Buscar

... PRE-EMPLOYMENT SKILLS FOR VETERANS 1 Implementation of an Occupation Based Pre-Employment Skills Program for Veterans Overcoming Homelessness, Addiction, and Mental Illness Molly Sears May, 2018 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: Becky Barton, DHS, OTR, FAOTA PRE-EMPLOYMENT SKILLS FOR VETERANS 2 A Capstone Project Entitled Implementation of an Occupation Based Pre-Employment Skills Program for Veterans Overcoming Homelessness, Addiction, and Mental Illness Submitted to the School of Occupational Therapy at University of Indianapolis in partial fulfillment for the requirements of the Doctor of Occupational Therapy degree. By Molly Sears, OTS Approved by: Faculty Capstone Advisor Date Doctoral Capstone Coordinator Date Accepted on this date by the Chair of the School of Occupational Therapy: Chair, School of Occupational Therapy Date PRE-EMPLOYMENT SKILLS FOR VETERANS 3 Abstract This paper explores the effectiveness of an occupation based pre-employment workshop implementing resume building and interview skills at the Richard L. Roudebush VA Medical Center domiciliary in Indianapolis, Indiana. A needs assessment was conducted and from the information gathered from this process, it was evident that there was a limited amount of opportunities for resume and interview practice in order to increase the veterans confidence and overall performance with these life skills. From this information a pre-employment skills workshop was formulated in collaboration with the employment specialist at the domiciliary. The pre-employment skills workshop was implemented once a week for four consecutive weeks. Three veterans completed the workshop in its entirety and nine veterans completed two to three sessions of the workshop. Pre and post surveys measuring confidence level and knowledge of basic resume and interview skills were administered before and after workshop experience. Based on results collected from the surveys, it was identified that the pre-employment skills workshop was effective in increasing confidence and overall knowledge of these skills needed to obtain meaningful employment. PRE-EMPLOYMENT SKILLS FOR VETERANS 4 Implementation of an Occupation Based Pre-Employment Skills Program for Veterans Overcoming Homelessness, Addiction, and Mental Illness The percentage of homeless veterans in the United States is consistently growing each year. According to The National Coalition for Homeless Veterans, Veterans make up 23% of the homeless adult population in the United States and an additional 1.4 million veterans have an increased chance of becoming homeless (Driscoll, 2006; National Coalition for Homeless Veterans, n.d.). Along with being homeless, 45% of veterans also have a mental illness and 70% of homeless veterans have substance abuse disorders (American Psychological Association, n.d.). As stated, veterans often times also have a mental illness or substance abuse disorder, which is a contributing factor to their homelessness. According to the American Psychological Association (n.d.), post-traumatic stress disorder (PTSD) and traumatic brain injury (TBI) are often referred to as signature wounds that are prevalent post returning home from combat. Depression and suicidal ideation are also health issues veterans face post war and often are a co-morbidity with PTSD. Veterans with a confirmed diagnosis of PTSD and two or more comorbidities were 5.7 times more likely to have suicide ideational thoughts than Veterans that did not have these diagnoses. Military sexual trauma (MST) is an additional risk factor associated with PTSD, especially for female veterans. Female veterans that were exposed to military sexual trauma are nine times more likely to develop PTSD than those who were not exposed to this trauma while serving in the military (American Psychological Association, n.d.). PRE-EMPLOYMENT SKILLS FOR VETERANS 5 Contributing factors to Homelessness Homeless veterans often face additional barriers such as lack of access to healthcare, inability to afford appropriate housing, inadequate social support to cope with mental illness and or substance/alcohol abuse, absence of skills that can be transferred into the civilian workplace and low-self-esteem (Driscoll, 2006; Conrad et al., 1998; Rosencheck & Fontana, 1994; Applewhite, 1997). Housing. Lack of affordable housing is a significant barrier for Veterans who have little to no income. Veterans with a criminal background or substance abuse history have increased difficulty with this process as public assistance resources do not favor these social factors. Along with these obstacles, the United States in its entirety has a limited amount of suitable and sheltered housing to offer low-income individuals. There are some VA programs dedicated to housing homeless veterans, but these programs only encompass about 60 percent of homeless veterans and only last for a short duration (Driscoll, 2006). Lack of access to healthcare. Physical and mental disabilities are heavily prevalent within the homeless veteran population. Statistics in relation to veterans enrolled in a VA or community-based program indicate that 63 percent of the veterans have a history of drug abuse, 69 percent have a documented mental health condition, and 70 percent have alcohol abuse issues. As a result of the increased need for healthcare services within the veteran population, there has been an increase in patient wait times for services needed. Veterans may have to wait anywhere from two to six months to receive treatment, which leads to frustration and lack of faith in the VA healthcare system. PRE-EMPLOYMENT SKILLS FOR VETERANS 6 Although the VA has taken an initiative to increase the size and availability of their programs, a significant number of veterans are also unable to participate in VA and community-based services due to lack of opportunities within their communities (Driscoll, 2006). Social support. Conrad et al. (1998), indicates that homeless veterans are more likely to obtain and maintain appropriate housing when surrounded with familial support. Family support assists homeless veterans in remaining accountable to their actions and provides them with a reason to obtain housing (Conrad et al., 1998). Rosencheck and Fontana (1994), indicate that social isolation and lack of support post discharge from the military are often predictors of future homelessness. Lack of transferable skills. There is a significant rate of underemployment and unemployment within the veteran population. This is due to the fact that veterans have a limited number of skills that can directly be transferred into the civilian workplace. This substantially impacts younger veterans as they typically do not have any civilian work experience post-combat. When these veterans do have skills that transfer into the civilian workplace, they often correlate with jobs of a lower pay scale. For instance, jobs that include clerical, warehouse, and food service work are often adopted by homeless veterans (Driscoll, 2006). Lack of self-esteem. According to Applewhite (1997), veterans often experience a lack of self-esteem, which presents as a barrier to overcome homelessness. Veterans also may experience a lack of self-esteem due to their lack of ability to obtain employment or low pay rates they may receive (Applewhite, 1997). Based on previous research from Livingston and Miller (2006), homeless individuals may also lack the life PRE-EMPLOYMENT SKILLS FOR VETERANS 7 skills needed to obtain and maintain housing and a job, which can lead to limited selfconfidence when attempting to engage in these tasks. Purpose of Doctoral Capstone Experience. The purpose of this doctoral capstone experience was to incorporate occupation-based practice when working with homeless veterans with mental health conditions to increase self-confidence to enhance their abilities to obtain employment within the community. As a result, this will increase the veterans independence and success after discharge to potentially reduce the risk of becoming homeless again. This capstone experience will take place within the Indianapolis VAMC domiciliary and be focused towards veterans that are not already employed or lack the confidence and skills needed to obtain employment. Program development and education will be the main focus of this capstone experience. Theory. The Person-Environment-Occupation-Performance (PEOP) model was used to guide this doctoral capstone experience as this model focuses on daily occupations and increased occupational performance with these occupations using clientcentered care (Cole & Tufano, 2008). This relates to this capstone experience as it focuses on incorporating occupation-based practice within the domiciliary to increase self-confidence and occupational performance for the occupation of work/productivity. The PEOP theory also takes into consideration factors such as the person, his or her environment, and his or her desired occupations that impact their occupational performance (Cole & Tufano, 2008). This is relevant when working with a communitybased homeless and mental health population as these individuals environments and daily occupations are often perceived as barriers that negatively impact their occupational PRE-EMPLOYMENT SKILLS FOR VETERANS 8 performance. Based on the PEOP model, these barriers can be assessed and addressed with interventions focused on reducing these barriers (Cole & Tufano, 2008). Assessment techniques incorporating the use of the PEOP focus on strengths and weaknesses that impact occupational performance. In order to address these weaknesses and build upon strengths, interventions incorporate strategies such as increasing selfefficacy, occupation-related resources and tasks as well as motivation factors (Cole & Tufano, 2008). These are all techniques that were employed by this doctoral capstone in order to enhance the skills needed to develop mastery over the occupation of work/productivity to increase occupational performance. Richard L. Roudebush VAMC Domiciliary. The Domiciliary Care program is the oldest healthcare program implemented through the U.S. Department of Veteran Affairs. This program was established in the 1860s and was implemented to home soldiers with disabilities of the civil war as well as soldiers of lower socioeconomic status. The domiciliary still encompasses homeless veterans but has now transitioned into a clinical setting incorporating veterans with mental health diagnoses. The domiciliary also now incorporates Mental Health Residential Rehabilitation and Treatment Programs (MH RRTPs). These programs incorporate classes, groups, and individual treatment sessions facilitated by healthcare professionals such as clinical psychologists, clinical pharmacists, clinical licensed social workers, and recreational therapists. These classes and groups are geared toward addressing the veterans homelessness, addiction recovery, coping skills, discovering healthy leisure activities, and addressing aspects of gaining independence within the community such as obtaining housing, job skills training, preemployment training, money management, and medication management. The PRE-EMPLOYMENT SKILLS FOR VETERANS 9 Indianapolis domiciliary is a 50-bed facility that has an average stay of 90 to 180 days (U.S. Department of Veteran Affairs, n.d.). Role of Occupational Therapy. Occupational therapists have the potential to create a substantial impact within a community-based mental health setting. Occupational therapists can incorporate occupation-based practice within this type of setting in order to implement graded practice to increase self-esteem and self-confidence of clients. According to Krupa et al. (2009, p.156), The actual doing of occupations is believed to be transformative, promoting adaptation, creating personal and social identities, connecting people to their communities, and enabling personal growth and development. Occupation-based practice is within the skill set of an occupational therapy practitioner due to expertise in occupational performance, activity analysis and design, environmental analysis, neurophysiology, psychosocial development, and group dynamics (American Occupational Therapy Association [AOTA], 2016, p.1). Occupational therapy practitioners are also qualified to specifically address the specific needs of the veteran population by focusing on skills needed for successful transitioning and re-entry back into the community (AOTA, 2016). Community reintegration for veterans is an emerging area of practice within the field occupational therapy due to the increased number of veterans returning from combat with mental health issues (AOTA, n.d.). The profession of occupational therapy also has a distinct value when addressing the needs of the homeless population. When addressing this population, occupational therapists focus on the occupational deprivation and injustices these individuals experience. According to the Occupational Therapy Practice Framework: Domain and PRE-EMPLOYMENT SKILLS FOR VETERANS 10 Process, 3rd edition (AOTA, 2014), occupational justice is a concept that is imbedded within the profession. Occupational justice is described as a justice that recognizes occupational rights to inclusive participation in everyday occupations for all persons in society, regardless of age, ability, gender, social class, or other differences (AOTA, 2014, p.S9). As noted within this framework, occupational therapy practitioners have the qualifications to recognize the occupational injustices individuals in the homeless population may face and use this information to create interventions focused on enhancing advocacy and self-esteem within the community (AOTA, 2014). Review of Literature. When reviewing occupation-based practice that provides community-based services for the homeless and mental health population, there is a lack of evidence focusing on the use of this practice when implementing pre-employment skills. According to a prior Cochrane review, when examining employment interventions that focus on training of interpersonal skills such as assertiveness and self-esteem, the effectiveness of such interventions is unknown due to a lack of evidence (Thomas, Gray & McGinty, 2010). Although there is a lack of evidence within this area of practice, there has been some research that supports occupation-based interventions within the homeless and mental health population. According to Herzberg, Ray and Swenson Miller (2009), results from the Ansell-Casey Life Skill Assessment and Quiz demonstrates effectiveness in the use of life skills interventions used within their study, which included interventions such as the use of mock interviews, resume building, and interview skills. In another study comparing the effectiveness of a life skills group versus a group focusing on recreation in an inpatient psychiatric hospital, the life skills group demonstrated more PRE-EMPLOYMENT SKILLS FOR VETERANS 11 improvement in skill acquisition in relation to community reintegration (Gibson, DAmico, Jaffe & Arbesman, 2011). Results from a systematic review indicate interventions implemented by an occupational therapy practitioner should enhance employment and educational resources for individuals that are homeless (Thomas, Gray & McGinty, 2011). Needs Assessment According to Scaffa and Reitz (2014), a needs assessment can be interpreted as an organized manner of determining the needs, roots of issues and future strategies to assist with improving an organization. A specific need can be determined as the gaps in what is currently being implemented within an organization and what is needed for future organization expansion (Scaffa & Reitz, 2014). Several components were utilized to assess the needs of the population and organization at the domiciliary in Indianapolis. The data collection methods of secondary archival data search, face-to-face interviews and community forums were the main components used in this process (Scaffa & Reitz, 2014). These methods were used due to the availability of the resources, ability to obtain multiple viewpoints as well as build rapport with the organization and clients residing within the domiciliary (Scaffa & Reitz, 2014). Secondary archival data search was utilized by accessing peer-reviewed journals on the University of Indianapolis Library database. These articles were used to identify the occupational performance needs and effective programs implemented within similar settings and populations as the Indianapolis VA domiciliary. PRE-EMPLOYMENT SKILLS FOR VETERANS 12 Observations of the different classes offered at the domiciliary were conducted as one aspect of the needs assessment. These classes were led by clinical social workers, clinical pharmacists, clinical psychologists, recreational therapists and employment specialists. The classes focused on aspects such as identifying healthy coping strategies, financial planning, therapeutic arts, and relapse prevention. One on one interviews were also held with a large number of the staff in the domiciliary in order for these professionals to describe their role and identify areas in their current programming where there were gaps. Attending business, interdisciplinary team, and community meetings were also part of the needs assessment process. At the interdisciplinary team meetings, common issues of the veterans were examined and possible solutions were collaboratively discussed among the team. Community meetings involved both staff and veterans at the domiciliary. During these meetings, issues at the domiciliary were discussed and veterans were able to discuss any issues they may be experiencing within their care at the domiciliary. Lastly, at the business meetings, program development and continuous quality improvement ideas were discussed among the interdisciplinary team members. Statistics were often examined during the business meetings in order to assess program effectiveness. Based off the strategies implemented during the needs assessment, the concept of lack of occupation-based practice was evident, specifically when focusing on the vocational rehabilitation sector of the domiciliary. As reported by the employment specialist, chief of the domiciliary and veterans at the site there was a lack of time and resources for veterans to work on their resume with assistance from the employment specialist. The employment specialist has several one on one meetings throughout the day PRE-EMPLOYMENT SKILLS FOR VETERANS 13 with veterans and has one 2-hour slot per week where she is accessible to assist the veterans with creating resumes or practicing interview skills. A large number of the veterans also lack the knowledge, resources, computer skills and confidence to be able to create a resume independently. As a result, during one on one sessions the employment specialist typically had to create a resume for them instead of allowing them to do this independently with verbal cueing and step by step guidance. This leaves the veterans unable to engage in the task themselves, which inhibits their ability to demonstrate independence and self-efficacy in these performance skills. Based on these results, the concept of a pre-employment skills group focusing on resume building and interview skills was confirmed. The program was designated to focus on the group level of programming in order to incorporate demonstration, practice strategies and social support to assist with skill development (Scaffa & Reitz, 2014). Once this program development idea was confirmed, goals and objectives were created in order to establish accountability and create specific, measurable, and performance based programming (Scaffa & Reitz, 2014). When examining other occupational performance needs of similar populations and settings there are several areas that compare and differ to the needs currently present at the domiciliary in Indianapolis. According to Herzberg and Finlayson (2001), one of the main barriers at a homeless shelter in Ft. Lauderdale, Florida was a lack of time and space to implement programming. Strategies utilized in the needs assessment of this homeless shelter were participant observation, focus groups with the individuals residing in the homeless shelter and interviews with staff working at the facility. As a result of this needs assessment, the occupational performance needs were: pre-employment skills PRE-EMPLOYMENT SKILLS FOR VETERANS 14 training, stress management techniques training, self-care training, social skills training and community living management training (Herzberg & Finlayson, 2001). At a homeless shelter located in Canada, the Canadian Occupational Performance Measure (COPM) was utilized in the needs assessment and identified the top eight occupational performance needs as: employment, social relationships, active recreation, quiet recreation, finances, housing, return to school and personal care (Tryssenaar, Jones, & Lee, 1999). According to Tryssenaar et al. (1999), physical, psychosocial and financial issues were among the main barriers that led to these individuals occupational performance needs. In a study examining the young veteran population on a university campus, the COPM was utilized to assess the occupational performance needs of veterans ages 20-29 years old. In the leisure category on the COPM, social participation and formation of relationships were noted as the largest barriers. Within the category of productivity, the top two major school challenges were described as being unable to relate to other classmates as well as not having the skills to be successful with academic coursework. Participants listed some examples of these skills as difficulty with concentration and the ability to relearn skills needed for this environment. In relation to the self-care section, veterans ranked weight gain and lack of sleep as occupational performance challenges that they were experiencing (Plach & Sells, 2013). Research was conducted from an outpatient mental health program where a life skills recovery curriculum was offered. Individuals with a dual diagnosis, an individual with a mental health diagnosis and substance abuse disorder, were participants in this life skills group. Occupational performance areas such as ADLs, time management, stress PRE-EMPLOYMENT SKILLS FOR VETERANS 15 management and social skills were noted as areas of improvement needed prior to the life skills recovery curriculum being implemented (Precin, 2016). Implementation phase This doctoral capstone experience lasted from January of 2018 to April of 2018. The needs assessment process took place in the month of January and lasted approximately three weeks. Information was gathered during the needs assessment to formulate the most prominent gaps of program implementation within the site. It was identified that current programming, specifically focused on employment services, could incorporate more occupation based methods within the current system. From this information, a workshop was designed in order to increase confidence and knowledge with pre-employment skills for the homeless veteran population at the domiciliary. Recruitment. The program implementation phase was initiated with recruitment of residents to be involved in the pre-employment skills workshop series. Recruitment techniques involved announcements of the workshop at the community meetings two weeks prior to the workshop taking place. This also involved distributing flyers about the workshop at the community meetings each week. The workshop was also listed in the domiciliary program that was distributed monthly to inform residents of classes that were available each month. Volunteers within the professional VA community were also recruited to assist with implementing the mock interview portion of the workshop. These volunteers were recruited using snowball sampling as the recreational therapist at the site was able to disseminate the information about the mock interviews along to her fellow colleagues at the VA Medical Center. Three volunteers confirmed to assist with this phase of the workshop series by being the interviewer for the mock interviews. PRE-EMPLOYMENT SKILLS FOR VETERANS 16 Participants. Participants for the workshop included veterans residing at the Indianapolis domiciliary with interest in further expanding their pre-employment skills to enhance their ability to obtain employment. The veterans that participated in the workshop all had a status of being homeless as well as had a mental illness or substance use disorder. Mental health diagnoses represented within the group consisted of depression and PTSD. Substance use disorder diagnoses represented within the group consisted of alcohol dependence and opioid dependence. Procedure. Collaboration took place with the employment specialist in order to organize workshop sessions and incorporate resources to assist with this process. From this collaboration, a four series workshop was designed with a focus of a different theme each week. Sessions held each week were approximately 45 minutes to one-hour long and incorporated themes of focus for each week such as resume building, interview skills, mock interview practice and workshop reflection. The first two sessions of the preemployment skills workshop involved use of a PowerPoint to disseminate information to the veterans. The first sessions PowerPoint incorporated information related to resume building skills such as different types of resumes, sections to include on a resume and appropriate wording to use on a resume (see Appendix C). After this, the veterans were provided with ample time to work on their resumes with assistance when needed. The second sessions PowerPoint included information relevant to interview performance skills. This PowerPoint included strategies for how to prepare for an interview and how to perform well during an interview (see Appendix D). After the veterans were provided resources over this topic, mock interviews were performed with their peers. For the third session, the veterans engaged in a mock interview with individuals from the professional PRE-EMPLOYMENT SKILLS FOR VETERANS 17 VA community. An occupational therapy manager, physical therapy manager and member of the veterans council at the VA medical center were among the volunteers to participate in this process. The interviewers were provided with a list of 10 performance based interview questions to ask the veterans throughout the interview process (see Appendix B). Veterans participated in a 15-20-minute mock interview and then received brief feedback over their performance. Lastly, during the fourth session of the workshop the veterans participated in a reflective experience that focused on what was learned throughout the sessions, overall group feedback from the mock interviews and veterans feedback about the workshop experience. This session was organized as a discussion format and veterans were able to provide any feedback they felt comfortable to share. The employment specialist was present each session of the workshop in order to monitor the group and provide assistance when needed. Outcome Measure. The effectiveness of the program was measured with pre and post surveys administered at the first session and the fourth session of the workshop (see Appendix A). Surveys incorporated use of a 5-point likert scale to measure the veterans level of confidence with these pre-employment skills before and after the workshop. The scoring for the 5-point likert scale consisted of 5=strongly disagree, 4=disagree, 3=neutral, 2=agree and 1=strongly agree. Upon administration of the workshop series, nine veterans completed pre-surveys and three veterans completed a post-survey due to drop outs from the workshop. Drop outs from the workshop were caused by medical appointments the veterans had to attend at the same time as the workshop or lack of interest in further attending the workshop. In order to ensure confidentiality of the outcome measures, the surveys were stored in the recreational therapy office at the VA PRE-EMPLOYMENT SKILLS FOR VETERANS 18 domiciliary, which was locked and a key was required to get in by any staff member. After data was collected from the surveys for the internal program evaluation, the evidence was destroyed using a file shredder. Leadership. Leadership was demonstrated through coordinating with the staff at the domiciliary in order to implement the pre-employment skills program. Collaboration with the recreational therapist was an essential component of this process in order to develop effective recruitment techniques to secure veterans attendance in the group as well as secure volunteers to assist with the mock interviews. Collaboration was also needed when working with the employment specialist to establish the goals of the group as well as collect any resources needed to assist with the group process. Effective communication with veterans, staff and volunteers was needed in order to disseminate information such as components of the workshop. This was also required to help with coordinating a time and place for where and when the workshop would take place. Responsibility was assumed for creating and gathering any materials needed to implement the workshop each week. Lastly, communication with the volunteers for the mock interviews was needed to acquire information about veterans performance and integrate this information into the final session for the workshop. Staff Development. Upon establishing the workshop at the domiciliary, staff was educated over the purpose and plan for the workshop. Staff was able to effectively use this knowledge when recommending workshops for veterans to attend that would benefit them. In order to promote staff development in relation to this doctoral capstone project. Staff members were provided with education about the workshop and the effectiveness of PRE-EMPLOYMENT SKILLS FOR VETERANS 19 the workshop thus far. Discussion of the workshops effectiveness will assist in justifying the importance of carrying on the workshop once the doctoral capstone was finished. Outcomes The first round of the pre-employment skills workshop was completed on February 28th, 2018. Nine veterans participated in the first session of the workshop. At the second session, four new veterans attended and two of the same veterans returned to participate. All six of these veterans signed up to participate in the mock interviews to be held the following week. All veterans returned to participate in the mock interviews. In the following session, five out of the six veterans returned to receive group feedback about the mock interviews as well as provide feedback about their experience of the preemployment skills workshop. Feedback discussed during the final session was disseminated in a discussion format and veterans responded with questions when appropriate. Veterans then provided feedback over their workshop experiences. Main comments from veterans consisted of: more games to be incorporated into the sessions to remain engaged as well as more one on one feedback about mock interview performance. The employment specialist, as well as volunteers, were also provided with a written forum to submit feedback about the workshop experience. Feedback received from the employment specialist suggested that changing the workshop to a closed group would better ensure the same veterans would be attending all four of the group sessions. This would also provide more reliable data to assess effectiveness of workshop. The majority of volunteer feedback suggested the idea of providing simpler interview questions for the veterans to answer. This was because the volunteers felt as if the questions were too PRE-EMPLOYMENT SKILLS FOR VETERANS 20 difficult for the veterans to answer as the questions were derived from a list of performance based interviewing questions. Three veterans completed all four sessions of the workshop, therefore the results from from the pre and post surveys were recorded and synthesized for these three participants only. There were eight questions presented on the pre and post survey focusing on level of confidence and knowledge of resume building and interview skills. Each of these questions was scored using a likert scale with 1=strongly disagree, 2=disagree, 3=neutral, 4=agree and 5=strongly agree. For the pre-survey, the average score for all eight questions for participant 1 was three, four for participant 2, and three for participant 3. For the post-survey, participant 1 had an average score of 4.6, participant 2 had an average score of five, and participant 3 had an average score of five when combining the average score for all eight questions. These scores indicated that after each participant attended all four sessions of the workshop, their confidence and knowledge of the material increased as a result. Sustainability. In order to sustain the pre-employment skills program, a resource binder was created with all the information needed to implement the workshop. This binder includes PowerPoints focused on resume building and interview skills created specifically for the program. The binder also includes names and contact information for the volunteers that participated in the mock interviews so that these individuals can be conveniently contacted in the future. The same participant recruitment techniques will be utilized to gain veteran participation. This includes making flyers to hand out, as well as making announcements at community meetings each week. Veterans will also be responsible for signing up for each class in order to get an accurate number of how many PRE-EMPLOYMENT SKILLS FOR VETERANS 21 individuals will be participating in the workshop each time. Currently, the workshop includes four one-hour long sessions that are held each week of the month. Since staff does not have time to implement this class weekly, sessions will be reduced to two two-hour long sessions. The resume building session as well as the interview skills session will be combined into one session as a result of this. These group sessions will also only be offered every other month as opposed to monthly. There is great potential for an additional employment specialist to be added to the staff in the near future. If this occurs, the new employment specialist will take on the responsibilities of this workshop as part of her job role. If another employment specialist is not hired the current employment specialist will take on the role of this program. The current employment specialist has attended all four sessions of the workshop, therefore understands the process of the program and expectations that need to be met for each session. The current employment specialist will also be able to train the new employment specialist if one is hired to the team. The pre and post surveys will continue to be utilized in order to track progress made throughout the workshop. These surveys will be updated as seen fit by the employment specialist. The data obtained from the surveys will be input to an excel document to keep track of long-term success of the program. The employment specialist will continue to receive verbal feedback or create an open-ended review form to obtain feedback from the veterans about the program. This information will continue to be obtained during the last session of the workshop so that adjustments can be made prior to the next round of the workshop if necessary. The employment specialist will also have a PRE-EMPLOYMENT SKILLS FOR VETERANS 22 colleague observe one session every three months to identify any improvements that can be made from this perspective. Responding to needs of society. During the needs assessment, it was identified that there was a lack of occupation-based practice, especially within the vocational rehabilitation sector the Indianapolis domiciliary. It was also determined that the veterans within this facility lack the confidence and education in order to successfully and independently create a resume as well as perform well in an interview. This notion was also identified by Livingston and Miller (2006), as noted that homeless individuals often lack the ability to obtain and maintain employment. The lack of ability to obtain and maintain employment often leads to continued homelessness for these veterans. By responding to the employment needs of these veterans, this will allow these individuals to increase their stability within this aspect of their life in order to decrease their chance of becoming homeless again. Overall Learning. Professional interaction was demonstrated in a variety forms throughout the doctoral capstone experience. Written communication was demonstrated via email, surveys, PowerPoints and flyers. Professional emails were sent to staff within the domiciliary as well as at the Veterans Affairs Medical Center in order to set up meetings as well as recruit volunteers to participate in doctoral capstone experience. Surveys were utilized in order to effectively assess the veterans confidence level with resume and interview skills before and after workshop was implemented. PowerPoints were utilized during workshop experience to disseminate information regarding resume building and interview skills. Lastly, flyers were created and distributed to the veterans as PRE-EMPLOYMENT SKILLS FOR VETERANS 23 reminders of when the workshop would take place and what the focus of the workshop would consist of each week. Oral communication was also presented in multiple forms throughout this experience. During community meetings with domiciliary staff and veterans, announcements were made pertaining to information related to the pre-employment skills workshop. Oral communication was utilized during workshop to disseminate information as well as answer questions from the veterans. This form of professional communication was also utilized while interacting with staff, volunteers and the veterans during group sessions and meetings. Non-verbal communication was also an imperative aspect of demonstrating professionalism throughout the doctoral capstone experience. During staff meetings, professional non-verbal communication was demonstrated by sitting up and remaining alert and engaged throughout the duration of the meeting. This type of communication was also needed with one on one meetings with site mentor to demonstrate that constructive feedback was appreciated and understood. There is a significant importance in professional communication when working with other professionals, organizations, clients and their families. From this experience, I have learned that all types of professional communication are important in establishing rapport as well as creating a sense of credibility for yourself as a professional. From this experience, I have learned the process of completing a needs assessment for an organization, creating and implementing programming, how to measure effectiveness of programming, making adjustments to enhance programming and creating a plan for program sustainability. I have also learned that new programming tends to take several PRE-EMPLOYMENT SKILLS FOR VETERANS months before it becomes successful. Through this experience, I discovered how to identify issues with programming as well as make changes to the issues in order to enhance program effectiveness. As a future occupational therapist, these are valuable skills to bring to any organization in order to enhance patient care as well as program development. 24 PRE-EMPLOYMENT SKILLS FOR VETERANS 25 References American Occupational Therapy Association. (2014). Occupational therapy practice framework: Domain and process (3rd ed.). American Journal of Occupational Therapy, 68(Suppl. 1), S1-S48. American Occupational Therapy Association. (2016). Occupational therapys distinct value: mental health promotion, prevention, and intervention across the lifespan. Retrieved from https://www.aota.org/~/media/Corporate/Files/Practice/MentalHealth/DistinctValue-Mental-Health.pdf American Occupational Therapy Association. (n.d). Veterans and wounded warriors mental health. Retrieved from https://www.aota.org/Practice/MentalHealth/Emerging-Niche/Veteran.aspx American Psychological Association (n.d.). The mental health needs of veterans, service members and their families. Retrieved from https://www.apa.org/advocacy/military-veterans/mental-health-needs.pdf Applewhite, S. L. (1997). Homeless veterans: perspectives on social services use. Social Work, 42(1), 19-30. Cole, M.B., & Tufano, R. (2008). Applied theories in occupational therapy: A practical approach. Thorofare, NJ: SLACK, Inc. Conrad, K. J., Hultman, C. I., Pope, A. R., Lyons, J. S., Baxter, W. C., Daghenstani, A. N., et al. (1998). Case managed residential care for homeless addicted veterans: Results of a true experiment. Medical Care, 36, 40-53. PRE-EMPLOYMENT SKILLS FOR VETERANS 26 Driscoll, J. (November, 2006). Report of the veteran homelessness work groups at the national symposium for the needs of young veterans. Retrieved from http://www.nchv.org/images/uploads/Causes_of_Homelessness_Work_Group_Re port.NCHV_.2_.pdf Gibson, R. W., DAmico, M., Jaffe, L., & Arbesman, M. (2011). Occupational therapy interventions for recovery in the areas of community integration and normative life roles for adults with serious mental illness: A systematic review. American Journal of Occupational Therapy, 65, 247256. doi: 10.5014/ajot.2011.001297 Herzberg, G., & Finlayson, M. (2001). Development of occupational therapy in a homeless shelter. Occupational Therapy In Health Care, 13(3-4), 131-144. doi:10.1080/J003v13n03_11 Herzberg, G., Ray, S., Swenson Miller, K. (2009). The status of occupational therapy: addressing the needs of people experiencing homelessness. Occupational Therapy In Health Care. Krupa, T., Fossey, E., Anthony, W. A., Brown, C., & Pitts, D. B. (2009). Doing daily life: How occupational therapy can inform psychiatric rehabilitation practice. Psychiatric Rehabilitation Journal, 32, 155161. Livingston, B. W. & Miller, K. S. (2006). Systems of care for persons who are homeless in the United States. Occupational Therapy in Health Care, 20, 31-46. National Coalition for Homeless Veterans. (n.d.). FAQ about homeless veterans. Retrieved from http://nchv.org/index.php/news/media/background_and_statistics/ PRE-EMPLOYMENT SKILLS FOR VETERANS 27 Plach, H.L., & Sells, C.H. (2013). Occupational performance needs of young veterans. American Journal of Occupational Therapy, 67, 73-81. http://dx.doi.org/10.5014/ajot.2013.003871 Precin, P. (2016). Effectiveness of the living skills curriculum on dual diagnosis clients. American Journal of Occupational Therapy, 70. doi:10.5014/ajot.2016.70S1RP101A Rosenheck, R., & Fontana, A. (1994). A model of homelessness among male veterans of the Vietnam War generation. American Journal of Psychiatry, 151, 421-427. Scaffa, M., & Reitz, S.M. (2014). Occupational therapy in community-based practice settings (2nd ed.). Philadelphia, PA: FA Davis Company. Thomas, Y., Gray, M., & McGinty, S. (2011). A systematic review of occupational therapy interventions with homeless people. Occupational Therapy In Health Care, 25(1), 38-53. doi:10.3109/07380577.2010.528554 Tryssenaar, J., Jones, E. J., & Lee, D. (1999). Occupational performance needs of a shelter population. Canadian Journal Of Occupational Therapy. Revue Canadienne D'ergotherapie, 66(4), 188-196. U.S. Department of Veteran Affairs. (n.d.). Domiciliary care for homeless veterans program. Retrieved from https://www.va.gov/homeless/dchv.asp PRE-EMPLOYMENT SKILLS FOR VETERANS 28 Appendix A Pre-employment skills group pre-survey Strongly Disagree-----1-----2-----3-----4-----5-----Strongly Agree 1. I feel confident while participating in a job interview. 1 2 3 4 5 2. I am able to articulate my work skills successfully on a resume and during an interview. 1 2 3 4 5 3. I understand the steps to take to prepare for an interview. 1 2 3 4 5 4. I practice before completing an interview (performing a mock interview with a peer). 1 2 3 4 5 5. I feel confident in my ability to organize a resume. 1 2 3 4 5 6. Participating in a mock interview before completing a job interview would be beneficial. 1 2 3 4 5 7. I have an understanding of appropriate social skills needed in order to successfully complete a job interview. 1 2 3 4 5 8. I understand what key features to include on a resume in order to best represent myself to an employer. 1 2 3 4 5 PRE-EMPLOYMENT SKILLS FOR VETERANS 29 Pre-employment skills group post-survey Strongly Disagree-----1-----2-----3-----4-----5-----Strongly Agree 1. My confidence level has increased in relation to participating in a job interview. 1 2 3 4 5 2. I have a better understanding of how to articulate my work skills successfully on a resume and during an interview. 1 2 3 4 5 3. I understand the steps to take to prepare for an interview. 1 2 3 4 5 4. I will start to practice before completing an interview (performing a mock interview with a peer). 1 2 3 4 5 5. I feel more confident in my ability to organize a resume. 1 2 3 4 5 6. Participating in a mock interview before completing a job interview was beneficial. 1 2 3 4 5 7. I have an understanding of appropriate social skills needed in order to successfully complete a job interview. 1 2 3 4 5 8. I have a better understanding of what key features to include on a resume in order to best represent myself to an employer. 1 2 3 4 5 PRE-EMPLOYMENT SKILLS FOR VETERANS 30 Appendix B Interview questions: 1. Describe a change in your work you have personally had to make in the last couple years. At the time, how did you feel about making the change? What did you do to make the change? 2. What is your biggest weakness? 3. Give a specific example of a time when you had to deal with an angry customer. What was the problem and what was the outcome? What was your role in diffusing the situation? 4. Describe a situation where you felt you had not communicated well. How did you correct the situation? 5. Describe a time when you worked as a member of a team to accomplish a goal of your organization. What role did you play? 6. Describe a negative work experience you learned from. Describe the circumstances and give an example to show you applied the learning to a work situation. 7. Give two examples of things you've done in previous jobs that demonstrate your willingness to work hard. 8. Give me a specific example of a time when you used good judgment and logic in solving a problem. 9. What is your typical way of dealing with conflict? Give me an example. What have you learned from dealing with conflict? 10. Describe a time when you went over and above your job expectation. PRE-EMPLOYMENT SKILLS FOR VETERANS Appendix C PRE-EMPLOYMENT SKILLS WORKSHOP SESSION #1 WHAT IS OCCUPATIONAL THERAPY? The therapeutic use of everyday life activities (occupations) with individuals or groups for the purpose of enhancing or enabling participation in roles, habits, and routines in home, school, workplace, community, and other settings. Occupational therapy incorporates knowledge of the person, their environment, and valued occupations in order to implement occupation-based intervention plans. Types of occupations: ADLs, IADLs, rest and sleep, education, work, play, leisure, and social participation 31 PRE-EMPLOYMENT SKILLS FOR VETERANS TIMELINE Workshop agenda: Session #1: Resources on resume building. Session #2: Resources on interview skills and mock interview with peers. Session #3: Mock interview with individual from the community. Session #4: Reflection/wrap up of workshop INTRODUCTION Pre-survey Name What do you hope to gain from this workshop? 32 PRE-EMPLOYMENT SKILLS FOR VETERANS IT ALL STARTS WITH THE RESUME Purpose of Resume: Leave a lasting first impression on the prospective employer you are applying to. Opportunity to sell yourself. Demonstrate your strengths Past achievements Get an interview! RESUME LAYOUT Two main formats: Chronological Functional Should be clean, neat, and organized Include name, address, email and phone number to make it easier for employer to contact you. 1-2 pages Should be easy to read Bullet points Clear language 33 PRE-EMPLOYMENT SKILLS FOR VETERANS CHRONOLOGICAL RESUME Typically works well for individuals with a strong, solid work history. Lists work histories with the most recent work history listed first. Most employers prefer a chronological resume. FUNCTIONAL RESUME Focuses on skills and experience rather than chronological work history. Instead of a work history section this might include a professional experience or accomplishments section. May not list employment history at all or just include a brief bullet pointed list of work history at the bottom of the resume. May be beneficial for individuals switching careers, with employment gaps, or those that are new to the workforce. 34 PRE-EMPLOYMENT SKILLS FOR VETERANS 35 COMPONENTS OF RESUME: o -Professional summary or objective o -Education o -Experience PROFESSIONAL SUMMARY VS. OBJECTIVE Objectives can be used if specific and clear. Should be tailored towards the employer and job you are applying to. Objective Examples: For Career Changers: Accomplished administrator seeking to leverage extensive background in personnel management, recruitment, employee relations and benefits administration in an entry-level human resources position. Extremely motivated for career change goal and eager to contribute to a company's HR division. Entry-Level Workers: Dedicated CIS graduate pursuing a help-desk position. When Targeting a Specific Position: Elementary teacher for ABC School District. A professional summary is becoming the new objective. 3-5 sentence paragraph summarizing skills, experience, education, and accomplishments. Do not use I statements. Professional Summary Example: Experienced precision machinist with extensive knowledge of production and distribution environments. Superior manufacturing and mechanical skills. Electrical installation and maintenance experience. Excellent attention to detail and precise tasks. PRE-EMPLOYMENT SKILLS FOR VETERANS PROFESSIONAL EXPERIENCE This section should incorporate skills and accomplishments related to work positions from the past or present. Provide specific details of duties performed, tools/equipment, responsibilities and accomplishments within the workplace. Use Action verbs (past tense for previous employment and present tense for current employment) No first person language (I, me, we) Use Problem, Action, Result format for Accomplishment statements Example: Resolved employee grievances by introducing dispute resolution process, lowering grievance rates by 50% in the first year. EXAMPLES OF ACTION VERBS 36 PRE-EMPLOYMENT SKILLS FOR VETERANS MILITARY EXPERIENCE Can be included within professional experience section or stand alone as its own section. Include same information as non-military related employment. Civilianize job, roles, and terms related to your job. Incorporate accomplishments Demonstrate awards and recognitions received and WHY you received them. MILITARY EXPERIENCE EXAMPLE Job title: Infantry Fight Vehicle Operator/Commanders Radio Transmitter operator o Operated and maintained heavy equipment vital to the success of the organization; oversaw daily operations, policy compliance and standard operating procedure compliance of all aspects of tracked vehicle. o Hand selected by senior leadership to serve as commanders aide; only junior leader chosen for position out of 100 applicants. o Maintained various weapons for marksmanship training and daily use; resulted in 100 percent accountability of assigned weapons with zero defect in functions due to proper maintenance. o Received award for competence and performance during a highly stressful training exercise and recognized as being in the top tenth percentile of peers. 37 PRE-EMPLOYMENT SKILLS FOR VETERANS ACTIVITY: PROFESSIONAL EXPERIENCES REFLECTION Think of three skills needed to perform your job in the military or in a previous work environment. Discuss with a partner how these three skills can assist you within the type of job you are currently wanting to apply for? EDUCATION Formal education and degrees awarded Can include college credit hours in relevant topic areas, when degree is not awarded yet. Any specialized training High-school does not need to be included if you have post-secondary education. 38 PRE-EMPLOYMENT SKILLS FOR VETERANS QUICK TIPS: Keep resumes up to date. Customize your resume to fit the job you are applying for. Have 3-4 reliable references Confirm it is okay to have them as a reference Cant think of a reference from a previous work environment? consider other experiences such as volunteering, previous professors, etc. Double check for spelling and grammar errors! Have a peer read through your resume Save as a PDF if possible This will eliminate formatting errors when turning in a resume online. WORK TIME Free time to work on resume and ask questions. Homework: complete or update current resume using strategies learned in todays session and bring to next weeks session. 39 PRE-EMPLOYMENT SKILLS FOR VETERANS Appendix D INTERVIEW SUCCESS SESSION #2 PURPOSE OF AN INTERVIEW v Allows you to demonstrate skills and qualifications in a way that the company will invite you back to be an employee. v How can you benefit the company? v What is different about you than other applicants? v An interview also gives you a chance to understand the company and the position they are trying to fill. v Is the company and job position a good match for you? 40 PRE-EMPLOYMENT SKILLS FOR VETERANS HOW DO I PREPARE FOR AN INTERVIEW? v Research the company or organization! v Know the companys mission, vision, and values v The internet can be a helpful resource to find this information. v Prepare a list of 2-3 questions to ask after the interview is over. v Research potential interview questions. v Practice! ACTIVITY 1: What are some appropriate questions to ask at the end of an interview? 41 PRE-EMPLOYMENT SKILLS FOR VETERANS APPEARANCE & PREPAREDNESS v First impressions are everything! v Always dress for success (Business Casual and no jeans) v Shake hands with everyone upon entering the room and introduce yourself. v Bring multiple copies of your resume and have one in front of you during the interview. v Bring a professional notebook with you to take notes throughout the interview. IMPORTANCE OF PROMPTNESS vPrint out directions the day before your interview. vIf able, perform a test drive to the company the day before your interview to avoid getting lost. vBeing on time is late, and being early is on time! vArrive 10-15 minutes early for your interview. 42 PRE-EMPLOYMENT SKILLS FOR VETERANS COMMUNICATION STRATEGIES v Avoid talking with your hands. v Speak clearly and loud enough v Pay attention to your posture while sitting (Try not to slouch!) v Make eye contact! v Turn cell phones off or silence them. v Try to answer questions within 20 seconds. ATTITUDE DURING INTERVIEW v Be confident! (but dont be over confident) v Smile and be positive v Be interested and engaged in the conversation. v Be open and honest v Be a good listener 43 PRE-EMPLOYMENT SKILLS FOR VETERANS ADDRESSING YOUR WEAKNESSES: Turn your weaknesses into a positive! Demonstrate how you address your negatives. For example: Im really disorganized but I have been trying to use a planner and this really helps me to stay organized and accountable. When asked how did you handle conflict in a workplace If you did not handle conflict well, demonstrate how you have learned from this experience and the steps you would take to handle conflict differently the next time. QUICK TIPS: v Dont ask about money at the first interview. v Ask each of the interviewers for their business cards. v Send a thank you email or card to each of the interviewers after the interview. v Dont criticize previous employers. 44 PRE-EMPLOYMENT SKILLS FOR VETERANS ACTIVITY 2: Choose a partner and perform a mock interview with them. Use the list of questions provided. Next week you will participate in a mock interview with individuals with managerial experience from the community. https://www.va.gov/PBI/questions.asp This is a great resource to assist with preparing for future interviews by reading these questions and thinking/rehearsing how you would answer them. Utilize Level I and II questions when practicing. 45  ...

