapted from Revel et al. (1991) and Treleaven et al. (2003). Normal cervical proprioception has been established as joint position error < 4.5 degrees with a sensitivity of 86% and a specificity of 93% in patients with chronic cervical pain (Revel, et al., 1991). The Cervical Relocation test was found to have a sensitivity of 72% and a specificity of 75% when differentiating between cervicogenic vertigo and benign paroxysmal positional vertigo (L'Heureux-Leabeau et al., 2014). Test-retest reliability for relocation to neutral head position was found to be adequate to excellent with ICC = .45 .80 (Lee et al., 2006). Interrater and intrarater reliability among physical therapists has been found to range from ICC = .97 .99 in patients following whiplash injury (Loudon et al., 1997). Additionally, the cervical relocation test demonstrates predictive validity with 60% sensitivity and 54% specificity for whiplash-associated disorders and healthy controls (Treleaven et al., 2006) and discriminant validity (Treleaven et al., 2003). Loudon et al. (1997) also found a significant difference between an average error score with patients with whiplash compared to normal controls. Dizziness Handicap Inventory Two self-report measures were also completed to assess participants' subjective perception of their symptoms of dizziness and pain as well as the associated handicap. The DHI ADOLESCENT CONCUSSIONS 25 has been found to have strong psychometric properties for vestibular dysfunctions (Shirley Ryan AbilityLab, 2013) and has been utilized to quantify levels of impairment and subjective dizziness in patients following a concussion (Alsalaheen et al., 2010; Quatman-Yates et al., 2020). Jacobson and Newman (1990) demonstrated excellent test-retest reliability (r = .97) and excellent internal consistency (Cronbachs alpha = .89) for total score with central and peripheral vestibular pathology. Criterion validity has also been established. An excellent correlation was found between the DHI and the Activities-specific Balance Confidence scale (r = -.64) (Whitney et al., 1999) and a good correlation was found between DHI and the Short Form Health Survey (SF-36) in persons with vestibular disorders (r = .53 to .72) (Fielder 1996). Furthermore, Gottshall et al. (2003) found a significant correlation between DHI and DVA test one week following a mild traumatic brain injury. Vestibular/Ocular Motor Screen The VOMS was used to screen for vestibular and ocular impairments. The VOMS is a brief symptom provocation measure that assesses four domains including headache, dizziness, nausea, and fogginess within the oculomotor and vestibular ocular subtests of smooth pursuits, horizontal and vertical saccades, convergence, horizontal and vertical vestibular ocular reflex (HVOR and VVOR), and VMS (Kontos et al., 2017). Participants rated their symptoms of headache, dizziness, nausea, and fogginess before and after performing the test components on a Likert-type scale where 0 indicated no symptoms and 10 indicates severe symptoms (Alkathiry et al., 2019; Kontos et al., 2017). A total symptom score (TSS) and total symptom change score (TSCS) for each subtest can then be calculated (Yorke et al., 2016). The VOMS has demonstrated high internal consistency Cronbachs = .92 - .97 and sensitivity using the total symptom score (Moran et al., 2018; Mucha et al., 2014), and a medium ADOLESCENT CONCUSSIONS 26 to high internal consistency for the individual subtests (Iverson et al., 2021). However, Tomczyk and colleagues (2021) suggested change scores can be even more clinically useful in assessing an individuals vestibular and oculomotor impairments following concussion among high school and collegiate athletes. Additionally, researchers have reported the use of overall change scores and identified an associated optimal clinical cut-off of 3 points with an AUC of .73 (Elbin et al., 2021). The VOMS has growing research supporting its use in acute sports-related concussion assessment. The tool can identify concussed from non-concussed athletes (Mucha et al., 2014) and yields very low rates of false positives among children and adolescents (Iverson et al., 2021; Moran et al., 2018). The VOMS can also predict the return to sport following sports-related concussion (Anzalone et al., 2016) and document prospective changes (Elbin et al., 2018) including those associated with athletes who are receiving vestibular physical therapy (Alsalaheen et al., 2020). Combining the scores for VOR, VMS, and near-point convergence (NPC) resulted in a predictive probability AUC of .89 for recognizing a concussion injury (Mucha et al., 2014). Furthermore, researchers have found testing order not influential in the severity of scores among healthy high school athletes (D'Amico et al., 2021), and the tool shows greater stability under athletic exertion compared to other frequently utilized assessment tools for this population (Worts et al., 2018). Lastly, the VOMS items demonstrate moderate concurrent validity with the Post Concussion Symptom Scale (PCSS) (Mucha et al., 2014) and a moderate to strong concurrent validity with the DHI sub-scales (Eagle et al., 2022). Numeric Pain Rating Scale Lastly, neck pain was also assessed as part of the evaluation using the NPRS. Herr and colleagues (2004) found excellent interrater reliability with 100% agreement between two testers ADOLESCENT CONCUSSIONS 27 and excellent internal consistency (Cronbachs alpha = .87 - .88). Additionally, excellent convergent validity has been established with the Visual Analog Scale (r = .94, 95% CI [.93.95]) (Bijur et al., 2003). Procedures Screening When a new patient was referred to outpatient vestibular physical therapy with a diagnosis of concussion, the primary researcher who was also the evaluating therapist, performed a thorough chart review of the patients EMR before the evaluation visit to determine if the patient met the study eligibility. A total of 23 adolescents with a concussion were referred to vestibular physical therapy during the recruitment period and screened for eligibility for enrollment into the study. Recruitment For patients who met the criteria for enrollment, the evaluating therapist contacted the potential participant's guardian via phone prior to the day of the evaluation. During the phone conversation, the evaluating therapist (P. C.) introduced the study, informed the guardian of the patient's eligibility, and specified they would receive further information on the study when they present for the physical therapy evaluation. For patients who expressed interest in participating in the study, a 15-minute extra time block was allotted just prior to the evaluation for further discussion of the study. Recruitment started in February 2021 following obtaining approval from both the Northwestern and University of Indianapolis IRBs and continued until February 2022. Fourteen participants were enrolled in the study. A flowchart is provided in Figure 1 indicating the reasons for exclusion or inability to recruit participants. ADOLESCENT CONCUSSIONS 28 Informed Consent and Assent If the study participant's parent or guardian agreed to study participation, the informed consent and assent process was conducted prior to the onset of the physical therapy evaluation. Study participants and their guardian were informed of any risks or benefits in participating in the study as well as Health Insurance Portability and Accountability Act (HIPAA) requirements by the evaluating therapist. Information regarding how the data would be utilized and secured by the research team was discussed. If in agreement, participants and guardians were asked by the evaluating therapist/primary researcher to complete an assent and consent form, respectively. All participants and their guardians were given opportunities to have any questions or concerns regarding the study addressed before the physical therapy evaluation began within the outpatient physical therapy clinic. The consent and assent documents were stored in the media manager of the EMR. Testing During the physical therapy evaluation, instruments used were tests and measures standard and recommended for the practice of vestibular therapists specialized in treatment in patients with concussions, are free for clinician use, and have documented reliability and validity. Those instruments include the following: the DVA, Cervical JPET, NPRS, VOMS, and DHI. The physical performance tests and measures of oculomotor, vestibular, and cervical proprioception systems which were included in the study were collected in a standardized manner including identical instructions given to participants when conducting the tests in an outpatient clinical examination room. Tests and measures were performed in the same sequence and as described in Shirley Ryan AbilityLab rehabilitation measures database for the DVA (2014), JPET (2013), and NPRS (2013). The VOMS was performed according to procedures ADOLESCENT CONCUSSIONS 29 described by Mucha et al. (2014). The DVA was performed in standing and the remaining tests were performed in sitting. The DHI, a self-report measure, was issued and completed by the participant before the evaluation. Data Collection During each participants evaluation, P. C. recorded the measures in the EMR as is standard practice for a physical therapy evaluation. Then, immediately following the evaluation, the therapist calculated and scored the outcome measures and recorded the raw and total scores within the EMR. Each calculation was performed at least twice to ensure accurate calculations. Calculations computed included the mean score of the cervical JPET test, the total sum score on the DHI, the total and change scores on the VOMS for VMS and HVOR subtests (0-40), the change score of the dizziness domain for the VMS and HVOR (0-10), and the differential score for the DVA two conditions. Any paper documents including the self-report measure (DHI) and the JPET target with individual trials marked, were uploaded into the media manager of the NWM EMR for future reference. The written evaluation and calculated scores were recorded in the EMR within 24 hours of completion. Data of interest for this study was then extracted from Epic, the NWM EMR, by the primary researcher and transferred to a password protected Excel spreadsheet. At that time, the data was screened for accuracy and missing data. To assess for accuracy, the primary researcher recalculated scores in Excel using the raw scores from the paper documents scanned into Epic and compared to the recorded calculated scores. If data appeared to be missing, the primary researcher returned to the medical record to collect necessary data or followed up with the participant and parent as appropriate. Names and personal identifiers were not used by the primary researcher when extracting from the EPIC EMR database and transferring to the Excel spreadsheet. At that time, participants were assigned a unique, 8-digit ADOLESCENT CONCUSSIONS 30 identification number representing the clinic, month and date of the evaluation, and sequential order following recruitment into the study. Data Management The primary researcher imported data into the IBM SPSS for Windows, Version 28.0 (IBM Corp., Armonk, NY) and prepared the data for analysis once an appropriate sample size had been reached. Data were stored on the primary researchers password protected NWM assigned laptop computer. Data were cleaned to identify any outliers and rectify any data entry errors (Cottrell & McKenzie, 2011). The owner of this data was NWM and procedures for data utilization were addressed according to the NWM and University of Indianapolis IRB requirements. Data Analysis Data analysis was conducted utilizing IBM SPSS for Windows, Version 28.0 (IBM Corp., Armonk, NY). All tests were two-tailed, and an alpha level of .05 was considered statistically significant. Descriptive statistics were calculated to describe the sample and outcome variables. Continuous variables were reported as means, standard deviations, medians, and minimum and maximum values. Non-normally distributed continuous variables were identified according to the Shapiro-Wilk test and noted. Continuous variables included participants' age (years), duration of time since concussion injury (in days), length of stay in physical therapy (number of visits), length of stay in weeks, Cervical JPET (measured in cm and an average score for 6 trials to the right and left), score on non-instrumented DVA test, DHI score (0-100), VOMS VMS and HVOR scores (0-40), and NPRS score (0-10) when neck pain was present. Nominal data including gender (female, male) , sport involvement (contact, non-contact), and presence of neck pain (yes, no) were reported as frequencies and percentages. ADOLESCENT CONCUSSIONS 31 Inferential statistics were also conducted to determine the correlation among variables. Bivariate correlation results and scatterplots were assessed for linear relationships, outliers, and homoscedasticity (Keller & Kelvin, 2013). To address the research question of what the relationship is between Cervical JPET scores (right, left, and average) and DVA scores (line differential) post-concussion, Spearman rho correlations were used (Cottrell & McKenzie, 2011; Keller & Kelvin, 2013). To address the second research question, Spearman rho correlations were used to assess the association between DVA scores and other participant impairment variables. Pearson correlation coefficients were used to determine associations between Cervical JPET measures and other participant impairment variables except for VOMS measures, LOS in weeks, and age in years which required nonparametric Spearman rho correlations. Correlation strength was interpreted using the descriptive terms as follows: .30 < r < .50 = weak correlation; .50 < r < .70 = moderate correlation; and r > .70 = strong correlation (Moore et al., 2013). A Fishers exact test was conducted to determine whether differences existed between adolescents who had a concussion resulting from a contact sport versus a noncontact sport and neck pain or no neck pain. An independent t test was performed to compare Cervical JPET scores to whether or not the concussion was due to contact or non-contact sports and the MannWhitney U for DVA scores. Appropriate bivariate analysis tests (Fishers exact, independent t, and Mann-Whitney U) were also run for secondary outcome variables including the VOMS and participant demographics to determine if differences exist. Results Descriptive statistics for the overall demographics of the participants are displayed in Table 1 and 2. Of the 14 adolescents enrolled in the study (M = 14.6, SD = 1.34, range = 12-17 years), a total of 50% (n = 7) of the sample was female. Fifty percent (n = 7) presented with neck ADOLESCENT CONCUSSIONS 32 pain and 64.3% (n = 9) experienced a concussion resulting from a contact sport. Participants mean age was 14.64 years and the mean days from injury until the first clinical visit was 15.79. Descriptive statistics for the primary study variables are displayed in Table 3. A minority of participants, 28.6% (n = 4), had an abnormal DVA score (i.e., greater than 2-line differential); however, most participants, 64.3% (n = 9), reported dizziness with DVA testing. A minority of participants also had an abnormal finding for the right, left, and average Cervical JPET measures. However, 85.7% (n = 12) had VOMS change scores above the clinical cutoff for the VMS subtest and 71.4% (n = 10) were above clinical cutoff for the HVOR subtest. In addition, 85.7% (n = 12) participants had a moderate to severe perception of handicap on the DHI. Research Question 1 Spearman rho correlations were used to determine the association between DVA scores and Cervical JPET measures. Please see Table 4. Overall, the correlations between the DVA scores and the Cervical JPET scores ranged from .17 to .22. However, they did not meet statistical significance (p < .05), and therefore, no association between variables was found. Research Question 2 Correlations between primary outcome variables and other outcome variables are also displayed in Table 4. The associations between DVA scores and other outcome variables were mostly negligible to weak and exceeded the significance level of .05. The association between the DVA score and the HVOR dizziness domain change score using the Spearman rho approached a moderate level of association, rs = .46; p = .098. Most correlations between Cervical JPET measures and other outcome variables range from -.46 to .40 but did not meet statistical significance (p < .05). However, right Cervical JPET and VOMS baseline scores showed a moderate statistically significant positive correlation (rs = .56, p = .036). Correlations ADOLESCENT CONCUSSIONS 33 between primary outcome measures and participant demographics can be seen in Table 5. Negative moderate statistically significant correlations were found between DVA score and number of PT visits (rs = -.59, p = .028) and the average Cervical JPE measures and participants age (rs = -.57, p = .033). A Mann-Whitney U test was used to determine if there was a significant difference between DVA scores for those with contact and non-contact involvement, but no significant statistical differences were found. Please see Table 6. An independent t test was used to compare Cervical JPET measures and number of PT visits to determine if differences among participants with a concussion from contact versus non-contact sports were statistically significant. A statistically significant difference was found t(12) = 2.87, p = .014, 95% CI [-2.93, -.398] for the left Cervical JPET. The effect size was huge (d = 1.60). Furthermore, a significant difference in mean Cervical JPET measures was also found between participants who had a contact concussion and those who dd not, t(12) = -2.33, p = .038, 95% CI [-3.08, -1.01] with a very large effect size (d = 1.30). In addition, a difference was found for PT visits t(12) = 2.32, p = .039, 95% CI [0.37, 11.54] with a very large effect size (d = 1.29). Lastly, a Mann-Whitney U test was used to determine if any differences existed between participants with or without neck pain for DVA scores and VOMS subtests. The Mann-Whitney U test, Z = -2.82, p = .005 indicated the groups differed statistically for VOMS baseline score at an alpha level of .05 with a huge effect size (d = 2.29). Please see Table 7 for additional results. An independent t test was used to determine if any differences existed for Cervical JPET measures and PT visits, but no statistically significant differences were found between participants with or without neck pain. ADOLESCENT CONCUSSIONS 34 Discussion The purpose of this study was to examine whether an association exists between DVA and cervical proprioception among adolescents following a concussion and to identify the characteristics or impairments most closely related to those measures. A negligible association was found between the primary outcome variables of DVA scores and cervical JPET measures. Furthermore, most of the participants scored below the clinical cut-off for both primary outcome measures, indicating most participants fell within the normal limits for DVA and cervical joint repositioning errors despite their moderate level of perceived disability from dizziness. This suggests their experience of dizziness cannot be simplified to a single, direct association with their peripheral vestibular or cervical sensorimotor systems. Although a relationship was not found between the two primary outcome variables, a few clinical gems were identified. Dynamic Visual Acuity Results In this study, only 28.5% (n = 4) of participants presented with an abnormal clinical DVA while over twice as many experienced provocation or exacerbation of dizziness with the testing. These results expand upon the current conflicting evidence within the literature regarding VOR and DVA testing following a concussion. Many authors have found abnormalities above the normal clinical threshold for DVA post-concussion (Gottshall et al., 2003; Schneider et al., 2014; Wright et al., 2017; Zhou & Brodsky, 2015) or a positive correlation between DVA loss and head impacts (Miyashita & Ullucci, 2020). However, other researchers have not found a DVA change or loss following a concussion (Alshehri et al., 2016; McDevitt et al., 2015; Schneider et al., 2018). Moreover, Cochrane and colleagues (2021) reported no differences between children with and without a concussion for objective clinical tests of vestibular, balance, or oculomotor function. ADOLESCENT CONCUSSIONS 35 Within the study performed by Zhou and Brodsky (2015), a much higher percentage, 55%, of children (n = 23) were found to have abnormal DVA testing compared to the current study. This difference could be due to multiple factors. First, their sample differed in multiple ways. The mean age of their sample was younger (M = 13.9 years, SD = 2.8) with a broader age range (8 18 years) as well as unequal in gender with 25 females and 17 males. Also, in general, participants were tested less acutely (M = 26 weeks, SD = 20; range = 1 - 96) than in the current study (Zhou & Brodsky, 2015). Finally, computerized DVA test was utilized in their study. Resultantly, the researchers were able to determine the laterality of the DVA function and identified some participants with unilateral abnormalities. The clinical non-instrumented DVA test utilized in the current study does not have the same capability. In contrast to Zhou and Brodsky's study (2015), Schneider and colleagues (2018) worked with a sample of similar age to the current study (13 17 years). However, their participants were predominantly male (83.6%). They found no difference in either non-instrumented or computerized DVA testing pre- and post-concussion. However, in comparison to the current study, a similar median of 2 and range of 1 to 3 was reported for their clinical DVA repeat measures post-concussion. Although DVA loss has not been consistently identified with testing throughout the literature, symptoms experienced during the DVA or other VOR testing post-concussion do seem to be a consistent finding (Alshehri et al., 2016; Christy et al., 2019; Corwin et al., 2015; Ellis et al., 2015; Wright et al., 2017). Alshehri et al. (2016) did not find statistically abnormal degradation of visual acuity or an abnormal gain during a dynamic task compared to the stable condition, but did find an increase in headache, dizziness, and nausea during the testing. Similarly, Christy et al. (2019) found no difference between concussed and non-concussed ADOLESCENT CONCUSSIONS 36 athletes for VOR function according to rotational chair testing or Cervical Evoked Myogenic Potential (cVEMP) test; yet the majority of concussed athletes had symptom provocation, especially at higher frequencies. Furthermore, in this current study, most participants were above the abnormal cut-off for the VOMS change score and more specifically the HVOR change score which reflects an increased symptom provocation with a dynamic visual acuity task. Whether or not the score is above the clinically abnormal threshold, symptom provocation with DVA testing is clinically relevant. This is especially the case when assessing adolescents who are struggling to return to school or want to return to their sport. Provocation of symptoms with dynamic gaze stability (VOR) can negatively impact the attention and concentration necessary for reading and computer use and lead to less desirable outcomes. Similarly, the ability to focus on a target with clear vision while one's head and body are moving without symptoms interfering with the task is essential for an athlete to safely perform complex balance and agility skills. Wallace and Lifshitz (2016) have argued that "provocation of symptoms during the DVA indicates injury-induced damage" (p. 160). Some other authors have suggested that abnormal DVA testing may not reflect a specific peripheral vestibular system injury or impairment but rather may reflect dysfunction of the central processing of visual and vestibular sensory input (Christy et al., 2019; Zhou & Brodsky, 2015). Furthermore, the history of motion sickness or sensitivity susceptibility also appears to be predictive of prolonged vestibular ocular impairments and associated with a greater number of adolescents' affective complaints post-concussion (Sufrinko et al., 2019). The current study found the DVA score was approaching a weak positive correlation with the VOMS VMS change score for the dizziness domain within this current study as well. Recent research has implicated motion sickness susceptibility as a possible preexisting risk factor for prolonged vestibular ocular dysfunction ADOLESCENT CONCUSSIONS 37 post-concussion (Elbin et al., 2019) and may be linked to the symptom provocation observed with DVA testing in the current study and other similar findings. A statistically significant moderate negative correlation between DVA and PT visits was identified in this study. According to this statistical finding, participants who were above the abnormal cut-off for the DVA required fewer physical therapy visits to return to their normal level of function. However, one of the four participants stopped therapy without a formal discharge due to work commitments, and therefore, her exact status and function are unknown. Although everyone experiences different symptoms and recovery trajectories with a concussion, patients who have greater severity or number of symptoms initially seem to experience prolonged recovery (Iverson et al., 2017). Therefore, this finding conflicts with much of the prior evidence. With such a small sample size, an abrupt discharge from therapy may have contributed to the unexpected findings. Cervical Proprioception Results The cervical JPET correlations and comparisons yielded multiple clinically relevant results. First, a statistically significant difference was found for the left and average cervical JPET between those participants engaged in contact versus non-contact sports. Those participants engaged in contact sports had greater cervical repositioning errors, especially with left repositioning to center from a right rotated position. This finding supports prior literature results in which athletes who have engaged in contact sports have had greater cervical spine JPET (Cheever et al., 2021b; Hides et al., 2017; Lark & McCarthy, 2007; Leung et al., 2022; Pinsault et al., 2010). Additionally, Hides and colleagues (2017) found left repositioning to neutral from a right cervical rotation position to have significantly greater odds of sustaining a head and neck injury during contact sports. This asymmetrical finding seems to correspond with ADOLESCENT CONCUSSIONS 38 the current study and deserves further examination to determine whether this might relate to dominant handedness or another internal or external characteristic of the athlete. Within the current study, only two participants in the contact group were female, and therefore, most of the contact group was male while the entire noncontact group was female. This may indicate gender as a differentiating factor in cervical proprioception among contact and noncontact groups. Much of the prior literature involving the assessment of contact groups and cervical proprioception has largely investigated males and male-dominated sports (Farley et al., 2021; Hides et al., 2017; Lark & McCarthy, 2007; Leung et al., 2018; Leung et al., 2022). A few have more recently begun to look at female participation (Cheever et al., 2021a) or mixed groups (Cheever et al., 2021b; Schneider et al., 2018). Continued investigation of females engaged in contact sports compared to males may be warranted. The number of required PT visits was significantly more for the current study's noncontact versus the contact group. According to Iverson and colleagues (2017), gender does appear to be a risk factor for prolonged recovery. In general, females take longer to recover from a concussion and tend to report more symptoms before and after the injury (Iverson et al., 2017). Another association identified in this study was a moderate negative correlation between the average cervical JPET measure and the participants age. This indicates the younger participants in this study were more likely to have cervical repositioning errors. This finding may reflect their sensorimotor development. A systematic review on sensorimotor function during adolescence by Quatman-Yates and colleagues (2012) reported that sensorimotor regressions are common in adolescence and a greater risk for injury may exist for those adolescents who are experiencing a growth spurt or adolescent awkwardness. Their findings would appear to ADOLESCENT CONCUSSIONS 39 substantiate why younger participants in this study had greater impaired cervical proprioception in general. Interestingly, no difference was found in cervical JPET measures among participants with or without neck pain. Although most participants did not have cervical JPET measures above the clinical cut-off for abnormality, a significant difference was not found between the groups for right, left, or average repositioning errors. Typically, the presence or absence of neck pain and a known neck injury are factors that direct an evaluating therapist to assess cervical sensorimotor function with the cervical JPET or another such measure to determine if a portion of a patient's dizziness is cervicogenic, resulting from the cervical spine (Aligene & Lin, 2013; Reiley et al., 2017; Treleaven, 2017). A key feature in differentiating cervicogenic dizziness from vestibular dysfunction is the associated neck pain (Ernst et al., 2005). However, in the case of a concussion, differentiating between the symptoms resulting from the concussion or a possible subsequent neck injury can be challenging due to their shared causes and symptoms (Cheever et al., 2016). Previous authors have emphasized the importance of screening the neck because neck pain is a common symptom occurring following a concussion (Benson et al., 2011; Schneider et al., 2018), and comorbidity of cervical dysfunctions can contribute to prolonged recovery following a concussion, especially among pediatric athletes (Cheever et al., 2021c; Ellis et al., 2018). Kennedy and colleagues (2019) reported that 90% of patients with persistent symptoms after a concussion had neck problems, particularly in the upper cervical spine. The current study would support the importance of screening the cervical spine and cervical proprioception following a concussion regardless of neck pain. Neuromuscular reeducation and sensorimotor retraining are beneficial in reducing dizziness after a concussion. However, a retrospective study involving 73 children and ADOLESCENT CONCUSSIONS 40 adolescents revealed that cervical joint proprioception is not examined in a large percentage of children and adolescents post-concussion when examining the cervical spine involvement (Tiwari et al., 2019). Furthermore, Bailey et al. (2021) suggested cervical muscle strength, endurance, and proprioception may contribute to a lower frequency of concussions and found a reduced number of concussions associated with participation in a neck training program among rugby players. In a prospective cohort study (N = 165), Farley et al. (2021) found those rugby players with a right rotation reposition error were associated with a 5% concussion risk for every 10% increase in right rotation reposition error. Furthermore, Hammerle and colleagues (2019) found a decrease in dizziness among military concussion patients with cervical proprioception training compared to those who received the typical vestibular rehabilitation therapy regardless of whether they had neck pain or no neck pain post-injury. The current studys results indicate cervical sensorimotor dysfunction may exist in the absence of neck pain among this patient population. This is significant for clinicians to know as it highlights the importance of performing a thorough examination of the cervical spine even when a patient may deny neck pain or injury. A concussion examination should include cervical sensorimotor measures such as the cervical JPET in multiple directions. Future studies should further determine whether the presence or absence of neck pain is a significant subjective factor in cervical sensorimotor impairment and cervicogenic dizziness. Clinical Application The findings of this study are clinically meaningful because knowing there are negligible associations between DVA and cervical JPET may help inform practicing physical therapists to appreciate the complexity of the visual, vestibular, and somatosensory systems function. These results highlight the heterogeneous nature of concussion injuries and the dizziness associated ADOLESCENT CONCUSSIONS 41 with a concussion is not isolated to vestibular system deficits. Clinical implications of these findings include the necessity of a multifaceted, thorough assessment and individualized approach to treatment. Evaluating clinicians should include an array of objective measures that not only assess the function of the vestibular, ocular, and sensorimotor systems but also the associated symptom provocation brought about by the testing and functional tasks. Consideration regarding preexisting factors including history of motion sensitivity, gender, developmental stage, and underlying neck pathology also need to be considered. Identifying impairments within concussion subtypes but recognizing cross over between the subtypes is essential (Ellis et al., 2015; Lumba-Brown et al., 2020). Furthermore, a comprehensive assessment of the cervical spine and cervical proprioception to identify underlying cervicogenic dizziness should be evaluated whether or not an adolescent presents with neck pain. Study Limitations and Implications for Future Research A few limitations to this study are notable. First, the inability to meet the targeted number of participants for the study is the largest limitation. The study primarily relied on internal direct referrals from a subspecialty Sports Medicine physician with concussion expertise. Some potential participants were not recruited due to the centralized scheduling system within Northwestern Medicine scheduling the patient with another therapist before the primary investigator could recruit the patient for participation. The small sample size contributed to inadequate power within the study and therefore, resulted in a reduced chance of detecting a true correlation or effect. Therefore, future studies should attempt to examine the relationship between these two variables with a larger sample size to ensure more optimal power to more conclusively determine if any relationship exists between DVA and cervical proprioception following a concussion among the adolescent population. ADOLESCENT CONCUSSIONS 42 Second, this study used the non-instrumented, clinical DVA to assess the participants dynamic visual acuity. Although this tool was used due to the lack of access to a computerized version, the clinical version of the test does come with some potential pitfalls. The velocity of head movement and frequency of turns were attempted to be controlled via the use of a metronome, but room for human error always exists. Furthermore, the computerized DVA can laterality of dysfunction (Zhou & Brodsky, 2015). Future studies may want to consider instrumented versions of the primary outcome variables with a larger sample size to confirm whether a lack of association between the variables exists. Another limitation is the study did not include neuropsychological screening or any concussion-specific self-report measure which could identify cognitive or psychological impairments. Trauma can trigger mental health issues, especially among adolescents (Schneider et al., 2016). Literature also suggests that adolescents may be more at risk for the social and psychological impacts of a concussion or possess varying motivational considerations which impact their lived experiences (Valovich McLeod et al., 2017) and may influence their return to normal functioning (Iverson et al., 2017). Future studies may include additional self-report measures specific to concussion to help capture possible cognitive or other impairments which may impact participants' performance with clinical assessments. Lastly, the study is a prospective, cross-sectional quasi-experimental design and the correlational nature limits the ability of the study to explore any cause-and-effect relationships. The study involved adolescents between the ages of 12 to 18 years, and therefore, it is unknown if similar results would be found among children or collegiate athletes. The results cannot be generalized or applied to other age groups. Future studies may consider including other age ADOLESCENT CONCUSSIONS 43 groups and matched controls for comparison of results to determine if demonstrated differences are a result of the concussion or other extraneous factors. Conclusion In summary, this study found no significant correlation between DVA and cervical JPET among an adolescent population. Neither DVA score nor cervical JPET measures were clinically above abnormal cut-offs for this small sample. However, DVA provoked symptoms in most participants. Participants with higher initial DVA scores required fewer PT visits, and younger participants had more cervical joint repositioning errors with cervical JPET. Lastly, cervical proprioception was more impaired with those adolescents involved in contact versus non-contact, but surprisingly, a difference did not appear to exist between those participants with neck pain and no neck pain. 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Prognosticators of persistent symptoms following pediatric concussion: A systematic review. Journal of American ADOLESCENT CONCUSSIONS 61 Medical Association Pediatrics, 167(3), 259-265. https://doi.org/10.1001/2013.jamapediatrics.216 Zhang, A. L., Sing, D. C., Rugg, C. M., Feeley, B. T., & Senter, C. (2016). The rise of concussions in the adolescent population. The Orthopaedic Journal of Sports Medicine, 4(8), 1-6. https://doi.org/10.1177/2325967116662458 Zhou, G., & Brodsky, J. R. (2015). Objective vestibular testing of children with dizziness and balance complaints following sports-related concussions. Pediatric Otolaryngology, 152(6), 1133-1139. https://doi.org/10.1177/0194599815576720 Zuckerman, S. L., Yengo-Kahn, A. M., Buckley, T. A., Solomon, G. S., Sills, A. K., & Kerr, Z. Y. (2016). Predictors of postconcussion syndrome in collegiate student-athletes. Neurosurgical Focus, 40(4), 1-10. https://doi.org/10.3171/2016.1.FOCUS1559 ADOLESCENT CONCUSSIONS Table 1 Descriptive Statistics for Participant Demographics and Injury Characteristics (N = 14) n (%) Gender Female 7 (50) Male 7 (50) Sport Contact No 5 (35.7) Yes 9 (64.3) Cheerleading 2 (14.3) Volleyball 2 (14.3) Weight-lifting 1 (7.2) Hockey 1 (7.2) Soccer 4 (28.6) Wrestling 4 (28.6) Sport Contact Type Non-Contact Contact Neck pain No 7 (50) Yes 7 (50) 62 ADOLESCENT CONCUSSIONS 63 Table 2 Descriptive Statistics Age and Injury Characteristics (N = 14) M (SD) Mdn Min Max Age (years) 14.64 (1.34) 15.0 12.0 17.0 Time since injury (days) 15.79 (9.55) 13.0 5.0 33.0 Physical therapy visits 7.57 (5.32) 5.5 2.0 18.0 LOS in therapy (weeks) a 5.61 (6.12) 4.1 1.6 24.8 Note: SD = standard deviation; Min = minimum; Max = maximum; LOS = length of stay ADOLESCENT CONCUSSIONS 64 Table 3 Descriptive Statistics for Outcome Variables (N = 14) M (SD) Mdn Min Max n (%) Abnormal a DVA Score 2.00 (0.96) 2.00 1.00 4.00 4 (28.6) Dizziness with 3.29 (2.95) 3.25 0 7.00 9 (64.3) Right 4.75 (1.95) 4.39 1.75 7.50 4 (28.6) Left 4.54 (1.30) 4.27 2.47 6.80 0 (0) Average 4.65 (1.42) 4.33 2.75 7.00 1 (7.1) 12.29 (5.92) 12.75 1.00 20.00 13 (92.8) 6.22 (3.97) 6.25 0.50 16.50 12 (85.7) 10.21 (6.02) 11.25 0 20.00 13 (92.8) 4.14 (2.90) 3.50 0 10.50 10 (71.4) 3.21 (2.67) 3.50 0 7.00 9 (64.3) 2.29 (2.14) 2.50 0 6.50 9 (64.3) DVA Cervical JPET VOMS TSS VMS VOMS TSCS VMS VOMS TSS HVOR VOMS TSCS HVOR VOMS VMS Dizziness TSCS VOMS HVOR Dizziness TSCS ADOLESCENT CONCUSSIONS DHI Score Neck Pain NPRS 65 38.71 (13.33) 39.00 12.00 62.00 12 (85.7) 1.46 (1.95) 0.50 0 5.00 7 (50.0) Score Note. SD = standard deviation; Min = minimum; Max = maximum; DVA = Dynamic Visual Acuity; JPET = Joint Position Error Test; VOMS = Vestibular/Ocular Motor Screen; TSS = Total symptom score; HVOR = horizontal vestibular ocular reflex; VMS = visual motion sensitivity; TSCS = total symptom change score (0-40); DHI = Dizziness Handicap Inventory (0100); NPRS = Numeric Pain Rating Scale (0-10). a Clinically abnormal: DVA clinical cut-off 2-line differential; Dizziness with DVA considered abnormal if > 0 on 0 to 10 scale; Cervical JPET cut-off > 7 cm; VOMS cut-off score 2; DHI cut-off > 31 indicating moderate or severe perception of impairment; Neck pain NPRS considered abnormal if > 0 on 0 to 10 scale. ADOLESCENT CONCUSSIONS 66 Table 4 Spearman Rho Correlations Between Outcome Variable Scores (N = 14) DVA score R Cervical JPET L Cervical JPET Avg Cervical JPET rs p DVA Score rs p rs p rs p .19 .510 .17 .564 .22 .460 R Cervical JPET .19 .510 L Cervical JPET .17 .564 Avg Cervical JPET .22 .460 VOMS Base -.08 .777 .56 .036* .18 .539 .39 .164 VOMS Dizziness Base -.40 .157 -.13 .668 -.33 .243 -.33 .257 VMS TSS -17 .563 .26 .380 -.15 .609 -.02 .940 VMS TSCS .17 .573 -.26 .369 -.46 .102 -.44 .112 VMS Dizziness CS .30 .299 -.21 .474 -.28 .338 -.31 .285 HVOR TSS -.04 .894 .40 .158 -.01 .970 .26 .378 HVOR TSCS .10 .734 .17 .558 -.21 .476 .06 .851 HVOR Dizziness CS .46 .098 .08 .783 -.13 .667 -.02 .938 DHI Score a -.10 .740 .08 .789 -.11 .699 -.00b .994 Neck pain NPRS score -.15 .618 .26 .367 -.13 .665 -.01 .981 Note: DVA = Dynamic Visual Acuity, Cervical JPET = Cervical Joint Position Error Test; R = repositioning to the right from an active left rotation, L = repositioning to the left from an active right rotation, and A = average of scores from right and left relocation. VOMS = Vestibular/Ocular Motor Screen; TSS = Total symptom score (0-40); VMS = Visual motion ADOLESCENT CONCUSSIONS sensitivity; TSCS = Total symptom change score (0-40); DHI = Dizziness Handicap Inventory (0-100); NPRS = Numeric Pain Rating Scale. a Pearson correlation reported. b r = -.002 * significant < .05 level 67 ADOLESCENT CONCUSSIONS 68 Table 5 Correlations with Demographics and Participant Impairment Variables (N =14) DVA score a R Cervical JPET L Cervical Avg Cervical JPET JPET rs p r p r p r p Days post injury -.42 .133 -.26 .380 -.48 .084 -.39 .165 Age (years) a -.11 .701 -45 .109 -.35 .214 -.57 .033 * PT visits -.59 .028 * .11 .717 -.07 .814 .04 .894 LOS (weeks) a -.50 .070 .10 .725 .04 .905 -.00b .994 Note: DVA = Dynamic Visual Acuity; JPET = Joint Position Error test; R = repositioning to the right from an active left rotation, L = repositioning to the left from an active right rotation, and Avg = average of their scores from right and left relocation; PT = physical therapy; LOS = length of stay a Spearman rho correlation reported b rs = -.002 * significant < .05 level ADOLESCENT CONCUSSIONS 69 Table 6 Comparison of Outcome Variables Between Non-Contact and Contact Groups (N = 14) Non-contact Contact (n = 5) (n = 9) M (SD) M (SD) t 95% CI LL ES .233 0.67 UL 1, 1-3 a 2, 1-4a -1.19 b 3.77 (0.84) 5.28 (2.21) -1.83c -3.33 0.30 .094 1.01 3.47 (0.88) 5.14 (1.11) -2.87 -2.93 -0.40 .014 1.60 3.63 (0.85) 5.22 (1.38) -2.33 -3.08 -0.10 .038 1.30 11.40 (6.15) 5.44 (3.58) 2.32 0.37 11.54 .039 1.29 DVA R Cervical p JPET L Cervical JPET Avg Cervical JPET PT visits Note. Non-contact = cheerleading, volleyball, and weightlifting; Contact = wrestling, soccer, and hockey; EF = Effect size (Cohens d): DVA = Dynamic Visual Acuity, Cervical JPET = Cervical Joint Position Error Test, R = repositioning to the right from an active left rotation, L = repositioning to the left from an active right rotation, and A = average of scores from right and left relocation; PT = physical therapy. a Median and range reported b Mann-Whitney U test reported. c Welch test reported. ADOLESCENT CONCUSSIONS 70 Table 7 Comparison of Outcome Variables Between Neck Pain and No Neck Pain Groups (N = 14) Neck Pain No Neck Pain (n = 7) (n = 7) M (SD) M (SD) t 95% CI LL DVA R Cervical p ES .840 0.11 UL 2, 1-4 a 2, 1-3 a -0.20b 5.21(1.75) 4.27(2.15) -0.90 -3.23 1.34 .387 0.48 4.53(1.25) 4.56(1.44) 0.04 -1.54 1.60 .971 0.02 4.88(1.45) 4.42(1.47) -0.58 -2.15 1.24 .572 0.31 2.5, 0-6 a 9.5, 3.0-16.5 a -2.82b .005 2.30 JPET L Cervical JPET Ave Cervical JPET VOMS Baseline Note. EF = Effect size (Cohens d); DVA = Dynamic Visual Acuity, Cervical JPET = Cervical Joint Position Error Test, R = repositioning to the right from an active left rotation, L = repositioning to the left from an active right rotation, and A = average of scores from right and left relocation; PT = physical therapy; VOMS = Vestibular/Ocular Motor Screening baseline score (0-40). a Median (minimum - maximum) reported. b Mann-Whitney U test with Z test statistic reported. ADOLESCENT CONCUSSIONS 71 Figure 1 Participant Recruitment Flowchart Assessed for eligibility (N= 23) Excluded (n = 9) Not meeting inclusion criteria (n = 7) o Prior neurological -brain lesion o OCD, autism diagnosis, > 6 months since injury, and post-concussion syndrome diagnosis o Chiari malformation o Received vestibular PT post-concussion prior to referral o No subjective complaint of dizziness with physicians exam o Neck pain with disc protrusion but concussion symptoms resolved before PT referral o Orthopedic injuries including shoulder and elbow pain at time of concussion Elected to not participate (n = 2) Recruited and obtained consent and assent (N = 14) Note. OCD = obsessive compulsive disorder; PT = physical the ADOLESCENT CONCUSSIONS 72 Appendix A Northwestern Memorial HealthCare Institutional Review Board Approval Notice Northwestern Memorial HealthCare Institutional Review Board (NMHC IRB) 25 North Winfield Road Winfield, IL 60190 Phone: 630-933-6528 Fax: 630-933-2713 Approval Notice Initial Review (Expedited) Continuing Review NOT Required December 15, 2020 Pam Cornwell, PT, MHS, NCS 2635 Church Road Suite 103 Aurora, IL 60502 RE: Research Protocol 20-074 Dynamic Visual Acuity and Cervical Proprioception Following Adolescent Concussions Dear Ms. Cornwell: Initial expedited review of the above-named study was completed by the IRB Chair as authorized by 45 CFR 46.110 category(s) Expedited Category 5 & 46.404/50.51. This project now meets all the criteria for approval. If all other Northwestern Medicine approvals have been obtained, the research may begin. Approval Date: Protocol Version: Consent and Authorization: December 15, 2020 Version 2, August 5, 2020 v2, 12.15.20 Blood and Tissue Consent: Date Yearly Check-in Deadline: December 14, 2021 ADOLESCENT CONCUSSIONS 73 Note: All other documents submitted as part of this application were reviewed and approved by the IRB. Please refer to the initial submission event in IRB Manager for the complete list of materials. Please note that while this study does not require formal continuing review, yearly checl<-in is required. Please submit a yearly check-in form in the electronic IRB system by the deadline above. It is your responsibility to ensure modifications, unanticipated problems, deviations, and closure of the study are reported to the IRB timely. Please keep in mind that you, as Principal Investigator, have responsibilities and obligations related to this study. The NMHC IRB policies can be found on Policy Manager on the Intranet, within the electronic IRB system, or by request from the IRB office. Communication: Investigators are obligated to maintain communication with the IRB for the duration of the research according to federal regulations and NMHC IRB policies in order to ensure adequate protection of research subjects. Conduct of study: It is the investigator's responsibility to ensure that he/she and his/her research staff are fully trained and aware of all scientific, protocol, human subjects, privacy, and ethical matters related to the conduct of the research. If you are uncertain of any of these areas, please call the IRB office at 630-933-6528 before undertaking the research. Informed consent document: Unless other arrangements have been approved by the IRB and noted in this approval letter, it is the PI's responsibility to ensure that a copy of the signed consent document is put into the subject's medical record if the study involves Northwestern Medicine patients. In all cases, the original should be kept in the research files and a signed copy should be given to the subject. Verification of consent: The PI is responsible for documentation in the case history (research file and/or medical record) that the informed consent/authorization process took place and that an informed consent document, if applicable, was signed by the subject prior to participation in the study. This documentation must be done to demonstrate that the appropriate discussion took place with the prospective subject about the elements of informed consent/authorization and that their questions were answered. Status changes to studies: An investigator must immediately notify the IRB in writing whenever a protocol is placed on hold or suspended by the sponsor for any reason or if the study is temporarily or permanently closed to subject accrual. Protocol and Informed Consent Document revision: Any changes to the protocol and/or informed consent/authorization document must be reviewed and approved by the NMHC IRB prior to implementation. The only except is where the change is avoiding an immediate apparent hazard to a subject. External agencies (i.e. pharmaceutical companies, device vendors, etc.) may provide information to assist in the process, but have no authority to grant approval or authorizations or deviations from the original protocol or informed consent/authorization ADOLESCENT CONCUSSIONS document. The NMHC IRB requires any changes that may affect a subject's willingness to participate or continue participation in a research study to be submitted promptly. Problems that require prompt reporting to the IRB: You must promptly report significant problems that occur during the conduct of the research to the NMHC IRB. The IRB will then determine if reporting to external agencies is necessary. Recruitment materials: Recruitment materials to be viewed by potential research subjects (advertisements, letters to potential subjects, internet postings, and any other media for subject recruitment) require IRB review and approval prior to taping, publication, distribution and/or posting. If you have any questions or need further help, please contact the IRB Office at 630-933-6528. Sincerely NM RB hair 74 ADOLESCENT CONCUSSIONS 75 Appendix B University of Indianapolis Institutional Review Board Notification of Approval Human Research Protections Program (HRPP) 800/232-8634 x5774 1400 East Hanna Ave Sease, Room 201L Indianapolis, IN 46227 1 (317) 781-5774 http://irb.uindy.edu hrpp@uindy.edu NOTIFICATION OF APPROVAL Study Number: Approval Date: Version: 01358 January 29, 2021 1 Title: Dynamic Visual Acuity and Cervical Proprioception following adolescent concussions. Stephanie Miller, PhD, PT, NCS Krannert School of Physical Therapy February 2, 2021 Dear Dr. Miller, The above-referenced human subjects research project has been approved by the University of Indianapolis Institutional Review Board (UIndy IRB) operating under Federal Wide Assurance FWA00027197. Level of Review: Expedited research activities pose no greater than minimal risk to research subjects. Approval Limitations: This approval is limited to the activities described in the application. It is expected that the research be carried out strictly according to the approved protocol. Changes / Modifications: No changes are to be made to the approved protocol or consent form/s without prior review and approval by the UIndy IRB. All changes (e.g., procedure, study locations, recruitment materials, study instruments, informed consent, research personnel, etc.) must be prospectively reviewed and approved by the IRB before they are implemented. Adverse Events and Unanticipated Problems: Any adverse events or unanticipated problems relating to the research must be reported to the HRPP office as soon as possible. Continuing Review: Continuing review for this protocol is not required. However, the HRPP office will do an annual check in with you to obtain an update. ADOLESCENT CONCUSSIONS 76 HRPP Jan 2019 Human Research Protections Program (HRPP) 800/232-8634 x5774 1400 East Hanna Ave Sease, Room 201L Indianapolis, IN 46227 1 (317) 781-5774 http://irb.uindy.edu hrpp@uindy.edu Additional Information: Please contact the UIndy HRPP office hrpp@uindy.edu with any questions or concerns about this letter or other HRPP matters. Please keep a copy of this letter for your records. Sincerely, Erin Fekete, Ph.D. Faculty IRB Chair Interim Associate Dean and Director of Psychological Sciences Associate Professor of Psychology College of Applied Behavioral Sciences University of Indianapolis ADOLESCENT CONCUSSIONS 77 Appendix C IRB Yearly Check-in Notice Northwestern Memorial HealthCare Institutional Review Board (NMHC IRB) 25 North Winfield Road Winfield, IL 60190 Phone: 630-933-6528 Fax: 630-933-2713 Yearly Check-In Notice HSPP Requirements Met December 13, 2021 Pam Cornwell, PT, MHS, NCS 2635 Church Road Suite 103 Aurora, IL 60502 RE: Research Protocol #: 20-074 Dynamic Visual Acuity and Cervical Proprioception Following Adolescent Concussions Dear Ms. Cornwell: The yearly check-in for the above referenced study was received by the HSPP Office. Please note that while this study does not require formal continuing review, yearly check-in is required. Please submit a yearly check-in form in the electronic IRB system by the deadline of December 14, 2022. It is your responsibility to ensure modifications, unanticipated problems, deviations, and closure of the study are reported to the IRB timely. Protocol Version: Version 2, August 5, 2020 Consent and Authorization: v2, 12.15.20 Date Yearly Check-in Deadline: December 14, 2022 If you have any questions or need further help, please contact the IRB office at 630-933-6528. Sincerely, NMHC Human Subject Protection Program ADOLESCENT CONCUSSIONS 78 Appendix D Vestibular/Ocular Motor Screening Scoring Sheet VOMS SCORING SHEET Symptoms on a 0 10 (severe) scale Modified from Mucha A, Collins MW, Elbin RJ, FurmanJM, TroutmanEnseki C, DeWolf RM, Marchetti G, Kontos AP. Vestibular/Ocular Motor Test N/T Headache Dizziness Nausea Fogginess Comments Baseline Symptoms (Pre VOMS) Smooth Pursuit Saccades (horizontal) Saccades (vertical) Convergence (NPC) #1 _____ cm #2 _____ cm normal 5 cm or < (2") #3 _____ cm VOR Horizontal (180 bpm) VOR Vertical (180 bpm) Visual Motion Sensitivity (50 bpm) Brief Instructions : patient seated unless noted otherwise. 940 y/o, 1 day or > after injury Pursuit one stick, 3' away and level with patient's nose, move stick slowly 1.5' to the left and 1.5' to the right. Repeat moving stick vertically. Slow : 2 seconds to go L to R & again L to R. 2 repetitions each direction. ADOLESCENT CONCUSSIONS Saccade start 2 sticks, 3 feet away and level with patient's nose . Each stick 1.5' to the left and right of nose. Look over & back 10x. Repeat vertically. Patient is to move eyes as fast as they can. NPC 1 stick, 3' away and level with patient's nose. Move stick slowly towards nose. Stop when they report seeing double or you see an eye turn/drift. Measure distance to nose. VOR Hold one stick, 3' away and level with patient's nose. Speed of head movement, 180 bpm. Patient is asked to turn head 20 degrees left and right, 10 times maintaining focus on target. Repeat vertically. Visual Motion Sensitivity Standing, patient holds stick or thumb; arms reach in front of nose. While maintaining fixation on stick, rotate head arms and trunk left and right 80 degrees 5x at 50 bpm. Name:______________________________________ DOB:__________ DOI:__________ Date:___________ 79 ADOLESCENT CONCUSSIONS 80 Appendix E Dizziness Handicap Inventory The Dizziness Handicap Inventory ( DHI ) P1. E2. F3. P4. F5. Does looking up increase your problem? Because of your problem, do you feel frustrated? Because of your problem, do you restrict your travel for business or recreation? Does walking down the aisle of a supermarket increase your problems? Because of your problem, do you have difficulty getting into or out of bed? F6. Does your problem significantly restrict your participation in social activities, such as going out to dinner, going to the movies, dancing, or going to parties? F7. Because of your problem, do you have difficulty reading? o o Yes Sometimes o No o o Yes Sometimes o No o o Yes Sometimes o No o o Yes Sometimes o No o o Yes Sometimes o No o o Yes Sometimes o No o o Yes Sometimes o No P8. Does performing more ambitious activities such as sports, dancing, household chores (sweeping or putting dishes away) increase your problems? o o Yes Sometimes o No E9. o o Yes Sometimes o No Because of your problem, are you afraid to leave your home without having without having someone accompany you? E10. P11. Because of your problem have you been embarrassed in front of others? Do quick movements of your head increase your problem? o o Yes Sometimes o No o o Yes Sometimes ADOLESCENT CONCUSSIONS F12. P13. Because of your problem, do you avoid heights? Does turning over in bed increase your problem? F14. Because of your problem, is it difficult for you to do strenuous homework or yard work? E15. F16. P17. Because of your problem, are you afraid people may think you are intoxicated? Because of your problem, is it difficult for you to go for a walk by yourself? Does walking down a sidewalk increase your problem? E18.Because of your problem, is it difficult for you to concentrate F19. Because of your problem, is it difficult for you to walk around your house in the dark? E20. Because of your problem, are you afraid to stay home alone? E21. Because of your problem, do you feel handicapped? E22. Has the problem placed stress on your relationships with members of your family or friends? E23. Because of your problem, are you depressed? 81 o No o o Yes Sometimes o No o o Yes Sometimes o No o o Yes Sometimes o No o o Yes Sometimes o No o o Yes Sometimes o No o o Yes Sometimes o No o o Yes Sometimes o No o o Yes Sometimes o No o o Yes Sometimes o No o o Yes Sometimes o No o o Yes Sometimes o No o o Yes Sometimes ADOLESCENT CONCUSSIONS F24. Does your problem interfere with your job or household responsibilities? P25. Does bending over increase your problem? 82 o No o o Yes Sometimes o No o o Yes Sometimes o No Used with permission from GP Jacobson. Jacobson GP, Newman CW: The development of the Dizziness Handicap Inventory. Arch Otolaryngol Head Neck Surg 1990;116: 424-427 DHI Scoring Instructions The patient is asked to answer each question as it pertains to dizziness or unsteadiness problems, specifically considering their condition during the last month. Questions are designed to incorporate functional (F), physical (P), and emotional (E) impacts on disability. To each item, the following scores can be assigned: No=0 Sometimes=2 Yes=4 Scores: Scores greater than 10 points should be referred to balance specialists for further evaluation. 16-34 Points (mild handicap) 36-52 Points (moderate handicap) 54+ Points (severe handicap) ADOLESCENT CONCUSSIONS 83 Appendix F Cervical Joint Position Error Target Target Distance: 90cm ADOLESCENT CONCUSSIONS 84 2011 Skill Works, Inc. All Rights Reserved. Rob Landel, PT, DPT, OCS www.skillworks.biz Errors of >4.5 (for this target, beyond the yellow circle) are likely to be significant. Treleaven J, Jull G, Sterling M. Dizziness and unsteadiness following whiplash injury: characteristic features and relationship with cervical joint position error. J Rehabil Med. 2003; 35(1):36-43. Distance from center of the target to a 4.5-degree error depends the distance the patient is from the target. This target is calibrated for a patient who is 90 cm away. If the patient (center of axis of rotation to the target, thus, the crown of the head) is 90 cm from the target, then a 7 cm error from the center of the target translates to a 4.5 degree error: Arctan of 7cm/90cm = 4.5 degrees On a calculator, arctan is often shown as tan-1. Wall Axis Error 7cm error () 90cm So, the error in degrees is the arctan (or tan-1) 7/90, or 4.5. ADOLESCENT CONCUSSIONS 2011 Skill Works, Inc. All Rights Reserved. 85 Rob Landel, PT, DPT, OCS www.skillworks.biz  ...