... Running head: IMPLEMENTATION OF A NICU DEVELOPMENTAL SKILLS FAIR Implementation of a Developmental Skills Fair in a Neonatal Intensive Care Unit Meghan Winter Crull May, 2018 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: Alison Nichols, OTR, OTD IMPLEMENTATION OF A NICU DEVELOPMENTAL SKILLS FAIR A Capstone Project Entitled Implementation of a Developmental Skills Fair in a Neonatal Intensive Care Unit Submitted to the School of Occupational Therapy at University of Indianapolis in partial fulfillment for the requirements of the Doctor of Occupational Therapy degree. By Meghan Winter Crull Doctorate of Occupational Therapy Student Approved by: Faculty Capstone Advisor Date Doctoral Capstone Coordinator Date Accepted on this date by the Chair of the School of Occupational Therapy: Chair, School of Occupational Therapy Date 2 IMPLEMENTATION OF A NICU DEVELOPMENTAL SKILLS FAIR 3 Abstract The Doctoral Capstone Experience encapsulated integrating evidence, clinical skills, and occupational theory into an interprofessional education session to set a standard of practice in the Neonatal Intensive Care Unit (NICU) at Eskenazi Health. The purpose of the Developmental Skills Fair was to collaboratively provide education on developmentally supportive care to the NICU nursing staff of Eskenazi Health to promote an evidence-based standard of practice. Research was gathered on the seven Core Measures of Developmental Care and the neuroprotective interventions of family-centered care, positioning, cycled lighting, safe sleep, noise/sound control, infant-driven feeding, kangaroo mother care, and infant massage into daily practice. Education was provided via poster sessions and a positioning in-service was held by a representative from Dandle Lion Medical. Nurses completed a pre-/post-test survey to assess knowledge on developmental care and measure effectiveness and nursing perceptions of the Developmental Skills Fair. There was an improvement in knowledge on developmentally supportive care following the education session, noted by an overall increase in post-test survey scores. The majority of nurses also strongly agreed that they had gained knowledge and the standard of practice would improve due to the Developmental Skills Fair. The information gathered will be used to provide further education and continue to improve the standard of practice in the NICU. IMPLEMENTATION OF A NICU DEVELOPMENTAL SKILLS FAIR 4 Implementation of a Developmental Skills Fair in the Neonatal Intensive Care Unit In 2015, approximately 10% of infants in the United States were born prematurely, many of them being treated by physicians, nurses, and therapists within a Neonatal Intensive Care Unit (NICU) (Martin, Hamilton, Osterman, Driscoll, & Mathews, 2015). While the focus of the infants care is typically on physical and motor delays, it is also important to consider and treat their developing sensory systems. Altimier and Phillips (2016) stated that a large portion of neurodevelopment occurs within the third trimester of gestation; however, premature infants typically spend this critical period of development in a NICU, a significantly different environment than the uterus. When infants experience stimulation that is inappropriate for their gestational age, it has the ability to alter the course of their brain and sensory development (Altimier & Phillips, 2016). Therefore, it is imperative that healthcare professionals within the NICU protect and support the neurodevelopment of premature infants. The Neonatal Integrative Developmental Care Model (Altimier & Phillips, 2016) aims to improve the care and experience infants receive while in the NICU by promoting neuroprotective and family-centered care. Neuroprotective care incorporates strategies that prevent cell death and harm to the infants developing central nervous system (Altimier & Phillips, 2016). There are seven core measures that outline evidence-based and developmentally supportive protocols: healing environment, partnering with families, positioning and handling, safeguarding sleep, minimizing stress and pain, protecting skin, and optimizing nutrition (Altimier & Phillips, 2016). The earlier an infant is born, the more vulnerable its central nervous system is, and the more crucial it is to invoke effective and consistent developmentally supportive and neuroprotective care. Occupational therapists can implement the seven core measures of developmental care under the theory of Occupational Adaptation, originally published by Janet Schkade and Sally IMPLEMENTATION OF A NICU DEVELOPMENTAL SKILLS FAIR 5 Shultz in 1992. The focus of this theory is the person and his or her relationship with their occupational environment (Cole & Tufano, 2008), and therefore the premature infant in the NICU. Occupational Adaptation has four guiding constructs: occupations, adaptive capacity, relative mastery, and occupational adaptation process (Cole & Tufano, 2008). The occupations of an infant are to sleep, eat, and engage in play as to develop their sensory organization, fine and gross motor skills, cognition, and social skills (Case-Smith & OBrien, 2015). When an infant is born prematurely, they miss the rapid-brain growth that occurs within the third trimester (Madlinger-Lewis et al., 2014; Waitzman, 2007) and the proprioceptive feedback from the uterus that promotes physiological flexion (flexion of the shoulders, hips, and knees, scapular protraction, and posterior pelvic tilt) (Madlinger-Lewis et al., 2014). Infants are driven toward mastery of their occupations, but if they are in an unsupportive and overstimulating environment, their capacity for adaptation is notably limited. Occupational therapists can create a supportive environment by using the Neonatal Integrative Developmental Care Model to formulate neuroprotective interventions and encourage the adaptive processes of the infant. Occupational therapists can also provide education on these developmentally supportive interventions to the health care professionals that care for infants in a NICU for consistent neuroprotective care. Implementing developmental care within the NICU allows the infant to grow, develop, and focus on their engagement and mastery of desired occupations. Occupational therapys role within the NICU is to focus on, the interaction among the biological, developmental, and social-emotional aspects of human function as expressed in daily activities and occupations (Vergara et al., 2006). Developmentally supportive techniques can be implemented by therapists as well as the nurses who are with the infants every hour of each day. Promoting the coordination of care across all NICU disciplines ensures consistent IMPLEMENTATION OF A NICU DEVELOPMENTAL SKILLS FAIR 6 developmentally supportive care. Research suggests that team training, collaboration, and communication are necessary to achieve common goals (Smith & Cole, 2009). Hospitals around the nation have been implementing educational programs that focus on the seven core measures of neurodevelopment in their NICUs with success (Altimier, Kenner, & Damus, 2015; Mosqueda-Pena et al., 2016). To create a standard of practice that reflects the Neonatal Integrative Developmental Care Model, the developmental care team at Eskenazi Health implemented a Developmental Skills Fair. Evidence-based principles and protocols were presented with the purpose of educating NICU staff on neuroprotective and developmentally supportive interventions to create a standardization of practice. Background & Significance Current research supports the implementation of developmentally supportive interventions including family-centered care (Coughlin, Gibbins, & Hoath, 2009; Lester et al., 2011; McGrath & Samra, 2011; Ramezani, Shirazi, Sarvestani, & Moattari, 2014; Trajkovski, Schmied, Vickers, & Jackson, 2012; Vohr et al., 2006), positioning (Altimier & Phillips, 2016; Hartley, Miller, & Gephart, 2015; Hill, Engle, Jorgensen, Kralik, & Whitman, 2005; MadlingerLewis et al., 2014; Sweeney & Gutierrez, 2002), cycled lighting (Guyer et al., 2012; Morag & Ohlsson, 2013; Vasquez-Ruiz et al., 2014), safe sleep (Altimier & Phillips, 2016; Dufer & Godfrey, 2017; Moon, 2017), noise and sound control (Almadhoob & Ohlsson, 2015; American Academy of Pediatrics, 1997; Graven & Brown, 2008; Lahav & Skoe, 2014; Parra, deSuremain, Audeoud, Ego, & Debillon, 2017; Wachman & Lahav, 2011), infant-driven feeding (Foster, Psaila, & Patterson, 2016; Gewolb, Vice, Schwietzer-Kennedy, Tociak, & Bosma, 2001; Wellington & Perlman, 2015), kangaroo mother care (Altimier & Phillips, 2016; Athanasopoulou & Fox, 2014; Boundy et al., 2017; Clark-Gambelunghe & Clark, 2015; IMPLEMENTATION OF A NICU DEVELOPMENTAL SKILLS FAIR 7 Cleveland et al., 2017; Feldman, Eidelman, Sirota & Weller, 2002; Feldman, Rosenthal & Eidelman, 2014; Gianni et al., 2016; Lawn, Mwansa-Kambafwile, Horta, Barros & Cousnes, 2010; Ludington-Hoe, Anderson, Swinth, Thompson & Hadeed, 2004), and infant massage (Cooke, 2015; Diego, Field, & Hernandez-Reif, 2014; Field, Diego, & Hernandez-Reif, 2010; Beachy, 2003; Kulkarni, Kaushik, Gupta, Sharma, & Agrawal, 2010). These interventions, individually and collectively, provide a premature infant with the adaptive capacity to overcome the physiological barriers impeding their occupational performance. Family-Centered Care Family-centered care (FCC) promotes developmentally supportive care by educating and engaging parents in neuroprotective practices while their infant is in the NICU. Medical staff, including nurses, therapists, and physicians, can implement FCC into their daily practice through equal family participation, maintenance of respect and dignity, and knowledge transformation. Equal family participation considers family members to be an active participant in the daily care of the infant, collaborating on the planning, regulating, and implementation of care (McGrath & Samra, 2011). Maintaining respect and dignity requires medical staff to view and treat the family with the understanding that they have the most significant role in providing for the infants current and future developmental and societal needs (Ramezani et al., 2014). Knowledge transformation between healthcare professionals and family is required for optimal care of the infant. Education to families should be provided in accordance with the familys level of education and in a variety of learning styles, including visually, orally, and through demonstration (Trajkovski et al., 2012). Research suggests that these examples of FCC may decrease length of stay (Coughlin, Gibbins, & Hoath, 2009) and improve family perception of responsibility and capability of care towards the infant (McGrath & Samra, 2011), maternal IMPLEMENTATION OF A NICU DEVELOPMENTAL SKILLS FAIR 8 mental health (Lester et al., 2011), family satisfaction (Lester et al., 2011), parent-infant attachment (Ramezani et al., 2014), well-being of the infant (Ramezani et al., 2014), and opportunities for breast feeding and skin-to-skin contact (Vohr et al., 2006). Research also suggests that the first step toward implementing FCC is to provide education and support to nursing staff for improved perception and effectiveness of incorporating FCC into daily practice (Trajkovski et al., 2012). Client-centered care is a cornerstone of occupational therapy practice and involving parents in the everyday care of their infant will enable them to assist with the infants occupations and their adaptation of performance long after they leave the NICU. Positioning Positioning aides provide proprioception and comfort to the infant by simulating the borders of a uterine wall (Altimier & Phillips, 2016). Placing the infant in physiological flexion promotes proper joint alignment, bone density, neuromuscular development, brain development, and organization for state control (Altimier & Phillips, 2016; Madlinger-Lewis et al., 2014). An infant left in an extension pattern is at risk for a disruption in the development of motor skills, state control (Hill et al., 2005), and oral motor skills (Madlinger-Lewis et al., 2014). Offering facilitated tuck into a position of physiological flexion has also shown to reduce the expression of pain in premature infants (Hartley, Miller, & Gephart, 2015). Supportive positioning also improves symmetrical development, which is crucial for early development, reflex and motor responses (Madlinger-Lewis et al., 2014), and shaping the musculoskeletal system (Sweeney & Gutierrez, 2002). An example of a positioning aide is the Dandle-Roo, which is a structured blanket made of stretchable, organic cotton with adjustable straps for the upper extremities, a pouch for the lower extremities, and a head boundary (Dandle Lion Medical, 2012, August 8). Madlinger-Lewis et al. (2014) supported the use of the Dandle-Roo to increase symmetry of IMPLEMENTATION OF A NICU DEVELOPMENTAL SKILLS FAIR 9 reflexes and motor responses with preterm infants. The core measure of supportive positioning with a swaddle or positional aides enables an infant to feel organized. It teaches them an adaptive process of self-soothing by bringing their hands to midline, up to the mouth, and into the other hand. This teaches the infant sensory organization needed to engage in a variety of occupations. Cycled Lighting Cycled lighting is the adjustment of lighting throughout the day to imitate a typical environment, with the goal of decreasing overstimulation of the infants developing visual system. When implementing cycled lighting, the lights are on for approximately 12 hours during the day with a three-hour period of dim lighting to encourage rest. After the 12-hour day period, the lights are off and blinds are down throughout the night. Research suggests that cycled lighting promotes weight gain (Guyer et al., 2017; Vasquez-Ruiz et al, 2012), stabilization of heart rate (Vasquez-Ruiz et al., 2012), and maturation of behavioral state regulation (Guyer et al., 2017). Guyer et al. (2017) also found that cycled lighting elicited a significant decrease in fussing and crying behavior. Morag & Ohlsson (2013) found that cycled lighting on dimmers trended towards more favorable outcomes than constant darkness or brightness in a NICU. Implementing cycled lighting coincides with the core measures of creating a healing environment and protecting sleep. An increase in weight gain and an improvement in state control sets the infant up for success when learning how to adapt to their sensory environment and perform meaningful occupations. Safe Sleep Sleep is a time for brain growth, and premature infants require this time for the development of neurological pathways. Sleep deprivation can affect behavior and brain function in the long-term, because of a reduction in brain plasticity (Altimier & Phillips, 2016). Therefore, IMPLEMENTATION OF A NICU DEVELOPMENTAL SKILLS FAIR 10 it is important that infants are not awakened unless necessary. It is also imperative that the safe sleep protocol is implemented for developmentally appropriate infants. The American Academy of Pediatrics recommends that infants sleep on their backs up until their first birthday, on a firm surface such as a safety approved crib, in the same room as their parents for the first six months of life, and without any soft objects or loose bedding in the crib (Moon, 2017). It is important to model safe sleep within the NICU as well as educate parents before infant discharge. Dufer & Godfrey (2017) found that a safe sleep handout and educational session increased parental knowledge of the safe sleep recommendations and significantly improved compliance after the infant was discharged home. Allowing an infant to rest, modeling safe sleep, and providing parents with education in the NICU follows the core measure of safeguarding sleep and partnering with families. It also allows for optimal brain development that infants need to focus on their occupations and adapt to the demand for mastery. Noise and Sound Control Auditory overstimulation of the infant can impair the development of their immature auditory system and may contribute to the development of language and attention disorders (Lahav & Skoe, 2014). A functional vestibular system completes formation at approximately 2529 weeks gestation and the hair cells of the ear can lose their sensitivity to pitch if exposed to sound levels of 60 decibels (dBA) or greater (AAP, 1997; Graven & Brown, 2008). The American Academy of Pediatrics (1997) recommended that sound levels in the room of an infant in a NICU remain under 45 dBA. For comparison, 40 dBA is the quiet noise in a typical home, whereas 60 dBA is the moderate noise of a normal conversation (AAP, 1997). Inside an incubator, less than 30 dBA is required for maintaining a sleep state (AAP, 1997), which is necessary for growth (Altimier & Phillips, 2016). Parra et al. (2017) reported that the noise of IMPLEMENTATION OF A NICU DEVELOPMENTAL SKILLS FAIR 11 conversation and device alarms are the two main sources of increased noise that can be controlled. Preterm infants typically have decreased autonomic and self-regulatory control due to their immaturity, which is why loud sounds and higher frequencies can affect their physiological stability (Wachman & Lahav, 2011). More specifically, those noises can increase the stress on the infant, which causes an increase in metabolic rate and therefore expending calories needed for optimal growth (Almadhoob & Ohlsson, 2015). Managing the auditory stimulation within an infants room supports the core measures of creating a healing environment and minimizing stress. This encourages the brain development and adaptive properties crucial for mastery of occupations. Infant-Driven Feeding Preterm infants are at an increased risk for feeding difficulties due to possible poor suck, swallow, and breathe reflex coordination; autonomic instability; and less organized sleep-wake cycles (Gewolb et al., 2001). Therefore, the developmentally supportive practice of cue-based, or infant-driven, feeding has been implemented in NICUs with research suggesting overall benefits for infants and their providers (Wellington & Perlman, 2015). Emphasis is placed on quality of feeding with an infant-driven feeding protocol, allowing the infant to determine when they feed and the amount they consume orally (Wellington & Perlman, 2015). When non-nutritive sucking on a pacifier was used in coordination with gavage feedings, Foster, Psaila, and Patterson (2016) found significant improvements in transitions from gavage to full oral feedings and a decrease in hospital length of stay. Wellington & Perlman (2015) found that when waiting for infants to demonstrate cuing and readiness, they quickly advanced to full feeds, were discharged earlier, and nurses recorded less time spent feeding. Following an infant-driven feeding protocol follows the core measure of optimizing nutrition and ensures that the occupation of feeding and eating IMPLEMENTATION OF A NICU DEVELOPMENTAL SKILLS FAIR 12 remains positive and pleasurable. This takes away environmental pressures, supporting the infants learning of adaptive processes. Kangaroo Mother Care At the foundation of the Neonatal Integrative Developmental Care Model is Kangaroo Mother Care (KMC) because skin-to-skin contact (SSC) is the most normal environment for newborns (Altimier & Phillips, 2016). KMC is defined by the World Health Organization (2017) as a method that involves early, continuous, and prolonged skin-to-skin contact between an infant and their mother or father. At birth, the tactile senses of the infant are the most developed of the sensory pathways (Clark-Gambelunghe & Clark, 2015), which correlates with the research that states KMC can be significantly beneficial for an infant as well as its mother (Athanasopoulou & Fox, 2014; Boundy et al., 2017; Cleveland et al., 2017; Feldman et al., 2002; Feldman, Rosenthal & Eidelman, 2014; Lawn et al., 2010; Ludington-Hoe et al., 2004). Feldman, Rosenthal, and Eidelman (2014) found that KMC increased autonomic functioning and enhanced the infants cognitive development, executive functioning, organized sleep, and stress response from six months to 10 years of age. Maternal attachment behavior and a reduction in maternal anxiety were also noted (Feldman, Rosenthal & Eidelman, 2014). Research has shown that KMC decreases infant infection rates (Lawn et al., 2010), mortality, risk of sepsis, hypothermia, hypoglycemia, pain measures, and hospital readmission (Boundy et al., 2017). KMC also improves cardiorespiratory and thermal stability (Boundy et al., 2017), duration of breastfeeding and milk production (Gianni et al., 2016), infant to parent interactions (Athanasopoulou & Fox, 2014), neurodevelopmental outcomes (Feldman et al., 2002; Feldman, Rosenthal & Eidelman, 2014), head-circumference growth (Boundy et al., 2017), and sleep patterns (Ludington-Hoe et al., 2004). KMC embodies each of the seven core principles by IMPLEMENTATION OF A NICU DEVELOPMENTAL SKILLS FAIR 13 providing a safe and supportive environment, keeping the family as active participants, facilitating supportive positioning, contributing to regulation of the sleep cycle, minimizing stress and pain, supporting thermoregulation, and improving the mothers milk supply (Altimier & Phillips, 2016). Skin-to-skin contact provides an infant with the skills to adapt to their new environment and master their desired occupations. Infant Massage The skin is the largest organ in the human body, and at birth, the tactile sense of an infant is the most developed sensory system (Clark-Gambelunghe & Clark, 2015). Reportedly 95% of touch experienced by an infant in a NICU is not intentionally comforting (Smith, 2012), which is why providing intervention specifically for infant comfort is so important. Research suggests that infant massage with oil promotes weight gain (Beachy, 2003; Cooke, 2015; Diego, Field, & Hernandez-Reif, 2014; Field, Diego, & Hernandez-Reif, 2010; Kulkarni et al., 2010), improves sleep-wake patterns (Kulkarni et al., 2010), enhances neuromotor development (Kulkarni et al., 2010), facilitates parent-infant bonding (Cooke, 2015; Field, Diego, & Hernandez-Reif, 2010; Kulkarni et al., 2010), and reduces hospital length of stay (Beachy, 2003; Field, Diego, & Hernandez-Reif, 2010; Kulkarni et al., 2010). Field, Diego, and Hernandez-Reif (2010) found that using coconut oil during an infant massage was significantly more effective than mineral oil or powder in infant weight gain and decreasing hospital length of stay. Promoting infant massage in the NICU facilitates the core measures of partnering with families, minimizing stress and pain, and protecting skin. Infant massage improves the infants weight gain and body awareness, which is crucial for the adaptive skills required for optimal performance in desired occupations. IMPLEMENTATION OF A NICU DEVELOPMENTAL SKILLS FAIR 14 Summary of Literature The literature supports a collaborative education session to implement a neuroprotective and developmentally supportive standard of practice based on the Seven Core Measures of Developmental Care (Smith & Cole, 2009; Altimier, Kenner, & Damus, 2015; Mosqueda-Pena et al., 2016). Therefore, with the Neonatal Integrative Developmental Care Model as a guide, the developmental team at Eskenazi Health developed seven stations led by the occupational and speech therapy team members. The therapy-driven portion of the skills fair focused on the following developmental care target areas: family-centered care, positioning, cycled lighting, safe sleep, noise and sound control, infant-driven feeding, kangaroo mother care, and infant massage. The purpose of the therapy-driven portion of the developmental skills fair was to provide education on neuroprotective and developmentally supportive protocols to create a standardized practice within the NICU. It is important to continuously consider the infants developing occupations and the developmentally supportive ways that caregivers in the NICU can use the Occupational Adaptation theory to enable infants for occupational adaptation and eventual mastery of their occupations. Screening and Evaluation The concept of implementing a therapy-based portion within the Developmental Skills Fair was originally introduced in the fall of 2017 by members of the Developmental Care Committee. The developmental care team consists of representatives from nursing management, nursing staff, occupational therapy, and speech therapy who meet once a month to discuss the status of the NICU with an interdisciplinary approach. The developmental care team collaboratively discussed the concept of holding educational sessions for the staff to address issues mentioned by team members. To achieve a better understanding of the issues that led to IMPLEMENTATION OF A NICU DEVELOPMENTAL SKILLS FAIR 15 the formation of a developmental skills fair, I interviewed members of the developmental care team via email. While I was not an original member of the developmental care team, it was crucial to understand the complexity of care within the NICU and the roles each member plays. Two members of nursing management and four members of the therapy department were interviewed on their view of the necessity for a developmental skills fair, the issues seen in everyday practice, and their goals for the fair. One member stated that many nurses and other staff members turn to therapists to deliver developmental supportive care (T. Rexroat, personal communication, February 12, 2018) and although other members stated that the level of care in the NICU had increasingly become developmentally driven, daily practice could continue to improve (D. Tingley, personal communication, February 9, 2018; K. Panther, personal communication, February 6, 2018; T. Galyan, personal communication, January 30, 2018). Members stated that there needed to be a shift in practice to become more developmentally based and infant-driven (K. Panther, personal communication, February 6, 2018) and that our therapy expertise in developmentally supportive and neuroprotective protocols could assist the nurses in their everyday care of infants (D. Tingley, personal communication, February 9, 2018). One member stated that the nurses felt as though they needed more training and many new nurses were interested in more education (D. Arnold, personal communication, February 6, 2018). Members felt that a group-based education session would be an effective method to get a single message of developmental care across to all members of the nursing staff while offering an opportunity for discussion (D. Arnold, personal communication, February 6, 2018; T. Galyan, personal communication, January 30, 2018; T. Rexroat, personal communication, February 12, 2018). IMPLEMENTATION OF A NICU DEVELOPMENTAL SKILLS FAIR 16 Members noted inconsistencies both at the individual (D. Tingley, personal communication, February 9, 2018, K. Panther, personal communication, February 6, 2018) and organizational level (D. Arnold, personal communication, February 6, 2018; T. Galyan, personal communication, January 30, 2018), as well as a desire from all disciplines for more education (D. Arnold, personal communication, February 6, 2018; D. Tingley, personal communication, February 9, 2018; K. Panther, personal communication, February 6, 2018; S. Felker, personal communication, February 10, 2018; T. Galyan, personal communication, January 30, 2018; T. Rexroat, personal communication, February 12, 2018). There are many members of the nursing staff that do not directly work with either occupational or speech therapists due to only working night shifts or weekend shifts, so it is more difficult for those nurses to understand the role of therapy, the purpose of developmentally supportive recommendations, and how to implement the level of neuroprotective care required (T. Rexroat, personal communication, February 12, 2018). Compared to other areas of practice, the specialized knowledge required to work in a NICU is vast, which requires time dedicated to continuing education and advancing skills (Vergara et al., 2006). Experience in pediatric care is important for NICU practice because an understanding of typical and atypical development is required. In addition to standard education and pediatric experience, advanced clinical reasoning and skills are required due to the fragility and immaturity of many of the infants (Vergara et al., 2006). A standard of neuroprotective and developmentally supportive care would ensure best practice as Eskenazi Health plans to transition to a Level III NICU, where more advanced skills are required (D. Tingley, personal communication, February 9, 2018, K. Panther, personal communication, February 6, 2018; S. Felker, personal communication, February 10, 2018). In contrast to other NICUs in the area, members stated that the developmental care team at Eskenazi Health continuously strive toward IMPLEMENTATION OF A NICU DEVELOPMENTAL SKILLS FAIR 17 improving their evidence-based level of care (D. Tingley, personal communication, February 9, 2018) and supported advancing standards of developmental based care (S. Felker, personal communication, February 10, 2018) with continuous, daily support from therapists (T. Rexroat, personal communication, February 12, 2018). To address the needs delineated by the developmental care team, an interdisciplinary approach was necessary for a successful education session (Petri, 2010). Therefore, the team scheduled the developmental skills fair to coincide with a mandatory skills fair for all NICU nursing staff. Goals for this educational session were to increase a consistency of developmentally based care (K. Panther, personal communication, February 6, 2018, T. Galyan, personal communication, January 30, 2018), provide an opportunity for the nurses to ask questions and improve skills (D. Arnold, personal communication, February 6, 2018; T. Rexroat, personal communication, February 12, 2018), initiate a shift in everyday practice to become more infant-driven (S. Felker, personal communication, February 10, 2018) and developmentally supportive (D. Tingley, personal communication, February 9, 2018), and to test the effectiveness of the therapy portion of the developmental skills fair (S. Felker, personal communication, February 10, 2018). Using evidence-based research to structure the fair, the developmental care team created education sessions that covered family-centered care, cycled lighting, noise and sound control, safe sleep, kangaroo mother care, infant-driven feeding, positioning, and infant massage as well as coordinated with a representative from Dandle Lion Medical for a positioning in-service. Implementation Planning for the developmental skills fair included monthly meetings with the entire developmental care committee and continuous communication with the therapy team members IMPLEMENTATION OF A NICU DEVELOPMENTAL SKILLS FAIR 18 and nursing management, either in person or through email. Planning also required obtaining research and feedback from the therapy team members to provide evidence-based and developmentally supportive information. The research and feedback were used to create questions for a pre-/post-test survey (Appendix A; Appendix B) as well as the posters for the session (Appendix C). All of the information shared at the developmental skills fair was checked to ensure compliance of Eskenazi Healths NICU policies and procedures. The Developmental Skills Fair session dates and times were confirmed and shared with all of the nursing staff, including a letter that explained our purpose, goals, and appreciation. The dates and times for the fair were spread over five days at different times of day to offer a session for all nursing staff, including those who typically work the day shift, night shift, weekend shift, or are contracted PRN. Prior to arriving at the fair, the nurses were sent an email containing a Google Forms link to sign up for a session and completed the pre-test survey. The nurses completed multiple stations during the session, including hospital-wide skills tests, therapy-based poster sessions, and a positioning in-service hosted by a representative from Dandle Lion Medical. The pre-/post-test survey and the therapy-based poster sessions covered the following topics of developmental care: family-centered care, positioning, cycled lighting, safe sleep, noise and sound control, infant-driven feeding, kangaroo mother care, and infant massage. Two therapists covered the poster sessions at the fair by introducing the topic, the evidence that supports it, and how to best implement it into everyday practice. A handout with the evidence was available for each poster session upon request. The therapists were available to answer questions as well as converse with nursing staff on the covered topics. After the completion of the therapy-based portion of the fair, it was required that the nurses complete a paper form of the post-test survey before leaving. The pre-/post-test survey included two questions covering basics IMPLEMENTATION OF A NICU DEVELOPMENTAL SKILLS FAIR 19 of developmental care, two questions on cycled lighting protocols, one question on noise levels in the NICU, two questions on infant-driven feeding, one question on safe sleep protocol, three questions regarding positioning, two questions on KMC, one question on infant massage, and one question on family-centered care in the NICU. The posttest survey included two additional questions on a likert scale regarding perception and successfulness of the therapy-driven portion of the fair. The post-test survey questions were compared and analyzed with the corresponding pre-test survey questions. Leadership Skills & Promotion of Staff Development I demonstrated leadership skills by taking the initiative to communicate with each member of the developmental care team either in person, during developmental care committee meetings, or via email. A specific strategy that I implemented was a pre-/post-test questionnaire administered to understand the knowledge learned on developmentally based care as well as successfulness of the therapy portion of the developmental skills fair. The pre-/post-test focused on professional skills and competencies required for optimal and evidence-based care within the NICU. Issuing a pre-/post-test ensured that staff had the opportunity to improve their professional skills and competencies within the NICU. I also demonstrated leadership skills by organizing the sessions posters, handouts, questions, and themes. I attended and led each poster session throughout the developmental skills fair. I also coordinated with the Dandle Lion Medical representative for each in-service session to assist with set-up and clean-up as well as troubleshoot any issues. I demonstrated leadership skills and professionalism throughout the planning, implementation, and discontinuation of the project by being available for anyone with questions, open to feedback, prepared for each session and in-service, and independent with all tasks associated with the skills fair. IMPLEMENTATION OF A NICU DEVELOPMENTAL SKILLS FAIR 20 The main goal of the developmental skills fair was to educate nursing staff on developmentally supportive care to ensure an evidence-based and neuroprotective standard of care. The sessions on family-centered care, cycled lighting, safe sleep, noise/sound control, infant-driven feeding, KMC, and infant massage are interventions specifically aimed to shift everyday practice towards developmentally focused. The education provided directly relates to the nurses everyday roles and responsibilities in the NICU and will promote standardized practice. The developmental skills fair offered nursing staff the opportunity to advance their knowledge and skills, ask questions, and improve their overall understanding of developmentally supportive care. Discontinuation & Outcome A strategy identified and developed to enable occupational therapys future education efforts in the NICU was the implementation of a pre-/post-test survey (Appendix A; Appendix B). The purpose of the survey was to measure nursing knowledge on developmentally based care. A total of 54 nurses took the pre-test survey to the implementation of the developmental skills fair. The scores ranged from 6 to 14 points with an average of 11.41 out of a total possible score of 14 points. The most frequently missed question was one that asked to select one picture of four options in which demonstrated the incorrect use of a positioning aide. Half of the nurses (27 nurses) answered this question incorrectly. Other frequently missed questions concerned safe sleep, with 32% answering incorrectly, and appropriate sound levels, with 30% answering incorrectly. After the completion of the developmental skills fair, the 54 post-test survey scores were analyzed and compared with the pre-test survey scores. The post-test survey scores ranged from 12 to 14 points and averaged 13.63 out of a total 14 possible points. The average improvement from pre-test survey score was 2.15 points. The improvement in scores indicates IMPLEMENTATION OF A NICU DEVELOPMENTAL SKILLS FAIR 21 that the educational poster session was successful in improving the overall knowledge of the nursing staff. The survey also offered an insight into the areas in which the therapists in the NICU should focus on for future nursing education. As previously stated, the questions covering positioning, safe sleep, and noise/sound control were the most frequently missed. Therefore, future education could continue to focus on these topics of developmentally support care to ensure neuroprotective care in the NICU. A quality improvement measure that was put into place was asking for nursing perception of the developmental skills fair. Questions were asked using a Likert scale, with answer options ranging from strongly agree to strongly disagree. The majority of the nurses (74%) strongly agreed that they gained knowledge from the educational session and thought the education provided at the session would improve standard of practice in the NICU. Feedback and barriers to practice were also verbally received from nurses during the poster session, documented, and shared with the therapy team. Feedback from the therapy team was also gathered to measure perception of success, areas for improvement, and ideas for future plans. Future education will be provided by the therapy team members and will include the use of the posters and information handouts created for the developmental skills fair. One poster used for the education session could be displayed each month in the NICU, for not only nurses to see but also physicians, medical students, respiratory therapists, and parents. The poster of the month can also include an email update on current or new research, answers to questions gathered during the skills fair, or other information pertaining to the topic of the month. The therapy team and developmental care team can coordinate this monthly education in the future. Future program changes or advancements could also include a follow-up with nursing staff during daily care to ensure developmentally supportive care. Therapists could also select IMPLEMENTATION OF A NICU DEVELOPMENTAL SKILLS FAIR 22 Positioning Champions, members of the nursing staff who are competent in developmentally supportive positioning and can advocate and ensure proper positioning. The Positioning Champions could collaborate with therapy team leaders to then create a competency check-off on positioning for new nurses working in the NICU. The therapy team could also extend developmentally supportive care education to the respiratory therapists, residents, and medical students rotating through the NICU. A continuation of the program can include handouts made from the posters and evidence for future nurses or residents who join the NICU care team. The developmental skills fair, as well as future education and programs, respond to societys need of developmentally supportive care for infants in the NICU. Nursing staff, as demonstrated through the pre-/post-test survey, gained knowledge on developmentally supportive care that will improve the standard of practice in their NICU. Those improvements in care will benefit infants and their families for years to come. A high standard of practice is also necessary as Eskenazi plans to transition to a Level III NICU. Treating younger and sicker infants demands consistent developmentally support care, and the developmental skills fair helps answer the need for that level of care. Overall Learning The Doctoral Capstone Experience advanced my clinical practice skills by implementing a project that required collecting evidence, collaborating with both occupational and speech therapists, evaluating and treating NICU infants independently, and educating other health professionals. The time I spent working alongside another occupational therapist in the NICU enhanced my clinical skills and decision making when evaluating and planning interventions for infants. I gained incredible amounts of knowledge in occupational therapy practice in the NICU, as well as the best ways to collaborate with other health professionals and advocate for the role IMPLEMENTATION OF A NICU DEVELOPMENTAL SKILLS FAIR 23 of occupational therapy. The project required me to work collaboratively with four other therapists, while representing their roles in the NICU. I was required to be sensitive to and respectful of their goals for the fair, requests for information on the posters, needs regarding presenting at the fair, and their individual schedules. The education portion of the Doctoral Capstone Experience required the utmost professionalism, as I had to provide evidence-based information to many nurses that have been working for many years, as well as those not familiar with the role of occupational therapists in the NICU. I had to ensure effective and respectful communication when delivering the education on developmental based care. I explained my role in and the purpose of the Developmental Skills Fair and the pre-/post-test survey. I provided education in an informative, yet engaging and respectful manner to all of the nurses. The interaction with these healthcare professionals was an integral part of the experience. The skills that I gained while working with a variety of healthcare professionals and implementing an education session surpassed the knowledge and experience that I gained in previous fieldwork rotations. The Doctoral Capstone Experience and Project not only required the skills of an entry-level occupational therapy practitioner, but the professionalism and independence of a doctoral-level occupational therapist. The Doctoral Capstone Experience and Project, among many things, has prepared me for a more advanced and well-rounded role as an occupational therapy practitioner. Similar to many other entry-level graduates, I will enter into my first career feeling comfortable and competent in my clinical and decision-making skills. Although in contrast with other entry-level graduates, I will be interested in and capable of implementing evidence-based practice, engaging with other professionals in collaborative care, advocating for my role as an occupational therapist, and creating projects that respond to societys need and advance the level of care in the area I work. IMPLEMENTATION OF A NICU DEVELOPMENTAL SKILLS FAIR 24 References Almadhoob, A., & Ohlsson, A. (2015). Sound reduction management in the neonatal intensive care unit for preterm or very low birth weight infants. The Cochrane Database of Systematic Reviews, 1. doi: 10.1002/14651858.CD010333.pub2 Altimier, L., Kenner, C., & Damus, K. (2015). The Wee Care Neuroprotective NICU Program (Wee Care): The effect of a comprehensive developmental care training program on seven neuroprotective core measures for family-centered developmental care of premature neonates. Newborn & Infant Nursing Reviews 15, 6-16. Altimier, L., & Phillips, R. M. (2016). The neonatal integrative developmental care model: Seven neuroprotective core measures for family-centered developmental care. Newborn & Infant Nursing Reviews, 16, 230-244. Athanasopoulou, E., & Fox, J. R. (2014). Effects of kangaroo mother care on maternal mood and interaction patterns between parents and their preterm, low birth weight infants: A systematic review. Infant Mental Health Journal, 35(3), 245-262. American Academy of Pediatrics. (1997). Noise: A hazard for the fetus and newborn. Pediatrics, 100(4). doi: 10.1542/peds.100.4.724 Beachy, J. (2003). Premature Infant Massage in the NICU. Neonatal Network, 3(7), 39-45. doi: 10.1891/0730-0832.22.3.39 Boundy, E. O. Dastjerdi, R., Spiegelman, D., Fawzi, W. W., Missmer, S. A., Lieberman, E., & Chan, G. J. (2017). Kangaroo mother care and neonatal outcomes: A meta-anaylsis. Pediatrics, 137(1). Case-Smith, J., & OBrien, J. C. (2015). Occupational therapy for children and adolescents. St. Louis, MO: Elsevier. IMPLEMENTATION OF A NICU DEVELOPMENTAL SKILLS FAIR 25 Clark-Gambelunghe, M. B., & Clark, D. A. (2015). Sensory development. Pediatrics of North America, 62(2), 367-384. Cleveland, L. Hill, C. M., Pulse, W. S., DiCioccio, H. C., Field, T., & White-Traut, R. (2017). Systematic review of skin-to-skin care for full-term, health newborns. Journal of Obstetric, Gynecologic, & Neonatal Nursing, 46(6), 857-869. doi: 10.1016/j.jogn. 2017.08.005. Cole, M. B., & Tufano, R. (2008). Applied theory in occupational therapy: A practical approach. Thorofare, New Jersey: SLACK Incorporated. Cooke, A. (2015). Infant massage: The practice and evidence-base to support it. British Journal of Midwifery, 23(3). doi: 10.12968/bjom.2015.23.3.166 Coughlin, M., Gibbins, S., & Hoath, S. (2009). Core measures for developmentally supportive care in neonatal intensive care units: theory, precedence and practice. Journal of Advanced Nursing, 65(10), 2239-2248. doi: 10.1111/j.1365-2648.2009.05052.x Dandle Lion Medical (2012, August 8). Dandle Roo. Dufer, H., & Godfrey, K. (2017). Integration of safe sleep and Sudden Infant Death Syndrome (SIDS) education among parents of preterm infants in the Neonatal Intensive Care Unit (NICU). Journal Of Neonatal Nursing, 23(2), 103-108. doi:10.1016/j.jnn.2016.09.001 Diego, M. A., Field, T., & Hernandez-Reif, M. (2014). Preterm infant weight gain is increased by massage therapy and exercise via different underlying mechanisms. Early Human Development, 90(3), 137-140. doi: 10.1016/j.earlhumdev.2014.01.009 Feldman, R., Eidelman, A. I., Sirota, L., & Weller, A. (2002). Comparison of skin-to-skin (kangaroo) and traditional care: Parenting outcomes and preterm infant development. Pediatrics 110(1), 16-26. IMPLEMENTATION OF A NICU DEVELOPMENTAL SKILLS FAIR 26 Feldman, R., Rosenthal, Z., & Eidelman, A. I. (2014). Maternal-preterm skin-to-skin contact enhances child physiological organization and cognitive control across the first 10 years of life. Biological Psychology, 75, 56-64 Field, T., Diego, M., & Hernandez-Reif, M. (2010). Preterm infant massage therapy research: A review. Infant Behavior and Development, 33(2), 115-124. doi: 10.1016/j.infbeh. 2009.12.004 Foster, J. P., Psaila, K., & Patterson, T. (2016). Non-nutritive sucking for increasing physiological stability and nutrition in preterm infants. Cochrane Database of Systematic Reviews, 10. doi: 10.1002/14651858.CD001071.pub3. Gewolb, I. H., Vice, F. L., Schwietzer-Kennedy, E. L., Tociak, V. L., & Bosma, J. F. (2001). Developmental patterns of rhythmic suck and swallow in preterm infants. Developmental Medicine and Child Neurology, 43, 22-27. Gianni, M. L., Bezze, E., Sannino, P., Stori, E., Pievani, L., Roggero, P., & Mosca, F. (2016). Facilitators and barriers of breastfeeding late preterm infants according to mothers experiences. Biomed Central Pediatrics, 16(1), 179. Graven, S. N., & Browne, J. V. (2008). Auditory development in the fetus and infant. Newborn & Infant Nursing Reviews, 8(4), 187-193 Guyer, C. Huber, R., Fontijn J., Bucher, H. U., Nicolai, H., Werner, H., & Jenni, O. G. (2012). Cycled light exposure reduces fussing and crying in very preterm infants. Pediatrics, 30(1). doi: 10.1542/peds.2011-2671 Hartley K. A., Miller, C. S., & Gephart, S. M. (2015) Facilitated tucking to reduce pain in neonates evidence for best practice. Advances in Neonatal Care,15(3), 201-08. IMPLEMENTATION OF A NICU DEVELOPMENTAL SKILLS FAIR 27 Hill, S., Engle, S., Jorgensen, J., Kralik, A., & Whitman, K. (2005). Effects of facilitated tucking during routine care of infants born preterm. Pediatric Physical Therapy, 17(2), 158-163 Kulkarni, A., Kaushik, J. S., Gupta, P., Sharma, H., & Agrawal, R. K. (2010). Massage and touch therapy in neonates: The current evidence. Indian Pediatrics, 47(9), 771-776. Lahav, A. & Skoe, E. (2014) An acoustic gap between the NICU and womb: A potential risk for compromised neuroplasticity of the auditory system in preterm infants. Frontiers in Neuroscience, 8, 381. Lawn, J. E., Mwansa-Kambafwile, J., Horta, B. L., Barros, F. C., & Cousnes, S. (2010). Kangaroo care to prevent neonatal deaths to due preterm birth complications. International Journal of Epidemiology, 39(1), 144-145. Lester, B. M., Miller, R. J., Hawes, K., Salisbury, A., Bigsby, R., Sullivan, M. C., & Padbury, J. F. (2011). Infant neurobehavioral development. Seminars in Perinatology, 35(1), 8-19. doi: 10.1053/j.semperi.2010.10.003 Ludington-Hoe, S. M., Anderson, G. C., Swinth, J. Y., Thompson, C., & Hadeed, A. J. (2004). Randomized controlled trial of kangaroo care: Cardiorespiratory and thermal effects on healthy preterm infants. Neonatal Network, 23(3), 39-48. Madlinger-Lewis, L., Reynolds L., Zarem, C., Crapnell, T., Inder, T., & Pineda, R. (2014). The effects of alternative positioning on preterm infants in the neonatal intensive care unit: A randomized clinical trial. Research in Developmental Disabilities, 35(2), 490-497. doi: 10.1016/j.ridd.2013.11.019 Martin, J. A., Hamilton, B. E., Osterman, M. J. K., Driscoll, A. K., & Mathews, T. J. (2015). Births: Final for 2015. National Vital Statistics Reports, 66(1), 1-3. IMPLEMENTATION OF A NICU DEVELOPMENTAL SKILLS FAIR 28 McGrath, J. M., Samra, H. A., & Kenner, C. (2011). Family-centered developmental care practicers and research: what will the next century bring?. Journal of Perinatal & Neonatal Nursing, 25(2), 165-170. doi: 10.1097/JPN.0b013e31821a6706 Moon, R. Y. (2017, January 12). How to Keep Your Sleeping Baby Safe: AAP Policy Explained. Retrieved from: https://www.healthychildren.org/English/agesstages/baby/sleep/Pages/A-Parents-Guide-to-Safe-Sleep.aspx Morag, I. & Ohlosson, A. (2013). Cycled light in the intensive care unit for preterm and low birth weight infants. The Cochrane Database of Systematic Reviews, 1. doi: 10.1002/14651858.CD006982.pub2 Mosqueda-Pena, R., Lora-Pablos, D., Pavon-Munoz, A., Ureta-Velasco, N., Moral-Pumarega, M. T., & Pallas-Alonso, C. R. (2016). Impact of a developmental care training course on the knowledge and satisfaction of health care professionals in neonatal units: A multicenter study. Pediatrics and Neonatology 57, 97-104. Parra, J., deSuremain, A., Audeoud, B., Ego, A., & Debillon, T. (2017). Sound levels in a neonatal intensive care unit significantly exceeded recommendations, especially inside incubators. Acta Paediatrica, 106, 1909-1914. doi: 10.1111/apa.13906 Petri, L. (2010). Concept analysis of interdisciplinary collaboration. Nursing Forum, 45(2), 7382. doi: 10.1111/j.1744-6198.2010.00167.x Ramezani, T., Shirazi, Z. H., Sarvestani, R. S., & Moattari, M. (2014). Family-centered care in neonatal intensive care unit: A concept analysis. International Journal of Community Based Nursing and Midwifery, 2(4), 268-278. Smith, J. R., & Cole, F. S. (2009). Patient safety: Effective interdisciplinary teamwork through IMPLEMENTATION OF A NICU DEVELOPMENTAL SKILLS FAIR 29 simulation and debriefing in the neonatal ICU. Critical Care Nursing Clinics of North America, 21(2), 163-179. Smith, J. R. (2012). Comforting touch in the very preterm hospitalized infant: an integrative review. Advances in Neonatal Care, 12(6), 349-365. doi: 10.1097/ANC. 0b013e31826093ee Sweeney, J. K., & Gutierrez, T. (2002). Musculoskeletal implications of preterm infant positioning in the NICU. Journal of Perinatal & Neonatal Nursing, 16(1), 58-70. Trajkovski, S., Schmied, V., Vickers, M., & Jackson, D. (2012). Neonatal nurses perspectives of family-centered care: A qualitative study. Journal of Clinical Nursing, 21(17-18), 2477-2487. doi: 10.1111/j.1365-2702.2012.04138.x Vasquez-Ruiz, S., Maya-Barrios, J. A., Torres-Narvaez, P., Vega-Martinez, B. R., RojasGranados, A., Escobar, C., & Angeles-Castellanos, M. (2014). A light/dark cycle in the NICU accelerates body weight gain and shortens time to discharge in preterm infants. Early Human Development, 40, 535-540. Vergara, E., Anzalone, M., Bigsby, R., Gorga, D., Holloway, E., Hunter, J., & Strzyzewski, S. (2006). Specialized knowledge and skills for occupational therapy practice in the neonatal intensive care unit. American Journal of Occupational Therapy, 60(6), 659-668. Vohr, B. R., Poindexter, B. B., Dusick, A. M., McKinley, L. T., Wright, L. L., Langer, J. C., & Poole, K. (2006). Beneficial effects of breast milk in the neonatal intensive care unit on the developmental outcome of extremely low birth weight infants at 18 months age. Journal of the American Academy of Pediatrics, 118(1). Wachman, E. M., & Lahav, A. (2011). The effects of noise on preterm infants in the NICU. Archives of Disease in Childhood. Fetal and Neonatal Edition, 96, 305-309. IMPLEMENTATION OF A NICU DEVELOPMENTAL SKILLS FAIR 30 Waitzman, K. A. (2007). The importance of positioning the near-term infant for sleep, play, and development. Newborn and Infant Nursing Reviews, 7(2), 76-81. Wellington, A., & Perlman, J. M. (2015). Infant-driven feeding in premature infants: A quality improvement project. Archives of Disease in Childhood. Fetal and Neonatal Edition, 100(6), 495-500. doi: 10.1136/archdischild-2015-308296 World Health Organization. (2017, November 17). Care of the preterm and low-birth-weight newborn. Retrieved from http://www.who.int/maternal_child_adolescent/newborns/ prematurity/en/ IMPLEMENTATION OF A NICU DEVELOPMENTAL SKILLS FAIR Appendix A 31 IMPLEMENTATION OF A NICU DEVELOPMENTAL SKILLS FAIR 32 IMPLEMENTATION OF A NICU DEVELOPMENTAL SKILLS FAIR 33 IMPLEMENTATION OF A NICU DEVELOPMENTAL SKILLS FAIR 34 IMPLEMENTATION OF A NICU DEVELOPMENTAL SKILLS FAIR 35 IMPLEMENTATION OF A NICU DEVELOPMENTAL SKILLS FAIR Appendix B 36 IMPLEMENTATION OF A NICU DEVELOPMENTAL SKILLS FAIR 37 IMPLEMENTATION OF A NICU DEVELOPMENTAL SKILLS FAIR 38 IMPLEMENTATION OF A NICU DEVELOPMENTAL SKILLS FAIR 39 IMPLEMENTATION OF A NICU DEVELOPMENTAL SKILLS FAIR Appendix C DEVELOPMENTAL CARE The Neonatal Integrative Developmental Care Model aims to improve the care and experience infants receive while in the NICU by promoting neuro-protective, neuro-supportive, and familycentered care. Neuro-protective care incorporates strategies that prevent cell death and harm to the infants developing central nervous system. Neuro-supportive care facilitates the continuation of typical infant development through proactive and purposeful strategies. Developmental care is the provision of individualized, developmentally appropriate care of the infant to maximize neurological development and reduce long-term cognitive and behavioral problems. How to implement developmentally supportive care: Establish a healing environment through Cycled Lighting and Noise Control Partner with families to provide Family-Centered Care Position and Handle in a developmentally supportive manner Safeguard Sleep by implementing Safe Sleep Protocol Minimize stress and pain by creating a healing environment and encouraging parent participation in Kangaroo Care and Infant Massage Optimize nutrition through Infant-Driven Feeding Family-Centered Care has been shown to decrease length of stay, enhance parent-infant attachment and bonding, improve well-being of preterm infants, support better mental health outcomes, and promote greater patient and family satisfaction. How to implement Family-Centered Care: Allow family members to have an active role in planning, regulating, and implementing care Maintain family respect and dignity Transfer knowledge to family members in accordance with the familys level of education and with a variety of learning styles (verbal, written, demonstration) Encourage parent-infant interaction: breastfeeding, Kangaroo Care, diaper/clothing change, etc. Understanding Infant Stress Cues can assist with ensuring Developmental Care o o o o o o o Gag/Spit Up Hiccup Burp Yawn Sneeze Frown Whimper o o o o o o o Gasp Tongue Thrust Pass Gas Gape Face Eye Floating Gaze Aversion Grimace o o o o o o Salute Fuss Stretch Arch Finger Splay Airplane o Sitting on Air 40 IMPLEMENTATION OF A NICU DEVELOPMENTAL SKILLS FAIR 41 IMPLEMENTATION OF A NICU DEVELOPMENTAL SKILLS FAIR 42 IMPLEMENTATION OF A NICU DEVELOPMENTAL SKILLS FAIR 43  ...

...  ...