... 1 2-Gen: Occupational Therapy Program for Intergeneration Trauma and Family Reintegration for Female Offenders Shanele Tyler May 22, 2022 A capstone project submitted in partial fulfillment for the requirements of the Doctor of Occupational Therapy degree from the University of Indianapolis, School of Occupational Therapy. Under the direction of the faculty capstone advisor: Christine Kroll, OTD., MS, OTR., FAOTA. 2 Abstract Current literature acknowledges the lack of community reentry opportunities available to female inmates, especially the lack of parenting classes geared towards mothers. This paper examines the role of occupational therapy within the reunification process for formerly incarcerated mothers and their children using trauma-informed care. I partnered with the Public Advocates for Community Reentry (PACE) to develop a resource guide and weekly session outline to support and assist in the implementation address personal traumas and self-growth and provide education on better parenting skills. The staff survey supported the ability of the 2-Gen program and felt that they and the clients could use it to their benefit in the future. The promotion of adaptability and restoration was obtained by utilizing the Ecology of Human Performance to find supporting evidence from peer-reviewed scholarly articles and published journals. Keywords: occupational therapy, parenting, reunification, trauma-informed care, PACE, criminal justice 3 Introduction More than 10.77 million people are incarcerated worldwide, and 2 million are in the United States of America (Institute for Crime & Justice Policy Research, 2021). Imprisonment is understood to be a way to protect society by removing those that have committed an injustice. In theory, people are reformed after serving their sentence, and thus would not another crime. However, rehabilitation services are not the focus of incarceration. Therefore, when people are released, theyve gained knowledge or skills that increase the chances of recidivism (Muoz et al., 2016). The alienation of these individuals can lead to occupational deprivation in and out of the correctional facility. Due to the stigma that comes with their time spent, reintegration is also challenging. Where occupational therapy comes into play is to restore participation and balance. Occupational therapy refers to the therapeutic services for individuals within the criminal justice system (Hitch et al., 2015). Occupational therapists can make a significant impact within the criminal justice, but there is a lack of guidelines within the profession of the criminal justice system. From this view, rehabilitation is multidisciplinary teamwork; forensic occupational therapy is a vital part of the treatment and rehabilitation (Ozkan et al., 2018). With the collaboration of PACE, the rehabilitation of these individuals is more tangible. Public Advocates for Community Reentry (PACE) is a nonprofit organization whose mission is to serve individuals impacted by the criminal justice system. PACE opened its doors in 1968, but then they were referred to as Offender Aid & Restoration (OAR). OAR officially changed the name to PACE in 2010 to focus on meeting the 4 needs of those who were incarcerated and on the ex-convicts that had made it out of the system and wanted to return to the community. PACE offers services that include family reunification, transitional housing, substance abuse education group, career coaching, and so forth (PACE Indy, n.d.). The United Way of Central Indiana (UWCI) sponsored the two-generational (2gen) program to provide occupational therapy-based interventions to clients with criminal records and their families. As a result ,in 2021, PACEs human resources created a contract with an occupational therapist to launch their pilot program focusing on intergenerational trauma (Hensley,2021). Schedule to start in the Spring of 2022, the program will educate the staff and clients through trauma-informed care (PACE Indy,2022). The 2-Gen program is where my capstone comes into place. My project is working with the clients on the protocol and creating a resource guide for all take-home materials and continued education. Training to prevent or reduce intergeneration trauma will assist this population as it addresses the lack of awareness of trauma-informed care and provides space for identification of and healing from intergenerational trauma. As a byproduct of the DCE, the staff of PACE received education on trauma-informed care using the services offered by an occupational therapist practitioner The following paper describes literature relating to trauma-informed care and generational trauma and provides information that informed the resource guides. Background According to the Prison Policy Initiative (2022), the United States is home to almost 2 million people in the criminal justice system. Of the 2 million, 2.3 thousand are 5 female inmates, including girls in juvenile detention centers. Female inmates in local jails have grown twice the rate of their male counterparts. In addition, 80% of women are mothers, most of whom were the primary caretakers for their children before incarceration (Kajstura, 2019). However, a needs assessment by the U.S. Department of Justice (1998) noted that offenders programs were often not gendered sensitive. Nor did the programs have objectives focused on parenting as a mother, self-actualization, and decreasing the effects of abuse and victimization experienced by most women. Women in the criminal justice system experience and watch numerous traumatic situations, but it is also essential to look at the trauma they encountered before their incarceration. Harris (2016) noted that mothers deprived of healthy parental figures with limited opportunities for adjustment develop a cycle of intergenerational trauma. The author said that her limitation included the small sample size of the population and the self-reported assessment tool they used. Harris (2016) encouraged a longitudinal study with a more diverse representation and a larger sample size to dimmish generalizability to entire populations, and decrease response bias for a more accurate result to services. In a similar study by Frye and Dawe (2008), the researchers looked at the effectiveness of delivering a parenting program in a prison where the women could live with their children. The program, Parenting under Pressure (PUP), was designed to respond to the individual needs of each family for ten weeks. The author noted that the women who completed the program reported significant improvements in lifestyle, overall well-being, and relationship with their children. However, similar to the previous article, the authors noted these women had higher levels of psychological distress and complex trauma. The limitations pointed out in this study were due to the program being 6 at a community center, transportation was challenging and access to community resources and funding in general, was difficult (Frye & Dawe, 2008). Project PACE has a grant for a small sample size to trial a program for intergenerational trauma. Yehuda and Lehrner (2018) define intergenerational trauma as that exposure to highly adverse events impacts individuals so much that their offspring find themselves grappling with their parents posttraumatic state. With that insight, it fueled my project to find topics to heal the individuals intergenerational trauma. It also provided the resources to stop the trauma from continuing with their children and allow everyone to start the healing process. Part of my DCE project is developing a resource guide to assist all PACE participants, not just those in the pilot program. Also, it is vital to keep in mind that the articles and resources are broad enough to benefit all individuals. In comparison, both studies were concerned about not being diverse enough in their participants. I hope the resource guide will help educate all races and ethnicities. Similar to the second study, PACE will host the 2-Gen meeting. Still, with improvements in technology, we have the option to host video meetings so that the women will not have to worry about transportation. Under the Ecology of Human Performance (EHP) scope, the DCE project will provide means to adapt, modify, or recreate the reunification with their families. EHP is a framework that looks at a persons context, task, and performance and takes a therapeutic intervention to understand the human occupation (Cole & Tufano, 2019). With this 7 framework, I constructed a project that provided the client multiple opportunities to participate in tasks based on their role as a parent and as an individual post-prison release. DCE project included a resource guide and an outline of group sessions for the 2Gen program at PACE. In the resource binder, there will be activities for the clients to complete on their own, with their children, and for their children to promote learning development. Prior to starting the sessions, we used the following assessments to gather information on the participants: Occupational Profile, Ace Screening Tool, Parental Stress Scale, and Parental Competency Scale. In the third session, we used the Sensory Profile to assist us in gathering sensory information from the mothers on their sensory threshold to prepare them for the sensory education. The EHP frame of reference guided the development of the 2-Gen sessions and the selection of the screening tools. The EHP provided the ability to adapt and modify the sessions to be more individualized for those involved. Regarding the group outlines, each group for the ten weeks was outlined using a PowerPoint slide deck with two additional weeks of material as spares. Each weekly topic includes an education piece, providing definitions, an area for discussion and questions, then the activity related to the issue of the session. After a client has completed the weeks session, they will receive a copy of the PowerPoint slide/word document that they can place into their resource binder to refer to later. They will also receive homework that will set them up for the next session. The sessions follow no particular order and allow for adaptations based on the clients or treating therapists digression. For example, one week is dedicated to communication skills with children. The client comes into the session with their child, and we define parenting styles. Then the 8 components of communication, both verbal and non-verbal, and ask them how they respond to different situations. Lastly, for an activity, there is an option of a board game for the parent to play with their child or a role-playing session to act out. Homework is sent home with the client to reflect on what they learned during the session and activities that would prepare them for the next session. Outcome Measure For the DCE project, I used several assessment tools for the clients to complete at the initial evaluation. I also created three different surveys for the clients and the staff of PACE to complete. I built a feedback survey for the staff and I created two satisfaction surveys for the clients. One them to finish halfway through and another at the end of their program. Unfortunately, due to the capstone coming to an end, I cannot report on the results of the clients survey. A thematic analysis was used for the staff survey responses. For the staff survey, a Likert scale was utilized, with one being the lowest score or highly unsatisfied to five being the highest score, or highest satisfied. In terms of the nominal data, the average rating for the Likert scale questions was as follows: 1. Rate the readability of the guide for our client population; 4.46/5 2. How satisfied are you with the topics being covered?; 4.69/5 3. How satisfied are you with some of the activities included?; 4.31/5 The initial survey for the staff of PACE received a total of 13 responses. Based on the Likert scale results, I concluded that the staffs resource guide and activity folder have a high likeability rating. 9 For the thematic analysis, I reviewed the following open-ended questions, How satisfied are you with the Guide overall? Anything you would like to add or remove?. Of the 13 responses, ten responded to the open-ended question. Five out of the ten expressed that the Guide looked good and was very relevant to the client population. Three of the ten described legibility issues with spacing concerns and the possibility of translating to multiple languages. The last theme of accessibility came from responses expressing the need to include activities that will be beneficial for developmentally limited children or make sections small but with larger print sizes for easier readability. The most common themes were general appreciation, accessibility, and legibility Summary The DCE, in collaboration with PACE, developed and trialed, a program to address intergenerational trauma and its effect on parenting as a mother postprison release. After creating the resource guide to provide the outline for the program, I created two surveys to receive feedback from the PACE staff and the clients that complete the 2-Gen program. The staff voiced interest in the guide and provided effective feedback for the guide efficiently for the population. My site mentor took responsibility for the future distribution of the materials and implementation. Conclusion The Doctoral Capstone Project resulted in a formal resource guide, which supported a trial program funded by a United Way grant for intergenerational trauma in the female prison population. The resource guide is editable and may be updated as the program evolves. Based on my experience in the work release center, the sessions with the women in the 2-Gen, and the research I have conducted, more attention is needed to 10 support the healing of intergenerational trauma and the need for effective parental courses for incarcerated mothers and fathers alike. A lot of these individuals come from a long history of traumatic events within their lineage. After they have served their time, there should be programs in place to promote rehabilitation and healing to stop the criminal behaviors from manifesting again. 11 References Cole, M., & Tufano, R. (2019). Applied Theories in Occupational Therapy: A Practical Approach (Second ed.). Slack Incorporated. Frye, S., & Dawe, S. (2008). Interventions for women prisoners and their children in the post-release period. Clinical Psychologist, 12(3), 99108. https://doi.org/10.1080/13284200802516522 Harris, M. (2016) Incarcerated mothers: Trauma and attachment issues. Smith College studies on Social Work, 87(1). 26-42. https://doi.org/10.1080/00377317.2017.1246796 Hensley, K. (2021, December 28). PACE fills programmatic gaps with Occupational Therapist. PACE Indy. https://www.paceindy.org/pace-fills-programmatic-gapswith-occupational-therapist/ Hitch, D., Hii, Q., & Davey, I. (2015). Occupational therapy in forensic psychiatry: Recent developments in our understandings (20072013). British Journal of Occupational Therapy, 79(4), 197205. https://doi.org/10.1177/0308022615591018 Institute for Crime & Justice Policy Research. (2021, December). World Prison Population List (13 edition). World Prison Brief. https://www.prisonstudies.org/sites/default/files/resources/downloads/world_priso n_population_list_13th_edition.pdf Kajstura, A. (2019). Womens mass incarceration: The whole pie 2019 [Press release]. www.prisonpolicy.org/factsheets/women_pie_chart_report_2019.pdf Morash, M., Bynum, T, & Koons, B. (1998) Women offenders: Programming needs and promising approaches. www.ojp.gov/pdffiles/171668.pdf Muoz, 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 12 Ozkan, E., Belhan, S., Yaran, M., & Zarif, M. (2018). Occupational Therapy in Forensic Settings. Occupational Therapy - Therapeutic and Creative Use of Activity, 52 70. https://doi.org/10.5772/intechopen.79366 Pace Indy (2022) 2022 Annual report: Public advocates in community reentry. PACE public advocates in community reentry. https://www.paceindy.org/wpcontent/uploads/2022/04/2021-Annual-Report-FINAL.pdf PACE Indy. (n.d.). About Us. Retrieved April 23, 2022, from https://www.paceindy.org/about-us/ Prison Policy Initiative (2022, March 14) Mass incarceration: The whole pie 2022 [Press release]. www.prisonpolicy.org/factsheets/pie2022_allimages.pdf US Department of Justice (August 1998). Women offenders Programming needs and promising approaches. National Institute of justice. www.ojp.gov/pdffiles/171558.pdf Yehuda, R., & Lehrner, A. (2018). Intergenerational transmission of trauma effects: putative role of epigenetic mechanisms. World Psychiatry, 17(3), 243257. https://doi.org/10.1002/wps.20568 13 APPENDIX A 2022 2-Gen Resource Guide Breea Vest, OTD, OTR Shanele Tyler, OTS 14 Table of Contexts 1. Introduction 2 2. Trauma 3 3. Building and keeping boundaries 5 4. Self-care and esteem 9 5. Relationships after incarceration 13 6. Calm parenting 16 7. Consequences and punishments 18 8. Sensory education 22 9. References 24 10. Appendix 33 15 Hello, Welcome and Thank You for joining Two-generation or 2-GEN. 2-GEN is a project funded and sponsored by the United Way of Central Indiana (UWCI) and supported by Public Advocates in Community Re-Entry (PACE) that Breea Vest initiated. Breea Vest is a licensed occupational therapist (O.T.D.) who has a passion for using client-centered and therapeutic services for individuals the criminal justice system has impacted. Breea created the 2-GEN project to utilize occupation-based and client-centered services to decrease the risk of passing Trauma through generations and promote positive familial relationships. The programs goals include providing education, resources, and support to improve relationships and parenting between mothers and their children post-incarceration. What is PACE? Founded in 1960, Public Advocates in Community Re-Entry (PACE) aimed to provide volunteering experience to prisoners in the Indiana Reformatory in Pendleton, Indiana. Fast forward 50 years, PACEs mission has widened. It includes wanting to give a variety of services to help both currently and previously incarcerated individuals and their families to lead productive lives and return to the community. What is occupational therapy? Occupational therapy is a healthcare profession that helps individuals of all ages Their goal is to help people overcome barriers that affect a persons emotional, social, and physical needs while regaining independence and self-confidence. Within the realm of community reentry, the OTs role is to provide client-centered care to address areas of shortcomings. Well provide resources for coping, role-playing opportunities, interpersonal communication activities, education on age-appropriate activities, career development, time management, and much more. 16 Trauma What is TRAUMA? Trauma can come from extreme events that a person is involved in or witnesses. Examples of traumatic events are community violence, bullying, disaster, sexual abuse, sex trafficking, intimate partner violence, etc. Trauma is an injury to living tissue caused by an external agent, emotional stress, physical damage, or an emotional upset 22. Other definitions include: COMPLEX TRAUMA: Refers to constant or multiple stressors during a defenseless period in someones life. 20 ACUTE TRAUMA: A single distressing event that is extreme enough to threaten a person emotionally and physically. I.e., car accident, sexual abuse CHRONIC TRAUMA: Multiple, long-term stressful, traumatic events over an extended period, I.e., bullying, war, serious illness 79 INTERGENERATIONAL TRAUMA Intergenerational Trauma: Trauma that has been passed down through generations. It is an experience that was overwhelming and unresolved with such a significant impact on ones life that it can be passed down to ones children and for generations. 10 HISTORICAL TRAUMA: A multi-generational trauma experienced by a specific cultural, racial, or ethnic group. It is related to major events that brutalized a particular group of people because of their status as suppressed individuals. 80 Examples include slavery, the Holocaust, forced migrations, and violent colonization Generational Trauma also has signs and symptoms: 15. 17 Lack of trust Difficult time connecting with others Separation Substance abuse Attention seeking behavior Trauma often mirrors the symptoms of post-traumatic stress disorder or PTSD: 2 Grumpy and angry outbursts Feeling tense and anxious Feeling detached from others and/or emotionally and mentally numbed Reduced interest in life In children, PTSD can manifest as: Bedwetting after learning to use the bathroom Inability to speak Acting out Potential treatments for Trauma: Open a conversation with your parents about their lives and how they coped. Notice any underlying patterns, attitudes, or stories from your family that you continue to display. Talk through these areas with a trusted friend, family member, or therapist and consider an alternative way of coping or communicating. Promote a sense of empathy and compassion for your family and the struggles they experience. Recreate a new habit that you want your children to demonstrate and believe about their family, themselves, and the world. 8 18 BUILDING AND KEEPING BOUNDARIES 1. List Your Most Important Priorities Whats non-negotiable to you? What are your hard limits, the rules you refuse to bend? Those are your most important priorities, and thats where you can start your focus. Boundaries come in many shapes and forms, including physical, emotional, moral, and financial limits. Self-awareness is the first step toward change. Think about past times when you maintained certain limits. Take some time and consider writing down these limits. How did it feel to respect yourself in that way? Now reflect on some times when you backtracked or compromised your needs? How did you feel then? These questions will help you learn how to set boundaries. 2. Pay Attention to Your Intuition Do you know that nagging voice in the back of your head thats telling you something isnt a good idea? Chances are, its guiding you in the right direction! Why not consider listening to it next time? Research shows that our beliefs help us process underlying information to make better and faster decisions. In other words, if the thought of babysitting your neighbors child fills you with dread, pay attention to that feeling. Likewise, if a job offer doesnt feel right, it might not be the right job for you! Of course, we sometimes need to do things we dont want to do. But suppose you routinely accept invitations or over-extend yourself past your limits. In that case, you arent listening to your gut, which means you might not be respecting your own boundaries. 3. Assume Responsibility for Your Needs No matter how much you love your friends and family, its still your job to care for yourself. Always have an alternative plan to avoid entirely depending on others to make you happy. Learning to take responsibility for your life means: Avoiding blaming other people for your emotions Accepting hard times as a regular part of growth Taking ownership over your actions and how they affect others Making decisions that serve your best interest When you start being responsible for yourself and your needs, you stop having high expectations for how other people should behave. You also avoid being a victim of your environment, and this mindset can help simplify your boundaries. 19 4. Practice Saying No No is a complete sentence. That truth may seem unthinkable, mainly if you hold attitudes that no makes you a mean person or lousy friend. But saying no to other people often means saying yes to yourself, and why shouldnt you matter? If giving a plain no feels too uncomfortable, you can try one of these phrases: I wish I could, but Unfortunately, that wont work for me. Thanks for thinking of me, but Im going to have to turn it down. I cant do it this time. Try to avoid lying about why youre saying no. Although a white lie may seem harmless, its easy to forget what you said or get caught in your own ideas. If someone finds out you lied to them, they will probably feel more betrayed and hurt than if you had just told them the truth. 5. Use I-Statements I-statements help you communicate your needs and feelings without attacking the other person. They can be highly effective. Many times, we rush to you-statements (you hurt my feelings! You never want to go anywhere. You dont care about my job!) when we feel angry or hurt. You-statements come across as accusing them or blaming them, and they often result in the other person becoming defensive or withdrawn. This push-pull pattern only leads to continue hard feelings. I-statements should be clear, but you should be mindful of your tone and word choice. The goal isnt to induce guilt or shame. Instead, its about asserting your needs and reaching a reasonable solution with someone else. Proper I-statements sound like: I felt ___ when you ____. I would really prefer I hope to Moving forward, I need to 6. Avoid Extreme Apologizing Remember, firm boundaries dont require anyone elses approval. Moreover, apologizing doesnt necessarily change how the other person might feel about you! Compare these two boundaries: Im sorry, something just came up, and I wont be able to attend the meeting. Im hoping I can join next time! Im really sorry, I wont be able to attend the meeting. Ive been so swamped. I know this meeting was important to you, and I was really hoping I could make it. I 20 know we need to prepare some things, and I feel so bad that Im canceling you at the last moment. Your time is so precious, and I hate disrespecting it. Notice the difference? In the first example, youre offering a direct boundary with a simple apology for any inconvenience it may cause. But in the second statement, the boundary becomes muddled by guilt and fear. Youre practically begging for the other person to validate that its okay you set the boundary. 7. Be Consistent with Applying Your Boundaries Consistency means following through with your boundaries, even if you dont want to do it at that moment. Your boundaries wont carry much weight if you dont enforce them. If people know youll give in to what they want, they might just ignore your requests altogether. For example, lets say your coworker routinely procrastinates during her tasks at work. You feel annoyed when she asks for help, and you tell her youre too busy. But a few days later, when its time to finish a group project, you pick up her slack in the end. She might apologize and avoid making the same mistake. Or, because she knew she could rely on you, the pattern may repeat itself. If you say youre going to do something, you must do it. Thats why continued practice is everything. 8. Expect the Discomfort Unfortunately, setting boundaries doesnt always feel good. In fact, it can feel incredibly awkward or even painful. You might feel guilty asking for what you need, even if the other person seems understanding. Additionally, some people might not respect your boundaries. This pushback can feel disappointing, especially if you arent expecting it. Remember that this doesnt mean you need to back down. Discomfort can sometimes be a part of the growth process. It isnt your responsibility to make other people happy when setting boundaries. Its certainly a nice bonus, but if thats your main focus, you arent setting an actual boundary- youre trying to compromise with other people. 9. Always Remind Yourself of the Benefits Setting boundaries can feel like a significant adjustment if youre used to pleasing others or rejecting your own needs. At times, you may question if its even worth it, especially if someone doesnt respect your boundary. It may be helpful to remind yourself of a mantra to remind yourself of the benefits, such as: My boundaries allow me to love myself Boundaries protect me from resentment 21 I am allowed to have limits I am grateful to give myself what I need My boundaries give me healthier relationships If you continue to struggle, reflect on the people you know who have firm boundaries. What do you admire about them? Can they inspire you during this vulnerable time? 10. Seek Professional Support Sometimes, self-help strategies arent enough. Therapy can help you understand the barriers that make boundaries challenging. Your therapist can work with you on self-empowerment and assertiveness training skills. They can also teach you healthy coping skills to manage the emotional discomfort associated with setting limits. 76 Some common barriers include: Having a history of trauma Being in an abusive relationship Struggling with a mental health condition like depression or anxiety Low self-esteem Growing up in a household with overly rigid boundaries or no boundaries at all 22 Self-Care and Esteem What is self-esteem? Self-esteem is the opinion we have of ourselves. When we have low selfesteem, we tend to see ourselves in a more negative and critical light and are less able to take on lifes challenges. It is important to identify negative beliefs you may have about yourself to improve self-esteem. 74 What is confidence? Self-confidence is the faith you have in your skills and abilities. Selfconfidence is fueled by self-esteem and how positive we are about ourselves. 74 How do you become self-aware? To take care of yourself, you must know who you are. Self-awareness is the ability to step back and observe ourselves, our feelings, and our thoughts. The journey to self-awareness takes bravery because confronting the uncomfortable can be scary. Its also important to practice self-compassion and self-care. 75 Activities to improve self-confidence, self-perception, and take care of yourself! Rules with self-care: 1. It should not feel like a chore 2. It is about progress, not perfection 3. You deserve this USE POSITIVE SELF-TALK Positive self-affirmation o I am confident. o I am getting better and better every day. o I am strong. o Today will be a productive day. 23 Be kind to yourself Keep up with something you are good at Everyone is good at something, whether it is cooking, singing, etc. People tend to be in a good mood when participating in something they are doing and are good at. Invest in new hobbies; Meditation Yoga & fitness o Yoga With Adriene - YouTube 70 https://www.youtube.com/c/yogawithadriene o o o Tumor Fitness - YouTube 71 https://www.youtube.com/channel/UCwFnQQ2wLJCoz6I8iiMtZ_Q o Go for a hike or take a walk Find a creative outlet o Crochet/knitting 24 How to Knit: Easy for Beginners - YouTube 72 https://www.youtube.com/watch?v=p_R1UDsNOMk How to Crochet for Absolute Beginners: Part 1 - YouTube 74 o Painting o Journaling 100 Journaling Questions and Prompts to Spark Your Creativity (developgoodhabits.com) 75 Journaling Prompts Intelligent Change o Creative writing Podcast options o Self-care for extremely busy women with Suzanne Falter o Self-Care Sunday with Kayley Reed Society o The Self Love Fix with Beatrice Health o Think Positive: Daily Affirmation with Dacia Arritola o Affirmations of a Bad B*tch with Tiona Thompson Basic self-care options o Stay hydrated o Increase daily step count o Take time to stretch before bed o Get at least 7-9 hours of sleep o Write a bucket list o Check-in with neighbors o Declutter your home o Recycle o Follow feng shui rules to bring peace to your home. 25 Relationships after Incarceration Communication Communication is more than just talking, interpersonal skills include active listening, body language, and verbal communication. o Body language Facial expression Smiling: Keep your expression natural and try to avoid extreme reactions Movement; move forward with purpose - Sherrilyn Kenyon Fidgeting: may indicate nervousness or boredom 19 Appearance Gesture: hand movements with speech often help with the understanding of what is being said 18 Posture: can reflect emotions, attitudes, and level of confidence o Active listening 5 Pay attention Show that you are listening, make frequent eye contact, give small verbal comments Offer feedback: this is a part where verbal communication is important; ask follow-up questions and be ready to offer comments, if prompted. Rebuilding relationships Children o Young children 17 For children of incarcerated mothers, Mothers Day is not very joyful. Due to the separation and limited contact, the relationships are ruined, and mending can become challenging due to obstacles that are still present with reentry. A few ways to approach the route of reconnection include: Apologize: hold yourself accountable and take responsibility. 26 Expect nothing: no one must forgive you. Children may forgive but may not want you back in their lives more often than not. Reach out because you want to, but understand that your life, sobriety, and happiness are not dictated by the acceptance of others. Love language: teach yourself to love in your childs love language. 3 Recognize that your childs perspective is valid: allow your child to speak freely about how they are hurt. You may disagree, but your child has a right to their feelings. Do the work: your child may be willing to meet you part way, but you have to do the work. Eventually, your child may respond positively if you consistently act in healthy ways. Dont give up: if the relationship means something to you, keep working on yourself and reaching out in healthy ways. o Adult children 16 Setting and respecting healthy boundaries and privacy If tension is rising, take a break and step away before saying anything you regret later. Treat your children like the adult they are. Try asking for advice in areas where they are knowledgeable in. Get in the habit of sharing jokes. Laughter is a great way of decreasing tension Caregivers 21 o Stop the spiral before it starts. Be proactive and acknowledge possible triggers before reacting. o Work on expressing yourself in a way that wont trigger a negative situation. o Dont launch yourself into a personal attack- step away and take a break if need to. o Regain your own self-control and potentially help others regain theirs - it takes two to de-escalate a situation. o Acknowledge your differences: talking about the different ways each one reacts and responds differently can be helpful o Express gratitude: it reduces conflict and cements our feelings about the good parts of our connection. Of course, 27 a partner who feels appreciated is more likely to feel encouraged to be even more loving and supportive in the future. Setting and respecting boundaries A boundary is an imaginary line that separates me from you. It separates your physical space, your feelings, needs, and responsibilities from others. Your boundaries also tell other people how they can treat you what is acceptable and what isnt. Without boundaries, people may take advantage of you because you havent set limits about how you expect to be treated. 11 Disagree on boundaries If boundaries are established by another person, its important to respect their comfort level. Its important to communicate and ask questions to understand the others persons boundaries. If someones boundaries are uncomfortable to you, its important to look inside yourself and continue to work on self: Why are you being triggered? o If possible, take a break from the situation. Doesnt have to be long, just long enough for you to process and calm yourself down. Identify the emotions you are feeling and acknowledge that the person is also feeling an intense emotion Use language that communicates your emotions and hold yourself accountable 28 Calm Parenting Parents are going to get angry with their children. Its a tale as old as time, and key to realizing that parenting is challenging and comes with its ups and downs. We want to acknowledge what triggers and regain control of ourselves before we react unconsciously. If you start to notice that your child is no longer responding to your anger, they could have developed a defense against it. You are only human, so the body reacts accordingly; you may feel an intense surge of adrenaline and the need to fight, flight or freeze. That need to respond immediately because it is what your body is telling you to do, the urge to teach your child a lesson and ask questions later. Acknowledging your triggers, your body displays signs of increased irritation sometimes before you notice; 77. Clenched fists Grinding teeth Biting your lip Fidgety Your pulse is quickening Calm yourself before you react: taking deep breaths and shaking off the tension you feel. 78 - Wait before disciplining o Take a few times to calm your nerves o Dont stew in the situation and make yourself more upset o Verbally express to your child the consequences and discuss the situation after your personal time out. - Avoid threats o Threats made while youre angry are always unreasonable. Tell your child you have to think of the appropriate consequence (if the consequences are not already established) - Monitor word choice 29 - - - - o We have the power to calm or upset ourselves and the person we are speaking with by our own tone of voice and choice of words. Consider you are a part of the problem o That responsibility for managing your own emotions first. It is hard to be a peaceful parent because everything that triggers you will make you act your worse. Its important to role model the behavior you wish to see. Still angry? o Look at your own emotional past o Seek help Avoid physical force o Spanking or slapping is a temporary fix that releases the anger you have, but it can result in a lifetime of distrust from your kid o If you are unable to control yourself, apologize to your child. If spanking is unavoidable, complete with self-control Say this, not that! (23, 12) Do not Stop crying. Youre fine. You act just like mother/father. Suggestions Why are you crying? Im not happy with your behavior because...(focus on behavior/action) Thats only for boys/girls. Say nothing. Remember that interest or hobbies are not gender-specific This is my house; youre just living in it. Because I said so Stop crying, or Ill give you something to cry about You know the rules. Please stick to them. Explain why you feel a certain way about it 30 Consequences & Punishment Parenting styles 1 Authoritarian: This parenting style is a one-way mode. Parents establish strict rules and children obey. Theres little room for negotiations from the child, and rules are usually not explained. These parents have elevated expectations and limited flexibility. PRO CON Children raised in a disciplined Can lead to higher levels of household will be the most wellaggression, difficulties managing behaved due to the anger, poor self-esteem, and consequences of misbehaving potential for rebellion later Authoritative: Normally develops a close, nurturing relationship with their child. Clear guidelines and reasoning behind discipline. PRO CON Encourage effective Gaining and maintaining a management of emotions, balance is not always easy independence, and a higher level of self-esteem and academic achievement Permissive: Warm and nurturing with minimal to no expectations or rules. Communication remains open, and parents allow their children to figure out situations on their own. Rarely uses of disciplines, more friendly. PRO CON Tend to be more creative and Little understanding of right and comfortable with self and selfwrong, few consequences, lack of expression. Close relations with structure parents Uninvolved: Children are given a lot of freedom. Parents fulfill basic needs and stay detached. Children may be self-sufficient and capable because they had to be. PRO CON Often keep out of parents The child is more likely to engage business, better at looking out for in negative behavior, poor attachment, and social skills themselves 31 Punishment vs. consequences Consequences teach, punishments control o Punishment: To mistreat, abuse, or hurt 7 o Consequences: an act or instance of following something as an effect, result, or outcome 6 Types of consequences Logical: actions taken by parents Ex: stays out beyond curfew hours; curfew time becomes earlier Stealing; pays victim out of own pocket Natural: occurs naturally without enforcement from parent Ex: Child spends allowance foolishly; there is no money for the newly released video game Child cheats in playing with friends; friends will start to stay away. Punishment/consequences by age range 25 Consistency is key, Explain to your children your expectations before punishing them Establish standards early Recognize the good behaviors as well Infants: Change tone of voice: Use a different, deeper tone when teaching Redirect your baby Remove object of reach from the child Toddlers Incorporate time outs: recommended for ages 2+ 13 o The trick is to stop engaging with your child o Length of time out = childs age Create a visual representation of behavior School-aged 4 Time-out = cool downtime o Removing privileges o Losing cell phone or screen time privileges o Postponing activities with chores Tweens/teens 24 Limiting freedoms/ independence 32 Creating a contract. Assign extra responsibility Make it clear that rights must be earned How to maintain control when your child makes you angry 14 Commit to staying in control o Give yourself a moment to get calmer Expect your children to push your buttons o In a sense, your child is testing the limits, but it is your job to remain calm and make sure they know where the limits are. If the boundaries are to be pushed, they should be held accountable Know what you are responsible for as a parent o Parents do have responsibilities. Parents should coach their children and parents set rules for the family and how the children are accountable to those rules with consequences. The rest is up to the child. o If you feel responsible for solving your childs problems, theyre not going to feel like they have to solve it for themselves. As they get older, they will become more reliant on you, and youre going to get more annoyed that they arent fending for themselves. 33 Sensory Education The body has 7 senses that help interact with the world around it: Tactile: touch Auditory: hearing Visual: eyes Gustatory: taste Olfactory: smell Vestibular: balance and where you are in space Proprioceptive: muscle movement and force. Interoception: Your ability to understand and feel whats happening inside your body (i.e., knowing if your heart is beating fast or if you need to use the bathroom). Everyone processes sensory differently. Some people require to be active and participate more. Research also states that experiencing traumatic events during childhood can cause difficulties with understanding information that people, things, and the environment provide. 9. Poor sensory understanding can show up in multiple different ways: - Avoids touching messy textures - Covers ears in noisy environments - Unable to sit for long periods of time - Get nervous when feet leave the ground - Eats limited food textures. It can also manifest with difficulty with trust, forming secure attachments and social relationships, anxiety, depression, aggression, poor school performance, and risky behaviors such as substance abuse Ways to improve sensory processing include: 34 - Using different soaps and bath aides during baths and showers to help with tactile sensations Allow your kids to help with mealtimes Create a space that is dedicated to minimizing sensory distractions Practice some breathing exercises. Yoga 35 References 1. Baumet, G. (2021, October 22). Parenting Styles: Pros and Cons of Each Style. Mindfulness and Ancestral Wisdom for Busy People | Granola Babies. https://gisellebaumet.com/blog/parenting-styles 2. Brazier, Y. (2019). 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Amazon. https://www.amazon.com/You-Come-Earth-SophieBlackall/dp/145213779X/ref=sr_1_1?crid=2PNZX1NZIQ83N&keywords=if+y ou+come+to+earth&qid=1652897509&s=books&sprefix=if+you+come+to +earth%2Cstripbooks%2C82&sr=1-1 51. Thompkins-Bigelow, J. (2020, July 7). Your Name Is a Song: Thompkins-Bigelow, Jamilah, Uribe, Luisa: 9781943147724: Books: Amazon.com. Amazon. https://www.amazon.com/Your-Name-SongJamilah-ThompkinsBigelow/dp/B07W4XJ184/ref=sr_1_1?crid=3F2BHSEQHU83P&keywords= your+name+is+a+song&qid=1652897658&s=books&sprefix=your+name+i s+a+song%2Cstripbooks%2C87&sr=1-1 52. John, J. (2021, August 3). Cat Problems (Animal Problems): John, Jory, Smith, Lane: 9780593302132: Amazon.com: Books. Amazon. https://www.amazon.com/Cat-Problems-Animal-JoryJohn/dp/0593302133/ref=sr_1_1?crid=1DG6XXN1GBED7&keywords=cat+p roblems&qid=1652897699&s=books&sprefix=cat+problems%2Cstripbook s%2C91&sr=1-1 53. Hoffman, M. (2018, June 12). Fruit Bowl: Hoffmann, Mark: 9781524719913: Books. 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Retrieved May 19, 2022, from https://www.selfimprovementbox.com/self-confidence-vs-selfesteem/#:%7E:text=%20What%20is%20the%20Difference%20Self%20Co nfidence%20vs,is%20all%20about%20one%20assessing%20themselves. . .%20More%20 75. Baulch, J. (2022, May 3). Self-Awareness: The Key to Taking Care of Your Mental Health and Wellbeing. Inner Melbourne Psychology. https://www.innermelbpsychology.com.au/self-awareness-mentalhealth/ 76. ChoosingTherapy.com. (2022, April 7). 10 Tips for Setting Healthy Boundaries. Choosing Therapy. Retrieved April 19, 2022, from https://www.choosingtherapy.com/setting-boundaries/ 77. The Pragmatic Parent. (2020, July 30). New Ideas to Help You Practice Calm Parenting & Stop Yelling When You Feel Mad. https://www.thepragmaticparent.com/calm-parenting-stop-yellingwhen-angry/#:%7E:text=Give%20your%20child%20a%2020second%20hug.%20Push%20your,bring%20you%20back%20to%20a%20 state%20of%20calm. 78. Markham, L. (2016, May 11). How to Handle Your Anger at Your Child. PsychologyToday. https://www.psychologytoday.com/us/blog/peaceful-parents-happykids/201605/how-handle-your-anger-your-child 79. Allarakha, S. (2021, February 8). What Are the 3 Types of Trauma? MedicineNet. https://www.medicinenet.com/what_are_the_3_types_of_trauma/article .htm 80. The Administration for Children and Families. (n.d.). What is Historical Trauma? Retrieved June 7, 2022, from https://www.acf.hhs.gov/trauma-toolkit/traumaconcept#:%7E:text=Historical%20trauma%20is%20multigenerational%2 0trauma,violent%20colonization%20of%20Native%20Americans. 44 APPENDIX B 45 46 APPENDIX C 47 48 APPENDIX D Week DCE Stage (orientation, screening/evaluation, implementation, discontinuation, dissemination) 1 Orientation 2 3 Orientation Orientation Weekly Goal Tasks Date complete Complete orientation at sight Meeting with key personnel 4/8/2022 Complete orientation at Duvall Ensure that all paperwork is completed for submission IRB certification Objectives Creating a realistic plan for execution for program Finalize MOU. 4/14/2022 Continue with resource Complete one 4/22/2022 full week with Duvall work rehab classes Get CI previous created materials for guide Created a guideline to follow for sessions to follow. 4 Screening Review outcome Draft of assessments/pre- resource post test guide 4/28/22 49 Gaining and reviews files of potential 2-gen participants 5 Screening Attended session with Breea of 2gen session Scheduling prospective 2_Gen clients for in person sessions 5/6/22 Meeting with case manager to discuss clients situations 6 Implementation Complete week with Duvall work rehab classes (co-teach) 5/12/2022 7 Implementation Yoga session One-page during handouts for the Duval men to follow along Typing resumes for career workshop Yoga session Typing all during resumes for the Duval Duvall clients Complete week with Duvall work rehab classes (co-teach) 5/17/2022 8 Implementation 9 Implementation Yoga session during Duval Evaluation Yoga session 2 gen one on during one session Duval Complete 5/31/2022 week with Duvall work rehab classes (Independent) Finalized 5/7/2022 resource guide and send of out 10 Complete 5/24/2022 week with Duvall work rehab classes (Independent) 50 11 Implementation/Screening 12 Implementation Introduction & Assessments Self-care & 2 gen one on Hierarchy one session of needs (independent): Sensory integration 2 gen one -on one session (independent) feedback survey Outcomes of feedback survey data analysis Apply edits to resources guides 6/13/2022 6/20/2022 Coordinate with Breea for new edits. 13 14 Last week at Duvall/ Discontinuation/Dissemination midterm survey & personal boundaries File transfers to Breeas drive 2 gen one on one: 6/27/2022 Combine Resource guide and weekly session objective into one binder for final project Final evaluation 7/6/2022 51  ...