... Running head: IDENTIFYING ROLES, RESPONSIBILITIES AND COMPETENCIES Identifying roles, responsibilities, and competencies of an occupational therapy manager within an outpatient rehabilitation facility Jill Hecht, OTS May 2018 A capstone project submitted in partial fulfillment for the requirements of the Doctor of Occupational Therapy degree from the University of Indianapolis, School of Occupational Therapy. Under the direction of the faculty capstone advisor: Dr. Jim McPherson, PhD, OTR IDENTIFYING ROLES, RESPONSIBILITIES AND COMPETENCIES A Capstone Project Entitled Identifying roles, responsibilities, and competencies of an occupational therapy manager within an outpatient rehabilitation facility Submitted to the School of Occupational Therapy at University of Indianapolis in partial fulfillment for the requirements of the Doctor of Occupational Therapy degree. By Jill Hecht Occupational Therapy Student Approved by: Faculty Capstone Advisor Date Doctoral Capstone Coordinator Date Accepted on this date by the Chair of the School of Occupational Therapy: Chair, School of Occupational Therapy Date IDENTIFYING ROLES, RESPONSIBILITIES AND COMPETENCIES 3 Abstract The role of an occupational therapy manager is critical in order to advocate for the profession of occupational therapy while also guaranteeing clinical practice is maintained (AOTA, 2011). However, occupational therapy students, practitioners, and managers must be knowledgeable and competent in certain areas of management in order to provide the best services possible (AOTA, 2011). The purpose of this Doctoral Capstone Experience (DCE) included learning and performing skills beyond entry level pertaining to administration and policy and program development within an outpatient rehabilitation facility by performing the common roles, responsibilities, and competencies of an occupational therapy manager. The methods by which this was completed was through research of the literature to provide background information on administration in occupational therapy, conducting a needs assessment at the facility, writing goals and objectives based off the needs assessment data, and converting the goals and objectives into a Goal Attainment Scale (GAS). The outcomes of this project included meeting all goals in the GAS and creating a quality improvement plan for the facility. The Dynamical Systems Theory guided managerial decision making throughout the DCE to enable the student to work professionally with the organization, which therefore allowed the student to achieve and improve multiple administrative skills. This DCE will be a guide for future Doctor of Occupational Therapy Students and future site mentors, and the newly acquired skills will contribute to the students future practice. IDENTIFYING ROLES, RESPONSIBILITIES AND COMPETENCIES 4 Introduction According to AOTA (2011), management is defined as a process of how one works with others in order to achieve desired goals or stated outcomes (p. 62). The role of an occupational therapy manager has never before been so critical for advocating for the profession of occupational therapy and for maintaining the functions of clinical practice (AOTA, 2011). The need for greater efficiency and management has increased due to new health care legislation threats, therefore occupational therapy practitioners with leadership and management skills are in high demand (AOTA, 2011). In order for occupational therapy students, practitioners, and managers to provide the best services possible, it is important for them to first understand the overall role of a manager; know how to run a business/program/department; lead and organize; provide evidence based practice; understand public policy and guarantee high professional standards; and provide supervision and guidance to new occupational therapy practitioners and leaders (AOTA, 2011). Occupational therapy management has many roles, responsibilities, and skills sets that are involved. However, this Doctoral Capstone Experience (DCE) included learning and performing skills beyond entry level pertaining to administration, policy, and program development within an outpatient rehabilitation facility. This DCE had concentrations in financial planning, budgeting, and responsibilities pertaining to the certification with Centers for Medicare and Medicaid Services (CMS IDENTIFYING ROLES, RESPONSIBILITIES AND COMPETENCIES 5 Literature Review Dynamical Systems Theory in Occupational Therapy Management Use of a theory to guide an occupational therapy manager during management tasks can increase guidance of the managers team (AOTA, 2011). The occupational therapy manager may be using a theory as a frame of reference for managerial decision making every day without even realizing it. Management has moved from a hierarchical process or, a top-down model with designated leaders to more of a heterarchical process or, a bottom-up model that helps to better use input from all levels of the organization, which then allows for leaders to emerge during the implementation of the task/process (AOTA, 2011). Research has shown that using a bottom-up model in management produces greater stability and dynamic response (Shastri & Diwekar, 2006). In the practice of occupational therapy, Gary Kielhofner, one of the first occupational therapists to incorporate systems theory into practice and publisher of the Model of Human Occupation (Cole & Tufano, 2008), based most of his theoretical work on open systems, or systems that continually interact with, and then change in response to, the environment (Robbins & Coulter, 2009). And, in more recent years, Kielhofner has transformed his theory to incorporate what is call the Dynamical Systems Theory (AOTA, 2011). Dynamical Systems Theory, founded by Edward Lorenz, is the new science that is based on chaos, complexity, and non-linear dynamics (Hunt & Ropo, 2003). Use of this theory in occupational therapy management can help managers guide their teams toward openness, purposefulness, multidimensionality, and self-organization (AOTA, 2011). This approach to management is more of a method or approach, rather than a set of techniques or protocols. It IDENTIFYING ROLES, RESPONSIBILITIES AND COMPETENCIES 6 includes the process of creating, reinforcing, and valuing relationships within the setting (AOTA, 2011). One can use the concepts of the Dynamical Systems Theory to provide a theoretical frame of reference for managerial decision making. For instance, when a manager uses a representation of core values to lead organization and management, he or she uses the dynamical system theory frame of reference (AOTA, 2011). The use of theory within an occupational therapy management position can help increase the correct decision-making process and, therefore, lead the managers team in the appropriate direction (AOTA, 2011). This theory may act as an organizing framework to aid in managerial decisions and was utilized as such throughout this DCE. Common Roles, Responsibilities, and Competencies of an Occupational Therapy Manager An occupational therapy manager has many roles, responsibilities, and skills sets that are important for day to day tasks. A manager must adapt to a changing society but with certain fundamentals persisting, such as exhibiting a sense of confidence in self and in others, being a practitioner to allow others to grow and overcome obstacles, and energizing the workplace environment to help influence others to find success (AOTA, 2011). Occupational therapy managers and practitioners both have unique and specific roles, responsibilities, and skills sets (which refers to ones ability to have unique and specific roles, responsibilities, and competencies) (AOTA, 2011). However, although some of these roles, responsibilities, and competencies separate the two positions in the context of which they are performed, many of them also mirror those of the other position. For example, only a manager deals with strategic planning, staff development, and policy management, but both a manager IDENTIFYING ROLES, RESPONSIBILITIES AND COMPETENCIES 7 and practitioner acknowledge strengths, clinical reason, and engage others in occupation (AOTA, 2011) The most common roles, responsibilities, and competencies that an occupational therapy manager may assume include categories of organizing and staffing, directing, controlling, information management, and planning (AOTA, 2011; Braveman, 2006). Described below are the categories, along with the importance of and how an occupational therapy manager may assume these roles, responsibilities, and competencies. Organizing and staffing. The category of organizing is more related to mid-level and upper management, rather than first-line supervisors, and includes designing workable units, determining lines of authority and communication, and developing and managing patterns of coordination (Braveman, 2006, p. 125). Organizing involves steps to ensure that the organizations goals can be achieved as efficiently as possible, including creating the most effective grouping of activities, incorporating the necessary guidelines for the activities, and coordinating systems (Braveman, 2006). If a manager carries out organization efficiently, then it can clearly detail who is responsible for work tasks, who has the authority to make decisions, work activities, and what is expected of individuals and groups regarding levels of performance (Braveman, 2006). The process of staffing coincides greatly with the process of organizing. In order to complete the process of staffing, a manager must first be efficient with organizing. Staffing ensures that the organization has the appropriate quality and quantity of staff in order to reach its mission and goals (Braveman, 2006). This category includes the roles, responsibilities, and skills sets of recruitment and hiring of staff; orientation, training, and education of staff; further development of staff; and discipline and separation of staff (Braveman, 2006). IDENTIFYING ROLES, RESPONSIBILITIES AND COMPETENCIES 8 Directing. The category of directing includes the manager providing guidance and leadership to ensure work within the organization is goal oriented (Liebler, Levine, & Rothman, 1992). Management activities that are included in directing include mentoring or coaching (Braveman, 2006). In regard to this category, a manager is usually responsible for the formation of a staff development plan or program, which can include opportunities for continuing education or professional development, along with incorporating these within the organizations budget (Braveman, 2006). Controlling. The category of controlling relates to controlling resources and includes comparing actual performance with expectations and eliminating obstacles to achieve goals (Braveman, 2006). The process of controlling includes three phases, including establishing standards, measuring performance, and correcting deviations (Braveman, 2006). A manager can control everyday situations by using control mechanisms, or control indicators, which a process that constantly monitors the product of a system (Braveman, 2006). This helps indicate when performance falls below standards and a problem is to be addressed (Braveman, 2006). A common example of a control mechanism that an occupational therapy manager may use includes noting the amount of time it takes for the therapy department to respond to a referral after it is received so action can be taken if the time surpasses a predetermined period of time (Braveman, 2006). In order for an occupational therapy manager to be effective with the process of controlling, the process must first be organized in a manner that allows he or she to become aware of a problem in a timely and efficient manner and provide enough information so he or she can take the appropriate action (Braveman, 2006). Information management. An occupational therapy manager deals with great amounts of data and information daily, and this can become overwhelming especially with continuously IDENTIFYING ROLES, RESPONSIBILITIES AND COMPETENCIES 9 improving technology (Braveman, 2006). However, this improving technology does have its advantages as it allows one to quickly communicate with another department, access the Internet, and automatically collect and report data from documentation or billing systems (Braveman, 2006). On any given day, a manager may receive reports related to the budget, staff productivity, continuous quality improvement efforts, rates of client visits, etc., but the manager must be able to organize this data to turn it into useful information that can be easily interpreted, and also identify the specific use for the data (Braveman, 2006). Planning. Braveman (2006) states that the category of planning encompasses the process of establishing short-term and long-term goals, measureable objectives, and action plans related to the mission of the organization (p. 111). Within this category, strategic planning, financial planning, facility planning, and producing policies and procedures are all involved (Braveman, 2006). Strategic planning is one main subcategory that an occupational therapy manager must master. This type of planning determines the long-terms goals of an organization by creating strategies to reach these goals (Liebler, Levine, & Rothman, 1992). At times, strategic planning can be a difficult task for an occupational therapy manager because of its creative thinking of the future, which can be challenging in a workplace with high productivity demands (Braveman, 2006). A manager can initiate or revise a strategic plan by first taking time to review and/or modify the organizations mission and vision statements, which individually describe the organizations purpose and aspirational and inspirational message of what the organization would like to become (Braveman, 2006). One of the most important subcategories of planning and crucial aspects of a manager is the skill of financial planning and budgeting of the organization (AOTA, 2011). As stated by IDENTIFYING ROLES, RESPONSIBILITIES AND COMPETENCIES 10 AOTA (2011), the face of healthcare is ever changing, and reform measures affect occupational therapy services financially. Change requires planning, and planning must contain budgeting and financial planning, which are the building blocks of a businesss strategic plan (AOTA, 2011). Therefore, it is important for occupational therapy managers to adapt to change in order to meet the varying demands of the healthcare system by using sound business principles (AOTA, 2011). It is important that a manager has knowledge regarding financial planning, budgeting, and financial aspects of human resource management, along with accounting to aid with management of cash flow, improve profitability, develop a budget, and manage risk (AOTA, 2011). The manager must also be knowledgeable on funding sources in order to understand the unique and different structures that are available (AOTA, 2011). Lastly, the manager must be able to think critically and use evidence to support sound business decisions when a financial problem emerges (AOTA, 2011). Facility planning is yet another aspect of the category planning but may not be as commonly faced by managers as other aspects previously mentioned (Braveman, 2006). Braveman (2006) states that facility planning includes planning for and designing new facilities and spaces, and very few occupational therapy programs teach students how to do such a task; therefore, this task can be daunting for an occupational therapy manager if he or she is poorly prepared. To help fulfill this aspect of management, an occupational therapy manager can consider certain steps, including visiting other facilities for ideas, compiling likes and dislikes of designs from other managers at the facility or from other facilities, and collaborating on ideas with staff (Braveman, 2006). The final subcategory of planning includes writing policies and procedures for the organization. These policies and procedures are meant to guide staff and their use of materials, IDENTIFYING ROLES, RESPONSIBILITIES AND COMPETENCIES 11 supplies, facilities, and equipment. Braveman (2006) states that policies are statements of values that coincide with the mission statement of the organization, and procedures outline the specific actions that need to be taken and criteria to adhere to the policies. Most organizations follow a standard format to determine what to include in each policy and procedure and the policy and procedure manual overall (Braveman, 2006). For example, the facility which this DCE is taking place follows the guidelines for CMS and the Indiana SBOH requirements for a comprehensive outpatient rehabilitation facility (CORF). These policies and procedures should be frequently reviewed and updated and should be easily accessible for all staff (Braveman, 2006). An efficient manager must be able to identify and state the importance of the policies and procedures and ensure that the organization is complying with all requirements and updating them regularly (Braveman, 2006). Centers for Medicare and Medicaid Services Certification The location of this DCE is currently a certified Medicare and Medicaid Comprehensive Outpatient Rehabilitation Facility (CORF) provider that has undergone the CMS and Indiana SBOH surveys to obtain and maintain this certification. This means that this facility provides coordinated outpatient diagnostic, therapeutic, and restorative services, at a single fixed location, to outpatients for the rehabilitation of injured, disabled or sick individuals (Comprehensive Outpatient Rehabilitation Facilities, 2013). Centers for Medicare and Medicaid Services (CMS) provides oversight for providers and facilitys compliance with Medicare health and safety standards, and also makes this information available to beneficiaries, providers/suppliers, researchers, and State surveyors (Quality, safety & oversight General information, 2018). A survey of the providers and facilities is completed on behalf of CMS by the individual State Survey Agencies (Quality, IDENTIFYING ROLES, RESPONSIBILITIES AND COMPETENCIES 12 safety & oversight General information, 2018). This overall process is referred to the certification process (Quality, safety & oversight General information, 2018), which includes the following: Conducting investigations and fact-finding surveys to verify if the health care entity complies with the requirements Certifying and recertifying the health care entity to determine if it is qualified to participate in the programs Explaining requirements to current and potential providers and suppliers regarding applicable Federal regulations to allow them to qualify for participation in the programs and to maintain standards of health care that coincide with certain requirements (Quality, safety & oversight General information, 2018) For this certification process, CMS has established Survey protocols and Interpretive Guidelines in order to lead the personnel directing the surveys, which, as stated above, will be the State Survey Agency (Comprehensive outpatient rehabilitation facilities, 2012). The Interpretive Guidelines include the following: Survey tag number Wording of the regulation Additional survey procedures and probes to guide the surveyors (Comprehensive outpatient rehabilitation facilities, 2012) These protocols and guidelines describe the regulations; all personnel directing the surveys must utilize them when determining if a provider or facility is complying with Federal requirements (Comprehensive outpatient rehabilitation facilities, 2012). The survey is conducted by following the protocols and requirements in the statute and regulations that are appropriate to IDENTIFYING ROLES, RESPONSIBILITIES AND COMPETENCIES 13 the provider or facility in order to determine if a citation of non-compliance is appropriate, meaning there is a violation of the regulations in the providers or facilitys performance or practice (Comprehensive outpatient rehabilitation facilities, 2012). The procedure for noncompliance is stated below under the subheading Non-compliance of regulations. Services of the provider. As previously stated, the location of this DCE is located at a certified CMS CORF. The services that may be provided in a CORF include physical therapy, occupational therapy, and speech-language pathology (Comprehensive Outpatient Rehabilitation Facilities, 2013), and there are three organizations that can qualify as this provider, including a rehabilitation agency, clinic, or public health agency (Outpatient rehabilitation providers, 2013). In order for these organizations to be eligible to participate as providers of outpatient physical therapy or speech-language pathology services, they must be in compliance with all applicable Medicare requirements specific to a CORF, which are listed in the State Operations Manual, Appendix K Guidance to Surveyors: Comprehensive Outpatient Rehabilitation Facilities (Centers for Medicare and Medicaid, 2014). These requirements include Compliance with State and Local Laws, Disaster Procedures, Utilization Review Plan, and many more (Centers for Medicare and Medicaid, 2014). The State survey verifies that the services the organization intends to provide are actually being provided (Outpatient rehabilitation providers, 2013), and that the organization provides core services, including consultation with and medical supervision of non-physician staff including the creation and review of the plan of treatment, and physical therapy, social, or psychological services (Comprehensive Outpatient Rehabilitation Facilities (2013). Non-compliance of regulations. If an adverse action is initiated by a participating Medicare and/or Medicaid provider and supplier, the CMS Regional Office and State survey IDENTIFYING ROLES, RESPONSIBILITIES AND COMPETENCIES 14 agency follow the procedure in the State Operations Manual (Quality, safety & oversight Enforcement, 2018). The procedure is indicated in the State Operations Manual in Chapter 3, and the procedure must pertain to the type of facility that the adverse action is found (Quality, safety & oversight Enforcement, 2018). The procedure for a CORF and related facilities is stated below: Cause for Termination: An agreement may be terminated if the provider is determined that they: o Are not complying with the terms of the agreement, the provisions of title XVIII of the Social Security Act, or other declared regulations o Have not supplied information regarding payments o Refuse to allow examination of fiscal and other records necessary in order to verify information furnished as a basis for claiming payment under the Medicare program or o Refuse to allow photocopying of any records or information necessary to verify compliance with requirements (Quality, safety & oversight Enforcement, 2018) Compliance with Requirements: For each type of provider subject to certification, there is a set of conditions with corresponding subcategories of related quality standards. The State Agency determines if and how each standard is met. If a facility fails to meet each and every condition, then it cannot participate in Medicare (Quality, safety & oversight Enforcement, 2018). Statement of Deficiencies: If the State Agency identifies items of non-compliance, or deficiencies, during the facilitys survey, the facility is given a Statement of Deficiencies. The facility is allowed ten calendar days to respond with a Plan of IDENTIFYING ROLES, RESPONSIBILITIES AND COMPETENCIES 15 Correction for each deficiency noted. If the facility fails to take such action, then the State Agency certifies the facility noncompliance notwithstanding a Plan of Correction Medicare (Quality, safety & oversight Enforcement, 2018). Today, the role of an occupational therapy manager is critical in order to advocate for the profession of occupational therapy while also ensuring clinical practice is maintained (AOTA, 2011). However, occupational therapy students, practitioners, and managers must be knowledgeable and competent in certain areas of management in order to provide the best services possible (AOTA, 2011). Therefore, the purpose of this DCE was to obtain skills beyond entry level pertaining to administration and policy and program development within an outpatient rehabilitation facility by performing the common roles, responsibilities, and competencies of an occupational therapy manager to obtain competence. Methods Setting This DCE project took place at an outpatient rehabilitation facility in Indianapolis. The facility had a total of six rehabilitation sites. Three of the facilities were located within the Indianapolis area, including the main location, and the remaining three locations were located no more than eighty miles outside of Indianapolis. The Doctoral student primarily worked out of the main location with the site mentor, who was the director of therapy and managed all of the therapists at the main and satellite locations. However, the student periodically visited the satellite locations throughout the DCE. Population The population for this DCE consisted of the therapy department at the outpatient rehabilitation facility. The director of therapy manages all of the therapists at the main and IDENTIFYING ROLES, RESPONSIBILITIES AND COMPETENCIES 16 satellite locations. There was a total of twenty-one therapists, with twelve therapists on average working at the main location, and one to two therapists on average working at each of the satellite locations; this number is determined based on the average patient census for each location. These therapists work in the specialty area of hand therapy, with a majority of them being Certified Hand Therapists. This outpatient rehabilitation facility was chosen based on personal interest of the student completing the DCE. Procedure: Evaluation and Screening Process Research of the literature was completed to provide background information on an administrative role in an outpatient rehabilitation facility, with specifications on financial planning and budgeting, the SBOH and CMS regulations and survey, and theory to guide administration for a rehabilitation facility. A systematic search of the literature was conducted through the University of Indianapolis database, including EBSCOhost and OT Search, along with Google Scholar and textbooks from previous coursework from the Doctor of Occupational Therapy program at the University of Indianapolis. The key words and phrases are stated in Figure 1, which were used to identify literature published between 1992 and 2018, with a majority it being within the last ten years. The information obtained was reviewed and analyzed for relevant information pertaining to the purpose of this DCE. All data were obtained lawfully and reported accurately. Occupational Therapy Administration Centers for Medicare and Medicaid Therapy manager State Board of Health Manager Survey IDENTIFYING ROLES, RESPONSIBILITIES AND COMPETENCIES Roles and responsibilities of therapy manager 17 Certification Financial planning Budgeting Regulations Leadership Theory in management Figure 1. Key words and phrases. This figure illustrates all of the key words and phrases used, specifically the main categories, along with their subcategories. Coinciding with the review of the literature, a needs assessment was completed at the facility to determine any important needs, issues, or opportunities of interest, and then determine how to address them (Sleezer, Russ-Eft, & Gupta, 2014). A needs assessment structures any issues or opportunities of interest, creates relationships among the people who are involved, and frames the learning, training, and performance improvement plans (Sleezer, Russ-Eft, & Gupta, 2014). As described by Sleezer, Russ-Eft, and Gupta (2014), there are five needs assessment approaches: knowledge and skills assessment, job and task analysis, competency-based needs assessment, strategic needs assessment, and complex needs assessment. For this DCE, a complex needs assessment approach was utilized, which required the analyst (student) to combine components from the other approaches to needs assessment, apply expertise from other subject areas and, most importantly, to innovate (Sleezer, Russ-Eft, & Gupta, 2014, p. 29-30). This allowed the student to see the organization as a whole, rather than just focusing on one specific area. Semi-structured face-to-face interviews were conducted with the director of therapy (site mentor) on two separate occasions. The data from the interviews were then analyzed by the IDENTIFYING ROLES, RESPONSIBILITIES AND COMPETENCIES 18 student and divided into categories and subcategories. The categories were then written as a goal, and the subcategories were written as objectives to the corresponding goal. This resulted in five goals with an array of objectives; these goals and objectives were verified by the director of therapy to ensure accuracy of interpretation of the data. The final goals and objects are stated below: Goal 1: Learn and perform skills beyond entry level pertaining to the common roles, responsibilities, and competencies of an occupational therapy manager within an outpatient rehabilitation facility. Objective: Complete tasks identified by site mentor regarding managerial tasks. Objective: Site mentor will educate student on common roles, responsibilities, and competencies of an occupational therapy manager within an outpatient rehabilitation facility. Goal 2: Complete all tasks pertaining to maintaining certification for Centers for Medicare and Medicaid (CMS)/Indiana State Board of Health for all locations. Objective: Become educated on all documents for the Indiana State Board of Health and CMS Regulations. Objective: Convert all documents from the Master Policy and Procedure Manuals into an electronic system for all locations to utilize. Objective: Organize and update all documents when necessary. Objective: Complete an overall comprehensive, organized, and standardized manual in electronic form, and hard copies if necessary. Objective: Educate appropriate personnel of the new Manuals by method that best suits the personnel. IDENTIFYING ROLES, RESPONSIBILITIES AND COMPETENCIES 19 Goal 3: Complete managerial tasks regarding financial planning and budgeting. Objective: Complete appropriate research and evaluation of financial planning and budgeting. Objective: Complete tasks identified by site mentor. Goal 4: Complete managerial tasks to prepare for the Hand Care Conference in May 2018, as needs arise. Objective: Complete tasks identified by site mentor and/or Education Coordinator for Hand Care Conference. Objective: Increase organization by assisting with planning for Hand Care Conference. Objective: Have an educational role by assisting with planning for Hand Care Conference. Objective: Attend meetings regarding Hand Care Conference. Goal 5: Complete all other goals and objectives as stated by site mentor in relation to an administrative role as needs arise. Objective: Attend periodic meetings with site mentor to discuss such goals/objectives. Once the final goals and objectives were completed, the principal goals and objectives were converted into a Goal Attainment Scale (GAS); this is stated in Figure 2. As described by Krasny-Pacini, Evans, Sohlberg, and Chevignard (2016), a GAS is a method for writing personalized evaluation scales to quantify progress regarding identified goals (p. 157). The GAS was developed based on criteria stated by Krasny-Pacini et al. (2016), specifically in a manner to ensure minimal bias and clearly state five levels of goal attainment. The GAS was IDENTIFYING ROLES, RESPONSIBILITIES AND COMPETENCIES 20 utilized at the end of the DCE to determine if the stated goals were met or not met, and to what extent they were completed. Results of the GAS will be further discussed. Goal 1 Success of Goal Much less than expected (-2) Somewhat less than expected (-1) Goal 2 Goal 3 Goal 4 Goal 5 Goal 6 Become educated on all materials pertaining to the Master Policy and Procedures Manuals. Convert materials from the Master Policy and Procedure Manuals from all facilities into an electronic system and into a comprehensive, organized, and standardized manner for each facility to utilize. Educate appropriate personnel of the new manuals by method that best suits the personnel. Complete financial planning and budgeting task by evaluating all current pricings of therapy supplies from vendors. Complete managerial tasks identified for student in order to prepare for facilitys conference in May 2018. Student and site mentor to attend meetings to discuss any projects and current management concerns. Become educated on all materials pertaining to the Master Policy and Procedure Manuals for CMS/SBOH by 6 weeks. Convert 50% of materials from the Master Policy and Procedure Manuals from all facilities into an electronic system and into a comprehensive, organized, and standardized manner for each facility to utilize by 16 weeks. Educate appropriate personnel of the new manuals by method that best suits the personnel within 3 visits with poor follow through by 16 weeks. Complete 0% of financial planning and budgeting task. Complete 0% of managerial tasks identified for student in order to prepare for the facilitys conference in May 2018, as needs arise. Student and site mentor to attend meetings once every 3 weeks to discuss any projects and current management concerns. Become educated on all materials pertaining to the Master Policy and Procedure Manuals for CMS/SBOH by 5 weeks. Convert 75% of materials from the Master Policy and Procedure Manuals from all facilities into an electronic system and into a comprehensive, organized, and standardized manner for each facility to utilize by 16 weeks. Educate appropriate personnel of the new manuals by method that best suits the personnel within 2 visits with poor follow through by 16 weeks. Complete 25% of financial planning and budgeting task by evaluating a portion of current pricing of therapy supplies from vendors. Complete 25% of managerial tasks identified for student in order to prepare for the facilitys conference in May 2018, as needs arise. Student and site mentor to attend meetings once every other week to discuss any projects and current management concerns. IDENTIFYING ROLES, RESPONSIBILITIES AND COMPETENCIES Expected (0) Somewhat more than expected (+1) Much more than expected (+2) 21 Become educated on all materials pertaining to the Master Policy and Procedure Manuals for CMS/SBOH by 4 weeks. Convert all materials from the Master Policy and Procedure Manuals from all facilities into an electronic system and into a comprehensive, organized, and standardized manner for each facility to utilize by 16 weeks. Educate appropriate personnel of the new manuals by method that best suits the personnel within one visit with poor follow through by 16 weeks. Complete 50% of financial planning and budgeting task by evaluating all current pricings of therapy supplies from vendors. Complete 50% of managerial tasks identified for student in order to prepare for the facilitys conference in May 2018, as needs arise. Student and site mentor to attend meetings 1 time a week to discuss any projects and current management concerns. Become educated on all materials pertaining to the Master Policy and Procedure Manuals for CMS/SBOH by 3 weeks. Convert all materials from the Master Policy and Procedure Manuals from all facilities into an electronic system and into a comprehensive, organized, and standardized manner for each facility to utilize by 12 weeks. Educate appropriate personnel of the new manuals by method that best suits the personnel within one visit with fair follow through by 16 weeks. Complete 75% of financial planning and budgeting task by evaluating all current pricings of therapy supplies from vendors, along with approximate shipping costs. Complete 75% of managerial tasks identified for student in order to prepare for the facilitys conference in May 2018, as needs arise. Student and site mentor to attend meetings 3 times a week to discuss any projects and current management concerns. Become educated on all materials pertaining to the Master Policy and Procedure Manuals for CMS/SBOH by 2 weeks. Convert all materials from the Master Policy and Procedure Manuals from all facilities into an electronic system and into a comprehensive, organized, and standardized manner for each facility to utilize by 8 weeks. Educate appropriate personnel of the new manuals by method that best suits the personnel within one visit with successful follow through by 16 weeks. Complete 100% of financial planning and budgeting task by evaluating all current pricings of therapy supplies from vendors, along with approximate shipping costs and comparison to over the counter pricings for a complete overview of pricing costs. Complete all managerial tasks identified for student in order to prepare for the facilitys conference in May 2018, as needs arise. Student and site mentor to attend daily meetings to discuss any projects and current management concerns. Figure 2. Goal Attainment Scale. This figure demonstrates the goals in the Goal Attainment Scale to determine if the stated goals were met or not met and to what extent they were completed by the end of the DCE. Compare and Contrast Evaluation and Screening to Traditional Occupational Therapy. Performing an evaluation in occupational therapy can be achieved in different manners, whether this be a practitioner evaluating a client or a manager evaluating the therapy IDENTIFYING ROLES, RESPONSIBILITIES AND COMPETENCIES 22 department. As previously stated, the evaluation that was completed for this DCE consisted of conducting research related to administration in an outpatient rehabilitation facility and completing a needs assessment for the therapy department. This was completed due to the nature of the DCE being geared more towards administrative skills rather than clinical skills or practitioner skills. The occupational therapy practitioners working in the therapy department at this facility also complete evaluations, however these evaluations are completed on their clients, which are individual people. This evaluation can consist of a variety of tools/methods, including an occupational profile, range of motion measurements, grip and pinch strength testing, sensation testing, and the QuickDASH Outcome Measure (AOTA, 2017; Bcher & Hume, 2002; Institute for Work and Health, 2006). For this DCE, the client for the evaluation included the entire therapy department due to the student performing an administrative role; therefore, the student had to evaluate the therapy department as a whole, rather than just one small section of the department. The complex needs assessment that was conducted allowed the student to evaluate the entire department to assess any important needs, issues, or opportunities of interest, and then determine how to address them (Sleezer, Russ-Eft, & Gupta, 2014). This also pertains to occupational therapy practitioners working in the therapy department. When evaluating clients, the practitioner must take into consideration the individual as a whole, not just the individuals deficit or injured area, and assess the individuals needs, issues, or opportunities of interest and then progress into the intervention process. Therefore, the occupational therapy practitioner must have a variety of evaluation tools in his or her toolkit; specifically for this site, this consisted of the occupational profile to gain a better understanding of the individual as a whole, goniometry to determine range of motion of the joint relative to the affected area, a hand dynamometer to assess grip strength of IDENTIFYING ROLES, RESPONSIBILITIES AND COMPETENCIES 23 the affected limb, a pinch gauge to assess pinch strength of the affected limb, and the QuickDASH to assess the clients function with everyday occupations (AOTA, 2017; Bcher & Hume, 2002; Institute for Work and Health, 2006). Although there are many similarities between an evaluation for an administrator and an evaluation for a practitioner at this facility, there are many differences as well. One example is that when in an administrative position, the client is the entire therapy department and everything it consists of, such as the therapists, other staff members, clients, equipment, etc. Whereas for a practitioner, the client is the actual individual receiving treatment and any family he or she may have with them. The actual evaluation process also varies. The complex needs assessment that was conducted mainly consisted of a face-to-face interview and observation over a period of time, which was approximately three different meeting times (Sleezer, Russ-Eft, & Gupta, 2014). Conversely, although the practitioners evaluation does consist of an interview (occupational profile) and observation, the practitioner also assesses the individuals deficit(s) or injured area through methods previously mentioned (AOTA, 2017; Bcher & Hume, 2002; Institute for Work and Health, 2006). This evaluation is also completed during an appointment time, which can range from thirty to sixty minutes. No matter the client, an evaluation process is necessary in order to determine any needs, issues, or opportunities of interest and decide how to address them (Sleezer, Russ-Eft, & Gupta, 2014). Once one identifies the clients needs, issues, or opportunities of interest, one can then decide which evaluation tool(s) would be the most beneficial. This is to ensure the client is evaluated as a whole and any of the evaluation techniques/tools previously stated can be included. IDENTIFYING ROLES, RESPONSIBILITIES AND COMPETENCIES 24 Procedure: Implementation Phase After completion of research and screening/evaluation of the organization, the implementation phase of the DCE was started. The student used the GAS as a guideline to pursue all projects. The primary project consisted of creating overall comprehensive, organized, updated, and standardized electronic versions of the facilitys Master Policy and Procedure Manuals, which included all CMS regulations for a CORF. The student first became familiar with the organizations Master Policy and Procedure Manuals, then with all regulations listed in the State Operations Manual, Appendix K Guidance to Surveyors: Comprehensive Outpatient Rehabilitation Facilities (Centers for Medicare and Medicaid, 2014). This was completed to ensure the student was competent. Once the student was educated on such information, the student then converted the materials into an electronic system set up by the facilitys Information Technology Services Department. This process was completed for the facilitys main site and then all succeeding satellites. During this process, the student updated and acquired documentation for the regulations when necessary. This was accomplished for all of the facilitys locations and was completed within the twelve weeks of the DCE. Once this portion of the project was completed, the student created a master checklist and an instructional guide for the director of therapy and for the staff at each location to assist with maintaining the updated electronic manuals to ensure compliance with CMS. The master list and instructional guide consisted of all materials that need to be updated in the manuals, when they need to be updated, and step-by-step instructions on how to apply the updated materials to the electronic system. The documents were provided in both physical and electronic versions; the electronic version allowed the staff to quickly search the document title to determine the location of the material(s). After this was completed, all appropriate personnel IDENTIFYING ROLES, RESPONSIBILITIES AND COMPETENCIES 25 were educated on the new manuals by methods that best suit them. These personnel consisted of a senior therapist(s) from each site, and the method of education was either face-to-face education or via phone conference. The goal was to inform each personnel of the new manuals within one visit/phone conference with successful follow through by the end of the sixteen-week DCE. This project was a top priority for this facility as it will help guide the staff of this organization at all six of the facilities (Braveman, 2006). In order for this organization to maintain eligibility to participate as a provider of outpatient occupational therapy, physical therapy, or speech-language pathology services for CMS, it must be in compliance with all applicable requirements specific to this organization, which as previously stated is a CORF (Comprehensive Outpatient Rehabilitation Facilities, 2013; Centers for Medicare and Medicaid, 2014). Therefore, to maintain certification with CMS, it is important that the Master Policy and Procedure Manuals are frequently reviewed and updated and are easily accessible to all staff (Braveman, 2006). The State surveyor from the Indiana State Board of Health completes the survey of the organization which determines this eligibility (Quality, safety & oversight Enforcement, 2018). The organization may be at risk for termination of CMS participation if the provider: Is not complying with the requirements, Is not complying with the terms of the agreement, Has not supplied any information regarding payments, Refuses to allow examination or photocopying of any records for proof of requirements (Quality, safety & oversight Enforcement, 2018). IDENTIFYING ROLES, RESPONSIBILITIES AND COMPETENCIES 26 Throughout the completion of the primary project, other administrative-related tasks were also completed when needs arose. These tasks consisted of financial planning and budgeting duties and responsibilities pertaining to preparation for the facilitys biennial conference in May of 2018. These tasks would typically have been the responsibilities of the manager. During the implementation phase, the student had to demonstrate many leadership skills that an individual in an administrative role must possess. For example, leadership skills must be presented in order to obtain the appropriate information to complete a specified task or to obtain and develop updated documentation and appropriate materials to fulfill the CMS/SBOH requirements. These leadership skills included, but were not limited to, planning (including strategic planning, financial planning, and developing/updating policies and procedures), completing information management, communicating with the appropriate personnel, completing research to determine effective solutions, and maintaining a high level of organization of all working materials to effectively complete all tasks. Discontinuation and Outcomes As stated by AOTA (2011), the best services are provided when students, practitioners, and managers understand the overall roles, responsibilities, and competencies of an occupational therapy manager. Overall, the stated goals in the GAS and the outcomes of this DCE project allowed the student to obtain an understanding of such components. Considering the Project Triangle as discussed by Bonnel & Smith (2018), the projects purpose, methods, and expected outcomes must all be within alignment to one another in order to make the project a cohesive whole. The purpose of this DCE includes obtaining skills beyond entry level pertaining to administration and policy and program development within an outpatient rehabilitation facility; completing and implementing all tasks pertaining to the Master Policy and Procedure Manuals; IDENTIFYING ROLES, RESPONSIBILITIES AND COMPETENCIES 27 completing administrative tasks regarding financial planning and budgeting; and completing all other administrative tasks stated by the site mentor. The method by which these goals were discovered was through research of the literature, conducting a needs assessment at the facility, writing goals and objectives based off the needs assessment data, and converting the goals and objective into a GAS. The expected outcomes included all goals stated in the GAS in Figure 2 with a minimum score of zero. At the end of the DCE, the site mentor scored the GAS based off of the students final position with all projects and tasks. As demonstrated in Figure 3, the final outcomes at the end of the DCE were exhibited by all goals having a score of +2, which is greater than the expected outcome of zero. Goal 1 Success of Goal Much less than expected (-2) Goal 2 Goal 3 Goal 4 Goal 5 Goal 6 Become educated on all materials pertaining to the Master Policy and Procedures Manuals. Convert materials from the Master Policy and Procedure Manuals from all facilities into an electronic system and comprehensive, organized, and standardized manner for each facility to utilize. Educate appropriate personnel of the new manuals by method that best suits the personnel. Complete financial planning and budgeting task by evaluating all current pricings of therapy supplies from vendors. Complete managerial tasks identified for student in order to prepare for facilitys conference in May 2018. Student and site mentor to attend meetings to discuss any projects and current management concerns. Become educated on all materials pertaining to the Master Policy and Procedure Manuals for CMS/SBOH by 6 weeks. Convert 50% of materials from the Master Policy and Procedure Manuals from all facilities into an electronic system and comprehensive, organized, and standardized manner for each facility to utilize by 16 weeks. Educate appropriate personnel of the new manuals by method that best suits the personnel within 3 visits with poor follow through by 16 weeks. Complete 0% of financial planning and budgeting task. Complete 0% of managerial tasks identified for student in order to prepare for the facilitys conference in May 2018, as needs arise. Student and site mentor to attend meetings once every 3 weeks to discuss any projects and current management concerns. IDENTIFYING ROLES, RESPONSIBILITIES AND COMPETENCIES Somewhat less than expected (-1) Expected (0) Somewhat more than expected (+1) Much more than expected (+2) 28 Become educated on all materials pertaining to the Master Policy and Procedure Manuals for CMS/SBOH by 5 weeks. Convert 75% of materials from the Master Policy and Procedure Manuals from all facilities into an electronic system and comprehensive, organized, and standardized manner for each facility to utilize by 16 weeks. Educate appropriate personnel of the new manuals by method that best suits the personnel within 2 visits with poor follow through by 16 weeks. Complete 25% of financial planning and budgeting task by evaluating a portion of current pricing of therapy supplies from vendors. Complete 25% of managerial tasks identified for student in order to prepare for the facilitys conference in May 2018, as needs arise. Student and site mentor to attend meetings once every other week to discuss any projects and current management concerns. Become educated on all materials pertaining to the Master Policy and Procedure Manuals for CMS/SBOH by 4 weeks. Convert all materials from the Master Policy and Procedure Manuals from all facilities into an electronic system and comprehensive, organized, and standardized manner for each facility to utilize by 16 weeks. Educate appropriate personnel of the new manuals by method that best suits the personnel within one visit with poor follow through by 16 weeks. Complete 50% of financial planning and budgeting task by evaluating all current pricings of therapy supplies from vendors. Complete 50% of managerial tasks identified for student in order to prepare for the facilitys conference in May 2018, as needs arise. Student and site mentor to attend meetings 1 time a week to discuss any projects and current management concerns. Become educated on all materials pertaining to the Master Policy and Procedure Manuals for CMS/SBOH by 3 weeks. Convert all materials from the Master Policy and Procedure Manuals from all facilities into an electronic system and comprehensive, organized, and standardized manner for each facility to utilize by 12 weeks. Educate appropriate personnel of the new manuals by method that best suits the personnel within one visit with fair follow through by 16 weeks. Complete 75% of financial planning and budgeting task by evaluating all current pricings of therapy supplies from vendors, along with approximate shipping costs. Complete 75% of managerial tasks identified for student in order to prepare for the facilitys conference in May 2018, as needs arise. Student and site mentor to attend meetings 3 times a week to discuss any projects and current management concerns. Become educated on all materials pertaining to the Master Policy and Procedure Manuals for CMS/SBOH by 2 weeks. Convert all materials from the Master Policy and Procedure Manuals from all facilities into an electronic system and comprehensive, organized, and standardized manner for each facility to utilize by 8 weeks. Educate appropriate personnel of the new manuals by method that best suits the personnel within one visit with successful follow through by 16 weeks. Complete 100% of financial planning and budgeting task by evaluating all current pricings of therapy supplies from vendors, along with approximate shipping costs and comparison to over the counter pricings for a complete overview of pricing costs. Complete all managerial tasks identified for student in order to prepare for the facilitys conference in May 2018, as needs arise. Student and site mentor to attend daily meetings to discuss any projects and current management concerns. IDENTIFYING ROLES, RESPONSIBILITIES AND COMPETENCIES 29 Figure 3. Scored Goal Attainment Scale. This figure demonstrates the goals in the GAS with a final score provided to each goal based on the students final position with all projects/tasks at the end of the DCE. Each goal with the corresponding score is displayed in bold. Quality Improvement A continuous quality improvement plan was developed to address any issues that came about during the DCE and to ensure that there was a process for continuing this project once the DCE was completed. Throughout the DCE, the student requested feedback from the site mentor as she was the director of therapy and possessed increased experience and history with the organization. This was completed to guarantee all projects were being accomplished correctly and to ensure the director of therapy was aware of the results of projects since she is the primary individual in charge of the manuals. Materials in the manuals must be updated periodically throughout the year. The director of therapy is primarily responsible for the manuals; however, each satellite location has one to two therapists who will be responsible for all materials for that specific site. To assist the organization with continuing to maintain and update the electronic Master Policy and Procedure Manuals, a master checklist and instructional guide were created for the director of therapy and for the appropriate staff at each site. The documents consisted of all materials that need to be updated in the manuals, when they need to be updated, and step-by-step instructions on how to apply the updated materials to the electronic system. The director of therapy and appropriate staff were educated on this process and demonstrated competency. The director of therapy will have access to the electronic system at all times; therefore, she will be able to oversee if all sites have imported the updated materials at the appropriate times throughout the year and are maintaining the manuals overall to ensure that compliance with all policies, procedures, and requirements of CMS are maintained. IDENTIFYING ROLES, RESPONSIBILITIES AND COMPETENCIES 30 Needs of Society An individual in an administrative role must adapt to the changing needs of society by exhibiting confidence in self and in staff, helping others overcome obstacles, and energizing the workplace environment to help others find success (AOTA, 2011). All tasks completed throughout this DCE demonstrated these fundamentals. However, tasks specifically pertaining to the Master Policy and Procedure Manuals had the greatest impact on responding to societys changing needs. Due to the nature of the environment, the organization is continuously changing. Therefore, the manuals must be continually updated and maintained. If this process does not occur, then the organization may not be meeting all of the CMS requirements, which can put it at risk for termination of CMS participation. Medicare patients constitute a large portion of the facilitys clientele; therefore, this will limit the availability of high quality outpatient hand therapy services in the Indianapolis area. High quality care is ensured and will continue to be provided by this facility through the student updating the manuals during the DCE and through education of staff of the new version of the manuals to continue this process post DCE. Discussion Managerial decision making can be guided by use of a theory as a frame of reference. Research has shown that using a bottom-up model, such as the Dynamical Systems Theory, produces greater stability and dynamic responses (Shastri & Diwekar, 2006). Occupational therapy managers may use this theory in management as an organizing framework and also to help guide their teams toward openness, purposefulness, multidimensionality, and selforganization (AOTA, 2011). Throughout the DCE, the Dynamical Systems Theory was utilized to guide the student to complete the managerial projects that the student assumed responsibility for. By use of this theory, the student was able to work professionally with the site mentor, staff, IDENTIFYING ROLES, RESPONSIBILITIES AND COMPETENCIES 31 and organization as a whole, which then allowed the student to achieve and improve a variety of skills that an individual in an administrative role requires. These skills included leadership, advocacy, teamwork, communication, organization, timeliness, flexibility, information management, planning, and many more, and were demonstrated while performing the many roles, responsibilities, and competencies of an occupational therapy manager. These skills were learned through independently completing all projects stated in the GAS and by collaborating with the site mentor and staff members at the facility. Effective communication skills were essential for this DCE due to the communicable need of collaborating with the site mentor and other staff members of the organization for all managerial projects. This communication was accomplished through verbal and electronic communication. Verbal communication was predominantly the appropriate form of communication due to a majority of the staff that the student was working with being located at the main facility, which is the main location of the DCE. However, staff members at the satellite locations required electronic communication or telecommunication, whichever was the fastest and most effective manner of communication. All communication was kept professional and, if applicable, confidential. To ensure professional and successful communication, the student always ensured the staff expressed competence of the information being discussed. Specifically regarding the projects pertaining to the CMS regulations, financial planning, and budgeting tasks, the knowledge of these roles and responsibilities will be of great value to the student and the completion of these projects will be beneficial to the site. There is great importance for rehabilitation facilities to maintain certification as a CMS provider and to adapt to change in order to meet the varying financial demands of the healthcare system (ATOA, 2011). IDENTIFYING ROLES, RESPONSIBILITIES AND COMPETENCIES 32 Future Practice The student completing this DCE was with the first entry-level Doctor of Occupational Therapy class at the University of Indianapolis and in the Indianapolis area. This being said, this was one of the first projects of this kind being implemented in the Indianapolis area. This project will assist with paving the way for future Doctor of Occupational Therapy students completing a capstone project, whether in the Indianapolis area or throughout the United States. This project will also give the organization where the project was completed a basis of what this experience can consist of and what can be expected of future capstone projects for Doctor of Occupational Therapy students. Along with paving the way for other Doctor of Occupational Therapy students, this capstone project will also contribute to the students future practice. Administration and program and policy development are common areas in occupational therapy that an occupational therapy student, practitioner, and manager must be educated on. There is great need for staff and managers at rehabilitation facilities to ensure that certification as CMS providers is maintained and to adapt to change; this must be completed in order to meet the varying financial demands of the healthcare system (ATOA, 2011). Therefore, these newly acquired skills pertaining to administration and program and policy development are great experience and will be advantageous for the student as a future occupational therapy practitioner and potential manager. Limitations Although leadership skills were demonstrated throughout, there were components that limited the student in fulfilling certain leadership roles. Many of the leadership roles of an administrator stems from experience and time working with the organization; this was not possible for the student due to a limited amount of time spent with the organization and no IDENTIFYING ROLES, RESPONSIBILITIES AND COMPETENCIES 33 previous experience working at the facility. In order to overcome this obstacle, the student completed research if necessary before addressing the issue at hand; if questions still arose then the site mentor or another knowledgeable staff member was addressed. Conclusion As stated, the purpose of this DCE was to obtain skills beyond entry level pertaining to administration and policy and program development within an outpatient rehabilitation facility by performing the common roles, responsibilities, and competencies of an occupational therapy manager to obtain competence. This DCE provides significant information to future entry level Doctor of Occupational Therapy students and possible site mentors for what a DCE can consist of and to the organization this DCE was completed at for future Doctor of Occupational Therapy students. Students, occupational therapy practitioners, and managers must understand the roles, responsibilities, and competencies that an occupational therapy manager may possess in order to provide the best therapy services possible (AOTA, 2011). IDENTIFYING ROLES, RESPONSIBILITIES AND COMPETENCIES 34 References AOTA (2011). The occupational therapy manager (5th ed.) Bethesda, MD: AOTA Press. AOTA. (2017). AOTA occupational profile template. Retrieved from https://www.aota.org/~/media/Corporate/Files/Practice/Manage/Documentation/AOTAOccupational-Profile-Template.pdf Bonnel, W. E., & Smith, K. V. (2018). Proposal writing for nursing capstones and clinical projects (2nd ed.). New York: Springer. Braveman, B. (2006). Roles and functions of managers. In B. Braveman (Ed.), Leading and managing occupational therapy services: An evidence-based approach. Philadelphia, PA: F.A. Davis Company. Bcher, C. & Hume, K.I. (2002). Assessment following hand trauma: A review of some commonly employed methods. British Journal of Hand Therapy, 7(3): 79-84. Centers for Medicare and Medicaid (2014). State operations manual, appendix K guidance to surveyors: Comprehensive outpatient rehabilitation facilities. Cole, M., & Tufano, R. (2008). Applied theories in occupational therapy: A practical approach. Thorofare, NJ: SLACK Incorporated. Comprehensive outpatient rehabilitation facilities. (2012, March 5). Retrieved January 14, 2018 from https://www.cms.gov/Medicare/Provider-Enrollment-andCertification/GuidanceforLawsAndRegulations/CORF.html Comprehensive Outpatient Rehabilitation Facilities. (2013, April 11). Retrieved January 14, 2018, from https://www.cms.gov/Medicare/Provider-Enrollment-andCertification/CertificationandComplianc/CORFs.html IDENTIFYING ROLES, RESPONSIBILITIES AND COMPETENCIES 35 Hunt, J. G., & Ropo, A. (2003). Longitudinal organizational research and the third scientific discipline. Group and Organization Management, 28, 315-340. Institute for Work and Health. (2006). The quickDASH outcome measure. Retrieved from https://www.hss.edu/physician-files/fufa/Fufa-quickdash-questionnaire.pdf Krasny-Pacini, A., Evans, J., Sohlberg, M. M., & Chevignard, M. (2016). Proposed criteria for appraising goal attainment scales used as outcome measures in rehabilitation research. American Congress of Rehabilitation Medicine, 97: 167-170. Liebler, J. G., Levine, R. E., & Rothman, J. (1992). Management principles for health professionals. Gaithersburg, MD: Aspen. Outpatient rehabilitation providers. (2013, April 11). Retrieved January 14, 2018 from https://www.cms.gov/Medicare/Provider-Enrollment-andCertification/CertificationandComplianc/OutpatientRehab.html Quality, safety & oversight General information. (2018, January 10). Retrieved January 14, 2018 from https://www.cms.gov/Medicare/Provider-Enrollment-andCertification/SurveyCertificationGenInfo/index.html Quality, safety & oversight - Enforcement. (2018, January 10). Retrieved January 14, 2018 from https://www.cms.gov/Medicare/Provider-Enrollment-andCertification/SurveyCertificationEnforcement/index.html Robbins, S. P., & Coulter, M. (2009). Management (10th ed.). Upper Saddle River, NJ: Prentice Hall. Shastri, Y., & Diwekar, U. (2006). Sustainable ecosystem management using optimal control theory: Part 1. Journal of Theoretical Biology, 241, 506-521. IDENTIFYING ROLES, RESPONSIBILITIES AND COMPETENCIES 36 Sleezer, C. M., Russ-Eft, D., & Gupta, K. (2014). Practical guide to needs assessment. Retrieved from https://ebookcentral.proquest.com  ...

... HOPE IN A NEW LAND: DEVELOPING AN AFTERSCHOOL PROGRAM FOR REFUGEE CHILDREN By Kendra Shaw An Honors Project submitted to the University of Indianapolis Strain Honors College in partial fulfillment of the requirements for a Baccalaureate degree with distinction. Written under the direction of Dr. Jyotika Saksena. March 20, 2017 Approved by: ______________________________________________________________________ Dr. Jyotika Saksena, Faculty Advisor ______________________________________________________________________ Dr. James B. Williams, Interim Executive Director, Strain Honors College ______________________________________________________________________ First Reader ______________________________________________________________________ Second Reader K. Shaw 2 Abstract If children of refugees are to thrive, not just adapt and survive, when they relocate to a new country, it is essential that the organizations in their new home provide sufficient programs in language acquisition, cultural awareness, and community building (Greenburg, 2014). These types of programs enable them to learn the language, understand cultural differences, and achieve in school. Specifically for Indianapolis, there is a gap in the programs that are offered for refugees; however, this teaching binder aimed to begin filling that space. Throughout the project, I engaged in community-based participatory research and worked with Exodus Refugee Immigration, a local non-profit, to develop lesson plans for an after-school program for refugee students in middle school. The final project contains ten prepared lesson plans with copies of the created worksheets and activities, a job description for the teacher, a case statement, and recommendations for further development. It also includes a reflection of the knowledge that I have gained and the passion that has been sparked to culturally and academically support the refugee students arriving in Indianapolis, Indiana. K. Shaw 3 Acknowledgment Dedicated to Exodus Refugee Immigration, especially the students and staff who helped me discover a passion for teaching English in multicultural settings. Special thanks to Dr. Saksena, Dr. Newman, my family, and close friends for sharing their wisdom and compassion for others with me while at the University of Indianapolis. K. Shaw 4 Table of Contents Cover Page ...............................................................................................................1 Abstract ...................................................................................................................2 Acknowledgement ...................................................................................................3 Statement of Purpose ...............................................................................................5 Introduction ..............................................................................................................6 Method/Procedure ..................................................................................................12 Analysis/Conclusion ..............................................................................................24 Reflection ...............................................................................................................26 References ..............................................................................................................27 Appendices .............................................................................................................29 Appendix A: Permission from Exodus ......................................................29 Appendix B: CITI Training .......................................................................30 Appendix C: Student Interview Request Form ..........................................32 Appendix D: Interview Questions .............................................................33 Appendix E: Teaching Binder ...................................................................34 Appendix F: Case Statement ......................................................................96 Appendix G: Teachers Job Description ..................................................100 K. Shaw 5 Statement of Purpose The purpose of this project was to create a teaching binder that included the materials that Exodus Refugee Immigration, a local non-profit, would need to initiate an after-school program for refugee children in grades six through eight in Indianapolis, Indiana. Currently, Exodus offers Language, Cultural Orientation, and Readiness for Employment (LCORE) classes; however, they are designed primarily for adults to gain self-sufficiency skills. The focus of this project was to help the organization expand its classes to better reach the children by creating ten lesson plans with practice worksheets and activities that provided the students with an introduction to the English language and to the cultural differences of America, especially within the education system. The binder also included the job description for the teacher and suggestions on the implementation stage of the program, such as a case statement to give to funders. The project was based on the knowledge about case statements, non-profits, and teaching English that I had gathered from my internship with LCORE, as well as from the Writing for Non-Profits class and Materials Development for Teaching English to Speakers of Other Languages class at UIndy. The purpose was that an organization, like Exodus, will be able to use the binder to spark consideration for an educational program that would both culturally and academically support young refugees in Indianapolis. K. Shaw 6 Introduction According to the United Nation High Commissioner for Refugees (UNHCR), a refugee is a person who, owing to a well-founded fear of being persecuted for reasons of race, religion, nationality, membership of a particular social group, or political opinion, is outside the country of his nationality (UNHCR, 2016). In other words, refugees are people fleeing from their country of origin and are unable to return due to violence or persecution. They are protected by international law, and in 2014, the number of refugees rose to 14.4 million (UNHCR, 2016). With the increase of refugees, organizations that coordinate their relocation and resettlement have become crucial to efficient and smooth transitions between countries, as well as language acquisition and cultural orientation. Since the resettlement program started in the United States in 1975, Americans have welcomed over three million refugees (Exodus, 2013). In Indianapolis, Exodus Refugee Immigration resettled 947 new refugees in 2016, which is a record high for the organization (Exodus, 2013). As a result, it is important to look at the programs typically offered by nonprofits in order to identify strengths and weaknesses. Specifically, in this project I describe and analyze the programs offered to refugees in Indianapolis by nonprofit organizations to show that there is a lack of sufficient programs specially designed for children. I then describe a few after-school programs for refugee children that have been implemented in other cities in the United States to show that this type of program is feasible. Finally, I conclude that the teaching binder was the first step to developing an after-school program for middle school-aged refugees in Indianapolis, Indiana. K. Shaw 7 Refugee Resettlement in Indianapolis There are three main nonprofits located in Indianapolis that serve refugee families: Exodus Refugee Immigration, Catholic Charities Indianapolis, and Burmese American Community Institute (BACI). Exodus Refugee Immigration aims to welcome families and provide them with the means to live self-sufficiently. One way Exodus achieves this goal is with the Language, Cultural Orientation and Readiness for Employment (LCORE) class. LCORE is a thirty-six session, eighteen-week program designed to teach practical English and occupational skills (Exodus, 2013). Currently, refugees take an assessment of their language skills and then are placed in one of the four levels for English training. The employable adults are taught practical skills needed to successfully transition to life within Indianapolis. For example, during my internship with Exodus, a few lessons I taught were how to fill out job applications and how to report a problem within the workforce. Similar to Exodus Refugee, Catholic Charities also aims to welcome and resettle refugees to Indianapolis. The organization offers pre-arrival assistance by supplying housing, furniture, food, clothing, and airport reception (Archdiocese of Indianapolis, 2016). In addition, within and up to thirty days after the families arrive, the volunteers provide community orientation and collaborate with the employable adults on creating a job plan (Archdiocese of Indianapolis, 2016). If needed, Catholic Charities refers their clients to English as a Second Language (ESL) classes for employment readiness. Finally, the Burmese American Community Institute (BACI) focuses on the Burmese refugee population that has lived within the United States for at least 180 days, K. Shaw 8 so it is unique in its programs (BACI, 2009). In addition to language training and practical skill development, BACI has a few programs the Upward College Program and Summer Scholars Program-- for college preparedness of high school students. The summer program is an intensive eight-week research project on the Burmese community that ends with an academically written paper (BACI, 2009). It is an opportunity for the students to demonstrate the writing abilities that they will need for college, and allows them to discover more about their own culture and how it is embraced within the city. While the amount of services offered to refugees by these organizations is incredible and expansive, the emphasis on supporting refugees self-sufficiency seems limited to the employable adults with only BACI reaching high school students in order to prepare them for college. This is shown by the lack of English and cultural orientation classes offered to the middle or elementary school-aged students. In fact, one of the teachers at Exodus explained that the organization primarily works to make families self-sufficient, which means that most of [the] services are towards adults (K. Reeves, personal communication, Jan 18, 2017). However, Exodus did pilot a youth orientation day in the summer of 2016 that provided refugees between the ages of five and seventeen with their own cultural introduction to the city separate from the adult orientation day. An LCORE teacher explained that the program, which was started with an AmeriCorps staff member, introduced the refugees to a wide range of topics, such as hygiene and body language, and included field trips (K. Reeves, personal communication, January 18, 2017). The youth orientation day, which will be continued according to Reeves and further discussed K. Shaw 9 in the procedure, demonstrates that Exodus already recognizes the need for a program aimed at the younger refugees (K. Reeves, personal communication, January 18, 2017). In other words, specific lessons tailored to the learning styles and materials appropriate for refugee children are in their early stages of development by the LCORE teachers and youth program specialist, but there is a lack of an after-school program to further support their cultural awareness and English acquisition in Indianapolis. After-School Programs in Other States Throughout the United States, there are a few cities that have implemented afterschool programs. For example, OurBRIDGE is a nonprofit in Charlotte, North Carolina that teaches English and culturally-oriented curriculum to seventy refugee and immigrant students between kindergarten to fifth grade from over twenty countries (Misra, 2015). The classroom is full of puzzles and books, and the curriculum is designed so that the students have opportunities to practice their English skills and share music, food, and holidays from their culture with others in the class, which means that they explore topics that they would not necessarily learn in school (OGorman, 2014). The nonprofit also builds relationships between students by creating an environment where they can learn from and identify with others experiencing similar situations. OurBRIDGE shows that the goals of cultural orientation, language acquisition, and community building are feasible for young refugees and can be accomplished through after-school programs. This argument is further supported by RefugeeONE, another program for refugee children in Chicago, Illinois. Their youth are reached through the school-readiness program that teaches them about schools in America and through the six-week summer K. Shaw 10 camp that helps incoming students catch up to their class levels knowledge (RefugeeONE, 2016). Throughout the school year, RefugeeONE teaches the children after school about health, nutrition, English, school, and various other topics. The volunteers keep the students engaged with crafts, sports, service projects, and interactive activities (RefugeeONE, 2016). The goal is to provide supplemental lessons to boost the students confidence, sense of belonging to a community, and academic performance. A few studies have concluded that these goals are feasible with after-school programs, especially ones that combine a variety of teaching styles. For example, Greenberg (2014) looked at immigrant children between the ages of two and twelve who participate in after-school programs, such as the New York City Beacon Community Center. The center uses school buildings for activities, including sports and arts. She noted that after-school programs for children are particularly important during middle school because these students spend more hours out of school than in school, so how they spend their time after school is dismissed is crucial for their development. As a result, participating in a program in addition to school is important because it improved comprehension, increased the sense of belonging to a group, and led to positive social and emotional development (Greenburg, 2014). This is because the program was a safe and structured environment that taught language skills, music, cooking, and cultural histories so that the children learned from each others backgrounds. Just like with immigrants to the United States, refugee children would benefit from cultural support. Townsend (2009) adds that particular types of games should be included for children to ensure that they encounter and practice new vocabulary words in different K. Shaw 11 contexts. One program in southern California, Language Workshop, uses a variety of activities to encourage collaboration and learning of increasingly difficult words that the children might encounter in school (Townsend, 2009). For example, teaching sessions are fast-paced with interactive assignments mixed with informational text for content relevance of the new words. After the students are first introduced to the vocabulary, they participate in games, such as the picture puzzler. The students match words to pictures, which can be used to spark discussion about the multiple meanings of words and what the pictures could represent (Townsend, 2009). For another game, there are two dice with one having words on each side and the other having a task, like act it out or write a sentence, on each side. The students take turns rolling the dice and completing the task. The practice and exposure of the words helps improve memory and build friendships as students complete the activities together (Townsend, 2009). As evidenced by the above discussion, there are many programs offered by Exodus Refugee, BACI, and Catholic Charities to refugee families relocating to Indianapolis. In addition, there are a few cities throughout the United States that have implemented after-school programs specifically tailored to middle or elementary schoolaged refugee children, and such programs have received positive feedback from the students and local schools. However, there is a lack of an after-school program specifically designed for the refugees and refugee organizations in Indianapolis. Developing the lesson plans for the teaching binder with Exodus was the first step towards better providing for and academically supporting the refugee students in the city. K. Shaw 12 Method and Procedure Below are the steps that I took to complete the teaching binder with the first ten lessons needed to initiate an after-school program for Exodus Refugee. To maximize the lessons usefulness for the organization, I utilized Community-Based Participatory Research (CBPR). CBPR is a collaborative approach to research that equitably involves all partners in the research processand begins with a research topic of importance to the communitywith the aim of achieving social change (U.S. Department of Health & Human Services, 2015). In other words, it is a method used to engage the community members in research and developing solutions to community issues. The community members are both the co-designers and beneficiaries of the solutions. For this project, I collaborated with Exodus, a non-profit organization that serves the refugee community in Indianapolis, at every stage. Together, other teachers and I received input from the young adults that were attending the adult classes to identify the gap in the programs that were offered. This process is further explained in the procedure. In addition, I discussed the content that was covered in the lessons with the teachers and continually consulted the youth coordinator. It was important to work with Exodus because the staff members are extremely familiar with the target audience of the program. Also, the collaboration allowed me to create lessons that would benefit the organization and young refugees. If I had developed the lesson plans without the organizations input on the project, I could have created a solution to a problem that did not exist or even designed content that was not needed by the teachers. Essentially, the community-based K. Shaw 13 participatory research methodology was appropriate for this project, and is demonstrated in the following procedure. 1. Drew on past experiences to initiate the project. Throughout my career at UIndy, I have been blessed with opportunities that have helped prepare me for this honors project. As an International Relations major, I have been introduced to topics, such as non-profits, minority cultures, and refugee populations. Specifically, I took the International Organizations class taught by Dr. Saksena as an honors option course. I received the honors credit by reading Chasing Chaos by Jessica Alexander, presenting the information and analysis I garnered from Alexanders book, completing an internship with Exodus Refugee, and writing an academic daily journal about my experiences as an intern. It was the combination of these tasks and the International Organizations class that sparked the idea for this project. First of all, I read Jessica Alexanders book Chasing Chaos, in which she described the problems of the aid industry. During her ten years of humanitarian aid work, she saw people that required help but no programs covered their needs. Her words changed my perspective of non-profits to include a more critical outlook because there may be more efficient ways for organizations to support beneficiaries. Through her analysis and observations, the book helped me question if young refugees were being supported linguistically by Exodus because there was no English class tailored for them. As a Spanish major, I had gained a personal perspective on the need for continual support of language acquisition in order to better understand a new language. K. Shaw 14 For my year-long internship, I served as a community teacher for Exodus. I taught six to twelve hours a week in four classrooms, with all four language proficiency levels, and with class sizes that ranged from five to thirty students. In addition, I made copies for class and created intake folders for each incoming refugee adult. The internship, as well as job shadowing with and translating for the development team at Christel House International, have instilled in me a love for the refugee population in Indianapolis and the basic skills that I needed to complete this project. In addition to the honors class and internship, another UIndy class had a big impact on my preparedness for the binder. During my junior year, I took English 489: Writing for Nonprofits taught by Prof. McKelvey. For his class, I wrote a case statement, co-wrote a grant and ghost-wrote letters of support for a computer program with Grain of Rice Project in Kenya, and partnered with the Burmese American Community Institute to draft and submit a Wikipedia page. I also read Writing for a Good Cause by Joseph Barbato and Danielle Furlich, which provided me with insight on the technical and passionate writing style needed to successfully initiate programs. As a result of these opportunities, and because of my connections with Exodus, attached below is an email from my previous supervisor, Kari Fritz, granting me permission to use Exoduss name for the project and to use her and the teaching team as a resource in the review process of the ten lesson plans. Also, attached below is my CITI Training Certificate that shows that I have completed the required modules. K. Shaw 15 2. Recorded daily observations. As previously mentioned, I served as a community teacher for Exodus Refugee and completed a daily academic journal. I kept a record of the content that I taught and the tasks I completed while working in the classrooms and office. I also wrote down concerns, critics of the program, and other observations about the students. For example, I noted that the adults were easily distracted during class. This was because a few of the women would bring their children. As a result, the parents and other students had to multi-task to engage with the material while monitoring the children. In addition, the teachers had to attempt to keep the attention of the adults in order to encourage class participation with the activities while children were running around the room. The room was often loud, which caused difficulty in hearing the lesson and the students responses. These observations demonstrated that there was a need for a classroom designed for the younger refugees so that the parents could focus in class. 3. Initiated content development of the lesson plans. I identified the broad topics that are covered and incorporated within the English lessons by using the observations mentioned above as well as questions the teachers had received from middle-school aged students. The teachers and I did not conduct a formal survey to the students to determine their interests in specific topics; however, students informally asked questions during and after class about future lessons. For example, a few students who were below the age of eighteen had started attending the community classes in order to begin learning self-sufficiency skills and to support their studies at school. In fact, three youth-aged refugees asked one of the volunteers if K. Shaw 16 future lessons would include information about high school and college because they were interested in knowing how they could start preparing. When I was teaching the lesson about forms and personal information, the younger refugees wanted to know what typical forms for school or college applications looked like and how they were different from the information required for a job application or medical appointment. As a result, I decided to focus this project on the American educational system. Initially, I had planned on covering a wider range of topics, including the weather and clothing. However, the need for lessons was more narrowly tailored as shown by the students interests that were expressed to the teachers and to me. 4. Interviewed the youth coordinator at Exodus Refugee. Even though the observations and questions from the students highlighted that there was a need for a classroom or lesson plans tailored for young refugees, I wanted to ensure that a refugee resettlement organization, like Exodus, would be able to initiate a new program, especially because focus of those types of non-profits is on selfsustainability and employment. I filled out the student interview request form for Exodus, which is attached in the appendix. After I was given clearance to interview the staff, one of the LCORE teachers Kari Fritz connected me with Kelly Reeves, the new Youth Cultural Orientation Specialist at Exodus. I asked her three questions related to the new cultural orientation for the youth and potential English lessons for an after-school program for children. The specific questions I asked are attached below. Reeves explained that an AmeriCorps staff member had recently piloted a youth cultural orientation day for students aged five to seventeen separate from the adults K. Shaw 17 orientation at Exodus (K. Reeves, personal communication, January 18, 2017). Although the orientation day for young refugees is outside of the primary goal of making families self-sufficient, it is considered a supportive program. Supportive programs help families adjust or give services, such as special medical care, to cases that require more attention (K. Reeves, personal communication, January 18, 2017). In other words, the youth program is considered supportive of the goals of a refugee resettlement agency because it aims to help the children of the families adjust to life in their new home. The youth cultural orientation introduces topics on education instead of on employment, which is the topic typically covered in the adult orientation. The program covers: the rules of the school, enrollment, school supplies, uniforms/dress code, hygiene, the calendar and attendance, school culture, body language, ages/grades, riding the bus, arriving at school, gym, recess, lunch time, school personnel, different ways to be successful in schools, grading scale, cultural shock/adjustment tips, good touch/bad touch, extra-curricular activities and clubs, laws for youth, following a schedule, going to lockers, after graduation, paying for education after high school, emergencies, drills, general safety, and school vocabulary in English (K. Reeves, personal communication, January 18, 2017). The teachers also incorporate a few interactive activities, such as Simon Says, to demonstrate typical American games that might be played in school. After I learned how expansive the cultural orientation was for the students, I reconsidered my plan for the after-school program because the youth day seemed to cover a lot of the same topics that I was planning on covering in the program. However, Kelly mentioned that Exodus was aiming to create ways, such as an activity book, for the K. Shaw 18 children to remember the vast amount of information that they had been exposed to (K. Reeves, personal communication, January 18, 2017). The after-school program would serve as another means to reintroduce and reinforce the topics covered in orientation. In addition, the after-school program would be more focused on supporting the students English skills as well as using appropriate content for the activities. 5. Attended Dr. Newmans Materials Development for TESOL class. Throughout this semester, I have attended Dr. Karen Newmans TESOL class to gain further knowledge on designing materials for specific age groups. Her class has helped me ensure that the lesson plans are culturally and linguistically appropriate for English as a Second Language (ESL) students. For example, I am reading Materials and Methods in ELT: A Teachers Guide by McDonough, Shaw, and Masuhara. The authors explain that teachers must consider the students motivations for learning English, their cultural backgrounds, age, and interests among other factors when choosing or developing lesson plans (2013). I did this by listening to the refugees questions about class and deciding to focus my content on skills, such as navigating a lunch line, that the students would need to have to succeed in middle school. 6. Developed the outline of the lesson plans. Once I had determined that I would focus on supporting the students English skills with content about education, I developed the ten lesson plans. They are based on the outlines given to the LCORE teachers and volunteers at Exodus that are used for the adult community classes. For each lesson, the outline includes learning goals, a list of needed materials for the activities, a review from the previous lesson, descriptions of K. Shaw 19 each activity, and an estimated time frame of how long each section should last. I followed the organizations lesson plan template to help keep the lessons consistent between programs offered and guide the teacher on how long an activity should be conducted. The outlines also include extension activities in case there is extra time at the end of the lesson. The lesson plans and subsequent activities are attached below. 7. Adapted a few lesson plans In addition to modeling the lesson plan outlines after the ones used at Exodus, a few of the lessons for the children were adapted from the adult community classes. McDonough, Shaw and Masuhara define adapting as the process of changing or adjusting the various parts of teaching material (2013, 64). This means that the teacher should add, delete, modify, and/or simplify activities in a lesson plan in order to make them more relevant to the students. Graves notes that the first step to adapting material is to get inside it by looking at the organization and by reading the objectives (1999, 176). This allows the teacher to evaluate the overall structure of the information presented to determine if it is suitable for his or her specific needs and the context of the class. The teacher should then look at the content or topics covered within the lesson. Material may need to be adapted for several reasons. For example, the existing lesson may not have enough grammar, or may introduce too many new vocabulary words in one reading passage, or may rely on technology that is not available. All of these examples highlight the fact that material is closely related to the reality of the teaching environment in which it is going to be used. This means that the original purpose of the material may not be appropriate for the current situation or students. Essentially, the teacher wants K. Shaw 20 congruence between the material and teaching environment (McDonough, Shaw, & Masuhara, 2013). For this project, I used the above analysis of adapting materials to modify a few activities. For example, I utilized the provided lesson plans at Exodus and taught a lesson on food to the adult class. The students were shown pictures of different food in order to practice the vocabulary and identification. After they had completed the flashcard activity, they were asked to choose the food they would purchase from a grocery store. While the students enjoyed the scenario of picking out food at a store and paying for it, the activity was not appropriate for the middle-school aged refugees. The young students would often not go to the store with their parents. Also, the store location did not fit into my overall theme of school-based activities. As a result, I created new flashcards with foods typically offered in a school cafeteria. After introducing the words, I had the students act as if they were going through a cafeteria lunch line. The change of location was more appropriate for the students because they will need to know how to navigate a cafeteria line and interact with the lunch people when they attend school. 8. Created the worksheets and activities for each lesson plan. There are at least four worksheets or activities for each lesson plan, and at least one of the activities includes conversations with other students. This helps build community and relationships between the students as well as gives them a chance to practice verbal English skills. Many of the activities were inspired by the assigned reading in Dr. Newmans TESOL class. For example, Sanderson argued that newspapers provide ample resources for materials in a classroom, especially because the language is K. Shaw 21 authentic (1999). This means that students would be exposed to real, everyday language if they read a newspaper article or story. They can also be used to teach higher-order reading skills, such as predicting the topic of an article based on the title and picture. I included this type of activity in teaching binder. I ask the students to look at a picture and title of an article and then predict the topic, which is a transferable skill. Sanderson also notes that cartoons can spark creativity for students or can even be used to introduce idioms to advanced students (1999). Since the refugees may not be advanced in their English skills, I chose to include an activity in which they create their own cartoon strips to illustrate a story. Literature by Burns also influenced the lesson plans. She insists that a holistic approach is needed when teaching with speaking activities (2012). In other words, a teacher should model the speaking task, give students the opportunity to prepare and/or practice their responses, and then ask them to speak (2012). This can help encourage shy students to speak and minimizes anxiety about talking in a new language. Burns also points out that it is helpful to recycle speaking material and review information. I incorporated her suggestions into the lesson plans by including a review speaking activity at the beginning of each lesson. Because they students were previously exposed to the vocabulary words and material, they should be able to immediately provide an answer to the question asked at the beginning of class. However, for the other speaking activities, such as sharing an opinion with the class, I give students a chance to discuss their response and practice with a partner. K. Shaw 22 9. Tested out a few of the activities. After I developed the activities that are included in the lesson plans, I practiced a few of them in the TESOL class. For example, I introduced the Spelling Race Game, which involves cut-out letters of vocabulary words. I divided my classmates into groups of two and had them work together to spell the days of the week correctly as I gave directions, such as Please spell the name of the day that comes after Monday. Once the activity was completed, my classmates responded that the activity was enjoyable and engaging because they had to compete against each other, it encouraged teamwork within the groups, and could easily be adapted to other skill levels and content by changing the words that were intended to be spelled out. Because of the positive feedback, I included the spelling activity in the second lesson, which is about the calendar. 10. Wrote and designed a four-page case statement. The case statement was based on my experience in the Writing for Non-Profits class. It is written in the passionate and technical writing style that is suggested by nonprofit and grant writers to best convey the need of the program without sounding negative or desperate (Barbato & Furlich, 2000). The case statement demonstrates one way that Exodus could implement the after-school program, utilizing its current classroom space around Indianapolis. It includes a description of the after-school program, images of community members and a possible location for the class. Essentially, it is a fancy brochure rationalizing the importance and feasibility of the program. The case statement can be distributed to funders, donors, and interested parties as a way to introduce them to the new program being developed and ask for their support. K. Shaw 23 11. Wrote a description of the teachers job. The description serves as an orientation to the job for the teacher and volunteers in the classroom. It details the daily requirements of leading the after-school program so that they can better prepare to serve the children. The job description is attached below. 12. Submitted the lesson plans and activities. Throughout the development process, I submitted lesson plans and activities to Dr. Newman and the LCORE teachers for feedback to improve the content and ensure that I am using appropriate activities for the lesson and various learning styles. This ensured that various interested parties were continually involved and included in the process of the project, which demonstrates the community-based participatory research method. K. Shaw 24 Analysis and Conclusion There are key elements that teachers look for when evaluating and analyzing lessons and materials. McDonough, Shaw, and Masuhara explain that the material should appropriately address the intended audience, context, and the students proficiency and age levels (2013). Unfortunately, I currently do not know if my teaching binder meets all of these requirements. This is because I have not implemented the program nor taught the young refugees, which means that I have not been able to conduct a formal needs analysis of the students. A needs analysis, which is an activity designed to test the linguistic abilities of the students, can and should be implemented if the program starts to ensure that the activities are tailored for the correct levels. In addition, because I am not certain of the level of proficiency of the students, I have created activities and lesson plans that are flexible and adaptable if needed. Flexibility is also a key component to look for when evaluating teaching material (McDonough, Shaw, and Masuhara, 2013). Tomlinson adds that a lesson should be useful for different learning styles and draw attention to specific linguistic features or grammar (1998). I have attempted to accommodate various learning styles by including audio instructions, visual aids, and hands-on activities in every lesson. Not only will this help the students learn, but will give them opportunities to interact with their classmates. However, Tomlinson would suggest that I add more opportunities when students can provide feedback on the lessons and give suggestions for future content (1998). This would help the students feel more engaged in the material itself as well as give them more control over the specific words K. Shaw 25 and linguistic features that they learn. If students are given more control of what they learn, they may be more motivated to review the material. One strong critique against my lessons includes the lack of authentic listening materials. Lingzhu and Yuanyuan emphasize the importance of authentic listening materials because they reflect everyday speech and are not artificially crafted (2010). In addition, authentic speech can look and sound very different than the written language. For example, speech includes verbal pauses, repetitions, filler words, incomplete sentences, and restarts to a sentence (Lingzhu & Yuanyuan, 2010). While I did include a few listening activities with supplementary scripts, they were crafted to specifically include vocabulary from the lessons. I did this partly because the material is not aimed at advanced English students, so I did not want to burden them with unique sentence structures and new vocabulary all at once. However, the materials could be improved in the future by incorporating authentic listening materials, such as a record phone call. In conclusion, there are many ways, as mentioned, that the existing lesson plans and activities can be improved. Other teachers may want to add more activities that focus on specific verb tenses, or even expand one lesson into two. Essentially, the project needs to be continued with continual consultation with Exodus for further development of more lesson plans and activities. After at least ten more lesson plans are created, the organization can begin to implement the program by fundraising, setting up the classroom, and talking with the refugee families. The end goal is that young refugees attending middle school will be supported with an after-school program in Indianapolis. K. Shaw 26 Reflection As previously mentioned, the University of Indianapolis has opened the doors to several amazing opportunities, including the internship at Exodus Refugee and the classes that sparked the idea for the teaching binder. This honors project has helped me to combine the academic knowledge I gained in International Organizations, Materials and Methods, and Writing for Non-Profits with the hands-on experiences of teaching in an English classroom. As a result, I have developed the ability to critically view organizations, to identify weaknesses or gaps in the solutions or services offered to a community, to collaborate with individuals from a non-profit, to accept critical feedback and adjust my work, to design and adapt lesson plans, and to create culturally and linguistically appropriate materials and activities for middle-school refugees. In addition, working alongside the teachers and youth coordinator at Exodus has deepened my passion for helping others. I am extremely grateful to have worked with such incredible people as the Exodus teachers and staff, Dr. Saksena, and Dr. Newman. This is especially because designing the new lesson plans and activities has allowed me to practice and demonstrate the practical skills that I will need to teach overseas or with non-profits in the future. In fact, I will continue to utilize and improve these new skills after graduation. I have been accepted to serve as a Peace Corps volunteer in Nicaragua for 27 months, during which I will develop and teach English lessons to high school students. I have greater confidence in myself to truly help the students because of the honors program, my amazing advisors on this project, and the teaching binder I have created to initiate an after-school program for refugee children in Indianapolis, Indiana. K. Shaw 27 References Archdiocese of Indianapolis. (2016). Refugee and immigrant services. Catholic Charities Indianapolis. http://www.archindy.org/cc/indianapolis/programs-crisis.html Barbato, J., and Furlich, D. S. (2000). Writing for a good cause: The complete guide to crafting proposals and other persuasive places for non-profits. New York: Simon & Schuster, Inc. Burmese American Community Institute (BACI). (2009). Educational programs. Retrieved from http://www.baci-indy.org/ Burns, A. (2012). Teaching speaking: A holistic approach. New York: Cambridge University Press. Exodus Refugee Immigration. (2013). Our programs. Retrieved from https://exodusrefugee.org. Graves, K. (1999). Designing language courses: A guide for teachers. Heinle & Heinle. Greenberg, JP. (2014). Significance of after-school programming for immigrant children during middle childhood: Opportunities for school social work. Social Work, 59(3), 243-51. Lingzhu, J., and Yuanyuan, Z. (2010). The use of authentic materials in teaching EFL listening. Humanising language teaching, 12(4). McDonough, J., Shaw, C., and Masuhara, H. (2013). Materials and methods in ELT: A teachers guide. 3rd ed. West Sussex, United Kingdom: John Wiley & Sons, Inc. K. Shaw 28 Misra, T. (2015). Inside an after-school program for refugee children. The Atlantic. Retrieved from http://www.theatlantic.com/education/archive/2015/12/whats-itlike-to-run-an-after-school-program-for-refugee-children/418617 OGorman, C. (2014). Our bridge program offers classroom aid to immigrant children. The Charlotte Observer. Retrieved from http://www.charlotteobserver.com/news/local/ community/south-charlotte/article 9196730.html RefugeeONE. (2016). Resettlement services. Retrieved from http://www.refugeeone.org/ Sanderson, P. (1999). Using newspapers in the classroom. New York: Cambridge University Press. Tomlinson, B. (1998). Introduction. In B. Tomlinson (Ed.), Materials development in language teaching. New York: Cambridge University Press. Townsend, D. (2009). Building academic vocabulary in after-school settings: Games for growth with middle school English-language learners. Journal of Adolescent & Adult Literacy, 53(3), 242-251. doi:10.1598/JAAL.53.3.5. United Nation High Commissioner for Refugees (UNHCR). (2016). Refugees. http://www.unhcr.org/en-us/refugees.html U.S. Department of Health & Human Services. (2015). 2015 Poverty Guideline. Retrieved from http://aspe.hhs.gov/2015-poverty-guidelines K. Shaw 29 Appendices Appendix A: Permission Email from Exodus Refugee Immigration Kari Moore to me Aug 31 Hi Kendra, Nice to hear from you! Sorry for my delayed response. I was on airport duty last week so everything got pushed back. I think that it would be fine for you to do this project on Exodus. Just a couple of questions. How much time do you anticipate needing from staff to complete this? We are approaching the end of our fiscal year and have very heavy arrival numbers until September 30, so I want to be sure we'd have the capacity to answer questions. Also, will you be requesting any additional photos, video, etc? Thanks, Kendra! Kari K. Shaw 30 Appendix B: CITI Training COLLABORATIVE INSTITUTIONAL TRAINING INITIATIVE (CITI PROGRAM) COURSEWORK REQUIREMENTS REPORT* * NOTE: Scores on this Requirements Report reflect quiz completions at the time all requirements for the course were met. See list below for details. See separate Transcript Report for more recent quiz scores, including those on optional (supplemental) course elements. Name: Email: Institution Affiliation: Institution Unit: Phone: Kendra Shaw (ID: 5441532) kjshaw@uindy.edu University of Indianapolis (ID: 473) International Relations 3098460828 Human Subjects Research (HSR) Curriculum Group: Course Learner Group: Group 3: Non-Health Related Research Stage 1 - Basic Course Stage: Report ID: Completion Date: Expiration Date: Minimum Passing: Reported Score*: 18939524 03-Aug-2016 03-Aug-2018 80 99 REQUIRED AND ELECTIVE MODULES ONLY Belmont Report and CITI Course Introduction (ID: 1127) History and Ethical Principles - SBE (ID: 490) Defining Research with Human Subjects - SBE (ID: 491) The Federal Regulations - SBE (ID: 502) Assessing Risk - SBE (ID: 503) Informed Consent - SBE (ID: 504) Privacy and Confidentiality - SBE (ID: 505) Populations in Research Requiring Additional Considerations and/or Protections (ID: 16680) Illegal Activities or Undocumented Status in Human Research (ID: 16656) Students in Research (ID: 1321) Internet-Based Research - SBE (ID: 510) Conflicts of Interest in Research Involving Human Subjects (ID: 488) Unanticipated Problems and Reporting Requirements in Social and Behavioral Research (ID: 14928) Cultural Competence in Research (ID: 15166) Research with Prisoners - SBE (ID: 506) Research with Persons who are Socially or Economically Disadvantaged (ID: 16539) Research with Older Adults (ID: 16502) Gender and Sexuality Diversity (GSD) in Human Research (ID: 16556) Research with Children - SBE (ID: 507) International Research - SBE (ID: 509) Avoiding Group Harms - International Research Perspectives (ID: 14081) DATE COMPLETED 03-Aug-2016 03-Aug-2016 03-Aug-2016 03-Aug-2016 03-Aug-2016 03-Aug-2016 03-Aug-2016 03-Aug-2016 03-Aug-2016 03-Aug-2016 03-Aug-2016 03-Aug-2016 03-Aug-2016 03-Aug-2016 03-Aug-2016 03-Aug-2016 03-Aug-2016 03-Aug-2016 03-Aug-2016 03-Aug-2016 03-Aug-2016 For this Report to be valid, the learner identified above must have had a valid affiliation with the CITI Program subscribing institution identified above or have been a paid Independent Learner. f Verify at: https://www.citiprogram.org/verify/index.cfm?verify=41e28ac3-2f0e-4d23-8a4d-1c5de2cbbe2 CITI Program Email: support@citiprogram.org Phone: 888-529-5929 Web: https://www.citiprogram.or g K. Shaw 31 COLLABORATIVE INSTITUTIONAL TRAINING INITIATIVE (CITI PROGRAM) COURSEWORK TRANSCRIPT REPORT** ** NOTE: Scores on this Transcript Report reflect the most current quiz completions, including quizzes on optional (supplemental) elements of the course. See list below for details. See separate Requirements Report for the reported scores at the time all requirements for the course were met. Name: Email: Institution Affiliation: Institution Unit: Phone: Kendra Shaw (ID: 5441532) kjshaw@uindy.edu University of Indianapolis (ID: 473) International Relations 3098460828 Human Subjects Research (HSR) Curriculum Group: Course Learner Group: Group 3: Non-Health Related Research Stage 1 - Basic Course Stage: Report ID: Report Date: Current Score**: 18939524 03-Aug-2016 100 REQUIRED, ELECTIVE, AND SUPPLEMENTAL MODULES Students in Research (ID: 1321) History and Ethical Principles - SBE (ID: 490) Defining Research with Human Subjects - SBE (ID: 491) Belmont Report and CITI Course Introduction (ID: 1127) The Federal Regulations - SBE (ID: 502) Assessing Risk - SBE (ID: 503) Informed Consent - SBE (ID: 504) Privacy and Confidentiality - SBE (ID: 505) Research with Prisoners - SBE (ID: 506) Research with Children - SBE (ID: 507) International Research - SBE (ID: 509) Internet-Based Research - SBE (ID: 510) Unanticipated Problems and Reporting Requirements in Social and Behavioral Research (ID: 14928) Conflicts of Interest in Research Involving Human Subjects (ID: 488) Cultural Competence in Research (ID: 15166) Avoiding Group Harms - International Research Perspectives (ID: 14081) Research with Older Adults (ID: 16502) Research with Persons who are Socially or Economically Disadvantaged (ID: 16539) Gender and Sexuality Diversity (GSD) in Human Research (ID: 16556) Illegal Activities or Undocumented Status in Human Research (ID: 16656) Populations in Research Requiring Additional Considerations and/or Protections (ID: 16680) MOST RECENT 03-Aug-2016 03-Aug-2016 03-Aug-2016 03-Aug-2016 03-Aug-2016 03-Aug-2016 03-Aug-2016 03-Aug-2016 03-Aug-2016 03-Aug-2016 03-Aug-2016 03-Aug-2016 03-Aug-2016 03-Aug-2016 03-Aug-2016 03-Aug-2016 03-Aug-2016 03-Aug-2016 03-Aug-2016 03-Aug-2016 03-Aug-2016 For this Report to be valid, the learner identified above must have had a valid affiliation with the CITI Program subscribing institution identified above or have been a paid Independent Learner. Verify at : https://www.citiprogram.org/verify/index.cfm?verify=41e28ac3-2f0e-4d23-8a4d-1c5de2cbbe2f Collaborative Institutional Training Initiative (CITI Program) Email: support@citiprogram.org Phone: 888-529-5929 Web: https://www.citiprogram.org K. Shaw 32 Appendix C: Student Interview Request Form Student Interview, Observation & Research Requests Name: Kendra Shaw Contact Telephone # & Email: 309-846-0828; kjshaw@uindy.edu School: University of Indianapolis Class: Honors Project Professors Name & Contact Information: Dr. Jyotika Saksena; jsaksena@uindy.edu Purpose: The goal of my honors project is to develop teaching material (about 10 lessons) for school-aged children of refugee families in Indianapolis. This will help me learn how to create lesson plans and/or modify existing ones for a different age group or language skill level. Observation**: English Class Interview: In person Cultural Orientation (No observation required) Email (unless its easier to talk in person) Telephone Length of time: I will be working on my project throughout the rest of this month and throughout next semester. However, if the staff is available, I will only need to communicate with the LCORE teachers one or two times in December/January and then again in late March. My goal is to ask the teachers what subjects they would recommend teaching to children, if they have noticed a need for lessons geared towards clients under 18 years old, and if they would review the worksheets I will have created for the lesson plans in March. Staff involved: LCORE teachers Will the interview include: No. Video* Audio* Photos* Will the information shared be used in any of the following ways: For the final project manuscript, I will be mentioning that I talked with LCORE staff in the methodology and justification sections. I will be also be presenting my lesson plans to the honors department at the end of next semester. Publication* Public presentation* Internet* K. Shaw 33 Appendix D: Interview Questions for the Youth Coordinator 1. Have (How have) you noticed a need for orientation and/or lessons more specifically tailored to the younger clients of Exodus? 2. What topics do you cover in the cultural orientation? 3. What topics would you suggest or believe would best benefit the students if there was a community class for 5th-8th graders? Or would restructuring a few of the adult English lessons, such as the weather or school system, be useful? K. Shaw 34 Appendix E: Teaching Binder: Lesson Plans and Activities Lesson 1: Introductions OBJECTIVES: Students will be able to: (1) Introduce themselves and others. (2) Ask for help or for an interpreter. MATERIALS: (1) Blank name tags (2) Beach ball (3) World map (4) Get to know your partner Sheet OBJECTIVE 1 PROCEDURE: Wave to the students and say: Hello. My name is _______. If they dont understand, gesture to yourself when repeating your name. Hand out My name is name tags. Fill out one for yourself and have the students write their names on the line. Write on the board: My name is ______. Whats your name? Ask various students. If they understand, add: Nice to meet you. Nice to meet you, too. Have students stand in a circle. Ask the same question and toss the beach ball to a student, who answers the question. That student then asks the question and tosses the ball to another student in the circle. After all students have had a turn, consider adding the following questions: What is your first name? What is your last name? Explain that in the United States, people typically have a first name and a last name. If needed, write on the board first name and last name and use your name as an example. Have the students return to their seats. Write on the board: Where are you from? Im from_____. Lay out the world map to show the students the United States and explain that you are from the US (if applicable). Elicit responses and point out their countries. Next, write on the board: How old are you? Im ____ years old. Model the typical response with your information and ask various students. Put students into pairs. If there is an uneven number, make a group of three or work with one of the students yourself. Hand out Get to know your partner information chart, one to each student. Explain that each student is to ask his or her partner the questions on the paper and then record the answers in the designated box. Encourage the students to ask other questions they know already, such as Do you have siblings? After the charts have been filled out, explain to the students that they will use the charts to introduce their partners to the rest of the class. Give them a few minutes to prepare and write out phrases or sentences about their partners that they will use during the introduction. TIME: 15 min. 20 min. 15 min. K. Shaw 35 Go around the room and have each student introduce his/her partner to the class. The introduction should at least include the partners first and last name, country of origin, and age. Encourage the students to share other information that they may have learned about their partners. OBJECTIVE 2 PROCEDURE: Explain to the students that they should practice introducing themselves to their classmates at school. Also, other students and the teachers may ask them similar questions to the ones practiced above. If the students do not understand what is being asked, explain that they can and should ask for help. Write on the board: I need help. I need a _________ interpreter. Have students practice these statements with their partners, inserting the language they speak in the blank. For clarity, give an example on the board. 10 min. EXTENSION ACTIVITY: Have the students switch partners and introduce themselves to their new partners, using the questions that were introduced and practiced earlier. 5 min. K. Shaw 36 K. Shaw 37 Get to Know Your Partner Sheet Instructions: Work with a partner. Ask your partner the questions and write your partners responses in the box next to the question. Follow the example. Question Your Partners Response What is your first name? My partners first name is Christopher. Where are you from? Christopher is from Malaysia. Now your turn. Add your own questions in the blank question boxes. Question Your Partners Response What is your first name? What is your last name? Where are you from? How old are you? Write a few phrases or sentences about your partner to share with the class. ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ K. Shaw 38 Lesson 2: Calendar OBJECTIVES: Students will be able to: (1) Say and write the days of the week and months of the year. (2) Read an academic calendar and identify todays date. MATERIALS: (1) Calendar (2) Days of the Week cards (3) Days of the Week worksheet (4) Months of the Year cards (5) Months of the Year worksheet (6) Academic calendar REVIEW from previous lesson: Review: Hello. My name is_____. Whats your name? Nice to meet you. Nice to meet you, too. Ask various students. You may also include Where are you from? Im from ____. How old are you? Im ____ years old. OBJECTIVE 1 PROCEDURE: Show a calendar. Say Sunday, Monday, Tuesday, Wednesday, Thursday, Friday, Saturday while pointing at the days of the week on the calendar. Say each day again and have the students repeat to practice. Write the days of the week on the board. Read through them with the students, having them repeat the words. Organize the students into groups of 7. Give each group Days of the Week cards. Make sure each student within the group is given one of the days of the week. Have the students work together to put the days of the week in order. When all groups are done, ask various groups to read out the order. Collect the cards and have the students return to their seats if standing. Hand out the Days of the Week worksheet. Have students write in the days of the week at the top of the calendar. On the board, draw a copy of the worksheet. Choose 7 students and have each one write one of the days of the week on the board. Show the calendar again and name all the months of the year. Encourage students to repeat the months. Write the months on the board and read through them with the students. Choose 12 students. Hand out the Months of the Year cards, giving one to each student. Have the students with the months come to the front of the group. Together with the rest of the class, have the students line up in order. Hand out the Months of the Year worksheet. The worksheet has 12 lines with only a few of the months filled in. Have the students complete the task by writing in the missing months of the year. Review the correct answers. OBJECTIVE 2 PROCEDURE: Hand out an academic calendar. TIME: 5 min. 20 min. 20 min. K. Shaw 39 Explain that middle schools in the United States typically start in August or September and that students attend classes Monday through Friday. Emphasize that it is important to attend class unless there is an X or mark on the calendar that shows that there is no school that day. Point out an example of a holiday or no-school day. Write on the board and say: What is the date today? Attempt to elicit the correct date from the students, or have them point to the date on the calendar. Write the correct day and date, for example: Friday, May 18, 2017. Encourage students to practice asking the date and stating the date in pairs. EXTENSION ACTIVITY: If time allows, organize students into pairs and hand each pair Days of the Week cards. Have the students race the other teams to put the days in order. 15 min. 5 min. K. Shaw 40 Sunday Monday Tuesday Wednesday Thursday Friday Saturday K. Shaw 41 Days of the Week Worksheet Instructions: Fill in the seven boxes with the days of the week, starting with Sunday. Day 1: Day 2: Day 3: Day 4: Day 5: Day 6: Day 7: K. Shaw 42 January February March April May June K. Shaw 43 July August September October November December K. Shaw 44 Months of the Year Worksheet Instructions: Fill in the boxes of the missing months of the year. February September June K. Shaw 45 What is the date of today? ___________________________________________ Give an example of one holiday, or no-school date. _______________________________ What days of the week do students attend school? __________________________________ What months of the year do students attend school? _______________________________________________________________________________ _______________________________________________________________________________ K. Shaw 46 Lesson 3: Telling Time OBJECTIVES: MATERIALS: Students will be able to: (1) Spelling game squares (1) Tell time on a digital and analog clock. (2) Paper analog clock with movable hands (2) Read a class schedule and discuss a typical (3) Telling Time Worksheet day at school. (4) Paper plates (5) Small and medium arrows (6) Metal brads (7) Index cards REVIEW from previous lesson: TIME: Review: Ask students: What is todays date? What are the days of the week? Elicit responses starting with Sunday. Hand out the squares with letters on them. Ask students to spell the day of the 10 min. week as you say the word. For example, say Monday and have the students race to spell Monday correctly. Continue until all days have been practiced. OBJECTIVE 1 PROCEDURE: Show the students an analog clock with movable hands. Put the hands on the current time. Write on the board and ask: What time is it? Elicit responses from the students. If they do not understand, explain that the shorter hand points to the hour and the longer hand points to the minute. Demonstrate how to write the time on the board. For example, 12:30. Continue changing the time on the clock and asking the students to tell time. Hand out Telling Time Worksheet. Have students match the digital clock to the analog clock. Review the answers together. Hand out paper plates, small arrows, medium arrows, and metal brads. Give one of each to each student. Have students write the hours on the paper plate to create the face of the clock, using your analog clock as an example. Help students secure the two hands (one small and one medium) onto the plate with a metal brad. Once the clocks are created, ask students to display the time on the clock as you say them. For example, ask students to show what 3:20 looks like. If they understand the content, consider adding half past or fifteen after. Have students pair up to practice changing the time shown on the clock and asking what time it is to their partners. OBJECTIVE 2 PROCEDURE: Explain to students that it is important to know the time so that they are not late to class. Attending every class and being in the classroom when the teacher begins talking is important. Teachers may count students tardy. Show the class schedule example. Explain that for junior high, the school day is broken up into different blocks or subjects. Ask them questions, like What 25 min. 25 min. K. Shaw 47 time is block 2? When is lunch? Encourage them to ask questions about the schedule or about a school day. Hand out 5 index cards to each student. Have them draw out activities that they complete throughout the day in order to create their own cartoon strip. Make sure they include a time in the corner of each card to show about what time they complete the specific activity. On the back of the index cards, have them list out or write a paragraph of their typical day (if they have already started school, then encourage them to talk about their school day). Review the present tense if needed. Ask for a few volunteers to share what they wrote about their typical day to the rest of the class. EXTENSION ACTIVITY: In pairs, have the students share their cartoon strip with their partner. 5 min. K. Shaw 48 MO NDAY T UESDA Y W EDNESDAY THURSDAY FRI DAYSA TURDAYSU NDAY K. Shaw 49 K. Shaw 50 **The teacher can use this template as the example of a clock when introducing the topic. Students can use paper plates to write in the numbers on their own. The hands will be attached to the paper plate with a metal brad. K. Shaw 51 Class Schedule Example K. Shaw 52 Lesson 4: School Supplies OBJECTIVES: Students will be able to: (1) Identify and write about school supplies. (2) Write sentences with subject-verb agreement. MATERIALS: (1) Paper analog clock with hands (2) Picture cards of school supplies (3) School Supplies Worksheet (4) Bingo cards and markers REVIEW from previous lesson: Review: Ask students: What is todays date? What time is it? Elicit responses and write the correct answer on the board. Show the analog clock and change the time. Ask the students to tell the time. Continue practicing until all students have had a chance to answer. OBJECTIVE 1 PROCEDURE: Write school supplies on the board. Ask students to give examples of things they will need for, or have already used at, school. Record their answers. Show the backpack with the school supply picture cards in it. Write backpack on the board. Then, pull out each picture and say the word of the object as you show the picture. Encourage students to repeat the words after you introduce them. Write all of the vocabulary words on the board. Hold up one card at a time and ask students: What is this? Hand out the School Supplies Worksheet. For the first half of the worksheet, have students write the name of the object on the line below. For the second half, have student draw the school supply above the vocabulary word. Review the answers. Once they understand the content, add: Can you describe this object? How can I use this? Encourage the students to work with a partner, discussing how each object might be used in a classroom. Ask for pairs to volunteer descriptions with each vocabulary word. For review, play school bingo. Explain that you will say the name of a school supply or word previously learned. The students will have to find the matching picture or word on their card and mark the space with the bingo tokens. The goal is to get 5 tokens in a row, horizontally, vertically, or diagonally. When someone gets all 5, have that student say the name of the school supplies that are marked on his/her card and check the answers. OBJECTIVE 2 PROCEDURE: Hold up one of the picture cards and write on the board: This is a _______. Or I have a _________. Then grab two matching items, such as pencils, and write: These are _____. Have students practice these sentences using the new TIME: 5 min. 35 min. K. Shaw 53 vocabulary. Highlight the differences between the verbs when there are two or more objects. Also, emphasize that the endings of the words will typically be different when the object is made plural, which affects the verb. Draw two columns on the board with the left side labeled one and the right side labeled two or more. Write the singular and plural form of each vocabulary word. Have the students practice. Hand out the sentences strips. Have pairs of students work together to choose either is or are given the various endings of singular and plural objects. Model an example sentence, such as: There + are + pencils. Ask the pairs to come to the board to write out a sentence that they created. EXTENSION ACTIVITY: Organize the students into pairs, labeling one student A and one student B. Have student A describe a school supply while student B attempts to guess which supply is being described. Have the students switch roles. 20 min. 5 min. K. Shaw 54 School Supply Flashcards K. Shaw 55 K. Shaw 56 K. Shaw 57 School Supplies Worksheet Write the name of the object on the line below the picture. _______________ __________________ _________________ ______________ Above each vocabulary word, draw a picture of the school supply. Pencil___ Highlighter____ Ruler__ Binder___ Eraser____ Sheet of paper____ Calculator Folder____ K. Shaw 58 Review Bingo Example clock Monday Tuesday Thursday August Notebook Eraser September May January Free Space Ruler July Backpack Pen Friday Wednesday Sheet of paper Pencil December K. Shaw 59 **These will be cut apart and the students will create sentences with them. There are is I have They folder pen folders pencil erasers pencils backpacks pens glue stick highlighters rulers ruler piece of paper calculator binder K. Shaw 60 Lesson 5: People and Behaviors OBJECTIVES: MATERIALS: Students will be able to: (1) School supply picture cards (1) Identify people at school and the roles they (2) Picture file of people and cultural play in the school building. behaviors (2) Understand cultural behaviors in the classroom. REVIEW from previous lesson: Review: Write school supplies on the board and ask students to work with a partner to write down or draw school supply words or objects. Have the pairs give you at least one object and write the answer on the board. Use the school supply picture cards to review all the vocabulary. OBJECTIVE 1 PROCEDURE: Organize students into groups of 3. Give each group one of the pictures from the people and cultural behavior picture file. Each picture consists of a scene that could take place in a school building and includes a behavior, such as students raising their hand, or a person, such as a teacher. Encourage students to write the words of objects or people they recognize. Ask them to discuss within their groups and write phrases or words to answer these questions: What do you see in the picture? What job do they have? Have the groups show their pictures and present the information they wrote down. Make sure all students have an opportunity to share with the class. After each group has presented the picture, ask the rest of the students to comment on the picture or add to the groups answers. Add your own comments as needed to ensure that the students understand who is portrayed. Write on the board the names of the people. For example, write teacher, nurse, counselor, principal, lunch helper, etc. Ask the students to repeat the words. If needed, write out a short job description of each person. To review, ask students questions, such as: What does a nurse do? TIME: 5 min. 30 min. OBJECTIVE 2 PROCEDURE: Have each group of 3 refer back to the same picture from the picture file. This time ask them to orally answer the following questions: What are the people doing in the picture? Are there any unique or odd behaviors portrayed? How is the behavior similar or different to classrooms in your culture? Again, ask the groups to share their responses. Provide clarification as needed. Emphasize that teachers in the United States are very friendly. 25 min. EXTENSION ACTIVITY: Have students describe or draw the typical classroom in their culture. 5 min. K. Shaw 61 K. Shaw 62 K. Shaw 63 K. Shaw 64 K. Shaw 65 K. Shaw 66 Lesson 6: Safety OBJECTIVES: Students will be able to: (1) Write out their addresses and emergency phone numbers. (2) Know how to call the police. MATERIALS: (1) Personal Information sheet (half a page) (2) Address flashcards (3) IPAD (4) Sample 911 Call sheet (5) Information Gap activity REVIEW from previous lesson: Review: Ask students: What people are in school buildings? What jobs do they do? Elicit responses from various students. Re-emphasize that teachers in the United States are friendly and will help the students if they need it. OBJECTIVE 1 PROCEDURE: Draw a replica of the Personal Address sheet on the board. Ask and write on the board: What is your address? If students respond, fill in the blanks. If no one responds or only partially responds, write out a fake, local address. For example, write 203 Madison St., Apt 202, Indianapolis, IN 46227. Use the address flashcards. Show the Indiana map and Indianapolis map, pointing out the area where the classroom is located and where the students live. Explain that Indianapolis is the city and Indiana is the state. Be sure to explain that Indiana becomes IN on the address form. Show examples of streets on the Indianapolis map and then show the street sign flashcard. With each card, point to the example on the board, highlighting the section that is being portrayed on the card. Show the apartment card and ask: Do you live in an apartment? If so, elicit an apartment number and point out the corresponding information. Ask: What is your zip code? Elicit a response from the students. Go through each part of the form, having students repeat the parts of the address. Continue to use the address flashcards if needed. Erase the board. Hand out the address cards, giving one to each student. Have each of the students with a card come to the front of the group. Tell the rest of the class to put the address is order as shown on the information form. Have the students practice saying the address and write it on the board. Let them sit down. Ask: What is your phone number? Elicit an answer from a student and write the number on the board. If no one answers, write a fake number. Be sure the area code is included and that the numbers are divided correctly. For example, write (309) 579-5148. Read the number out loud, having the students repeat it. If needed, review and practice the numbers 1-9. Hand out the Personal Information half-sheet. Demonstrate and explain that the students are to fill in their own information on the form. If they do not TIME: 5 min. 30 min. K. Shaw 67 remember their addresses, encourage them to ask their family members when they go home. Also, explain that the students could and should carry the sheet with them in case they need to get home and cant remember their addresses. OBJECTIVE 2 PROCEDURE: Explain that it is important to know how to say their addresses, or at least can give their location, especially in an emergency. Tell students that if they are at school and need medical attention, feel pressured, or uncomfortable in any situation that they can talk to their teachers or any adult in the school building. However, if they are not at school and need help, they can call the police. Say: To call the policy in an emergency, dial 911 on a telephone. Hand out the Sample 911 Call sheet. Use the IPAD and play the sample 911 call recording, or read out the conversation yourself. Have the students fill in the missing words. Ask various students to give the missing words. Then, have the students read the conversation to themselves and circle any words that they are unfamiliar with. Answer any questions. Organize the students into pairs and have one student pretend to be the police and the other pretend to be the student calling the police. Encourage one group to come to the front of the class and demonstrate the conversation. EXTENSION ACTIVITY: Have students stand up and find a student to partner with that normally sits across the room. Hand out the Information Gap activity, making one Student A and the other Student B. Explain that they have different information on their papers, so they will have to ask each other questions, like What is the zip code? in order to fill in the missing information. 5 min. 20 min. 5 min. K. Shaw 68 Personal Information Sheet ________________ _________________ (First name) (Last name) Address: ________________________________________, ___________, (Street) (Apartment) ____________________, ______, __________ (City) (State) (Zip code) Phone number: (_____) ______-_______ Personal Information Sheet ________________ _________________ (First name) (Last name) Address: ________________________________________, ___________, (Street) (Apartment) ____________________, ______, __________ (City) (State) (Zip code) Phone number: (_____) ______-_______ K. Shaw 69 K. Shaw 70 K. Shaw 71 Sample 911 Call Sheet Read the following scenario. Listen to the conversation and fill in the missing blanks. **The underlined words represent the blanks for the students. Scenario: A student is calling the police from his house after his mom fell and hurt her leg. Police: 911, what is your emergency? Student: Hello, my mom is hurt. Police: Can you tell me what happened? Student: Yes, she fell down the stairs. Police: When did she fall? Student: She fell a few minutes ago. Police: Okay, remain calm. What is your address? Where are you right now? Student: I am at my house. The address is 2098 E. Hanna, Ave, Indianapolis, IN 46227. Police: I will send an ambulance to your address immediately. Stay with your mom until the medical team arrives, okay? Student: Okay. Thank you. K. Shaw 72 Information Gap Activity Student A: ____John_________ _________________ (First name) (Last name) Address: ________________________________________, ___Apt. 307___, (Street) (Apartment) ____________________, __IN__, ___46227___ (City) (State) (Zip code) Phone number: (_____) ______-_______ Information Gap Activity Student B: ________________ ______Bawi_________ (First name) (Last name) Address: ____4729 East St.________________________, ___________, (Street) (Apartment) ___Indianapolis_______, ______, __________ (City) (State) (Zip code) Phone number: (462) 1249 - 6278 K. Shaw 73 Lesson 7: Lunch Time OBJECTIVES: MATERIALS: Students will be able to: (1) School cafeteria card (1) Identify and say various foods from a (2) Food flashcards with matching words school cafeteria. (3) Lunch tray and silverware templates (2) Write which foods they like and dont like. (4) I (dont) like Worksheet REVIEW from previous lesson: Ask: What is your address? Ask various students to respond. Write out an example address if needed. Then, ask: What is your phone number? Again, ask students to give an answer. Write the correct format of a phone number on the board to help. OBJECTIVE 1 PROCEDURE: Say: Today we are going to talk about food at school. Show the cafeteria card and ask students to describe what they see. Be sure to write cafeteria on the board and highlight the lunch person, tray, and line of food. Show each of the food flashcards. State the name of the food and encourage students to repeat the word. Write each word on the board. Organize the students into groups of 4 and give each group a set of food flashcards with the corresponding words. Ask the students to race against each other to match the food to the correct word. After the teams are done, hold up each food card and ask: What food is this? Collect the food cards and stack similar foods together. For example, put all of the hamburgers in a line as if the table is a food line. Explain to the students that the typical steps of getting food in a school cafeteria. Act out each step with the lunch tray template and food line you have created. o Stand in line to get food (if they did not bring their own lunches). o Pick up a fork and/or spoon. o Look at the food line to know the options and tell the lunch person. (Students should be prepared to hear: What would you like? Or Would you like _____?). o Hold the tray and add extra food offered, such as a chip bag. o Choose a drink and add it to the tray. o Hand the next lunch person the lunch ticket, pay for the food, or enter a code (this depends on the middle school). o Take the tray and sit down at a table. o Talk with friends until lunch is over. o Dump trash in the trash bucket and put tray in the designated spot. TIME: 5 min. 40 min. K. Shaw 74 After you model the appropriate behavior in the lunch cafeteria, have the students line up and act out going through the lunch line. You pretend to be the lunch person and ask students what they would like to eat. After the students have placed food on their trays, have them sit down and tell a partner which foods they chose. Ask for one pair to volunteer and demonstrate the conversation. Then, announce that lunch time is over and that all students should dump their trays by helping sort the food and cleaning up the flashcards. OBJECTIVE 2 PROCEDURE: Write on the board in two columns: I dont like and I like Using facial expressions and pointing at food, explain that you dont like certain foods and that you do like certain foods. Hand out the I (dont) like Worksheet. Ask students to write down or draw foods that they do and dont like in the columns. Encourage them to use foods that they already know or foods that they are used to eating at home. Ask students to work in pairs and ask each other: What do you like to eat? What do you not like to eat? Write these questions on the board. Then, ask various students for examples of foods that they do and dont like. If they already understand the content, have students also explain why they do or dont like the food. Also, include descriptive words, such as salty or sweet. EXTENSION ACTIVITY: Ask students to draw foods that they like and dont like eating that were not included in the flashcards. Write the names of the food on the board. 15 min. 5 min. K. Shaw 75 K. Shaw 76 K. Shaw 77 peas carrots milk applesauce K. Shaw 78 chips chicken nuggets hamburger apple K. Shaw 79 cookie salad noodles fries K. Shaw 80 I (Dont) Like Worksheet I like I dont like K. Shaw 81 Lesson 8: Hobbies and Activities OBJECTIVES: MATERIALS: Students will be able to: (1) Playground and open grass pictures (1) Identify and say various activities, such as (2) Activity flashcards baseball and jump rope. (3) Similarities Worksheet (2) Discuss and write a few sentences about their own hobbies and interests. REVIEW from previous lesson: Make two columns and write I like and I dont like on top of each column. Ask: What do you like to eat? What do you not like to eat? Elicit responses from students and record their answers in the appropriate column. OBJECTIVE 1 PROCEDURE: Show students either the playground set or open grass picture. Ask them to draw themselves playing in the field or on the playground. Then, ask them to write a few words, phrases, and/or sentences about what they would like to do if they were on the playground or in the open field of grass. Ask: What activity would you do in this playground/field? Give students time to write their responses. Have the students share their answers with a partner. Ask them to say their answer for the whole class. Write their activity on the board. Continue until all students have a turn. Read through the list and encourage the students to pronounce the words. Show the activity flashcards and emphasize any activity that was not mentioned. Hold up each card and ask them to respond with the activity. After the students have identified the activities, organize them into groups of 4. Give each group a set of the activity flashcards. Explain that the students within the groups will take turns picking up one of the cards and acting out the activity. The other 3 students in the group have to guess the activity. OBJECTIVE 2 PROCEDURE: Have students pick one of the activities mentioned on the flashcards that they enjoy doing. Encourage them to write down a few reasons why they like it. Ask: What activity do you like? Why do you like that activity? Ask various students. Have students practice these questions and answers in pairs. Hand out the Similarities Worksheet. Have the students stand up and explain that they are to go around to different people in the room and ask others about the activities they like doing. For example, they could ask each other: What do you like doing? Do you like ____? Why do you like____? The goal is for students to find one thing in common with the person that they are talking to and to write that persons name and the similarity down on the TIME: 5 min. 30 min. 25 min. K. Shaw 82 worksheet. For example, if both students like baseball, then they would each write down the name of the other student and that they like baseball. EXTENSION ACTIVITY: Have the students share a few similarities they discovered with the others. 5 min. K. Shaw 83 K. Shaw 84 K. Shaw 85 K. Shaw 86 Similarities Worksheet Move around the room and ask other students: What activities do you like? Do you like ____? Why do you like _____? Write down the other students names and similarities you have with each one in the boxes below. Students name Similarities K. Shaw 87 Lesson 9: Successful Habits at School OBJECTIVES: MATERIALS: Students will be able to: (1) Activities flashcards (1) Engage in reading skills, such as predicting (2) Newspaper story and questions and discussing a passage. (3) Successful habits flashcards (2) Identify habits that will help them be successful at school. REVIEW from previous lesson: Ask: What activity do you like? Elicit answers from various students. Review the activities flashcards if needed. Then, have students act out their favorite activities while their partners try and guess the activity. OBJECTIVE 1 PROCEDURE: Hand out the newspaper article worksheet. The students should start by looking at the title and the picture. Then, ask them to complete the prereading activity. Tell them to write a few phrases or sentences about what they think the article will be about or the information it might include. Ask a few to share their predictions. Have students read through the article, circling any words that they do not know. Encourage students to tell you what words they are unfamiliar with so that you can create a list of the words on the board. After you have created the list, read through the words and give a definition or description of the word. Have students practice pronouncing the words. Again, have the students read through the article. Walk around the classroom and make sure to answer any questions the students might have about the article. After they have read it a second time, ask them to answer the comprehension questions. Then, organize them into groups of 3. Have each group discuss responses to the questions. Ask for a few groups to share their responses. Focus on the question about the positive study habits. Explain the importance of studying and completing homework for school. OBJECTIVE 2 PROCEDURE: Explain that the article mentioned a few examples of habits that students should start or have to help them in school. Ask: What other things can students do to help them in school? Elicit responses. Record their answers. Show the successful habits cards, adding them to the list on the board if not already mentioned. Explain the importance of each habit. Read through the list on the board, having students practice pronouncing the words. Put students into pairs. Have each student tell his/her pair one specific habit that he/she is going to start (or continue) doing at school. TIME: 5 min. 30 min. 25 min. K. Shaw 88 EXTENSION ACTIVITY: Split the class into 2 teams. Write a vocabulary word on the board with a few of the letters missing. For example, write Sl_e_ (sleep) and have one student from each team race to write the missing letters on the board. Continue until all students have had a chance to participate. 5 min. K. Shaw 89 Newspaper Story Pre-reading Activities 1. Look at the title of the article and the picture. 2. What do you think the story will be about? _______________________________ __________________________________________________________________ 3. Read the following paragraph. Circle words that you do not know. Good Study Habits to Help You Succeed in the New School Year by Sylvan Learning Develop a Study Plan. First things first: students need to know when a test will take place, the types of questions that will be included and the topics that will be covered. From there, students should create a study plan and allow ample time to prepare theres nothing worse than cramming the night before an exam. Parents can help by buying a wall calendar and asking the student to assign topics and tasks for each day leading up to a due date or exam. Setting goals for each session is also key to success. Reading Response Questions 1. What should students know? ________________________________________ 2. What is a study plan? ______________________________________________ 3. What is one study habit mentioned? __________________________________ K. Shaw 90 Study for tests Ask for help Use a planner Sleep 8 hours Work with others Take notes K. Shaw 91 Lesson 10: Future Schooling OBJECTIVES: Students will be able to: (1) Identify similarities and differences between middle school, high school, and college. (2) Write using the future tense I will MATERIALS: (1) Successful Habits flashcards (2) IPAD (3) Day in the Life of a College Student script (4) 2 Hula Hoops (5) Sticky notes (6) I will Practice sheet (7) Letter template REVIEW from previous lesson: TIME: Ask: What are habits that help you in school? Elicit responses and write 5 min. them on the board. Use the successful habits flashcards if needed. Have students practice identifying the habits by holding up the pictures. OBJECTIVE 1 PROCEDURE: Ask: What do you see yourself doing in the future? Have the students draw out a picture that shows where they see themselves in the future. Give them time to draw, and then have them explain their picture or future plans to a partner or small group. Encourage a few students to share. For clarification, write down specific careers or new words based on the students drawings and explanations. Read through the list of words. Say: Many of you will be in either high school or college in a few years. Write out the words high school and college on the board. Explain that high school is after middle school and includes students from about the ages of 1418. The classes are usually harder and more homework is given to the students. However, there is still a cafeteria, lockers, similar personnel, etc. Draw a Venn diagram on the board and label one circle Middle School and the other High School. Point out that differences go in the circles where they dont overlap and that similarities go where the two overlap. Ask students to help you write in the similarities and differences between middle school and high school on the board. Work to complete the diagram. Encourage students to reflect on their middle school experiences so far and ask questions about high school to see if it is similar. Say: After high school, many students chose to attend college. Explain that a college has specific programs of study, such as nursing or music education. Also, mention that the students are able to choose which classes they want to take each semester (you may need to explain the words semester, too). Use the IPAD and play the recording about the day in the life of a college student. You may need to read the script if there is no technology. Ask students to write down phrases that they hear. Repeat the recording again. 15 min. 10 min. K. Shaw 92 Pass out the recording script. Ask students to read the letter and circle any words that they do not know. Explain the unfamiliar vocabulary. Hand out a few sticky notes to each student. Prop up the hula hoops with them overlapping, creating a 3-D version of the Venn diagram. Have the students write a similarity or difference between middle school and college on each sticky note. Explain that once they write on the note, that they are to bring it up and place in within the hula hoops. Review all of the responses. 20 min. OBJECTIVE 2 PROCEDURE: Write on the board: In a few years, I will be in high school. Explain that in English, people place the word will in front of the verb in order to show that the action happens in the future. If needed, provide more example sentences. Hand out the letter template with starter phrases at the top. For example, one says Tomorrow, I will Have the students complete the sentences. Answer questions they may have about the temporal words, such as tomorrow. Draw a calendar on the board to help. Ask a few students to share their answers. 10 min. EXTENSION ACTIVITY: Ask the students to write a letter to another student in the class. The students should include a reflection on life in middle school and a few sentences about what they want to do after school. They should practice using I will in it. 5 min. K. Shaw 93 Day in the Life of a College Student (Recording Script) **taken from http://www.collegexpress.com/articles-and-advice/studentlife/articles/living-campus/day-life-college-student/ The college schedule is very different than the traditional high school schedule. Typically, there is a lot more flexibility with your college classes. In middle school or high school, you were probably told that you had to take US History, which was offered every day at 10:00 am. In college, youll probably need to take a history class, but you could have 10 choices, which would be offered on different days, at different times, and for different durations. The other cool thing about the college schedule is that you usually have more opportunities to explore your interests and passions. For example, you will be picking a major that will determine the types of classes you will specialize in. In high school, you have a set curriculum of classes you have to take across all subject areas. However, college is like high school in that you will have the opportunity to get involved by joining different clubs, organizations, and maybe even by getting a part-time job. Most schools have hundreds of extracurricular activities, and it is pretty easy to start one as well. So, as you can imagine, your schedule can get crazy with meetings, band practice, sport practice, play rehearsal, and work hours. K. Shaw 94 Future Tense Practice Complete the following sentences about the future. 1. Tomorrow, I will __________________________________________________. 2. In two years, I will__________________________________________________. 3. In ten years, I will__________________________________________________. 4. For my future career, I will___________________________________________. 5. _________________________________________________________________. 6. _________________________________________________________________. K. Shaw 95 Letter Template Write a letter to another student in class. Talk about a day at school and about your future plans. Practice using I will in sentences. _____________ (todays date) Dear _____________, ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ___________________, ______________ (Your name) K. Shaw 96 Appendix F: Case Statement LOOK AHEAD. INVEST IN THE FUTURE. The Path to an After-School Program for Refugee Children. Our Mission Exodus Refugee Immigration is a non-profit organization that aims to provide the goods, services, support, and resources needed for refugees to establish a selfsufficient life in Indianapolis, Indiana. According to the United Nations High Commissioner for Refugees, a refugee is a person who, owing to a well-founded fear of being persecuted for race, religion, nationality, membership of a particular social group, or political opinion, is unable to remain in, or return to, the country of his or her nationality. As a resettlement center, Exodus is often the last resort for families who have spent an average of 17 years in exile from their home country. The staff is the welcoming committee to their new lives. Right Now In 2015, Exodus served 892 persons from more than 20 countries, including Burma, The Congo, Syria, Iraq, and Ecuador. Within the first 90 days, the staff provides: Housing, food, clothing, and furniture Case-management services, transportation, and interpreters Connections to social benefits, employment, and health care Basic orientation to the United States English language and cultural orientation classes These programs provide support during the initial culture shock or feelings of insecurity, and encourage self-reliance by teaching the adults to navigate the city and the English language. K. Shaw 97 Once they have successfully completed the four levels of education, the adults use their new language skills to obtain and sustain jobs, such as translating. They give back to the community through work and service. Chindianapolis, or the south side of Indianapolis, is a prime example of the diversity the refugees bring to an area. Around 8,000 Chin Burmese persons have built a community together that not only provides stability and a sense of belonging to incoming families, but gives the surrounding neighborhoods the chance to learn and engage a unique culture. Looking Ahead The first 90 days are crucial, but not just for the adults. Currently, the Language, Cultural Orientation, and Readiness for Employment (LCORE) program, implements a 36 session, 18-week program to teach English and practical skills to adult refugees. While the parents participate in the English classes, the children aged 5 to 18 years old are enrolled in school with little outside support. With the new program, LCORE will: Expand its objectives to include students during the 18-week program Provide support for the transition into the Indianapolis system Improve English and practical skills for school readiness Offer one-on-one assistance with homework Encourage language acquisition, which is easier at a young age Help students stay up to speed with their class level Stimulate relationships and interactions between classmates Even the parents will benefit. Oftentimes, the children already attend the community sessions with their parents, so a separate learning space will allow the adults to focus on their specific assignments. K. Shaw 98 Similar Programs in Other Cities RefugeeOne in New York City: Offers a program for children to receive homework help, do arts and crafts, play sports, participate in community service projects, and learn about health. Provides a six-week camp to help children catch up to their class level Supplies every child with a backpack and school supplies OurBRIDGE in North Carolina: Provides projects to 70 kids for improving and applying language skills Explores topics not covered in schools Attributes to the cultural richness of the surrounding community Exodus will use these examples as a guide to help Indianapolis better accommodate and support refugee children with integration activities and language lessons. The Madison Avenue classroom space. Designing and Equipping the Classroom The after-school program will be located on the south side of Indianapolis where a significant number of refugees reside. Exodus currently rents a space. Approximately 1,250 square feet, the Madison Avenue building includes: Space for four classrooms o one larger community room and three smaller spaces o three designed for adult learning o equipped with mounted whiteboards, markers, and extra paper o furnished with tables and chairs K. Shaw 99 One common entrance for welcoming and placement testing Restroom facilities for both staff and students The available classroom space will include: A bright and stimulating interior Interactive activities, puzzles, and educational games Two bookshelves full of English books for beginners to encourage language acquisition and assist with homework A whiteboard, table, and chairs Utilizing the available classroom for the childrens after school program will provide a safe, family-oriented environment for education and development. The children will receive hands-on, age-specific support while their parents participate in their English lessons for employment. With the new program, EVERYONE is learning and unlocking dreams. A Timely Solution The current focus is on obtaining the supplies, books, and furniture necessary. With your contribution, the classroom could be stocked with backpacks full of school supplies and bookshelves full of language books before the next school semester starts. Now is the time to invest in the next generations future, no matter where they came from. Help them dream to succeed in their changing environment. Help a child be school and life ready! Thank you! K. Shaw 100 Appendix G: Teachers Job Description Welcome to the after-school program! If you are reading this, you are about to become a part of an incredible community of refugees. This program is designed to linguistically, culturally, and academically support middleschool aged refugees in Indianapolis. As the teacher of the English class, you will complete the following tasks: 1. Welcome the students to the classroom as they walk in. Encourage them to talk to each other and/or get a snack until the others arrive. 2. Review the lesson plan and double check that you have all the needed materials. The white board, markers, sheets of paper, and pencils should be located in the classroom. Please become familiar with the classroom set-up and put back any materials that you use. 3. Follow the lesson plan, using the board, visual aids, and activities provided. The lessons are currently tailored to refugees that have limited exposure to the English language. If you realize that students are really struggling with the material, cut out an activity or two from the lesson, or reduce the number of new vocabulary words. On the other hand, feel free to modify activities to make them harder if students are quickly completing activities. 4. Throughout the lesson, do not be afraid to wait while there is a silent pause after you have asked a question. Oftentimes, the students are trying to come up with an answer before speaking. Keep the atmosphere engaging and encouraging, but also be sure to get students to participate. 5. For each activity, look at the roughly estimated time frame allotted for it. However, it is okay if you have to skip an activity. It is better to go slow and make sure that the students understand the content than to rush through the lesson just to complete all the activities. 6. After the lesson is complete, have students help you clean up. Answer any questions they may have about the lesson or about their homework from school. If you have any questions, do not hesitate to call your supervisor. Thank you in advance for all of your help with the after-school program!  ...