... Entry-Level Occupational Therapy Student Perceptions of Occupational Balance in Graduate School: A Qualitative Study Submitted to the Faculty of the College of Health Sciences University of Indianapolis In partial fulfillment of the requirements for the degree Doctor of Health Science By: Stephanie Bachman, OTD, OTR/L, CLA Copyright April 27, 2022 By: Stephanie Bachman, OTD, OTR/L, CLA All rights reserved Approved by: Penelope Moyers, EdD, OT, FAOTA Committee Chair ______________________________ Lucinda Dale, EdD, OTR, CHT, FAOTA Committee Member ______________________________ Laura Santurri, PhD, MPH, CPH Committee Member ______________________________ Accepted by: Laura Santurri, PhD, MPH, CPH Director, DHSc Program Chair, Interprofessional Health & Aging Studies University of Indianapolis ______________________________ Stephanie Kelly, PT, PhD Dean, College of Health Sciences University of Indianapolis ______________________________ STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE Entry-Level Occupational Therapy Student Perceptions of Occupational Balance in Graduate School: A Qualitative Study Stephanie A. Bachman Department of Interprofessional Health & Aging Studies, University of Indianapolis Author Note I have no known conflicts of interest to disclose. Correspondence concerning this article should be addressed to Stephanie Bachman, Master of Occupational Therapy Program, Walsh University, North Canton, OH 44720. E-mail: sbachman@walsh.edu 1 STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE 2 Abstract Objective: The objective of this study was to examine how entry-level graduate occupational therapy (OT) students incorporate strategies to manage occupational balance, or a persons combination of activities in self-care, work, and leisure. Methods: Grounded theory methodology was used to develop a theory of the occupational balance of entry-level graduate OT students. Twenty-six students were recruited using convenience and maximum variation sampling. Open-ended interviews were conducted through videoconferencing. Data analysis through constant comparison of transcripts, field notes, and memos consisted of open, axial, process, and selective coding. A storyline narrative with diagrams displayed relationships among concepts while providing evidence to support inductively derived theoretical propositional statements. Results: Students in OT programs progressed through a continuous cycle of three phases of occupational balance during graduate school: occupational balance, balance disruptions, and return to occupational balance. A disruption in occupational balance resulted in students implementing strategies to return to occupational balance. Strategies included developing an individualized plan for organization, sharing experiences with cohort peers, and scheduling time for self-care. Internal contexts, including personal values, and external contexts, including COVID-19, shaped students use of strategies to manage an occupational balance disruption. Conclusions: Entry-level students in OT described cyclical phases of occupational balance experienced throughout the graduate program. The specific contexts, such as COVID-19 externally and personal values internally, influenced the occupational balance cycle and the strategies for return to occupational balance. Keywords: occupational balance, graduate school, occupational therapy student STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE 3 Acknowledgements As I move toward the end of my time in this doctoral program, I am overcome with emotion. Reflecting on the amount of personal and professional growth I experienced makes me so grateful for all of the people in my life who made this possible. I would like to take this opportunity to thank the individuals who supported me through this journey. First, I would like to thank my husband, Frank, and my two sons, Edward and Joey. Your love, encouragement, and confidence in me helped push me to keep working toward my goal. I do not believe I could have accomplished this without the three of you by my side. I appreciate all of the pep talks and hugs you gave me, but most of all, the added work you took on so I could write! I would like to thank my parents, who first believed in me and pushed me out of my comfort zone long ago. Their ability to see my potential is what helped me get to where I am today. Next, I would like to thank my colleagues at Walsh University. Your support, assistance, and expertise were invaluable to me throughout this process. Dr. Pamela Ritzline, I am forever grateful you gave up your personal time to proofread my paper. And to the students, who helped me understand the importance of my own life balance, thank you! Last, but certainly not least, I would like to thank my committee. Each of you played such an important role in making this possible. Dr. Laura Santurri, you helped me find a committee! Your consistent positivity helped me persist. You inspire me to be more like you - a better leader in my academic role. Dr. Lucinda Dale, your revisions, suggestions, grammar pointers, and willingness to meet with me any time I needed it were so helpful. I always felt better about my progress after seeing your smiling face! And, Dr. Penny Moyers, you pushed me STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE to achieve more than I thought possible. I appreciate the little nudges you gave me to get over myself and just do it! I gained so much knowledge from you and will be forever grateful you were my mentor. I learned so much about the research process and professional writing while working on this project, but I learned even more about myself and what I am capable of achieving. With deepest gratitude, Stephanie Bachman 4 STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE 5 Table of Contents Title Page.1 Abstract2 Acknowledgements..3 Chapter 1: Introduction7 Problem Statement...8 Purpose Statement9 Research Questions..9 Significance of the Study.9 Chapter 2: Literature Review.10 Professional Burnout Among Occupational Therapists.12 Theories of Balance...14 Occupational Balance in Graduate School16 Strategies for Obtaining Occupational Balance in Graduate School.18 Measuring Occupational Balance......21 Chapter 3: Methods25 Study Design. 25 Participants.26 Setting27 Procedures..27 Study Rigor37 Chapter 4: Results..38 Chapter 5: Discussion..113 STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE 6 Theory of Occupational Balance.132 Study Limitations136 Implications for Education and Research137 Conclusion...140 References141 Table 1: Characteristics of Students by OBQ scores...154 Table 2: Most Frequently Used Occupational Balance Strategies by OBQ Score..155 Table 3: Propositional Statements Developed During Data Analysis.156 Figure 1: Phase Diagram......159 Figure 2: Conditional/Consequential Matrix of Graduate Student Occupational Balance..160 Appendix A: Initial Interview Guide...161 STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE 7 Entry-Level Occupational Therapy Student Perceptions of Occupational Balance in Graduate School: A Qualitative Study The transition from undergraduate to graduate school presents new challenges for students pursuing careers in the health professions (Govender et al., 2015). These challenges require exploration and integration of coping strategies while developing profession-specific practice skills (Govender et al., 2015). Graduate students report high-stress levels resulting from balancing academic requirements with financial and personal obligations (Myers et al., 2012; Pfeifer et al., 2008; Rummell, 2015; Willyard, 2012). Researchers who investigate student stress often focus on medical students and those in allied health professions other than occupational therapy (OT) (Enns et al., 2018; Myers et al., 2012). The literature lacks studies regarding the stress that entry-level OT graduate students experienced compared to the stress of students in other health profession programs (Govender et al., 2015; Malek-Ismail & Krajnik, 2018; McCombie et al., 2016). Graduate students may experience a lack of occupational balance in daily activities due to high academic demands in entry-level professional programs (Porath & Rosenblum, 2019). Students often reported spending more time in educational activities than self-care, work, or leisure pursuits (Porath & Rosenblum, 2019). Pfeifer et al. (2008) discovered that entry-level OT graduate students struggled with balancing academics, family life, and employment. MalekIsmail and Krajnik (2018) found that when entry-level OT graduate students took time for leisure activities or socialization, they perceived feelings of guilt and reported fear of falling behind. Occupations are the daily life activities in which people engage (American Occupational Therapy Association [AOTA], 2014, p. S6). Students who experience stress due to lack of balance between academic responsibilities and personal life may be more prone to stress STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE 8 once acculturated into the OT profession. According to Costa (2018), a strong factor predisposing occupational therapists to burnout is the feeling of work infringing on home life. Workplace employee health initiatives are more mainstream due to a surge in mental health disorders, preventable diseases, and symptoms of burnout, such as decreased quality of life and poor work performance (Mattke et al., 2013; Page et al., 2014). The movement toward a healthier workforce led to a plethora of studies on well-being that include conceptual understandings of the meaning of balance in a persons life. Wilcock et al. (1997) introduced the term occupational balance and described the association between occupational balance and health. Occupational balance is instrumental to mental and physical health and feelings of well-being and life satisfaction (Wagman et al., 2012a). In contrast, authors state occupational imbalance causes fatigue, feelings of stress, and negative thought patterns (Christiansen, 2007; Yazdani et al., 2018). Occupational therapists typically refer to occupational balance as a healthy mix of activities in the self-care, work, and leisure categories of occupation (AOTA, 2014). Problem Statement The perfectionistic traits common in entry-level OT graduate students (Wagner & Causey-Upton, 2017), combined with their reported difficulty achieving occupational balance, place students at risk for burnout before they enter the profession. Professional burnout can manifest in physical, emotional, and behavioral symptoms (Costa, 2018). Occupational therapists who enter the profession demonstrating behaviors consistent with burnout are at a higher risk for mental and physical health problems (Costa, 2018; Poulsen et al., 2014). Burnout may manifest early in a therapists career if the person is not equipped with self-care practices to help cope with the high demands of a career focused on helping others (Maslach & Leiter, 2008). Faculty STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE 9 should consider incorporating occupational balance in entry-level graduate programs and should demonstrate behaviors consistent with occupational balance to equip students for managing stress in the workplace and for avoiding burnout once assimilated into the profession. Purpose Statement The purpose of this study was to examine how entry-level graduate students in OT incorporate strategies to manage occupational balance in their role as students. The researcher inductively developed a theoretical explanation of the strategies students incorporated to achieve occupational balance and how these approaches evolved when students experienced a life role change while in the entry-level graduate program. The researcher also studied strategies students used to manage the student role during different semesters of the OT program. Research Questions The researcher sought to address the following research question and sub-questions: How do entry-level students in OT incorporate strategies to manage occupational balance in their role as a student in the graduate program? o What are the differences in the occupational balance strategies of OT students who report high, medium, and low occupational balance? o What happens to the way entry-level OT graduate students manage occupational balance when they experience a change in the expectations of their student role or other life roles? o For entry-level graduate students in different semesters of the OT program, how do the strategies for managing the student role change? Significance of the Study The findings from this research, along with the theory presented, may improve STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE 10 understanding for both faculty and students of the challenges to occupational balance that entrylevel OT graduate students experience. These challenges the OT students experience during the entry-level graduate program may lead to disruptions in occupational balance and future problems of career burnout unless the student successfully negotiates these challenges. Additionally, an explanation regarding the achievement of occupational balance may assist faculty with designing curricula, providing guidance, and developing social supports that encourage the use of occupational balance strategies as students transition to and complete an entry-level graduate program in OT. Quality of life may improve as a result of remaining in occupational balance throughout the time in the entry-level OT graduate program, which could lead to richer educational experiences for students. Most importantly, graduates from entry-level OT programs may be better equipped with the knowledge and skills to recognize and avoid burnout as practicing occupational therapists. Literature Review Erlandsson and Christiansen (2015) defined balance as making adjustments or changes in an attempt to find equilibrium within a system (p. 118). Incorporating balance into life to achieve a sense of satisfaction is a concept foundational to the profession of OT. This researcher reviewed literature about balance and occupational balance theories for this section. The researcher suggested burnout among occupational therapists is a possible result of disruption in occupational balance. Finally, a summary is provided of the literature about occupational balance and strategies to improve this balance for entry-level OT graduate students. Researchers identified common conceptual components of occupational balance (Backman, 2004; Wagman et al., 2012a; Wilcock et al., 1997). Occupational balance is the contentment a person possesses concerning time spent in self-care, work, and leisure occupations STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE 11 (AOTA, 2014; Backman, 2004; Wagman et al., 2012a; Wilcock et al., 1997). Yazdani et al. (2018) noted that occupations should have meaning to the person and be directly related to a persons necessary and preferred occupational roles. Yazdani et al. (2018) conducted a qualitative study of nine occupational therapists concluding that three components of doing should be considered when evaluating life balance: the person performing the occupation, the occupation itself, and the context in which the person is completing the occupation (p. 295). The value a person assigns to an occupation may differ from that of another person performing the same occupation (Backman, 2004). This individualized perception of occupations adds to the complexity of the concept of occupational balance and exemplifies the need to investigate each persons balance across all their occupations occurring in multiple contexts (AOTA, 2014; Backman, 2004; Yazdani et al., 2018). Meyer (1922) discussed the importance of balancing work and play in determining a persons self-worth. Wilcock et al. (1997) investigated the connection between health and living a balanced life. The researchers introduced the term occupational balance and defined it as a balance of occupations in the physical, mental, social, and rest categories of occupation (Wilcock et al., 1997). Wilcock et al. (1997) also determined that optimal occupational balance differs among people. Christiansen (2007) postulated that occupations need to provide a sense of purpose in life for a person to thrive and show resilience. A person achieves this sense of purpose through participation in a variety of self-selected occupations that are intrinsically meaningful to them (Westhorp, 2003). Each day, the chosen occupations may fluctuate depending on environmental demands, skill development, and motivation (Westhorp, 2003, p. 103). Occupational balance positively impacts overall physical health and feelings of wellbeing (Eriksson et al., 2011; Pettican & Prior, 2011; Wagman et al., 2012b). Pentland and STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE 12 McColl (2009) found balance to occur when a person participates in occupations that are meaningful and congruent with personal values, as well as meets the contextual demands on the person. A person must engage in occupations that help fulfill all life roles to report a sense of balance (Pentland & McColl, 2009). A mismatch between a persons desired and actual occupations increases the potential for physical and mental health problems to arise (Matuska & Barrett, 2019). These mismatches can occur due to unexpected changes or disruptions to a persons occupational pattern (Erlandsson & Hkansson, 2009). For example, increased demands at work may require a person to spend more time on work tasks and less on family obligations (Erlandsson & Hkansson, 2009). Problems in occupational balance results in reports of exhaustion, increased stress levels, and negative thought patterns (Christiansen, 2007; Yazdani et al., 2018), which may lead to feelings of burnout, especially in helping professionals, such as occupational therapists (Costa, 2018; Janus et al., 2018; Poulsen et al., 2014). Professional Burnout Among Occupational Therapists Reports of workplace burnout are prevalent, which led to the inclusion of the term occupational burnout in the newest revision of the International Classification of Diseases (ICD11) (World Health Organization, 2019). In a Swedish study of health professionals, including occupational therapists, Wagman et al. (2017) found 98.7% of participants reported they were highly satisfied with the meaningfulness of their daily work serving others. In contrast, participants were dissatisfied with the amount of time available to dedicate to rest and recovery (Wagman et al., 2017, pg. 21). A career helping others regain independence can be intrinsically rewarding; however, if a person does not receive adequate respite, continually giving of the self may lead to stress and professional burnout (Janus et al., 2018; Poulsen et al., 2014). Occupational therapists spend most of their time assisting clients with various limitations to daily STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE 13 functioning, leaving very little time for self-preservation (Janus et al., 2018). Poulsen et al. (2014) found strong correlations of burnout with occupational therapists' perceptions regarding a high workload, an inability to detach from work when at home, and longevity in the profession between six and ten years. Similarly, Wressle and Samuelsson (2014) reported work-related stress among occupational therapists primarily from high workloads and less time allotted for personalized client care and attention. Warning signs of stress and burnout included fatigue, irritability, callousness, and diminished work attendance or performance (Costa, 2018). The results of these studies may lead to the conclusion that entry-level graduate students who experience challenges to occupational balance while enrolled in an OT program most likely will experience increased levels of stress and may begin to show signs of burnout before entering their professional careers. In 2008, the Institute for Healthcare Improvement introduced the Triple Aim of Healthcare to promote high-quality healthcare standards in the US (Berwick et al., 2008). The authors of the Triple Aim focused on the improvement necessary to advance the healthcare experience, address the overall health of populations, and reduce the cost of healthcare (Berwick et al., 2008). Bodenheimer and Sinsky (2014) and Sikka et al. (2015) proposed the addition of a fourth aim that involved improving the lives of the healthcare provider. A move to a more business-centered healthcare model may have contributed to increasing burnout among healthcare workers because organizational leaders focus on productivity and efficiency rather than the needs and wants of the client (Sikka et al., 2015). Advocates of the fourth aim highlight that healthcare workers who display behaviors consistent with work satisfaction demonstrate characteristics of teamwork, job engagement, and an improved ability to achieve the Triple Aim (Bodenheimer & Sinsky, 2014; Sikka et al., 2015). Graduates from entry- STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE 14 level OT programs who possess self-care practices to identify characteristics of burnout and who can integrate adaptive coping strategies may risk less burnout when encountering the daily challenges of employment as occupational therapists (Bodenheimer & Sinsky, 2014; Sikka et al., 2015). Theories of Balance An emerging trend in organizations across the US is a focus on employee wellness (Mattke et al., 2013; Page et al., 2014). The emphasis on employee well-being results from escalating mental health conditions and preventable diseases, such as diabetes and heart disease (Mattke et al., 2013; Page et al., 2014). Administrators are integrating wellness programs into employee benefit packages in the attempt to offset the costs of preventable health conditions, improve the quality of life of employees, limit absenteeism, and thus, increase productivity (Benavides & David, 2010). The Centers for Disease Control and Prevention (CDC) (2019) provides resources to help companies establish programs to improve employee quality of life and make positive improvements to modifiable health risks. This nationwide movement towards a healthier workforce prompted researchers to investigate the meaning and importance of balance in a persons life. Researchers interchangeably use the terms life balance, work-life balance, and occupational balance. Definitions of the terms work-life balance, life balance, and occupational balance are similar in the literature. Rummell (2015) and Sirgy and Lee (2018) described work-life balance as an equilibrium among the time allocated for work or school-related and professional activities and the time dedicated to all other life roles. The increased stress that results from a disproportionate amount of time spent in work, school, and professional activities leads to decreased overall life satisfaction, unethical decision making, increased symptoms of job STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE 15 burnout, and reduced attention to personal health (Rummell, 2015; Sirgy & Lee, 2018). Rummell (2015) found that the stress level related to problems in work-life or school-life balance was more pronounced in students enrolled in graduate psychology programs during their first or second year in a program. The author stated that students might not have adequate time to learn appropriate coping mechanisms and described the need for further research in this area (Rummell, 2015). Researchers, including in the literature specific to OT, used the terms occupational balance and life balance interchangeably. For this reason, identifying specific theories of occupational balance proved difficult. Many researchers (Enns et al., 2018; Malek-Ismail & Krajnik, 2018; Myers et al., 2012; Rummell, 2015; Willyard, 2012) characterized life balance as similar to occupational balance. Veenhoven (2009) defined life balance as a combination of lifestyle choices that produce the most happiness over time (p. 35). Matuska (2010) stated if a person meets their basic needs, regardless of the specific occupation, the person will feel they achieved life balance and contentment with life (Matuska, 2010). Matuska and Christiansen (2008) defined a balanced lifestyle similarly but added that the occupation must be sustainable within the context of his or her current life circumstances (p. 11). Westhorp (2003) described balance as engagement in a variety of chosen occupations that are meaningful to the person and promote health and well-being (p.103). The balance of occupations is unique to each person but should include mental, physical, social, emotional, and spiritual occupations (Westhorp, 2003, p. 104). Anaby et al. (2010b) explained that occupational balance includes all areas of life personal, work, and leisure. The authors investigated how people find balance among different activities in life, such as learning, playing, socializing, etc. (p. 82). They also indicated balance is subjective and based upon a STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE 16 persons satisfaction with the chosen occupations (Anaby et al., 2010b). Wilcock and Hocking (2015) theorized that occupational balance encompasses lifebalance and work-life balance. The authors stated that occupational balance is a complex concept that can refer to individual people and populations (Wilcock & Hocking, 2015). Additionally, Wilcock and Hocking (2015) postulated that occupational balance fluctuates and depends on the circumstances and the environments where engagement in occupation occurs. Balance occurs when basic human needs are met and supported through a total configuration of occupation over time (Wilcock & Hocking, 2015, p. 309). Occupational Balance in Entry-Level Graduate School Researchers (Enns et al., 2018; Malek-Ismail & Krajnik, 2018; Myers et al., 2012; Rummell, 2015; Willyard, 2012) described the transitions of students enrolled in healthcare programs from undergraduate to entry-level graduate programs, including information about the level of stress students reported during their tenure in an entry-level professional graduate program. Entry-level graduate programs typically are year-round and require completion of up to 15 credit hours a semester in addition to mandatory fieldwork or clinical experiences (How Much Time Per Week, 2017). Multiple studies included reports from students about heightened stress levels while earning a graduate degree as the result of spending more than 50 hours per week in academic-related activities combined with ongoing personal and financial obligations (Myers et al., 2012; Pfeifer et al., 2008; Rummell, 2015; Sirgy & Lee, 2018; Willyard, 2012). In addition to the financial and time constraints that accompany enrollment in a graduate program, students who enter a graduate program directly after earning a bachelors degree often have to delay personal interests, such as getting married and having children, to focus efforts on academic pursuits (Benshoff et al., 2015; Di Pierro, 2010). Students who return to graduate STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE 17 school after a hiatus or in preparation for a second career may be encumbered with caring for a child or an aging parent or supporting a family while financing their education (Di Pierro, 2010). Although researchers have investigated stress and coping in graduate students, most studies are from the social sciences, not OT (Enns et al., 2018; Myers et al., 2012). One exception is MalekIsmail and Krajnik (2018), who investigated balance among students enrolled in entry-level OT graduate programs during the first semester. Although a definition of balance did not emerge from this study, Malek-Ismail and Krajnik (2018) found students perceived challenges to occupational balance at the beginning of the first semester of graduate school, with the perception of balance fluctuating throughout the first semester. The continuous rebalancing (p.8) described in the research findings was dependent on social support, course workload, expectations of faculty, and each students level of self-determination (p. 13) (Malek-Ismail & Krajnik, 2018). High academic demands combined with a lack of time to adequately complete all requirements may decrease occupational balance among students in entry-level healthcare programs (Watkins et al., 2011). El-Ghoroury et al. (2012) surveyed students in graduate psychology programs to identify barriers to wellness. The researchers reported that 59% of the students identified poor work-school life balance and indicated this lack of balance disrupted their ability to function (El-Ghoroury et al., 2012). Rummell (2015) stated that students enrolled in graduate psychology programs reported dissatisfaction with the lack of importance placed on self-care in their educational programs and suggested an increased emphasis on self-care should occur throughout graduate school. Admittance into entry-level OT graduate programs is competitive, with less than 20% of applicants accepted in 2017 (Accreditation Council for Occupational Therapy Education STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE 18 [ACOTE], 2018). Wagner and Causey-Upton (2017) reported that students accepted into these programs demonstrated high achieving behaviors and perfectionistic traits. These researchers found that students who identified as perfectionists reported a lack of exercise and limited time for eating and socializing due to the way they budgeted out-of-class time for academic coursework (Wagner & Causey-Upton, 2017). Students in entry-level OT graduate programs reported increased stress related to managing coursework, social relationships, and financial obligations (Govender et al., 2015; Pfeifer et al., 2008). Malek-Ismail and Krajnik (2018) conducted a qualitative study with 33 students in the first semester of an entry-level OT graduate program. The authors (Malek-Ismail & Krajnik, 2018) indicated that students described a cycle of adjustment (p. 7) when transitioning to graduate school. They (Malek-Ismail & Krajnik, 2018) further identified the overarching theme of turbulence and rebalancing (p. 7) as indicative of the first semester of the entry-level OT graduate program. Strategies for Obtaining Occupational Balance in Entry-Level Graduate School Researchers investigated the lack of life balance with students from medicine, athletic training, and nursing (Aufricht et al. 2019; Barrett et al., 2016; Cino, 2016; Schmidt & Hansson, 2018) but did not identify strategies to manage a disruption to occupational balance. Results of studies from the profession of OT included strategies students employ to manage stress, but researchers did not discern the effect of these strategies on the achievement of occupational balance (Govender et al., 2015; McCombie et al., 2016). Cino (2016) advocated the importance of teaching self-reflection as a component in the nursing curriculum to help students find balance in life. The author discussed the importance of self-awareness in leading a healthy life (Cino, 2016). By increasing self-awareness, students improved their ability to identify stressors and use personal coping strategies, thus improving STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE 19 mental health to a level associated with a more balanced life. Specific suggestions for improving student mental health included scheduling mind-body activities and quality time with spouses and children. Cino (2016) also identified the importance of prioritizing healthy habits, such as sleep, proper nutrition, and exercise, to improve overall life balance (Cino, 2016). In the form of an accountability partner, peer support assisted participants with adhering to their established self-care plan and improving perceived life balance (Cino, 2016). Schmidt and Hansson (2018) completed a systematic review of the literature, combining the results of studies investigating the well-being of doctoral students. The researchers found that students reported the necessity of using coping strategies to manage stress to achieve physical and mental health (Schmidt & Hansson, 2018). Schmidt and Hanssons (2018) review addressed recommendations to improve well-being in doctoral students that included the use of social support networks, planned academic and personal activities to ensure adequate time, and engagement in an exercise program. Aufricht et al. (2019) provided suggestions for medical students to improve satisfaction with work-life balance and to avoid burnout while in graduate school. The authors proposed improving student-to-student and faculty-to-student communication and developing a support group or mentoring program for students (Aufrict et al., 2019). Another recommendation was for working professionals to meet with students and discuss the identification of early warning signs of burnout (Aufrict et al., 2019). Barrett et al. (2016) used qualitative methodology to investigate the perceptions of students in athletic training programs regarding their preceptors ability to maintain a work-life balance. Students observed that preceptors implemented strategies to improve work-life balance, which included setting priorities, asking for assistance from co-workers to manage work STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE 20 demands, and sharing familial responsibilities with a supportive partner (Barrett et al., 2016). Students reported feelings of hope (p. 116) when faculty and preceptors modeled these behaviors that demonstrated the possibility for achieving work-life balance as a working professional (Barrett et al., 2016). Another outcome Barrett et al. (2016) reported was the importance of faculty mentoring students to improve their awareness of workplace expectations (p. 116) and to suggest methods to integrate work-life balance principles into life as a student. Tompkins et al. (2016) found students who perceived faculty support were more likely to report satisfaction with their graduate program and life in general while in graduate school. Students who believed they had support from faculty advisors and had a clear understanding of expectations reported fewer symptoms of burnout and increased satisfaction during their tenure in a graduate program (Clark et al., 2009; Myers et al., 2012; Rummell, 2015). Haertl (2008) described the learning process as a partnership between the educator and the student, enhanced by effective communication that included building trust and incorporating student-centered adaptations to meet course learning objectives. In a study of 2,279 graduate students, Evans et al. (2018) identified a strong negative relationship between faculty supportive mentoring and the rate of depression and anxiety among students. Rummell (2015) surveyed students in graduate psychology programs and discovered 44% reported faculty placed too little emphasis on self-care, with 18% of the participants suggesting their program needed to foster a deeper connection between faculty and students. Instructors in academic programs primarily focus on teaching discipline-specific knowledge students will need once they embark on their professional careers (Di Pierro, 2010). Graduate classrooms include a mix of students who enter directly after earning an undergraduate STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE 21 degree and students returning to graduate school after a hiatus (Di Pierro, 2010). Often, the returning students manage issues, such as financial obligations, but also may be engaged in the role of parent to a child or caregiver to an aging adult (Di Pierro, 2010). These contextual circumstances outside of the academic realm may prove too much for students to manage on their own (Di Pierro, 2010); thus, assistance from a faculty mentor may be necessary to ensure student success. A dearth of literature exists specific to perceptions of interactions between OT faculty and students enrolled in entry-level OT graduate programs. Malek-Ismail and Krajnik (2018) found that students perceived that instructors in entry-level OT graduate programs taught content too quickly and deliberately planned for multiple assignments to be due concurrently. These factors led students to question the concepts of occupational balance and health that academic programs integrate throughout the coursework for becoming an occupational therapist. In addition, the students perceived the faculty did not practice the concepts they were teaching (Malek-Ismail & Krajnik, 2018). Measuring Occupational Balance A search of the literature produced three methods of measuring occupational balance (Anaby et al., 2010a; Dur et al., 2014; Wagman & Hkansson, 2014b). Anaby et al. (2010a) proposed definitions of occupational balance and imbalance as the patterns among a persons daily occupations. Balance is a state of harmony or congruence across a persons occupations, and imbalance is perceived disharmony, lack of fit, or interference among occupations (Anaby et al., 2010a, p. 281). The authors (Anaby et al., 2010a) used the Cross Impact Matrix (CIM) (Little, 1984) and the Intergoal Relations Questionnaire (IRQ) (Riediger & Freund, 2004) to measure the contextual factors impacting balance and the resultant satisfaction with a persons STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE 22 life. The authors also used two subjective measures of well-being (Anaby et al., 2010a), The Satisfaction with Life Scale (Diener et al., 1985) and The Positive and Negative Affect Scales (Watson et al., 1988). They reported inconclusive findings with no correlations between the CIM (Little, 1984) and reported well-being (Anaby et al., 2010a). Anaby et al. (2010a) found the IRQ (Riediger & Freund, 2004) to be useful in identifying conflicting occupations. The authors defined conflicting occupations as those that take resources (e.g., time, money, and energy) away from pursuing another desired occupation (Anaby et al., 2010a). The authors recommended further research about the topic of conflicting occupations as their sample size was small (Anaby et al., 2010a). Dur et al. (2014) defined occupational balance as an academically defined construct lacking a relationship to the experiences of real people (p. 2). The authors (Dur et al., 2014) further explained that definitions occupational therapists developed are from researchers perspectives rather than from those who receive OT services. Dur et al. (2014) did not propose a definition of occupational balance but developed a tool, called The Occupational BalanceQuestionnaire (OB-Quest), through a qualitative study of healthy people and people diagnosed with an autoimmune disease. Based on the qualitative data obtained and a quantitative examination of the scale's internal consistency, Dur et al. (2014) developed the final 10-item questionnaire. The final version of the OB-Quest addressed seven components of occupational balance, four of which were not measured by other instruments (Dur et al., 2014). The four components unique to the OB-Quest were: challenging and relaxing activities, involvement in stressful activities and fewer stressing activities, the impact of health conditions on activities, and adaptation of activities to changed living conditions (Dur et al., 2014, p. 6). Initially, Dur et al. (2014) discovered low internal consistency of the OB-Quest. The STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE 23 researchers separated several of the original components of the OB-Quest, which improved internal consistency (Dur et al., 2014). For example, the item challenging and relaxing activities was eliminated and replaced with too much demand and too little demand (Dur et al., 2014, p. 5). Adaptation of activities to changed living conditions was replaced with two items (Dur et al., 2014, p. 5) to differentiate balance differences when a person experienced a change in a state of health compared to a change in professional life or employment status (Dur et al., 2014, p. 6). Lastly, the researchers divided the rest and sleep component into two separate items (Dur et al., 2014, p. 5). After dividing these components of the OB-Quest, they (Dur et al., 2014) reported that the improved internal consistency challenged the unidimensional concept of occupational balance (p. 6) and concluded occupational balance is multidimensional (Dur et al., 2014, p. 6). Dur et al. (2014) also emphasized that researchers have not investigated occupational balance sufficiently and suggested further research to determine whether occupational balance is a continuum or whether balanced and unbalanced are separate constructs (Dur et al., 2014). Wagman and Hkansson (2014b) defined occupational balance as a four-part concept focusing on the variation in the occupational pattern, the amount of each occupation as well as the total number of occupations in relation to the available resources, and the meaningfulness in the occupations (p. 228). The authors (Wagman & Hkansson, 2014b) originally developed the Occupational Balance Questionnaire (OBQ) as a 13-item outcome measure. Information from focus groups provided data for the conceptual development of the instrument. The groups included women diagnosed with stress-related disorders and working men and women categorized as healthy (Wagman & Hkansson, 2014b). The researchers combined the results of the focus group data with information from a concept analysis of occupational balance to STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE 24 develop the final 13-item questionnaire (Wagman & Hkansson, 2014b). Yu et al. (2018) used the OBQ, the 36-item Short Form Survey, version 2 (SF-36v2) (Ware, 2000), and a 10-item version of the Perceived Stress Scale (PSS-10) (Ezzati et al., 2014) to investigate relationships among occupational balance, stress, and well-being. The researchers reported a positive relationship between occupational balance and robust mental health and wellbeing. A significant negative correlation (r = -.72, p = .0001) was found between OBQ and PSS10 scores, but OBQ scores were significantly and positively correlated (r = .65, p = .001) with SF-36v2 Mental Component Scores (Yu et al., 2018, p. 122). Researchers developed measures of occupational balance (Anaby et al., 2010a; Dur et al., 2014; Wagman & Hkansson, 2014b) even though occupational balance is a complex construct that depends on the situational context (Anaby et al., 2010a; Dur et al., 2014; Wagman & Hkansson, 2014b). Although many authors explored occupational balance (Backman, 2004; Wagman et al., 2012a; Wilcock et al., 1997; Yazdani et al., 2018), definitions of occupational balance are varied and seem similar to other terms, such as life-balance. The original OBQ demonstrated favorable psychometric properties, but the authors recommended further studies to examine construct validity (Wagman & Hkansson, 2014b, p. 230). Hkansson et al. (2020) published the results of construct validity testing of the original OBQ. Participants in the study were general residents of Sweden. Testing occurred in two groups. The first group responded to the original 13-item OBQ. Results suggested participants could not adequately differentiate among the six response categories (Hkansson et al., 2020, p. 444). Based upon these results, the researchers decreased the number of response categories from six to four. The second sample responded to the questionnaire using the revised version of the OBQ. The results demonstrated good reliability of the new response categories with a Person STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE 25 separation index of 0.92 (Hkansson et al., 2020). Two of the thirteen items revealed a problem with the ability to discriminate responses, and therefore the researchers removed these items. The present study included the resulting 11-item OBQ (OBQ11) with four responses categories. The present researcher's study addressed several gaps identified in the literature. The first is that most of the authors in the literature used the terms life-balance and occupational balance synonymously, and many researchers from the OT literature used the term life-balance (Matuska & Christiansen, 2009). Another gap noted is that researchers have not applied theories of occupational balance to entry-level OT graduate students. The researcher conducted the present study to explore entry-level OT graduate students occupational balance and examine how entrylevel OT students' experiences in a graduate program promoted or inhibited occupational balance. A theory of occupational balance was inductively derived to explain how some students find occupational balance, even under challenging circumstances, but others experience difficulty achieving occupational balance when encountering similar challenges. Lastly, this study addressed a gap in knowledge of effective strategies students in entry-level OT graduate programs use to achieve occupational balance. Understanding this information can help OT educators guide their entry-level students in developing practices that will foster occupational balance while in the graduate student role. Identifying effective methods to achieve occupational balance may equip OT students with the ability to continue using the strategies as entry-level practitioners and decrease the chance of burnout as an occupational therapist. Methods Study Design The researcher used a grounded theory approach to design this study and address the lack of evidence regarding how entry-level OT students define and achieve occupational balance STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE 26 amid challenges encountered in graduate school. According to Corbin and Strauss (2015), researchers use data from grounded theory research to develop theoretical explanations of concepts that provide alternative perspectives. Information obtained through a grounded theory study can describe experiences that can help people develop a deeper understanding of a situation and effective methods to respond to it (Corbin & Strauss, 2015). Grounded theory is a methodology that researchers employ to examine a problem from a new viewpoint and to understand how different people approach a similar circumstance in different ways (Corbin & Strauss, 2015). The researcher of the present study did not find a theory in the literature to explain how some students in entry-level OT graduate programs find occupational balance but others experience difficulty, even when encountering similar circumstances. Given the utility of the grounded theory approach in providing a theoretical explanation of everyday phenomena (Corbin & Strauss, 2015), it was an appropriate methodology for studying occupational balance in entrylevel OT graduate students. Before initiating the study procedures, the researcher obtained Institutional Review Board (IRB) approval from the University of Indianapolis and Walsh University. Participants The researcher sampled participants in two phases. The researcher recruited participants through purposeful sampling to obtain a preliminary sample of entry-level OT graduate students (Creswell & Poth, 2018). The initial sample was a sample of convenience and included students in their second year of the full-time master of occupational therapy (MOT) program at the researchers institution. STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE 27 The researcher sought a more heterogeneous sample using maximum variation sampling once the researcher analyzed the data and developed initial categories of data (Creswell & Poth, 2018). Maximum variation sampling consisted of entry-level OT graduate students from other universities in any year of study in their program. The researcher recruited students from entrylevel master and entry-level doctoral OT programs for the second sampling. The researcher secured additional participants until no new concepts resulted from data analysis, and no established categories could be further developed (Corbin & Strauss, 2015). Inclusion and Exclusion Criteria The researcher included only participants currently enrolled in entry-level OT graduate programs in this study. The researcher excluded participants who were enrolled part-time in an entry-level OT graduate program or who did not speak English. Setting The researcher recruited a purposeful sample from a small Catholic university in the Midwest. The institution offers nine graduate programs, including a MOT program. Each cohort in the MOT program ranged between 32 and 36 students. Students enrolled in the MOT program on a full-time basis represented all regions of the US; however, a majority were local to the area. Maximum variation sampling included entry-level OT graduate students from other universities in the Midwest at various points in their academic journey. Procedures Recruitment The researcher included students in the second year of their program in the initial purposeful sample because the researcher no longer evaluated students in courses. Due to the researchers current role as the program director, the researcher planned to refer any student STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE 28 issues of the research participants that arose to the school's dean for action; however, no issues developed during the study timeframe. The researcher utilized SurveyMonkey during the recruitment phase. SurveyMonkey is programmed to use multifactor authentication to access data, including complex password protection procedures (2020). SurveyMonkey staff include trained data security personnel who oversee network and system data (SurveyMonkey, 2020). They conduct regular internal and external penetration tests and, based on results, make security modifications as indicated (SurveyMonkey, 2020). SurveyMonkey (2020) is programmed to encrypt all data, including backups, to maintain confidentiality. The researcher initially recruited participants for this study via an email sent to students in the second year of the MOT program. SurveyMonkey was programmed to enable participants to proceed to the OBQ11 (P. Wagman, personal communication, May 11, 2020) (See instrument section for details). The researcher also included a link at the end of the survey to a Google calendar appointment page (Google, 2020) so the participants could schedule a virtual meeting for the first interview. Before each scheduled interview, the researcher sent a reminder through the Google calendar site of the interview date and time to the participants (Google, 2020). Instrument The OBQ11 (P. Wagman, personal communication, May 11, 2020) is an 11 item selfreport questionnaire with a four-step ordinal scale, ranging from strongly disagree to strongly agree. Wagman and Hkansson (2014b) indicated the questionnaire may be analyzed on an item level or as a summed score with a higher rating indicating higher occupational balance (p. 228). The original researchers assigned a zero to the lowest response category and a three to the highest response category. Therefore, the highest score possible using this instrument was 33. STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE 29 Wagman and Hkansson (2014b) determined content validity for the original OBQ using a content validity index, finding the instrument had a score of 0.90, indicating good content validity (p. 228). Internal consistency was tested with a sample of 67 participants (Wagman & Hkansson, 2014b), with Cronbachs alpha 0.936, indicating good internal consistency (Wagman & Hkansson, 2014b). The authors did not detect a floor or ceiling effect; however, construct validity needed further analysis (Wagman & Hkansson, 2014b). After conducting a study (n = 168) to assess internal construct validity, Hkansson et al. (2020) revised the original OBQ, removing two items and decreasing response categories from a six to a four-point Likert scale. The revised tool, the OBQ11, did not demonstrate any floor effects and had a small ceiling effect of 3% (n = 6) (Hkansson et al., 2020, p. 445). In addition, Hkansson et al. (2020) demonstrated the OBQ11 measures occupational balance less precisely at the extreme levels of occupational balance (p. 446). The authors also concluded that the OBQ11 might indicate a lower level of occupational balance than what exists for a person (Hkansson et al., 2020, p. 447). The researcher used the resulting OBQ11 (P. Wagman, personal communication, May 11, 2020) in the present study. Occupational balance was defined as high, medium, or low using the OBQ11 with 11 items and four response categories (Hkansson et al., 2020). The researcher assigned numbers to each response category using the same method as the developers of the OBQ (Hkansson et al., 2020). For this study, the researcher defined high occupational balance as a score greater than or equal to 24, medium occupational balance as a score greater than or equal to 18 but less than 24, and low occupational balance as a score less than 18. The researcher developed these groups of occupational balance scores using IBM SPSS (Version 26) software to select the best way to group the data into categories most congruent with their qualitative STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE 30 responses during the data collection process. The developers of the OBQ11 have not published the questionnaire for use; therefore, the researcher contacted the developers for a copy of the questionnaire and to obtain written permission to use the questionnaire in this study (P. Wagman, personal communication, May 11, 2020). Data Collection The researcher collected data through one-on-one Zoom (https://zoom.us/) video interviews with each participant in a quiet environment conducive to audio recording to comply with COVID-19 pandemic guidance. The researcher incorporated a guide to facilitate the initial participant interview (Creswell & Poth, 2018); however, the initial interview was unstructured, using open-ended questions to provide participants an opportunity to speak openly about their experiences. The researcher developed the questions, and experts from the University of Indianapolis Doctor of Health Science program reviewed them and recommended revisions. The researcher revised the questions as suggested. See Appendix A for the interview guide. The researcher recorded video interviews through Zoom computer software that encrypts recordings with password protection (Zoom Security Guide, 2019). The researcher also audio recorded the video interviews using a password-protected cellular phone. The researcher documented field notes during all interviews. The interviews lasted an average of 49 minutes. Interviews continued until conceptual saturation was achieved (Corbin & Strauss, 2015). The researcher interviewed each participant at least one time. Through theoretical sampling, the researcher identified participants for additional interviews. Subsequent interviews were conducted with four participants to reach saturation and allow member checking to ensure trustworthiness (Krefting, 1991). The researcher did not utilize STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE 31 an interview guide for subsequent interviews; however, focused open-ended questions required to obtain theoretical saturation were derived from ongoing analysis of the data (Corbin & Strauss, 2015). In addition to open-ended questions, the researcher used contrast questions (Spradley, 2016) for the successive interviews. Specific contrast questions consisted of rating questions, which compelled participants to rate, in order of effectiveness, methods of achieving occupational balance; dyadic contrast questions which asked participants to identify differences between two existing codes; and contrast set sorting questions, which encouraged participants to share how they perceived specific categories and codes to be similar or different (Spradley, 2016). The researcher documented in a reflective journal throughout data collection and data analysis (Corbin & Strauss, 2015; Creswell & Poth, 2018). The journal included personal thoughts about students ability to achieve occupational balance to guide further interview questions in subsequent interviews. The reflective journal also served as an audit trail to document the process of decision-making throughout data analysis (Creswell & Poth, 2018). Additionally, new thoughts or ideas that arose during the process were recorded in the journal to assist in the data analysis. Data Management and Analysis Information the researcher received from SurveyMonkey in URL format was maintained in a folder on the researchers computer separate from any other data to ensure confidentiality. The researcher used password protection on the computer. The researcher deleted all URLs from the computer upon completion of the study. The researcher deleted audio recordings on the cellular phone per IRB protocols. The researcher uploaded audio recordings from Zoom to the researchers password-protected STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE 32 computer following each interview. The researcher used multiple features of Zoom to ensure information security, including encryption requiring a session key so only the researcher could access the audio files (Zoom Security Guide, 2019). The researcher transcribed all interviews from the Zoom audio files within one week of conducting the interviews to create a verbatim transcription and assigned each participant a code to de-identify the transcript (Creswell & Poth, 2018). The researcher reviewed each transcript within a week and sent a copy through e-mail for each respective participant to review for accuracy. The researcher asked participants to respond via e-mail to confirm the accuracy or to suggest revisions. After verifying the accuracy of each transcript, the researcher reviewed each again to gain an overall perception of the content before completing any coding processes (Creswell & Poth, 2018). Once the researcher completed this process, the researcher completed open coding of all transcripts using constant comparative analysis to compare the codes across transcripts (Corbin & Strauss, 2015; Volstedt & Rezat, 2019). The researcher then organized common codes together to shape the initial categories of data (Corbin & Strauss, 2015; Draucker et al., 2007; Volstedt & Rezat, 2019). After the researcher established preliminary categories, the researcher used theoretical data sampling to identify students for subsequent interviews (Corbin & Strauss, 2015). The researcher identified five students from the convenience sample for a second interview. Four responded and engaged