... Running head: HEALTH PROMOTION AND WELLNESS 1 Health Promotion and Wellness Education: An Occupation Based Cooking Group for Cancer Survivors LeAnn VanDeman, OTS May 5th, 2018 A capstone project submitted in partial fulfillment for the requirements of the Doctor of Occupational Therapy degree from the University of Indianapolis, School of Occupational Therapy. Under the direction of the faculty capstone advisor: Katie Polo, DHS, OTR/L, CLT-LANA Running head: HEALTH PROMOTION AND WELLNESS A Capstone Project Entitled Health Promotion and Wellness Education Through Occupation Based Cooking Group for Cancer Survivors: A Doctoral Capstone Experience Submitted to the School of Occupational Therapy at University of Indianapolis in partial fulfillment for the requirements of the Doctor of Occupational Therapy degree. By LeAnn VanDeman Doctorate of Occupational Therapy Student Approved by: Faculty Capstone Advisor Date Doctoral Capstone Coordinator Date Accepted on this date by the Chair of the School of Occupational Therapy: Chair, School of Occupational Therapy Date 2 Running head: HEALTH PROMOTION AND WELLNESS 3 Abstract This article aims to explore the distinct value of occupational therapy in the communitybased cancer survivorship setting through the integration of occupational therapy and health promotion and wellness education into a pre-existing occupation-based group ran by a dietician. As many cancer survivors experience unmet needs, occupational therapists can help address limitations in occupational performance due to symptoms including fatigue, pain, impaired cognition, sleep disturbances, and sexual dysfunction through the use of meaningful activities. This program incorporated occupational therapy and health and wellness education into a cooking class through educational and performance-based sessions. Progress and satisfaction of participants performance was measured using formative and summative evaluations in the form of surveys and phone interviews. The addition of education regarding energy conservation, compensatory strategies, and stress management into a nutrition course helped cancer survivors increase occupational performance during meal preparation. Sustainability of this project will be dependent on grant funding and further collaboration between the occupational therapist and dietician. The role of occupational therapy was described through a doctoral capstone experience at Cancer Support Community, a non-for-profit facility. Running head: HEALTH PROMOTION AND WELLNESS 4 Literature Review In 2011, the American Occupational Therapy Association (AOTA) identified a list of emerging practice areas for the profession of occupational therapy in the upcoming years (2018). This list included the emerging area of cancer care and oncology under the rehabilitation, disability, and participation emerging niches (AOTA, 2018). The need for support and further research regarding cancer survivors continues to be relevant as the number of cancer survivors rises. The American Cancer Society, reports 15.5 million Americans were living a history of cancer or had been recently diagnosed in 2016 and estimate another 1.7 million new cases of cancer to be reported in 2018 (2018). Although there is an increase in reported cases of cancer in the United States, increased survival rates have been seen as treatment and time of detection have advanced (American Cancer Society, 2018). As survival rates continue to rise, the number of cancer survivors requiring assistance will increase. The National Cancer Institute (NCI) defines a survivor as one who remains alive and continues to function during and after overcoming a serious hardship or life-threatening disease. In cancer, a person is considered to be a survivor from the time of diagnosis until the end of life (2016, para 1). Even though, some of these individuals have completed their cancer treatment, and are no longer receiving chemotherapy or radiation, they are still subject to long-lasting residual side effects of their treatment throughout the rest of their lives. A Danish study in 2008 found that fatigue, lack of concentration, sleep disturbances, swelling, pain, weight change, sexual dysfunction, and digestive problems were common late-term effects among various cancer survivors (Hybye et al., 2008). These late-term effects have been found to impact the occupational performance and quality of life for individuals (Hwang, Lokietz, Lozano, & Parke, 2015). Running head: HEALTH PROMOTION AND WELLNESS 5 Hwang et al. (2015) studied the quality of life and deficits of functional performance among cancer survivors after diagnosis. Researchers found that there was a significant difference between perceived quality of life during the first year of survivorship and the year before diagnosis, with participants reporting lower quality of life during the first year of survivorship (Hwang et al., 2015). This is consistent with the findings of Burg et al. (2015), that cancer survivors were experiencing various unmet needs impacting daily function including physical, emotional, social support, personal control needs, and more. These unmet needs begin to justify the demand for occupational therapy services among this population. Currently, research and documentation about the unique benefit that occupational therapy has to offer cancer survivors is limited. However, research has shown that occupational therapy can help individuals through physical activity and symptom management interventions (Hunter, Gibson, Arbesman & DAmico, 2017). By using non-pharmacological interventions, occupational therapists are able to provide education and services regarding energy conservation, problem solving and cognition, exercise, and physical agent modalities (Hunter et al., 2017). However, Hunter and her colleagues stress that current research frequently does not contain an emphasis on functional outcomes or participation, which is a key focus of occupational therapy (Hunter et al., 2017). By focusing on the occupational performance and meaningful activities of cancer survivors, occupational therapists can provide community-based programs and activities that will help prevent occupational deprivation within this population (Polo & Smith, 2017). AOTA reports that interventions that address daily activities, lifestyle, sleep and fatigue, cognition, therapeutic exercise, and lymphedema will increase the occupational performance, independence, and quality of life among cancer survivors (AOTA, 2011). Specifically addressing the management of activities of daily living (ADLs) and instrumental activities of daily living Running head: HEALTH PROMOTION AND WELLNESS 6 (IADLs) is crucial as it allows therapists to target specific issues that are preventing survivors from engaging in their meaningful occupations. By using a holistic approach, occupational therapists can guide survivors through interventions that focus on eliminating barriers to occupational participation (AOTA, 2011). Since certain needs of cancer survivors continue to be unmet, survivors experience distress as they are unable to complete tasks and/or are forced to ask others for help (Burg et al., 2015, Ockerby, Livingston, OConnell, & Gaskin, 2013). Ockerby et al. (2013) found that one of the most common services provided by caregivers is provision and preparation of meals and drinks. Meal preparation is a common IADL that is completed multiple times a day and includes planning, preparing, and serving well-balanced, nutritious meals and cleaning up food and utensils after meals (AOTA, 2014, p. 20). Although many survivors have family or friends who are willing to help them with meal preparation, many individuals have feelings of guilt for increasing burden on caregivers (Locher et al., 2010). Therefore, if survivors are unable to prepare meals independently and/or do not have a caregiver who can assist them, they will likely be unable to eat healthy meals during their survivorship. Also, since meal preparation and cooking are an important part of a survivors life and many individuals enjoy this, the inability to complete these tasks could cause survivors to feel distressed and upset (Ockerby et al.,2013). Locher et al. (2010) reports that women experienced feeling a loss control, since they were once in charge of many aspects of their lives, and now they must rely on others to make decisions and complete tasks that they once enjoyed. With this being said, occupational therapy and health and wellness education can help cancer survivors discover ways to participate in meal preparation and the other activities that are meaningful to them through community occupation-based programs. Running head: HEALTH PROMOTION AND WELLNESS 7 Occupational therapy can help cancer survivors participate in their meaningful occupations by addressing their physical limitations and helping them manage symptoms (Hunter et al., 2017). By addressing fatigue, cognition, and emotional and social support through community occupation-based programs, occupational therapist can help improve the symptoms that limit cancer survivors occupational performance (Burg et al., 2015). The objective of this doctoral capstone experience is to provide health promotion and wellness education to cancer survivors through occupation-based programs at Cancer Support Community (CSC). Health Belief Model (HBM) will be used to guide the integration of health promotion and wellness education into programs at CSC as it has been found to support the evaluation of other community-based educational programs (Scaffa & Reitz, 2014). This model uses the ideas of perceived susceptibility, perceived severity, perceived benefit, perceived barriers, and cue to action to determine if individual will make a health-related change (Scaffa & Reitz, 2014). By using the HBM, a therapist can complete a needs assessment that will determine the perceived susceptibility and severity of individuals, which will inform therapist on how vulnerable the individual thinks they are to the health problem occurring and how dangerous the individual thinks it would be if they had that health issue (Scaffa & Reitz, 2014). Occupational therapists can then help educate the individuals on the perceived benefit of taking action to prevent health issues, and then help modify tasks and educate them on way to minimize perceived barriers to overcoming potential or current health issues. Lastly, the therapist can provide cues to action by encouraging individuals to participate in programs and providing education and demonstration to give the individuals a way to limit their health risks. For this doctoral experience, the therapists will be able to determine what is limiting cancer survivors when completing the IADL of meal preparation. They can then determine the potential health risks such as fatigue and impaired Running head: HEALTH PROMOTION AND WELLNESS 8 cognition that impact performance during meal preparation and cooking. As they determine the needs of the population, the therapists can provide education and encouragement to overcome these health risks and limit barriers to action in order to improve quality of life. In addition to the HBM, the Ecology of Human Performance model (EHP) will also be used to develop proper education for cancer survivors with occupation-based cooking programs. The EHP will be beneficial when integrating health promotion and education as it can successfully asses the relationships between the four parts of the model, including: the person, tasks, context, and personal-context-task-transaction (Cole & Tufano, 2008). The EHP model will be used to see how the symptoms impacting cancer survivors inhibit their skills and abilities and create a change in their performance range during meal preparation. It will also aid in identifying which skills fall within and outside of an individuals performance range, giving the therapist a way to grade the activities and provide appropriate education through different contexts. This client centered model will allow the occupational therapist to determine barriers or limitations for each individual and offer suggestions that are specific to their needs when cooking. Screening and Evaluation Pre-planning and Exploration The initial screening for this doctoral capstone project included exploration of the site (CSC main campus) through discussion with staff, identification of barriers and resources, and research of current literature regarding community-based practice and cancer survivorship. This exploration is part of the preplanning phase in program development and is consistent with the chart review process a therapist would complete while in the outpatient or inpatient setting (Scaffa & Reitz, 2014). Prior to beginning discussion with the staff, literature was reviewed to Running head: HEALTH PROMOTION AND WELLNESS 9 understand common symptoms and conditions that cancer survivors experience. While reviewing literature, it was found that cancer survivors often experience fatigue, cognition impairments, sleep disturbances, pain, digestive problems, and other conditions due to cancer and related treatments (Hybye et al., 2008). These symptoms and issues that coincide with survivorship often go unmet (Burg et al., 2015), thus justifying further investigation to determine what needs cancer survivors at CSC experience. As part of the pre-planning phase, interviews were completed with organizational and program stakeholders, including the executive vice president of CSC and the nutritionist who leads the Cooking for Wellness class. During these interviews, the executive vice president of CSC discussed the need for occupational therapy techniques within their Cooking for Wellness class. She explained that this class is typically led by a nutritionist and discusses the importance of eating and preparing healthy foods. However, the nutritionist expressed that the cooking course has limited information regarding occupational performance and how this can increase quality of life. The nutritionist showed excitement with the idea of including health promotion and wellness education and indicated this interdisciplinary collaboration could improve carry over for her participants and improve occupational engagement. After identifying the need for occupational therapy services at CSC, potential barriers and resources were identified and further data was collected. Support and Barriers There are many resources available at CSC that increase the quality of the programs they offer. The main campus of CSC is fully equipped with a full-size kitchen that is used for all Cooking for Wellness classes and can be used for demonstration and assessment of client performance. CSC also provides all of the cooking supplies needed for this class at no cost to the Running head: HEALTH PROMOTION AND WELLNESS 10 participants. The main barrier identified by the occupational therapy student was that the Cooking for Wellness course is only offered once a month. This limits the participants ability to be consistently immersed within the information and ensure correct carry-over of techniques learned into daily life. Therefore, it will be important to provide participants with resources when they are not in the class, so that they can continue to reflect on what they have learned at home as they try to address the goals they will create at the educational session. After identifying barriers and resources to implementation of health promotion and wellness education, the class and client needs were evaluated. Needs Assessment Unlike many practice areas that deliver direct one-on-one care, community-based occupational therapy utilizes a needs assessment to collect and analyze data in this setting. The intent of a needs assessment is to determine priorities and needs of a population instead of diagnostic information about the patient like in other practice areas (Scaffa & Reitz, 2014). Therefore, formal assessment tools were not used to determine the needs of the population. Instead, telephone interviews were conducted with a key informant and members of the Cooking for Wellness class. Key informants are persons, typically formal or informal leaders, who have expert knowledge about a phenomenon of interest (Scaffa & Reitz, 2014, p. 67). In this case, the key informant was the nutritionist, as she had increased knowledge about the class and the individuals that attend each month. Through a phone interview, the nutritionist was asked four simple questions about the structure of class, the participants, and the needs she felt should be addressed (see Appendix A). She expressed that the class normally addresses how to properly cook and preserve different types of foods. She also stated that health benefits of certain foods are discussed, however, she Running head: HEALTH PROMOTION AND WELLNESS 11 reports that she does not typically addresses subjects such as energy conservation or cognition. She also stated that the individuals in her group struggle with symptoms such as chemo-brain, fatigue, and lymphedema, and that limited education often impacts participants performance while cooking. Participants were also asked questions regarding cancer-related symptoms and barriers to completing meal preparation via telephone interviews (see Appendix A). Participants reported that similar symptoms including fatigue, chemo-brain, pain, and peripheral neuropathy impact their performance while cooking. Reports from the Wellness for Cooking participants were consistent with the reports from Pergolotti, Williams, Campbell, Munoz, & Muss (2016) in that cancer survivors experience cancer-related fatigue, upper extremity impairments, lymphedema, and peripheral neuropathy, as well as, functional impairments. These functional impairments and symptoms can impact the individuals quality of life and prevent them from completing the ADLs and IADLs they enjoy, including cooking. Functional impairments and cancer related symptoms have been identified as limiting factors of occupational performance in other practice areas as well. In one study, researchers used the Canadian Occupational Performance Measure (COPM) to determine needs of thoracic cancer survivors in the rehabilitation setting and found that the majority of patients reported self-care tasks and functional mobility as their primary problem (Bentley, Hussain, Maddocks, & Wilcock). Eighteen percent of participants also reported difficulty or problems with cooking in addition to self-care task. This is consistent with the report from the Cooking for Wellness participants in that some of the participants reported some difficulty with cooking while others did not. Even though cooking and meal preparation is not the primary difficulty noted in the inpatient setting, it is important to note that individuals in the inpatient setting typically have Running head: HEALTH PROMOTION AND WELLNESS 12 more acute issues, and their impairments may be more significant than those in communitybased settings. Therefore, the primary focus for survivors in the inpatient setting is ADLs, and they often do not receive services addressing IADL activities such as cooking. However, services regarding IADL performance are crucial as the impact quality of life and overall wellness. The participants of the Cooking for Wellness class at CSC did not specifically report an issue with self-care tasks. However, they reported that fatigue, pain, cognition, and lymphedema occasionally impact their ability to complete IADLs effectively and limit their occupational performance and engagement. Therefore, the focus of this doctoral capstone will be to provide health promotion and wellness education regarding symptom management, possible activity and environmental modification, and compensatory strategies to enhance safety and independence while increasing occupational performance and engagement when cooking. Implementation Program Planning Prior to beginning program planning, pre-planning exploration and a needs assessment was completed; which revealed that cancer survivors frequently experience symptoms of fatigue, chemo-brain, lymphedema, and pain that limit their ability to complete meaningful occupations. After identifying the needs of the cancer survivors at CSC through phone interviews, it was determined that health promotion and wellness education would be provided at CSCs Cooking for Wellness class to help manage the symptoms experienced and increase occupational performance and satisfaction when preparing meals. The goal of this educational session was to educate cancer survivors on the role of occupational therapy in cancer survivorship. Another goal was to provide techniques that could help cancer survivors increase their performance while cooking and completing other daily tasks. A review of literature was conducted to determine Running head: HEALTH PROMOTION AND WELLNESS 13 what information should be given to participants to help combat symptoms of fatigue, chemobrain, and pain while preparing meals. Topics identified included energy conservation, compensatory strategies, and stress management. Then, an educational presentation was created over these three topics, and an explanation of occupational therapy and its distinct value in cancer survivorship was given to the cancer survivors during the first Cooking for Wellness class held at CSC. Energy Conservation Energy conservation was the primary focus of the educational presentation as it provides ways to reduce fatigue and pain related to stress (St. Joseph's Healthcare Hamilton, 2013). Energy conservation includes techniques that help individuals minimize the amount of energy they must use to complete a task (St. Joseph's Healthcare Hamilton, 2013). This includes being aware of how individuals prioritize their time, plan their day, pace themselves, and position their body when completing a task (St. Joseph's Healthcare Hamilton, 2013). By following these techniques, individuals are able to continue completing the daily tasks that are important to them without becoming so exhausted that they cannot participate in their meaningful activities (St. Joseph's Healthcare Hamilton, 2013). Compensatory Strategies Compensatory strategies were also discussed during the session as these techniques can include activity and environmental modifications for cancer survivors that help combat chemobrain and fatigue. By using resources such as planners, to-do lists, and timers, individuals who have memory difficulties can cue themselves to pick up items at the grocery store or prepare ingredients for a meal. Cancer survivors can also modify their environment by changing where items are in their kitchen. This can help limit the amount of energy an individual must exert Running head: HEALTH PROMOTION AND WELLNESS 14 when finding or using an item while cooking and can help them compensate for fatigue they may be experiencing. Stress Management The last topic that was discussed during the educational presentation was stress management. It is important to discuss ways that cancer survivors can limit stress as stress can cause fatigue and other unhealthy behaviors (Mayo Clinic, 2018). It is necessary to instruct participants on the importance of exercising regularly, using relaxation techniques, and setting time aside for things that they enjoy. This can minimize stress and help manage other symptoms such as, fatigue, anxiety and depression (Mayo Clinic, 2018). The above educational topics were organized into individual handouts that were distributed at the first Cooking for Wellness class. An additional handout was created to explain what occupational therapys role in cancer and survivorship is and what common cancer related symptoms were discussed during the session. Collaboration with the nutritionist was conducted to ensure proper use of time during the session and to discuss if she felt that the information that would be provided by the student would help meet the needs of the participants. Implementation of Health Promotion and Wellness Education Educational Session The beginning of the educational session included instruction from the nutritionist regarding healthy recipes that the participants could make at home. The nutritionist described in detail the types of foods and spices she was using and explained the different cancer-fighting properties of each item. After the nutritionist completed her session, health promotion and education regarding occupational therapy techniques began. First, a pre-test survey was distributed as part of the formative evaluation. (Formative and summative evaluations are Running head: HEALTH PROMOTION AND WELLNESS 15 described further the Outcome section of this paper) Following the survey, participants were given a Cooking for Wellness handout. This handout included information regarding occupational therapy, common cancer-related symptoms and listed ways that occupational therapy can assist cancer survivors who experience these symptoms. This resource was provided so that individuals could follow along with the educational lecture as it was presented and refer to the information at home. The simple Cooking for Wellness handout also had a section where participants could list goals in relation to cooking and meal preparation, as well as, strategies they could implement to reach their goals. After introductions and a review of common symptoms experienced by cancer survivors, information regarding compensatory strategies, stress management, and energy conservation was presented. Information that was provided included definitions of the techniques as well as examples for how individuals could use these methods when cooking and completing other daily tasks. This was followed by a question and answer session. Individuals were given the opportunity to ask the occupational therapy student any questions regarding the techniques they had learned and how to implement these in their daily life. They were also able to discuss any problems they had been having, and group discussion was geared toward finding solutions for these issues. Once the individuals felt comfortable with the information they had been given, they were then asked to complete the goal section on their Cooking for Wellness handout. Individuals were asked to create goals related to cooking and meal preparation that they could address throughout the next few weeks at home. The occupational therapy student provided the class with examples and discussed appropriate goals as well as strategies they could implement to reach these goals. It was emphasized that each individual is unique and has their own difficulties, therefore, each person may have a different goal than their neighbor. Running head: HEALTH PROMOTION AND WELLNESS 16 Participants were encouraged to ask questions during this process to ensure their goals were realistic and attainable. Lastly, a post-test survey was distributed as part of the formative evaluation and the group was dismissed. Selected participants were recruited for interviews as part of the summative evaluation. Performance Session During the performance session, individuals were split into four different groups where each group was asked to prepare a different portion of the meal. At the beginning of the session, the occupational therapy student reminded participants about the information they had learned in the previous session and the nutritionist discussed different aspects of the meal. Throughout the session the student went from group to group discussing meal specific techniques that participants could use when cooking these meal during the session and at home. The student asked what techniques they had been using at home. At the end of the session, the occupational therapy student provided an overview of information about the techniques regarding each meal and supplied participants with formative evaluation regarding the performance session and a summative evaluation pertaining to the entire program. Leadership Skills and Staff Development Various leadership skills were required for implementation of the health promotion and wellness educational session. First, strong communication and interpersonal skills were needed for collaboration with the staff at CSC and with the nutritionist who co-lead the Cooking for Wellness class. These interpersonal skills made it possible to collaboratively create a program that benefited the participants by targeting their symptoms and limitations. Having the ability to communicate ideas with others was also imperative, as it allowed the occupational therapy student to effectively educate the participants and answer questions during the Cooking for Running head: HEALTH PROMOTION AND WELLNESS 17 Wellness class. Since this DCE took place in a community-based setting, being flexible was also a crucial part of completing the Cooking for Wellness program. CSC is consistently working to provide services for its participants, therefore, staff must be flexible when setting dates for events, determining where the events will take place, and determining what information may need to be presented. Lastly it was important that staff showed outward positivity. Many participants at CSC are looking for support and education, so staying positive was imperative to help encourage and provide advice to participants. Staff development and education was necessary at the beginning of this process as many members of the CSC team didn't understand occupational therapys role in cancer survivorship. A brief description of occupational therapy was given to the staff, and they were then encouraged to ask questions to help build a better understanding of how occupational therapy can assist the cancer survivors at CSC. This process was vital so that staff could appropriately refer participants to Cooking for Wellness program. The handouts provided during the Cooking for Wellness education session were supplied to the nutritionist for future use. This will be necessary if the occupational therapy student is no longer present at CSC. A resource binder was also created by the occupational therapy students at CSC. This binder includes a copy of each of the handouts that were given to the Cooking for Wellness participants and nutritionist and was left in the resource library at CSC. These resources could be accessed by any member of the staff or participant after the completion of the doctoral capstone experience. Outcomes Educational Session Formative Evaluation Running head: HEALTH PROMOTION AND WELLNESS 18 Prior the completion of this doctoral experience, the efficacy of implementing health promotion and wellness education into to the Cooking for Wellness group was assessed. This was done through the use of formative and summative evaluations. The formative evaluation consisted of a pre/post-test survey including Likert scale questions that evaluated the efficacy of the presentation given at the Cooking for Wellness class by the occupational therapy student. The pre/post-tests helped determine participant confidence and understanding of different topics. Topics included the role of occupational therapy, how cancer-related symptoms impact performance, how to manage these symptoms, their ability to address functional deficits when cooking, and strategies to improve performance. Seven of the fifteen participants that attended the educational session completed all of the pre-test and all or part of the post-test. After reviewing the survey responses, there was an overall increase in understanding of each topic by at least one participant. The participants demonstrated the greatest increase in confidence when addressing functional deficits caused by cancer-related treatments and when listing ways to improve performance while cooking. Due to limited feedback from this session, it would be imperative that future sessions place extra emphasis on the completion of these surveys to ensure that the program remains effective and beneficial to the participants. However, these surveys supported that continued education on ways to improve occupational performance when cooking would be beneficial in the future. Summative Evaluation In addition to the formative evaluation, a summative evaluation was completed through phone surveys with randomly selected participants a week after the educational session. The formative evaluation was used to continue quality improvement of the education session. This evaluation included a satisfaction survey that identified the Cooking for Wellness participants Running head: HEALTH PROMOTION AND WELLNESS 19 opinions of the session and allowed the occupational therapy student to assess what participants valued during the session. (see Appendix C) Using Likert scale questions, overall satisfaction with the course and likelihood to implement what participants have learned was rated. Open ended questions were used to explore what parts of the session the participant enjoyed and what areas they felt could be improved. The use of open-ended questions gave the participants the ability to state their specific opinion and did not limit them to predetermined answers. After completion of the phone surveys, it was found that participants each had a unique reasoning why they valued the session. For example, participants reported that they were happy that someone was taking the time to discuss these topics with them and that the handouts provided made it easy for them to review the information later. Participants also reported that they were very likely to implement what they had learned. In addition, participants reported they were already implementing the energy conservation and compensatory strategies techniques, such as collecting all of the items needed at one time to limit the amount of energy needed to collect supplies. Participants were also asked to suggest a way in which the program could be improved if continued in the future. Overall, group members suggested using more visual aids and hands on techniques as well as physical and personal examples when educating the class. The nutritionist was also asked to answer questions regarding the quality of the health promotion and wellness education. (see Appendix C) She was asked open-ended questions that allowed her to express what she found beneficial and what she thought should change if the health promotion and wellness education was continued. The nutritionist was also asked about ideas for sustainability of the project. During the phone interview, the nutritionist expressed that she thought the program went well and that she found the tips about organizing the work space and planning meals very beneficial. She also believed that more specific examples about certain Running head: HEALTH PROMOTION AND WELLNESS 20 cancers and how they affect the body and performance would be helpful. For example, she stated that individuals who have limited range of motion due to a surgery or radiation treatment may want more specific examples of how they can address these limitations in the future. Lastly, the nutritionist was asked how the health promotion and wellness education could be continued in the Cooking for Wellness program. She stated the she likes using interdisciplinary programs to provide the best care for her participants and that she would love to continue this partnership in the future. However, she suggested that the collaborative sessions only be once every few months. She stated that incorporating health promotion and wellness education at every other or every third session would provide the opportunity for the individuals to implement what they have learned, and it would keep the information fresh and prevent it from becoming repetitive. Finally, she said that continued use of fun hands-on activities would encourage the participants to use the techniques they have learned from both disciplines in the future. Findings from the summative evaluation were a critical component to determining the effectiveness of the session and will help to guide future modifications of this project. Performance Session Formative Evaluation Eight of the eleven participants completed the formative evaluation at the end of the performance session. By reviewing the post-test survey, it was found that nearly all participant reported their main goal when cooking was to be able to prepare healthy and nutrition meals. After the educational session four weeks prior, participants reported using techniques such as making lists to decrease energy use when walking in the grocery store and planning their week in advance to help allocate time and energy for cooking. Many participants also reported that they plan to continue to use the techniques they learned from the health promotion and wellness Running head: HEALTH PROMOTION AND WELLNESS 21 education to reach their cooking and meal preparation goals in the future. When talking with participants during the performance session, many participants reported trying to complete recipes by breaking down the steps so that they could take breaks and not become fatigued. The most common responses for not implementing the techniques or strategies they learned during the program were lack of time or inconvenience. Overall Program Summative Evaluation Upon completion of the final session (performance session), a summative evaluation in the form of a post-survey was distributed to participants. Eight of the eleven participants completed the summative evaluation (n=8). Participants reported that the most beneficial things they learned during the program included healthy recipes, proper positioning, and ways to conserve energy when cooking and grocery shopping. All participants that completed the posttest survey reported that they would not change anything about the program in the future, and they did not feel that had any needs that were unmet by the program. All participants reported that they were very likely (n=7) or somewhat likely (n=1) to attend a course like this in the future. Due to the positive responses from the participants, it would be important to continue assessing the needs of participants to help address any new limitations as the program continues in the future. Discontinuation Prior to the discontinuation of this program, sustainability and future modifications of the health promotion and wellness education program were considered. First, financial support for future sessions and occupational therapists was evaluated. Due to the overwhelming support from local grocery stores, all of the supplies needed for the Cooking for Wellness meals are Running head: HEALTH PROMOTION AND WELLNESS 22 completely free to the participants and the instructors and this will be continued in future sessions. To cover the cost of a licensed occupational therapist at the Cooking for Wellness classes, grants were researched by the occupational therapy student, a fellow OT student, and grant writing team. Grant funding would allow the hiring of an occupational therapist, and any other supplies he/she might need to continue the cooking program in the future. In the future, the occupational therapist will need to utilize information from formative and summative evaluations to continue quality improvement of the program. (see Appendix C) These evaluations will allow the therapist to gauge the effectiveness of the program as well as determine if participants feel that their current needs are being met. By continuously using these evaluations, the therapist will be able to identify if the participants need more education on different topics or if they require a different type of hands on experience. As the therapist continues to draw information from the needs assessment, evaluations, and participant and staff report, he/she will be able to ensure continued quality improvement of the Cooking for Wellness program. It will also be crucial that the occupational therapist or occupational therapy student continues to assess the changing needs of this population. As the needs of society and the population at CSC change, it will be important to respond and change the objectives of the program to target these needs. The HBM and the EHP model will be used to determine the changing needs of society and the participants at CSC. By using these models, the occupational therapist will be able to determine any changes in the participants performance and continue to gear sessions towards increasing their performance range as participants improve. As previously stated in the literature review, the occupational therapist can also use principles from the HBM to determine the perceived susceptibility and severity of individuals in regard to different Running head: HEALTH PROMOTION AND WELLNESS 23 conditions. This will allow the therapist to determine how to change questions within the needs assessment so that he/she can modify the program to increase participants perceived benefit and help create a cue to action to increase health-related change among cancer survivors (Scaffa & Reitz, 2014). Response to Societys Need After AOTA listed cancer care and oncology as an emerging practice area, it supported further investigation into the needs of this population as this information can help address societys changing needs (AOTA, 2011). As stated in the literature review, cancer and its late term effects have been found to impact the occupational performance of cancer survivors (Hwang et al., 2015). Therefore, incorporating health promotion and wellness education within the Cooking for Wellness Program at CSC has helped address the some of the needs of the cancer survivor population within the occupation of cooking. Throughout this program, literature was reviewed, and participants were interviewed to determine what the needs of the population at this site were. This program created the opportunity for cancer survivors to address deficits in occupational performance when cooking. The information and techniques participants learned regarding energy conservation, compensatory strategies, and stress management can be used when cooking and when completing other daily living tasks. By addressing the limitations that are impacting occupational performance within this population, this program was able to meet the changing needs of society within this emerging practice area. Overall Learning & Experience Communication Effective communication played an integral role during this doctoral capstone experience. Since CSC has partnerships at multiple hospitals in the area, staff members were Running head: HEALTH PROMOTION AND WELLNESS 24 often out of the office working at a different site. This meant that electronic communication via email was required. The occupational therapy student had to learn to be direct when sending emails and take the opportunity to talk to individuals in person when given the chance. Also, sending professional emails when addressing staff, participants, and other health care providers was essential. Since the occupational therapy student had not met many of the individuals that were being contacted, it was important that the emails were professional, contained appropriate greetings, and were free from grammatical errors. When speaking with staff and participants, it was crucial that clear, concise, and simple language was used. Many individuals that the occupational therapy student worked with were not familiar with occupational therapy or its scope of practice. Therefore, the student had to use simple language that was not exclusive to the field of occupational therapy so that participants and staff were able to understand the information that was being presented to them. Being able to discuss different topics and provide education in a way that individuals understand was a crucial component of this doctoral capstone experience and helped ensure successful integration of health promotion and wellness education at CSC. Staff Interaction Throughout the sixteen weeks of this capstone experience, the occupational therapy student was able to work with a variety of professionals and interns from different disciplines including art therapy, social work, program development, nutrition, marriage family therapy, and marketing. During this time, each discipline was able to share how they work to improve the lives of cancer survivors. This helped all members of the CSC staff work as a team, as each person understood how their co-workers could help meet the needs of their mission. When collaborating with the nutritionist during Cooking for Wellness, the occupational therapy student Running head: HEALTH PROMOTION AND WELLNESS 25 was able to see how eating the right foods can impact your body. The student was also able to learn how to direct conversation during a session observing and working with the nutritionist. The nutritionist led a high energy group and was able to help participants enjoy their time in the class, but she also ensured that that they were receiving all of the information that was necessary. Interaction with different disciplines allowed the occupational therapy student to practice collaborating with different members of the care team and helped give insight to the similarities and difference of each discipline. This knowledge will help the occupational therapy student determine which disciplines may be useful when continuing health promotion and education during the Cooking for Wellness program in the future. Leadership and Advocacy During this doctoral capstone experience, leadership and advocacy were demonstrated to ensure the successful implementation of the Cooking for Wellness program. Upon arrival to CSC, advocacy for the distinct role that occupational therapy has in cancer and survivorship was required. First, the student began sharing with the staff how occupational therapy can benefit survivors. This information was shared with the entire staff and the nutritionist who leads the Cooking for Wellness class. After the staff understood how occupational therapy can help benefit the participants at CSC, the advocacy for the cancer survivors began. The occupational therapy student discussed the current unmet needs that many cancer survivors experience and began discussing possible ways to meet these needs. It was through this advocacy for survivors, that the collaboration between the OT student and the nutritionist began to help address these needs through the Cooking for Wellness program. Leadership skills were required throughout this doctoral capstone experience as it was primarily self-driven by the OT student. During this experience, time management and self- Running head: HEALTH PROMOTION AND WELLNESS 26 motivation were used daily. Time management was necessary as there were many requirements for this experience, including creating PowerPoints and handouts, developing treatments plans, organizing presentations, reviewing literature, and helping CSC staff with other needs. Therefore, the OT student had to be diligent with her time to ensure that all of the requirements were met. Group management skills were also needed for the implementation of health promotion and wellness education during the Cooking for Wellness program as the class has 1030 participants each month. This meant the OT student had to be able to lead the group and ensure that all of the objectives were met each session. This sometimes meant the student had to limit talking by group members who were dominating the conversation or redirect participants to progress the session. Lastly, group management skills were also used during the education presentations to help guide conversation and ensure that the participants felt they received all of the information they needed about each topic. Overall Experience Overall this experience gave the occupational therapy student the opportunity to practice working with a variety of disciplines and individuals. She was able to practice being flexible and working as a team to reach the target objective. CSCs goal is to provide cancer survivors and their families with services so that no one has to go through cancer alone. During this experience, the occupational therapy student was able to use leadership and communication skills to help address some of the functional performance limitations that individuals were experiencing when cooking and completing other meaningful tasks. With the help of the CSC staff and other interns, the student had the opportunity to learn and practice how to lead a group effectively and how to respond to the needs of participants. This doctoral experience helped the student learn how to be confident when educating individuals about occupational therapy and different strategies to Running head: HEALTH PROMOTION AND WELLNESS combat decreased occupational performance. Moving forward in practice, the occupational therapy student will be able to use the skills learned during this experience to effectively treat and educate clients and to contribute as a positive member of the health care team. 27 Running head: HEALTH PROMOTION AND WELLNESS 28 References American Cancer Society. (2018). Cancer facts and figures. Retrieved from https://www.cancer.org/content/dam/cancer-org/research/cancer-facts-andstatistics/annual-cancer-facts-and-figures/2018/cancer-facts-and-figures-2018.pdf American Occupational Therapy Association. (2018). Cancer care and oncology. Retrieved from https://www.aota.org/Practice/Rehabilitation-Disability/Emerging-Niche/Cancer.aspx American Occupational Therapy Association. (2014). Occupational therapy practice framework: Domain and process (3rd ed.). American Journal of Occupational Therapy, 68(Suppl. 1), S1-S48. American Occupational Therapy Association. (2011). The role of occupational therapy in oncology. Retrieved from https://www.aota.org/~/media/Corporate/Files/AboutOT/Professionals/WhatIsOT/RDP/F acts/Oncology%20fact%20sheet.pdf Bentley, R., Hussain, A., Maddocks, M., & Wilcock, A. (2013). Occupational therapy needs of patients with thoracic cancer at the time of diagnosis: Findings of a dedicated rehabilitation service. Supportive Care in Cancer, 21(6), 1519-1524. doi:10.1007/s00520-012-1687-1 Burg, M. A., Adorno, G., Lopez, E. S., Loerzel, V., Stein, K., Wallace, C., & Sharma, D. B. (2015). Current unmet needs of cancer survivors: Analysis of open-ended responses to the American Cancer Society Study of cancer survivors II. Cancer, 121(4), 623-630. doi:10.1002/cncr.28951 Campbell, C. (2010). Occupational therapy and caner: Not just end of life care. OT Practice. 15(13). Running head: HEALTH PROMOTION AND WELLNESS 29 Cole, M.B., & Tufano, R. (2008). Applied theories in occupational therapy: A practical approach. Thorofare, NJ: SLACK, Inc. Hybye, M. T., Dalton, S. O., Christensen, J., Larsen, L. R., Kuhn, K. G., Jensen, J. N., & ... Johansen, C. (2008). Research in Danish cancer rehabilitation: Social characteristics and late effects of cancer among participants in the FOCARE research project. Acta Oncologica, 47(1), 47-55. doi:10.1080/02841860701418846 Hunter, E. G., Gibson, R. W., Arbesman, M., & DAmico, M. (2017). Centennial Topics Systematic review of occupational therapy and adult cancer rehabilitation: Part 1. impact of physical activity and symptom management interventions. American Journal of Occupational Therapy, 71, 7102100030. https://doi.org/10.5014/ajot.2017.023564 Hwang, E. J., Lokietz, N. C., Lozano, R. L., & Parke, M. A. (2015). Functional deficits and quality of life among cancer survivors: Implications for occupational therapy in cancer survivorship care. American Journal of Occupational Therapy, 69, 6906290010. http://dx.doi.org/10.5014/ajot.2015.015974 Locher, J. L., Robinson, C. O., Bailey, F. A., Carroll, W. R., Heimburger, D. C., Saif, M. W., & ... Ritchie, C. S. (2010). Disruptions in the organization of meal preparation and consumption among older cancer patients and their family caregivers. PsychoOncology, 19(9), 967-974. doi:10.1002/pon.1656 Mayo Clinic. (2018). Health lifestyle: Stress management. Retrieved from https://www.mayoclinic.org/healthy-lifestyle/stress-management/in-depth/stresssymptoms/art-20050987 National Cancer Institute. (2018). NCI dictionary of cancer terms. Retrieved from https://www.cancer.gov/publications/dictionaries/cancer-terms?cdrid=450125 Running head: HEALTH PROMOTION AND WELLNESS 30 Ockerby, C., Livingston, P., OConnell, B., Gaskin, C. J. (2013). The role of informal caregivers during cancer patients recovery from chemotherapy. Scandinavian Journal of Caring Sciences, 27, 147-155. doi:10.1111/j.1471-6712.2012.01015.x Pergolotti, M., Williams, G. R., Campbell, C., Munoz, L. A., & Muss, H. B. (2016). Occupational therapy for adults with cancer: Why it matters. The Oncologist, 21(3), 314319. doi:10.1634/theoncologist.2015-0335 Polo, K. M., & Smith, C. (2017). Centennial TopicsTaking our seat at the table: Community cancer survivorship. American Journal of Occupational Therapy, 71, 7102100010. https://doi.org/10.5014/ajot.2017.020693 Scaffa, M. E. & Reitz, S.M. (2014). Occupational therapy in community based practice settings (2nded.). Philadelphia: F.A.Davis. St. Joseph's Healthcare Hamilton. (2013). Energy conservation. Retrieved from https://www.stjo es.ca/patients-visitors/patient-education/ae/PD%208278%20Energy%20Conservation.pdf Running head: HEALTH PROMOTION AND WELLNESS 31 Appendix A Needs Assessment Questions Cooking for Wellness Instructor Questions 1. What do you normally address in your classes/group? 2. What symptoms do you feel are the most common among your group? 3. What are the most common barriers to cooking that you hear voiced in your group? 4. Are there any subjects you would like to be addressed when educating the group? Cooking for Wellness Participant Questions 1. Do you currently feel like you experience and symptoms due to cancer or cancer-related treatment? (Fatigue, pain, weakness, etc.) 2. Do you currently experience barriers to cooking a meal? If so, what? (Fatigue, pain, weakness, etc.) 3. How many meals are you able to cook per week? 4. Do you currently do anything to increase your success when cooking? If so, what? 5. What do you feel like would help you most in relation to cooking meals successfully? Running head: HEALTH PROMOTION AND WELLNESS Appendix B Cooking for Wellness Handouts Figure 1. Cooking for Wellness Handout 32 Running head: HEALTH PROMOTION AND WELLNESS Figure 2. Energy Conservation Handout 33 Running head: HEALTH PROMOTION AND WELLNESS 34 Running head: HEALTH PROMOTION AND WELLNESS Figure 3. Compensatory Strategies Handout 35 Running head: HEALTH PROMOTION AND WELLNESS Figure 4. Stress Management Handout 36 Running head: HEALTH PROMOTION AND WELLNESS 37 Running head: HEALTH PROMOTION AND WELLNESS Appendix C Outcome Measures Educational Session: Formative Evaluation 38 Running head: HEALTH PROMOTION AND WELLNESS Educational Session: Summative Evaluation - Participants Educational Session: Summative Evaluation - Nutritionist 39 Running head: HEALTH PROMOTION AND WELLNESS Performance Session: Formative Evaluation 40 Running head: HEALTH PROMOTION AND WELLNESS Overall Program: Summative Evaluation 41 Running head: HEALTH PROMOTION AND WELLNESS 42  ...