in open card sorting using the program Proven By Users (provenbyusers.com) to determine whether the researchers preliminary interpretation of the data aligned with the students interpretation (Spradley, 2016). The researcher entered the preliminary codes into the Proven By Users program and asked students to group the codes into categories. After completing the card sorting, the researcher contacted the participant and conducted a STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE 33 second video interview. Subsequent interviews provided additional information about repeated patterns in the data and categories that appeared crucial to the developing theory (Draucker et al., 2007). After maximum variation sampling, the researcher e-mailed five participants requesting a second interview; however, no one responded to the request. The researcher, however, established credibility through other methods involving maximum variation sampling, triangulation of data sources, and member checking of initial transcript accuracy (Creswell & Poth, 2018; Corbin & Strauss, 2015; Krefting, 1991; Letts et al., 2007). The researcher also used a reflective journal to document thinking throughout the study as well as explained outliers in the data to ensure consideration of participant views (Krefting, 1991; Letts et al., 2007). The researcher used the axial coding paradigm of Corbin and Strauss (2015) to relate causal conditions, context, intervening conditions, action/interaction strategies, and consequences of the phenomenon of occupational balance (Volstedt & Rezat, 2019, p. 88). The axial coding phase involved constant comparative analysis to compare codes among transcripts and to reveal similarities and differences (Corbin & Strauss, 2015; Volstedt & Rezat, 2019). The researcher grouped similar codes under a common word or phrase or category and added subsequent evidence to support the groupings the researcher discovered (Corbin & Strauss, 2015). By relating the data to the paradigm constructs, a deeper understanding of occupational balance occurred, and the researcher discovered new associations essential for theory development (Volstedt & Rezat, 2019). The researcher incorporated total summed ratings from the OBQ11 (P. Wagman, personal communication, May 11, 2020) into categories of high, medium, and low occupational balance to compare and contrast the strategies the participants utilized to maintain or return to occupational balance. A storyline developed based on the evolving categories using definitional STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE 34 and hypothetical statements (Birks et al., 2009). Definitional statements explained the categories of data, and hypothetical or propositional statements explained relationships among categories (Birks et al., 2009, p. 407). The researcher continued to return to the storyline to ensure evidence from the data supported propositional statements and concepts within the storyline to further develop the theory. The storyline was adjusted accordingly when data were not supportive (Birks et al., 2009). The categories originally developed in open coding and analyzed through axial coding were revised during the selective coding process to shape the evolving theory. The researcher noted outliers in the data that the emerging theory had not addressed (Corbin & Strauss, 2015; Volstedt & Rezat, 2019). The researcher expanded and further explained categories during selective coding to integrate the outliers into the emerging theory (Volstedt & Rezat, 2019), thereby improving the validity or the accuracy of the theory. To determine whether the categories that developed during axial coding fit with all of the other categories, the researcher asked questions, such as what is the research all about? and what seems to be going on here? (Volstedt & Rezat, 2019, p. 89). The researcher discovered situational actions or interactional strategies through the process coding (Corbin & Strauss, 2015, p. 283) that emerged as possible steps or phases the entry-level OT graduate students employed to achieve occupational balance. Based on the evolving theory and additional questions that repeatedly surfaced during data analysis, the researcher conducted additional interviews with the participants until conceptual saturation occurred (Corbin & Strauss, 2015). Corbin and Strauss (2015) defined conceptual saturation as the point where the researcher believes there is adequate data to describe each category fully, accurately represent the storyline, account for outliers, and identify gaps in the data (pp. 407- STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE 35 410). Member checking occurred in the axial and selective coding phases. The researcher asked participants to review the evolving theory looking for gaps and any misinterpretations (Creswell & Poth, 2018). The researcher shared the participants interview transcripts, the results of the coding process, and the storyline to obtain feedback about the evolving theory (Volstedt & Rezat, 2019). For example, the researcher integrated contrast questions and card sorting (Spradley, 2016) to determine whether the participant's interpretation of the codes was congruent with the researchers interpretation. The request for member checking returned a 73% (19/26) response rate for initial interview transcript checking and a 40% (4/10) response rate for coding and storyline checking. The researcher sent three e-mails to participants who did not respond, requesting participation with member checking. The lack of response presents a threat to credibility; however, the researcher established credibility through other methods discussed in the study rigor section. The researcher set up an online card sort for member checking, using the Proven By Users site, and sent a link to each participant with a unique URL to complete the activity (Proven By Users, 2020). The researcher completed the card sort analysis immediately in the software using the groups view in the program that sorted the codes into the categories the students developed (Proven By Users, 2020). The researcher compared her preliminary categories to the student-generated categories and used the similarities and differences to develop contrast questions for the second interview. The researcher then scheduled a second interview with participants to ask contrast questions and record any additional information the participants wished to add after reading the data or engaging in card sorting. Once the researcher completed the second interviews, the researcher re-coded the data using open coding and constant STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE 36 comparative analysis to compare the codes across interviews and with those previously established (Corbin & Strauss, 2015; Volstedt & Rezat, 2019). The researcher then organized common codes together to create new categories of data and compared the new codes to the previously established codes (Corbin & Strauss, 2015; Draucker et al., 2007; Volstedt & Rezat, 2019). The researcher organized codes identified and supporting participant quotes in a codebook for open coding, diagrams to display the relationship of codes to categories, axial coding tables, memos, storyline memos, and process visuals resulting from all interviews (Buckley & Waring, 2013; Creswell & Poth, 2018). The researcher used memoing to develop concepts from the raw data and attempted to link the concepts through statements of possible theory (Corbin & Strauss, 2015). In addition, the researcher used an audit trail to document the researchers thought processes regarding the development of codes and theory construction (Creswell & Poth, 2018). Lastly, the researcher developed multiple visual representations of the evolving categories and theory to explain the relationship of the codes to each other (Corbin & Strauss, 2015). The researcher communicated with a data analysis expert from the University of Indianapolis, who has extensive qualitative research and data analysis background throughout the data collection and analysis process. The researcher and data analysis expert scheduled virtual meetings as needed to review the data collection and the open, axial, and selective coding processes during data collection. At the point of analysis where the researcher believed adequate codes and categories existed to finalize a theory, the researcher collaborated with the data analysis expert to determine the thoroughness of the analysis and identify any gaps or problems with integration (Corbin & Strauss, 2015). STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE 37 Once the data analysis expert was satisfied with the internal consistency and logic of the completed processes, the researcher used the guidelines of Corbin and Strauss (2015) to begin theory finalization. First, the researcher analyzed the theory for any discrepancy in the logic or problems with how the concepts fit together (Corbin & Strauss, 2015). The researcher examined the data categories to ensure they were thoroughly defined and consisted of variability to ensure saturation (Corbin & Strauss, 2015). Next, the researcher reviewed portions of the theory deemed to be lacking solid support and integrated additional data supporting the categories to strengthen the theory (Corbin & Strauss, 2015). Finally, the researcher disclosed factors that may limit the theory's applicability and disclosed areas for future study (Corbin & Strauss, 2015). Study Rigor The researcher established credibility through maximum variation sampling, continually recruiting new subjects to interview and attempting to re-interview subjects as needed to allow for data saturation (Corbin & Strauss, 2015; Krefting, 1991). The researcher triangulated data sources by recruiting participants from different universities at different points in the entry-level OT graduate education process (Krefting, 1991). The researcher incorporated member checking to ensure the accuracy of the information and increase the study's credibility (Creswell & Poth, 2018; Krefting, 1991; Letts et al., 2007). The researcher engaged in reflexivity using a journal to document the thinking throughout the study (Krefting, 1991; Letts et al., 2007). Lastly, the researcher explained any outliers in the data through refinement of the developed theory, thereby ensuring incorporation of all participants views (Krefting, 1991). To address transferability, the researcher described the sample while protecting confidentiality and provided information about the context of the study in detail (Krefting, 1991; Letts et al., 2007). Member checking strategies also determined whether the data were STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE 38 representative of all members of the sample (Krefting, 1991). The researcher implemented an audit trail to increase the dependability of the study (Creswell & Poth, 2018; Krefting, 1991; Letts et al., 2007). The researcher utilized Kreftings (1991) re-coding procedure of waiting for some time before returning to the data and then re-coding, adding information from the participant card sorting interviews that verified codes and categories. This coding-recoding process helped ensure the codes were representative of the data and the participants experience, thus increasing dependability (Krefting, 1991). The researcher addressed confirmability using reflective journaling to identify and fully account for researcher bias (Letts et al., 2007). Triangulation of data across participants and interviews confirmed the conclusions (Krefting, 1991). A data analysis expert from the University of Indianapolis audited the coding and theory development process to ensure the researcher used proper procedures and clearly defined steps (Krefting, 1991; Letts et al., 2007). Results The sample size of 26 students resulted from convenience and maximum variation sampling. Sample characteristics are described in aggregate to maintain participant confidentiality. Twenty-four females and two males comprised the sample. The convenience sample consisted of thirteen students in their fourth semester of the program and the last didactic semester before level II fieldwork. Participants in the convenience sample were students from a post-baccalaureate entry-level MOT program. The maximum variation sample consisted of 13 students, 10 in an entry-level master program and three in an entry-level doctoral program. Five students were in the first year of entry-level graduate school, and one student was in the middle of the program. Five students STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE 39 were in the last semester of didactic classwork before level II fieldwork, and two were in the final year of doctoral work. Overview of Findings The following results address the main research question and three sub-questions. For the main research question, How do entry-level students in OT incorporate strategies to manage occupational balance in their role as a student in the graduate program?, the results from the data analysis demonstrated that students progressed through three phases of occupational balance. The three phases are depicted in Figure 1 and include: occupational balance, balance disruptions, and return to occupational balance. Once a student experienced a disruption to occupational balance, the student needed to identify the disruption. Some students self-identified disruptions, but others received input that helped them recognize changes in their occupational balance. Students then had to desire a return to balance to be motivated to implement a strategy to achieve balance. Examples of strategies students integrated to achieve occupational balance included developing an individualized plan for organizing school work, sharing experiences with cohort peers, and scheduling time for self-care. The first sub-question, What are the differences in the occupational balance strategies of entry-level OT graduate students who report high, medium, and low occupational balance?, resulted in the data analysis revealing that most students reported feeling they were occupationally balanced even though their scores spanned across all occupational balance levels. See Table 1. As shown in Table 2, students in the high occupational balance category used more strategies for returning to occupational balance following a disruption than students in the medium and low categories. All students reported using trial and error to determine which strategy to use in novel situations, such as beginning a new course, experiencing a different style STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE 40 of instruction, or taking a class online for the first time. Over time in the entry-level OT graduate program, all students indicated they learned to use information from past disruptions to help return to occupational balance following a similar disruption. For the second sub-question, What happens to the way entry-level OT graduate students manage occupational balance when they experience a change in the expectations of their student role or other life roles?, data analysis indicated that at different points throughout the entry-level OT graduate program, students encountered people, policies, changes in roles and expectations, or events that led to a disruption in occupational balance. Figure 2 displays the various internal and external contexts that influenced student occupational balance. These contexts interact in dynamic ways (Corbin & Strauss, 2015). The arrows on the diagram indicate this dynamic interaction. Each contextual layer influences the other layers in an ever-changing sequence of actions and interactions. As described in Figure 2, values and previous life experiences influenced how the students viewed a situation and formulated a reaction. Internal to their academic program, faculty and program peer interactions influenced whether an entry-level OT graduate student remained in a state of occupational balance when faced with challenges or whether a student experienced a disruption to occupational balance. Program policies, such as professional and academic standards, and university structure, such as semester length, also contributed to a students occupational balance. The availability of external support systems, such as family members and peers external to graduate school, also influenced students reaction to stressors and their ability to return to occupational balance after a disruption. Lastly, external circumstances, such as the COVID-19 pandemic, led to disruptions in occupational balance. STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE 41 For the third sub-question, For entry-level graduate students in different semesters of the OT program, how do the strategies for managing the student role change?, data analysis demonstrated that occupational balance of students in entry-level OT graduate programs occurred under various conditions as noted in Figure 2. Students developed and integrated distinctive strategies for managing occupational balance disruptions during different periods of the entry-level OT graduate program. During the initial transition to graduate school, students experimented with more strategies to mitigate the disruption to occupational balance than they did in subsequent semesters. The first semester in an entry-level graduate program was overwhelming to most students. Not only were students beginning a new program, but they also had few, if any, friends and did not have any experience with the rigor of entry-level OT graduate school. Students in entry-level OT graduate programs developed knowledge of specific strategies to use when they experienced a disruption to occupational balance in subsequent semesters. By incorporating previous successful strategies, students could move back into occupational balance quicker than they did in the first semester. See Figure 1. An exception was the changes experienced from the COVID-19 pandemic, which created a disruption to occupational balance that students did not recover from quickly. Students equated the changes to the student role experienced during the COVID-19 pandemic, such as courses moving to an online format, to changes the students experienced during the initial transition to entry-level OT graduate school. The disruption that ensued required students to reexamine their strategies to return to occupational balance and, in some instances, to develop new strategies for this novel situation. Most of the OT students reported feeling they were occupationally balanced by the time they completed the entry-level graduate program. They learned how to integrate strategies, such STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE 42 as sharing experiences with cohort peers, developing methods of organizing school work, and making time for self-care. Rather than wait for a disruption to occur, as they did at the beginning of the entry-level OT graduate program, students were proactive in employing strategies to continuously improve occupational balance and, therefore, experienced fewer occupational balance disruptions. How Do Entry-Level Students in OT Incorporate Strategies to Manage Occupational Balance in Their Role as a Student in the Graduate Program? To address the main research question, entry-level OT graduate students first discussed the meaning of occupational balance and the importance of identifying an occupational balance disruption in their lives. Students also discussed various strategies to assist in returning to occupational balance following a disruption. The Meaning of Occupational Balance is Expressed Through Personal Values and Past Life Experience Students in the entry-level OT programs first discussed the meaning of occupational balance in their lives as graduate students. All students appeared to have their own understanding of the term. Life experiences and personal values informed each students description of the meaning of occupational balance in life. Student Life Experiences Provide Them a Perspective of Occupational Balance. Students' life experiences in entry-level OT graduate programs influenced the meaning of occupational balance. Students whose caregivers provided schedules for them when they were younger understood time management and recognized the importance of optimizing time in entry-level OT graduate school. One student helped with the familys business and the care of a grandfather. STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE 43 I think in terms of time management because at home growing up the way our household is, I wake up and my grandfather has like a strict schedule that he has to follow that we would have to follow for him in terms of like food and stuff. Its our business too, we had like a motel. So I feel like in terms of, like, time management, it comes from a lot of that like growing up like them. (Interview 15, p. 12) Another entry-level OT graduate student expressed being more prepared for the workload required in a graduate program compared to some peers. The student enrolled in heavy course loads during the last two years of undergraduate education to graduate a year early. This experience helped with preparation to manage the intense academic requirements. I think that for the most part I did make that transition easier than most of my peers [because] I have taken over 20 credit hours for the last two years of undergrad. I knew I wanted to come to grad school, so I was going to do five years instead of six. So I've kind of been prepping in the workload sense. (Interview 13, p. 13) Other entry-level OT graduate students played competitive sports in the past. When dividing time between academics and sports, an imposed structure and an efficient use of limited time were necessary. Students reported they capitalized on the organizational and time management skills learned in the past when they transitioned to entry-level OT graduate school. One student explained, From my undergrad experience being a bio major, and I played volleyball, so my time management skills are like impeccable. I like to pride myself on that because Ive learned how, like okay, I have 15 minutes, lets finish this assignment and submit it. I dont use my 15 minutes to just like sit on my phone or something. (Interview 9, p. 3) STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE 44 Another entry-level OT graduate student, a past student-athlete, easily integrated the coursework into a daily routine. In addition, the student was accustomed to a full schedule with the ability to use free time better to complete academic work when busy playing sports, working at a job, or engaging in other activities. The student described using time efficiently as follows, I think from having an experience as being a student-athlete in college like where I felt like my whole day was just like jam-packed, and I didnt have a lot of free time to be like, hmm like should I do this right now? I was more productive with my time when it was more structured. Where like if I have more free time I think Ill be able to focus so much more energy on school, but I think when I have a job or something else going on, that forces me to use that open time to catch up on assignments and stuff. (Interview 21, p. 4) One entry-level OT graduate student reported a structured life throughout growing up due to engagement in athletics. However, once entering graduate school, a sport no longer distracted from academics; the student consequently studied more during free time. Although the student indicated a reluctance to obtain a job, the added structure improved the students study habits providing a finite time to complete homework. All my life has been so structured. Like my entire life, I played multiple sports. as well as school. This summer was the first time I didnt have like soccer to like be doing. I was just doing school. and I was like, yeah, I need something else to like keep me busy doing something. And while I kind of ... still wish I wasnt doing it [working a paid job] as much as I was doing it this summer, it was definitely out of necessity to like have something else to do. (Interview 10, p. 12) STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE 45 Another entry-level OT graduate student reported taking a year off to work in a job related to OT. The experience made the student more prepared for the expectations of graduate school. Most kids went to undergrad at my school so they're a little younger than me and they're fresh out of undergrad where Im a little older. I took a year off and like worked as a caregiver. Now I feel like I have a bit better understanding of how like a grad program would work as opposed to undergrad (Interview 14, p. 9). Student Personal Values Assist Students in Maintaining Occupational Balance. Students in entry-level OT graduate programs also described how personal values contributed to the meaning of occupational balance. For example, one student reported that family instilled the value of making time for self-care; therefore, self-care was essential for occupational balance. In my early years of undergrad, I did a poor job of that self-care and it affected me in a lot of ways. But, as I like experienced stuff and talked to people it just matured me. I developed a different way of thinking. I've come from a home that was like, you know, it doesn't matter how much money you have, or it doesn't matter you know how many friends, you think you have. If you don't take care of like yourself first and you know the inside. If you don't develop that, you're going to always be lacking. (Interview 1, p. 10) Multiple entry-level OT graduate students mentioned the value of time as contributing to the meaning of occupational balance. Some students explained occupational balance as an equilibrium of time divided among academics, self-care activities, and friends and family. One student reported satisfaction with occupational balance. STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE 46 I would say its [life] balanced cuz I feel like I have time to go to the gym and then like go kind of do things that I want to do to with doing school and stuff too. (Interview 15, p. 13) Another entry-level OT graduate student explained how they spent free time positively influenced the perception of occupational balance. The student discussed the importance of time to engage in desired activities beyond academics. The freedom to spend free time in nonacademic activities, such as reading or listening to music, was crucial to the student. [Balance is] just like doing something that I want to do to truly have time where its like I can do whatever I want for the next, like 10 hours on a Saturday, or something like that. I really, really feel better like, if I can read a book for 30 minutes before I go to bed, or even just any time in the day. self-care, going for those walks, listening to music, calling friends and family. (Interview 24, p. 14) Another entry-level OT graduate student reported an internal push to earn high grades throughout earlier school years, creating a challenge for coping if receiving a lower grade in graduate school. This diminished threshold for accepting an undesirable grade caused disruptions to occupational balance while in the entry-level OT graduate program. It was just me like pushing myself, and like I freaked out. I did average. And I was like, I just, I don't do average. I don't like average" (Interview 10, p. 7). A firm understanding of values helped one entry-level OT graduate student make the difficult decision to postpone graduation to focus on personal health while planning for the birth of a first child. Im like adding expecting a child and that whole role demand and transition and everything. Ive actually decided to postpone my graduation because I wasnt STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE 47 managing my time very well, and finding self-care time didnt exist. And having to make a really hard decision to say, I have to take time off, I have to say no to this thing [entry-level graduate school] that Ive been working towards, in order to take care of myself. (Interview 22, p. 7) Postponing Occupational Balance for a Temporary Disruption is Acceptable. Some entry-level OT graduate students agreed that a disruption in occupational balance was a certainty in graduate school, but the disruption was acceptable because it was temporary. One entry-level OT graduate student expressed thoughts about the short-term high demands of academic work as worthwhile to achieve the goal of becoming an occupational therapist. The student adjusted the weekly work schedule to meet coursework demands. Aside from like relationships and family, school is probably the most important thing to me right now. Just because I know its temporary, and I mean, its shaping the rest of my life right now. So if I have a huge assignment and I can only work two hours a day [at paid employment] this week I will work more next week or something. So I make everything else flexible. (Interview 13, p. 15) Similarly, another entry-level OT graduate student discussed the necessity to devote as much time as possible to studying in graduate school, explaining time for leisure would come after graduation. If the opportunity is there, why wouldnt I take it to better my grades, because theres always going to be time to read for leisure later, but I am in school now for a year and a half (Interview 26, p. 8). One entry-level OT graduate student expressed thoughts about the future as an occupational therapist helped motivation. Envisioning the future, working one job, and having free time to enjoy chosen activities made the amount of time spent studying worthwhile. STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE 48 I know 100% that I work too much. And thats academic work and work work. But again, its a short term, temporary sacrifice for eventually, Ill have a big girl job, and I wont have to work a part-time job, and I will come home, and Ill be able to just like join a formal running club or go to like a class that I really enjoy. But for the moment, its very much like a short-term sacrifice for long-term gain for me. (Interview 26, p. 14) Occupational Balance Disruptions Can be Identified Entry-level OT graduate students reported the importance of understanding when they were experiencing a disruption to occupational balance so they could act to regain a sense of balance. Most students were able to identify aspects of their behavior that indicated a disruption. Other students reported peers or family members helped them identify when they needed to integrate a strategy to regain occupational balance. Students Self-Identify Disruptions to Occupational Balance. All entry-level OT students acknowledged a disruption to occupational balance during their graduate education. Some recognized the disruption while it occurred; others identified the disruption when they reflected on an event or a specific time period. One entry-level OT graduate student realized a lack of occupational balance occurred after the first two semesters. The student reported the decision to study during free time, including weekends, resulted in reduced socialization with friends. The student explained the strategy to complete academic work increased stress. I definitely prioritized school first and second semester more than anything, and I felt I didn't have time for social life. I wasn't seeing my friends. The first semester, I'd go home Friday, but I'd be doing homework all day Friday. Saturday Id spend studyingI wasn't hanging out with my friends; that just stressed me out. (Interview 5, p. 6) STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE 49 One entry-level OT graduate student reported engaging in academic tasks nonstop during the first semester. The student indicated completion of schoolwork rather than management of selfcare needs resulted in a decline in health. In the first semester, I would do basically school all the time. I gained quite a bit of weight because I didn't really take a lot of time for myself, or I would just get something that was really easy to eat so that I could only do school. (Interview 13, p. 15) One entry-level OT graduate student described an inability to concentrate during class, which the student thought was normal, and initially attempted to manage alone. However, after confiding in a physician, the student initiated a plan to remedy the problem. I'd sit in class, and all I could focus on was like the homework that I needed to do, or the work that I needed to do for work [paid employment]. And I'd sit there and spiral and completely zone out of class and it was something that like I silently dealt with and thought it was normal and I went to my doctor finally, and she was like yeah that's not normal. (Interview 3, p. 15) Similarly, another entry-level OT graduate student reported an inability to focus indicated an occupational balance disruption. For example, after studying, the student discovered the lack of recall of the content reviewed. The student recognized that time engaging in an activity outside of academics improved attention with schoolwork. Past a certain time of like me like staring at my notes I'm just like, I'm not retaining anything. So I'd be like nothing's getting done so I might as well do something I like until I'm in a better state of mind. (Interview 2, p. 8) STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE 50 One entry-level OT graduate student described experiencing moments of anxiety and self-doubt, which contributed to the realization of the need to take breaks from studying to engage in something outside of academics. "I think I just kind of came to it [knowing I need to take breaks] because I just like, like, well, I mean, had a couple of like freak out moments like where I was just like panicking. I was like, I can't do this" (Interview 8, p. 7). Another entry-level OT student also reported a mental and physical response to stress during graduate school. The student reported heightened anxiety with the increased workload that resulted in an inability to sleep. The student explained, I get very overwhelmed when I know I have like a lot I need to do. And if I can't get it all done I get very anxious and then it's like, all I can think about. And then I can't shut off and then it's hard to sleep. Usually I don't sleep that well if I have like a huge test or something I don't sleep well at night. (Interview 5, p. 11) Other entry-level OT graduate students reported disengagement from social situations signaled an interruption in their occupational balance. For example, one student typically accepted social invitations from peers. When the student declined an invitation, the student reflected and assessed the situation. Out of character behavior indicated the need to change the situation. I also noticed it in like the social aspects of like if somebody invites me to something, and I pass it up, and Im continuously passing it up or saying no Im too busy. I sit back [because] Im not that type of person who would say that kind of thing. (Interview 22, p. 14) One entry-level OT graduate student attempted to participate in social events during the first semester of the graduate program but focused on the homework waiting rather than enjoying STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE 51 the situation. I wasn't really enjoying myself [first semester] because I was thinking about things that were going to be due and stuff" (Interview 4, p. 9). Similarly, another entry-level OT graduate student reported a desire to engage in self-care activities but instead spent the time thinking about academics. I wanted to take time for myself. But when I would take time, all I could do was think about school. Like I should be doing this, I have an assignment, like I could never actually relax and turn my mind off" (Interview 7, p. 4). One entry-level OT graduate student described feeling guilty with less than perfect performance on an assignment or exam during the first semester. The student perceived a lack of trying to succeed when not engaging in academics constantly. I felt guilty if I wasn't working on homework the first semester because I realized like sometimes if I didn't get you know, that 100% on a test, like I could have put more time in or studied more, or worked on an assignment. I felt like I wasn't doing my best if I wasn't working nonstop. (Interview 13, p. 4) Another entry-level OT graduate student reported taking time to watch a movie with roommates or to go for a walk during the week. Spending time in these self-care activities provoked feelings of guilt at times, but the student recognized this time as necessary for self-care and productivity and did not compromise the self-care time. During the week I sometimes feel guilty about like hanging out with my roommates when maybe I could be doing something more like productive. What is productive? Because people would say watching a movie and taking care of yourself is productive. I definitely have felt like guilty but in the end Im always happy that I chose to like take care of myself. (Interview 20, p. 12) STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE 52 Fluctuations in occupational balance throughout the graduate program helped one entrylevel OT student learn to recognize a disruption to occupational balance. In addition, the preferred feelings elicited when in occupational balance motivated the student to take steps to remain in a state of occupational balance. I know what balance feels like, and I value that, and I think going through those seasons of balance versus no balance, when I get to the places where Im not, I have a lot more insight or self-awareness, to be like, something's not right, I need to make changes. Knowing what balance feels like makes me want to be more balanced. (Interview 22, p. 14) Other entry-level graduate students reported the OT program helped them recognize challenges to occupational balance in their lives and to develop a plan to remedy these challenges. For example, one student valued and desired exercise but did not take the time to follow through with regular exercising. Completing a life balance inventory as a course requirement provided insight to restart an exercise program. We did a life balance inventory, and that made me realize some things that I wasn't making time for working out. That was something I had completely abandoned the first semester, and I really wanted to make the time for that because if I didn't I would just spend all of my time reading, and I don't think I would have ever stopped for a break. So I started to do that [work out]. (Interview 11, p. 7) Another entry-level OT graduate student was in the same program and completed the same occupational balance assignment. The results helped the student make changes that improved occupational balance throughout the remainder of the time in the entry-level OT graduate program. STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE 53 Id say it's much more balanced now (fourth semester) than at the very beginning of the program. Um, some of that I think is having to do with actually like taking a life balance inventory, and seeing what is balanced and unbalanced and where I need to improve. (Interview 4, p. 11) Other People in a Students Life Can Identify Disruptions to Occupational Balance. Some entry-level OT graduate students indicated they did not realize a disruption to occupational balance due to schoolwork until other people suggested the possibility. For example, a video chat with a father who was inquiring about the weeks activities led one student to reflect on present study habits. The student indicated studying as the only activity of the week. And my dad was like, you do realize that not every single person in this program is sitting home studying like every second? Like, you need to do something other than studying. You're going to be miserable (Interview 6, p. 11). As the student began talking to peers, the student discovered other students were not spending as much time on academics. Instead, they were engaging in activities outside of studying. When I talked to other people they weren't like, oh, I just studied like all weekend, I didn't do anything. And then I started to think about, like, what did I used to do like in undergrad? I used to go to the gym. I used to go with my friends on the weekends. I used to go to the football games [and] basketball games. And now I'm basically just studying all the time. (Interview 6, p. 11) Simultaneously, the entry-level OT graduate student analyzed the impact on mental and physical well-being from the extended periods spent studying and concluded changes were necessary. When I got here, I didn't do any physical activity. I barely was like making time for like STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE 54 eating and socializing and I realized how mentally draining and exhausted I was (Interview 6, p. 10). Another entry-level OT graduate student experienced panic attacks several times a week during the first semester of graduate school. I was having panic attacks at least five times a week. And curling up in my bed and like sobbing, and so just wasn't productive and I wasn't happy (Interview 3, p. 6). Finally, the students mother suggested the student was working too hard in the entry-level OT graduate program and was risking the students health as a result. I had some very serious conversations with my mom about how you can't fill someone else's glass up when your glass is empty (Interview 3, p. 6). One entry-level OT graduate student reported setting high personal expectations but was not meeting the desired academic goals. My parents [were] like there's nothing wrong with sometimes being average it's okay. And they're the ones who are kind of more like stop being so hard on yourself (Interview 10, p. 7). Moving home during the COVID-19 pandemic provided the student with a new perspective on the situation. The student explained, I think living with them [parents] this summer was one of the best things for me because they'd be like, you need to take a break from the computer. Like go get dinner. Go do something. You need see your friends. What are you doing? Stop doing homework. (Interview 10, p. 7) Similarly, another entry-level OT graduate students spouse suggested the need to prioritize time based on personal values rather than compromise self-care to spend more time on academics. My husband's a PhD student, too, so he understands the graduate level, understands the demand. But he's huge in just taking a step back and saying hey I don't think you're doing well. You need to evaluate this. Don't you have this value of self-care? I STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE 55 haven't seen you read a book. Ive seen you work until like 11 pm and you would never do that before you would have stopped work at 7 pm. (Interview 22, p. 8) Students Implement Strategies to Return to Occupational Balance Most disruptions to occupational balance appeared to occur during the first-semester transition to graduate school, but students reported fluctuations in occupational balance across the entire entry-level OT program experience. Students identified adaptation strategies, experiences, new thought processes, and support systems that helped them regain a sense of occupational balance throughout their time in entry-level OT graduate school. Students reported using various strategies depending on their current circumstances and past experiences. Students in OT Adapted Methods for Learning to Improve Their Effectiveness and Efficiency. When a disruption occurred, entry-level OT graduate students described the development of strategies to help them adapt to the novelty of their situation. One student explained the need to develop different study habits because previous methods were no longer adequate for the OT graduate program requirements. Once I got into graduate school, it was, it was a whole new ballgame. I had to retrain myself on different study habits and really breaking down content each day, making sure that I was focusing on things long term so that I could fully understand the process and be able to apply them. (Interview 3, p. 6) Similarly, another entry-level OT graduate student learned to employ more effective study habits to filter essential unfamiliar concepts. For example, the student used study time learning novel information rather than repeatedly reviewing information already learned. Even if I knew a topic, I was spending all the time reading every single word of every single chapter. I would like go through and highlight, and then I go through and take STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE 56 notes. And like I was spending a lot of time looking at the same information and it was sticking with me, but not because I was looking at it, the four times, like I just had already known it. And so I like I got into better methods of highlighting less, writing down only like new information, things I didn't know, more important information. (Interview 10, p. 4) Another entry-level OT student indicated finding a way to organize school work was crucial to success in graduate school. I know people in the class who color code every single thing we have to do and thats overwhelming to me. And I know people who dont write anything down in the program and theyre still killing it. So just finding that that medium or finding that mode of kinda tracking information. (Interview 1, p. 5) Entry-level OT students reported taking advantage of situational factors to help improve their occupational balance during their time in graduate school. For example, several students reported the benefits of a weekday without class to complete the assignments for the current week or start the course work for the upcoming week. One entry-level OT graduate student devoted a day off to catch up on school work, engage in self-care, or socialize with friends. Fridays we don't have class. So usually in morning on Friday I do some of the assignments that are due during the week so I can prepare and maybe not have to spend all weekend on something. Or I might just take time for myself and relax, or maybe meet people. (Interview 4, p. 3) Another entry-level OT graduate student had Fridays free from classes and spent the time to rest and complete assignments for the week. "I actually don't have any class on Friday at all STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE 57 thissemester, which is nice. So, Friday, I can just sleep in, and hopefully finish up everything and turn everything in (Interview 14, p. 4). Students Use Support Systems to Assist with Managing Disruptions to Occupational Balance. Entry-level OT students reported the support of family, faculty, supervisors, and peers was vital to persisting in graduate school. In addition, students reported needing others for financial and emotional support. Entry-level OT graduate students reported cohort peers sometimes created anxiety, but were critical in offering moral support, study assistance, and motivation during difficult periods. Students Seek Parental Support to Assist with Managing Disruptions to Occupational Balance. Parents were instrumental for several entry-level OT graduate students to maintain or regain occupational balance. For example, one student explained how parental financial support helped with acclimation to graduate school. In addition, the student acknowledged reduced stress without having to worry about buying food, paying rent, or purchasing textbooks. The student also reported support from parents, friends, and others was motivating throughout time in the entry-level OT graduate program. My family has helped a lot. My parents, especially, because even though I am um paying for grad school, they're allowing me to like live at home still. And I don't have to worry about rent or anything. Or my textbooks they'll help take care of that. Just knowing that somebody is encouraging me. My friends and boyfriend and people around me, they want me to do well. So I think that's more like encouragement and support that way. (Interview 4, p. 10) Several entry-level OT students reported turning to their mothers for support when overwhelmed with the demands of graduate school. One student stated, If I'm really stressed STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE 58 out, I always call my mom. Always. So, she'll just calm me down like you're fine. Like, calm down. You'll be fine (Interview 5, p. 11). In the same way, another student called their mother during periods of high stress. The student explained these conversations helped to recognize the importance of self-care. I always like would call mom like if I was freaking out about school stuff, and you know she's I guess she's kind of the one that got me to just be like, you need to relax. You need to take time for yourself at the end of the day. You know, not to go overboard studying sometimes. So it was kind of, I guess, her helping me realizing that I couldn't constantly be studying, like I needed to do something for myself. (Interview 8, p. 8) The mother of another entry-level OT student helped with experiences of self-doubt about succeeding in the graduate program. The mother provided encouragement and helped the student analyze alternatives should the fears be realized. I also went to my mom, I'm really close with her. And she just kind of always told me it would be okay. And I'd be like, what am I going to do if I get kicked out? And she would kind of talk me through like okay, you're not going to get kicked out. But if you do we can come up with a plan. Theres other options. So just kind of knowing that my life would [not] be over if something happened, kind of made me be like okay, you'll be fine. (Interview 12, p. 8) Students Seek Faculty Support to Assist with Managing Disruptions to Occupational Balance. Several entry-level OT students discussed the positive impact faculty had on their experience in the graduate program. Faculty accessibility was important to one student, who indicated that knowing faculty were available was reassuring even if not needed. The student explained, STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE 59 [Faculty] being supportive, and knowing that that support is there if we need anything, has been so beneficial. I knew that I could knock on anyone's door, and drive them bonkers, and ask them a million questions, and they would all get answered. (Interview 3, p. 8) Another entry-level OT student found the relationship with the faculty advisor to be a vital part of beginning graduate school. Initially, the student did not know anyone, so spending focused time with the advisor helped improve the students comfort with the transition. I know before coming like the we each got like advisors, which are faculty members. So I think that kind of like allowed like one on one time with your advisor at least like, if you don't know anyone else, you have that faculty member to kind of go to and like get comfortable with and stuff too. (Interview 15, p. 7) When one entry-level OT graduate student did not do well on an exam, the student met with the professor to discuss the grade. The professor shared some of the struggles from when the professor was a student, which created camaraderie with the professor, increasing the students self-confidence in the course. I think talking to my professor, like she had also let me know like, she didn't always do the greatest whenever she was in the same like position as I was. And I think hearing that, and learning that type of thing was helpful to me because it made me feel like I wasn't alone and that this is normal. (Interview 11, p. 11) Another entry-level OT graduate student explained the importance of visiting professors during office hours to discuss course content. The student described the benefits when faculty expressed concern for their well-being as people. In addition, faculty who were accommodating when life circumstances arose in a students life contributed to a sense of well-being. STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE 60 Thereve been times, where Ive wanted additional feedback and Ive gone in for office hours and they've talked to me. Yeah and even just understanding from you know, a personal level even just little things like you know somebody having to be out of town for a funeral and just being understanding of are you okay, like stuff like that. (Interview 23, p. 7) One entry-level OT graduate student observed the faculty model occupational balance. The student described a professor stepping down from a leadership position because it took her away from things she enjoyed in life. The student realized if someone in an esteemed position took action to improve her self-care and happiness, the student should do the same. Ive also seen my academic advisor model the work-life balance. She was our program director for a while. It like ripped her away from the things she enjoyed, and she end up stepping down back into a professors position. Seeing her say Im not happy at this level, I need to take a step back, was good for me because I felt if this person, at this level, is willing to do that for their health for what makes them feel satisfied and fulfilled, like I should be able to do that too. (Interview 22, p. 9) Faculty Who Do Not Provide Support to Students Contribute to Occupational Balance Disruptions. Conversely, other entry-level OT graduate students did not perceive a connection to faculty and often perceived increased stress at the thought of interacting with them. This increased stress disrupted occupational balance. One student reported faculty wanted to meet with students to discuss courses but stated it was difficult to develop relationships with faculty. The student explained, "it's hard to talk, the professors. They want us so badly to talk to them, and it's like, well, they're so intimidating" (Interview 7, p. 6). STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE 61 One entry-level OT graduate student indicated faculty could have assisted the students more during the transition to the graduate program and the move online secondary to the COVID-19 pandemic. The student explained faculty listened when students revealed their mental health needs; however, the faculty did not act upon the information. In addition, many students experienced an occupational balance disruption and needed support from faculty regarding concerns. The student suggested minor changes, such as decreased speed of courses and staggered due dates, which could have improved the student experience and occupational balance. I do think they could have done something more to help us. There were several times that we all opened up about our mental health and it felt like we were being heard, only to have nothing come out of it. There needs to be more actual listening and accommodations for our mental health and how we are currently feeling about the pacing, the layout, and the assignments included in the curriculum. We wanted to be heard. Instead, we were heard and given opportunities to speak, but then they would move on like everything was normal, even though some of us cried opening up to them. A lot of us had a hard time transitioning from undergrad and transitioning online with COVID-19. (Interview 25, p. 14) One entry-level OT graduate student suggested that faculty needed to consider many students had mental health concerns when they began the OT program, and the stress of the graduate program compounded them. The student suggested faculty needed to be aware that most of us before coming into grad school already struggled with anxiety or perfectionism, depression, things [like] that. And then obviously those things get worse when were under stress. So just having that realization (Interview 2, p. 4). STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE 62 Another entry-level OT graduate student reported frustration with the lack of availability of professors. For example, the student discussed one instructor who canceled office hours but did not offer alternative times to meet. The student stated the lack of accessibility often interfered with completing assignments promptly and created an occupational balance disruption. You can reach out to them [professors], but then you have to fit around their schedule (Interview 17, p. 12). Another entry-level OT graduate student expressed an understanding that professors took steps to help students prepare for the rigor of graduate school; however, in reality, this attempted help often overwhelmed students and instead disrupted occupational balance. The student provided the example of graduates who came in and shared their entry-level graduate program experiences with the new cohort of OT students. Rather than feeling comforted, students left the meeting questioning their ability to succeed in the program. I think they've [instructors] had to adjust a lot. I think they thought that they were helping in a lot of ways, when in reality they were making us more stressed out. I think my generation is definitely more stressed out just naturally. So having a new graduate from our program come and say, there will be semesters where you're on top of it, and you have a great system for studying, and then the next semester it doesn't work and we're all like excuse me? So really we left that meeting going, so Im going to fail. I'm not reassured um but, like, I think, to them that that was helpful to have our peers talking to us. It's like, no actually that was terrifying. (Interview 19, p. 12) Developing and Maintaining Peer Relationships Assist Students in Managing Disruptions to Occupational Balance. Entry-level OT graduate cohort peers were vital to students occupational balance. One student reported the relationships developed within an entry- STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE 63 level OT graduate program cohort assisted with a disruption to occupational balance to move away from believing they were not performing to personal standards on an assignment. The student explained that comparing grades with peers developed a sense of camaraderie. Knowing another student experienced a similar academic difficulty helped the student cope with a substandard grade and led to improved occupational balance. My group of friends, like we typically share grades with each other. So it really makes you feel better if like someone else did poorly too. Knowing other people did bad as well, like makes you feel better about it. (Interview 18, p. 10) Studying with peers was a valuable learning strategy for another entry-level OT graduate student who described seeing a parallel between problem-solving course content with other students and working through patient cases with a care team once becoming an occupational therapist. I think that talking it [course content] aloud with a peer has really helped, and I can see how that really translates to practice because I often see in my work environment [therapy aide] different therapists discussing specific issues and treatments and things like that. And so just hearing it out loud, and processing with somebody else I think has been something that I'm so glad has developed over the course of this program. (Interview 11, p. 9) Several entry-level OT students recognized that socialization was a strategy they could employ to help them regain occupational balance in graduate school. For example, one student indicated studying during free time was the main way to succeed in entry-level OT graduate school. The student explained that being around others outside of her entry-level OT graduate program and engaging in non-academic activities helped divert attention from school work. STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE 64 I think the easiest way to like distract from that [feeling a student needs to always be doing schoolwork] is being around other people. We have like a game night, that's like really good mental break for me, because Im no longer thinking about the things I need to get done, it's like really concentrated, and just like having fun, and what we're doing in that moment. (Interview 25, p. 13) Similarly, another entry-level graduate student expressed the importance of friends in the OT cohort. The student indicated others who had similar experiences provided a sense of hope. These companions provided support in times of stress and helped the student regain occupational balance to complete the graduate program successfully. The student explained, I feel like I need those people to continually lift me up. Having that close knit relationship with people who understand what you're going through um is very beneficial. I honestly could not have made it out without my friends in the program. (Interview 3, p. 7) One entry-level student reported the importance of having peers in the graduate program to discuss the stress experienced in the OT program. The student explained that friends who graduated from their undergraduate education and went to work did not understand the entrylevel graduate program experiences and, therefore, could not assist with improving occupational balance. One of my best friends was in speech path. So I'd like call her, and she would get like the grad school aspect of it. No one gets it unless you're in grad school. So a lot of my friends at home like are in business. And so theyre stressed at work, and just can't relate. (Interview 5, p. 11) STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE 65 One entry-level OT graduate student avoided certain peers because of their negativity about the program. The student explained, I feel like sometimes my peers go down a pessimistic view of our program and the teachers. And so sometimes I try to just steer away from that because I don't really want their group consensus (Interview 17, p. 13). Another entry-level OT graduate student also commented on the negativity of the cohort in the group chat they used to communicate. As a result, the student left the group to avoid undue stress and disruption to occupational balance. People would say something like oh well, the teachers grading so subjectively, or once or twice, it was much harsher than that. And it was just like okay Im done. I don't need to be in here [group chat]. It was mostly just drama, and everybodys feelings about every assignment, and it's just a lot less stressful to not be in it. (Interview 24, p. 9) Similarly, another entry-level OT graduate student indicated listening to some students discuss class assignments created feelings of unease. The student chose to avoid interacting with these peers to avoid undue stress. The student explained, I am very limited in who I talk to about class frustrations anymore. Like right now, um, they are going crazy about the assignment details that we don't know for assignments that are due this week. Um, and so, honestly, the group chat is really just chaotic. (Interview 17, p. 12) One entry-level OT graduate student expressed the importance of finding peers who had a similar approach to completing assignments to maintain a state of occupational balance. The student described peers at the ends of a continuum those who completed assignments exceptionally early and those who procrastinated starting them. Finding peers who managed STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE 66 assignments in a similar way, however, was difficult. The entry-level OT graduate student reported that interacting with students who viewed deadlines differently was stress-inducing and caused disruptions to occupational balance. I think that we also as like a cohort, and a class really stressed each other out. People will finish things really early, and then you have the people who finished things like the last second. And I think like we struggle with like finding that balance, and finding other people who are like in that middle range. (Interview 10, p. 9) Participating in Multiple Occupational Roles Contributes to Student Occupational Balance. Several entry-level OT graduate students provided information about the influence of participating in multiple occupational roles on their occupational balance. One role to improve occupational balance that students discussed was working at a job. Some students reported obtaining paid employment, so they had something to focus on other than school. Developing relationships outside of school, and having a physical location to engage with others that was not home or school, helped improve their sense of occupational balance. Work provided benefits that a focus on schoolwork alone did not afford them. In addition, as one student described, working at a job provided a sense of purpose and improved overall mental health. And then second semester I decided to get a job. Just because like I wanted to work and like I wanted to just do something out[side of school]. And I learned, like my study habits too that way. Now being able to do my schoolwork, and then, like, Ill go to work and like Ill focus on work because the first semester I did it [only focused on schoolwork], and like it was not good for my mental health. (Interview 8, p. 11) Several entry-level OT graduate students described the importance of engaging in more than one life role, so they did not define their identity solely as a student. Personal happiness and STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE 67 acceptance by others required engagement in more than the student role. As one student stated, You cant let one facet of your life overrule everything else, because then youre just not going to be happy, and youre not going to like, be like, somebody others want to really be around (Interview 6, p. 10). Participating in multiple occupational roles provided a sense of occupational balance for entry-level OT graduate students, who also reported an inherent need to engage in activities outside of their academics. I just I have a lot of interests, and I never want to limit those interests (Interview 19, p. 11). Another entry-level OT graduate student compared feelings about occupational balance to a future career as an occupational therapist. Thats kind of what like OT is about, the different roles and identities and all of that. People arent just like defined by one like characteristic of themselves, and that you know people have a broad scope of identities that contribute to who they are, and they [identities] are all are important. (Interview 2, p. 10) Engaging in and exploring other desired occupational roles equated to this entry-level OT graduate student's sense of identity and a view of successful occupational balance. The student explained, I value the balance and kind of see the importance of not just being like my only identity is being a student, and kind of being like, Oh, like there is other parts to me that I have time to explore. (Interview 2, p. 5) Getting a job helped one entry-level OT graduate student regain a sense of normalcy in life. The student stated it was enjoyable to be around people again after the limited socialization during the COVID-19 pandemic. Engaging in work evoked feelings of competence. Additionally, the student enjoyed that the work was not mentally challenging and therefore was a nice contrast to the intensity of coursework. STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE 68 I am very excited about having a job right now, like that's been really great to be like in person somewhere else, and like meeting new people and just getting to like see people again. But it's also in an environment that like I really love It's so easy, and a nice place where I can go, and like mostly not mess anything up. (Interview 21, p. 15) The student also indicated that working at a job helped improve efficiency with using free time to complete academic assignments. The student explained, I think when I have a job or something else going on that forces me to use that open time to catch up on assignments and stuff I think Im more disciplined about it (Interview 21, p. 4). Another entry-level OT graduate student worked during the graduate program but purposefully obtained a job outside of OT to take a mental break from academic work. The job choice improved occupational balance as it provided the opportunity to explore another life interest and forced the student to spend time in something other than academics. A huge portion of my work life balance was um I purposefully got a job at a place that had nothing to do with anything occupational therapy. I worked at a garden center because I liked horticulture, plants, that kind of thing. I worked there on the weekends. And that was nice for me, because I could be like well I can't study from eight to six because Im working. I wanted that like totally different thing to not be OT related to give myself a break. (Interview 22, p. 13) Some entry-level OT students chose to postpone obtaining a job until the second semester to allow themselves time to acclimate to the academic rigor of graduate school. As one student stated, STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE 69 I kind of chose just to not work my first semester, just because I knew the course load was going to be extremely crazy, and I just wasn't going to be able to fit it in. I didn't really want to stress myself out too much. (Interview 8, p. 6) Another entry-level OT student also expressed belief in not working during the first semester of graduate school. The student explained, I purposely didn't work [first semester] because I didn't really know the rigor of the grad school program because I knew it wasn't going to be like undergrad. I knew it required more work and more time, and so I didn't want to overwhelm myself at the beginning. I wanted to give myself a chance to kind of get in the groove of things and kind of understand grad school before I took on another responsibility. (Interview 9, p. 5) Students who Made Time for Self-Care Demonstrated the Ability to Minimize Disruptions to Occupational Balance. Several entry-level OT students experienced a mindset shift during their time in the graduate program that changed their perspectives toward taking care of themselves. They developed strategies to help regain occupational balance during periods of high stress. For example, one entry-level OT student started to keep a gratitude journal while in the graduate program after experiencing severe periods of being overwhelmed accompanied by panic attacks. The journal helped to refocus energy on the good things in life, which helped manage the stress related to academics. I needed to find something that was good and find the peace in each day, and that [gratitude journal] helps me cope, just because I was just seeing and hearing so much negative. (Interview 3, p.14) Another entry-level OT student focused on the end goal of becoming an occupational therapist during the difficult times during graduate school. To help with coping, the student concentrated STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE 70 through spiritual reflection on the difficulty gaining acceptance into the program and why becoming an occupational therapist was important. I thanked God every day that I was in the program because it was a rigorous application process. I was thankful to be there, and even though some days were more difficult than others, I knew that this was the profession that I wanted to pursue and I knew why I wanted to do it. (Interview 11, p. 16) One entry-level OT graduate student learned that fatigue at the beginning of a week indicated the need to stop working on homework earlier in the evening to rest. The student explained, At the beginning of the week if I know I'm just completely exhausted like I'll kind of, call it quits for the night. And I'll just say, I'll get it done tomorrow or whatever (Interview 8, p. 8). Planning a self-care activity in their day provided some students with the accountability to follow through. For example, one entry-level OT graduate student found that tracking everything in a planner for the week helped visualize and schedule workouts to ensure completion. The student explained, I have a planner. So, I write everything in, and then I try to put in like during the week when I will plan in my workouts" (Interview 11, p. 6). Similarly, two other entry-level OT graduate students also scheduled time in their planners to exercise. On Tuesdays when I have like no time, and I have to find time to work out, I put that in there [in a planner] (Interview 12, p. 5). "In pink here [in Google calendar] I put my personal events. Here you can see I went on a walk with my, my roommate and the neighbors downstairs. So that was in there (Interview 17, p. 7). Another entry-level OT graduate student explained using a calendar alarm as a reminder to go on a run. STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE 71 I also have in my phone calendar, like every other day, I have an alarm go off, so it reminds me to like go on a run. And so sticking to that Im also like, oh my gosh that's in my schedule, I need to do that too. (Interview 20, p. 5) One entry-level OT graduate student gradually scheduled more integrated self-care time. The student began by planning time one evening a week to watch TV with some friends. I made small changes to like incorporate more time for myself. I started going to a Bachelor watch party every Monday night with some of the girls in the class. And that was my like socialization my like break from studying. And then as it [time in the program] progressed, I just realized like, how important it is to not let one aspect consume your life. (Interview 6, p. 10) The entry-level OT graduate student explained that progression through the program provided a sense of value for time away from academic work and led to steps to ensure time for self-care. The student scheduled time every day for relaxation, which improved contentment with life. So now I've been more like aware and conscious of, like, making sure I either schedule time to do things for me or just, like, make sure that I'm not hyper focusing on one thing. Like I try right now, every single day for an hour I like set aside time to just go for a walk outside, and if I finish my walk earlier than an hour when I get home I can like, do whatever I want and just really relax. (Interview 6, p. 10) Some entry-level OT graduate students found that using the weekend to rest helped them achieve occupational balance. One student explained, I try really hard not to do things on Sunday. Its kind of my chill day kind of a recharge day (Interview 24, p. 4). Another entrylevel OT graduate student also took a break from academics on the weekend. The student completed homework during the week to spend the weekends in leisure and social activities. STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE 72 Weekends are normally um less school for me because I kind of try to do all my homework during the week. So I like to work out and hang out with my friends, see my boyfriend, see my family, stuff like that, kind of more relaxing. (Interview 9, p. 2) Knowing When to Seek Professional Assistance Helped Students Manage Disruptions to Occupational Balance. Two entry-level OT students reported heightened anxiety in the graduate program that interfered with their ability to regain occupational balance. Both explained they needed to begin medication therapy as a strategy to cope with the anxiety. The first entry-level OT graduate student explained daily medication helped with remaining calm in stressful situations. The student further explained, So I've been put on medicine and I have a very good, like emergency one in case I start to spiral because it does still happen, but a lot less. Im a lot more mellow" (Interview 3, p. 16). The second entry-level OT student also started medication while in the graduate program but did not attribute the cause directly to the stress of academics. Since childhood, the student experienced anxiety and realized managing it independently took a lot of energy away from other endeavors. At the beginning of entry-level OT graduate school, the student discovered other students struggled with anxiety and sought treatment. It [seeing a doctor to get on medication] happened in graduate school, but I don't think it's because of graduate school. It was just I finally was ready to address it [anxiety], and realized that it was taking up a lot of my mental capacity. I finally feel like I can sit down and breathe and Im not like going 100 miles an hour. Talking to other students in the program, a lot of people have medication, and then also just being an OT and learning about people. People receive OT for anxiety and depression. I was like STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE 73 oh, this is an actual thing, and nobody's going to think that Im lesser-than because of it. (Interview 26, p. 13) What are the Differences in the Occupational Balance Strategies of Entry-Level OT Graduate Students Who Report High, Medium, and Low Occupational Balance? To address the first sub-question, entry-level OT graduate students completed the Occupational Balance Questionnaire (OBQ11) (Hkansson et al., 2020; P. Wagman personal communication, May 11, 2020) electronically after signing the consent form. The researcher scored the OBQ11 using the scale provided by the questionnaire (P. Wagman, personal communication, May 11, 2020). Twenty-two students completed the questionnaire and the researcher analyzed their interview responses along with their OBQ11 (Hkansson et al., 2020; P. Wagman personal communication, May 11, 2020) score to determine whether patterns emerged between the OBQ11 (Hkansson et al., 2020; P. Wagman personal communication, May 11, 2020) score and occupational balance strategies. For the purpose of this research study, the researcher developed three categories of occupational balance based on OBQ11 (Hkansson et al., 2020; P. Wagman personal communication, May 11, 2020) scores; low (score 17), medium (score 18 to 23), and high (score 24). Table 1 displays a summary of the characteristics of entry-level OT graduate students in each category of occupational balance. Entry-level OT graduate students who scored in the high occupational balance category were fewest in number (n = 4) and students who scored in the medium occupational balance category were the highest in number (n = 11). Entrylevel OT graduate students who scored in the low range of occupational balance were in the middle (n = 7). Even though the scores on the OBQ11 (Hkansson et al., 2020; P. Wagman personal communication, May 11, 2020) differed, during the interview process, 19 of the 22 STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE 74 students reported they believed their life was occupationally balanced and only three students reported they were not occupationally balanced. Eighteen of the 22 entry-level OT graduate students who completed the questionnaire reported involvement in paid employment. Types of jobs and the flexibility of the hours were variable within and among the three groups of students. The numbers of students who used working as a strategy for occupational balance were similar across the three categories of scores on the OBQ11 (Hkansson et al., 2020; P. Wagman personal communication, May 11, 2020). Three out of the four entry-level OT graduate students who scored in the high balance category reported time off between their undergraduate and graduate education. The students indicated the time off assisted them with making the transition to graduate school. Even though the sample sizes for each category of the OBQ11 were small, none of the students in the low occupational balance category reported a gap in time between undergraduate and graduate education. Taking time off between undergraduate and graduate education could lead to occupational balance in graduate school. For example, one entry-level OT graduate student who took a gap year before graduate school described being older than the other students in the cohort. The student indicated this was an advantage because the students life experiences increased security in the learning process, which helped maintain occupational balance, even during difficult stages of the program. I will say I think Im like easily the oldest person in my cohort And so I think that's given me [a different viewpoint]. And maybe it's just like life experience or being a little bit more comfortable being out of my comfort zone that has made my experience a little bit different than some of the other girls. I just feel like a little bit less self-conscious I guess at this point like in my life. (Interview 21, p. 12) STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE 75 All groups of occupational balance involving entry-level OT graduate students employed a variety of occupational balance strategies and adapted the strategies to the specific situation the students encountered. For some strategies, only one student used the particular approach; however, more than 50% of students in each category of occupational balance used several of the same strategies. Table 2 outlines the most regularly used strategies of occupational balance common to each group of entry-level OT graduate students. All groups integrated three strategies to promote occupational balance, including shared experiences with cohort peers, an individualized plan for organization, and scheduled time for self-care. Of interest, the number of commonly used strategies of occupational balance corresponded to the score on the questionnaire. For example, entry-level OT graduate students who scored in the low category of occupational balance incorporated the least number of strategies of occupational balance. Additionally, the total number of strategies increased by each score category. The students who scored in the high category of occupational balance shared some strategies with students in the middle category of occupational balance, but the students in the high category also integrated unique strategies. What Happens to the Way Entry-Level OT Graduate Students Manage Occupational Balance When They Experience a Change in the Expectations of Their Student Role or Other Life Roles? To address sub-question two, entry-level OT graduate students discussed how changes to life roles influenced occupational balance. Students also experienced changes in their occupational balance due to the COVID-19 pandemic. Additionally, several students expressed the importance of reflecting on current and past experiences to identify new ways of viewing their present situation. STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE 76 Changes in Life Roles During the Graduate Program Influence Occupational Balance Several entry-level OT graduate students reported experiencing changes to life roles that influenced their occupational balance. Many entry-level OT graduate students reported the need to obtain paid employment to offset some of the costs associated with graduate education. One entry-level student worked at a job from the start of OT graduate school. The student reported the work schedule interfered with academics. Because of the extended hours, I had to kind of push my school assignments back I ended up having to do a lot of the assignments and a lot of the schoolwork over the weekend, which impacted my ability to kinda engage in the activities I wanted to with my friends. (Interview 1, p. 3). Another entry-level OT student worked at a job since starting graduate school. When the COVID-19 pandemic forced entry-level graduate courses online, returning to live with parents was necessary for the student. The summer semester was light on credit hours. The student had more free time without classes to attend. These two factors led the student to work more hours than previously in entry-level OT graduate school, thereby disrupting the current occupational balance. During summer, since we went to all online, I actually went home, and that's when Iworked about 25 to 30 hours a week at a pool. I thought I [had] lots of time, like we dropped down in credits again, and then I think we had Fridays off, and I was like, okay, like I should get a job. And my boss was like, oh great, and scheduled me like at least five days a week, which is not what I was hoping. I was hoping like maybe three. So that was summer was really crazy for me. (Interview 10, p. 3) STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE 77 After returning to campus and resuming a coaching position at the university, the entry-level OT graduate student found occupational balance returned. So, moving back up here and getting back into coaching and then being at that 12 credit hours my life has calmed down a little bit" (Interview 10, p. 3). Another entry-level OT student worked at a job during the graduate program but stopped working when the COVID-19 pandemic began. An initial disruption to occupational balance occurred as the student tried to organize time between work and academics with the transition back to work during the final semester of the program. At first, like when I went back to work this semester, I was like all over the place again because I work a lot. But now that I'm like in like my fourth week working back there I know what like timeframes I have to get stuff done. So I'm pretty good with it. But yeah, at first it's stressful because it's like you work all day, and like, then I'll come home, and I'm like, oh, I still have stuff to get done. (Interview 8, p. 6) Several entry-level OT graduate students reported a flexible employer assisted with lessening their stress. One student recalled experiencing last-minute course changes that interfered with a work schedule. They're very flexible [work], which is helpful to be able to say, hey, I can't work Tuesdays now because they just made us a class from two to four (Interview 7, p. 8). Another entry-level OT graduate student reported the supervisor permitted the student to clock out to attend a virtual class. My boss lets me kind of just go into his office, and I just Zoom into class. So, it's pretty nice. I just kind of clock out and then clock back in after class" (Interview 8, p. 2). A third entry-level OT graduate student had a supervisor who considered the students academic requirements. The supervisor permitted the student to call off on a scheduled workday to prioritize academic assignments. STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE 78 Im very lucky that like if I have homework tomorrow, I could just tell my boss I have like so much school work to do that I cant come in, and she'll be very understanding, and then like she'll just say it's fine. (Interview 15, p. 11) Other entry-level OT graduate students reported completing some homework during work, which significantly decreased their stress. For example, one student worked as a therapy aide for a physical therapy clinic and reported that the supervisor allowed homework completion to occur among work duties. The student explained, While I'm at work, if I have a break between patients, Ill sit there and like my boss like lets me have my computer. So yesterday when I was working I was doing an assignment for school (Interview 8, p. 4). Similarly, another student was a receptionist at a gym, and could work on homework during less busy periods. I work at a gym. I would just sit at the front desk. I'm actually really lucky because I am able to do some of my homework there. So during those four hours when I'm not doing anything, I am allowed to get some homework done. (Interview 9, p. 3) Working as a nanny afforded another entry-level OT graduate student flexibility to complete academic requirements while the children were napping or engaging in online school work. The kids nap from two to four every day so I do my homework. The kids are also homeschooled, so if they are both on their computer doing their homeschool work, I'm allowed to have like books out to read or study or do whatever. (Interview 12, p. 2) One student became pregnant with a first child during the capstone experience, near the projected graduation from the entry-level OT graduate program. The student described the challenge of finishing a doctoral degree but also desired to enjoy preparing for the birth experience with a spouse. The student expressed the belief in a lack of time to read books for STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE 79 expecting parents or engage in other self-care practices, which signified that the student was not occupationally balanced. I was like, okay, my due date is in two months, and I have these things I want to learn, and Im just like, am I never going to learn them? When I have something I want to do, but I can't find the time to do it, that sometimes is an indicator to me that I might have too much on my plate or not balanced enough ... It's like reading an extra book or telling myself, I can afford a half-hour walk outside, and saying no, I can't. I can't afford that. I can't find that space. Like that's in my mind. Im like something's not there if I can't find the time, so that's usually an indicator for me. (Interview 22, p. 14) Another entry-level OT student lived with parents to save money while in graduate school. The students father was caring for grandparents, so the student assumed some of the responsibilities at home that the father typically completed. My grandma just broke her leg, so she just came home, and my grandpa has like severe dementia, and so my dad is kind of like taking over the responsibilitiescaring for them So that's why I've kind of stepped it up, helping in the kitchen and cleaning and making sure that like everything's okay around here so that he can worry about everything over there and not worry about anything at home. (Interview 9, p. 5) The entry-level OT graduate student indicated the increase in household responsibilities disrupted occupational balance; however, the student did not focus on the lack of occupational balance but instead thought of adaptations that would enable adjustment to the situation. The student explained, It kind of just, it is what it is. So you got to make it work. I try not to stress myself out about it because I know that like this situation can't change. So I just kind of got to adapt STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE 80 my my life right now until everything kind of settles down with my grandparents. (Interview 9, p. 5) Another entry-level OT graduate student discussed a similar situation at home. At the time of the interview, the student lived with a parent. However, the students sister, who lived in another state, visited for an extended period. The student explained, My sister's home right now, and she had her [ACL]surgery like two weeks ago. We're all kind of helpingShe's pretty dependent at this stage, and so I think we've all been kind of trying to take turns with helping her with basic things and getting to like physical therapy appointments and stuff. (Interview 21, p. 5) The entry-level OT graduate student reported positive feelings from having a sister home they could not visit during the COVID-19 pandemic. The time with family was a welcome respite from academic demands. It also alleviated some of the isolation associated with the stay-at-home orders. We didn't see her at all during the pandemic, so we do not take like family time for granted. So Im like more than happy to like have just a chill weekend at home with them. (Interview 21, p. 8) The entry-level OT graduate student stated having the family together again was nice and viewed the situation as positive. We get like three bonus months with her, which I guess, we didn't see her all of last year, so yeah, I have my whole family under the roof now, which has been a good thing (Interview 21, p. 2). STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE 81 Experiencing the COVID-19 Pandemic Created Traumatic Disruptions That Significantly Challenged Occupational Balance and Required Altered Strategies to Manage When the public health officials enacted the stay-at-home orders (Acton, 2020; Wolf, 2020) in response to the COVID-19 pandemic, entry-level OT graduate students experienced a disruption in their occupational balance. The orders forced people to stay at home and OT courses to move online; consequently, entry-level OT students experienced similar feelings as when they first transitioned to graduate school. Suddenly, the way they attended class changed. Anxiety levels increased for students who reported a mentally and physically challenging time. Previously implemented strategies for regaining occupational balance were no longer adequate. One entry-level OT graduate student shared these feelings in reaction to the COVID-19 pandemic. I feel like lately, especially with being in this wonky format and trying to figure things out after COVID, it's been a lot more difficult and a lot more unbalanced. And I feel a lot more stressed and a lot more exhausted, just mentally and physically. (Interview 3, p. 5) One entry-level OT student expressed feelings of being overwhelmed with the unpredictability in graduate school. The COVID-19 pandemic contributed to this state of mind, but the political climate combined with the amount of work to complete for school added stress. We just have a million things to do, and then the stress of COVID, and the election year, and just so much uncertainty. It was a lot (Interview 19, p. 12). The methods entry-level OT graduate students used to prepare for class and study were no longer effective as more distractions surrounded them at home than when they studied on campus. For example, one entry-level OT graduate student described a lack of experience with STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE 82 online learning as a barrier. The student recognized the need for more self-discipline than when attending class face-to-face. The student explained, And then our second semester started out like really great, and I was like, okay I can do this, and then COVID happened. So then halfway through, we started online, and then we're like, okay, I don't know how to do this. I don't know how to have class online. I don't know how to keep myself disciplined at home. If I have a break [on campus], I can just do an assignment versus if I have a break at home, I'm like hmmI could take a nap or something. (Interview 7, p. 6) Similarly, another entry-level OT graduate student enjoyed having a plan and was uncomfortable with unforeseen changes due to the COVID-19 pandemic in the schedule because these changes decreased the sense of control over life. I do not like it when things are changed. I like having the syllabus. I like knowing what's going on, and then, when, at the last minute, they're like the speakers this day and not this day, is not a thing I love to happen. (Interview 25, p. 8) Entry-level OT graduate students reported being home all of the time resulted in difficulty setting boundaries between academics and other aspects of life, such as relaxing. One entry-level OT graduate student completed most studying on campus before the COVID-19 pandemic, using time at home for repose. The student described the frustration with the move online as follows, Trying to figure out that separation between school, and like just relaxing and having time [for myself]. [Before] I could pretty much just associate school with okay, I was in the classroom, or I was on campus studying. Whereas now my bedroom is also STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE 83 school, so just finding times where it was like okay, I need to focus now, but also times where like I can just relax. (Interview 23, p. 5) The comfort of attending class from home also negatively influenced entry-level OT graduate students ability to focus on academics. Students reported avoiding comfortable positioning during homework completion and attendance at virtual class sessions. The added distractions of television and family members also impeded concentration at home. One entrylevel OT graduate student discussed the experience of attempting to complete academic work at home. I'd go somewhere that wasn't like in my house or sit at the kitchen table so it's not as comfortable, even though, like your back hurts, you're not in a comfy bed where youre gonna like fall asleep. It's hard to work at home because there's like a couch and a TV, and my grandma's there, and it's easily distractible at the house. (Interview 7, p. 3) Family also was a factor in another entry-level OT graduate students productivity with homework during the stay-at-home orders. The student indicated other people in the home impeded adherence to a schedule and attention to the academic tasks needing completion. The student stated, I didn't focus as well. So I would like do something, go get distracted by my family, come back do some more. So my schedule is off. And I was at home, and my mom would just be coming in. My brother was home, like a lot of lot was going on. (Interview 5, p. 4) Another entry-level OT graduate student reported when professors moved courses online, they continued teaching as though everything was normal. Meanwhile, the student did not make the transition effortlessly and spent most of the day on the computer to complete the required STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE 84 coursework. Being on the computer for extended periods challenged the student and was an unhealthy practice. When we had the shutdown with the pandemic there was not a very easy transition to online classes with the professors. They just kind of went about things business as usual, just over a screen. I found myself waking up at like 6 a.m. and being on my computer until after midnight just trying to get everything done, and I was like, this isn't healthy. (Interview 19, p. 9) One entry-level OT graduate student reported changing the organization method used when institutions moved courses online secondary to the COVID-19 pandemic. The uncertainty that accompanied virtual coursework created anxiety. In addition, the student indicated apprehension regarding diminished in-person conversations and time to practice therapeutic techniques. My organization changed, so that caused me some anxiety. I just was a little unsure of like what it was going to be like virtually. I liked having like an assignment done, and going and talking to a professor and say, hey, this is what I have, is this correct? And I like that face-to-face interaction that I get so, I was like, worried about that. And I like the hands-on stuff. So I was very worried about those kinds of things. (Interview 12, p. 6) Another entry-level OT graduate student also experienced difficulty with the transition to online courses. The student discovered that course changes negatively impacted organizational coursework strategies, resulting in uncharacteristically forgetting to submit completed assignments. The lack of interaction with peers also contributed to this atypical behavior because they no longer discussed assignments and course content. The student explained, STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE 85 Shifting from in-person to online was not without struggle. There were assignments that I would complete, but I wouldnt turn them in because the schedule would change, or I just dont have that in-person time to talk with my peers, and say hey did you guys do this assignment? And kinda discuss what we were thinking, and just what we were taking away from each class. So it was a lot harder for me to at first to kinda grasp on everything. (Interview 1, p. 4) The move to online courses occurred quickly, and entry-level OT graduate students found instructors often made changes to accommodate the unplanned format. For example, assignment instructions and due dates changed to adapt to the virtual learning environment. These changes reportedly exacerbated students' anxiety and the uncertainty they were already experiencing. One entry-level OT graduate student explained, It kind of stresses me out if I think about what's going on next month, especially nowadays, it seems like the curriculum is just adjusting and changing like so frequently" (Interview 14, p. 2). Another entry-level OT graduate student learned not to plan as much as before the COVID-19 pandemic. In addition, the student learned to adjust organization techniques to the frequent schedule changes, thus experiencing less stress when they occurred. Ive learned that you can't [plan ahead] because it's constantly changing. Like we have these presentations that are coming up, and I think our schedule changed twice since the beginning of the semester. So Im just like, as it comes, Ill write it in [my planner] because if I write it in pen and then it changes, Ill be all messed up. (Interview 20, p. 6) Other schedule changes that occurred moved weekday courses to the weekend for some entrylevel OT graduate students. As one student shared, STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE 86 We were supposed to have our orthotics class on Mondays and because of the pandemic, we've changed it. So instead of having a normal lecture-lab weekly on Mondays, which was what we signed up for, instead were doing mostly online lectures, and then we are meeting three times in Friday [and] Saturday [in] pairs. (Interview 17, p. 4) Entry-level OT graduate students with scheduled appointments outside of their academic life reported increased frustration when changes to class schedules occurred with little notice. One student reported feeling these changes were unfair and problematic, creating the need to call and reschedule other commitments. I have one professor who just keeps changing everything, and I understand it's because she has [guest] speakers, but like there are some times that I like had appointments planned, and she's like, sorry, this is no longer at night, now we have to do this morning thing, because I know you guys all have a gap. Which is unfair to people who are working but I have so many medical appointments that it's like I now have to call three different locations and change my appointment. (Interview 25, p. 8) Some colleges and universities eliminated extended breaks from class and ended the fall semester early in an attempt to finish coursework before the end-of-year holidays. However, this accelerated timeline was hurried to the entry-level OT graduate students and created extreme fatigue. One student described feelings at the time. Right now, we don't have any like scheduled breaks. The last semester we didn't have a fall break, and then we started a week early, so we were fitting four months of school into three and a half. So there was like that two week extra that we were trying to fit in STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE 87 and we were just burnt out. So like you don't sprint a marathon, but right now we're sprinting a marathon, and we're exhausted. (Interview 19, p. 12) Another entry-level OT graduate student endured a similar experience with moving schedules at the university in the fall and the spring semester. In the fall, they moved the start date forward. They moved the end day in December forward, and then they took our breaks. And then they did the same thing in this semester, but the reverse, so like we started really late in January. We get out about the same time, but it's because they cut out like all spring break. (Interview 24, p. 5) In addition to the changes associated with academic courses, the stay-at-home orders accompanying the COVID-19 pandemic impeded the ability to socialize with others. For example, one entry-level OT graduate student reported, Before COVID, I would go kind of spend time with my grandparents, and kind of get them out of the house, and we would walk around their development and whatnot. But I haven't seen them since March (Interview 13, p. 7). The lack of socialization also limited entry-level OT graduate students ability to develop connections with program peers, leaving some students feeling secluded and unhappy. One student provided an interpretation of the experience. We're all lacking social connection. I would love to be able to like drive out and see friends more. I think Id definitely be happier if I got to spend like in-person time with my cohort and forming relationships. I just know from past experience that, like when Ive been in more like isolated periods of my life, I just think Im overall less happy. (Interview 21, p. 14) STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE 88 Similarly, another entry-level OT graduate student limited the time spent with a significant other during the early months of the COVID-19 pandemic. The risk of contracting the virus and not attending lab courses contributed to the students decision. We would visit each other more if it wasn't for COVID. He [significant other] doesn't want to risk not being able to go to lab, and neither do I. Were both in very hands-on health care professions, so we need that lab time. (Interview 19, p. 14) The lack of socialization that accompanied the transition to online courses also influenced inter-cohort relationships among entry-level OT graduate students. Students expressed difficulty developing comfort with each other and professors, which limited effective course discussions and student confidence levels. One entry-level OT graduate student described the experience as follows, I think the more challenging thing has just been the fact that our cohort hasn't really gotten to know each other personally and do a lot of like social things that normally the first years do. It took our class a lot longer going into the first semester to just kind of like speak up in class more. I think we all just kind of felt uncomfortable, and didn't know each other and were obviously intimidated that like it's our first year in like a doctorate program, and like you can't see our faces or anything. (Interview 21, p. 6) In contrast to the difficulties many entry-level OT students faced, shifting from in-person to online courses lessened one students stress level in graduate school. The student perceived there was less activity in life to manage when attending class virtually. The student further explained, Yeah, I do [perceive I can fit everything in I need to do]. I think with like the virtual classes, there's more of like a, I don't want to say like lackadaisical, like it's more like I STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE 89 can just kind of like lay in my bed and be in class So I don't feel like I have to like I have so much going on all the time because I just kind of like pull out my computer and like I'm in class So I almost feel like if it was just like normal times, it would be more overwhelming And so it's almost been nice in that sense, but also like I wish it was back to normal. (Interview 16, p. 7) Another entry-level OT graduate student also described a more relaxed atmosphere with online classes. Sometimes we dont even have our cameras on, so it can be pretty casual on there [synchronous video course session] (Interview 14, p. 3). The COVID-19 pandemic impacted entry-level OT graduate students academic lives as well as their ability to work. Some businesses closed as the result of the restrictions placed on them. Many entry-level OT graduate students lost their jobs, which impacted their ability to engage in social events. As one student explained, With COVID, it's just been hard. Im used to working a few different jobs, just to try and make ends meet. Last year, I had five different jobs. They all gave me enough money to have some flexibility with what I could do [with my friends], whereas now I only have two [jobs], so I have a little bit less flexibility. (Interview 19, p. 6) Another entry-level OT graduate student experienced a similar job loss secondary to the COVID19 pandemic. "I worked at Burlingtons the first semester and then Panera up until the beginning of summer semester, and then the pandemic hit, and that threw a wrench in everything" (Interview 1, p. 12). The student found another job, but it was not an ideal location and at times compounded the stress of entry-level graduate school. [Now] I drive like 40-45 minutes, you know every time I have to work, um, which kinda comes out to be four days a week. Figuring out a way to avoid or minimize the STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE 90 X factor, so traffic or an accident or terrible weather, just figuring that out [adds stress]. (Interview 1, p. 6) Another entry-level OT student was a cross country student-athlete and a graduate student. The COVID-19 pandemic disrupted the students schedule. Weightlifting sessions and long runs, typically scheduled and performed in a group, had to be completed independently. The student completed the requirements with a friend on the team to assist with accountability. What Im used to is like a structured routine. My roommates on the team as well, so like typically, we will do [runs] together if we can it helps us like get out of bed a little easier. And then, the lifts, we have to do two lifts a week, and again, those are independent. We're just expected to get them in. (Interview 18, p.4) Conversely, the move online secondary to the COVID-19 pandemic reduced another entry-level OT graduate students test anxiety. Previously, the student listened as others discussed the examination content they studied, making the student question current study habits. The student was not exposed to these conversations online. Additionally, the student experienced less noise in the home environment than in the classroom, making it easier to concentrate. But now also it's [anxiety] definitely decreased with more online and the anxiety around exams is so much less because Im logging on to the lockdown browser to take the exam online, and I can't hear people flipping, or I can't hear people like chattering right before the exam starts of oh, do you remember what these seven steps are? ... That is so much less and its so nice. (Interview 26, p. 9) One entry-level OT graduate student reported the move online helped to learn that engaging in activities outside of academics would not impact grades. I feel like having that STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE 91 [classes] online allowed you like, oh, I'm just gonna watch Netflix. Oh, well I did that, and it turned out okay like I still got everything done (Interview 7, p. 6). During the COVID-19 pandemic, one entry-level OT graduate student indicated professors made an extra effort to maintain personal contact with students. They also provided information about self-care to help students cope with the move online. This semester Ive got like three professors that are every week they're posting like wellness tips, self-care, or doing check-ins. So they've really gone above and beyond, really, I think, to make sure they still connect with us on a personal level. (Interview 24, p. 11) Reflecting on Past Graduate Program Experiences Helped Students Manage Disruptions to Occupational Balance When an occupational balance disruption occurred, entry-level OT graduate students described the importance of personal reflection on past and current circumstances to assist in viewing their circumstances differently. For example, one student initially integrated strategies that cohort peers used to study. Over time, the student realized the need to develop an individualized approach to studying in graduate school. The student learned to accept some peers studied longer or differently; and over time, developed self-trust in choosing study habits, regardless of what others were doing. What works for