... Title: Health Literacy in Early Intervention: Assessing Documentation of E.I. Therapists Paige Creighton May 2018 A capstone project submitted in partial fulfillment for the requirements of the Doctor of Occupational Therapy degree from the University of Indianapolis, School of Occupational Therapy. Under the direction of the faculty capstone advisor: Taylor McGann, OTR, MS, OTD A Capstone Project Entitled Health Literacy in Early Intervention: Assessing Documentation of E.I. Therapists Submitted to the School of Occupational Therapy at University of Indianapolis in partial fulfillment for the requirements of the Doctor of Occupational Therapy degree. By Paige Creighton Occupational Therapy Student Approved by: Faculty Capstone Advisor Date Doctoral Capstone Coordinator Date Accepted on this date by the Chair of the School of Occupational Therapy: Chair, School of Occupational Therapy Date Running head: HEALTH LITERACY IN EARLY INTERVENTION Health Literacy in Early Intervention: Assessing Documentation of E.I. Therapists Paige Creighton University of Indianapolis HEALTH LITERACY IN EARLY INTERVENTION 2 Abstract This doctoral capstone experience aimed to explore the readability of early intervention therapist notes to improve health literacy in a pediatric therapy clinic. As defined by the American Occupational Therapy Association (AOTA) health literacy is the ability of individuals to gather, interpret, and use information to make suitable health-related decisions (AOTA, 2011). Documentation was evaluated from each of the four disciplines represented at this clinic including occupational, physical, speech, and developmental therapies. Therapy notes from each child were evaluated over a three-month period. This information was then entered into an online software that generates a readability score based on the grade level of the writing. Documentation should aim to be written at a 6 th -8th grade level (Smith & Gutman, 2011). Averages over all four disciplines ranged from a grade level of 5.6-15. These outcomes emphasize the importance of health literacy specifically for this setting. Overall, this doctoral capstone experience looked to establish a way in which to improve health literacy for the clinic to ensure quality services are being provided to the pediatric client and their family. This paper further examines the implications of health literacy on early intervention therapists and families. HEALTH LITERACY IN EARLY INTERVENTION 3 Literature Review The American Occupational Therapy Association (2011) defines health literacy as, the ability of individuals to gather, interpret, and use information to make suitable health-related decisions. Health literacy affects all areas of health care as we encourage patients, parents, and caregivers to obtain the best information for their own health and wellbeing as well as that of the individuals they are caring for. There are multiple components to health literacy described in the Health Literacy Guidebook (2014) as schooling, general literacy, culture, language, personal history, state of mind, illness, medication side effects, eyesight, stress, and degree of trust. They further explain that health literacy isnt just the ability to read and write. We need to, as a population, have the ability to read prescription labels, understand instructions from doctors and other health professionals, follow through with referral information, and have a basic understanding of our results from testing. These skills allow for more clear communication between the patient or client and the health professional (Abrams et al, 2014). The purpose of this literature review is to examine current resources surrounding the topic of parent health literacy and how parents literacy affects carry over of treatment at home. Health Literacy and Occupational Therapy Health literacy and occupational therapy are complimentary to each other. As a profession, we strive to understand how an individuals abilities coincide with their context and interactions in each situation. One of the key factors of health literacy is encouraging individuals to develop more control over their own health (Levasseur & Carrier, 2012). Levasseur & Carrier (2012) describe how health literacy may be a more appropriate predictor of health status than, education, socioeconomic status, employment, race, or gender. If an individual has poor health literacy they may be less likely to use health services thus impacting economic, social, and HEALTH LITERACY IN EARLY INTERVENTION 4 cultural factors. Levasseur and Carrier (2012) give an example that if a therapist asks you not to use the stairs but you continue to use them anyway due to lack of understanding of the given instructions and then suffer an injury, then this behavior overtime leads to more health services being used that could be prevented. Countries such as the United States, Australia, and Canada have an estimated 40-60% of their populations falling within a low health literacy level (Levasseur & Carrier, 2012). On average, an American citizen reads at a 6 th grade level, but most health information is written at a 10 th grade level (Smith & Gutman, 2011). Another study by Keim-Malpass, Letzkus, and Kennedy (2015) found that nearly 36% of adults in the United States have limited health literacy and this number is closer to 50% with individuals from lowincome backgrounds. The above researchers state that limited health literacy of adults is a key indicator of adverse health outcomes such as increased measures of morbidity, poor adherence to medications, limited levels of shared decision-making, more unintended readmissions, and higher utilization of health care resources compared to adults with more functional levels of health literacy (Keim-Malpass, Letzkus, & Kennedy, 2015). As a whole, our population would benefit from an increase in health literacy to improve overall quality of life in the United States. As a profession, occupational therapy would benefit from working to improve health literacy in order to generate increased carryover and understanding of treatment either for the direct therapy recipient or the parent of a child. In 2011 the American Journal of Occupational Therapy published an article by Dr. Diane Smith and Dr. Sharon Gutman in which the issue of health literacy in occupational therapy practice was specifically addressed. Smith and Gutman (2011) discuss that as a profession we have the ability to make a difference in the promotion of client health literacy. This is accomplished through the unique lens of occupational therapy when looking at the person, environment, and occupation of each individual. The article also provides HEALTH LITERACY IN EARLY INTERVENTION 5 an example of looking at each of these aspects, the complex interaction of the person and the health care environment and how this interaction facilitates or hinders performance of the tasks necessary for people to effectively manage their health (Smith & Gutman, 2011, p.368). Family Centered Care Historically health professionals have focused on bringing changes to the child as separate from the family. In the 1970s and 1980s this changed to what we expect to see of parents today which is parents carrying on the treatment programs at home (Hanna & Rodger, 2002). This is especially important in early intervention services (birth to three) where the therapist works with the child for one hour each week thus requiring the parents to follow through with therapy to see major gains. Hanna and Rodger (2002) describe this idea of familycentered care specifically in early intervention settings in order to provide optimal care to the child. Parenting, from an occupational therapy perspective, is an occupation, also known as an everyday activity that brings purpose and meaning to ones life. Therapists need to be understanding of parents perspectives on parenting and the impact of therapy on the parenting process (Hanna & Rodger, 2002). Without this viewpoint, we are unable to truly establish a family centered approach to therapy. Health Literacy of Parents Health literacy of parents can have unforeseen impacts on a therapists goals. Hassan and Heptulla (2010) specifically looked at parents who have a child with the diagnosis of diabetes. They found that parents with lower levels of health literacy led to their child having a higher A1C (blood test to diagnose diabetes) number of 10.4% than individuals with adequate health literacy who had an A1C number of 8.6%. This specific example details the effect of parent literacy on the child. A similar study involving children with glaucoma found that decreased HEALTH LITERACY IN EARLY INTERVENTION 6 parent health literacy contributed to decreased medication adherence (Freedman et. al., 2012). It is also important to have a good understanding of the health literacy of each individual parent. Lyons, OMalley, OConnor, and Monaghan (2010) examined the expectations and experiences of parents who had children receiving early-intervention services. Parents felt uncertain what role they would play in therapy and if they were expected to follow through on exercises with the child at home. According to Smith and Gutman (2011) nearly half of all Americans have problems understanding and following through with given health information. Throughout this project I will be using the Model of Human Occupation (MOHO) to guide my thinking. The design of this model focuses on the volition of the individual. Our volition, or internal drive, guides what we do with our time spent in occupations (Kielhofner, Burke, & Igi, 1980). This will correlate with my project in that my goal is to determine how to adapt therapists notes to better suit the needs of the parents. The therapists already have the internal drive to improve the lives of their pediatric clients. My hope is that the therapists see a carryover in treatment from parents, thus encouraging them to continue to adapt their note writing. This model can be used as a framework to guide therapists into determining not only their own internal volition, but also the volition of the child and his or her family members. In conclusion, literature was found that addressed health literacy in occupational therapy, family centered care, and health literacy of parents. Pediatric occupational therapy relies heavily on the buy-in and understanding of parents. Health literacy coincides with occupational therapy in that through therapy we are looking to address the individual to provide the best possible outcome while health literacy looks at providing the best outcomes of an individual through understanding their own health. Family centered care is an important tenant of early intervention services. Families are often unsure of their role when they have a child receiving early HEALTH LITERACY IN EARLY INTERVENTION 7 intervention services. As previously stated, in the United States the average adult is reading at a 6-8th grade level. It is important for therapists to recognize this as they complete documentation for families. There is ample literature on health literacy in pediatrics among the nursing and speech therapy perspectives, but little that addresses occupational therapy. In the studies that did address pediatric occupational therapy and health literacy they focused more on one specific diagnosis. This doctoral capstone experience will examine occupational, physical, speech, and developmental therapists early intervention notes to determine their current level of readability. This will be compared to the national average reading level of the American adult. Therapists will be educated on ways to adapt their documentation to better suit the needs of the parents with the hope that parents will be more likely to carryover treatment at home to provide better outcomes for the pediatric clients. Screening and Evaluation Processes A random selection of three therapists from each discipline were contacted via email to describe the reasoning and details of the project. A letter of agreement was attached to this email for each therapist to sign allowing the student to access the providers early intervention notes. After receiving signed approval from the therapists, the early interventio n documentation was reviewed for one client covering a three-month time period. Each note was then transcribed into an online program called Readable (www.readable.io) that establishes the reading level of the note. This website assesses the average reading level of text and offers suggestions for how to simplify the text (Conquer Your Readability Today, 2018). Suggestions are highlighted in the note and tips are given to make the text more readable. Each therapists notes over the threemonth time period were compared to find the average reading level with comparisons made to the national average. HEALTH LITERACY IN EARLY INTERVENTION 8 As mentioned above in the literature review the average reading level of an adult in the United States is at a 6th -8th grade level, while most health information is written at a 10 th grade level (Smith & Gutman, 2011). The impact of low health literacy affects each discipline of therapy. Pediatric occupational therapists have the opportunity to adapt their note writing and handouts to improve health literacy in order to promote the optimal environment for learning and growth of both the child and the parent (Levasseur & Carrier, 2011). Impact of Low Health Literacy The impact of low health literacy affects multiple facets of therapy. Rehabilitation professionals put focus on the capacities, functioning, participation, and empowerment of clients in their everyday lives (Levasseur & Carrier, 2010). Improving health literacy of individuals, or making our information suitable to the individuals needs could lead to an increase in the general populations health, decline in the use of health services, reduction in average costs of treatment, decline in work accidents, increased productivity, growth in the economy, and an overall reduction of health inequities (Levasseur & Carrier, 2010). These are a few examples that highlight the importance of health literacy and are issues that were evaluated when evaluating the topic of this capstone project. A study by Frauenholtz, Conrad-Hiebner, and Mendenhall (2015) states that many health care providers did not believe that parent health literacy influenced their work. While pursuing their education, healthcare providers need to understand how health literacy can impact their work with families. Providers who adapt their services to meet the needs of the individual could possibly provide more effective services for the child and their family (Frauenholtz, Conrad-Hiebner, & Mendenhall, 2015). Framework HEALTH LITERACY IN EARLY INTERVENTION 9 The occupational therapy practice framework (OTPF-3) is the document that guides our practice. The OTPF-3 provides definitions to help the reader further understand the OT process. One of these terms is occupational performance which is, the accomplishment of the selected occupation resulting from the dynamic transaction among the client, the context and environment, and the activity or occupation (Occupational Therapy Practice Framework: Domain and Process, 2014). This term can be incorporated into this capstone project as the gathered information from analyzing the therapists early intervention notes is used to collaborate with each therapist to produce more readable documentation. Readable documentation standards will be determined through best available evidence. Occupational participation is another term of value in the OTPF-3. This refers to a client on an individual or group level and the amount of assistance they need to participate in a given task (Occupational Therapy Practice Framework: Domain and Process, 2014). With this project we will be assessing occupational participation of the therapists. Participation for the therapist involves first agreeing to having their documentation utilized for the project and then accepting feedback on how to make these notes more parent applicable. The goal is that this project will lead to further occupational participation from parents of the child receiving services, but that will need to be further assessed in the future. Further diving into the OTPF-3 allows us to examine the specific overarching roles of the therapist and the parents. This project is specifically looking at the instrumental activity of daily living (IADL), or the activity that supports daily life in the home and community, care of others. The therapists are providing care to the child to enhance their development. They are also educating their clients parents to ensure carryover of treatment in the home. While verbal discussions occur within the home, the documentation of these discussions occurs within the HEALTH LITERACY IN EARLY INTERVENTION 10 therapy note. If the parent does not understand this note, they are unable to fully participate in supporting their child through therapeutic intervention. This requires parents to use the process skill of sequencing (Occupational Therapy Practice Framework: Domain and Process, 2014). Sequencing in this regard involves the parent understanding what is being demonstrated and explained by the therapist in a logical progression of skills. If the occupational therapist wants the parent to work on their baby bringing more toys to the mouth they should walk the parents step by step through how to accomplish this. The first step in the sequence might be getting the baby to bring their hands to their mouth and exploring their fingers. The next step would be to have them grasp a toy and work on bringing the toy to their mouth. If the baby will accept it, they could also work on accepting a pacifier. Health Literacy in the Other Settings Health literacy looks different within individual settings of occupational therapy. In early intervention, as mentioned throughout this paper, the focus of health literacy is on the parents. The parents need to be able to understand the given information from the therapist in order to provide the best level of developmental care for their child. In a traditional hospital setting, the focus is placed on the actual client receiving services because they are typically an adult who is responsible for his or her own care. This leads occupational therapists to adapt education and communication style based on their work setting. One study examined two different settings, a rehab facility and a skilled nursing facility (SNF), to determine their ability to meet the health literacy needs of the clients they serve. The results of this study by Smith, Hendrick, Earhart, Galloway, and Arndt (2010) demonstrate the impact of low health literacy in the in-patient rehab setting. They found that the average reading level of the resources they provided to clients was at a 10 th grade level. This is significant for HEALTH LITERACY IN EARLY INTERVENTION 11 their clients in that the national average reading level is at the 6 th grade level. Through the survey, they found that the clients would prefer the therapist to use plain, everyday language, instead of the medical terminology taught to each discipline in the hospital. Within the skilled nursing facility there were many areas for improvement found. These areas included maps that were not at the eye level of an individual in a wheelchair, no translation services offered, and confusing admission paperwork that was written at a grade 14 level (Smith, Hendrick, Earhart, Galloway, & Arndt, 2010). The suggestion for improvements at both facilities included reassessing the materials for clients on a readability scale, and then modifying this to the recommended reading level. The suggestions for staff improvement was that they use clearer, less medical based language when speaking with clients and families (Smith, Hendrick, Earhart, Galloway, & Arndt, 2010). This study gives a good insight into the similarities and differences between pediatric occupational therapy and adult-based occupational therapy. Looking at the OTPF-3 to compare the early intervention setting with the hospital and skilled nursing setting can give us a better understanding of how these areas differ. The occupation in a hospital or SNF is based on what the client is trying to regain in their day to day life, rather than on care of others in the early intervention setting. A more common performance skill in these settings may be looking at a clients motor skills. In an in-patient rehab center many clients are there to receive care after a medical incident such as a stroke or cardio-vascular accident. This requires the occupational therapist to assess the clients motor skills and thus how they interact with and move about their environment to perform day-to-day tasks. Little research was found regarding health literacy in the emerging practice areas of occupational therapy. An area of interest in emerging practice areas is community therapy with older adults. This setting would likely include people with varying levels of health literacy, HEALTH LITERACY IN EARLY INTERVENTION 12 making it challenging to determine the reading level of individuals in the community. One study found that a common factor among individuals with lower health literacy was their age (MacLeod et. al., 2017). With the number of older adults increasing it is important that we are aware of their understanding of their own healthcare to ensure they are receiving the full benefits of the provided service. Implementation Phase Each therapist who turned in a signed consent form identified one client of theirs that had reports due in either November or December of 2017 and/or January or February of 2018. This established a period of approximately three months worth of documentatio n to analyze. The number of notes for each therapist differed due to client cancellations. Approximately six notes from each therapist was entered into the online software, Readable.IO. This software, as mentioned above, gives the average of several different readability formulas to establish a baseline grade level for the note. Each note was independently transcribed verbatim to discover its readability. The grade levels were then entered into a word document to keep track of each note. Notes were identified by the therapists initials and discipline (OT, PT, SLP, and DT) while client identifying information was omitted. Once a score was given for the note the software generates a tip for each note, identifying ways in which to improve the documentation. Information is also given on a readability report that identifies factors that could improve the readability score. This information includes text statistics, text composition, text quality, content composition, and keyword density. One report for each therapist was saved to provide an example for them. After the notes were entered into the software the average for each therapist was established to determine their average writing level. HEALTH LITERACY IN EARLY INTERVENTION 13 Finally, a handout was formulated that identified common items seen in the notes that could be altered to change their readability. This information was researched to provide the best evidence-based information available. Since the next clinic staff meeting will not be held until May, each therapist was emailed a copy of their results of the readability check. They were also given an attached handout that identified how to improve their note writing. Leadership As a doctoral student I understood the importance of improving my leadership skills and found the Doctoral Capstone Experience to be an excellent challenge. Through this project I was able to collaborate with multiple disciplines to provide the best possible outcomes for my project as well as for the work of therapists and through them the families we serve. Working with individuals who have been practicing for multiple years and perfecting their craft in their perspective fields was a daunting task, but an accomplishable one. I started the project off by sending a professional email to the therapist thoroughly describing my project and my expected outcomes. I insisted that they contact me with any questions or concerns regarding their involvement in this project. It was important to not rely heavily on outside sources for help, but to work through problems independently as they came up. This was a big shift from being a student where you have professors as your backbone to finishing up my capstone experience and stepping out of that comfort zone. The idea for this project was developed after discussions with the co-owner of the clinic. She mentioned her interest in providing the most family centered care available to the families that use their services. Through this starting point we determined to assess the health literacy of therapy notes to go forward with increasing family centered care. HEALTH LITERACY IN EARLY INTERVENTION 14 The service provision model that guided this project is the consultative model. The consultative model focuses on meeting all individuals involved in a projects needs (Dunn, 1988). With this project we focused on meeting the needs of the therapist, the pediatric client, the family, and the therapy clinic through addressing the needs of the child and the family first. This was accomplished by looking at the therapy notes to see where alterations can be made to make them more readable. Staff Development As a way to ensure that the staff would benefit from this project, research was found on ways to make documentation more readable. This information was then distributed to the therapists. The therapists also received the scores of each of their documents from the three month period in order to see their overall range of writing. A readability report (Readable.IO) was also given to them to show the breakdown of one of their notes. All of this information was made available to ensure the greatest carryover of the project. Each individual had varying levels of readable documentation and differed in needed changes to be made to their style of documentation. This was communicated to each of them on an individual basis as no two therapists are alike. One of the key job responsibilities of an early intervention therapist is communication with parents or guardians of their client. This project allowed us to work towards communication that is able to be understood by parents of all backgrounds. Information on health literacy was distributed to the therapists involved in this project and made available to the entire clinical staff. Evidence-based literature allowed the student to create a handout that offered a definition of health literacy, what the importance of this topic is, how therapists can contribute to improving health literacy, and tips to improve health literacy. Tips included using plain language, respecting the cultural diversity of your client, limiting the HEALTH LITERACY IN EARLY INTERVENTION 15 number of messages you are trying to get across, provide specific actions and recommendations for the reader, check for understanding using the teach-back method, write the way you talk, and involve the reader (Pontius, 2013, U.S. Department of Health and Human Services, n.d., and Levasseur & Carrier, 2010). Discontinuation and Outcome At the end of this project the overarching goal was to improve readability of early intervention notes to improve carryover of treatment in home pediatric therapy. This required specific objectives to achieve this goal. One way in which I had planned to achieve this goal was discussing with the therapists on an individual basis, either by email or in-person, the results received from Readable.IO over a three-month period of note writing. Each therapist received a word document that had the grade level of each note provided as well as possible tips on how to improve the individual notes as provided by the software. At the bottom of each document the therapist could see their average writing level. Averages over all four disciplines ranged from a grade level of 5.6 to a grade level of 15. This demonstrates the importance of educating each therapist differently. Some therapists had levels that were well within the 6 th -8th grade level which is recommended by the U.S. Department of Health and Human Services (n.d.). Each therapist was also given a health literacy fact sheet. This sheet was created by the student to include a definition of health literacy, why health literacy needs to be a point of interest, how health care professionals can contribute to improving health literacy, and tips to improve health literacy of documentation. This sheet also provided an overview of the averages of each disciplines writing level at this specific clinic. The results are discussed below. The speech therapists at this clinic had the highest readability level. The average of the three therapists notes that participated was a grade level of 12.85. This number may be high due HEALTH LITERACY IN EARLY INTERVENTION 16 to the fact that speech therapists need to include instructions for teaching children language, which is a high-level skill. The average of the physical therapists notes was a grade level of 7.5. Based on reviewing these notes they may be more readable due to the skills they are looking at in therapy such as walking, standing, and kicking. Most of the physical therapists had removed words from their notes such as gait or ambulate which may be more difficult for the reader to understand. The average for the developmental therapists was a grade level of 6.3. These therapists notes typically are focused on things that kids like to do such as playing, building, and throwing. Only one occupational therapist elected to participate with an average note writing level of 7.85. These notes included items like dressing, playing, and throwing. Quality Improvement The ideal plan for ongoing quality improvement is to reassess the therapist notes in the future. This would give the site an idea if the given information has been helpful to the therapists and has reduced their average writing level. The notes should be assessed approximately three months after receiving their health literacy scores and tips to improve documentation. Due to the time constraints of this doctoral capstone experience this project would have to be completed by another student or staff member. In the future, if a student attends this clinic for their doctoral capstone experience they would be able to continue with this project and take it a step further by implementing health literacy workshops, assessing the health literacy of handouts for parents, and looking at clinic notes in addition to early intervention notes. Health literacy is a topic that should be addressed by every healthcare professional, and the more we stress that to the therapists the better we will be able to serve our clients. Occupational Therapys Response HEALTH LITERACY IN EARLY INTERVENTION 17 As the population of our country continues to increase in diversity, therapists need to continue to be sensitive to the needs of a diverse culture. There are varying races, ages, education and socioeconomic levels with each family dynamic. It is important to remain aware of the differences between families and treat each family individually to ensure quality services are being provided. Occupational therapy is one discipline that needs to respond to these changing needs of society. The American Occupational Therapy Association (AOTA) released a statement on cultural competence and ethical practice stating that, occupational therapy practitioners should take a leadership role not only in disseminating knowledge about diverse client groups but also in actively advocating for fair, equitable, and culturally appropriate treatments of all clients served (AOTA, 2015). This statement can and should be applied to all therapy disciplines. Health care professionals have the opportunity to be leaders in cultural competence and this includes meeting the needs of families without judgement (Buchhorn & Lynch, 2010). Best practice for all disciplines means following the principles of client-centered care and acting with cultural competence to ensure that this is not overlooked. Overall Learning This project allowed for development of communication skills through email and in person. As a way to provide initial interaction with the therapists in the clinic I sent a professional email. This email included information on why I was at the clinic, what I would be doing during my time there, and what my goals were. Each therapist was encouraged to contact me via phone call, email, or in person at the clinic if any questions arise. Several therapists sent back questions via email and it was determined, after discussion with my site educator, that we would discuss the concerns together and she would send the email back to her staff. This showed the therapists that their co-worker was involved in this project and understanding of the questions HEALTH LITERACY IN EARLY INTERVENTION 18 they had. There were several therapists who I personally responded to in order to verbally demonstrate my excitement and commitment to this project. Questions were handled appropriately and in a timely fashion as they were received. Therapists had questions regarding HIPPA and were reassured that I was included under the HIPPA regulations of the clinic and would be following these guidelines. Also, a signed consent form was issued and returned by each therapist as a requirement for involvement in this project. As the project came to a close, I emailed each therapist to thank them for their participation. This email also included the information promised to them including their readability scores, tips to improve their health literacy on a note-to-note basis, and a health literacy handout. Further dissemination is planned for the entire clinic staff. The next staff meeting is held in May in which this information will be shared with all therapists including those that did not participate in this project. The health literacy handout will be provided to all therapists at this meeting to give them the resources needed to improve the health literacy of their documentation. Overall the doctoral capstone experience has been a tremendous learning experience. I have further developed skills in advocating for both myself as a future therapist as well as the parents in children in which I work with. Leadership skills have grown as I have been able to discuss my project in multiple settings and with many individuals. Scholarly dissemination is planned for an oral presentation in May, submission to journals, and poster submissions to professional conferences. HEALTH LITERACY IN EARLY INTERVENTION 19 References Abrams MA, Kurtz-Rossi S, Riffenburgh A, Savage BA. (2014) Building health literate organizations: A guidebook to achieving organizational change. Available at: http://www.HealthLiterateOrganization.org. American Occupational Therapy Association. (2011). AOTAs societal statement on health literacy. American Journal of Occupational Therapy, 65(suppl.), S78-79 doi: 10.5014/ajot.2011.65 AOTA. (2015). Occupational therapy code of ethics. American Journal of Occupational Therapy, 69, 6913410030p1-6913410030p8. doi:10.5014/ajot.2015.696S03 Buchhorn, M., & Lynch, H. (2010). Perspectives regarding occupational therapy practice with children and families. Journal of Occupational Therapy, Schools, & Early Intervention, 3(1), 105-112. doi:10.1080/19411241003684274 Dunn, W. (1988). Models of occupational therapy service provision in the school system. American Journal of Occupational Therapy, 42(11), 718-723. doi:10.5014/ajot.42.11.718 Frauenholtz, S., Conrad-Hiebner, A., & Mendenhall, A. N. (2015). Childrens mental health providers perceptions of mental health literacy among parents and caregivers. Journal of Family Social Work, 18(1), 40-56. doi:10.1080/10522158.2014.974116 Freedman, R., Jones, S., Lin, A., Robin, A., Muir, K. (2012) Influence of parental health literacy and dosing responsibility on pediatric glaucoma medication adherence. Archives of Ophthalmology, 130(3), 306. doi:10.1001/archopthalmol.2011.1788 Hanna, K., & Rodger, S. (2002). Towards family-centred practice in paediatric occupational therapy: A review of the literature on parent-therapist collaboration. Australian Occupational Therapy Journal, 49(1), 14-24. doi:10.1046/j.0045-0766.2001.00273.x HEALTH LITERACY IN EARLY INTERVENTION 20 Hassan, K., & Heptulla, R.A. (2010). Glycemic control in pediatric type 1 diabetes: Role of caregiver literacy. Pediatrics, 125(5). doi:10.1542/peds.2009-1486 Keim-Malpass, J., Letzkus, L. C., & Kennedy, C. (2015). Parent/caregiver health literacy among children with special health care needs: a systematic review of the literature. BMC Pediatrics, 15(1). doi:10.1186/s12887-015-0412-x Kielhofner, G., Burke, J. P., & Igi, C. H. (1980). A model of human occupation, part 4. Assessment and Intervention. American Journal of Occupational Therapy, 34(12), 777788. doi:10.5014/ajot.34.12.777 Levasseur, M., & Carrier, A. (2010). Do rehabilitation professionals need to consider their clients health literacy for effective practice? Clinical Rehabilitation, 24(8), 756-765. doi:10.1177/0269215509360752 Levasseur, M., & Carrier, A. (2011). Integrating health literacy into occupational therapy: Findings from a scoping review. Scandinavian Journal of Occupational Therapy, 19(4), 305-314. doi:10.3109/11038128.2011.588724 Lyons, R., Omalley, M. P., Oconnor, P., & Monaghan, U. (2010). Its just so lovely to hear him talking: Exploring the early-intervention expectations and experiences of parents. Child Language Teaching and Therapy, 26(1), 61-76. doi:10.1177/0265659009349975 Macleod, S., Musich, S., Gulyas, S., Cheng, Y., Tkatch, R., Cempellin, D., . . . Yeh, C. S. (2017). The impact of inadequate health literacy on patient satisfaction, healthcare utilization, and expenditures among older adults. Geriatric Nursing, 38(4), 334-341. doi:10.1016/j.gerinurse.2016.12.003 Occupational Therapy Practice Framework: Domain and Process (3rd Edition). (2014). American Journal of Occupational Therapy, 68(Supplement_1). doi:10.5014/ajot.2014.68s1 HEALTH LITERACY IN EARLY INTERVENTION 21 Pontius, D. J. (2013). Health literacy part 2. NASN School Nurse, 29(1), 30-42. doi:10.1177/1942602x13508786 Readable.IO. (2018). Conquer your readability today. Retrieved from https://readable.io/ Smith, D. L., & Gutman, S. A. (2011). Health literacy in occupational therapy practice and research. American Journal of Occupational Therapy, 65(4), 367-369. doi:10.5014/ajot.2011.002139\ Smith, D. L., Hedrick, W., Earhart, H., Galloway, H., & Arndt, A. (2010). Evaluating two health care facilities ability to meet health literacy needs: A role for occupational therapy. Occupational Therapy In Health Care, 24(4), 348-359. doi:10.3109/07380577.2010.507267 U.S. Department of Health and Human Services. (n.d.). Quick guide to health literacy. Retrieved from https://health.gov/communication/literacy/quickguide/Quickguide.pdf  ...

... Running head: OCCUPATIONAL THERAPY AND HEAD PREFERENCE 1 Head Orientation Preference in the Neonatal Intensive Care Unit: Occupational Therapys Role in Prevention and Treatment Elissa Pothast, OTS May, 2018 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: Alison Nichols, OTR, OTD OCCUPATIONAL THERAPY AND HEAD PREFERENCE A Capstone Project Entitled Head Orientation Preference in the Neonatal Intensive Care Unit: Occupational Therapys Role in Prevention and Treatment Submitted to the School of Occupational Therapy at University of Indianapolis in partial fulfillment for the requirements of the Doctor of Occupational Therapy degree. By Elissa Pothast, OTS Approved by: Faculty Capstone Advisor Date Doctoral Capstone Coordinator Date Accepted on this date by the Chair of the School of Occupational Therapy: Chair, School of Occupational Therapy Date 2 OCCUPATIONAL THERAPY AND HEAD ORIENTATION PREFERENCE 3 Abstract Background Head preference may be influenced by various factors, and several developmental skills rely on midline positioning of the head. If left untreated, head preferences can lead to significant conditions, such as deformational plagiocephaly or torticollis. Objectives The purpose of this project was to gather evidence, administer a needs assessment survey, and formulate a client-centered plan. Other objectives included implementing a new assessment tool, training the neonatal therapists in use of the tool, and creating an educational handout related to the topic. Implementation The Infant Head Turn Preference Scale measures both direction and strength of head preference. Four neonatal therapists were trained in use of the tool, and the full assessment was completed on 20 total infants. Parents and caregivers were educated and provided with a handout to increase awareness of head preference. Outcomes Neonatal therapists indicated they were comfortable and likely to administer the assessment in the future. The therapists strongly believed they had adequate resources to educate parents and caregivers on head preference. Conclusion The findings suggest the assessment may be a practical tool to utilize with the infants and the educational handout proved to be a valuable resource for the neonatal therapists. OCCUPATIONAL THERAPY AND HEAD ORIENTATION PREFERENCE 4 Literature Review The purpose of this Doctoral Capstone Experience (DCE) was to increase knowledge regarding the role of occupational therapy (OT) in prevention and treatment of head orientation preference and related conditions in the Neonatal Intensive Care Unit (NICU). The screening and evaluation phase of this DCE involved gaining information through a needs assessment survey of the neonatal therapists concerning the current practices of head orientation preference prevention, as well as analyzing evidence gathered from research. Subsequently, this DCE involved implementation of the Infant Head Turn Preference Scale, formal and informal training of the neonatal therapists regarding the use of the tool, creation of a handout to be used to educate parents, and implementation of intervention strategies based on each infants individual scores on the assessment tool (Dunsirn, Smyser, Liao, Inder, & Pineda, 2016). Overall, the goal is that the neonatal therapists continue to implement the Infant Head Turn Preference Scale and the parent and caregiver educational handout upon conclusion of this DCE in the effort to prevent and/or treat head orientation preferences before they develop into more significant conditions. Ecology of Human Performance The Ecology of Human Performance (EHP) model emphasizes a preventative, healthpromotional, and rehabilitative attitude (Cole & Tufano, 2008, p. 117), which directly relates to the importance of prevention and treatment of head orientation preference in the NICU. The main concepts considered in this model include the person, the task(s), and the context (Cole & Tufano, 2008). This model combines these components to define the personal-task-context transaction, or occupational performance, which was the ideal outcome of this DCE. OCCUPATIONAL THERAPY AND HEAD ORIENTATION PREFERENCE 5 Based on this DCE, the person was considered to be each infant in the NICU who was assessed and/or treated for head orientation preference. Each infant was treated as an individual, and the interventions were adapted as necessary. Each infant had a unique experience and different discharge considerations, so it was important as an OT practitioner to remember that the broad foundation of the condition often allowed for differing courses of intervention strategies for each infant. The task, based on this DCE, was the administration of the Infant Head Turn Preference Scale and interventions as necessary based on the results. The interventions took place in the NICU, and parents, caregivers, and staff were given suggestions to aid in treatment, such as alternating the side of crib on which routine care was completed. Parents and caregivers were also provided with additional verbal education and handouts prior to discharge to reinforce generalization of concepts to home. According to Cole and Tufano (2008), the context related to the EHP can be temporal or environmental, and the environmental aspects can be divided into physical, social, and cultural categories. The temporal contexts related to this DCE included gestational and adjusted age of the infant, developmental stage (muscle tone, reflexes, state control), and diagnoses. The physical environment included the NICU that the program is completed in. This was where the assessment tool and interventions were administered, and where parent and caregiver education took place. Parents and caregivers also had the opportunity to demonstrate understanding of materials while in the NICU environment. Educational material was also reinforced prior to discharge from the NICU, and the goal was to promote generalization of concepts to home and other relevant environments. The social environment in relation to this DCE included the significant relationships that the infant was a part of, which typically included parents, OCCUPATIONAL THERAPY AND HEAD ORIENTATION PREFERENCE 6 caregivers, other family members, and NICU staff. The cultural environment was typically decided by the parents or caregivers, and may have included but was not limited to spiritual, racial, or ethnic identity. The overall goal of this DCE was to promote optimal personal-context-task transaction, also known as occupational performance (Cole & Tufano, 2008). Optimal personal-context-task transaction included successful prevention and/or treatment of head orientation preferences. This may eventually be measured through the sites NICU follow-up clinic, where infants who were patients in the NICU return for re-assessment of developmental milestones at two months, six months, and one year adjusted age. The clinic can record the number of infants they see with head orientation preferences, torticollis, and/or plagiocephaly, and compare that to the numbers that were seen prior to the initiation of this DCE. The goal is that with a formal assessment tool for early detection and consequently treatment of head orientation preferences, the clinic may see fewer infants with significant head preferences or related conditions as a result. Head Orientation Preference Head orientation preference in infants can encompass several factors and is best defined as the preferred positioning of the head to one side, a strong push of the head into rotation to one side, and/or an inability to achieve or maintain the head in midline position (Dunsirn et al., 2016, p. 53). According to Nuysink et al. (2013), there is a higher prevalence of head orientation preference in preterm infants as compared to term infants. If not properly addressed, head preferences in preterm infants may only be further reinforced by typical care routines in the NICU (Hummel & Fortado, 2005). Researchers suggest that a variety of factors may lead to the development of head orientation preference. Medical treatments in the NICU, including endotracheal intubation or an OCCUPATIONAL THERAPY AND HEAD ORIENTATION PREFERENCE 7 intravenous line located in the scalp can cause an infants neck to be passively rotated to one side for an extended period, which may be a contributing factor to preferences (Dunsirn et al., 2016). Preferences may also be influenced by the intra-uterine environment, in which a fetal vertebral column to the left of the mother is associated with a predominant head-position to the right in infants with cephalic presentation during pregnancy (Fong, Savelsbergh, Van Geijn, & De Vries, 2005, p. 516). The extra-uterine environment can influence head orientation preference in instances when a parent, caregiver, or staff member tends to hold the infant on the same side each time, or routine care is completed on the same side of the crib each time in the NICU (Dunsirn et al., 2016; Nuysink et al., 2012). Developmental factors can also influence asymmetrical head orientation, as preterm infants have immature neuromotor systems and the weight of the infants head attempting to fight gravitys strong pull is significant compared to underdeveloped neck muscles (Nuysink et al., 2012). Several developmental skills rely on midline positioning of the head and support the importance of addressing head orientation preference before further concerns arise. According to Dunsirn et al. (2016), the development of a significant head orientation preference can impact function, including reflex patterns, muscle tone, visual orientation, and social interaction. The Moro reflex relies on midline positioning of the head as the head is dropped back slightly; therefore, a head orientation preference to one side may affect the infants ability to display an age-appropriate response (Futagi, Toribe, & Suzuki, 2012). Conversely, a head orientation preference may also affect the asymmetric tonic neck reflex (ATNR) as it is elicited when the infants head is turned to one direction, where the upper and lower extremities should extend on the side of the body the face is turned toward, and the extremities on the opposite side should flex (Lester, Tronick, & Brazelton, 2004). Head preferences may also result in asymmetric OCCUPATIONAL THERAPY AND HEAD ORIENTATION PREFERENCE 8 movement, and the potential for other complications in posture such as torticollis and deformational plagiocephaly (Dunsirn et al., 2016). Torticollis The development of a significant head orientation preference over an extended period can sometimes lead to a condition known as torticollis. Torticollis can be defined as involuntary flexion of neck into the affected side and rotation to the opposite directionthereby resulting in the ear tilting toward the shoulder and chin turning in the opposite direction (Tumturk et al., 2015, p. 1462). This flexion and rotation toward the affected side is the result of shortening or contracture of the sternocleidomastoid muscle in the neck and is a common musculoskeletal deformation in infants (He et al., 2017). Schertz, Zuk, and Green (2012) suggested that infants with a diagnosis of torticollis may be at a higher risk for later neurodevelopmental disorders, such as developmental coordination disorder and attention deficit hyperactivity disorder (ADHD). Early identification and intervention for head orientation preference is important to prevent limited range of motion (ROM) and fibrosis which can be associated with persistent torticollis (Hummel & Fortado, 2005). Deformational Plagiocephaly The presence of a significant head orientation preference is also a risk factor for the development of another condition known as deformational plagiocephaly. Plagiocephaly is defined as atypical development of asymmetrical head shape in infants, where one side of the occiput is flattened, with or without associated forehead and facial asymmetries (Leung, Mandrusiak, Watter, Gavranich, & Johnston, 2016, p. 31). Previously it was thought that this condition was purely cosmetic, but research suggests that infants with plagiocephaly have a higher likelihood of both psychomotor and cognitive developmental difficulties (Bialocerkowski, OCCUPATIONAL THERAPY AND HEAD ORIENTATION PREFERENCE 9 Vladusic, Wei Ng, 2008). Once these children reach school-age, they often present with visualperceptual problems, language disorders, minor developmental delays, learning disabilities, attention deficit disorder (ADD), or other behavioral difficulties (Miller & Clarren, 2000; Panchal, et al. 2001). Balan et al. (2002) also suggested that numerous children who are diagnosed with plagiocephaly are at a higher risk of developing auditory processing disorders. Other risk factors for the development of plagiocephaly include assisted delivery, being a firstborn child, male sex children, multiplets, and other neck problems (Bialocerkowski et al., 2008; Nuysink et al., 2012). Prolonged external pressure to one area of the head is what ultimately causes plagiocephaly; therefore, it is important to vary the infants feeding positions, position of head during sleep, and encourage tummy time activities when the infant is awake and supervised (Bialocerkowski et al., 2008). Role of Occupational Therapy An important role of the OT practitioner in the NICU is to address the relationship between the infants capabilities and the physical and social environment to foster the infants optimal development, which includes encouraging the development of age-appropriate occupations, motor functions, sensorimotor processes, and behavioral regulation (Nightlinger, 2011, p. 243; Vergara et al., 2006). Occupations may include feeding, sleeping, and play, and motor functions may include muscle tone, reflexes, and ROM (Vergara et al., 2006). Sensorimotor processes and behavioral regulation can encompass all of the infants developing sensory systems, quality of transitions between states, and self-regulation (Vergara et al., 2006). Many important developmental skills rely on midline positioning of the head; therefore, OT practitioners can play a crucial role in the prevention and treatment of head orientation preferences in order to optimize development. Various positioning interventions may include OCCUPATIONAL THERAPY AND HEAD ORIENTATION PREFERENCE 10 alternating the direction of the head of the bed and the addition of positioning devices to maintain midline positioning of the head (Dunsirn et al., 2016). Head orientation preference may also be addressed in OT treatment through parent and caregiver education in order to promote generalization of treatment interventions from the NICU to home. Researchers suggest encouraging frequent changes in handling and play positioning, promoting symmetrical positioning of infants head, alternating side of bed for care completion, and passive correction of head to opposite side if a preference becomes notable (Hummel & Fortado, 2005; Leung, Mandrusiak, Watter, Gavranich, and Johnston, 2017). It is also important to encourage parents and caregivers to allow the infant to spend adequate time in the prone position while awake and supervised, as this promotes lifting the head, strengthening neck muscles, and exploring the environment (Jones, 2004). In the prone position, head movement is less restricted, which can promote symmetry, but may also lead parents and caregivers to discover which side the infant has a strong head orientation preference toward. If this is the case, further interventions such as passive ROM stretches or soft tissue massage may be indicated to prevent progression and promote optimal function (Hummel & Fortado, 2005; Van Vlimmeren, Helders, Van Adrichem, & Engelbert, 2006). Ultimately, infants in the NICU experience a high risk of developing head orientation preferences and related conditions as a result of medical treatments, environmental influences, and developmental factors, which reinforces the importance of early evaluation and treatment. If not detected and treated early enough, a head orientation preference can also develop into more complicated conditions such as torticollis or deformational plagiocephaly. The evidence suggests a need for a theoretical model and updated guidelines for practice regarding head orientation preference. The EHP model considers the infant as the person; the task included the OCCUPATIONAL THERAPY AND HEAD ORIENTATION PREFERENCE 11 administration of the Infant Head Turn Preference Scale and interventions as necessary, and the temporal and environmental contexts involved several influencing factors, which produced the personal-task-context-transaction. By conducting a needs assessment survey, this DCE was holistic and person-centered, and the use of evidence strengthened the rationale to improve the quality of care the infants received. The use of a formal assessment tool for early detection also allowed for early intervention, parent education, and generalization of concepts to home, as well as the potential for an overall decrease in number of infants seen in early intervention and outpatient services with torticollis or deformational plagiocephaly. Screening and Evaluation Upon arrival to Franciscan Health, I was approached by an OT practitioner who had recently attended a continuing education course during which the lead educator discussed the topic of head orientation preference and the recent development of a new assessment tool to measure it, entitled the Infant Head Turn Preference Scale. I conducted a literature search for evidence-based research related to head orientation preference independently and met with the OT practitioner to formulate a plan for the project, as well as create formal goals and objectives. This plan included: the administration of a needs assessment survey, implementation of the Infant Head Turn Preference Scale, training the neonatal therapists in use of the tool, and creation of a handout to educate parents and caregivers on the topic of head orientation preference. Needs Assessment A needs assessment survey was created based on reported problem areas in regard to head orientation preference and the anticipated project plan, which was peer-reviewed by an OT practitioner prior to administrative review. The survey was administered to four neonatal OCCUPATIONAL THERAPY AND HEAD ORIENTATION PREFERENCE 12 therapists at Franciscan Health and responses were received from all four. Two of the therapists were physical therapy (PT) practitioners and two were OT practitioners. Appendix A illustrates the needs assessment survey that was administered to the neonatal practitioners. All therapists answered Yes to the question, Do you believe the NICU would benefit from having a quick assessment tool to measure head orientation preference? Table 1 below displays the average answers to needs assessment survey questions on a five-point Likert scale, with a score of one indicating the least level of comfort, likelihood, or adequacy, and a score of five indicating the most. Based on the Likert scale, the therapists indicated that they felt comfortable with administering an assessment tool, they were likely to administer it on a regular basis, and they strongly believed that the NICU did not have adequate resources to support parent and caregiver education regarding the topic of head orientation preference. Table 1 Average Needs Assessment Survey Responses on a Five-Point Likert Scale Question Needs Assessment Average How comfortable do you feel about the idea of implementing a 4.75 new assessment tool for measuring head orientation preference? How likely are you to use this tool on a regular basis? Do you feel like you have adequate written/visual resources to 4.75 2 support your education to parents and caregivers regarding head orientation preferences? The therapists were also asked two open-ended questions: What intervention strategies do you believe the staff complete successfully to combat head orientation preferences? and OCCUPATIONAL THERAPY AND HEAD ORIENTATION PREFERENCE 13 What could be improved in order to combat head orientation preferences more successfully? Responses varied amongst therapists, as some believed that the staff were successfully alternating infant heads and head of beds and using gel pillow positioning devices effectively, while others felt this was unsatisfactory and could benefit from improvement. Other suggestions for improvement that were more consistent among surveys included the need for increased parent education, provision of routine care to both sides of the crib, and the desire for creation of educational handouts to support teaching with parents and caregivers. The results of the needs assessment survey further reinforced the necessity of the elements of this DCE for this site and the neonatal therapy staff. The therapists strongly agreed that the NICU would benefit from the implementation of a formal assessment tool, they felt very comfortable with the idea of implementing the tool, and they were very likely to use the tool on a regular basis. The staff members were already extremely supportive of the use of the Infant Head Turn Preference Scale prior to being trained in its use, which reinforces the value of the assessment to this site and the staff. Another significant finding of the needs assessment was that the therapists believed they did not have adequate resources to support parent education on head orientation preference; therefore, the creation of an educational handout for parents and caregivers would be a valuable resource for both the neonatal therapists and the individuals being educated. Despite differing opinions on the strengths and weaknesses of the NICU staff in combatting head orientation preferences, an overall theme the survey demonstrated was a need for continued education staff members, parents, and caregivers on the importance of prevention and treatment of head orientation preference. Infant Head Turn Preference Scale OCCUPATIONAL THERAPY AND HEAD ORIENTATION PREFERENCE 14 Despite significant research regarding conditions that can result from head preference, few assessment tools exist to formally measure head orientation preference in order to create quantifiable goals and identify intervention strategies for infants in the NICU setting. The Infant Head Turn Preference Scale was developed in order to determine if head orientation preferences are correlated with NICU medical factors, associated with early infant neurobehavior, and/or a marker for developmental delays at two years of age (Dunsirn et al., 2016). This assessment tool measures both direction and strength of head orientation preference (Dunsirn et al., 2016). The examiner may only proceed with the assessment if the infant demonstrates a drowsy, quiet alert, or active alert state according to Brazelton and Nugents states of arousal (1995). If the infant demonstrates a deep or light sleep state, the examiner should attempt to arouse if needed and if the infant demonstrates a crying state, the examiner should attempt to calm before proceeding (Dunsirn et al., 2016). If unable to arouse or calm infant, the examiner should defer formal testing of head orientation preference until the infant can reach a more ideal arousal state for best assessment results (Dunsirn et al., 2016). Assessment tool scores range from 0-10, with a greater score indicating a greater head preference (Dunsirn et al., 2016). Infants may fall into one of the following categories as a result of the assessment: no head preference, minimal head preference, moderate head preference, or significant head preference (Dunsirn et al., 2016). In addition to measuring head orientation preference at rest, amount of cervical rotation, and severity of head orientation preference, the scale measures restrictions in passive neck rotation and head orientation preference in a variety of positions (Dunsirn et al., 2016). Significant outcomes of the assessment indicated that a greater head orientation preference is associated with worse selfregulation and sub-optimal reflexes at 34 weeks postmenstrual age, as well as lower Bayley OCCUPATIONAL THERAPY AND HEAD ORIENTATION PREFERENCE 15 Scales of Infant and Toddler Development-Third Edition (Bayley-III) fine motor and expressive language scores at age two (Dunsirn et al., 2016). Impact of Head Orientation Preference Head orientation preferences that are left untreated may lead to diagnosis of further complications during NICU follow-up clinics, early intervention services, or outpatient pediatric therapy services. The most common diagnoses related to head orientation preferences are postural asymmetries, such as torticollis and deformational plagiocephaly (Dunsirn et al., 2016). Infants who demonstrate a need to attend follow-up clinics or receive therapy services following their discharge from the NICU participate in a variety of assessments chosen by an OT practitioner in order to evaluate the severity of the condition and create a client-centered treatment plan with appropriate goals. Several formal and informal assessments exist to evaluate the presence and severity of torticollis. Informal assessment may include parent report, observation of head tilt, neck muscle strength, and craniofacial asymmetries, and palpation of the sternocleidomastoid and other neck muscles for tightness (Fradette, 2010). Formal assessment may involve measuring active and passive ROM, including neck rotation, flexion, and lateral flexion with use of a goniometer (Fradette, 2010). Other formal assessments include the muscle function scale, which quantitatively measures muscle function of the lateral neck flexors, and video-based pattern analysis, in which video documentation is used to analyze trunk convexity and cervical rotation deficits to determine if a torticollis pattern exists (hman, Nilsson, & Beckung, 2009; Philippi et al., 2006). Deformational plagiocephaly may also be assessed through the use of informal or formal assessment. Similarly to torticollis, plagiocephaly may be informally assessed through parent OCCUPATIONAL THERAPY AND HEAD ORIENTATION PREFERENCE 16 report and observation of craniofacial asymmetries (Fradette, 2010). Kennedy, Majnemer, Farmer, Barr, and Platt (2009) suggested the use of a log in which parents could record infant positioning over a specific period of time to determine how often infants spend in different positions throughout the day. Plagiocephaly may also be formally assessed through plagiocephalometry, in which skull asymmetries can by quantified and recorded over time (Van Vlimmeren et al., 2006). Infants with head position preferences who attend NICU follow-up clinics, outpatient therapy services, or receive early intervention services in the home may also participate in the typical evaluation process to assess developmental progression. Assessment tools may vary between practice settings and sites; however, some common tools to assess development and motor skills include: the Hawaii Early Learning Profile (HELP), Bruininks-Oseretsky Test of Motor Proficiency-II (BOT-II), Peabody Developmental Motor Scales-II (PDMS-II), Bayley Scales of Infant Development-II and III (Bayley-II and Bayley-III), and Alberta Infant Motor Skills (AIMS). Although these assessment tools are not specifically designed to detect torticollis or deformational plagiocephaly, researchers have found correlations between the presence of these conditions and delays in development as evidenced by the results of these assessments. On the Bayley-III, infants with deformational plagiocephaly scored lower on the assessment at 36 months of age than unaffected infants, indicating that infants with plagiocephaly may be at a higher risk for developmental delay (Collett et al., 2013). hman, Nilsson, and Lagerkvist (2009) found that infants with torticollis scored significantly lower on the AIMS compared to a control group, putting them at a higher risk for delay in early motor milestones; however, the authors suggested this may have also been influenced by limited time spent in prone while alert and supervised. OCCUPATIONAL THERAPY AND HEAD ORIENTATION PREFERENCE 17 Specific developmental difficulties that may be seen in NICU follow-up clinics, early intervention, or outpatient pediatric therapy associated with deformational plagiocephaly may include visual-perceptual problems, language disorders, minor developmental delays and learning disabilities, ADD, auditory processing disorders, or other behavioral difficulties (Balan et al., 2002; Miller & Clarren, 2000; Panchal, et al. 2001). Infants who are diagnosed with torticollis may be at a higher risk for neurodevelopmental difficulties, such as developmental coordination disorder or ADHD (Schertz, Zuk & Green, 2012). Other complications of leaving torticollis and deformational plagiocephaly untreated include severe shortening and fibrosis of the sternocleidomastoid muscle and craniofacial deformities (Lee et al., 2012; Wong, Lo, & Chen, 2003). With this in mind, it is particularly important to provide treatment to infants, as well as parent and caregiver education as early as possible. If parents or caregivers are not properly educated while their infant is still in the NICU, their infant may be more likely to require additional therapy services for more severe conditions after discharge. It is important to educate parents and caregivers that it is safe to place their infant in prone when they are awake and alert, as infants may lack adequate tummy time due to emphasis being placed on Back to Sleep practices (Jones, 2004). It is also essential to emphasize to parents that it is best to incorporate tummy time into the infants routine as soon as possible so they can become accustomed to it and begin to build strength in neck and other associated muscles. Parents and caregivers may also be unaware of the risks of placing an infant in different types of equipment for extended periods of time. Although they may understand not to leave an infant in a car seat for long periods of time, they may not understand that alternating between a car seat, stroller, swing, and bouncer seat still exposes the infant to the same position over an extended period of time and can lead to the OCCUPATIONAL THERAPY AND HEAD ORIENTATION PREFERENCE 18 development of torticollis or plagiocephaly. Parents and caregivers may also simply be unaware of tips and tricks that can prevent these conditions, such as varying holding and feeding positions, alternating head of bed, and incorporating the use of faces, books, pictures, baby safe mirrors, and toys to promote symmetrical head movement as the infants visual system matures. Implementation Phase Setting This DCE was implemented at Franciscan Health within the NICU setting. Each portion of the implementation phase was incorporated into infant care and parent education throughout the infants stay. This allowed for holistic, client-centered care and education to be provided within individual rooms and allowed for more privacy for the parents and caregivers during the implementation phase. The intention was that although these assessments, interventions, and parent education were provided within the NICU setting, the parents and caregivers have retained enough of the information to generalize to the home setting. Population Sections of the Infant Head Turn Preference Scale were practiced on several infants in the NICU; however, the full assessment was completed on 20 total infants. The population included infants ranging from just over 33 weeks adjusted age to just over 41 weeks adjusted age, as well as their parents and caregivers who were involved in the education process. Appendix B best illustrates infant demographics, however some of the most common diagnoses at time of assessment included prematurity, apnea of prematurity, neonatal abstinence syndrome (NAS), respiratory distress syndrome (RDS), infant of diabetic mother (IDM) and hypoglycemia. Infants were excluded from participation in the Infant Head Turn Preference Scale if the infants adjusted age was younger than 32 weeks, if the infant required higher than nasal cannula for OCCUPATIONAL THERAPY AND HEAD ORIENTATION PREFERENCE 19 respiratory support, or if the infant could not tolerate being placed in prone suspension for 15 seconds. Assessment and Intervention Assessment involved administration of the Infant Head Turn Preference Scale if the infant was above 32 weeks adjusted age, required a nasal cannula or less for respiratory support, and was able to tolerate being placed in prone suspension for 15 seconds. Occasionally, the assessment was administered at initial evaluation along with the standard evaluation. Other times, the assessment was administered at the beginning of a typical treatment session. An important part of proper administration of the tool was arriving to the infants room before the nursing check was initiated to ensure adequate observation of required items. This was critical as the first test item required the infant to be observed at rest while swaddled and supported, which must happen before the nurse arrives to the room and initiates routine care (Dunsirn et al., 2016). Another assessment tool item required observation of the infant during a diaper change with sandbags on each side of the head, which also required being present for the nursing check and being prepared with sandbags to observe the infants active head movements against them during the diaper changing task (Dunsirn et al., 2016). Scoring involved averaging the scores of the first four items, then adding that score to the scores of the last two items. The total score determined whether the infant demonstrated no, minimal, moderate, or significant head orientation preference as well as direction of preference. Based on the score obtained from the Infant Head Turn Preference Scale, a holistic, client-centered intervention plan was created for each infant. For infants who scored minimal head preference, intervention typically included alternating direction of the head of the bed every other day, incorporating tummy time, and varying infant position in the isolette or crib at each nursing check. Nursing staff members were OCCUPATIONAL THERAPY AND HEAD ORIENTATION PREFERENCE 20 also made aware of the infants head preference and were included in the intervention strategies. Parents and caregivers were educated and provided with an informative handout to increase their awareness of head orientation preference, possible causes of head orientation preference, developmental skills that rely on midline orientation of the head, and the risks of leaving preferences untreated. The handout also included information regarding positioning techniques, such as varying positions, alternating side of crib for routine care, early tummy time when the infant is awake and supervised, and additional resources for parents regarding tummy time. Lastly, the handout included environmental adaptations, such as alternating direction of the head of the bed, limiting time the infant spends in equipment, and incorporating use of faces, pictures, baby safe mirrors, and toys to encourage attention to both sides as the infants visual system matures. Appendix C illustrates the handout used to educate parents during the implementation phase of this DCE. Parents and caregivers were also exposed to demonstration of how to place their infant in the prone position for tummy time, and were also given opportunities to practice this in order to increase caregiver competency and comfort levels with the activity. On the rare occasion that infants scored moderate to significant head preference, the infants and parents received the same treatment and education as those who scored minimal head preference. However, the infants additionally received therapeutic touch interventions, including passive stretching and massage to the affected side of the neck. Passive stretches were completed at each nursing check by either nursing staff or therapy if present for treatment session. Massage was typically completed one time per day during therapy treatment sessions; however, if parents were present often, they were educated on stretching and massage techniques and encouraged to complete both techniques with each nursing check. Leadership Skills and Staff Development OCCUPATIONAL THERAPY AND HEAD ORIENTATION PREFERENCE 21 The implementation phase of this DCE required the use of several important leadership skills, including communication and building trust, responsibility, displaying expertise and developing others, giving and receiving feedback, and flexibility. I believe that the use of these skills helped the neonatal therapists and me become more proficient in the administration of the Infant Head Turn Preference Scale, and assisted in the development and implementation of the educational handout for parents and caregivers. The implementation of the Infant Head Turn Preference Scale required effective communication between neonatal therapists, as well as between therapist and parents or caregivers of the infants. Throughout the process, therapists often communicated with each other regarding what was going well or what was proving to be more difficult during administration of the assessment tool. At the beginning of the implementation phase, it was noted that the assessment tool did not specify a time period in which to observe the infant in each position, so the therapists collectively decided to observe each infant for approximately 15 seconds in each position with the goal of increasing consistency between therapists who administered the assessment. Communication was also an important skill when educating parents and caregivers, as it was important to build a relationship in order to ensure the parent or caregiver fully trusted and followed through with the education. Responsibility also played a vital role in this DCE, as this experience required spending significant time being self-directed and advocating for the project. This specific leadership skill allowed me to take charge of many aspects of the experience but also allowed me to seek assistance and advice from other therapists along the way. It was important that motivation was maintained throughout, and the other neonatal therapists assisted in maintaining that motivation by being invested in the process. OCCUPATIONAL THERAPY AND HEAD ORIENTATION PREFERENCE 22 Another important aspect of the implementation phase was displaying expertise and developing others. It was important to display expertise during the assessment and intervention process, which included proficiency during implementation of the Infant Head Turn Preference Scale, competency with interventions and parent or caregiver education, development of a quality educational handout to enhance learning, and preparation for potential questions asked by parents and caregivers. In comparison, the development of the expertise of others was directly related to one of the objectives of this DCE, which states that NICU staff will be trained in the use of the Infant Head Turn Preference Scale. The neonatal therapists were trained in the use of the assessment tool through one-on-one instruction as well as a formal in-service training session. One-on-one instruction involved one neonatal therapist and I practicing implementation of the assessment tool with the infants in the NICU, practicing scoring the assessment, and giving and receiving feedback in order to improve the training process. The formal in-service training involved all four neonatal therapists, and entailed a handout and presentation on the assessment tool, tips and tricks for implementation of the tool, education regarding the SmartPhrase that was created for documentation of assessment tool results, and a brief discussion on the parent and caregiver educational handout. Time was allotted at the end of the session for questions from the therapists and to allow the therapists to fill out the post-implementation survey. The goal was that the therapists felt comfortable and competent with administration and will continue the use of the tool after the conclusion of this DCE. Giving and receiving feedback was also important during this DCE, as this was a learning experience for everyone involved. Feedback was given to the neonatal therapists on what could be done to improve their administration of the assessment tool, such as increasing the number of infants to which the Infant Head Turn Preference Scale is administered and incorporating the OCCUPATIONAL THERAPY AND HEAD ORIENTATION PREFERENCE 23 parents or caregivers into the assessment. Feedback was also received throughout the training process regarding how to improve overall administration of the assessment tool, including placing the infants head in midline prior to observation of each item, facing the infant toward the therapist and directing auditory and visual stimuli toward midline, and ensuring the bed angle was at zero degrees. Additionally, the neonatal therapists were asked to provide feedback regarding the training they received, and all of the therapists felt that both the hands-on practice and the in-service training were adequate. Lastly, flexibility was a major theme throughout this experience. In the NICU setting, infants are seen for treatment at nursing checks based on scheduled feeding times; however, creating a schedule is not always possible due to multiple possible scenarios. It is also important to note that some parents are regularly present in the NICU, while others are seen for the first time on the day of discharge, which can make parent education more challenging. It was important to remain flexible and understand that schedules, evaluations, treatments, and parent education may not always go as originally planned. Discontinuation and Outcomes As the DCE reached conclusion, outcomes were assessed and plans were put in place for the discontinuation process of the experience. Outcomes were assessed through the use of a postimplementation survey in order to determine the effectiveness of the strategies employed during the implementation phase. The discontinuation phase included methods for continuous quality improvement, response to societys need, and strategies for sustainability. Outcomes A post-implementation survey was created based on the initial needs assessment survey and the implementation phase in order to adequately measure the goals and objectives of this OCCUPATIONAL THERAPY AND HEAD ORIENTATION PREFERENCE 24 DCE. This survey was also peer-reviewed by an OT practitioner prior to administration. The survey was administered to the same four neonatal therapists at Franciscan Health who participated in the needs assessment survey, and responses were received from all four. Appendix D illustrates the post-implementation survey that was administered to the neonatal practitioners and Table 2 below displays the average answers to post-implementation survey questions on the same five-point Likert scale that was used during the needs assessment survey. Based on the Likert scale, the therapists indicated that they felt comfortable with administering an assessment tool, and they were likely to administer it on a regular basis. The biggest difference between needs assessment and post-implementation responses was that at postimplementation, the therapists strongly believed that the NICU had adequate resources to educate parents and caregivers on head orientation preference after the creation of the parent handout. Table 2 Average Post-Implementation Survey Responses on a Five-Point Likert Scale Question Post-Implementation Average How comfortable do you feel implementing the Infant Head Turn 4.5 Preference Scale to measure head orientation preference? How likely are you to use this tool on a regular basis? Do you feel like you have adequate written/visual resources to support your education to parents and caregivers regarding head orientation preferences? 