X student is not going to work for Y student, and you need to be okay with the differences. Just look at who you are as an individual, what you need to do, and do it - not do what other people are doing (Interview 22, p. 11). Another entry-level OT student reported a similar realization but explained it was the second semester of the graduate program before accepting less than perfect grades became STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE 92 easier. The student did not believe the grades earned reflected time studying, so a lower grade took increased time to accept. I think that was so hard for me at first. I definitely think that it really didn't come to me to like be able to accept that [not earning all As] until around the second semester with the neuro course. I went into that professor's office, and talked about it and just, I know that was like a big point for me because it was to the point where I was almost emotional about not getting the grade that I thought that I was going to because of how hard I had studied and how long I had spent on it. (Interview 11, p. 10) Another entry-level OT graduate student discovered a lower grade in the graduate program signified something different from undergraduate education. In undergraduate courses, the student explained that students often studied material for a test and then advanced to the next topic, regardless of performance or understanding. In entry-level graduate school, a lower grade meant a student needed to review the material to ensure understanding. The need to study differently to learn the material adequately might be necessary. If you get a lower grade it means you didn't gain some of the information, and now you just need to go back and learn that information for your benefit. In undergrad, you just got the F, or the A, and you moved on to the next exam. It wasn't about going back, and really learning the information. So it was a huge shift to be like oh this lower grade or this higher grade, they represent something different. (Interview 22, p. 12) Another entry-level OT student explained past high performance in undergraduate education informed the academic goals set in the graduate program. The student realized these expectations were unrealistic and also unnecessary. The student learned to relax expectations for STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE 93 achievement in entry-level OT graduate school. The student realized future employers would not inquire about grades, so expecting perfection was unnecessary. There were definitely times I felt anxious, and it was kind of unnecessary to have those expectations for grades because when you get out of OT school, they're not going to be like, so what was your GPA in OT school? (Interview 20, p. 9) One entry-level OT graduate students understanding of occupational balance in the program evolved from experience with a disruption to occupational balance at the beginning of the program. No matter how busy you kind of are as a person, you have to make time for a wellbalanced life In undergrad, I was pretty into fitness. Like me and my friends would go to the student rec center and go to the workout groups three times a week. And then, when I got here [entry-level graduate school], I didnt do any physical activity. All I did was study. I barely was like making time for like eating and socializing. Um, and I realized how mentally draining and exhausted I was. I just realized like, how important it is to not let one aspect of life consume your life. (Interview 6, p. 3) One entry-level OT graduate student indicated gaining insight into personal capabilities during the first semester, which increased self-confidence and success in future courses. Overcoming that first semester when I didn't know if I was going to pass anatomy, to passing it, I was like, okay, if you got through a class that was this hard, that was this much, you can get through your other classes. (Interview 12, p. 11) Another entry-level OT graduate student gained a similar understanding. The student stated, I think once we do it, there's like, yeah, I can do this (Interview 4, p. 10). One entry-level OT student explained the difficulties experienced at the beginning of the graduate program were STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE 94 valuable experiences. Overcoming problems increased self-confidence. After completing a course, the student experienced more contentment than if the process had been stress-free. I just feel like grad school is such a journey that you learn so much on, that you want to struggle in the beginning, just so it feels so much better at the end when you finish it" (Interview 7, p. 18). Another entry-level OT graduate student recognized competition with peers was no longer existent. Instead, studying with others provided multiple viewpoints on a topic and allowed students to share their strengths to enhance the group's learning. But then you kind of realize that you're all in this together. And it's not really me versus you. It's like, let's study together instead of studying apart so that I can get your perspective on things because everyone has different perspectives on things when you learn and I liked learning that I could study with my peers, instead of like competing against them, so that I can get their knowledge and like their perspective on things. (Interview 9, p. 10) Similarly, another entry-level OT graduate student developed an appreciation for the different backgrounds of cohort peers. The student learned to leverage the strengths of others to help understand the complex material instead of creating comparisons and feelings of competition with each other. Everybody's going to have the thing that they're a little bit better at like because of their experience. My cohort classmates, who took the kinesiology undergrad, they're going to excel in biomechanics and anatomy just a little bit more than me because their background is just in that kind of stuff. (Interview 22, p. 10) STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE 95 For Entry-Level Graduate Students in Different Semesters of the OT Program, How Do the Strategies for Managing the Student Role Change? To address the third sub-question, entry-level OT students discussed how their occupational balance fluctuated across the graduate program. Entry-level OT students explained the differences in occupational balance they experienced at the beginning, middle, and end of the graduate program. Additionally, entry-level OT graduate students explained shifts in occupational balance that occurred from the beginning to the end of a single semester. Occupational Balance Fluctuates Within the Graduate Program Experience Entry-level OT students described moving from periods of occupational balance to disrupted occupational balance multiple times while enrolled in the graduate program. Contributing to these fluctuations were unfulfilled personal expectations, decreased comfort with peers and instructors, intensified academic requirements, expanded responsibilities outside of academics, and the diminished ability to implement support strategies. Entry-level OT graduate students appeared more likely to experience a disruption in occupational balance when experiencing changes in more than one area of life or as a reaction to an external circumstance, such as the COVID-19 pandemic. In addition, if the student did not possess adequate coping skills to manage the situation, the lack of occupational balance often intensified to a level requiring external support to shift back toward occupational balance. Occupational Balance Fluctuates From the Beginning to the End of the OT Program. Entry-level OT graduate students discussed the differences among occupational balance in the first semester of the graduate program compared to subsequent semesters. Transition to the graduate program was challenging for students and for many reasons often disrupted occupational balance. STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE 96 The First Semester of the OT Graduate Program Creates a Disruption to Occupational Balance. Each entry-level OT graduate student in the study experienced an interruption in occupational balance; however, the reasons for the disruption were varied. For example, one entry-level OT student reported diminished occupational balance during the initial transition to the graduate program due to the differences between graduate and undergraduate professional and academic requirements. The time students were required to be on campus combined with extensive course requirements were complex changes. The student stated, In undergrad, I had a lot less assignments due, and I felt like I just was in class a lot less (Interview 6, p. 5). In addition, the student described that the difference in course delivery impacted stress levels. Another big change was the speed at which some of the courses moved. And not only were we expected to know certain things for class, we had a quiz every class, which I found to be really like nerve-wracking. (Interview 6, p. 7) Another entry-level OT student reported a similar experience with the transition to graduate school, explaining little need to study during undergraduate education and, it wasnt until like grad school where I really had to study because everything was so new and some things didnt make sense um or we were just being tested a different way than before (Interview 4, p. 3). Several students reported feeling they should devote any free time to studying in the first semester of the entry-level OT graduate program. For one student, knowing subsequent coursework built on knowledge from the first semester intensified self-expectations for performance. STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE 97 I feel like I have to do like my absolute best with like all the assignments we have. Like I have to make sure I really read through everything, or Im not going to be able to, like, move on to the next topic that we do. (Interview 8, p. 5) The professional and academic standards of entry-level OT graduate programs created unease in students and contributed to students setting high expectations for themselves. Entrylevel OT students noted that they believed they needed to perform flawlessly with coursework during the first semester of the graduate program and that anything less than perfect resulted in feeling like a failure. One entry-level OT graduate student described this fear as follows, Sometimes I was afraid of being the one that did the worst on something. I mean, there's always going to be that person in the class, and you kind of really never want to be that person" (Interview 11, p. 10). Another entry-level OT graduate student reported, I definitely think, at times, I felt anxious about that, like achieving those grades. I think it like it pushed me to work a little harder. There were definitely times I felt anxious (Interview 20, p. 8). The academic standards of programs also contributed to diminished occupational balance during the first semester of entry-level OT graduate school. Several entry-level OT graduate students described placing high expectations on themselves for academic success. One entry-level OT student reported high self-expectations throughout life that intensified as the result of the academic requirements of the graduate program. I think some of it is just how I've always grown up. Um and just like part of my own like psychology. I just I placed expectations on myself and probably other people too. But I think our program also places like a really high like standard for us. I think that it's just something [name of University] has. So I think some of his school some of its just my own like personality. (Interview 4, p. 6) STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE 98 The entry-level OT graduate student reported that even with the high personal standards, the student did not complete all academic tasks during the first semester. The student reported feeling angry and anxious about the unfinished work. If I don't get done, then I feel overwhelmed, or a lot of the times Ill be mad at myself if I didnt like meet the high expectations I put on myself" (Interview 4, p. 6). Another entry-level graduate student expressed a high level of stress at first in reaction to the requirements of the OT program with regards to the minimum grade point average along with the difficulty of classes. The student explained, In my program, like a 79.5 if you get that or lower on an assignment, you have to redo it, whereas in like college in undergrad, even if you got a 70 that still was passing. So I think it just added a little bit of anxiety to me, that like I wanted to make sure I did my absolute best on everything. (Interview 6, p. 9) The uncertainty that accompanied the transition to graduate school, combined with the minimum grade point average requirement, created an occupational balance disruption for one entry-level OT student. The student explained the feeling as follows, Our first semester is your first semester of grad school. Its stressful, and you just cannot find time to fit all the readings and all the assignments in. You dont know whats going on half the time, and youre just scared that youre going to fail out of the program. (Interview 7, p. 6) Another entry-level OT graduate student devoted more time to academics during the first semester because friendships had not yet formed. The student was learning the nuances of the entry-level graduate program and did not have acquaintances to fill free time, so the student focused on schoolwork to satisfy engagement needs. STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE 99 I hadnt like found my friend group. And so I think like in order to like compensate for that, like, not knowing where your place is, a lot of students will just like do [school] work all the time. (Interview 16, p. 11) In addition to the pressure entry-level OT students perceived from the increased course load and high professional and academic standards of graduate school, listening as peers discussed their study habits created feelings of self-doubt and caused a disruption to occupational balance. Entry-level OT graduate students questioned their methods of studying when they discovered peers studied longer or reviewed extra material before exams. One student explained, So there's a lot of pressure to be like, well you know [someone else] put in five hours to study for this exam, but I reviewed it in 20 minutes, and I feel confident about it, like does that mean I need to put in another four and a half hours to be at the same level? (Interview 22, p. 11) Another entry-level OT graduate student explained that performance on an examination was stressful compared to that of peers. The student indicated this information added to the pressure to achieve As in graduate school, and created an occupational balance disruption. The assignments [in the learning management system] will have a little bar that tells you this is what the best grade in the class was, and here's what the worst grade in the class was, and here's the average, and here's you. And, like, I always find myself looking at it, which is probably a terrible habit, but I do anyways. You know, so yeah, I think I do set high expectations. (Interview 24, p. 13) The added dimension of professional behavior expectations in the graduate program increased the pressure to perform at a higher level than in undergraduate studies and interfered with another entry-level OT students occupational balance. STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE 100 And then you also needed to make sure you're having professional behaviors. I think that also scared me, like knowing that I needed to make sure that I looked like the part to come to class and stuff. Um, because like I didn't have to do that in undergrad. I could just kind of show up looking like whatever, um, and so that was definitely a big change for me. (Interview 6, p. 7) Some entry-level OT students were challenged to adapt to the structure of the graduate program and the mental flexibility the curriculum required of them. For example, one student disliked the rigidity of the graduate course schedule. Instead of registering for courses that fit into life, life had to fit around a dictated course schedule. The lack of control over the schedule created a disruption to the students occupational balance. Your schedule is set. Sometimes you have like an hour or so in between class when you can get something done. But otherwise, I feel like you're pretty much stocked with classes and you figure out when to do your homework or studying around that. (Interview 12, p. 4) One entry-level OT student described frustration with unplanned class obligations that arose during graduate school. In addition, the student explained the lack of advanced communication about changes created difficulty with planning and led to a disruption in occupational balance. There are a lot more unexpected class obligations. Maybe it's specifically, the way that this programs setup, but they don't always tell you about all of the fieldwork requirements that are needed at the beginning of the semester. And so sometimes things pop up. (Interview 17, p. 9) STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE 101 In contrast to most OT students, one entry-level student reported occupational balance improved at the beginning of graduate school. Before graduate school, living at home with an elderly grandparent, combined with assisting the family in running a business, afforded little private time. Being away from family in the entry-level graduate program allowed for concentration on personal needs and engagement in desired activities. At home I feel like its a lot harder because theres so much to do at home. I feel like I have a lot more free time in the grad school. Its easier for me to make time for myself because its just me to focus on. But when Im at home, its like I had to help my mom. My grandpa lives with us, my dad and everyone too. And I have to watch the business too that we have. (Interview 15, p. 3) Being in the Middle of the OT Graduate Program Led to Improved Occupational Balance. Entry-level OT students described feeling more comfortable with their study methods and organizational skills after successful completion of the first semester of graduate school. They also developed confidence as students and relaxed the extreme expectations they set during the first semester. In addition, one entry-level OT graduate student recognized the importance of learning to adapt organizational methods of managing coursework to course schedules to enhance feeling prepared throughout the semester. Every semester you kind of start out a little bit unorganized and then learn how to organize and fit in the balance. I reassess every single semester because there are schedule changes, and it was definitely harder before I knew every professor, because there are definitely like differences in how you're going to do assignments and what you're going to be doing, and the expectations. (Interview 11, p. 14) STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE 102 Another entry-level OT graduate student also reported increased competence with organization of time and integration of activities outside of academics. The student explained, Beginning of second semester, I kind of got my bearings with how grad school worked. And so then I would, while looking at my school calendar, plan things to do with my friends. So knowing I don't have a have an exam this upcoming week, but I have one next week. So like let's go out to dinner with my friends and hang out with them the weekend I don't have an exam. (Interview 9, p. 7) Similarly, a third entry-level OT graduate student reported relaxed personal expectations of working on academic assignments at all times outside of class. The student also found the chosen method of organization assisted with this process of occupational balance. First semester [I] would have been like, when are you gonna get this done? How are you going to get this done? And you're gonna have to stay up all night tonight to get it done, kind of thing. Now, I would be like, eh, you can find time tomorrow to do it. So I've definitely become more lax, but I've also become more organized in a sense. (Interview 12, p. 10) The entry-level student reported decreased expectations for perfection contributed to feelings of success in the OT graduate program. I think that first semester, I was very in like hyper-focus, like all or nothing mode, like this has to get done. This has to be perfect. I was just like everything has to be done almost perfectly in order to make it out of this alive. (Interview 12, p. 11) Familiarity with course instructors and how to approach them also helped decrease anxiety. The entry-level OT graduate student went on to explain, Comfort with the professors is there, yes, where I feel more comfortable like asking them, hey, we didn't talk about this STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE 103 assignment now can you explain it to me or send out a broader email to class (Interview 12, p. 12)? Another entry-level OT graduate student identified understanding a professors teaching style and preferences for completion of assignments positively contributed to occupational balance. I think that you learn how a professors style is as you go, and that changes how you're going to do certain assignments and the way you're going to write things, so I think [it] definitely was harder to adjust whenever I didn't know all the professors. (Interview 11, p. 14) One entry-level OT student perceived increased confidence in later semesters of the graduate program due to improved organization and prioritization of academic work. These factors combined with improved efficiency with completing the work contributed to a healthier occupational balance. The student explained, I feel like I have a better balance now (3rd semester), and with me being better at scheduling things and setting priorities. Its just like less work, and Im more confident in myself (Interview 2, p. 3). Improved occupational balance occurred for one entry-level OT graduate when obtaining the ability to retain foundational content, which allowed easier application to subsequent coursework. The student also developed more efficient methods for studying after the first semester. I think in the first semester of grad school I was taking a lot longer to read more thoroughly I would take really detailed notes. As I got further along in the program, I realized I don't need to take all those notes because I understand what is going on. It's not all new, its kind of more applying. (Interview 4, p. 2) STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE 104 Connecting course material to OT practice was more stimulating than learning basic, introductory information for the entry-level graduate student. In spring [second] semester, I think it was less of just the basic foundations of occupational therapy, and more applying it, so it felt like it was more fun, like learning that kind of stuff. So I think that kind of helped, it was more interesting. (Interview 4, p. 8) As time went on, another entry-level graduate student indicated familiarity with the language of OT and retention of the information from previous semesters. As a result, the student spent less time looking up terms and definitions in subsequent semesters of the graduate program. Sometimes it's not in-depth reading, especially like the further you go because it's like stuff you've already kind of learned about, so it's not like you need to read every single word on the page; you can kind of like skim. (Interview 7, p. 7) Being at the End of the OT Graduate Program Led to Improved Occupational Balance. Entry-level OT students often perceived the greatest occupational balance during the last semesters of didactic coursework in graduate school. One student stated, I definitely think that now I can organize my time and I'm able to do things and like balance my life (Interview 6, p. 7). The entry-level OT graduate student explained that the move from exam-based assessments in the early semesters to project-based assessments in later semesters improved occupational balance. The student finished assignments at convenient times, working around the students schedule. Additionally, the student reported the inability to identify a precise moment when adequate preparation for an examination occurred, whereas assignments seemed to have a definitive endpoint. STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE 105 As my program has progressed, it's [balance] shifted. The first two semesters were heavily exam-based. And then as the program has progressed, it's [assessment] moved less from exams and more towards assignments. That's like less stressful because I know when an assignments due, and I know that I if I have a big event coming up, I can work on that assignment a week ahead of time. Whereas an exam, um, even if I studied a week ago, if I had an event the day before the exam, I would still be like freaking out that I should have been like studying stuff last minute. (Interview 6, p. 6) Another entry-level OT graduate student reported a similar feeling. I wasn't as nervous to start this [third] semester as I was like even spring [second]. I'm definitely more comfortable. I know what to expect (Interview 5, p. 8). The entry-level OT graduate student further explained, It [balance] gets better as the semesters go on. Everything just clicks a lot more like especially now that we're in our third semester (Interview 5, p. 12). One entry-level student perceived occupational balance during the fourth and final semester in the OT graduate program. The student attributed the feeling of occupational balance to enrollment in fewer credit hours than in the first semester. Additionally, fewer hours in class equated to a feeling of more free time, although, in reality, the decreased time in class was only two hours per day. The student learned to value extra time during the COVID-19 pandemic when without a commute to school and realized the difference the extra time made in the day. The student explained, I feel like it [life] is [balanced] for sure. And I think it's because we have less credits this semester than we did first semester. And so I know that I don't have to stay in class for three hours a day, twice a week. Like I have, it's normally like two hours of class. And so that kind of allows me to have two more hours in my day, and you don't realize how STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE 106 much two hours is until I didn't have to drive it come COVID because I was like, I have all the time in the world. (Interview 9, p. 13) Another entry-level OT student explained the organization methods that evolved throughout the time in graduate school. For example, moving online during the COVID-19 pandemic helped students develop a more relaxed approach to planning the day. When I first came into grad school, I planned everything by the hour. I was very like, I need to know what Im doing at all times. I think that was because we were on campus, and it was so structured that like I needed that. Since going online, Ive changed completely, like the way that I plan out my day. (Interview 25, p. 6) For one entry-level OT student, the success experienced in previous semesters led to improved belief that continuing to do well in the graduate program was possible. I have more trust in myself. Um that I've that I'm able to do what like, I need to do and what's expected of me because I've done it throughout this whole program (Interview 2, p. 4). Another entry-level graduate student emphasized that application of skills beyond the didactic classroom reinforced the process to become an occupational therapist. This realization improved the students selfconfidence. The student stated, I think we felt smarter, because now we know things. And we've seen actual patients, a little bit We're applying what we're learning so I think it made it seem a little easier (Interview 4, p. 8). One entry-level OT student perceived the need to achieve a high grade point average from the start of the graduate program. This opinion resulted from past experiences of competing with others for high grades. However, by the fourth semester, the student expressed an understanding that to become an occupational therapist only required successful completion of the coursework, fieldwork, and certification exam regardless of the grades earned. STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE 107 When you realize that like your GPA in grad school like isn't a thing. And that it's whether you graduate, pass your fieldwork, pass your board exams. You get the same letters at the end of your name, whether you got a 4.0 or 3.8. And so I think that's where my mindset changed. (Interview 9, p. 11) Similarly, another entry-level OT graduate student explained reconceptualizing the fear of failure over time. The student learned that poor performance did not equate to failure but simply indicated that expectations were not met. I definitely think like coming into the program that like our whole cohort, everyone was like they needed to be perfect. And I feel like everyone was working [at their academics], like stressing so hard. They're like, oh no, like I missed this, I failed, you know. And it's like you didn't really fail; you just didn't do as good as you wanted to. (Interview 15, p. 6) Another entry-level OT student reported time spent in a level I fieldwork setting during the last semester of the graduate program improved occupational balance. The student explained, Right now, I feel like my life is probably the most balanced it's been since being in grad school. I've really enjoyed being able to go out on fieldwork. I think that honestly, that has probably brought me the most balance in my life because I'm able to see what all this is working towards, and like that, I love what I've been doing. (Interview 10, p. 11) The entry-level OT graduate student further explained that fieldwork clarified the rationale behind coursework. The fieldwork helped the student to visualize the future and gain the importance of integrating occupational balance into life as a student. This fall has just been like a weight was lifted off my shoulders like because I've been able to see it and do it [OT practice during fieldwork]. And so I think like I'm able to see STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE 108 the value of the school and the classroom and like spending the time to do the assignments, but also spending the time to like take care of myself. And I found a much greater balance right now than I like had had the past like three semesters. (Interview 10, p. 11) The confidence gained from level I fieldwork experiences improved occupational balance for one entry-level OT graduate student. The student reported feeling surprised by all they knew when participating in fieldwork. This recognition helped the student to stop worrying about coursework. The student realized understanding the material from the coursework would result in progression throughout the program. Going in [to level I fieldwork] and kind of realizing how much I actually do know. And like I felt confident in myself. So that's definitely like a booster of like like, I know what I'm doing. Like, I'm good. I don't need to stress myself out. I'll get my work done. So content-wise I'm not worried because of like seeing my grades, and like being in fieldwork, and kind of like having that realization. (Interview 9, p.13) Other students reported feeling the most occupational balance near the end of the entrylevel OT graduate program. One student stated, Honestly like now, as I prepare to like take boards and do [level II] fieldwork, for the most part, Id say I feel like Im in good balance" (Interview 18, p. 13). Another entry-level OT student attributed improved occupational balance to comfort with peers, professors, and knowledge of the profession toward the end of the graduate program. Improved efficiency with studying also contributed to the sense of occupational balance. I think just being more comfortable with each other and with our professors. I think we felt smarter because we now, we know things. Also I can do a lot more in a shorter STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE 109 amount of time versus reading a few chapters, and that taking me like a week to read the chapters, take notes, and understand it. (Interview 4, p. 8) In the fourth and final semester of didactic coursework, one entry-level OT graduate student achieved the ability to take personal time without feeling coursework was jeopardized. The student explained relaxing and enjoying free time would not have been possible in previous semesters. And so that's [relaxing] something I can finally do now [final semester]. If I want to watch a Netflix episode, or if I want to go to the dog park, I can turn my brain off for 30 to 45 minutes and actually enjoy my self-care. (Interview 7, p. 4). Similarly, one entry-level OT graduate student indicated an ability to relax and enjoy the educational experience for the first time since the start of the program by the last semester of coursework before level II fieldwork. The student stated, Im allowing myself to be comfortable in the situation Im in (Interview 1, p. 4). Some entry-level OT graduate students reported feeling unproductive or having low selfconfidence proceeding into the final semester of coursework. Although one student reported being more relaxed in the last semester, the student also experienced feelings of forgetting to do something. The student stated, I guess it's kind of like PTSD from previous semesters like something's due, something has to be done. And it's weird to not have that. So, I guess that's why I feel a little bit unproductive" (Interview 1, p. 10). The beginning of the final semester brought feelings of uneasiness for one entry-level OT graduate student. The student attributed the feelings to the unknown circumstances of the future. The student explained, So like right now, [self-confidence] is a little low just because like it's a new semester. We're doing new stuff right now, and I don't have feedback on anything yet. And I'm STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE 110 looking ahead at our objectives for level I fieldwork this semester and then like our level twos and think, wow, I have to actually do real work. Not that stuff wasnt real work before, but this is like real OT work, and it feels overwhelming. (Interview 4, p. 10) Occupational Balance Fluctuates From the Beginning to the End of a Semester. Entry-level OT graduate students reported occupational balance changed from the start to the end of a semester. Some students perceived improved occupational balance at the beginning of the semester. In addition to low academic demands at the initiation of a semester, the break between semesters contributed to feelings of occupational balance for one student. The student explained, In the beginning of the semester, I feel like Im on top of things. Ive had a break leading up to it, be it summer or winter break. But its always lighter in the beginning of the semester as well. (Interview 19, p. 13) One entry-level OT graduate student described organizing time during the first weeks of a semester. First, the student analyzed courses and determined which would be more difficult based on the content. Then the student estimated the time necessary to complete the associated work for each course. Lastly, the student planned time to study accordingly, allotting more time for the courses perceived to be more difficult. Getting a feel for the classes the first couple weeks for me, it's what's harder for me to understand? Like what class is going to be more difficult for me to retain the information? And then I would either spend more time on that class, because I knew that the other class is easier to understand the material. And so then I'd prioritize my time that I do my homework with the amount of work that comes with each class, and how hard the material is for me to like understand and retain. (Interview 9, p. 8) STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE 111 For other entry-level OT graduate students, the beginning of a semester created anxiety. Looking ahead at the assignments and the amount of work required for one course was daunting, leaving one student with feelings of insecurity about the ability to complete it. I just get super, super overwhelmedgoing over it all at once. It just breaks my spirit because you just have a lot of moments where youre like, Im not going to be able to get all this done (Interview 21, p. 9). Another entry-level OT graduate student reported improved occupational balance after the first weeks of a semester once course expectations were understood. The student stated, Being in the middle of a semester feels good to me. Like, I know whats coming up. I know what the professor expects, I know about when to expect grades back (Interview 12, p. 12). In contrast, another entry-level OT graduate student perceived less occupational balance once midterm exams passed as the result of a heavier academic workload at the end of the semester. I would say once midterms roll around is when I start feeling like I do not have enough hours in the day to get everything done that I need to. Um, yeah, so I think it definitely varies from week to week, and the point in the semester as well. (Interview 19, p. 13) One entry-level OT graduate student explained confidence improved with progression through a semester, which gradually decreased anxiety. As the semester kind of progresses, I definitely start to feel more confident, and then I can look at what's required in that, you know assignment, or what I do know for the assignment right now, and just kind of see how much I've almost like grown in that semester already. So I feel less anxious as a semester goes on for sure. (Interview 13, p. 16) STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE 112 Similarly, another entry-level OT graduate student also described improved feelings of self- assurance at the midpoint of a semester. The student specified comfort with the familiarity of the course content and expectations along with the rate of instructor feedback. The student explained, being in the middle of a semester feels good to me. Like, I know whats coming up. I know what the professor expects. I know about when to expect grades back (Interview 12, p. 12). One entry-level OT graduate student described fluctuations in perceived occupational balance throughout a semester. The student explained occupational balance was dependent on the amount and quality of academic work completed. Additionally, the student identified procrastination with completion of assignments led to feelings of failure. The student stated, Its kind of a process. Some days yeah, you feel really confident. Youre productive and you know are doing really good, and then other days you feel like youre overwhelmed or things are coming up and youve procrastinated on them and youre not feeling very successful. Its just, its a process. Maybe waves of like the ups and downs its more steady versus big high ups and way low downs. (Interview 4, p. 11) Summary of Results The researcher discovered entry-level OT graduate students progressed through three phases of occupational balance during their time in the program: occupational balance, balance disruptions, and return to occupational balance (See Figure 1). Once an entry-level OT graduate student experienced a disruption to occupational balance, the student needed to acknowledge the disruption and experience a desire to return to balance. For instance, some students actively made the decision to postpone occupational balance as they viewed the disruption to be a temporary aspect of being in graduate school. The desire to regain occupational balance led most STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE 113 of the students to implement a strategy to achieve balance. Examples of strategies students integrated to achieve occupational balance included development of an individualized plan to organize school work, shared experiences with cohort peers, and scheduled time for self-care. At different points throughout the graduate program, entry-level OT students encountered people, policies, changes in roles and expectations, or events that led to a disruption in occupational balance. Student values and previous life experiences influenced how the students viewed a situation and formulated a reaction to manage the occupational balance disruption. Students altered the strategies they integrated for managing occupational balance disruptions during different periods of the entry-level OT graduate program. During the initial transition to graduate school, entry-level OT students experimented with more strategies to mitigate the disruption to occupational balance than they did in subsequent semesters. As the graduate program progressed, entry-level OT students developed knowledge of specific strategies to successfully manage a disruption to occupational balance, which enabled the students to transition back to occupational balance quicker than they did in the first semester. One disruption that was an exception to this typical change process was the challenges to occupational balance experienced from the COVID-19 pandemic. The disruption from COVID-19 was characterized by a slow recovery of occupational balance. By the end of the entry-level graduate program, most OT students reported achieving a state of occupational balance. They learned to be proactive in the use of strategies to improve occupational balance and therefore experienced fewer disruptions to occupational balance. Discussion The purpose of this study was to examine how entry-level OT students incorporated strategies to manage occupational balance in their role as a graduate student. Data collected STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE 114 through interviews with 26 students enrolled in entry-level OT graduate programs were gathered and analyzed to inductively develop a theoretical explanation of the strategies that students used to achieve occupational balance. Additionally, the purpose was to determine how these approaches for returning to occupational balance changed when students experienced an alteration to life during the entry-level graduate program. The researcher also gleaned insight into the strategies students used to manage the student role during different semesters of the OT program. Table 3 lists the propositional statements developed during data analysis. These statements explain the relationships among the data categories of the researchers induced theory of occupational balance. The researcher was not able to locate any other study employing the grounded theory methodology to provide a theoretical explanation of the occupational balance of entry-level OT graduate students. Researchers used various terms to describe the concept of balance, including occupational balance, life balance, and work-life balance, often interchanging the terms. Comparing the findings of this study to other studies proved difficult due to the inconsistent use of terms. Regardless, propositions that appear unique to this study include: Other people in a students life can identify disruptions to the occupational balance of students Experiencing the COVID-19 pandemic created traumatic disruptions that significantly challenged occupational balance and required altered strategies to manage Reflecting on past entry-level OT graduate program experiences helped students manage disruptions to occupational balance The findings from this study have implications for OT students and educators. A specific focus on the phases of occupational balance experienced, the contexts that influence occupational STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE 115 balance, and the strategies integrated to overcome a disruption to occupational balance throughout an OT program may benefit students and educators. How Do Entry-Level Students in OT Incorporate Strategies to Manage Occupational Balance in Their Role as a Student in the Graduate Program? Entry-level OT graduate students interviewed for this study expressed various meanings they attributed to occupational balance and its importance in their lives. The life experiences brought into the entry-level OT graduate program prompted how students viewed occupational balance. Matuska and Christiansens (2008) model of lifestyle balance supports the findings in this study that past events influence current views of occupational balance. Although they did not discuss occupational balance specifically, the authors suggested that lifestyle balance exists as a range of occupations a person engages in throughout life, expecting variability in the degrees of satisfaction from the experiences. Similarly, the personal values the entry-level OT graduate students expressed in the present study contributed to maintaining a state of occupational balance. Entry-level OT graduate students who had the value of balance instilled in them during the formative years demonstrated a desire to remain occupationally balanced. Eklund et al. (2017) also discovered a relationship between engaging in occupations that support personal values and reported occupational balance. Eklund et al. (2017) provided evidence of the connection among a persons inherent personal values, choice of occupations, and sense of occupational balance. Matuska and Christiansen (2008) also discussed the importance of engaging in valued occupations, explaining that they contribute to a persons optimistic view of self and perceived lifestyle balance. Wagman et al. (2021) added that occupational balance is a subjective term and can vary significantly among people depending on the personal meanings a person ascribes to the term. STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE 116 All of the entry-level OT graduate students interviewed for this study described a disruption to occupational balance during the program. Several OT students expressed an understanding that the situation was temporary and was an expected part of the graduate program experience. The OT students perceived their balance would return to a more acceptable state upon graduating and embarking on a career as an occupational therapist. They expressed the belief that the short-term disruption was tolerable. Malek-Ismail and Krajnik (2018) conducted a study of MOT students during the first semester of the graduate program and reported students were willing to surrender some of their occupational balance for the short period of graduate school. Matuska and Christiansen (2008) suggested that people who are satisfied with how they use their time and are working toward important personal goals may perceive they are balanced even when devoting a disproportionate amount of time to one occupation. Similarly, Yazdani et al. (2018) emphasized that occupational balance is a constantly changing process and is dependent upon several factors, including stage of life (p. 295). Entry-level OT graduate students may perceive they are occupationally balanced even when managing rigorous academic workloads because they expect to spend the majority of time on schoolwork at this stage of life. Malek-Ismail and Krajnik (2018) reported findings that OT students in their study conveyed the ability to identify when the anxiety of the graduate program interfered with personal relationships and academic performance. Most entry-level OT graduate students interviewed for the present study stated they recognized when they were experiencing a disruption to occupational balance. This recognition enabled students in the present study to implement one or more strategies to overcome the disruption and return to a state of occupational balance. Similarly, Van Veld et al. (2018) conducted a study with students in the first year of a doctor of physical therapy (DPT) program. The authors discovered that students who were STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE 117 conscious of negative feelings about the graduate program could think intentionally about the positive aspects of their experience. Changing their thought process helped the students proactively modify their current circumstances to promote a positive outlook. A unique finding of the present study was that occasionally an OT student could not identify a disruption to occupational balance and required input from family, friends, or faculty to realize a change was necessary. Entry-level OT graduate students in the present study who experienced a disruption to occupational balance implemented various strategies to return to a state of occupational balance. The data analysis of the strategies students utilized resulted in five categories and are used to organize the discussion: adapting methods to effectively and efficiently learn using support systems participating in multiple occupational roles making time for self-care knowing when to seek professional assistance Entry-level OT graduate students implemented distinctive strategies during various stages of the program depending on the circumstance causing the disruption. Students utilized a trial-and-error approach to select a strategy at the start of the program. Students were able to reflect on past experiences and incorporate a strategy that was successful previously as they progressed through the program. Students in OT Adapted Methods for Learning to Improve Their Effectiveness and Efficiency Students interviewed for this study discussed the importance of developing a system to organize coursework in the entry-level OT graduate program that fit their unique style and STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE 118 habits. They explained that trying to adopt another students method of organizing school work was not helpful, and often, the method used in undergraduate education also was inadequate. Coursework organization, including any preparatory work, assignment due dates, and test dates, helped students distribute time among their courses. A system of organization also ensured students allotted sufficient time to lengthier assignments. For some students, a good method of organizing also helped students integrate socialization and self-care into their schedules without feeling they were subtracting from their academic work. Malek-Ismail and Krajniks (2018) findings supported the concept of developing an individualized organization system. The authors discovered that entry-level OT graduate students changed the way they organized their time from general to more detailed schedules to improve occupational balance (Malek-Ismail & Krajnik, 2018). Likewise, Matuska and Christiansen (2008), in their model of lifestyle balance, discussed how chosen occupations need to help a person to organize their time and energy in ways that enable them to meet important personal goals and renewal (p. 11). The researcher of the present study deduced that when OT students were able to organize time to increase their graduate school success, they reported improved occupational balance. Students in the present study also expressed the need to adapt their study habits in entrylevel OT graduate school. For example, several students explained memorizing material led to success in their undergraduate education but was not adequate for graduate school. Malek-Ismail and Krajnik (2018) reported similar findings in their study. Entry-level OT graduate students reported poor study practices in their undergraduate education because recall of information was sufficient for a test (Malek-Ismail & Krajnik, 2018). STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE 119 Students in the present study identified the need to learn the material to apply it in current and future classes in the entry-level OT graduate program and later as they transitioned to practice. Determining how to learn and retain material was an arduous process that OT students navigated throughout the first semesters of graduate school. Once they established a method that worked, they could apply this approach across their graduate courses. Although learning new methods for studying was stressful, students saw the value in retaining information to enhance their future careers as occupational therapists. In addition, entry-level OT graduate students perceived the material as more relevant than their undergraduate education. Malek-Ismail and Krajnik (2018) found that entry-level OT graduate students demonstrated intrinsic motivation and perceived [graduate] school as valuable and worth their time and effort (p. 14). In addition, Matuska and Christensen (2008), in their model of lifestyle balance, suggested a persons occupations should lead to feelings of competence. In the present study, entry-level OT graduate students who could integrate effective study methods to learn the academic concepts experienced success and increased confidence. Using Support Systems Like Govender et al. (2015), entry-level OT graduate students in the present study depended on the support of other people in their lives when they experienced an occupational balance disruption. Some students relied on peers intrinsic to and extrinsic to the entry-level OT graduate program to assist with difficult situations (Tompkins et al., 2016). Other students discussed their experiences of balance disruptions with family, supervisors, or faculty members. Van Veld et al. (2018) noted that DPT students in the first year of a doctor of physical therapy program commonly sought family and friends to ask advice or express frustrations with the STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE 120 program (Van Veld et al., 2018). Hearing another persons perspective on a situation often helped the DPT students shift their mindset toward a more positive outlook. Several entry-level OT students interviewed for this study discussed the importance of parental support during their time in graduate school. Similarly, Tompkins et al. (2016) reported students perceived family as being one of the strongest supports for graduate school. MalekIsmail and Krajnik (2018) also reported entry-level OT students in their study perceived family as a vital support system in graduate school. Parents of students included in the present study encouraged and demonstrated an unrelenting belief in their child that increased self-confidence to continue in the program, even when students believed they could not succeed. When entrylevel OT graduate students in the present study experienced an occupational balance disruption resulting from an unexpected grade, family were nonjudgmental and provided a different perspective to assist with understanding the situation. In the present study, students also explained their family emphasized self-care and helped them realize the need to engage in activities outside of academics. Entry-level OT graduate students interviewed for this study expressed the importance of relationships with faculty members. Some OT students perceived faculty to be intimidating at first, but most stated faculty assisted students with the transition to graduate school. Connecting with a faculty advisor was especially important to students who did not know anyone else in their cohort. Van Veld et al. (2018) noted first-year entry-level DPT students reported seeking faculty support more in the second and third semesters of the program compared to the first semester. Malek-Ismail and Krajnik (2018) also described the benefits of faculty assistance with the transition to entry-level OT graduate school. Students in the first semester of an MOT program STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE 121 perceived faculty were supportive and genuinely concerned about their well-being (Malek-Ismail & Krajnik, 2018). Entry-level OT graduate students in the present study expressed a sense of reassurance with the knowledge that faculty were available to discuss course content and assignments. Consultation with faculty provided students with confidence as they navigated unfamiliar coursework. Schmidt and Hansson (2018) conducted a literature review with discovery that faculty support positively influenced a students commitment to the academic work, consequently benefiting the students outlook. Rummell (2015) examined students in a graduate psychology program and found students who perceived a greater connection and mentorship with faculty had increased positive perceptions of the program (p. 394). One entry-level OT graduate student in the present study observed a faculty member model occupational balance, which provided the student with the confidence to set boundaries and practice self-care. Tompkins et al. (2016) concluded that a method to improve graduate student appreciation for self-care is to model the practices for them. In another study, first-semester entry-level OT graduate students observed an incongruence between self-care teachings in their program and the actual practice among the faculty (Malek-Ismail & Krajnik, 2018). Some entry-level OT graduate students in the present study perceived a lack of support from faculty that contributed to occupational balance disruptions. Students reported faculty seemed unaware of the stress students experienced as they entered entry-level graduate school. Faculty often compounded an occupational balance disruption with overwhelming amounts of information. Faculty often seemed narrowly focused on the course they were teaching instead of considering examination and project due dates that may coincide with those of other courses. This finding was similar to that of another study that explored the perceptions of first-semester STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE 122 entry-level MOT students. The MOT students indicated they believed faculty intentionally scheduled assignments to be due simultaneously (Malek-Ismail & Krajnik, 2018). One student in Malek-Ismail and Krajniks (2018) study explained faculty listened to mental health concerns of students but did not offer any assistance for success. The results of a study conducted with students in a graduate psychology program also supported this finding (Rummell, 2015). Forty percent of students surveyed for the study reported faculty in their program did not respect their opinion. Rummell (2015) also found students desired an improved relationship with faculty in their graduate program. In the present study, other entry-level OT graduate students reported faculty frequently do not honor their posted office hours, leaving students feeling overlooked. In the present study, students in entry-level OT graduate programs described peer relationships as crucial to survival in the program. Peers understood the demands of the graduate program and could provide encouragement and suggestions relevant to the circumstances. Eklund et al. (2017) supported this finding that supportive social networks can improve participation in occupations and contentment with occupational balance. Malek-Ismail and Krajnik (2018) also noted entry-level OT cohort peers to be the primary support for firstsemester MOT students as they shared the same experiences and could relate to student emotions. Govender et al. (2015) reported one of the most common coping mechanisms OT graduate students used to manage stress was social support. In the present study, socialization with peers outside of the entry-level OT graduate program was important. Peers outside of the graduate program provided a distraction from academics that helped students engage in self-care practices. Tompkins et al. (2016) supported the importance of peers outside of the graduate program. They ascertained that graduate students STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE 123 perceived the support they received from cohort peers and those outside of their program as equally important in their success (Tompkins et al., 2016). At times, entry-level OT graduate students in the present study reported that their cohort peers contributed to an occupational balance disruption when they voiced complaints about the program or projected their stress onto other students. Malek-Ismail and Krajnik (2018) also reported some entry-level OT graduate students expressed beliefs that cohort peers contributed to increased stress, although this finding was not a significant theme that emerged from their study. They explained some students imagined excessive worrying over class work was contagious (Malek-Ismail & Krajnik, 2018, p. 13). These authors (Malek-Ismail & Krajnik, 2018) described group work as distracting to students, compelling some to separate from their peers and select solo work instead. Similarly, Schmidt and Hansson (2018) performed a literature review to examine doctoral students well-being and discovered students could view peers as a support as well as an additional stressor. Participating in Multiple Occupational Roles Students in entry-level OT graduate programs interviewed for the present study discussed engagement in multiple occupational roles and the meaning to their occupational balance. Students expressed the belief that engagement in more than one role contributed to identity and helped them trust their identity was more than being a graduate student. Following a content analysis of existing literature completed in 2017, researchers identified a theme of occupational balance as having a mix of occupations (Eklund et al., 2017, p. 47), which demonstrates support for students to engage in more than one occupational role. STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE 124 Making Time for Self-Care Students in entry-level OT programs interviewed for the present study indicated that they gained an appreciation for self-care throughout their graduate program. Several reported ignoring personal needs during the first semester of the graduate program, and were often overwhelmed with the rigor and expectations of their program. Van Veld et al. (2018) reported a similar finding in students in an entry-level DPT graduate program during their first semester of graduate school. The DPT students reported that the time they spent in exercise decreased the first semester, stating they believed that all free time needed to be devoted to academics (Van Veld et al., 2018). Over time, entry-level OT graduate students in the present study learned the value of self-care, including leisure and socialization. They used personal time to cope with the stressors of graduate school. Van Veld et al.s (2018) finding supported the importance of student engagement in self-care. After the first semester, they reported that DPT students increased their engagement in exercise as a coping mechanism to mitigate the stress of graduate school. Schmidt and Hansson (2018) supported the importance of engaging in self-care practices during graduate school. They discovered that doctoral students engaged in exercise, yoga, and self-reflection as coping mechanisms for graduate school. In a model of lifestyle balance, Matuska and Christiansen (2008) stressed that a balanced lifestyle should include occupations that are healthful, meaningful, and sustainable (p. 11). Integrating self-care into life is beneficial to the physical and mental health of students. Cino (2016) reported that nursing students who made time for personal self-care had improved family relationships (p. 15). The findings of these studies support the addition of self-care promotion in graduate program curricula. STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE 125 A study investigating self-care practices among psychology graduate students indicated sleep hygiene decreased stress levels, but a relationship between engagement in exercise and lower stress was nonexistent (Myers et al., 2012). This finding contradicted the present study because entry-level OT graduate students specifically discussed finding time to exercise as a consistent form of self-care. Knowing When to Seek Professional Assistance Some of the students interviewed for the present study mentioned seeking professional assistance to manage anxiety during entry-level OT graduate school. They pursued counseling services indicating discussion of obstacles and concerns with an impartial third party was beneficial. Van Veld et al. (2018) noted that DPT students sought counseling services after the first semester of entry-level graduate school. In the present study, other students obtained medication to help manage panic attacks and anxiety. Other students in the present study required counseling and medication to successfully navigate the rigor of graduate school. What are the Differences in the Occupational Balance Strategies of Entry-Level OT Graduate Students Who Report High, Medium, and Low Occupational Balance? Entry-level OT graduate students completed the OBQ11 during the informed consent process (Hkansson et al., 2020; P. Wagman personal communication, May 11, 2020). During the interview process, 19 out of 22 students indicated they believed their life was occupationally balanced; however, scores on the OBQ11 varied. When the students completed the questionnaire, they answered 11 questions about current occupational balance. Some of the questions related to satisfaction with the variability of occupations and the amount of time spent in relaxation. The possibility exists that even though students spent a majority of their time on academic work and did not relax as much as they would like, the students still perceived STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE 126 occupational balance at this particular point in time when they completed the questionnaire. Anaby et al. (2010a) suggested occupational balance and occupational imbalance are not two opposing attributes, but are two distinct dimensions that can co-exist (p. 285). The researcher postulates from the results of the present study that student lives are dynamic and influenced by multiple contexts at any given point during the entry-level OT graduate program. The results led the researcher to determine that personal values, past experiences, program requirements, internal contexts, external contexts, and student support systems provide meaning to feelings of balance and underscore the importance of strategies students use to mitigate occupational balance disruptions. Myers et al. (2012) suggested that personality and beliefs about self-care practices influence self-care and stress levels. These dynamically changing variables are distinctive to the person, demonstrate the fluctuations in occupational balance, and contribute to difficulty measuring occupational balance (Myers et al., 2012). However, measuring occupational balance at specific points in time and considering simultaneous contextual factors may provide insights into the impact of current circumstances on perceived occupational balance (Myers et al., 2012). Similar to the present study, Malek-Ismail and Krajnik (2018) concluded that students move through periods of imbalance and balance as they transition from undergraduate to graduate education. However, Malek-Ismail and Krajnik (2018) did not quantify occupational balance using the OBQ or study students after the first semester of graduate school; therefore, comparing the present study to the results these authors found was not possible beyond the first semester. The researcher of the present study only discovered one study investigating the use of the OBQ11. The researchers in that study examined the construct validity of the OBQ11 (Hkansson STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE 127 et al., 2020). The researcher in the present study did not examine the quality of the instrument but categorized the participant responses into high, medium, and low categories to compare and contrast occupational balance strategies across the three groups. Additionally, other researchers used the original OBQ to examine persons from a more extensive age range (Hkansson et al., 2020; Wagman & Hkansson, 2014b; Yu et al., 2018) or with a specific diagnosis, such as rheumatoid arthritis (Wagman et al., 2020). Two exceptions were studies addressing the occupational balance in adults in Sweden (Wagman & Hkansson, 2014a) and health professionals in Sweden (Wagman et al., 2017). The authors did not find any significant differences among summed scores on the OBQ; however, Wagman and Hkansson (2014a) reported a significant positive correlation among three specific items on the OBQ and self-rated health and life satisfaction. These findings suggest that individual OBQ items may provide more useful information about managing occupational balance than the summed scores. What Happens to the Way Entry-Level OT Graduate Students Manage Occupational Balance When They Experience a Change in the Expectations of Their Student Role or Other Life Roles? Students in entry-level OT graduate programs interviewed for this study discussed several changes in their life roles that disrupted occupational balance. One of the changes was paid employment. Students secured a job for various reasons, including the necessity to afford living expenses. Backman (2004) suggested that occupational imbalance occurs when necessary and desired occupations intersect. These occupations can impede each other when an OT student does not allot enough time to entirely engage in one or both of them. If work interferes with the completion of academic work, a disruption to occupational balance may occur. STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE 128 Entry-level OT graduate students in the present study experienced other life roles that included planning for the birth of a child, caring for an ill family member, and assuming household responsibilities, all of which led to an occupational balance disruption. Yazdani et al. (2018) confirmed this finding by discussing potential causes of occupational balance disruptions, including role imbalance, responsibilities, and priorities at present (p. 293). These contextual factors diminish a persons control and may interfere with personal goals, disrupting occupational balance. Students in entry-level OT graduate programs interviewed for the present study indicated the COVID-19 pandemic was one of the major disruptions to occupational balance they experienced in school. Students experienced stress and anxiety when the COVID-19 pandemic began, similar to when they first transitioned to entry-level OT graduate school. Identifying an occupational balance disruption of equal or higher magnitude to the disruption that occurred during the initial transition to the entry-level graduate program was a unique finding to the present study. Previous authors did not discuss a major disruptive event like the COVID-19 pandemic for students in OT programs or in any other disciplines. Additionally, the researcher of the present study did not locate any studies investigating entry-level OT graduate student reactions to the COVID-19 pandemic. Students in the present study had to change their method of organization when the mode of delivery switched to virtual rather than in-person instruction. Students reported that they had to develop new study habits because their previous habits were no longer adequate. Mitschke et al. (2021) reported graduate students experienced personal challenges related to the COVID-19 pandemic, including higher levels of stress, feeling overwhelmed with responsibilities, and having difficulty concentrating on their classwork (p. 51). STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE 129 The unpredictability of changes when campuses closed and academic courses moved online was an overwhelming experience. Kee (2021) conducted a qualitative study to investigate the experiences of students in graduate programs during the COVID-19 pandemic. Kee (2021) reported students perceived a loss of control in their lives when governors across the country enacted stay-at-home orders. The author also noted that graduate students experienced heightened anxiety over the unpredictable nature of the move online (Kee, 2021). In addition, social isolation created a barrier to support systems, and many activities for self-care were no longer possible. Other authors also discovered that decreased interaction with others, including graduate program peers, created psychological disturbances for students (Varadarajan et al., 2021). Students in the present study enjoyed attending in-person classes as in-person attendance helped them focus on the course material and enabled the ability to distance themselves from the many distractions in their homes. As Kee (2021) reported, graduate students perceived face-toface courses helped them stay organized, promoted peer relationships, and improved course content discussions. Entry-level OT graduate students perceived their study habits and organization methods were no longer adequate, and planning was impossible due to the ongoing changes occurring in their academic lives when courses moved online. Several OT students expressed beliefs that a boundary between their academic and personal lives was nonexistent because their home became their classroom. Kee (2021) found graduate students believed the COVID-19 pandemic disrupted their work-life balance as they were using their homes for their personal and academic lives. In the present study, focusing on a lengthy online class or demonstrating the discipline to complete academics was difficult for some OT students. STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE 130 Similarly, Octaberlina and Muslimin (2020) reported students conveyed that the number of distractions in their homes was a barrier to online learning. Conversely, some entry-level OT graduate students in the present study reported improved occupational balance with the move to online learning. For example, several entrylevel OT graduate program students explained their commute was abolished. Students perceived they had more time to get homework completed because they did not have to engage in self-care routines to attend class in person. Varadarajan et al. (2021) also reported positive outcomes of the COVID-19 pandemic, including increased time for learning, self-care, time with family, and decreased time commuting to attend class. Students in the present study expressed the importance of personal reflection to assist in returning to occupational balance following a disruption. A finding unique to the present study was that students reflected on past experiences in the entry-level OT graduate program to help formulate appropriate responses to occupational balance disruptions. They also discussed changing their perspective away from seeking perfection and toward integrating personalized approaches to studying to improve performance in graduate school. Malek-Ismail and Krajnik (2018) stated entry-level OT graduate students demonstrated increased accountability for their actions by the end of the first semester of graduate school. Additionally, they explained that students realized they still could become an occupational therapist with less-than-perfect academic performance (Malek-Ismail & Krajnik, 2018). For Entry-Level Graduate Students in Different Semesters of the OT Program, How Do the Strategies for Managing the Student Role Change? Occupational therapy students interviewed for the present study experienced varying levels of occupational balance throughout their time in the entry-level graduate program. STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE 131 Students identified causes of occupational balance disruptions that included the start of the graduate program and the start of a new semester within the program. Personal responsibilities, comfort level with peers, and external circumstances influenced whether students experienced a disruption and the success with which they were able to integrate a strategy to return to a state of occupational balance. Occupational therapy students in the present study overwhelmingly described the first semester of the entry-level graduate program as the semester that caused the most occupational balance disruption. Students experienced new academic requirements and unfamiliar course structures and assessments in the first semester. Malek-Ismail and Krajnik (2018) confirmed that students reported a high level of life imbalance in the first semester of the OT graduate program (p. 8). Rummell (2015) also concluded students in graduate psychology programs experienced the heaviest academic workloads and the most stress in the earlier years of graduate school (p. 394). This finding contrasts with Govender et al. (2015), who discovered fourth-year OT graduate students reported the most stressors in the entry-level graduate program. In the present study, most of the OT students in the first semester managed disruptions initially through trial and error of various strategies they developed or other people suggested. Occupational therapy students in the first semester discussed spending increased time on academics, which translated to little time for self-care or leisure. They also perceived a lack of time to develop social connections, contributing to occupational balance disruptions. As entry-level OT graduate students in the present study learned to navigate graduate courses and developed relationships with peers and professors in later semesters, occupational balance disruptions lessened. Phillips (2010) supported this finding in a grounded theory study STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE 132 investigating the stressors of nurse anesthetists. The author found stress levels lessened and coping skills improved as students progressed through the graduate program (Phillips, 2010). In the present study, several entry-level OT graduate students described the beginning of a semester as disruptive due to exposure to new course content and new instructors. However, OT students became more comfortable with faculty and graduate program expectations as each semester progressed. Van Veld et al. (2018) discussed similar findings in their study. Students in a DPT program reported increased confidence in their ability to respond to stressful situations in the entry-level graduate program as they progressed through three consecutive semesters (Van Veld et al., 2018). Most entry-level OT graduate students in the present study perceived balanced lives by the end of the program. They reported increased time for socialization and self-care activities. Theory of Occupational Balance The researcher of the present study created a new theory of occupational balance for entry-level OT graduate students using a grounded theory approach. See Figure 1. The meaning of occupational balance is unique to each OT student based on personal values and life experiences. Occupational therapy students experienced micro and macro influences to occupational balance throughout their time in an entry-level graduate program. Whether a disruption occurs from these influences depends on the combination of various contextual factors the students may experience at the time of the occurrence. See Figure 2. Entry-level OT graduate students must identify their situation and its influence when occupational balance is disrupted. Students analyze situations either without help or with the assistance of others. Once the students are aware of the disruption in occupational balance, they must desire to return to a state of occupational balance and then consciously determine to do so. STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE 133 Recall that some students accepted occupational balance disruptions as acceptable because engagement in education was temporary. The return to occupational balance occurs through various strategies based upon the magnitude of the disruption and whether the students experienced something similar in the past. Finally, the students remain in a state of occupational balance until another disruption occurs as long as they continue implementing their chosen strategies. At that point, when another occupational balance disruption occurs that challenges the effectiveness of current strategies, the process of identifying the disruption, implementing new or modified strategies, and returning to occupational balance begins again. See Figure 1. The researcher did not find any other grounded theories in the literature of occupational balance in entry-level OT graduate students. A majority of the research on occupational balance focused on the concept of occupational balance (Westhorp, 2003) or on various definitions of occupational balance (Eklund et al., 2017; Yazdani et al., 2018). Other authors explored self-care practices graduate students used to assist in stress management (Myers et al., 2012) or described the role of coping mechanisms in altering stress levels in students enrolled in helping disciplines (Enns et al., 2018). However, the authors of these studies did not discuss occupational balance or life balance. There was one study where the authors investigated the occupational balance of entrylevel OT graduate students (Malek-Ismail & Krajnik, 2018). However, the authors interviewed students only in the first semester of an entry-level OT graduate program. They did not develop a theory of occupational balance, but their data analysis provided evidence that students experience different stages of occupational balance in the first semester of the graduate program (Malek-Ismail & Krajnik, 2018). STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE 134 Results of the present study advance the information from Malek-Ismail and Krajnik (2018) with the researcher able to identify specific strategies entry-level OT graduate students used to regain occupational balance. The researcher also was able to ascertain the role of faculty in the occupational balance of students. Furthermore, some students in the present study were unable to independently identify the need to make a change to return to occupational balance, a unique finding of this study. Another distinctive finding is that students who experienced a disruption to occupational balance may reflect on strategies used in the past to help them regain occupational balance. Lastly, the COVID-19 pandemic created an unexpected disruption such that most students described the resulting occupational balance disruption as difficult to manage. The information gleaned from students regarding the strategies to return to balance after a major disruptive event is also an original finding of this study. The researcher of the present study found that entry-level OT graduate students desired to engage in various occupations as a method to ascertain occupational balance. Additionally, participation in additional occupations outside of their student role promoted happiness and occupational balance. These findings align with Westhorps (2003) concept of occupational balance that people engage in multiple occupations to promote health and well-being (p. 103). Students in the present study conveyed the importance of determining the occupations in which they engaged to improve occupational balance. Westhorp (2003) also discussed the value of people controlling how to divide their time among occupations. Westhorp (2003) concluded people needed to engage in occupations that involve mental, physical, social, emotional, and spiritual components. In contrast, entry-level OT graduate students in the present study did not discuss spirituality specifically as it relates to occupational balance, except as an indirect reference. STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE 135 Westhorp (2003) did not discuss disruptions to occupational balance, but provided a model for achieving occupational balance. Westhorp (2003) discussed the need for a person to decide on essential occupations and how to engage in them by saying yes or no to activities. Results from the present study supported this concept in Westhorps (2003) model. Entry-level OT graduate students in the present study often reported the belief that academics were most important and thus did not have the option to say no to academic work. However, a focus on academics often led to an occupational balance disruption. As a result, students discovered they needed to say yes (Westhorp, 2003) to more self-care activities and other occupations if they desired to return to a state of occupational balance. Westhorp (2003) also described that a person must consider the effect of environmental change (p. 105) as needed at any point in the cycle to achieve occupational balance. Similarly, the results from the present study led the researcher to suggest that micro and macro contexts pressure a student to achieve occupational balance as indicated in the conditional/consequential matrix described earlier and shown in Figure 2. Matuska and Christiansen (2008) support the present study in their model of lifestyle balance. The authors discussed five aspects of occupations that lead to the perception of a balanced lifestyle. In their model, the authors explained that a persons choice of occupations must meet basic human needs, offer possibilities for developing relationships with others, encourage feelings of self-confidence, promote meaning in life, and assist in meeting selfestablished objectives (Matuska & Christiansen, 2008). Aligning with Matuska and Christiansens (2008) model, entry-level OT graduate students in the present study reported occupational balance disruptions when they could not engage in self-care practices or interact with peers or family. They also experienced disruptions when they did not perform as well as they expected on an academic assignment or discovered their method of organization was STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE 136 inadequate to achieve their goals. Matuska and Christiansen (2008) did not discuss what happens when a disruption to lifestyle balance occurs nor did they provide strategies to achieve or regain the perception of lifestyle balance. Like Westhorp (2003), Matuska and Christiansen (2008) acknowledged that the environment might influence a persons occupational engagement. The authors explained that this environmental influence might affect lifestyle balance; however, they did not provide specific strategies a person could implement if a disruption to lifestyle balance occurred. Study Limitations In the present study, the sample of 26 participants included students from seven universities; however, all universities were in the Midwest; therefore, the results may not apply to entry-level OT graduate students in other parts of the country. Sampling students from other parts of the country may produce a theory with propositions of occupational balance other than the ones derived in this study. Students were from different types of entry-level OT graduate programs, including masters and doctoral levels. In addition, students entered their entry-level OT graduate program at different points of their academic career, including direct entry as firstyear undergraduate students and post-baccalaureate students. Sampling students from one type of program may produce results specific to the program that would not apply to other educational levels, such as post-professional. Lastly, sampling of students occurred from various points in their entry-level OT graduate program from the first semester through the end of their program. Sampling students who are at the same place in their program may provide insights into how occupational balance varies across programs at specific points in the program. The researcher is an occupational therapist and works as a program director of an MOT program at a small university in the Midwest. The researcher interacts with students daily and STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE 137 discusses occupational balance in class and during advising sessions with students. As a result of these two facts, the researchers bias toward occupational balance as a useful concept may have unintendedly influenced the data collection and analysis processes. However, the researcher took steps to mitigate this personal bias during data collection and analysis, including using a reflective journal, establishing an audit trail, and writing memos. Additionally, 13 participants were current students at the university where the researcher works. As outlined in the method section, the researcher took steps to avoid coercion of these students during the data collection portion of this study; however, because participants were current students in the program, they may not have been forthcoming with information. Implications for Education and Research This study may benefit students in entry-level OT graduate programs, administrators, and faculty of those programs. Understanding student occupational balance and circumstances that can cause disruptions may help prevent disruptions from creating unmanageable stress. In addition, understanding strategies students can implement to return to occupational balance may help faculty suggest options for students who cannot self-manage an occupational disruption. Students in graduate programs may benefit from using the strategies the participants described in this study to return to occupational balance following a disruption. The information presented in this paper may be beneficial especially to OT students transitioning to entry-level graduate school. Data analysis from this study led the researcher to suggest that entry-level students experience disruptions to balance that are the most difficult to manage during the first semester of graduate school. Graduate programs present a new way of learning, yet many students are not equipped with study habits to transition without increased anxiety and stress. Additionally, many students relocate to a new city for their graduate program and do not have an STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE 138 easily accessible social network. Students in this study explained that time along with trial and error were necessary to figure out how to navigate the entry-level OT graduate program. Retaining occupational balance involved determining a study plan and selecting methods of organizing course work to manage the rigor of the program. Integrating the strategies from this study can provide a starting point for figuring out an effective method. This researcher found that students are uncomfortable speaking with faculty about concerns, especially at the outset of the entry-level OT graduate program. Faculty in entry-level OT graduate programs focus on the required curricular standards in the courses they teach. If students do not communicate concerns, faculty may not realize the anxiety and stress students experience in the entry-level OT graduate program. The results from this study provide faculty with insight into students viewpoints and encourage faculty to initiate communication with more reserved students who do not contact faculty. In addition, faculty can provide OT students with strategies discussed in this study as suggestions for improving occupational balance after experiencing disruptions throughout the entry-level graduate program. Finally, faculty can facilitate the relationship-building of students within the program. For example, faculty can assign peer mentors who can assist new entry-level OT graduate students in navigating some of the initial challenges of starting a new program (Mitschke et al., 2021). Another suggestion is to host networking sessions for new cohorts so students can meet peers and build relationships outside of the classroom (Mitschke et al., 2021). Results of the present study can inform program administrators and faculty about the implications of curriculum design for the occupational balance of entry-level OT graduate students. Accreditation standards require faculty in entry-level OT graduate programs to include extensive content (ACOTE, 2022). Leadership and faculty in entry-level OT graduate programs STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE 139 often are clinicians who transition to academics and do not possess extensive knowledge in curriculum design (Frantz & Smith, 2013; Lockhart-Keene & Potvin, 2018). This lack of knowledge can lead to unevenly dispersed credit hours among semesters. Students may experience several courses with greater difficulty or courses with dense and complex information in the same semester, which may increase student stress. Faculty may not discuss adequately course content and requirements with other faculty in the program leading to content redundancies or lengthy assignments due at the same time. All of these curriculum scenarios can cause an occupational balance disruption for entry-level OT graduate students. To assist entry-level OT graduate students return to occupational balance or avoid a disruption, faculty can plan time in class to complete assignments. Faculty meetings should include discussions about student behaviors that may indicate occupational balance disruptions. Faculty can plan curriculum retreats to review course content to ensure it is scaffolded and reinforced, avoiding unnecessary redundancies (Krusen, 2020). Integrating a curricular thread of self-care to teach OT students mindfulness techniques and other strategies may improve the ability of students to manage stress (Cahill, 2021). These skills may improve job satisfaction and quality of life once students become occupational therapists (Bodenheimer & Sinsky, 2014; Sikka et al., 2015). Overworked staff are more prone to errors and inconsistent attendance at work, which lead to decreased quality of care for service recipients (Costa, 2018). Teaching OT students the importance of self-care is imperative so students develop strategies to manage the stress that accompanies a career in healthcare (Bodenheimer & Sinsky, 2014; Sikka et al., 2015). As noted throughout this study, other circumstances may arise in a students career that may create a disruption of a similar or greater magnitude as the initial transition to graduate school. The COVID-19 pandemic was such a disruption. Understanding the causes of disruptions STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE 140 to occupational balance during these unexpected and disruptive situations should encourage faculty to automatically implement strategies to increase student retention and success. Researchers should design future studies to investigate changes in student occupational balance across time in the entry-level OT graduate program. For example, researchers can interview the same students during different points in their academic program to glean further insight into specific strategies to help students succeed. Additionally, separating doctoral level student data from master-level student data may demonstrate differences in occupational balance among OT students in different degree programs. Similarly, investigating the occupational balance strategies for OT students who matriculate into entry-level graduate programs before completing an undergraduate degree would be beneficial. Conclusion This researcher examined how entry-level OT graduate students incorporated strategies to manage occupational balance in their role as a student in the entry-level OT graduate program. Students developed a meaning of occupational balance based on past experiences and personal values. Disruptions to occupational balance occurred throughout the entry-level graduate program and within individual semesters. Students needed to identify disruptions to occupational balance before they could implement a strategy to return to occupational balance. This study reveals several strategies OT students implemented, including adapting methods to effectively and efficiently learn, using support systems, participating in multiple occupational roles, making time for self-care, and knowing when to seek professional assistance. STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE 141 References Accreditation Council for Occupational Therapy Education. 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Canadian Journal of Occupational Therapy, 85(2), 117-127. https://doi.org/10.117/0008417417734355 Zoom. (2019). Zoom security guide. https://zoom.us/docs/doc/Zoom-Security-WhitePaper.pdf STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE 154 Table 1 Characteristics of Students by OBQ11 Scores Low balance (score 17; n = 7) Gap between undergraduate and graduate school n=0 Medium balance (score 18 to 23; n = 11) n=3 High balance (score 24; n = 4) Employed n=6 n=8 n=4 Reported life was occupationally balanced at time of interview n=5 n = 10 n=4 n=3 Note. The total number of students who completed the OBQ11 was 22. Four students did not complete the OBQ11. Only data from the 22 students who completed the OBQ11 were included in Table 1. STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE 155 Table 2 Most Frequently Used Occupational Balance Strategies by OBQ11 Score Low balance (score 17; n = 7) Medium balance (score 18 to 23; n = 11) High balance (score 24; n = 4) Shared experiences with cohort peers Shared experiences with cohort peers Shared experiences with cohort peers Developed individualized plan for organization Developed individualized plan for organization Developed individualized plan for organization Scheduled time for self-care Scheduled time for self-care Scheduled time for self-care Use free time for self-care or to work on homework Used free time for self-care or to work on homework Made time for friends Made time for friends Used peer mentor Used peer mentor Reached out to faculty for assistance when needed Reached out to faculty for assistance when needed Took responsibility for own learning Prioritized time to balance time for all course work Obtained flexible paid employment Set realistic goals for completion and quality of academic work Note. The strategies above reflect those utilized by 50% of students with the designated OBQ11 score. The total number of students who completed the OBQ11 was 22. Four students did not complete the OBQ11. Only data from the 22 students who completed the OBQ11 were included in Table 2. STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE 156 Table 3 Propositional Statements Developed During Data Analysis Research question How do entry-level students in OT incorporate strategies to manage occupational balance in their role as a student in the graduate program? Propositional Statement The meaning of occupational balance is expressed through personal values and past life experience Sub Propositional Statement Student life experiences provide them a perspective of occupational balance Student personal values assist students in maintaining occupational balance Postponing occupational balance for a temporary disruption is acceptable Occupational balance disruptions can be identified Students self-identify disruptions to occupational balance Other people in a students life can identify disruptions to occupational balance Students implement strategies to return to occupational balance Students in OT adapted methods for learning to improve their effectiveness and efficiency Students use support systems to assist with managing disruptions to occupational balance Students seek parental support to assist with managing disruptions to occupational balance STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE Research question Propositional Statement Students seek faculty support to assist with managing disruptions to occupational balance 157 Sub Propositional Statement Faculty who do not provide support to students contribute to occupational balance disruptions Developing and maintaining peer relationships assist students in managing disruptions to occupational balance Students who made time for self-care demonstrated the ability to minimize disruptions to occupational balance Knowing when to seek professional assistance helped students manage disruptions to occupational balance What are the differences in the occupational balance strategies of entry-level OT graduate students who report high, medium, and low occupational balance? What happens to the way entry-level OT graduate students manage occupational balance when they experience a change in the expectations of their student role or in other life roles? Participating in multiple occupational roles contributes to student occupational balance Changes in life roles during the graduate program influence occupational balance STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE Research question Propositional Statement Experiencing the COVID-19 pandemic created traumatic disruptions that significantly challenged occupational balance and required altered strategies to manage 158 Sub Propositional Statement Reflecting on past graduate program experiences helped students manage disruptions to occupational balance For entry-level graduate students in different semesters of the OT program, how do the strategies for managing the student role change? Occupational balance fluctuates within the graduate program experience Occupational balance fluctuates from the beginning to the end of the program The first semester of the OT graduate program creates a disruption to occupational balance Being in the middle of the graduate program led to improved occupational balance Being at the end of the graduate program led to improved occupational balance Occupational balance fluctuates from the beginning to the end of a semester STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE Figure 1 Phase Diagram 159 STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE Figure 2 Conditional/Consequential Matrix of Graduate Student Occupational Balance 160 STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE 161 Appendix A Initial Interview Guide Thank you for agreeing to be interviewed today. My name is Stephanie Bachman. I am a student at the University of Indianapolis in the Doctor of Health Science Program. I will be conducting this interview as a part of my final doctoral project. The responses you provide during the interview will be kept confidential. Your responses will be used in the data analysis, written paper, and presentation of the final project, but any identifying information will be removed. The purpose of this project is to learn more about the experiences of entry-level graduate occupational therapy students. The purpose of this interview is to gain a greater understanding of what it is like to be a graduate student, including the challenges and successes you have with being a student while managing your other life roles. The time frame for the initial interview will be approximately 60 minutes. Your participation is voluntary, and you may choose not to answer one or more questions. Upon your request, the interview may be terminated at any time. Do you have any questions about the interview or how the data will be used? I will be taking notes during the interview, but to ensure I accurately record all of your responses, I would also like to audio record the interview. The recording will be deleted following its written transcription per institutional IRB protocol. All identifying information will be omitted from the transcription. Do you mind if I record the interview? (If the response is yes I will push the record button on the cellular phone digital audio recorder) Thank you, I have begun recording. STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE 162 Questions and Prompts Opening Question 1. Please tell me a little bit about your background, including how long you have been a OT graduate student. Possible prompts: How much schooling had you completed before you entered graduate school? How much longer do you have until you graduate? Grand Tour Question (Spradley, 2016) 2. Could you describe what a typical week is like for you as a OT graduate student? Possible prompts: Tell me about any time you might spend caring for other people or animals? Or the time you might spend on leisure activities or hobbies? Or the time you might spend in paid employment and/or volunteer work? Possible Mini-Tour Questions (Spradley, 2016) 3. Tell me about how you organize your time while in OT graduate school? Possible prompts: Tell me more about the way you fit everything you want to do into your daily or weekly routine? How do you make everything work? When you make everything work, what words or phrases would describe that feeling? 4. Tell me about a situation when you were unable to get everything done that you planned to do. How did you feel about that experience? Tell me about what you did to address the situation. What words or phrases would you use to describe when you cant make things work? 5. How does being in graduate school influence how you fit your daily activities together? (or substitute the native language that they give about words or phrases) Possible prompts: Tell me how your ability to get everything done changes each STUDENT PERCEPTIONS OF OCCUPATIONAL BALANCE semester? What happens? 163  ...

... Effectiveness of a Clinic-Based PCIMT Program on Upper Extremity Function and Movement Quality Submitted to the Faculty of the College of Health Sciences University of Indianapolis In partial fulfillment of the requirements for the degree Doctor of Health Science By: Regan L. Blankenship, MS, OTR/L Copyright April 28, 2022 By: Regan L. Blankenship, MS, OTR/L All rights reserved Approved by: Lori Breeden, EdD, OTR Committee Chair ______________________________ Katy Mitchell, PT, PhD Committee Member ______________________________ Stephanie C. DeLuca, PhD Committee Member ______________________________ Accepted by: Laura Santurri, PhD, MPH, CPH Director, DHSc Program Chair, Interprofessional Health & Aging Studies University of Indianapolis ______________________________ Stephanie Kelly, PT, PhD Dean, College of Health Sciences University of Indianapolis ______________________________ EFFECTIVENESS OF A CLINIC-BASED PCIMT PROGRAM Effectiveness of a Clinic-Based PCIMT Program on Upper Extremity Function and Movement Quality Regan L. Blankenship Department of Interprofessional Health and Aging Studies, University of Indianapolis 1 EFFECTIVENESS OF A CLINIC-BASED PCIMT PROGRAM 2 Abstract Pediatric constraint induced movement therapy (PCIMT) is a largely growing treatment method being utilized around the world, however, there are limited programs that are utilizing this type of program to meet the needs of children with unilateral hemiparesis. A vast majority of children who receive this type of intervention are enrolled in randomized controlled trials, or families seeking-out facilities who provide this service. The purpose of this study was to determine the effectiveness of a clinic-based PCIMT program on upper extremity function and movement quality utilizing standard assessments geared towards this specific population. Children who have unilateral hemiparesis are at a higher chance of developing unilateral neglect and being developmentally delayed in gross motor, fine motor, and visual motor milestones. Delays in these areas will impact a childs ability to participate in self-help skills and participate with peers which is critical for a childs development. A quantitative, retrospective study was used to gather data for comparison and analysis. This study examined a total of 31 children ages 2.5 through 8 years of age who were referred to the PCIMT program at a large pediatric hospital in the south. The children were measured using two standardized assessment tools (1) pediatric motor activity log and (2) Melbourne 2 assessment at the time of their initial evaluation and following the 3-week long intervention. Children were categorized by their Manual Abilities Classification Scale (MACS) or the Mini-Manual Abilities Classification Scale (Mini-MACS). Results from this study provide evidence to support clinic-based PCIMT programs to improve both function and movement quality for children with unilateral hemiparesis. EFFECTIVENESS OF A CLINIC-BASED PCIMT PROGRAM 3 Table of Contents Title Page ........................................................................................................................................ 1 Abstract ........................................................................................................................................... 2 Introduction ..................................................................................................................................... 5 Research Questions ..................................................................................................................... 8 Objectives .................................................................................................................................... 8 Significance of the Study ............................................................................................................ 9 Definition of Terms ..................................................................................................................... 9 Literature Review.......................................................................................................................... 10 Original Pediatric Constraint-Induced Movement Therapy Protocol ....................................... 10 ACQUIREc Protocol ................................................................................................................. 11 Clinic-Based Constraint-Induced Movement Therapy ............................................................. 12 Single Treatment of Constraint-Induced Movement Therapy .................................................. 14 Constraint-Induced Movement Therapy for Children with Acquired Brain Injury .................. 16 Multiple Treatments of Constraint-Induced Movement Therapy ............................................. 16 Long-Term Benefits of CIMT ................................................................................................... 18 Occupational Therapist Perceptions on PCIMT........................................................................ 18 Method .......................................................................................................................................... 20 Study Type and Design ............................................................................................................. 20 Participants ................................................................................................................................ 20 EFFECTIVENESS OF A CLINIC-BASED PCIMT PROGRAM 4 Inclusion Criteria .................................................................................................................. 20 Exclusion Criteria.................................................................................................................. 21 Data ........................................................................................................................................... 21 Instruments ................................................................................................................................ 21 Pediatric Motor Activity Log ................................................................................................. 21 Melbourne Assessment of Unilateral Upper Limb Function (MAUL)-2 ............................... 22 The Manual Ability Classification Scale or the Mini Manual Ability Classification Scale .. 23 Procedures ................................................................................................................................. 24 Data Collection...................................................................................................................... 24 Data Management .................................................................................................................. 25 Statistical Analysis ................................................................................................................ 25 Results ........................................................................................................................................... 27 Discussion ..................................................................................................................................... 35 Study limitations ....................................................................................................................... 37 Conclusion ................................................................................................................................. 38 References ..................................................................................................................................... 39 EFFECTIVENESS OF A CLINIC-BASED PCIMT PROGRAM 5 Effectiveness of a Clinic-Based PCIMT Program on Upper Extremity Function and Movement Quality Children with hemiparesis have decreased strength, movement quality, and function on one side of their body (Gordon & Okita, 2010; Reidy et al., 2012). Hemiparesis can be caused by a stroke or other lateralized brain injuries (Gordon & Okita, 2010; Reidy et al., 2012). Since upper limb function has a significant impact on a child's ability to participate in self-care tasks, play, and participate in developmental activities, hemiparesis can significantly impact functional skills (Jackman et al., 2020). Resultantly, children's inability to fully participate in daily skills can create social isolation, lowered self-esteem, and add to feelings of being marginalized (Mandich & Rodger, 2006; Novak & Honan, 2019). These feelings and the deficits associated with hemiparesis can impact a childs ability to be independent across the lifespan (Mandich & Rodger, 2006). Therapeutic efforts such as occupational and physical therapy are meant to ameliorate these impairments by using current evidence-based treatment approaches to improve movements, function, and skill (Mandich & Rodger, 2006; Novak & Honan, 2019). For the treatment of hemiparesis, one evidenced-based treatment approach is pediatric constraint-induced movement therapy (PCIMT; Boyd et al., 2017; Coker-Bolt et al., 2013; DeLuca et al., 2003; Novak et al., 2013; Pidcock et al., 2009; Reidy et al., 2012; Taub et al., 2004; Taub et al., 2011). The efficiency of PCIMT is supported through a wide array of research, including many randomized controlled trials. PCIMT is also increasingly used clinically (DeLuca et al., 2017). Descriptively, PCIMT is a treatment approach assumed to influence development of neural pathways by promoting connectivity within the brain to improve motor function. The therapeutic processes are based on behavioral approaches and learning theories (Pidcock et al., EFFECTIVENESS OF A CLINIC-BASED PCIMT PROGRAM 6 2009). For adults, Morris et al. (2006) established three main components to constraint-induced movement therapy (CIMT). The first is constraining the use of the less affected upper extremity; this could be using a mitt or a different method to continually remind the participant to use the more affected upper extremity (Morris et al., 2006). Second, repetitive, task-oriented training, including shaping and task practice (Morris et al., 2006). Third, adherence to behavioral strategies for carryover to the in-home environment; these include but are not limited to behavioral contract, home skill assignment, home practice, and daily schedule (Morris et al., 2006). For PCIMT, Ramey et al. (2013) proposed five main components as necessary for a protocol to be considered PCIMT: 1- Constraint of the less involved arm and hand; 2- High dose therapy efforts that are given for multiple hours a day, multiple days a week, for multiple weeks; 3- the use of shaping or operant conditioning to guide therapeutic activities; 4- treatment occurring in natural environments; and 5- the inclusion of a post-treatment planning transfer package. Ramey and colleagues (2013) further delineated that variation in the literature could be divided into approaches based on traditional or signature approaches of PCIMT, including all of the above components at sufficient levels, and modified and alternative PCIMT approaches that varied one or more of the components above. One approach to PCIMT has been titled ACQUIREc therapy (Acquisition of new motor and functional skills through Continuous practice and shaping to produce Quality movement in the Upper extremity through Intensive therapy that is Reinforced in the childs Everyday patterns and places) (DeLuca et al., 2013; DeLuca et al., 2007). This is a signature PCIMT protocol that has been rigorously tested in multiple randomized controlled trials (DeLuca et al., 2013; DeLuca et al., 2007; DeLuca et al., 2003; Ramey et al., 2013). ACQUIREc therapy was based, initially, on the adult versions of CIMT, but there were specific processes added in EFFECTIVENESS OF A CLINIC-BASED PCIMT PROGRAM 7 recognition of children's developmental needs. Despite the widespread research investigation into ACQUIREc Therapy and other forms of PCIMT, there has been little investigation into the clinical translation of PCIMT. This creates a significant knowledge gap because we cannot be sure that the efficacy and effectiveness of PCIMT found in research efforts can be duplicated in clinic-based settings where the heterogeneity of potential participants is broad. Pediatric clinics often see a broad array of etiologies that result in hemiparesis, and variations in classifications of severity levels can also be broad. Whereas some studies include a more homogeneous sample of children in order to increase the power of the sample to identify an effect if one exists. Deluca et al. (2017) explicitly called for more investigation into the use of clinic-based PCIMT, requesting that clinics gather data to inform pediatric rehabilitation and develop practice-based evidence. This project seeks to explore the effectiveness of a clinic-based PCIMT program on function and movement quality as measured by two standardized assessments, the Pediatric Motor Activity Log (PMAL) and Melbourne-2, and to examine the potential difference in change based on age-based classification scales called the Manual Abilities Classification Scale or the Mini-Manual Abilities Classification Scale (MACs or Mini-MACs; Imms et al., 2009; Randall et al., 2013; Uswatte et al., 2012). The clinic-based program was derived from the ACQUIREc Therapy protocol principles following four of the five components listed above. The only missing component is using a natural environment as the children in the program are being seen in an outpatient therapy clinic, and thus would be considered a modified PCIMT protocol. The program uses a long arm bivalve cast for constraint and children are required to wear it for 24 hours a day seven days a week for two weeks. The cast is to only be taken off if it gets wet or causing harm. The dosage level of the program consists of two weeks unimanual and one-week bimanual training. All tasks during treatment utilizes the MR3 cycle which is an acronym for EFFECTIVENESS OF A CLINIC-BASED PCIMT PROGRAM 8 movement, immediate and direct reinforcement, repetition, and refinement (DeLuca et al., 2013), which is explicitly defined in the ACQUIREc Therapy model, and the family is provided an extensive home exercise program for a transition package post-treatment to help children and families maintain and or improve on skills learned during therapy. Research Questions 1. Is there a significant difference in upper extremity function as measured by the PMAL before and after a three-week clinic-based PCIMT intervention? a. Does MACS or Mini-MACS level predict change on the PMAL following clinicbased CIMT treatment in upper extremity function based on MACs or MiniMACs classification as recorded prior to treatment? 2. Is there a significant difference in upper extremity movement quality measured by the Melbourne-2 before and after a three-week clinic-based PCIMT intervention? a. Does Macs or Mini-MACS level predict change on the Melbourne-2 following clinic-based CIMT treatment in upper extremity movement quality based on MACs or Mini-MACS classification as recorded prior to treatment? Objectives To answer the research questions, the following objectives were addressed: 1. To determine if a three-week PCIMT program will change the upper extremity function measured by the PMAL in children 30 months to eight years old. 2. To determine if a three-week PCIMT program will change upper extremity movement quality measured by the Melbourne-2 in children 30 months to eight-years-old. EFFECTIVENESS OF A CLINIC-BASED PCIMT PROGRAM 9 3. To determine if MACS or Mini-MACs, predicts upper extremity function measured by the PMAL when children 30 months to eight years old receive a three-week clinic-based PCIMT intervention. 4. To determine if MACS or Mini-MACs, predicts upper extremity movement quality measured by the Melbourne-2 when children 30 months to eight-years-old receive a three-week clinic-based PCIMT intervention. Significance of the Study Understanding the benefits of clinic-based PCIMT will significantly impact PCIMT programs' importance and overall benefits to children with unilateral upper extremity limitations. Additionally, understanding the benefits of PCIMT when looking at classification levels of upper extremity involvement can shape the ongoing development and research behind PCIMT and the possibility of predicting intervention outcomes. This study has the potential to benefit caregivers/parents of children with unilateral upper extremity deficits, therapists/clinics, physicians, and insurance companies. Definition of Terms Pediatric constraint-induced movement therapy - is a form of therapy where a child's unaffected upper extremity is casted for a specific period to force the affected upper extremity to complete daily activities to regain use and function of the involved upper extremity (Morris et al., 2006). Hemiplegia - is a partial or complete paralysis of one side of the body (DeLuca et al., 2003). Hemiparesis - is a weakness of one side of the body (DeLuca et al., 2003). Upper extremities - arms (Morris et al., 2006). EFFECTIVENESS OF A CLINIC-BASED PCIMT PROGRAM 10 Neurological impairments - an injury to the brain, spine, or the nerves that connect them. There are more than 600 different types of neurological impairments. The most common injuries seen for PCIMT programs are stroke, traumatic brain injuries, and cerebral palsy (Pedersen et al., 2016). Transfer package is a formal post-treatment plan to increase the likelihood of carryover of therapeutic gains made during treatment to use in daily life (DeLuca et al., 2013). Literature Review CIMT is a rehabilitation treatment that has been shown to improve affected upper extremity use following a neurological injury (Morris et al., 2006). CIMT has been suggested as the most highly recommended form of intervention for children with hemiparetic cerebral palsy (DeLuca et al., 2017). CIMT has been reviewed and researched in multiple randomized control trials (Boyd et al., 2017; DeLuca et al., 2003; Pidcock et al., 2009; Reidy et al., 2012; Taub et al., 2011), yet minimal research has been done to determine the effectiveness of CIMT in clinicbased settings (DeLuca et al., 2017). Despite the lack of research, there have been numerous workshops geared towards CIMT, and clinics have started using varying protocols to provide CIMT to their patients (DeLuca et al., 2017). There is a critical need to determine if clinic-based PCIMT programs can produce the same magnitude of results as rigorous randomized controlled trials (DeLuca et al., 2017). Original Pediatric Constraint-Induced Movement Therapy Protocol CIMT has evolved since it was initiated over three decades ago (Morris et al., 2006). Morris et al. (2006) stated that there are three main elements and multiple sub-elements of the original PCIMT protocol that are still used today. The elements of CIMT include: repetitive, task-oriented training (shaping and task practice); adherence-enhancing behavioral strategies EFFECTIVENESS OF A CLINIC-BASED PCIMT PROGRAM 11 (daily administration of the motor activity log, home diary, problem-solving to overcome apparent barriers to use of the more affected upper extremity in the real-world situation, behavioral contract, caregiver contract, home skill assignment, home practice, and daily schedule); and constraining the use of the more affected upper extremity (mitt restraint, any method to remind the participant to use the more-affected upper extremity continuously). CIMT has been researched in pediatrics with a focus on developing the ideal protocols and programs based on age, diagnosis, treatment dosage, and the number of times the application should be completed for most optimal outcomes (Coker-Bolt et al., 2013; Morris et al., 2006). ACQUIREc Protocol ACQUIREc (Acquisition of new motor and functional skills through Continuous practice and shaping to produce Quality movement in the Upper extremity through Intensive therapy that is Reinforced in the childs Everyday patterns and places (DeLuca et al., 2013) is a form of pediatric constraint-induced movement therapy tested in multiple randomized control trials (Boyd et al., 2017; DeLuca et al., 2003; DeLuca et al., 2007; DeLuca et al., 2013; Pidcock et al., 2009; Reidy et al., 2012; Taub et al., 2011), with a published manual (REF). The acronym is used to capture the protocol elements, which has now been trialed by over 400 children ages 12 months to 21 years (DeLuca et al., 2013). The ACQUIREc was the first protocol developed to apply all of the principles used in the adult version of CIMT that could be replicated for the pediatric population (DeLuca et al., 2013). This protocol, provides a framework which encourages participants to complete all of the required components of PCIMT with systematic documentation about each child's daily treatment, including duration, activities, and progress (DeLuca et al., 2013). EFFECTIVENESS OF A CLINIC-BASED PCIMT PROGRAM 12 The five main components of the ACQUIREc protocol includes: 1) constraint of the child's less involved upper extremity and hand with a long-arm cast to be worn continuously for approximately 3.5 weeks, 2) intensive therapy for 3-6 hours a day for five consecutive weekdays over four weeks, 3) therapeutic activities guided by operant conditioning, 4) treatment in naturalistic environments, and 5) joint development by the family and the therapist of a transfer package to support maintenance and continued improvement (DeLuca et al., 2013). Joint development and transfer package include and home-based exercise program that has been developed by the treating therapist and family to promote carryover of therapeutic gains into the home environment and to continue to demonstrate improvements of the involved upper extremity (DeLuca et al., 2013). Clinic-Based Constraint-Induced Movement Therapy Reidy et al., (2012) evaluated clinic-based constraint-induced movement therapy. The author aimed to evaluate the functional outcomes of a CIMT protocol implemented in an outpatient therapy center. The study consisted of 29 participants with hemiplegia, ages 1.6-19.1 years of age (Reidy et al., 2012). Participants were assigned to one of two protocols: a 6-hour per day protocol or a 3-hr per day protocol based on age, ambulatory status, and ability to follow commands (Reidy et al., 2012). Children who were over the age of three, ambulated independently, and consistently followed commands received the 6-hour protocol. Children under the age of three years, limited ambulation, or limited ability to follow commands received the 3-hour protocol (Reidy et al., 2012).The outcomes were measured at baseline and following the CIMT program using the Melbourne Assessment of Unilateral Upper Limb Function (MAUL), Quality of Upper extremity Skills Test (QUEST), Assisting Hand Assessment (AHA), and the Canadian Occupational Performance Measure (COPM; Reidy et al., 2012). The protocol EFFECTIVENESS OF A CLINIC-BASED PCIMT PROGRAM 13 was consistent over 23 days and scheduled based on parent preference of a consistent day and time and clinic availability (Reidy et al., 2012). Reidy et al. (2012) found the protocol to be effective in improving unimanual and bimanual hand skills in children with hemiplegia. However, there was no difference in outcomes between the three and six-hour groups and between younger and older participants. Based on the limited replication of CIMT in clinical practice DeLuca et al., (2017) aimed to determine if moderate to large size effects could be replicated in clinical practice for PCIMT. At the time of this study, there had been minimal evidence confirming effective use of PCIMT in clinical practice for a more heterogeneous clinical population (DeLuca et al., 2017). This prospective study included 88 children age 18 months to 12 years of age and received highintensity CIMT using ACQUIREc protocol. Children who were chosen for this study never received CIMT treatment previously were evaluated for medical stability (DeLuca et al., 2017). The outcomes were measured at baseline and following CIMT treatment (DeLuca et al., 2017). The assessments used for this study were: The PMAL, the Emerging Behaviors Scale (EBS), and the AHA (DeLuca et al., 2017). Results from this study reported a statistically significant positive difference for all outcomes (DeLuca et al., 2017). The authors of this study compared the percentage of change from baseline of the participants from this study to previous randomized controlled trials (RCTs); the results were highly similar; however, the magnitude was somewhat reduced in the more heterogeneous clinical sample (DeLuca et al., 2017). The authors state this difference could be due to several factors, including impairment levels, the sensitivity of the outcome measures, and measures on varying impairment levels (DeLuca et al., 2017). EFFECTIVENESS OF A CLINIC-BASED PCIMT PROGRAM 14 The outcomes of these two studies (DeLuca et al., 2017; Reidy et al.2012) demonstrate the possibility of paradigm shift to the use of therapeutic resources such as CIMT into clinicbased settings. These studies are foundational to the current project because results achieved in these two studies show a research environment can be replicated in a clinical setting. Further research needs to be completed to demonstrate the effectiveness of this treatment method in a clinical environment (Reidy et al., 2012). This current study endeavors to contribute to the literature on the effectiveness of PCIMT in a controlled clinic-based setting. Single Treatment of Constraint-Induced Movement Therapy Multiple studies have been published to discuss motor improvements of children with hemiplegia following a single episode of CIMT, concluding that there is strong evidence supporting its efficacy (Boyd et al., 2017; DeLuca et al., 2003; Pidcock et al., 2009; Reidy et al., 2012; Taub et al., 2011). Dickerson & Brown (2007) described a single-subject design for a 24month-old child diagnosed with chronic hemiparesis caused by a prenatal stroke with no active range of motion in the right shoulder, elbow, or wrist. The child participated in an applied behavioral analysis (ABA) design with one follow up evaluation, a 21-day home intensive PCIMT program consisting of six-hour treatments five days a week (Dickerson & Brown, 2007). Additionally, the child received 2 hours a week of physical therapy and one hour a week of speech therapy (Dickerson & Brown, 2007). Results indicate the participant made significant gains in right upper extremity function and specifically progressed from neglecting the right side to using the right arm for simple play activities (Dickerson & Brown, 2007). Additionally, the researchers observed an improvement in lower extremity mobility and speech (Dickerson & Brown, 2007). It was noted that the participant went from relying on a walker before study participation to walking independently (Dickerson & Brown, 2007). The sample size of this EFFECTIVENESS OF A CLINIC-BASED PCIMT PROGRAM 15 study limits generalizability; however, the improvements support the use of CIMT treatment for children with limited upper extremity function (Dickerson & Brown, 2007). Three Hour Treatment, Verse Six-Hour Treatment. Reidy et al.'s (2012) objective of their study was to investigate the effectiveness of a CIMT protocol in an outpatient clinic using a pretest and posttest design, which evaluated threehour and six-hour treatment sessions with full-time cast. The COPM, MAUL, AHA, and QUEST were the outcome measures used to determine the effectiveness of the protocol (Reidy et al., 2012). Not all protocols were used for each child due to the assessments (Reidy et al., 2012). The outcomes between the three and six-hour daily therapy protocols showed no statistically significant clinical significance between younger and older participants (Reidy et al., 2012). Case-Smith (2012) hypothesized that this might have been an effect of the 24 hours a day casting, which provided continuous opportunities for refining hand skills outside of treatment times. Case-Smith et al. (2012) investigated CIMT on the functional use of affected upper extremity between children with unilateral cerebral palsy. The authors compared outcomes over time, measured at pre-intervention, post-intervention, three-month, and six-month follow. There were two groups, participants who received therapy six hours a day for 21 days, and participants who received intervention three hours a day for 21 days (Case-Smith et al., 2012). In both groups, children showed significant improvements (p .01) immediately after treatment and three months (Case-Smith et al., 2012). The significant improvements were maintained at the six-month follow-up (Case-Smith et al., 2012). Post hoc tests revealed a significant difference for both groups from pre-intervention to 6-months post-intervention (Case-Smith et al., 2012). Participants lost a small amount of post-intervention improvements; however, the decrease was EFFECTIVENESS OF A CLINIC-BASED PCIMT PROGRAM 16 not statistically significant, indicating moderate-to-high level effects were sustained following CIMT treatment, regardless of the treatment time (Case-Smith et al., 2012). Constraint-Induced Movement Therapy for Children with Acquired Brain Injury Pedersen et al. (2016) sought to generate new knowledge about the pedagogical initiatives and frameworks involved during CIMT for children with acquired brain injury (ABI). This was novel since previous literature has focused on children with neurological impairments such as stroke and cerebral palsy. With these studies, the participants have never had a normal function of the involved upper extremity. Children with ABI had typical brain function and motor capacity before the brain injury. Given the time of the damage, certain neuropsychiatric disorders, including cognition, are impacted, which separate pedagogical challenges between these diagnoses (Pedersen et al., 2016). Pedersen et al. (2016) studied results for four children with ABI from 10 to 12 years of age who participated in 10 sessions for six hours each session (2 weeks; 60 hours total). The restraint used was a custom-made sling that was removed during eating, bimanual activities, and breaks (Pedersen et al., 2016). Grip strength, box, and blocks, and the COPM were used to determine improvements from pretest to posttest. Significant improvements in grip strength (p < .001) and in the Box and Blocks Test (p < .001) (Pedersen et al., 2016). All four children showed clinically significant changes in their COPM results for personal goals in performance and satisfaction. The results also indicate that children are able to find goal-specific CIMT interventions both meaningful and relevant to their daily lives, which increases the likelihood of maintaining skills and motivation (Pedersen et al., 2016). Multiple Treatments of Constraint-Induced Movement Therapy A case report outlined one childs improvements following two episodes of CIMT (DeLuca et al., 2003). Each treatment of CIMT consisted of a single long arm bivalve cast with EFFECTIVENESS OF A CLINIC-BASED PCIMT PROGRAM 17 three weeks of intensive intervention six hours a day. Following the first treatment, the second three week treatment was completed five months later (DeLuca et al., 2003). The authors described detailed improvements between both three-week treatments. During the first treatment of CIMT, the child developed independent reach, grasp, release weight-bearing (prone on elbows) gestures, self-feeding, sitting, and interactive play (DeLuca et al., 2003). During the second three-week treatment, the child increased independence and improved UE movement quality, supported by clinical evaluations and parent ratings (DeLuca et al., 2003). This case report provides evidence to support multiple episodes of Pediatric CIMT may be a useful intervention for young children with hemiparesis as improvements were gained in both interventions. In a pretest-posttest study, DeLuca et al., (2015) Investigated if more than one treatment of PCIMT would produce additional benefits. This was the first study to measure a third PCMIT treatment. Children in this study wore a full-length cast on their involved upper extremity full time for the first 18 days of treatment and participated in bimanual training for the last 3-4 days of treatment (DeLuca et al., 2015). The authors chose two assessment tools to measure performance during this study: The EBS and PMAL. All children participated in the full treatment of six hours a day, five days a week, for four consecutive weeks. DeLuca et al. (2015) found following the first treatment, there were functional improvements, which produced a mean (SD) gain of 13.2 (4.2), following the second treatment produced a mean increase of 7.3 (4.7). Following the third treatment, a mean increase of 6.5 (4.2) was achieved. These results indicate that multiple PCIMT treatments can produce clinically critical functional gains for children with hemiparetic CP (DeLuca et al., 2015). EFFECTIVENESS OF A CLINIC-BASED PCIMT PROGRAM 18 Long-Term Benefits of CIMT The purpose of a study by Nordstrand and Eliasson (2013) was to describe the hand function in young adults who had previously participated in a two-week CIMT camp six years earlier. Nordstrand and Eliasson (2013) had concerns that hand function might decrease with age. Eleven participants were re-assessed six years after participating in the CIMT camp (Nordstrand & Eliasson, 2013). Results were compared to baseline and post-intervention results (Nordstrand & Eliasson, 2013). Results showed hand function remained unchanged, grip strength increased and was comparable between hands, and grip strength improved in the affected hand almost as much as in the unaffected hand (Nordstrand & Eliasson, 2013). Concerns for decreased hand function were not supported by the results (Nordstrand & Eliasson, 2013). Occupational Therapist Perceptions on PCIMT Chakraborty et al. (2019) utilized a qualitative study to explore a pediatric occupational therapist's perceptions who had an awareness of CIMT as an intervention method. Eight pediatric occupational therapists were interviewed, focusing on the participants' knowledge of CIMT, implantation practices, and current perceptions of CIMT in pediatrics (Chakraborty et al., 2019). Results showed three emerging themes from the data: perceived benefits of CIMT, varying comfort levels with the intervention's delivery, and differing methods of implementation (Chakraborty et al., 2019). All eight participants perceived CIMT to be a beneficial intervention for children with hemiparesis, making comments regarding children's increase in the use of affected upper extremity in daily activities and play (Chakraborty et al., 2019). Concerns were raised from implantation, where the participants described different implementation methods when using CIMT; there was no consistent protocol reported among the participants (Chakraborty et al., 2019). Chakraborty et al. (2019) outlined the need for a standardized EFFECTIVENESS OF A CLINIC-BASED PCIMT PROGRAM 19 protocol for CIMT and further research into occupational therapist perceptions of CIMT to help identify any perceived barriers for carryover of this treatment method into clinical practice. Previous literature has shown the benefits of PCIMT in randomized controlled trials (Boyd et al., 2017; DeLuca et al., 2003; Pidcock et al., 2009; Reidy et al., 2012; Taub et al., 2011). However, there continues to be a gap into transitioning PCIMT into clinic-based settings with minimal research that shows the impact of CIMT in clinic-based environments (Reidy et al., 2012 & DeLuca et al., 2017). Understanding the benefits of clinic based PCIMT will significantly impact PCIMT programs' importance and overall benefits to children with unilateral upper extremity limitations. This projects aims to answer the following questions: (1) Is there a significant difference in upper extremity function as measured by the PMAL before and after a three-week clinic-based PCIMT intervention, (a) is there a significant difference following clinic-based CIMT treatment in upper extremity function based on upper extremity classification (MACs or Mini-MACs), (2) Is there a significant difference in upper extremity movement quality measured by the Melbourne-2 before and after a three-week clinic-based PCIMT intervention, and (a) is there a significant difference following clinic-based CIMT treatment in upper extremity movement quality based on upper extremity classification (MACs or MiniMACs)? The purpose of this project is to demonstrate the impact of a clinic based PCIMT program on children with unilateral hemiparesis. EFFECTIVENESS OF A CLINIC-BASED PCIMT PROGRAM 20 Method Study Type and Design This is a retrospective study completed to examine records associated with participants between 2.5 and 8 years of age who underwent a clinical 3-week PCIMT program for the treatment of hemiparesis. Prior to data collection, the study was approved by both Texas Childrens Hospital and University of Indianapolis institutional review boards. Participants Participants were identified through a query of the electronic medical records at Texas Childrens Hospital based on the following criteria: participants successfully completed the PCIMT program at Texas Childrens Hospital between January 2019 and May 2021; were between 2.5 years to 8 years at the time they completed PCIMT; and had a diagnosis of unilateral hemiparesis. Sample size was estimated using G*Power 3.1.9.7 software (Faul et al., 2007) based on conducting a paired t test to determine if there was a difference in PMAL scores before and after participating in the PCIMT program. The following parameters were set for the calculation: two-tailed test, effect size of 0.50, and power of 0.80. There are no similar study results published to allow for the calculation of effect size; therefore, a medium effect size of .50 was used. The minimum sample size through calculations was 34. To participate in the PCIMT program patients met the following inclusion and exclusion criteria: Inclusion Criteria 1. Patient must have not missed more than 1 day of the program. 2. Patient must have obtained a MACS/Mini-MACS score of 1-5 during their initial preintervention assessment EFFECTIVENESS OF A CLINIC-BASED PCIMT PROGRAM 21 3. Patient must have been between the ages of 2.5 years and 8 years of age at the start of the PCIMT program. Exclusion Criteria 1. Patient with uncontrolled seizures 2. Patient with contractures greater than 10 degrees in their involved upper extremity 3. Patient who had recently received Botox injections (6 months prior to participating in the program) in their hand or upper extremity 4. Children who were unable to follow verbal directions or who had uncontrolled aggressive behaviors. Data Extracted data from the electronic medical record (EMR) at Texas Childrens Hospital included participant demographics: age, diagnosis, MACS or Mini-MACS score and gender; as well as treatment parameters (e.g. time participated in the program in months, and number of sessions attended), and treatment outcome data used to measure upper extremity function. These measures include the PMAL and MAUL-2 scores. Instruments Pediatric Motor Activity Log The PMAL is a parental rating assessment in which parents rate their child's use of their effective upper extremity on a 5-point Likert-like scale (0 = no use, 5 = normal use) in comparison to the unaffected limb (DeLuca et al., 2003). The PMAL is used for children 2-8 years of age. Parents complete the log assessing their children on 22 arm-hand functional tasks in terms of how often and how well they use the affected upper extremity when compared to the unaffected upper extremity (DeLuca et al., 2017). After administering the PMAL, mean PMAL EFFECTIVENESS OF A CLINIC-BASED PCIMT PROGRAM 22 scores are calculated for the two sections of how well and how often by adding the range of possible total scores. PMAL has been shown to have high internal consistency (Cronbach's = .93) and test-retest reliability (r = .89) (Uswatte et al., 2012). Convergent validity was also supported by a moderate correlation between changes in the PMAL scores and affected arm use during play, r(53) = .50, p < .001 (Uswatte et al., 2012). Melbourne Assessment of Unilateral Upper Limb Function (MAUL)-2 The MAUL-2 is a standardized measure that assesses the range of movement, the fluidity of movement, accuracy, dexterity, and object manipulation through a series of unilateral activities (Reidy et al., 2012). The MAUL-2 is administered by a licensed Occupational Therapist. The test is comprised of 14 test items which require a child to reach, grasp, and manipulate simple items. Each of these items are video recorded for subsequent scoring. The MAUL-2 provides a standardized tool for administering the assessment with a standardized measure for camera location to provide the assessor with the best angle for scoring (Reidy et al., 2012). From there, a percentage score is calculated to determine the quality of movement of a childs more involved upper extremity (Randall et al., 2001). Standardized scores are available for children age 2.5 years to 15 years of age. Randall et al. (2014) found the final modified version (MAUL-2) of each subscale demonstrated good internal consistency, with high population stability index (PSI) values ranging form .81 and .92. Randall et al. (2012) found the MAUL-2 could also be used for individuals with a variety of neurological and physical impairments and help to establish criteria for determining severity level of upper limb impairment. There was strong evidence of differences in childrens percentage scores on MAUL-2 for the three clinical levels of upper limb impairment, F(2, 27) = 67.8, p = .001 (Randall et al., 2012). Post-hoc comparisons using Tukeys HSD test found EFFECTIVENESS OF A CLINIC-BASED PCIMT PROGRAM 23 evidence that the mean score for children classified as mildly impaired was 83.7 (8.0) which was different from the mean score for moderately impaired children of 58.9 (7.2); p = .02 (Randall et al., 2012). There was also evidence which found a difference between classification of moderate and severe, given that the mean score for the children classified as severely impaired was 38.1 (SD 12.1); p = .01 (Randall et al., 2012). The Melbourne Assessment was found to have good reliability on a sample of 20 children with varying types and degrees of cerebral palsy (Randall et al., 2001). Randall et al. (2001) found very high internal consistence of test items ( = 0.96), moderate to high agreement for both within and between raters for all test items (intraclass correlation coefficient [ICC] of at least .70) apart from item 16 (hand to mouth and down), and high interrater reliability ( = 0.95) and intrarater reliability ( = 0.95) for total test scores. The assessment was given to the same children by the same therapist after a two-week interval (Randall et al., 2001). Per Randall et al. (2001) the assessment is useful to monitor a childs individual change in their performance over time. Additionally, the assessment can also be used to compare performance of tasks between same aged children which makes the assessment a useful tool for assessing pre-intervention and post-intervention research studies (Randall et al., 2001). The Manual Ability Classification Scale or the Mini Manual Ability Classification Scale The MACS is a five-level, ordinal classification system which describes the manual ability of children aged 4 to 18 years of age (Burgess et al., 2018). The Mini MACS is a fivelevel, ordinal classification system which describes the manual ability of children age 1 to 4 years of age (Burgess et al., 2018). The five-level MACS/Mini-MACS scale is ordinal, which means that the differences between levels are not necessarily equal, nor are childrens manual abilities equally distributed across the five levels. EFFECTIVENESS OF A CLINIC-BASED PCIMT PROGRAM 24 The MACS level is determined by a licensed therapist or physician. Level is determined based on observation of the child and their ability to handle objects. The purpose of the MACS is to categorize a childs ability to handle objects in daily life skills (Burgess et al., 2018). Level one on the MACS represents the highest level of ability where the child is able to handle objects easily and without difficulty (Burgess et al., 2018). Level five is considered total assist and the child is unable to handle any objects (Burgess et al., 2018). The MACS/Mini-MACS provides written examples to allow therapist/healthcare professionals to determine the category for a childs current level of function (Eliasson et al., 2013). The authors also provide examples to help determine the difference between levels to help guide the categorization of function (Eliasson et al., 2013). Eliasson et al. (2006) used a one-way random effects model, Intraclass correlation coefficient (ICC) (1), due to different raters were assessing the children. Reliability was tested between pairs of therapists for 168 children, 70 females and 98 males with hemiplegia (n = 52), diplegia (n = 70), tetraplegia (n = 19), ataxia (n = 6), dyskinesia (n = 19), and unspecified CP (n = 2) between the ages of 4 and 18 years and between 25 parents and their childrens therapist. The results demonstrated that MACS has good validity and reliability. Based on a 95% confidence interval, the ICC between therapists was .97, and between parents and therapist was .96, indicating excellent agreement. Procedures Data Collection Data of children who participated in the CIMT program between January 2019 and May 2021 was extracted from the electronic medical record (EMR). From these participants, those who met the inclusion criteria were deidentified and organized into an Excel spreadsheet. Each EFFECTIVENESS OF A CLINIC-BASED PCIMT PROGRAM 25 chart was thoroughly reviewed by the primary researcher (R. S.) to determine if patients met the eligible criteria to be included in the study design. No data was collected from records where children did not meet inclusion criteria. Once a list of participants was finalized, data from each of the assessments was transferred to a separate Excel spreadsheet for coding prior to being transferred to software for analyzing. All identifiers were removed, and children were given a study identification number. Children were categorized by level of motor involvement using their MACS/Mini-MACS scores level 1-5. Any missing data was reported and categorized in final report of document. Children were excluded if MACS level was not identified in either evaluation or re-evaluation. Data Management All data files were kept under a dual inscription software to maintain HIPAA compliance and protect medical records. No patient identifiers were kept. Once patients were included/excluded they were each given a non-identifiable study number. The Microsoft Excel, Version 16.57 (Saxton, 2021). file with study identification numbers was inspected and cleaned to prepare it to be exported for data analysis. The Excel sheet was housed on Texas Childrens Hospitals server and was only accessed through this controlled server. Statistical Analysis Data analyses were completed using IBM SPSS Statistics for Macintosh, Version 27.0 (Armonk, NY: IBM Corp.). All statistical tests were two-tailed with a significance level set at .05. Normality of the data were assessed by visual inspection of histograms and Q-Q plots and use of the Shapiro-Wilk test. Nominal data was presented as frequency and percentage while interval and ratio data was reported as mean and standard deviation or median and interquartile range, depending on normality of data. To determine if there was a difference between pre- EFFECTIVENESS OF A CLINIC-BASED PCIMT PROGRAM 26 intervention and post-intervention a paired t test were used since the data was normally distributed. Ordinal logistic regression was used to determine if the MACS (Mini-MACS) significantly predicts the post-PMAL scores and change scores. Similarly, ordinal logistic regression was used to determine if the MACS (Mini-MACS) significantly predicted the postMelbourne-2 scores and change scores. In both cases, ordinal logistic regression was conducted due to the ordinal nature of the outcome variables. EFFECTIVENESS OF A CLINIC-BASED PCIMT PROGRAM 27 Results Total number of participants who met the inclusion and exclusion criteria was N=31 for the PMAL and N=27 for the MAUL-2. All 31 participants were given a Mini-MACs or MACs classification level. The age range was between 2 years 6 months (30 months) and 8 years 4 months (100 months). The participants age demographics are presented in Table 1 for the 31 participants. The participants Mini-MACs and MACs classification variables are presented in Table 2 for the 31 participants. Table 1 Age Demographics Classification Variables Under 3 3:0-3:11 4:0-4:11 5:0-5:11 6:0-6:11 7:0-7:11 8:0-8:11 n % 4 9 4 4 7 2 1 12.9% 29.0% 12.9% 12.9% 22.6% 6.5% 3.2% Table 2 Classification Variables of MiniMACs and MAC Classification Variables Mini-MACS II III IV MACS II III IV n % 5 6 3 16.1% 19.4% 9.7% 8 7 2 25.8% 22.6% 6.6% EFFECTIVENESS OF A CLINIC-BASED PCIMT PROGRAM 28 Planned data analyses included paired samples t-tests to look at pre- to post-treatment changes for each outcome measure. Paired samples testing was chosen to statistically account for the known relationship between pre- and post-treatment samples. The mean PMAL How Well rating pre-treatment was 1.78 (SD. =0.80) with a post-treatment mean of 3.09 (SD. = 0.80) with a resulting t = 12.02, p < 0.0001. The mean PMAL How Often rating pre-treatment was 1.63 (SD. = 0.78) with a post- treatment mean of 3.17 (SD. = 0.86); t = 10.84, p < 0.0001 indicating that the two times differed statistically in both how often and how well at an alpha 0.05 level. This indicates a 3-week intensive PCIMT clinic-based program significantly improved how often a child uses their affected upper extremity in daily tasks as well as how well they use their affected upper extremity to complete the same task. Figure 1 illustrates the difference in raw scores between pre- and post- PMAL in the how often category for all 31 participants, and figure 2 shows the difference in raw scores between pre- and post- PMAL in the how well category for all 31 participants following the 3-week intensive intervention. Figure 3 illustrates the difference between times in both how often and how well categories of the PMAL. Effect sizes can be found on table 2. EFFECTIVENESS OF A CLINIC-BASED PCIMT PROGRAM Figure 1 PMAL How Often Raw Score Difference Pre and Post Intervention 5 4.5 How Often Raw Score 4 3.5 3 2.5 2 1.5 1 0.5 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Participant Pre PMAL Often Post PMAL Often 29 EFFECTIVENESS OF A CLINIC-BASED PCIMT PROGRAM Figure 2 PMAL How Well Raw Score Difference Pre and Post Intervention 4.5 How Well Raw Score 4 3.5 3 2.5 2 1.5 1 0.5 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Participant Pre PMAL Well Post PMAL Well Figure 3 PMAL Average Score Over Time 4.5 PMAL Average Raw Score 4 3.5 3 2.5 2 1.5 1 0.5 0 PMAL How Well PMAL How Often Pre Post 30 EFFECTIVENESS OF A CLINIC-BASED PCIMT PROGRAM 31 The mean MAUL-2 ROM raw score was 15.00 (SD = 4.77) with a post-treatment mean of 17.7 (SD = 4.83) with a resulting t = 4.176, p 0.0001. The mean MAUL-2 accuracy raw score was 16.25 (SD = 5.48) with a post-treatment mean of 18.85 (SD = 4.45) with a resulting t = 4.84, p 0.0001. The mean MAUL-2 dexterity raw score was 7.07 (SD = 3.40) with a posttreatment mean of 8.81 (SD =3.14) with a resulting t = 3.73, p = 0.001. The mean MAUL-2 Fluency raw score was 10.96 (SD = 3.95) with a post-treatment mean of 13.59 (SD = 2.97) with a resulting t = 2.36, p = .026 indicating that the two time periods differed statistically in all four subtests of the Melbourne 2 at an alpha .05 level. Therefore, a 3-week intensive PCIMT clinicbased program increased ROM, accuracy, dexterity, and fluency of movement. Figure 4 shows the mean difference between pre and post MAUL-2 scores for range of motion, Figure 5 shows the mean difference between pre and post MAUL-2 scores for accuracy, Figure 6 shows the mean difference between pre and post MAUL-2 scores for dexterity, and Figure 7 shows the mean difference between pre and post MAUL-2 scores for fluency following 3-week intensive intervention. Effect sizes are found on Table 2. EFFECTIVENESS OF A CLINIC-BASED PCIMT PROGRAM Figure 4 Melbourne 2 Average Range of Motion Over Time Average Melbourne 2 score 25 20 15 10 5 0 Pre MA2 ROM Post MA2 ROM Figure 5 Melbourne 2 Average Accuracy Over Time Average Accuracy Raw Score 25 20 15 10 5 0 Pre MA2 Accuracy Post MA2 Accuracy 32 EFFECTIVENESS OF A CLINIC-BASED PCIMT PROGRAM Figure 6 Melbourne 2 Average Dexterity Over Time 14 Average Dexterity Raw Score 12 10 8 6 4 2 0 Pre MA2 Dexterity Post MA2 Dexterity Figure 7 Melbourne 2 Average Fluency Over Time 18 AVerage Fluency Raw Score 16 14 12 10 8 6 4 2 0 Pre MA2 Fluency Post MA2 Fluency 33 EFFECTIVENESS OF A CLINIC-BASED PCIMT PROGRAM 34 Table 2 Cohens Effect Size (differences over time) Subtest PMAL How Well PMAL How Often MAUL-2 ROM MAUL-2 Accuracy MAUL-2 Dexterity MAUL-2 Fluency d 1.63 1.88 0.56 0.52 0.53 0.76 Classification Very Large Very Large Medium Medium Medium Large Next, this study determined if the MACS/Mini-MACS (entered together as one variable) level significantly predicted change on the PMAL following clinic-based CIMT treatment in upper extremity function based on MACs or Mini-MACs classification as recorded prior to treatment. For these analyses linear regression techniques were utilized. MACs and Mini-MACs were not significant predictors of post PMAL how often change scores at F(1, 29)=.005, p=.944. The relationship between these variables was r=-.013, therefore 0% of the variance was shared between variables. This indicates that using Mini-MACs/MACs levels alone cannot predict PMAL How Often change after a 3-week intensive clinic-based PCIMT. In addition, MACs and Mini-MACs were not significant predictors of post PMAL how well change scores at F(1, 29)=.007, p=.934. The relationship between these variables was r=.015, therefore 0% of the variance was shared between variables. This indicates that using Mini-MACs/MACS levels alone cannot predict PMAL How Well change after a 3-week intensive clinic-based PCIMT. Lastly, this study determined if the MACS or Mini-MACS (entered together as one variable) level predicted change on the Melbourne-2 (the four domains: ROM, Accuracy, Dexterity, and Fluency) following clinic-based CIMT treatment in upper extremity movement quality based on MACs/Mini-MACS classification as recorded prior to treatment. For these EFFECTIVENESS OF A CLINIC-BASED PCIMT PROGRAM 35 analyses linear regressions were utilized. MACs/Mini-MACs were not significant predictors of ROM change at F(1, 24)=.000, p=1.000. The relationship between these variables was r=0, therefore 0 of the variance was shared between variables. MACs/ Mini-MACs were significant predictors of accuracy change at F(1, 24)=5.543, p=.027. The relationship between these variables was r=.433, therefore 18.8% of the variance was shared between variables. To estimate a participants post Melbourne raw change score the following equation can be used: post Melbourne raw change score = -1.420+1.312(MACS or Mini-MACs score). For example: if a patient has a MACs score of 3 than we can predict with 18.8% assurance the child will achieve a post MAUL-2 raw accuracy change score of 2.516. MACs/Mini-MACs were not significant predictors of dexterity change at F(1, 24)=1.800, p=.192. The relationship between these variables was r=.264, therefore 7% of the variance was shared between variables. MACs/ Mini-MACs were not significant predictors of fluency change at F(1, 24)=.008, p=.924. The relationship between these variables was r=.019, therefore 0% of the variance was shared between variables. These scores indicate that using the Mini-MACs or MACs level alone cannot be a significant predictor of post MAUL-2 raw change scores for ROM, dexterity and fluency. However, we can predict with 18.8% certainty post MAUL-2 raw accuracy score based on a childs Mini-MACs or MACs level. Discussion The purpose of this study was to determine the effectiveness of a clinic-based constraint induced movement therapy program for children age 18 months to eight years of age utilizing three different variables for measurement. For the purpose of classification, the Mini-MAC and MACs levels were used. For pre and post intervention scores, the parent questionnaire of PMA and therapist scored measure of MAUL-2 were utilized. This study was a retrospective design EFFECTIVENESS OF A CLINIC-BASED PCIMT PROGRAM 36 examining participant data from January 2019 to May 2021. There were 31 participants who met the inclusion and exclusion criteria whose results were used for the data entry. All 31 participants had pre and post PMAL scores and Mini MACs/MACs levels. However, only 27 participants had both pre and post MAUL-2 scores available for data comparison causing for a smaller sample size for the MAUL-2 results. Analysis of this study yielded interesting findings for both assessment variables, for pre and post assessment for PMAL, the results showed a significant difference in scores in both subtests of how well and how often. Showing improvements in both frequency of use and quality of movement, the affected upper extremity statistically improved following the 3-week intensive program. The results of the current study were comparative to DeLuca et al., (2017) where the mean PMAL quality of movement rating (How Well) pretreatment was 1.44 (s.d. = 1.01) with a post-treatment mean of 2.94 (s.d. = 0.94) with a resulting t = 13.40 p < 0.0001. The mean PMAL frequency of use rating (How Often) pre-treatment was 1.10 (s.d. = 0.78) with a post-treatment mean of 3.05 (s.d. = 0.96); t = 16.14, p < 0.0001. This study further adds to the research demonstrating significant change in pre and post clinic-based intervention for PCIMT. The MAUL-2 scores also made statistically significant gains in all four sub-tests. This change demonstrates that a clinic-based pediatric constraint induced movement therapy program can yield results producing valuable change in pre and post intervention scores. While this study examined separate subtests, Reidy et al. (2012), results found that total mean score for MAUL-2 improved significantly with p=.002. For this study, the Mini-MACs and MACs were used as one variable. When using the Mini-MACs or MACs classification system, theses scores were not significant predictors of five of the six subtest examined in this study (PMAL how often, PMAL how well, MAUL-2 ROM, EFFECTIVENESS OF A CLINIC-BASED PCIMT PROGRAM 37 MAUL-2 dexterity, and MAUL-2 fluency), meaning, using only a childs Mini-MACs or MACs classification system, we were unable to predict the post RAW score of these five specific variables following the 3-week intensive intervention. However, linear regression shows a predictability of 18.8% in post MAUL-2 accuracy scores, meaning, with the use of Mini-MACs or MACs score, there is a possibility to predict the post RAW score for accuracy in the MAUL-2 assessment variable. This can be a useful tool to show perspective parents and insurance companies for outcome prediction from a 3-week intensive PCIMT program. Study limitations This study had limitations. One limitation was missing data points in the MAUL-2 assessment which caused for a decreased sample size for MAUL-2 results (N=27) compared to the sample size for PMAL (N=31). There are few studies of clinic-based constraint induced movement therapy for this specific age range, which limits our ability to compare to various populations in other clinic-based settings. This study did not examine any specific population or diagnosis and only utilized Mini-MACS/MACs scores for classification. As this study is unique to this population, type of treatment, specific age range, and particular variables it is difficult to generalize to other populations. Minimum sample size through calculation with medium effect size of .50 was 34. However, only 31 participants met all the inclusion and exclusion criteria for the study, and of the 31, only 27 had all data points for both the PMAL and MAUL-2 assessments. An additional limitation was age range of the sample. Due to the assessments that were chosen, the age range had to be limited to 2.5 years to 8 which further limited the sample size selection. Lastly, for the purpose of this study, specific diagnoses were not considered when determining the sample size which led to a lack of a homogeneity. EFFECTIVENESS OF A CLINIC-BASED PCIMT PROGRAM 38 Conclusion Understanding the benefits of clinic-based PCIMT will significantly impact PCIMT programs importance and overall benefits to children with unilateral upper extremity limitations. The research questions aimed to (1) determine if a three-week PCIMT program will change the upper extremity function measured by the PMAL in children 30 months to eight years old, (2) to determine if a three-week PCIMT program will change upper extremity movement quality measured by the Melbourne-2 in children 30 months to eight-years-old. (3) to determine MACS or Mini-MACs, affects upper extremity function measured by the PMAL when children 30 months to eight years old receive a three-week clinic-based PCIMT intervention and (4) to determine measured by MACS or Mini-MACs, affects upper extremity movement quality measured by the Melbourne-2 when children 30 months to eight-years-old receive a three-week clinic-based PCIMT intervention. These questions led us to an examination of 31 participants (N=31 for PMAL and N=27 for MAUL-2). Our results indicate a clinic-based PCIMT program can significantly improve upper extremity functional use, quality of movement, ROM, dexterity, accuracy, and fluency when comparing pre and post 3-week intervention. Limitations of this study were sample size, age range, heterogeneity of the sample, and missing data. These results are important to clinical practice because, at the time of this study, there has been limited research to show clinical application of PCIMT programs. 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