4.75 5 OCCUPATIONAL THERAPY AND HEAD ORIENTATION PREFERENCE 25 The therapists were also asked three open-ended questions: What do you like about the assessment tool? What do you dislike? and Do you feel anything could have been done to better prepare you to administer the assessment tool? Common positive feedback included that the tool gave an objective measurement to assist in assessment of the infants, staff and parent education, and documentation, and that the assessment was easy to perform. One therapist commented on occasion infants may present with low muscle tone or weakness in which the head falls to one side or the other simply by chance versus a true head orientation preference, so it is important to be able to recognize the difference. All four neonatal therapists also believed they were adequately trained and did not feel anything else needed to be done to better prepare them to administer the assessment tool. Another therapist stated that both the one-on-one instruction and the formal in-service were very helpful and she plans to increase use of the tool in daily practice in order to become more comfortable with administration. The therapists were also prompted at the end of the survey to provide other feedback or ask questions as they felt necessary. One therapist who provided feedback regarding the in-service training stated that it was helpful to work through the process as a group in order to ensure consistency between therapists. Another therapist who provided feedback about the assessment tool stated, Thank you! We will definitely be using this tool. Overall, the results of the post-implementation survey indicate that the neonatal therapists believed that the Infant Head Turn Preference Scale is a practical tool for the NICU, they plan to continue use after conclusion of the DCE, and they believed the handout that was created is a valuable resource to educate parents and caregiver about the topic of head orientation preference. Continuous Quality Improvement OCCUPATIONAL THERAPY AND HEAD ORIENTATION PREFERENCE 26 Strategies for continuous quality improvement (CQI) were implemented at this site from the beginning of the DCE. For example, the basic concepts of strengths, weaknesses, opportunities, and threats (SWOT) analysis were initially incorporated into the needs assessment survey that was completed by the neonatal therapists (Helms & Nixon, 2010). Through this type of analysis, planners can better understand how strengths can be leveraged to realize new opportunities and understand how weaknesses can slow progress or magnify organizational threats (Helms & Nixon, 2010, p. 216). The use of the needs assessment survey at the beginning of the screening and evaluation process allowed the neonatal therapists and me to process strengths and weaknesses related to prevention and treatment of head orientation preference in the NICU. The use of the five-point Likert scale led to discovery of a weakness in the area of resources for parental education. If the strengths continued to progress, they would likely promote opportunities for optimal growth and development of the infants. In contrast, if the weaknesses continued to progress, they would likely become threats that could hinder optimal developmental and quality of care. By addressing these items in the needs assessment survey through SWOT analysis, the results highlighted key areas that required improvement and became the focus of the implementation phase. The element of SWOT analysis was also incorporated into the post-implementation survey in order to re-visit the items addressed in the needs assessment survey and analyze the effectiveness of the implementation phase. The topic of resources for parent and caregiver education was viewed as a weakness at the initiation of this DCE; however, as indicated by the post-implementation survey, it has turned into a strength overtime through the development of the parent and caregiver education handout. It is important to recognize that despite this becoming a strength through this DCE process, the neonatal therapists will need to continue to be OCCUPATIONAL THERAPY AND HEAD ORIENTATION PREFERENCE 27 intentional about the implementation of the Infant Head Turn Preference Scale and the educational handout upon conclusion of this DCE. Another method of continuous quality improvement that was incorporated into this DCE was increasing consistency between therapists when implementing the Infant Head Turn Preference Scale. This was done by agreeing upon a 15 second time frame for observation of each of the first four items on the assessment tool, as there was not originally a set time frame indicated by the writers of the tool. Scoring of items required the infant to demonstrate an angle of deviation from midline either 25% of the time, or 75% of the time, and the addition of a time frame allowed for a more concrete definition for scoring and more consistency between therapists (Dunsirn et al., 2016, p. 58). The remaining two items on the assessment tool involved observing the infants active head movements during a diaper change and assessing for restrictions in passive neck ROM and therefore did not require a timeframe for observation. Future plans for quality improvement were also discussed during the discontinuation phase of this DCE. The neonatal therapists were trained on the Infant Head Turn Preference Scale, but we also discussed the potential for including the nurses in the training, as they are also involved in implementing intervention techniques for the prevention and treatment of head orientation preferences. Since it is a brief assessment tool and it requires being present before the infant is disturbed and unswaddled, it could be a simple tool for the nurses to use during routine care completion. Response to Societys Need Other than the Infant Head Turn Preference Scale, only one other assessment tool exists to measure infant head orientation preference and is known as the head orientation profile (Leung et al., 2016). The Infant Head Turn Preference Scale was selected because it was OCCUPATIONAL THERAPY AND HEAD ORIENTATION PREFERENCE 28 determined to be a quicker and easier assessment to implement when compared to the process developed by Leung et al. (2016). Both assessments have the ability to measure direction of head orientation and strength; however, the Infant Head Turn Preference Scale involved simpler calculations allowing for quicker implementation and specified categories of no, minimal, moderate, and significant head preference in addition to a strength score. The neonatal therapists at Franciscan Health were searching for the quickest and simplest assessment tool to integrate into standard evaluations, so the Infant Head Turn Preference Scale was chosen in response to the sites needs. The neonatal therapists at Franciscan Health also indicated the need for a parent and caregiver educational handout during the needs assessment process; therefore, I responded to the sites need by creating and implementing an educational handout. Both the site and the population served responded well to this handout, and the parents and caregivers seemed to be receptive to the information. The handout may be revised in the future as further needs arise. Lastly, this DCE responded to societys need by providing the best quality of care possible for the infants in the NICU at this site. As healthcare providers, it is our responsibility to treat the infant holistically and address areas that need improvement. Through the use of the Infant Head Turn Preference Scale and the parent and caregiver educational handout, improved quality of care is being provided in regard to the prevention and treatment of head orientation preferences in the NICU setting at Franciscan Health. The goal is that in response to societys needs, we may reduce the incidence of more significant conditions such as deformational plagiocephaly or torticollis in the future. Sustainability OCCUPATIONAL THERAPY AND HEAD ORIENTATION PREFERENCE 29 Plans for sustainability of the items addressed in this DCE were also discussed during the discontinuation phase of the experience. Sustainability of this DCE will continue to rely on the individuals involved in the process and their dedication toward the goals and objectives of the project. After the OT student has left Franciscan Health, it will be the job of the neonatal therapy staff to maintain commitment to implementing the Infant Head Turn Preference Scale, use the handout that was created to educate parents and caregivers, continue to implement intervention strategies for the prevention and treatment of head orientation preferences, and preserve the process of continuous quality improvement in order to ensure the greatest quality of care is provided. The most effective methods for reaching sustainability of this DCE are through resource stabilization, objectives fit and internal support, and community outreach and education (Pluye, Potvin, Denis, Pelletier, & Mannoni, 2005; Workforce GPS, 2016). Resource Stabilization According to Pluye et al. (2005), sustainability of a program is encouraged by stabilization of the resources required to maintain the program. This DCE will be easily maintained with minimal resources at a low cost to the site. The Infant Head Turn Preference Scale can be found via an online database search for the Dunsirn et al. (2016) article, and printed anywhere in the NICU department. Several copies have been printed and are stored with other therapy-related evaluation forms. The parent and caregiver educational handout was created by the marketing department at Franciscan Health at a low cost that was also charged to the NICU department. Several copies of this handout have also been printed and are stored along with other educational handouts that are often used by the therapy department. Additional copies of the assessment tool and/or parent handout can also be obtained in bulk at an even lower cost from the print shop department at Franciscan Health and will be charged to the NICU department. OCCUPATIONAL THERAPY AND HEAD ORIENTATION PREFERENCE 30 Objectives Fit and Internal Support Also, according to Pluye et al. (2005), a program is more likely to be sustainable if the program objectives fit with the values of the organization and staff. The major objectives for this program were to gain knowledge and evidence-based research regarding head orientation preference, implement the Infant Head Turn Preference Scale, train the staff in the use of the tool, identify ways to prevent and treat head orientation preference, and create a parent and caregiver educational handout on the topic. However, the overall theme of the above objectives is that an OT practitioner saw a need, and advocated for a project that would provide the most holistic, high quality care that the infants and their families deserved. This directly aligns with Franciscan Healths mission of: Being advocates for those in need, providing a broad, coordinated continuum of health care services with an emphasis on improving the health of persons and communities, treating the mind, body and spirit with holistic and comprehensive medical options (Franciscan Health Inc., 2018). Given that this DCE project aligns well with Franciscan Healths mission, this increases the likelihood for sustainability of the project. Another way to maintain program sustainability is by obtaining internal support (Workforce GPS, 2016). For this DCE, there has been internal support from the neonatal therapists throughout the duration of the project. They are supportive of the project, and they seem to be willing to continue to maintain the process after the conclusion of the experience. I would like to obtain more internal support from the nursing staff. They are protective of the infants in their care, and many of them have a specific routine they go through during each nursing check, so at times it was difficult to convince them to modify their habits to allow for the implementation of the Infant Head Turn Preference Scale. Ideally, this internal support would be best obtained simply through increased education on the purpose and importance of the OCCUPATIONAL THERAPY AND HEAD ORIENTATION PREFERENCE 31 assessment tool. With the support of the neonatal therapists and increased acceptance of the nursing staff over time, this increases the prospect of sustainability for this DCE project. Community Outreach and Education Lastly, sustainability of this program may be assisted through community outreach and education (Workforce GPS, 2016). As stated above, this may involve informally educating nursing staff and other professions about the purpose and importance of implementation of the Infant Head Turn Preference Scale and the parent and caregiver educational handout. Other ways this may be accomplished in the future is by hosting in-service sessions to more formally educate other health professionals about the assessment tool, as well as informal educational sessions for parents and prospective parents, caregivers, and other members of the public to attend and learn more about the topic of head orientation preference and ways to prevent and treat the condition at home. The most important point is to increase awareness of the assessment tool for healthcare professionals and increase awareness of the topic by non-healthcare professionals. It is important to increase education about the elements of this DCE for program sustainability; however, it is also important to increase education on the topic of head orientation preference itself, especially to non-healthcare professionals in order to promote proactive behavior and increase prevention of head orientation preferences and other conditions. Overall Learning Overall through this experience I have gained a great amount of knowledge and clinical skills regarding the practice of OT in the NICU setting, as well as the topic of head orientation preference. I learned from evidenced-based research, textbooks, several mentors, and most importantly the parents, caregivers, and infants in the NICU throughout my time at Franciscan Health. I had the opportunity to study the Infant Head Turn Preference Scale, a fairly new OCCUPATIONAL THERAPY AND HEAD ORIENTATION PREFERENCE 32 assessment tool, and was able to teach the other neonatal therapists about the tool which further facilitated my learning. I also learned from evidenced-based research in order to create a foundation for this DCE project, and utilized it to formulate the parent and caregiver educational handout. In addition, I learned from the parents and caregivers along the way as they made comments and asked questions throughout their learning processes. Lastly, I learned from the infants, who were the most important part of this process and the center of this holistic plan for prevention and treatment of head orientation preference. Overall, I believe I maintained a professional approach throughout this DCE, while also developing several valuable connections and relationships. The NICU setting was intensely complicated, but allowed me to be involved in providing high-quality care and have a lasting impact on the infants and families who participated in this DCE. Communication Neonatal Therapists I believe I demonstrated effective communication with the other neonatal therapists who served as my mentors during my time in the NICU. I feel that I exhibited professional oral, written, and non-verbal communication during my interactions with each of the four therapists in person, as well as through written communication such as the needs assessment and postimplementation surveys, and e-mail. The therapists and I asked each other questions and exchanged feedback on several occasions, which I felt were effective methods to keeping lines of communication open and honest. I believe I was able to build rapport and lasting relationships with therapists who will continue to serve as my mentors as I begin my career as an OT practitioner. OCCUPATIONAL THERAPY AND HEAD ORIENTATION PREFERENCE 33 Effective communication was critical to many interactions with the neonatal therapists throughout my time at Franciscan Health, but perhaps the most important was my communication during both formal and informal training in use of the Infant Head Turn Preference Scale. I believe I exhibited professionalism during individual informal training, in which there was always open communication, time for questions, and opportunities to give and receive feedback while practicing the assessment tool. I also displayed effective and professional communication during the formal in-service training, in which I was required to exhibit competency with the assessment tool in order to properly train the neonatal therapists. There was also time allowed for questions and feedback during the formal training, as well as the use of the post-implementation survey for additional feedback. I believe I was able to receive both positive feedback and constructive criticism well, and the information received can be used to further improve the implementation process in the future. Other Healthcare Providers I also strongly relied on the relationships I built with other healthcare providers throughout my time in the NICU as we worked closely with them on a routine basis. One group of healthcare professionals with whom I believe I demonstrated effective communication and established professional relationships with was the nursing staff. In the NICU setting, the nursing staff can be protective of their infants so it is important to gain their trust, respect, support, and often collaborate with them when providing care to the infants. Additionally, some of the nursing staff have a very specific routine they prefer to maintain during nursing checks, so it was important during this DCE to effectively communicate and educate them regarding the purpose and significance of implementing the Infant Head Turn Preference Scale in order to encourage them to modify their routine. OCCUPATIONAL THERAPY AND HEAD ORIENTATION PREFERENCE 34 On occasion, I also worked closely alongside other healthcare professionals, such as neonatologists, neonatal nurse practitioners, respiratory therapists, speech therapists, social workers, and medical interpreters. It was important to develop effective oral and non-verbal communication with these professionals, respect each others time constraints, and oftentimes collaborate in order to provide the highest quality of care to the infants and their families. Lastly, I believe I exhibited professionalism in my written e-mail communication with the marketing department at Franciscan Health during the process of finalizing the parent and caregiver educational handout. The marketing department was responsible for transforming the rough draft of the handout into the final product with the Franciscan logo on it, so it was vital to establish an effective manner for communication. This ensured that our needs were met, in addition to respecting the requirements set forth by Franciscan Health that the marketing department must follow for the creation of educational handouts. Parents and Caregivers I believe that I exhibited effective communication with the parents and caregivers throughout this DCE. Oral and non-verbal communication involved education regarding the purpose, process, and results of the Infant Head Turn Preference Scale and providing the parents and caregivers with strategies for preventing and/or addressing head orientation preferences. Written education was also provided to the parents and caregivers in the form of the parent and caregiver educational handout after being educated verbally on the information, and the individuals were given the opportunity to ask questions if necessary. In addition to providing education, I believe it was imperative to build relationships with the parents and caregivers through the use of effective communication in order to gain their trust, respect, and support for treating their infant, similar to relationships built with the nursing staff. Many of these parents OCCUPATIONAL THERAPY AND HEAD ORIENTATION PREFERENCE 35 and caregivers were experiencing an extremely stressful, sometimes unexpected time in their lives, so it was important to keep an open line of communication with parents and caregivers, keep them informed, and include them in as much of the process with their infant as possible. Infants Lastly, I feel that effective communication with the infants was vital to the DCE process. Effective oral and non-verbal communication with these infants varied from therapeutic touch and use of oral stimulation for calming purposes, to visual input and auditory stimulation to increase alertness during implementation of the Infant Head Turn Preference Scale. For proper administration of the assessment tool, the authors indicated that the therapist may only proceed if the infant demonstrates a drowsy, quiet alert, or active alert state (Brazelton & Nugent, 1995; Dunsirn et al., 2016). The purpose of implementing the communication techniques described above was to increase the infants level of arousal or to calm the infant in order to reach an ideal arousal state for the most valid assessment results. Therapeutic touch included use of containment or firm, but gentle press holds, and oral stimulation included offering a pacifier for calming. Visual input included the use of the therapists face for visual stimulation and auditory stimulation involved verbal communication to increase alertness during the assessment. Visual and auditory stimulation was always provided with the infant facing the therapist and at the infants midline head position as not to influence head orientation preferences with additional input to one side. Conclusion The findings from this DCE suggest that the Infant Head Turn Preference Scale may be a practical tool to utilize with the infants in the NICU, and the parent and caregiver educational handout proved to be a valuable resource for the site and the neonatal therapists. The goal of OCCUPATIONAL THERAPY AND HEAD ORIENTATION PREFERENCE 36 implementing these resources was to promote early detection and intervention of head orientation preferences, as well as to promote parent and caregiver awareness, allow for their participation in prevention and treatment, and encourage generalization of concepts postdischarge. It is clear that OT practitioners play a critical role in the prevention and treatment of head orientation preferences. The overall goal of this DCE was to promote optimal occupational performance, which included successful prevention and/or treatment of head orientation preferences. Promotion of optimal occupational performance required careful consideration of each infant and their individual contexts prior to determining the appropriate course of assessment and intervention tasks. Through proper use of the Infant Head Turn Preference Scale, appropriate intervention strategies, and comprehensive parent and caregiver education, the neonatal therapists worked to reduce the impact of head orientation preferences on infants in the NICU; therefore, overall occupational performance was improved for each infant who participated in the DCE. Long-term use of these strategies may allow OT practitioners to influence a decrease in more significant conditions seen in NICU follow-up clinics, early intervention services, or outpatient pediatric therapy services, which would continue have a positive impact on the overall occupational performance of these infants. Further research may be conducted to assess the specific effect these strategies have on the number of cases of more severe diagnoses, such as torticollis and deformational plagiocephaly, that are seen in therapy services post-discharge from the NICU setting. OCCUPATIONAL THERAPY AND HEAD ORIENTATION PREFERENCE 37 References Balan, P., Kushnerenko, E., Sahlin, P., Huotilainen, M., Ntnen, R., & Hukki, J. (2002). Auditory ERPs reveal brain dysfunction in infants with plagiocephaly. Journal of Craniofacial Surgery, 13(4), 520-525. doi: 10.1097/00001665-200207000-00008 Bialocerkowski, A. E., Vladusic, S. L., Wei Ng, C. (2008). Prevalence, risk factors, and natural history of positional plagiocephaly: A systematic review. Developmental Medicine and Child Neurology, 50(1), 577-586. doi: 10.1111/j.1469-8749.2008.03029.x Brazelton, T. B., & Nugent, J. K. (1995). Neonatal Behavioral Assessment Scale (3rd ed.). London: MacKeith Press. Cole, M. B., and Tufano, R. (2008). Applied theories in occupational therapy: A practical approach. Thorofare, NJ: SLACK, Inc. Collett, B. R., Gray, K. E., Starr, J. R., Heike, C. L., Cunningham, M. L., & Speltz, M. L. (2013) Development at age 36 months in children with deformational plagiocephaly. Pediatrics, 131(1), e109-e115. doi: 10.1542/peds.2012-1779 Dunsirn, S., Smyser, C., Liao, S., Inder, T., & Pineda, R. (2016). Defining the nature and implications of head turn preference in the preterm infant. Early Human Development, 96(1), 53-60. doi: 10.1016/j.earlhumdev.2016.02.002. Fong, B. F, Savelsbergh, G. J. P., Van Geijn, H. P., & De Vries, J. I. P. (2005). Does intrauterine environment influence fetal head position preference? A comparison between breech and cephalic presentation. Early Human Development, 81(1), 507-517. doi: 10.1016/j.earlhumdev.2004.11.002 Fradette, J. (2010). Factors influencing decision making regarding intervention needs for infants with torticollis. (Unpublished masters thesis). McGill University: Montral. OCCUPATIONAL THERAPY AND HEAD ORIENTATION PREFERENCE 38 Franciscan Health, Inc. (2018). About us. Retrieved from https://www.franciscanhealth.org/about-us Futagi, Y., Toribe, Y., & Suzuki, Y. (2012). The grasp and moro reflex in infants: Hierarchy of primitive reflex responses. International Journal of Pediatrics, 2012, 1-10. doi: 10.1155/2012/191562 He, L., Yan, X., Li, J., Guan, B., Ma, L., Chen, Y., Xu, K. (2017). Comparison of 2 dosages of stretching treatment in infants with congenital muscular torticollis: A randomized trial. American Journal of Physical Medicine and Rehabilitation, 96(5), 333-340. doi: 10.1097/PHM.0000000000000623 Helms, M. M., & Nixon, J. (2010). Exploring SWOT analysis Where are we now? A review of academic research from the last decade. Journal of Strategy and Management, 3(3), 215251. doi: 10.1108/17554251011064837 Hummel, P., & Fortado, D. (2005). Impacting infant head shapes. Advances in Neonatal Care, 5(6), 329-340. doi: 10.1016/j.adnc.2005.08.009 Jones, M. W. (2004). Supine and prone infant positioning: A winning combination. The Journal of Perinatal Education, 13(1), 10-20. doi: 10.1624/105812404X109357 Kennedy, E., Majnemer, A., Farmer, J. P., Barr, R. G., & Platt, R. W. (2009) Motor development of infants with positional plagiocephaly. Physical & Occupational Therapy in Pediatrics, 29(3), 222-235. doi: 10.1080/01942630903011016 Lee, J. K., Moon, H. J., Park, M. S., Yoo, W. J., Choi, I. H., & Cho, T. J. (2012). Change of craniofacial deformity after sternocleidomastoid muscle release in pediatric patients with congenital muscular torticollis. Journal of Bone and Joint Surgery, 94(1), 1-7. doi: 10.2106/JBJS.K.01567 OCCUPATIONAL THERAPY AND HEAD ORIENTATION PREFERENCE 39 Lester, B. M., Tronick, E. Z., & Brazelton, T. B. (2004). The neonatal intensive care unit network neurobehavioral scale procedures. Pediatrics, 113(3), 641-667. Leung, A., Mandrusiak, A., Watter, P., Gavranich, J., & Johnston, L. M. (2016). Clinical assessment of head orientation profile development and its relationship with positional plagiocephaly in healthy term infants: A prospective study. Early Human Development, 96(1), 31-38. doi: 10.1016/j.earlhumdev.2016.03.001 Leung, A., Mandrusiak, A., Watter, P., Gavranich, J., & Johnston, L. M. (2017). Impact of parent practices of infant positioning on head orientation profile and development of positional plagiocephaly in healthy term infants. Physical and Occupational Therapy in Pediatrics, 17(1), 1-14. doi: 10.1080/01942638.2017.1287811 Miller, R. I., & Clarren, S. K. (2000). Long-term developmental outcomes in patients with deformational plagiocephaly. Pediatrics, 105(2), 1-5. Retrieved from http://pediatrics.aappublications.org/content/pediatrics/105/2/e26.full.pdf Nightlinger, K. (2011). Developmentally supportive care in the neonatal intensive care unit: An occupational therapists role. Neonatal Network, 30(4), 243-248. doi: 10.1891/0730 0832.30.4.243 Nuysink, J., Van Haastert, I. C., Eijsermans, M. J. C., Koopman-Esseboom, C., Van Der Net, J., De Vries, L. S., & Helders, P. J. M. (2012). Prevalence and predictors of idiopathic asymmetry in infants born preterm. Early Human Development, 88(1), 387-392. doi: 10.1016/j.earlhumdev.2011.10.001 Nuysink, J., Eijsermans, M. J. C., Van Haastert, I. C., Koopman-Esseboom, C., Helders, P. J. M., De Vries, L. S., & Van Der Net, J. (2013). Clinical course of asymmetric motor OCCUPATIONAL THERAPY AND HEAD ORIENTATION PREFERENCE 40 performance and deformational plagiocephaly in very preterm infants. Journal of Pediatrics, 163(3), 658-665. doi: 10.1016/j.jpeds.2013.04.015 hman, A. M., Nilsson, S., & Beckung, E. R. (2009). Validity and reliability of the muscle function scale, aimed to assess the lateral flexors of the neck in infants. Physiotherapy Theory and Practice, 25(2), 129-137. doi: 10.1080/09593980802686904 hman, A., Nilsson, S., & Lagerkvist, A. L. (2009). Are infants with torticollis at risk of a delay in early motor milestones compared with a control group of healthy infants? Developmental Medicine and Child Neurology, 51(7), 545-550. doi: 10.1111/j.14698749.2008.03195.x Panchal, J., Amirsheybani, H., Gurwitch, R., Cook, V., Francel, P., Neas., & Levine, N. (2001). Neurodevelopment in children with single-suture craniosynostosis and plagiocephaly without synostosis. Plastic and Reconstructive Surgery, 108(6), 1492-1498. doi: 10.1097/00006534-200111000-00007 Philippi, H., Faldum, A., Jung, T., Bergmann, H., Bauer, K., Gross, D., & Spranger, J. (2006). Patterns of postural asymmetry in infants: A standardized video-based analysis. European Journal of Pediatrics, 165(1), 158-164. doi: 10.1007/s00431-005-0027-6 Pluye, P., Potvin, L., Denis, J. L., Pelletier, J., & Mannoni, C. (2005). Program sustainability begins with the first events. Evaluation and Program Planning, 28, 123-137. doi:10.1016/j.evalprogplan.2004.10.003 Schertz, M., Zuk, L., & Green, D. (2012). Long-term neurodevelopmental follow-up of children with congenital muscular torticollis. Journal of Child Neurology, 28(10), 1215-1221. doi: 10.1177/0883073812455693 OCCUPATIONAL THERAPY AND HEAD ORIENTATION PREFERENCE 41 Tumturk, A., Ozcora, G. K., Bayram, A. K., Kabaklioglu, M., Doganay, S., Canpolat, M., Per, H. (2015) Torticollis in children: An alert symptom not to be turned away. Childs Nervous System, 31(1), 1461-1470. doi: 10.1007/s00381-015-2764-9 Van Vlimmeren, L. A., Helders, P. J. M., Van Adrichem, L. N. A., & Engelbert, R. H. H. (2006). Torticollis and plagiocephaly in infancy: Therapeutic strategies. Pediatric Rehabilitation, 9(1), 40-46. doi: 10.1080/13638490500037904 Vergara, E., Anzalone, M., Bigsby, R., Gorga, D., Holloway, E., Hunter, J., Strzyzewski, S. (2006). Specialized knowledge and skills for occupational therapy practice in the neonatal intensive care unit. American Journal of Occupational Therapy, 60, 659-668. doi:10.5014/ajot.60.6.659 Workforce GPS. (2016). Sustainability: Planning for the future. [Audio webinar]. Retrieved from https://youth.workforcegps.org/resources/2016/11/08/10/08/Sustainability Yu, C. C., Wong, F. H., Lo, L. J., & Chen, Y. R. (2003). Craniofacial deformity in patients with uncorrected congenital muscular torticollis: An assessment from three-dimensional computed tomography imaging. Plastic and Reconstructive Surgery, 113(1), 24-33. doi: 10.1097/01.PRS.0000096703.91122.69 OCCUPATIONAL THERAPY AND HEAD ORIENTATION PREFERENCE Appendix A. Infant Head Turn Preference Scale Needs Assessment Survey Date: ______________ Department: _________________________ Do you believe the NICU would benefit from having a quick assessment tool to measure head orientation preference? Yes No Maybe How comfortable do you feel about the idea of implementing a new assessment tool for measuring head orientation preference? 1 2 3 4 5 How likely are you to use this tool on a regular basis? 1 2 3 4 5 Do you feel like you have adequate written/visual resources to support your education to parents regarding head orientation preferences? 1 2 3 4 5 What intervention strategies do you believe the staff complete successfully to combat head orientation preferences? ______________________________________________________________________________ ______________________________________________________________________________ What could be improved in order to combat head position preferences more successfully? ______________________________________________________________________________ ______________________________________________________________________________ Thank you for your time! Needs Assessment Survey. This figure illustrates the needs assessment survey administered to four neonatal therapists. 42 OCCUPATIONAL THERAPY AND HEAD ORIENTATION PREFERENCE 43 Appendix B. This table illustrates the demographics of the infants involved in this experience at the time of assessment. Infant Gestational Age Adjusted Age Diagnoses 1 33+4 37+6 Prematurity, hypoglycemia, twin A 2 33+4 37+6 Prematurity, hypoglycemia, twin B 3 34+5 35+1 Prematurity, mother with eclamptic seizure while infant in utero, RF, RDS, hyperbilirubinemia 4 31+3 38+6 Prematurity, HTN, dysphagia, IDM 5 39+0 41+1 Mothers abdomen was struck two times while infant in utero, IUGR, NAS 6 34+1 35+0 Prematurity, IDM, polycythemia, apnea of prematurity, mild ventricular hypertrophy 7 33+3 36+0 Prematurity, cleft soft palate, vaginal mass 8 31+5 34+5 Prematurity 9 37+0 38+4 RDS, anomaly of rib, tobacco use during pregnancy 10 37+2 38+4 NAS 11 30+2 33+2 Prematurity, apnea of prematurity, breech presentation 12 38+6 41+2 NAS 13 34+1 36+0 Prematurity, polycythemia, breech presentation 14 28+2 35+4 Prematurity, apnea of prematurity, maternal substance abuse (alcohol and marijuana) OCCUPATIONAL THERAPY AND HEAD ORIENTATION PREFERENCE 44 15 38+0 39+2 RDS, RF 16 34+5 36+2 Prematurity, IDM, LGA 17 28+6 37+5 Prematurity, apnea of prematurity, chronic lung disease, anemia of prematurity, two-vessel umbilical cord, hydronephrosis of left kidney, left eye hemorrhage, retinopathy of prematurity 18 37+5 37+6 Hypoglycemia, IUGR 19 37+1 39+3 Feeding disturbance, reflux 20 33+0 35+6 Prematurity Note: RF=respiratory failure, RDS=respiratory distress syndrome, HTN=hypertension, IDM=infant of diabetic mother, IUGR=intrauterine growth restriction, NAS=neonatal abstinence syndrome, LGA= large for gestational age OCCUPATIONAL THERAPY AND HEAD ORIENTATION PREFERENCE Appendix C 45 OCCUPATIONAL THERAPY AND HEAD ORIENTATION PREFERENCE Educational handout. This figure illustrates the bi-fold handout used to educate parents and caregivers about head orientation preference during the implementation phase. 46 OCCUPATIONAL THERAPY AND HEAD ORIENTATION PREFERENCE 47 Appendix D Infant Head Turn Preference Scale Post-Implementation Survey Date: ______________ Department: _________________________ Least Most How comfortable do you feel implementing the Infant Head Turn Preference Scale to measure head orientation preference? 1 2 3 4 5 How likely are you to use this tool on a regular basis? 1 2 3 4 5 Do you feel you have adequate written/visual resources to support your education to parents regarding head orientation preferences? 1 2 3 4 5 What do you like about the assessment tool? What do you dislike? ______________________________________________________________________________ ______________________________________________________________________________ Do you feel anything could have been done to better prepare you to administer the assessment tool? ______________________________________________________________________________ ______________________________________________________________________________ Other feedback or questions: ______________________________________________________________________________ ______________________________________________________________________________ Thank you for your time! Post-Implementation Survey. This figure illustrates the post-implementation survey administered to four neonatal therapists.  ...

... Running head: FAMILY-CENTERED CARE IN THE NICU 1 Family-Centered and Developmentally Supportive Care in the Neonatal Intensive Care Unit Doron Kantor May, 2018 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: Alison Nichols, OTR, OTD FAMILY-CENTERED CARE IN THE NICU 2 A Capstone Project Entitled Family-Centered and Developmentally Supportive Care in the Neonatal Intensive Care Unit Submitted to the School of Occupational Therapy at University of Indianapolis in partial fulfillment for the requirements of the Doctor of Occupational Therapy degree. By Doron Kantor Doctor of Occupational Therapy Student Approved by: Faculty Capstone Advisor Date Doctoral Capstone Coordinator Date Accepted on this date by the Chair of the School of Occupational Therapy: Chair, School of Occupational Therapy Date FAMILY-CENTERED CARE IN THE NICU Abstract 3 While the intensive environment of the NICU can act as a barrier to parents fulfilling the parental occupation, evidence demonstrates that family-centered, developmentally supportive care leads to more successful outcomes for premature newborns and their families. A needs assessment at a Level III NICU in Indiana revealed the need to provide more thorough parent education to assist parents with fulfilling their role in the NICU. As a Doctoral Capstone Experience (DCE), the occupational therapy student developed and implemented a program to promote parent education and participation, supporting healthy infant-parent bonding in the NICU. The program included the creation of a NICU Binder and the presentation of Parent Education Courses to provide thorough education regarding principles of developmental care. The results of the post-session parent survey, a measure of parent satisfaction, indicated a positive outcome with a score of 4.5083/5.0. The post-program NICU staff survey, a measure of overall program satisfaction, indicated a positive outcome with a score of 4.725/5.0. The DCE also led to a more collaborative relationship between therapy and nursing in the NICU. The site will sustain the family-centered care program as NICU therapists continue the parent education sessions and add topics as deemed appropriate. FAMILY-CENTERED CARE IN THE NICU 4 Family-Centered and Developmentally Supportive Care in the Neonatal Intensive Care Unit Introduction Premature infants are likely the most vulnerable patients a healthcare provider can encounter (Westrup, 2015). Nearly 500,000 infants are born at less than 37 weeks gestational age or with low birth weight (less than 2500 grams) in the United States (Altimier & Phillips, 2016). Of these 500,000 infants, 10-15% are placed in the Neonatal Intensive Care Unit (NICU) due to their complex medical status. However, these infants, even those born as early as 23 weeks gestational age, have a greater chance of survival as a result of medical advancements that have occurred over the past 30 years (Altimier & Phillips, 2013). While survival rates are higher, premature infants still have a greater risk for medical and developmental impairments that can cause poor overall outcomes, and result in disability (Altimier & Phillips, 2013; Altimier & Phillips, 2016). There are many factors to consider when caring for premature infants in the NICU. In more recent years, healthcare providers and researchers have determined that family-centered neurodevelopmental supportive care, or neuroprotective family-centered developmental care, results in more successful outcomes for premature newborns and their families (Altimier & Phillips, 2013; Altimier & Phillips, 2016; Westrup, 2015). Neuroprotective developmental care involves providing interventions that support and protect the infants vulnerable, still-developing neurological and sensory systems (Altimier & Phillips, 2013; Altimier & Phillips, 2016). Familycentered care ensures that healthcare providers in the NICU approach care holistically by considering the needs of the parents and siblings in addition to the needs of the infant (Westrup, 2015). FAMILY-CENTERED CARE IN THE NICU Since family-centered, developmentally supportive care is evidenced as best practice, 5 these principles were used to expand best practice at a Level III NICU at a hospital in Indiana. Through collaboration between therapy services and NICU nursing, a family-centered, developmentally supportive program consisting of parent education and support was implemented. Literature Review Effects of Premature Birth on Neurodevelopment The majority of fetal neurodevelopment occurs during the third trimester of pregnancy (Altimier & Phillips, 2013). Therefore, when an infant is born prematurely, their neurologic system has not fully developed, and the infant is at higher risk for having neurodevelopmental problems. These infants often demonstrate impaired motor, sensory, cognitive, and behavioral development. Later in life, these initial impairments can lead to motor delays, cognitive deficits, learning disabilities, behavioral disorders, and poor emotional regulation (Altimier & Phillips, 2013; Altimier & Phillips, 2016). Sensory development and its effects. Neurosensory development is an integral part of an infants overall neurological development. The sensory system is meant to develop the following order: tactile, vestibular, olfactory, gustatory, auditory, and visual senses. Ideally, this process should not be tampered with as this can result in behavioral, cognitive, and functional deficits (Altimier & Phillips, 2013, p. 11). These deficits can occur because neurobehavioral development is closely intertwined with neurosensory development. When an infant experiences a sensory event, the brain is signaled to have a behavioral response. As such, sensory development is imperative to the development of behavioral and emotional self-regulation, cognition, and overall function. The underdeveloped sensory system of the premature infant does FAMILY-CENTERED CARE IN THE NICU 6 not allow the infant to appropriately understand, tolerate, or behaviorally regulate the sensations that they experience (Altimier & Phillips, 2013). A mothers womb is a protective environment that provides positive sensory experiences for the fetus. When an infant enters the world prematurely, he or she is removed from the protective environment of the womb without being fully prepared for the sensory experiences of the extra-uterine environment. Therefore, extra-uterine sensory experiences can be negative for the infant, and result in developmental problems due to how these experiences modify typical neurodevelopment (Altimier & Phillips, 2013). The NICU Setting and Neurodevelopmental Care By its nature as an intensive care unit, and in comparison to the environment of the womb, the NICU may provide negative extra-uterine sensory experiences. In order to create a more positive environment for infants in the NICU, Altimier & Phillips (2013) have developed The Neonatal Integrative Developmental Care Model which includes seven core measures for neuroprotective family-centered developmental care: (a) healing environment, (b) partnering with families, (c) positioning and handling, (d) safeguarding sleep, (e) minimizing stress and pain, (f) protecting skin, and (g) optimizing nutrition (Altimier & Phillips, 2013, p. 10). These seven measures combine to create a positive environment for the infant. In order to facilitate a healing environment, ideally each infant should have a single room to reduce stress factors for the infant and family, as well as to control infection. Furthermore, all sensations should be strictly monitored in the NICU. Temperature, touch, proprioception/vestibular, smell, taste, sound, and visual stimuli are all carefully controlled to ensure the infant receives the correct type and amount of sensory stimulation. Incubators or radiant warmers are used to help the infant with his/her thermoregulation. In addition, the NICU should be a quiet environment, FAMILY-CENTERED CARE IN THE NICU 7 with limited lighting and scents. When positioning, holding, or handling an infant, staff should use gentle touch and slow movements. Infants should ideally be positioned in flexion with hands to mouth to promote the natural posture he or she would be experiencing in the womb. Furthermore, body containment should be used to mimic the enclosed feeling of the womb as it helps to decrease stress and increase self-soothing. The NICU environment should promote and protect sleep cycles as the most neurodevelopment occurs during sleep, especially during rapid eye movement (REM) sleep (Allen, 2012; Calciolari & Montirosso, 2011; Graven, 2006). Therefore, infants should not be awakened for handling, care, or therapy during their REM sleep as this can disturb their development. Premature neonates also have very delicate and thin skin. Soaps and other products that are sensitive and gentle on skin should be used at all times. The use of adhesives should be avoided whenever possible, but if necessary, should be applied and removed gently. In terms of feeding, breast milk should be used whenever possible due to its many benefits for the infants health and development, and feeding schedules should occur based on each infants feeding cues (Boucher, Brazal, Graham-Certosini, Carnaghan-Sherrard, & Feely, 2011; Cosimano & Sandhurts, 2011; Gartner, Morton, Lawrence, Naylor, OHare, Schanler, & Eidelman, 2005). Using these measures will help to reduce the amount of stress and pain each infant experiences (Altimier & Phillips, 2013; Altimier & Phillips, 2016). Another example of developmentally supportive care is the Newborn Individualized Developmental Care and Assessment Program (NIDCAP). This program was originally developed by Dr. Heidelise Als, a Clinical and Developmental Psychologist from Harvard Medical School and Boston Childrens Hospital. The aim of the program is to structure the NICU environment to allow for the best outcomes for each infant. The program includes observation and analysis of five subsystems of behavior: autonomic, motor, state regulation or FAMILY-CENTERED CARE IN THE NICU state organization, attentional/interactional, and self-regulatory systems (Westrup, 2007, p. 8 445). The NIDCAP certified staff creates the infants developmental goals, care plan, and environment based upon these observations and analyses of the infants behavioral cues. NIDCAP has been shown to reduce length of stay, improve behavior, and improve electroencephalogram (EEG) and magnetic resonance imaging (MRI) results (Buehler, 2014). Westrup reported on a study by Tyebkhan, Peters, McPherson, and Hendson (2004), which found that very low birth weight (VLBW) infants who have had NIDCAP intervention have shorter hospital stays (Westrup, 2007, p. 446). Westrup also reported the results of Als, et al. (2004), which demonstrated beneficial structural changes in the NIDCAP infants compared with a control group in tissue distributions as well as in microstructural development of the white matter (Westrup, 2007, p. 446). The NIDCAP Federation describes the program as a cultural shift that results in better outcomes (Buehler, 2014). The principles of developmentally supportive care that both Altimier and Phillips (2013, 2016) and Westrup (2007) have described represent best practice. Therefore, these principles were used when implementing the family-centered, developmentally supportive care program at the Level III NICU at an Indiana hospital. While many of these principles were already being used at this NICU, it was critical to ensure that these principles carry over into any new program. Family-Centered Care The Neonatal Integrative Developmental Care Model (Altimier & Phillips, 2013; Altimier & Phillips, 2016) and NIDCAP (Westrup, 2007) are both developmentally supportive and family-centered programs. Both models recognize the importance of family-centered care in the NICU setting. For example, Core Measure 2 of Altimier and Phillips Seven Neuroprotective Measures is partnering with families (Altimier & Phillips, 2013; Altimier & Phillips, 2016). FAMILY-CENTERED CARE IN THE NICU 9 Westrup (2007) also explained that the role of the family is integral to developmental care. When an infant is born prematurely and requires admission to the NICU, the infants family experiences a crisis. Parents are often unfamiliar with the NICU and they may be intimidated by the intensive environment. Furthermore, the separation of the infant from the parents can negatively affect the formation of the parent-infant attachment, thereby affecting the parents ability to effectively understand and interact with their child (Altimier & Phillips, 2013; Westrup, 2015). If parents are not involved in their infants healing, development, and care in the NICU, both the infant and the parents are likely to experience negative outcomes (Altimier & Phillips, 2013). The goal of a family-centered approach to care in the NICU is to address the needs of parents and promote the involvement of the family in the healing, development, and care of the infant (Altimier & Phillips, 2013; Westrup, 2015). Several studies have shown that familycentered care programs have developmental benefits to the infant, encourage a positive parentinfant relationship, and support the needs of the parents and family, resulting in better outcomes for the infant, the parents, and the family as a whole (Bracht, OLeary, Lee, & OBrien, 2013; Dudek-Shriber, 2004; Goldstein, 2013; MeInyk et al., 2006; OBrien et al., 2013; Pineda, Bender, Hall, Shabosky, Annecca, & Smith, 2018; Welch et al, 2012; Westrup, 2007; Westrup, 2015). Many studies have focused on education and participation of caregivers. For example, MeInyk et al. (2006) developed the Creating Opportunities for Parent Empowerment (COPE) program, which implemented family-centered care through an educational-behavioral intervention and consisted of audiotaped educational sessions and participation in behavioral activities. COPE was shown to significantly reduce stress, depression, and anxiety in mothers. FAMILY-CENTERED CARE IN THE NICU 10 When the program was tested through a randomized, controlled trial, infants of parents enrolled in COPE had a shorter length of NICU stay by 3.8 days, and a shorter length of hospital stay by 3.9 days in comparison to the control group. Furthermore, sample-blind observers of parents enrolled in COPE reported mothers and fathers had more positive interactions with their infants than parents did in the control group. Welch et al. (2012) also published a randomized-controlled study regarding a familycentered care program called Family Nurture Intervention (FNI). The study used early interventions to address the infant-mother relationship, the emotional well-being of the mother, and the development of the premature infant (Welch et al, 2012). One hundred and thirty families participated in FNI, while 130 families received standard care as the control group. The intervention was based upon Calming Activities. For example, mothers participated in odor exchange, firm sustained touch, vocal soothing, and eye contact while the infant remained in the incubator. Once the infant was out of the incubator, the Calming Cycle consisted of holding and feeding. Another aspect of FNI was the implementation of family sessions that helped the mother engage, bond with, and care for her infant. The results of the study demonstrated that FNI increases activities and behaviors that improve infant development, the emotional well-being of the mother, and the infant-mother attachment relationship. The researchers concluded that their study provides evidence for using early and extensive mother-infant interactions, within the constraints of the NICU (Welch et al, 2012, p. 14). As such, this study supports the use of holistic family-centered care in the NICU for the benefit of both the infant and the family. Providing education for knowledge and skill, and allowing for participation in infant care are important and empowering methods of family-centered care. Another method is that of addressing the psychosocial health of parents and families in the NICU. For example, Morgan FAMILY-CENTERED CARE IN THE NICU 11 and Rimmer (2011) implemented the Family and Baby Project, a needs-led, non-judgmental service that could respond to individual cases (p. 156). Support workers in the Arrowe Park Hospital NICU provided two sessions a week that were specific to the needs of each family. Support workers completed intensive training that consisted of full neonatal induction and bereavement training (Morgan & Rimmer, 2011, p. 156). The researchers conducted a postdischarge questionnaire to the 60 parents who had participated in the program. One hundred percent of parents were highly satisfied with the support program (Morgan & Rimmer, 2011). Purdy, Craig, and Zeanah (2015) completed a review of literature to provide recommendations for how multiple disciplines can work together to provide the best care for parents and their psychosocial needs. The authors found the need for emotional support, parenting education, medical follow-up, home visit services, and interprofessional practice to support parents in the NICU. This supports the need for interdisciplinary work to address the continuum of parentinfant needs (Purdy, Craig, & Zeanah, 2015, p. S27). In order to achieve better outcomes for both infants and parents, Bracht, OLeary, Lee, and OBrien (2013) developed Family-Integrated Care, a program that addressed both the education and psychosocial/emotional support that parents need in the NICU. The researchers reported that a weekly parent education series for NICU parents was already occurring at the hospital. To expand family-centered care, the researchers enrolled mothers in groups of four or five and implemented daily educational sessions five days per week. The mothers in the program also acted as primary caregivers to their infants for at least eight hours per day and participated in medical rounds. A unique feature of this study was the inclusion of veteran parent mentors. These mentors were parents who had previously had an infant in the NICU. They provided parents with peer support and helped teach the educational sessions on coping, discharge FAMILY-CENTERED CARE IN THE NICU 12 planning, and breastfeeding (Bracht, OLeary, Lee, & OBrien, 2013, p. 122). The researchers evaluated the program through qualitative feedback from the participants at discharge. The results demonstrated, mothers were provided with the tools to parent their infants in the NICU, recognize their own strengths, increase their problem-solving strategies, and emotionally prepare them to take their infant home (Bracht, OLeary, Lee, OBrien, 2013, p. 115). Thus, the program was deemed successful and has since been adapted to provide the best possible parental education and support. Therapists Roles in Family-Centered Care The previously mentioned studies were primarily conducted by physicians and nurses. As the program I implemented consists of collaboration between therapists and nurses, the question was, What is the role of the therapist? In 2014, Goldstein, a physical therapist, published a systematic review of the literature regarding therapys role in family support and education in the NICU. Goldstein focused on the role of therapists as parent educators and categorized her findings into four main themes: (a) family context, (b) education assessment, (c) methods for teaching, and (d) topics for teaching. Family context referred to different stressors that affect families in the NICU. Goldstein found that the NICU Discharge Path can be used as an educational assessment to understand the family. By using this tool, therapists can more effectively partner with the family and empower parents. Goldstein concluded that therapists should focus on teaching parents about physical contact/handling, reading cues, anticipatory guidance/adjusting age for prematurity, equipment/positioning recommendations, and postural control. Furthermore, therapists should recognize parents as adult learners and adjust their teaching strategies based on parent preferences and benefits. She concluded that therapists need to use evidence-based strategies to focus on evidence-based topics during teaching sessions with FAMILY-CENTERED CARE IN THE NICU 13 parents. According to Goldstein, a therapists goal should be to provide family-centered care by providing parents with the knowledge and skills that will allow them to most positively affect their infants development. Recently, Pineda, an occupational therapist, partnered with a group of physicians and therapists to address the issue of parental presence in the NICU (Pineda, Bender, Hall, Shabosky, Annecca, and Smith, 2018). How can one implement family-centered care if parents are not present? Pineda and colleagues conducted their study at St. Louis Childrens Hospital in a Level III-IV NICU. The researchers collected parent participation information from documentation in electronic medical records. Their key findings were that parents were present in the NICU four days per week on average, and held their infants an average of two to three days per week while their infants were in the NICU. Participation in the NICU was more common for Caucasian mothers who were married, employed, or older, and had a supportive family, fewer children, or were actively producing breastmilk. Furthermore, parent participation occurred more for infants who were more medically stable and required fewer medical interventions. The infants who were held more by their parents benefitted with better short-term outcomes. If parents participated in skin-to-skin care, their infants had better short-term and long-term developmental outcomes. As such, both infant medical factors and family sociodemographic factors affected whether or not parents were present, how much they were present, and how much they actively participated in their infants care (Pineda, Bender, Hall, Shabosky, Annecca, & Smith, 2018). While Goldstein (2014), and Pineda et al (2018) provided evidence for therapys role in family-centered care, Gibbs, Boshoff, and Lane (2010) demonstrated that occupational therapists have a unique role in family-centered care in the NICU. In their article, the authors explained that occupational therapy has had a growing role in providing services to premature infants and FAMILY-CENTERED CARE IN THE NICU 14 their families. In fact, occupational therapists have a unique perspective since we understand parenting as an occupational role. The intensive environment of the NICU can act as a barrier to parents fulfilling that parental occupation (Gibbs, Boshoff, & Lane, 2010). As such, the authors explained that one can use the Person-Environment-Occupation (PEO) Model to understand parents and their occupational role. The PEO Model is useful for understanding parenting in the NICU as it allows one to analyze and understand the complex interactions that occur between a person, their environment, and their occupations (Gibbs, Boshoff, & Lane, 2010). For example, the interaction between the person and the occupation is altered due to the infants fragile medical condition. Parents may feel disconnected from their child as they have less physical contact, they may be frightened, and they may doubt their abilities to care for their child. Furthermore, the interactions between the person and the environment in the NICU may be affected by the geographical location of the hospital, or the communication between parents and medical staff. The geographical location of the facility may affect the parents ability to present in their childs life while the interactions between parents and medical staff may have an effect on the parents roles. The environment also affects the occupation since there are physical barriers due to medical equipment such as incubators and ventilators that impact the parents ability to care for their infant (Gibbs, Boshoff, & Lane, 2010). Since the PEO model allows one to understand these interactions in depth, the model will be used as the lens to understand parents and their needs when developing and implementing a family-centered, developmentally supported care program in the NICU. Literature Review Summary As evidenced by physicians, nurses, and therapists alike, family-centered care in the NICU results in more positive outcomes for parents and their infants (Bracht, OLeary, Lee, & FAMILY-CENTERED CARE IN THE NICU 15 OBrien, 2013; Dudek-Shriber, 2004; Goldstein, 2013; MeInyk et al., 2006; OBrien et al., 2013; Pineda, Bender, Hall, Shabosky, Annecca, & Smith, 2018; Welch et al, 2012; Westrup, 2007; Westrup, 2015). Specifically, family-centered care in the NICU helps reduce stress, promote parental attachment and bonding, improve infant self-regulation, sensory development, and neurodevelopment, and reduce length of stay and costs for families and hospitals (Altimier & Phillips, 2013; Westrup, 2015). However, the NICU often acts as a barrier to parenting (Gibbs, Boshoff, & Lane, 2010). Thus, to improve outcomes for infants and their families, healthcare providers in the NICU should use an interdisciplinary approach to encourage parent participation, as well as educate, empower, and support parents through family-centered care. Screening and Evaluation In the first four weeks of the doctoral capstone experience, a needs assessment was conducted to provide evidence of any gaps or un-addressed issues related to family-centered practice in the NICU. The needs assessment was an essential component of the experience as it helped to narrow the focus of the project to be site-specific and client-centered. Through the lens of the Person-Environment-Occupation model, the NICU environment and experience alters the infant-parent relationship, as well as the ability for the parent to fulfill this occupational role. The findings of the needs assessment helped determine the needs of the parents in the NICU and how best to address these needs to provide them more opportunity to fulfill their role as parent, thereby providing holistic, family-centered care. As such, the needs assessment informed the development and implementation of the family-centered care program (Bonnel & Smith, 2018). Site Profile and Context The site at which the program was implemented was a Level III NICU at a hospital in Indiana. According to the American Academy of Pediatrics, a Level III NICU provides care to FAMILY-CENTERED CARE IN THE NICU infants who are born at less than 32 weeks gestation, weigh less than 1500 grams, or have 16 critical medical or surgical needs, regardless of age or weight (American Academy of Pediatrics, 2012). In addition, a Level III NICU has continuously available personnel (neonatologists, neonatal nurses, respiratory therapists) and equipment to provide life support for as long as necessary (American Academy of Pediatrics, 2012, p. 593). The Level III NICU at which the doctoral capstone took place has been cited as the leading NICU in this area of the state since the 1970s (Franciscan Health, 2018). The current facility has 14 private suites, each of which can be expanded to accommodate for multiple births if necessary. In addition, the unit is specifically designed to be a healing environment for infants and their families. For example, the site has sound-dampening doors, adjustable lighting, and individual thermostats in each suite. A neonatologist and nursing staff is present within the unit 24 hours per day, seven days per week. Occupational therapists, physical therapists, respiratory therapists, and specialty nurses and physicians are called to the unit when necessary. While the staff at the site does not specifically report utilizing family-centered care, they have adopted practices that could be classified as family-centered care. Parents receive special access badges that allow them 24-hour access to the NICU. The unit also has a family resource center that serves as an area for parent and family retreat. The quiet room is available for parents to rest, and there is a shower in the family resource center for parents who would prefer to not leave the hospital. Evaluation Methods Clinical observations and qualitative surveys were utilized to complete a needs assessment. Due to Institutional Review Board regulations at the site, personal interviews were not allowed to be completed as part of the needs assessment. Clinical observations were made FAMILY-CENTERED CARE IN THE NICU 17 during visits to the NICU. A survey for parents and a survey for nurses were drafted and sent to the therapy supervisors and the NICU director for approval. Upon approval, surveys and accompanying boxes were placed in the NICU. Parent surveys were placed in the family resource center, while nursing surveys were placed in the staff break room. The unit secretary was made aware of the survey placements. Few surveys were returned initially. To remedy this, surveys were individually distributed to nurses and parents. Four nursing surveys were returned, and two parent surveys were returned. Refer to Appendix A and B for surveys. Evaluation Results Clinical observations of parent education and participation were made during the first four weeks of the doctoral capstone experience. It was observed that fewer parents were present in the NICU during the morning hours. Parents tended to visit in the late afternoon and evening hours. Parental presence in the NICU was specific to each family; some parents were rarely present in the unit, while others were present daily. When parents were present, nurses were encouraged to involve the parents in infant care. For example, if parents were present during care times, nurses assisted them with feedings, diaper changes, and baths. Lactation consultants were called in as needed. Nurses also supported infant/parent attachment by encouraging holding and skin-to-skin care whenever possible. Physical and occupational therapists and speech language pathologists were also involved in parent education and participation. Observations were made of therapists briefly educating parents on topics such as positioning, infant massage, and feeding. However, education was typically brief and occurred when parents attention was divided. Oftentimes, therapists were unable to provide parent education because parents were not present during therapy sessions. Therapists were typically in the NICU during the morning, hours which were characterized by FAMILY-CENTERED CARE IN THE NICU 18 less parental presence. Based on thorough clinical observations, a need at this site was for more complete and consistent parent education on topics related to infant development, as well as more parent participation in these activities while their infant is in the NICU. On the two parent surveys that were returned, one parent stated interest in interpreting infant behavior and wanted more information about the developmental follow-up clinic. Another parent was interested in all educational topics listed: (a) positioning and handling, (b) skin-toskin care, (c) interpreting infant behavior, (d) developmental milestones, (e) equipment, and (f) feeding. This parent was also interested in a parent group and the developmental follow-up clinic. Four nursing surveys were returned. All surveys indicated that parents needed knowledge about interpreting infant behavior, a parent group, and referral to the developmental clinic. Less frequently circled items included positioning and handling (3), developmental milestones (2), mental health resources (2), skin-to-skin care (1), equipment (1), and feeding (1). Nurses also commented that there was a need to educate parents on how to touch a sick baby as well as a need to help parents understand when they can begin holding and handling their baby based on the infants medical concerns and complexities. Problems Related to Occupational Performance When parents have an infant in the NICU, the typical infant/parent attachment process is altered (Goldstein, 2013). As such, parents occupational performance is affected. Furthermore, it can be difficult for parents to fulfill their occupational role as a parent (Gibbs, Boshoff, & Lane, 2010). Dudek-Shriber (2004) reported that the most stressful part of parents having an infant in the NICU was the change in their parental role and relationship with the infant. Depending on the medical status of their infant, parents may not be able to toilet, feed, bathe, FAMILY-CENTERED CARE IN THE NICU 19 hold, or comfort their child. As such, parents are unsure of what their role is with their infant when they are in the NICU (Dudek-Shriber, 2004). The results of the doctoral capstone needs assessment demonstrated that parents in the NICU need more education and support. It has been found that providing education and support is empowering for parents (Goldstein, 2013). By meeting these needs, the NICU staff can support the creation of a positive parent-infant relationship, thereby helping parents to fulfill their occupational role. Family-Centered Care in Other Settings Family-centered care has been studied and implemented in other settings by many disciplines. For example, in their 2018 study, Coats et al explored family-centered care in the Pediatric Intensive Care Unit (PICU), Cardiac Intensive Care Unit, and the Neonatal Intensive Care Unit. The authors explained that family-centered care supports family involvement and decreases stress by improving communication, helping manage stress and coping, and decreasing conflicts (Coats et al, 2018, p. 52). The authors focused on the role of nursing in family-centered care and studied nurses perspectives of benefits and challenges to implementing family-centered care in various intensive care settings. In the study, family-centered care was implemented through changes in the physical environment, facility policy, and clinical interaction. Changes in the physical environment included transitioning to individual private rooms. Policy changes included 24-hour unit access for families. The results of the study demonstrated benefits for families, but also challenges for nurses as a result of changing how care was delivered. The study by Coats et al. (2018) informed the assessment and implementation of a family-centered care program for the doctoral capstone experience. In addition, the authors demonstrated a need to consider benefits for families as well as challenges for healthcare professionals when implementing family-centered care in any setting. FAMILY-CENTERED CARE IN THE NICU Family-centered care has also been studied and implemented in early intervention 20 settings. Stoffel, Rhein, Khetani, Barnekow, James, and Schefkind (2017) discussed the importance of family engagement in early intervention. Stoffel and colleagues explained that partnering with families in early intervention is essential for quality care as it supports and encourages families to teach, nurture, and advocate for their children (Stoffel, et al., 2017). The authors reported that occupational therapy practitioners can partner with families when providing care, as well as when evaluating outcomes of therapy from the familys perspective. This study also informed the doctoral capstone experience as it highlighted the importance of evaluating a familys satisfaction and perspective of care and outcomes. This study supported the need to include a family/parent exit survey in the evaluation of the doctoral capstone program. A 2017 article by Lardinois, Gosselin, McCarty, Ollendick, and Covington also demonstrated the importance of family-centered care in pediatric care settings. The authors focused on physical therapy clinical education models in the pediatric setting, and the need to include family-centered care for all patient/client and family interactions (Lardinois, Gosselin, McCarty, Ollendick, & Covington, 2017, p. 131). The study examined communication, collaboration, and reflection for physical therapy students in the pediatric setting. The need for family-centered care as an Essential Core Competency emerged from the study. This study and the previously mentioned studies provided support and evidence for family-centered care implementation in various settings by various disciplines including occupational therapy, physical therapy, and nursing. These studies demonstrate the need for family-centered care across the continuum of care. According to the Centers for Disease Control and Prevention (CDC), low birthweight, premature birth, multiple births, and infections during pregnancy increase the risk for many FAMILY-CENTERED CARE IN THE NICU 21 developmental disabilities (CDC, 2017). NICU infants are often admitted due to one or more of the conditions described by the CDC. Therefore, NICU infants as a population are at higher risk for developmental disabilities, and are more likely to receive services such as early intervention and/or outpatient pediatric therapy after discharge from the NICU. If family-centered care begins in the NICU setting, parents may learn to advocate for themselves and their children early on, thus improving outcomes for their children and their family as a whole. Implementation The process of planning the family-centered program began through collaboration between the occupational therapy student and two therapy supervisors who had previous experience working in the hospitals NICU. The program idea developed from the intersection of the supervisors knowledge and expertise of the facility, and the students vision to promote family-centered care. After reviewing the surveys that were completed during the needs assessment, the student and supervisors developed specific interventions to be implemented. To address the needs related to family-centered care in the NICU, two interventions were implemented at the Indiana hospital Level III NICU during the DCE. The first was a NICU Binder that consisted of information to support parent understanding and involvement in the NICU. The binder included information about developmental care, understanding infant behavior, skin-to-skin contact, positioning and handling, protecting sleep, and developmental milestones. It also provided a list of additional resources to support parents. For example, information was provided about social work, mental health, the developmental follow-up clinic, early intervention, and outpatient therapy. Furthermore, certificates acknowledging the infants and their parents progress in the NICU were included throughout the binder to provide a more interactive intervention. The NICU Binder was not yet published by the Public Relations FAMILY-CENTERED CARE IN THE NICU 22 department at the conclusion of the DCE. Upon publication by the site, each family will receive a binder upon their childs admission to the NICU. Nursing will introduce the binder to parents and therapy will use and reference the binder with the parents and encourage parents to ask any questions. The second intervention was a series of parent education courses. Four courses occurred in the series. The courses were held on March 16, March 30, April 13, and April 25, 2018. The first two courses were held at 6:00 pm. The last two courses were held at 5:30 pm. The first course covered the topic of Positioning and Handling, and was taught by the occupational therapy student. The second course was Infant Massage, taught by the facility Massage Therapist. The occupational therapy student was present to assist the Massage Therapist in any way necessary. The last two courses were taught by the occupational therapy student: Interpreting Infant Behavior and Practicing Skin-to-Skin Care, and Developmental Milestones. Powerpoint presentations were used during each course. The Powerpoint presentations were printed as handouts for the attendees. In order to begin the series of courses, approval was needed from several groups. The program was first presented to the therapy management team. Upon receiving feedback and approval from the therapy management team, the program was then presented to the NICU director. Once the NICU director had the opportunity to make suggestions and gave approval, the occupational therapy student presented an in-service to the NICU nurses regarding the familycentered care program to support positive collaboration and inter-professional practice. The course series began on March 16, 2018 and occurred on a bi-weekly basis. Leadership Skills FAMILY-CENTERED CARE IN THE NICU Leadership skills were essential to the implementation phase of the DCE. Leadership 23 skills that were utilized include flexibility, communication, perseverance, and advocacy. Flexibility and communication were necessary for the DCE as many different groups of people were involved in the process. Flexibility was required to adjust schedules and plans to ensure all groups involved had the opportunity to provide feedback and to ensure all parties were in agreement. Clear communication was important when describing the DCE project to others. For example, the occupational therapy student needed to communicate the purpose and goals of the project to the project supervisors, the NICU nurses, the NICU director, and the social worker to ensure everyone understood. This was a new experience for the student and the facility; therefore, it required significant flexibility and communication on the parts of all involved. Perseverance and advocacy were also important to the DCE. Perseverance was a key skill to be utilized throughout the experience, especially when there were barriers in the process. For example, per facility policies, interviews were not allowed to be completed as part of the needs assessment. Therefore, perseverance was required to create a different process through which to complete the needs assessment. Perseverance continued to be used throughout the DCE to achieve the goals of the project. Advocacy was also necessary, especially when presenting the project to the NICU director and nurses. It was essential to advocate for family-centered care in the NICU and the role of occupational therapy in this setting and approach to care. The site utilized aspects of family-centered care, but there were still adjustments and changes that could be made to improve practice. Furthermore, therapy is not a constant presence in the NICU at this site; therefore, advocacy for occupational therapys distinct value and role was significant to the success of the project. Staff Development FAMILY-CENTERED CARE IN THE NICU 24 To promote staff development, the DCE project was presented to the NICU nursing staff in the form of an in-service. The evidence and research supporting the project were briefly presented, as well as an overview of the project to be implemented. This promoted familycentered care, as well as interprofessional, collaborative practice between nursing and therapy. The NICU binder and parent education PowerPoints were sent to the NICU therapists to ensure they were aware of what was implemented. Outcomes and Discontinuation Outcomes When evaluating the efficacy of a program, it is necessary to use an outcome measure to quantify the results. In the case of this DCE, the occupational therapy student created a survey for parents to complete after each parent education course attended (see Appendix C). The purpose of the survey was to serve as a measure of efficacy, utility, and satisfaction for the parent education courses. The survey was a five-point Likert scale with options ranging from Strongly Disagree (1) to Strongly Agree (5). A mother and father couple attended the first parent education meeting entitled Positioning and Handling on March 16, 2018. Following this first meeting, the average score of the survey was 4.8 out of five, demonstrating an overall positive experience. The attendees answered Strongly Agree (5) for questions one through seven, as well as question nine. They answered Excellent (5) for question 10. Both attendees answered Neutral (3) for question eight, The class gave me an opportunity to connect with other NICU parents. One parent couple attended Infant Massage, the second course in the four-course parent education series, on March 30, 2018. One attendee reported Strongly Agree (5) for questions two through seven, Agree (4) for questions one and eight, and Neutral (3) for question nine. FAMILY-CENTERED CARE IN THE NICU 25 This attendee gave the course an overall rating of Excellent. (5) The second attendee reported Agree (4) for questions one through six, as well as question nine. The second attendee answered Strongly Agree (5) for question seven, and Neutral (3) for question eight. This attendee rated the class as Good (4) overall. A question about the day and time of the course was added to the survey prior to the second course to capture information regarding scheduling for continuous quality improvement. Both attendees answered yes to this question, Was this a good day/time for you? The average score of the post-course survey was 4.3 out of five, demonstrating overall satisfaction with the course. Three individuals from one family, a mother, father, and grandmother, attended the third parent education meeting about skin-to-skin care and infant behavior cues on April 13, 2018. One individual recorded Strongly Agree (5) for questions one, two, five, and six. This individual recorded Agree (4) for questions three, four, seven, and nine, and rated the class as Excellent (5) overall. The other two attendees answered Agree (4) for questions one through seven, and question nine. They both gave the course an overall rating of Good (4). All attendees answered Neutral (3) or non-applicable for question eight. The average score of the post-session survey was 4.067 out of five, demonstrating an overall positive rating for the course. Two of the three attendees at the third meeting replied to the question regarding day and time. They both reported that the day and time worked well for them. It should be noted that the third meeting occurred on a Friday evening at 5:30 pm, while the previous two meetings occurred on Friday evenings at 6:00 pm. The time was changed on a trial basis to determine if a change in time made a difference for attendance. While three individuals attended this session, all three individuals were from the same family. This was consistent with attendance from the FAMILY-CENTERED CARE IN THE NICU 26 first two sessions in which one family attended each session. Therefore, the change in time did not seem to affect attendance. Three individuals from one family, a mother, father, and grandfather, attended the fourth parent education session, Developmental Milestones. The average score of the post-session survey for the fourth session was 4.867 out of five. Two attendees recorded Strongly Agree (5) to questions one through nine, and gave the session and overall rating of Excellent (5). The third attendee recorded Agree for questions one and nine, Strongly Agree for questions two through seven, Neutral for question eight, and also gave the session an overall rating of Excellent. It should be noted that the course was held on a Wednesday at 5:30 pm. The day was changed on a trial basis to determine if a change in day made a difference for attendance. The time was determined as a result of a discussion with nursing. Nurses reported 5:30 pm to be a more appropriate time due to care times beginning at 6:00 pm. All attendees agreed that the session was held at a good day and time. The change in the day of the week did not seem to make a difference for attendance. One family attended the last session, demonstrating consistency in the attendance of one family at a time throughout the session series. There were no repeat attendees. During the first and third courses, NICU census was greater than six infants. During the second and fourth courses, NICU census was six infants or less. The post-session parent surveys demonstrated an overall positive experience for each session (see Figure 1 for results). The average score across all sessions was 4.5083 out of five. Thus, the parent education sessions resulted in positive outcomes for parents. FAMILY-CENTERED CARE IN THE NICU 27 5 4.5 4 Average Score 3.5 3 2.5 2 1.5 1 Parent Education Session 1 Parent Education Parent Education Parent Education Session 2 Session 3 Session 4 All Sessions Parent Education Session Figure 1. Post-session parent survey results. This figure illustrates average survey scores for each parent education session and the average score for all sessions combined. A post-program survey was also distributed to NICU nursing and therapy staff in order to evaluate the overall effect of the program on the NICU (see Appendix D). Similar to the postsession parent survey, the post-program staff survey was a five-point Likert scale with options ranging from Strongly Disagree (1) to Strongly Agree (5). There were also three open-ended questions. Two of these questions asked for suggestions for topics and methods of presentation for the parent education series. The third question asked for any overall comments, suggestions, or concerns. Eight staff members returned completed surveys. Not all respondents answered the open-ended questions. The respondents who did answer the open-ended questions stated suggestions for including feeding as one of the parent education topics, creating videos that could be viewed in parent rooms, and providing specific training on the topic areas for the nurses. The Likert scale survey responses were analyzed by question (see Figure 2 for results). FAMILY-CENTERED CARE IN THE NICU The average score for questions one through five were 4.875, 4.625, 4.5, 4.75, and 4.875, 28 respectively. The average score for all survey responses was 4.725 out of five. These results demonstrated an overall positive outcome for the family-centered, developmentally supportive care program that was established at the Level III NICU in Indiana. 5 4.5 4 Average Score 3.5 3 2.5 2 1.5 1 Question 1 Question 2 Question 3 Question 4 Question 5 Overall Survey Survey Question Figure 2. Post-program staff survey results. This figure illustrates the average score for each postprogram staff survey question and the average score for all survey responses. The efficacy of the NICU Binder was unable to be determined, as the Binder was not finalized and distributed by the conclusion of the DCE. However, the fourth question on the Post-Program Staff Survey was, The NICU Binder will be useful to parents, nurses, and the unit as a whole. The average response to this question was 4.75 out of five, demonstrating a positive response to future implementation of the NICU Binder. Once the site officially implements the Binder, it would be beneficial to utilize parent and nursing surveys to determine the efficacy, utility, and satisfaction of the Binder. Discontinuation FAMILY-CENTERED CARE IN THE NICU 29 Sustainability and discontinuation are significant aspects of program planning (Bonnel & Smith, 2018). As such, specific actions were taken to ensure sustainability of the projects that were implemented during the DCE. First, while the post-session parent survey was utilized as an outcome measure, it also served as a measure for continuous quality improvement. As part of a new program, it was imperative that the site had a method to measure the efficacy, utility, and satisfaction of the parent education meetings. The site will continue to utilize the post-session parent survey as a continuous quality improvement measure. The site will modify the survey as needed as the program continues to grow. To ensure sustainability of the parent education meetings, physical, occupational, speech, and massage therapists will rotationally teach the parent education courses after the completion of the DCE. A schedule for the parent education meetings was created for the duration of 2018. The meetings will continue to be held biweekly throughout the year. The therapists will be responsible for signing themselves up to teach the courses based on their availability. The courses will continue as part of a four-course series: Positioning and Handling, Infant Massage, Behavior Cues and Skin-to-Skin Care, and Developmental Milestones. Following edits by the Public Relations department, the NICU Binder will be published and distributed to each NICU family upon admission to the unit. The NICU nurses will introduce the binder to parents upon arrival to the unit. NICU therapists and nurses will refer to and utilize the binder when providing individual parent education at bedside. NICU milestone certificates will be kept in a file cabinet on the unit. When an infant reaches a special milestone on the unit, the healthcare provider that witnesses the milestone will fill out the certificate and add it to the parents NICU Binder. This will be done in an effort to ensure the binder is an interactive and useful material. FAMILY-CENTERED CARE IN THE NICU At the conclusion of the DCE, the occupational therapy student met with the NICU 30 Director to discuss the results and sustainability of the program. The meeting focused on fostering future opportunities for collaboration between therapy and nursing in the NICU. As a result of this meeting, it was determined that a NICU therapist will attend the weekly interdisciplinary care conferences on Thursday mornings. Furthermore, the NICU therapists will be encouraged to utilize the white boards in infants rooms to communicate with nursing more consistently. These measures will help to sustain the collaborative relationship that was established during the DCE. In the near future, the NICU therapists and nurses plan to utilize the Infant Positioning Assessment Tool (IPAT) to assess infant positioning, and collaborate on creating a protocol for cue-based feeding on the unit. Since family-centered care has been shown to be best practice in the NICU, the project created during the DCE responds to societys needs by helping the site expand its practice in the area of family-centered care. Family-centered care programs have developmental benefits to the infant, encourage a positive parent-infant relationship, and support the needs of the parents and family, resulting in better outcomes for the infant, the parents, and the family as a whole (Bracht, OLeary, Lee, & OBrien, 2013; Dudek-Shriber, 2004; Goldstein, 2013; MeInyk et al., 2006; OBrien et al., 2013; Pineda, Bender, Hall, Shabosky, Annecca, & Smith, 2018; Welch et al, 2012; Westrup, 2007; Westrup, 2015). The family-centered care program that was established provided education and support to parents to help foster healthy infant development and the parent-infant bond. Overall Learning The 16-week Doctoral Capstone Experience ultimately resulted in the development of family-centered programs for the Level III NICU in an Indiana hospital. In order to develop FAMILY-CENTERED CARE IN THE NICU these programs, the student completed research of peer-reviewed journals and educational 31 materials to gain knowledge regarding developmental, family-centered care in the Neonatal Intensive Care Unit. The student spent many hours shadowing therapists, nurses, and social workers in the NICU, as well as attending unit rounds, to attain neonatal clinical skills and knowledge, and to understand the procedural and cultural aspects of the unit. Throughout the DCE, professional communication was critical to accomplishing the students goals. In order to implement new programs in the NICU, it was essential to build rapport and trust with the neonatal nurses, doctors, and therapists. A large portion of the experience involved building this rapport in order to promote buy-in and interdisciplinary collaboration. The student utilized professional written and verbal communication to establish this rapport. Interprofessional collaboration was a key component of the experience. Neonatal occupational therapists, physical therapists, and speech language pathologists were consulted throughout the creation of the materials, as well as the implementation of the program. When drafting the program materials, including the NICU Binder and the parent education presentations, the student asked for the assistance and advice of the NICU therapists. Therapists from each discipline provided constructive feedback that was utilized to edit and revise the materials as needed. The advice and suggestions from the therapists helped to ensure the documents presented developmentally appropriate information, and were clinically accurate, easily understood, and generally well-received. Upon approval of the program materials from the neonatal therapists and the students site mentors, the student presented the program materials to the NICU Director, charge nurses, nurses, and Medical Director. Throughout the multiple meetings and presentations with various FAMILY-CENTERED CARE IN THE NICU members of the NICU team, the student learned how to professionally and effectively 32 communicate with the NICU staff in a respectful and productive manner. In order to establish an interdisciplinary, cooperative environment, the student sought the NICU staffs comments, questions, concerns, and advice regarding the materials and the program implementation. The NICU staffs suggestions were constructive and helpful in developing the program. All suggestions or concerns were thoroughly discussed, considered, and employed with the guidance of the site mentors. Due to their continuous presence on the unit, neonatal nurses were the primary points of contact in the NICU. Therefore, it was critical that neonatal nurses were supportive and willing to participate in any new programming or initiatives in the NICU. Fortunately, the occupational therapy student was able to create positive, professional relationships with the neonatal nurses, and therefore gained their support and assistance with implementing the family-centered care program. As such, the DCE allowed the student to assist the site in creating more opportunities for communication and partnership between the NICU therapists and nurses. When presenting the parent education courses, the student applied therapeutic use of self to create a supportive, open, and non-judgmental environment for parents. It was essential to build rapport with the parents as clients during the courses. The courses were presented using non-medical terminology, anecdotal examples, and professional, yet personable, communication to ensure the courses were accessible and understandable for each parent. The doctoral capstone experience fostered the students development of communication, leadership, and interdisciplinary skills. By utilizing professional communication and leadership, as well as mutual respect and understanding for every member of the NICU community, the student was effective in creating positive relationships that were fundamental to the successful FAMILY-CENTERED CARE IN THE NICU implementation of the program. Overall, the student established positive professional 33 relationships with members of the NICU community, made an encouraging impact on the NICUs practice and culture, and established a well-received program that will be sustained into the future. FAMILY-CENTERED CARE IN THE NICU References 34 Allen, K.A. (2012). Promoting and protecting infant sleep. Advances in Neonatal Care, 12(5), 288-291. doi:10.1097/ANC.0b013e3182653899 Als, H., Duffy, F.H., McAnulty, G.B., Rivkin, M.J., Vajapeyam, S., Mulker, R.V., Warfield, S.K.,Eichenwald, E.C. (2004). Early experience alters brain function and structure. Pediatrics, 133(4), 846-857. Altimier, L., & Phillips, R.M. (2013). The neonatal integrative developmental care model: Seven neuroprotective core measures for family-centered developmental care. Newborn & Infant Nursing Reviews, 13, 9-22. http://dx.doi.org/10.1053.jnaninr.2012.12.002 Altimier, L., & Phillips, R.M. (2016). The neonatal integrative developmental care model: Advanced clinical applications of the seven core measures for neuroprotective familycentered developmental care. Newborn & Infant Nursing Reviews, 16, 230-244. http://dx.doi.org/10.1053.jnainr.2016.09.030 American Academy of Pediatrics. (2012). Levels of neonatal care. Pediatrics, 130(3), 587-597. Bracht, M., OLeary, L., Lee, S.K., & OBrien, K. (2013). Implementing family-integrated care in the NICU: A parent education and support program. Advances in Neonatal Care, 13(2), 115-126. doi: 10.1097/ANC.0b013e318285fb5b Boucher, C.A., Brazal, P.M., Graham-Certosini, C., Carnaghan-Sherrard, K., & Feely, N. (2011). Mothers breastfeeding experiences in the NICU. Neonatal Network, 30(1), 21-28. doi:10.1891/0730-0832.30.1.21 Bonnel, W., & Smith, K.V. (2018). Proposal writing for clinical nursing and DNP projects, Second edition. New York: Springer Publishing Company. FAMILY-CENTERED CARE IN THE NICU 35 Buehler, D. (Producer). (2014, May 13). NIDCAP: Three decades of training and supporting. Retrieved from http://nidcap.org/en/about-us/nidcap-three-decades-of-training-andsupporting-a-video/ Calciolari, G., & Montirosso, R. (2011). The sleep protection in the preterm infants. The Journal of Maternal-Fetal & Neonatal Medicine, 24(Suppl 1), 12-14. doi:10.3109/14767058.2011.607563 Centers for Disease Control and Prevention. (2017). Facts About Developmental Disabilities. Retrieved from https://www.cdc.gov/ncbddd/developmentaldisabilities/facts.html Coats, H., Bourget, E., Starks, H., Lindhorst, T., Saiki-Craighill, S., Curtis, R., & Doorenbos, A. (2018). Nurses reflections on benefits and challenges of implementing famiy-centered care in pediatric intensive care units. American Journal of Critical Care, 27(1), 52-58. https://doi.org/10.4037/ajcc2018353 Cosimano, A., & Sandhurst, H. (2011). Strategies for successful breastfeeding in the NICU. Neonatal Network, 30(5), 340-343. doi:10.1891/0730-0832.30.5.340 Dudek-Shriber, L. (2004). Parent stress in the neonatal intensive care unit and the influence of parent and infant characteristics. American Journal of Occupational Therapy, 58(5), 509520. Franciscan Health. (2018). Level III neonatal intensive care unit in Lafayette. Gartner, L.M, Morton, J., Lawrence, R.A., Naylor, A.J., OHare, D. Schanler, R.J., & Eidelman, A.I. (2005). Breastfeeding and the use of human milk. Pediatrics, 115(2), 496-506. Gibbs, D., Boshoff, K., & Lane, A. (2010). Understanding parenting occupations in neonatal FAMILY-CENTERED CARE IN THE NICU intensive care: Application of the Person-Environment-Occupation model. British 36 Journal of Occupational Therapy, 73(2), 55-63. doi:10.4276/030802210X12658062793762 Goldstein, L.A. (2013). Family support and education. Physical and Occupational Therapy in Pediatrics, 33(1), 139-169. doi:10.3109/01942638.2012.754393 Graven, S. (2006). Sleep and brain development. Clinics in Perinatology, 33(3), 693-706. https://doi.org/10.1016/j.clp.2006.06.009 Lardinois, K.L., Gosselin, D., McCarty, D., Ollendick, K., & Covington, K. (2017). A collaborative model of integrated clinical education in physical therapist education: Application to the pediatric essential core competency of family-centered care. Journal of Physical Therapy Education, 31(2), 131-136. Morgan, J., & Rimmer, T. (2011). The family and baby project: Social and psychological support for families on the NICU. Infant, 7(5), 155-157. MeInyk, B.M., Feinstein, N.F., Alpert-Gillis, L., Fairbanks, E., Crean, H.F., Sinkin, R.A., Stone, P.W.,Gross, S.J. (2006). Reducing premature infants length of stay and improving parents mental health outcomes with the Creating Opportunities for Parent Empowerment (COPE) neonatal intensive care unit program: A randomized, control trial. Pediatrics, 118(5), e1414-e1427. doi: 10.1542/peds.2005-2580 NIDCAP Federation International, Inc. (2018). What is NIDCAP? Retrieved from http://nidcap.org/en/families/what-is-nidcap/ OBrien, K., Bracht, M., Macdonnell, K., McBride, T., Robson, K., OLeary, L., Christie, K.,Lee, S.K. (2013). A pilot cohort analytic study of Family Integrated Care in a FAMILY-CENTERED CARE IN THE NICU 37 Canadian neonatal intensive care unit. BMC Pregnancy and Childbirth, 13(Suppl 1), S12S19. doi: 10.1186/1471-2393-13-S1-S12 Pineda, R., Bender, J., Hall, B., Shabosky, L., Annecca, A., & Smith, J (2018). Parent participation in the neonatal intensive care unit: Predictors and relationships to neurobehavior and developmental outcomes. Early Human Development, 177, 32-38. Purdy, I.B., Craig, J.W., & Zeanah, P. (2015). NICU discharge planning and beyond: Recommendations for parent psychosocial support. Journal of Perinatology, 35, S24S28. doi:10.1038/jp2015.146. Stoffel, A., Rhein, J., Khetani, M.A., Pizur-Barnekow, K., James, L.W., Schefkind, S. (2017). Family centered: Occupational therapys role in promoting meaningful family engagement in early intervention. OT Practice, 22(18), 8-13. Tyebkhan, J., Peters, K., Cote, J.J., McPherson, C.A., Hendson, L. (2004). The impact of developmental care in the NICU: The Edmonton RCT of NIDCAP [abstract]. Pediatric Research, 55, 55A. Welch, M. G., Hofer, M. A., Brunelli, S. A., Stark, R. I., Andrews, H. F., Austin, J., & Myers, M. M. (2012). Family nurture intervention (FNI): Methods and treatment protocol of a randomized controlled trial in the NICU. BMC Pediatrics, 12(1), 14. doi:10.1186/14712431-12-14 Westrup, B. (2007). Newborn individualized developmental care and assessment program (NIDCAP) Family-centered developmentally-supportive care. Early Human Development, 83, 443-449. Westrup, B. (2015). Family-centered developmentally supportive care: The Swedish example. Archives de Pdiatrie, 22, 1086-1091. http://dx.doi/10.1016/j.arcped.2015.07.005 FAMILY-CENTERED CARE IN THE NICU Appendix A 38 Parent Needs Assessment Survey My name is Doron, and I am an Occupational Therapy student from University of Indianapolis. I am completing my Doctoral Capstone Experience here at Franciscan, and I am focusing on the NICU. I have done quite a bit of research about what healthcare professionals can do to support parents in the NICU. I would love to know what you think you might benefit from. Please circle any of the following topics you would like more information on: 1. Positioning and Handling 2. Skin-to-Skin Care 3. Interpreting your infants behavior 4. Developmental Milestones 5. Equipment 6. Feeding Please circle any of the following you would be interested in: 1. Parent Group 2. Developmental Follow-Up Clinic 3. Mental Health Resources Do you have any other questions, comments, or concerns? FAMILY-CENTERED CARE IN THE NICU Appendix B 39 Nursing Needs Assessment Survey My name is Doron, and I am an Occupational Therapy student from University of Indianapolis. I am completing my Doctoral Capstone Experience here at Franciscan, and I am focusing on Family-Centered Care in the NICU. I have done quite a bit of research about what healthcare professionals can do to support parents and families in the NICU. I would love to know what you think parents might benefit from, and any other concerns/comments you might have. Please circle any of the following topics you think parents may need more information on: 1. Positioning and Handling 2. Skin-to-Skin Care 3. Interpreting infant behavior 4. Developmental Milestones 5. Equipment 6. Feeding Please circle any of the following you think parents may benefit from: 1. Parent Group 2. Developmental Follow-Up Clinic 3. Mental Health Resources Do you have any other questions, comments, or concerns? FAMILY-CENTERED CARE IN THE NICU Appendix C 40 Post-Session Parent Survey 1. The information helped me understand my baby and his/her development. Strongly Disagree Disagree Neutral Agree Strongly Agree 2. The class encouraged me to be involved with my babys care whenever possible. Strongly Disagree Disagree Neutral Agree Strongly Agree 3. The information will help me when I take my baby home. Strongly Disagree Disagree Neutral Agree Strongly Agree Agree Strongly Agree Agree Strongly Agree 4. The information was easy to understand. Strongly Disagree Disagree Neutral 5. The instructor was prepared and organized. Strongly Disagree Disagree Neutral 6. It was important to the instructor that I understood the information. Strongly Disagree Disagree Neutral Agree Strongly Agree 7. The instructor was friendly and answered my questions well. Strongly Disagree Disagree Neutral Agree Strongly Agree 8. The class gave me an opportunity to connect with other NICU parents. Strongly Disagree Disagree Neutral Agree Strongly Agree FAMILY-CENTERED CARE IN THE NICU 9. The class gave me more confidence when caring for my baby. Strongly Disagree Disagree 41 Neutral Agree Strongly Agree Average Good Excellent 10. Overall, I would rate the class as: Poor Fair 11. Was this a good day/time for you? If not, what would be a better day/time? 12. Please place any other comments, questions, concerns below. Thank you for coming! FAMILY-CENTERED CARE IN THE NICU 42 Appendix D Post-Program Staff Survey 1. The topics presented in the parent education meetings were relevant to infant care in the NICU. Strongly Disagree Disagree Neutral Agree Strongly Agree 2. The parent education meetings were effective at providing thorough parent education. Strongly Disagree Disagree Neutral Agree Strongly Agree 3. The parent education meetings benefitted the parents, infants, and the unit as a whole. Strongly Disagree Disagree Neutral Agree Strongly Agree 4. The NICU binder will be useful to parents, nurses, and the unit as a whole. Strongly Disagree Disagree Neutral Agree Strongly Agree 5. The family-centered care program was beneficial to providing best care in the NICU. Strongly Disagree Disagree Neutral Agree Strongly Agree 6. Are there any other topics you would include in the parent education meetings? 7. Are there other ways you would like the information to be presented? 8. Any other comments/questions/concerns? Thank you!  ...

... Running head: OCCUPATIONAL THERAPY AND BRAIN HEALTH Exploring the Role of Occupational Therapy in a Collaborative Care Program for Older Adults with Cognitive Impairment Kiersten Ham, OTS May, 2018 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: Julie Bednarski, OTD, MHS, OTR 1 OCCUPATIONAL THERAPY AND BRAIN HEALTH A Capstone Project Entitled Exploring the Role of Occupational Therapy in a Collaborative Care Program for Older Adults with Cognitive Impairment Submitted to the School of Occupational Therapy at University of Indianapolis in partial fulfillment for the requirements of the Doctor of Occupational Therapy degree. By Kiersten Ham OTS Approved by: Faculty Capstone Advisor Date Doctoral Capstone Coordinator Date Accepted on this date by the Chair of the School of Occupational Therapy: Chair, School of Occupational Therapy Date 2 OCCUPATIONAL THERAPY AND BRAIN HEALTH Exploring the Role of Occupational Therapy in a Collaborative Care Program for Older Adults with Cognitive Impairment Kiersten Ham University of Indianapolis 3 OCCUPATIONAL THERAPY AND BRAIN HEALTH 4 Abstract The proportion of adults aged 65 and older in the United States is steadily rising as the baby boomer population continues to age (Alzheimers Association, 2017). Given the prevalence of older adults with neurocognitive disorders, it is an international research priority to identify effective treatments to prevent, significantly delay progression, or positively intervene throughout the course of the disease (Posner et al., 2017). Rehabilitation professionals have the opportunity to target brain health through the reduction of modifiable risk factors. In an attempt to respond to this need, the role of occupational therapy in a collaborative care program targeting brain health in older adults with cognitive impairment was explored. Therapy services were not incorporated into the Aging Brain Care (ABC) program prior to the Doctoral Capstone Experience (DCE). Through advocacy, education, and interdisciplinary collaboration, 22 patients were referred to occupational and physical therapy. The referrals served as the outcome measure for the DCE. The gap between the outpatient therapy clinic and the ABC program was bridged. The aims of this paper were (1) to investigate the role of occupational therapy for older adults with cognitive impairment and (2) to describe the role of occupational therapy in a wellestablished brain care program. OCCUPATIONAL THERAPY AND BRAIN HEALTH 5 Exploring the Role of Occupational Therapy in a Collaborative Care Program for Older Adults with Cognitive Impairment Background The proportion of adults aged 65 and older in the United States is steadily rising as the baby boomer population continues to age (Alzheimer's Association, 2017). By 2050, the number of Americans age 65 and older is projected to nearly double, rising from 48 million to 88 million. The prevalence of neurocognitive disorders (NCDs) drastically increases with age (Hugo & Ganguli, 2014). Therefore, as the aging population grows, the prevalence of cognitive impairment and other dementias is expected to rise (Hugo & Ganguli, 2014). According to the Alzheimers Association (2017), there were approximately 110,000 individuals age 65 and up living with Alzheimers in Indiana in 2017. This number is expected to rise to 130,000 by 2025 (Alzheimers Association, 2017). Given the prevalence of cognitive impairment and other dementias, the search for effective treatments to prevent its onset, significantly delay its progression, or otherwise positively intervene in the disease course is an international research priority (Posner et al., 2017, p. 22-23). As people age, some degree of cognitive slowing can be typical (Hugo & Ganguli, 2014). Therefore, clinicians must determine (1) when cognitive changes are clinically significant, and (2) the underlying etiology of the cognitive decline (Hugo & Ganguli, 2014). Clinicians and researchers work diligently to increase the efficiency of diagnostic methods and criteria for NCDs. The fifth edition of the American Psychiatric Associations Diagnostic and Statistical Manual (DSM-5) provides the most recent diagnostic criteria for NCDs. The terms are described in greater detail in Appendix A (American Psychiatric Association [APA], 2013). In the DSM-5, Mild Neurocognitive Disorder (Mild NCD) has replaced the term Mild Cognitive Impairment OCCUPATIONAL THERAPY AND BRAIN HEALTH 6 (MCI), from the fourth edition of the DSM (DSM-IV) (APA, 2013). When discussing previous research throughout this paper, these terms will be used interchangeably to correlate to their respective study. Additionally, in the DSM-5, the term Major Neurocognitive Disorder (Major NCD) has replaced the term dementia, from the DSM-IV (APA, 2013). These terms will also be used interchangeably throughout this paper to correlate with their respective studies. Attention, memory, planning, problem solving, self-monitoring, and self-awareness are all components of an individuals cognition (Giles, 2017). Functional cognition is the utilization of these cognitive skills to complete self-care and community living skills. Cognitive impairment can be a result of human genetics, mental illness, transient or continuing life stresses or changes, or neurologic disease, injuries, and disorders (Giles, 2017). The cause of the cognitive impairment can determine if cognition will return to normal, maintain its current state, or progress into Alzheimers or other dementias (Alzheimers Association, 2017). Occupational therapy (OT) plays a vital role in the lives of individuals with cognitive impairment beyond normal aging. Occupational therapy practitioners focus their interventions on the relationship between the clients cognitive skills, functional performance, and environmental context to enhance the daily life experience of individuals with cognitive impairment, (Giles, 2017, p.1). By addressing deficits in functional cognition, OT can promote safety and independence required to age in place, increase quality of life, and decrease caregiver burden (Giles, 2017; Smallfield, 2017). The purpose of this literature review was to identify occupational therapys role for individuals with cognitive impairment and mood disorders, by synthesizing evidence-based research. OCCUPATIONAL THERAPY AND BRAIN HEALTH 7 Mild Neurocognitive Disorder/Mild Cognitive Impairment Mild cognitive impairment has been developed as a term for individuals who are experiencing cognitive changes but do not meet the definition of dementia, either clinically or functionally (Maskill, 2017). Mild cognitive impairment is divided into two subtypes: amnestic (aMCI) and non-amnestic (naMCI) (Csukly et al., 2016; Jekel et al., 2015). According to Jekel et al. (2015), individuals with aMCI are at a higher risk for developing Alzheimers disease, and individuals with naMCI are at a higher risk for developing non-Alzheimers dementia, such as Lewy body dementia. It is possible for MCI to revert to normal cognition or remain stable, such as when the cognitive impairment is being caused by medications or mood disorders (Alzheimers Association, 2017). However, individuals with MCI are more likely to develop Alzheimers or other dementias. Approximately 15 to 20 percent of older adults have MCI (Alzheimers Association, 2017). Major Neurocognitive Disorder/Dementia Dementia can result from a number of causes such as Alzheimers disease, vascular dementia, dementia with Lewy bodies (DLB), mixed dementia, frontotemporal lobar degeneration (FTLD), Parkinsons disease, Creutzfeldt-Jakob disease, and normal pressure hydrocephalus (Alzheimers Association, 2017). Dementia often impacts an individuals ability to perform everyday activities due to difficulty with memory, language, and problem-solving skills (Alzheimers Association, 2017). Alzheimers Disease Dementia caused by Alzheimers disease, also known as Alzheimers dementia, is a degenerative brain disease and is the most common cause of dementia (Alzheimers Association, 2017). Alzheimers disease commonly begins by damaging the neurons in the brain required for OCCUPATIONAL THERAPY AND BRAIN HEALTH 8 cognitive function. As the disease progresses, it destroys other parts of the brain required to perform basic bodily functions, ultimately resulting in death (Alzheimers Association, 2017). According to the Alzheimers Association (2017), approximately 5.5 million Americans are living with Alzheimers dementia. Out of those 5.5 million Americans, it is estimated that 5.3 million are age 65 and older, equating to one in ten Americans age 65 and older living with Alzheimers dementia (Alzheimers Association, 2017). This number is expected to rise to 7.1 million by 2025, nearly a 35 percent increase (Alzheimers Association, 2017). Occupational Therapy Intervention for Cognitive Impairment A variety of studies have examined the effectiveness of treatment for individuals with cognitive impairment. Individuals with cognitive impairment will encounter difficulty with occupation and performance patterns (Atchison & Dirette, 2012). Dawson, Judge, and Gerhart (2017) found that individuals with cognitive impairment can experience improvement in balance, lower extremity strength, and fast gait speed by participating in a moderate-intensity functional exercise program. Although improvements were noted in these areas, there were no improvements noted in cognition. This may indicate that improving functional activity may be beneficial with or without the improvement of cognitive function (Dawson et al., 2017). Interdisciplinary Approach Researchers have examined the effectiveness of numerous pharmacological interventions for slowing or reversing cognitive decline, however evidence suggests that these interventions have not altered functional outcomes or the progression to dementia (Rodakowski, Saghafi, Butters, & Skidmore, 2015). Therefore, the need to identify non-pharmacological interventions has increased. In addition, non-pharmacological interventions may be preferred, due to the adverse side effects and risks associated with pharmacological interventions (Rodakowski et al., OCCUPATIONAL THERAPY AND BRAIN HEALTH 9 2015). Rodakowski, Saghafi, Butters, and Skidmore (2015) examined the science related to nonpharmacological interventions designed to slow decline in older adults with MCI or early-stage dementia by reviewing 32 randomized controlled trials (RCT). Within the 32 RCT reviewed, interventions included cognitive training (remediation or compensation approaches), physical exercise, or psychotherapeutic interventions (Rodakowski et al., 2015). Through the review of literature for interventions for older adults in early stages of cognitive decline, Rodakowski et al. (2015) identified several findings for future interventions and research. Previous research on remediation and aerobic exercise interventions produced mixed findings. However, cognitive training focused on compensatory strategies and psychotherapy showed positive implications for intervention to address cognitive changes and impact the lives of older adults in early stages of cognitive decline (Rodakowski et al., 2015). Rodakowski et al. (2015) also found the benefits of synergistic pharmacological and nonpharmacological interventions were more effective than either intervention individually. Summary of Literature This literature review was conducted to gain an understanding of the role of OT for older adults with cognitive impairment beyond that of normal aging. As the baby boomer generation continues to age, the number of Americans with NCDs is expected to rise, following the populations shift to older ages (Alzheimers Association, 2017). Previous studies have produced mixed results on effective treatments for cognitive decline in older adults; However, evidence suggests that combination therapies can be significantly more effective than medication or nonpharmacological therapy alone (Rodakowski et al., 2015, p. 12). More research is needed to OCCUPATIONAL THERAPY AND BRAIN HEALTH 10 examine the synergistic benefits of pharmacological and non-pharmacological interventions to identify effective treatment for cognitive decline in older adults (Rodakowski et al., 2015). The Person-Environment-Occupation-Performance Model The Person-Environment-Occupation-Performance (PEOP) Model is a client-centered approach and can be applied to community-oriented health promotion programs (Cole & Tufano, 2008). The PEOP model examines the person-environment-occupation relationship and defines occupational performance as the outcome (Cole & Tufano, 2008). Individuals with cognitive impairment experience difficulty with the person-environment-occupation relationship, and new challenges are presented as the disease progresses, negatively impacting occupational performance. Occupational therapists can help identify these disruptions in the personenvironment-occupation relationship and assist the client in overcoming obstacles. For individuals with cognitive impairment, this model can increase quality of life and promote the ability to age in place for longer. Aging Brain Care Program The Doctoral Capstone Experience (DCE) described in this paper took place in an urban public health safety-net hospital serving Indianapolis, IN (Callahan et al., 2017). The DCE was in collaboration with the Aging Brain Care (ABC) program, an innovative collaborative care program designed to provide intensive primary care to community-dwelling individuals with brain care needs; it is considered best-practice primary care because it utilizes a collaborative care approach to brain care tested in a previous clinical trial (Callahan et al., 2017; Callahan et al., 2006). In the previous clinical trial, Callahan et al. (2006) found the collaborative care model resulted in significant improvements in behavioral and psychological symptoms of dementia, as well as increased quality of care and quality of life for the patient-caregiver dyad (Boustani et al., OCCUPATIONAL THERAPY AND BRAIN HEALTH 11 2011; Callahan et al., 2017). Information on the research, development, design, protocols, and outcomes associated with the ABC program have been described in greater detail in previous articles (Boustani et al., 2011; Callahan et al., 2017; Callahan et al., 2006; Callahan et al., 2014). There are currently six ABC physicians. Each physician provides care during a half-day clinic session one time per week. Each clinic is staffed by an ABC collaborative care team consisting of a geriatric psychiatrist or a geriatrician, a registered nurse, a social worker, two or more care coordinator assistants, and a medical assistant. Despite the positive outcomes found by Callahan et al. (2006), the best-practice collaborative care intervention has not slowed the rate of patients functional decline (Callahan, 2017). Prior to the DCE, the therapy department was not involved in the ABC program. The purpose of this DCE was to explore the role of OT in the collaborative care model focusing on brain health in older adults. Screening and Evaluation Needs Assessment The occupational therapy student (OTS) and site mentor met with the Director of Clinical Operations of the ABC program upon commencement of the DCE. During the meeting, the Director of Clinical Operations voiced concern for a lack of physical and functional assessment components in the neuropsychological evaluations performed for new ABC patients. The Director of Clinical Operations acknowledged that OT and physical therapy (PT) were not involved with the ABC program at that time, suggesting a disconnect between the two services. The OTS attended a half-day clinic session with two out of six ABC physicians each week to determine the role of OT and PT in the ABC program. The OTS observed a combination of new patient evaluations, family conferences, and return appointments. Although the ABC physicians and clinics follow standardized operating OCCUPATIONAL THERAPY AND BRAIN HEALTH 12 protocols (Boustani et al., 2011), each clinic, evaluation, and follow-up varied slightly based on the individual needs of the client and the personalization of each physician. The neuropsychological evaluations consistently included a semi-structured interview with a caregiver, an expanded Consortium to Establish a Registry for Alzheimers Disease (CERAD) neuropsychological battery, brain imaging, blood work, medication review, and a chart review of the medical history (Callahan et al., 2006). The physicians also performed a targeted neurological and cardiovascular physical examination including components such as eye movements, finger taps, respirations, pulse, heart rate, gastrointestinal sounds, cervical range of motion, a brief observation of gait, and informal manual muscle testing of the upper and lower extremity (Callahan et al., 2006). Through these observations, a lack of physical and functional baseline assessments was confirmed. During initial observations, the OTS also identified patients who could benefit from OT or PT, but were not referred, which confirmed the disconnect between the ABC program and therapy referrals. The OTS conducted a survey to obtain the ABC physicians perspective on the potential role OT and PT could add to the ABC program. Survey The primary objective of the survey was to understand supplemental assessments the physicians would find valuable, as an addition to the neuropsychological evaluation. A secondary objective was to identify potential barriers the ABC physicians faced in obtaining OT or PT referrals for their ABC patients. See Appendix B attached for the content of the survey. Four out of six survey responses were received. See Figure 1 and Table 1 for ABC physician responses to the survey. Responses to question one and two on the survey (see Figure 1 and Table 2) provided support to create an additional physical and functional baseline evaluation and helped guide appropriate assessment tool identification. OCCUPATIONAL THERAPY AND BRAIN HEALTH 13 Question three on the survey asked, What challenges have you faced in referring a patient for OT/PT services at Eskenazi Health? Responses to question three on the survey (see Table 1) emphasized the disconnect between the ABC program and the therapy department. The OTS addressed each of these responses through education, advocacy, and program development, as discussed throughout this paper. Through OTS observations, personal collaboration with ABC collaborative care team members, review of the literature, and the conducted survey, the need for additional physical and functional baseline assessment measures was confirmed. Rationale Individuals with MCI have a greater risk of developing Alzheimers disease or other dementias than individuals without MCI (Alzheimers Association, 2017). For individuals with cognitive impairment, early diagnosis and management of modifiable risk factors is imperative. A previous report concluded that regular physical activity and management of cardiovascular risk factors reduce the risk of cognitive decline and may potentially reduce the risk of dementia (Baumgart et al., 2015). A systematic review concluded that exercise can have a positive effect on the rate of cognitive decline in individuals with Alzheimers disease, and attention should be given to this concept in future research (Farina, Rusted, & Tabet, 2014). Therefore, physical function should receive equivalent attention as cognitive function. Due to the nature of cognitive impairment and the inevitable progression of major NCDs, intermittent intervention is indicated throughout the course of the disease to support the patientcaregiver dyad as they are faced with new challenges (Maskill, 2017). When baseline physical and functional assessments are utilized in conjunction with the current neuropsychological evaluation, the collaborative care team may be able to more effectively measure cognitive or physical decline. If tests show a significant decline in physical function upon reevaluation, OT or OCCUPATIONAL THERAPY AND BRAIN HEALTH 14 PT intervention may be necessary to promote safety and independence, and increase quality of life. Giles (2017) stated, Progressive cognitive disorders worsen over time, but with appropriate treatment, clients can often remain independent in self-care and other activities well into the disease process (p. 2). Occupational therapists can collaborate with the patient and caregiver to establish compensatory strategies, task simplification, and environmental modifications to overcome new barriers and create a supportive environment (Giles, 2017). Giles (2017) stated, addressing deficits in functional cognition that enable individuals to participate more fully in self-care, work, leisure, and community activities enhances quality of life while reducing the burden on caregivers and societal resources (p. 2). Although previous research on interventions that slow or reverse cognitive decline have produced varied results, identifying such interventions could have a significant impact on individual, familial, and societal burden (Rodakowski et al., 2015). The measure of efficacy of these interventions may best be detected through changes in (or at least maintenance of) cognitive function and impact of these changes on daily living (Rodakowski et al., 2015, p. 2). Adding physical and functional assessment components to the neuropsychological evaluation does not ensure a change, but it will provide a more holistic view of the patients baseline, which could aid in identifying future deficits and appropriate interventions. Compare and Contrast OT Process The physical and functional baseline evaluations were performed by an occupational and a physical therapist in the outpatient clinic. Therapists in the outpatient clinic utilize a variety of assessment tools based on the individual needs of the clients. The OT process in the outpatient clinic most commonly includes a physician referral, evaluation, plan of care, intervention, and discharge. The OT process for the baseline evaluations for ABC patients varied greatly compared OCCUPATIONAL THERAPY AND BRAIN HEALTH 15 to the traditional evaluations completed in the outpatient clinic. When a patient was referred from the ABC program for baseline testing, the initial objective was to provide evaluation only. The evaluation was intended to provide baseline information to aid in a more holistic view of the patient, allow for reevaluation as needed to identify decline in function, and provide intervention as necessary. However, if a current need was identified, the therapists had the opportunity to provide intervention immediately following the baseline assessment to address current needs. At this site, patients are typically required to call the outpatient therapy clinic to schedule their own appointments. In response to question three on the survey, one physician stated Largest obstacle was the requirement for the patient to make the appointment. At this site, if the patient is considered to be part of a vulnerable population, the outpatient therapy director will call the patient to set up their appointment. The outpatient therapy director confirmed that ABC patients are considered vulnerable due to their cognitive impairment. As a solution, the outpatient therapy director will screen referrals weekly, identify ABC referrals, and call the patients to set up their appointment. The OTS informed ABC team members of this change. Baseline Evaluation Assessment Tool Identification A lack of physical and functional baseline assessment measures was identified, as explained in the previous sections of this paper. Question one of the survey, asked ABC physicians to select components of assessments they would find valuable as an addition to the neuropsychological evaluation. See Appendix B for question one answer choices. Physician responses to question one can be found in Figure 1. In question two of the survey, ABC physicians were provided an open-ended format to state additional assessment components they would find valuable, that were not included in the first question on the survey (see Appendix B). Physician responses to question one can be found in Table 1. Feedback from the first and second OCCUPATIONAL THERAPY AND BRAIN HEALTH 16 question on the survey were used to guide supplemental assessment tool identification for the physical and functional baseline evaluations. The OTS informally met with an ABC physician and the director of the outpatient therapy clinic to guide assessment tool identification. Based on the meetings, the ideal assessment tools would encompass the following qualities: evidence-based, strong psychometric properties, norms for geriatric population, cost-efficient, performance or observation-based, and intended for outpatient-use, evaluation, and reevaluation. During the meeting with the director of the outpatient therapy clinic, the OTS was informed the evaluation would be a combined onehour OT and PT evaluation. The OTS conducted an extensive search to identify appropriate physical and functional assessment tools that would enhance the existing neuropsychological evaluation, fulfill the one-hour time constraint, and provide the desired qualities previously listed. A list of potential assessment tools was compiled. The OTS held individual meetings with the occupational therapist and physical therapist who would be completing the baseline evaluations. The objective of these meetings was to provide a brief synopsis of the services and evaluation process in the ABC program, articulate the objectives of the baseline evaluations, discuss the potential assessment tools and their respective qualities and purposes, and collaborate to determine the list of assessments that would be utilized. The OTS referenced the occupational and physical therapists feedback when determining appropriate assessment tools to be utilized. The ABC program utilizes an initial informant interview that provides a brief synopsis of the patients activities of daily living (ADLs) and instrumental activities of daily living (IADLs). There is value in informant-reported measures of functional abilities; however, subjective judgments may be prone to error and response bias (Harvey et al., 2017). Performance-based OCCUPATIONAL THERAPY AND BRAIN HEALTH 17 functional assessments are valuable due to the immediate clinical relevance as a direct measure of functioning and not a distal measure such as a word list recall (Harvey et al., 2017, p. 34). Leadership Skills to Effective Service Provision The OTS indirectly provided OT services through advocacy and consultation processes, on behalf of the ABC and its corresponding patients (American Occupational Therapy Association [AOTA], 2014). During initial observations, the OTS identified several patients who could benefit from OT or PT, but were not being referred. This confirmed the Director of Clinical Operations concern that there was likely a disconnect between the ABC program and therapy referrals. The third question on the survey asked, What challenges have you faced in referring a patient for OT/PT services at Eskenazi Health? One physician answered, have not tried to refer and one physician responded, I know very little about the programs. This suggested a need for advocacy and education of OT and PT services. The Occupational Therapy Practice Framework: Domain and Process 3rd Edition states, occupational therapy practitioners can indirectly affect the lives of clients through advocacy (AOTA, 2014, p. S11). The OTS educated the collaborative care team on the role of OT and PT and advocated for the professions and patients throughout the DCE, so current and future ABC patients could receive the appropriate care. Implementation The OTS was present in the ABC program for two half-day clinic sessions per week to educate the physicians and collaborative care team members on the objectives of the DCE, advocate for the role of OT and PT, and assist with ABC patient referrals. The OTS assisted in 22 ABC patient referrals for physical and functional baseline testing for the ABC program. The OTS additionally identified opportunities for OT or PT to benefit several patients who were OCCUPATIONAL THERAPY AND BRAIN HEALTH 18 referred for baseline testing to address present concerns such as chronic pain, physical dysfunction, decreased mobility, and decreased strength. The OTS educated the physicians and collaborative care team members on the role of OT and PT for these deficits, to support their understanding of the OT and PT professions and services available to ABC patients. The noted deficits were addressed in conjunction with the baseline evaluation. The first baseline evaluation occurred on week eleven of the DCE. Staff Development Through Education and Advocacy A previous study was conducted through the ABC program to determine whether a home-based OT intervention delivered one time a month over a two year period, in addition to the ABC collaborative care model, would slow the rate of functional decline among older adults with Alzheimers disease (Callahan et al., 2017). A slow in functional decline among older adults with Alzheimers disease was not definitively demonstrated (Callahan et al., 2017). Therefore, this DCE project and corresponding survey introducing the role of OT and PT in the ABC program caused hesitation in several ABC physicians. During week eight of the DCE, an ABC physician requested a formal meeting to discuss the role of OT and PT in the ABC program, as an alternative to filling out the brief survey (see Appendix B). Plans to attend the meeting were discussed by the site mentor and ABC Director of Clinical Operations. The OTS was not granted the opportunity to attend the meeting, due to a high volume of discussion topics previously included on the agenda. The collaborative care team members that the OTS collaborated with also serve on the care team for the other four ABC physicians. Therefore, as an alternative to educating and collaborating with the additional four ABC physicians, the OTS focused her efforts on the two collaborating physicians and the collaborative care team members. The OTS advocated for the OCCUPATIONAL THERAPY AND BRAIN HEALTH 19 role of OT and PT in the ABC program and educated the collaborative care team members on OT and PT services available to ABC patients. In week 12 of the DCE, the collaborative care team approached the OTS with a case study for an ABC patient from clinic with a different ABC physician. The OTS confirmed the need for OT and PT, educated on the services therapy could provide, and educated the team on the referral process. The collaborative care team members successfully advocated to the ABC physician and referred the patient for OT and PT. Brain Care Bundle The neuropsychological evaluation is performed on the initial visit for each new ABC patient. A family conference is held on the second visit, approximately two to four weeks following the initial visit. The family conference includes diagnosis and prognosis disclosure, direct clarification of patient and family questions, individualized self-management training manual, care recipient pharmacological prescriptions, care-recipient non-pharmacological prescriptions, pro-active referrals to community resources, and/or caregiver pharmacological and/or non-pharmacological prescriptions (Boustani et al., 2011). A brain care bundle is included in the training manual, and includes recommendations for brain exercises, physical exercise, socializing, diet, stress, and emotional wellness. Through dissemination of the brain care bundle, the OTS noted a gap in materials pertaining to physical activity, cognitive activity, local resources, and online resources. The OTS compiled resources to add to the brain care bundle. The compilation was presented to the Director of Clinical Operations on week nine of the DCE. The Director of Clinical Operations gave approval to the OTS to present the resources to the two collaborating ABC physicians. The compilation of additional resources was informally presented to the physicians on week ten of the DCE. The ABC physicians selected two of the resources to utilize; OCCUPATIONAL THERAPY AND BRAIN HEALTH 20 the first resource (see Appendix C) is a list of general physical activity recommendations and the second resource (see Appendix D) is a list of suggestions for endurance activities and locations. Due to the ABC programs emphasis on research and evidence-based practice, the physicians requested the resources be used as a continuous quality improvement project. Due to time constraints of the DCE, the OTS assisted with this process so the collaborative care team would be able to sustain this continuous quality improvement project. The two resources are being distributed in one ABC clinic. If the ABC team members find the resources to be effective through the continuous quality improvement project, the resources will be distributed as a part of the brain care bundle in all six ABC clinics. Discontinuation and Outcome The primary objective of the DCE was to explore the role of OT in the ABC program. Through advocacy, education, and interdisciplinary collaboration, 22 patients were referred to OT and PT. The referrals served as the outcome measure for the DCE. The gap between the outpatient therapy clinic and the ABC program was bridged. Several efforts were made to increase the sustainability of the project and maintain the connection between the two clinics. The first ABC patient was seen for a physical and functional baseline evaluation during week eleven of the DCE. After the first baseline evaluation, the OTS met with the referring ABC physician and the evaluating physical and occupational therapists. During this time, each interdisciplinary team member was given the opportunity to provide feedback. The OTS reviewed topics such as documentation content and assessment tools utilized. This feedback helped determine changes for future baseline evaluations to promote continuous quality improvement. The continued feedback and subsequent adaptations were essential to ensure the ABC physicians found the information obtained through the baseline evaluations to be valuable, OCCUPATIONAL THERAPY AND BRAIN HEALTH 21 accessible, and understandable. This was a desired and necessary outcome to promote the sustainability of this project. Throughout the DCE, the OTS was the primary source of communication between the outpatient therapy clinic and the ABC program. The OTS collaborated with appropriate interdisciplinary team members to identify and implement the most effective form of communication between the outpatient therapy clinic and the ABC program. This was done to help maintain the relationship that was established during the DCE. As previously stated, patients are typically expected to call the outpatient therapy clinic to schedule their therapy appointments. However, due to the vulnerability of this population, the director of the outpatient therapy clinic will scan therapy referrals weekly to identify ABC patients who have been referred for a baseline evaluation. She will then call the ABC patients to set up their appointment. ABC patients will also receive reminder phone calls the day prior to their appointment, in an effort to promote patient buy-in and attendance. After the first baseline evaluation, a gap in communication between therapy and the ABC program was evident; the ABC physicians were not notified when the OT and PT evaluation had been completed. To minimize potential gaps in future communication, the occupational and physical therapists will send an electronic provider-to-provider note to notify the referring physician of the completed evaluation. The OTS created a template for both occupational and physical therapy to utilize for baseline evaluations for ABC patients. The template was formatted to meet the desires of the ABC physicians, with an emphasis on information included in the assessment and plan. The template was also designed to include specific recommendations for ABC patients, as well as elaborate descriptions of the purpose of the evaluation and interpretation of outcome measures. OCCUPATIONAL THERAPY AND BRAIN HEALTH 22 The OTS also included a long list of abbreviations and what they stand for, so the physicians would have a reference for unfamiliar terms. The purpose of the template was to provide the ABC physicians with evaluation documentation that was understandable and valuable, while attempting to minimize the added documentation requirements for the evaluating occupational and physical therapists. The template was created as a result of continuous quality improvement efforts to promote sustainability. The OTS created two handouts to ease the referral process and support continued interdisciplinary collaboration after the completion of the DCE. The handouts are attached in Appendix E. The first referral process handout outlines the steps the physicians must complete in order to refer an ABC patient to the outpatient therapy clinic for a physical and functional baseline evaluation. Additionally, it outlines the referral process for OT and PT to address existing concerns. The outpatient therapy directors contact information is included in the first handout, so the ABC physicians and collaborative care team members will be able to direct their questions and concerns efficiently. The first handout was intended to serve as a reminder resource for the two collaborating ABC physicians, as well as an educational resource for the four ABC physicians who were not involved in the collaboration of the DCE. The second referral process handout includes a list of possible reasons a physician could refer a patient to OT or PT. The second handout is intended to be a resource for the ABC physicians to utilize when determining an appropriate plan of care for their patients in the future. Both handouts were posted in the ABC office and shared on the electronic drive to help maintain the connection that had been established between the outpatient therapy clinic and the ABC program. OCCUPATIONAL THERAPY AND BRAIN HEALTH 23 The OTS facilitated a meeting between the interdisciplinary team members, upon the conclusion of the DCE. The purpose of the meeting was to allow face-to-face collaboration between the outpatient therapy clinic and the ABC program, to increase the relationship that had been established. The meeting also provided an opportunity for pertinent interdisciplinary team members to collaborate and address any questions or concerns they had for each other. Enabling Occupational Therapy to Respond to Change There has been an increased focus on exploring cognitive and functional outcome measures that support the clinical trials targeting earlier intervention of individuals with cognitive impairment (Posner et al., 2017). The evaluation of new patients in the ABC program is extensive. However, the evaluation was lacking in physical and functional outcome measures prior to the DCE. Appropriate outcome measures were identified and implemented as a complimentary addition to the neuropsychological evaluation completed for ABC patients. Given the prevalence of cognitive impairment and other dementias, the search for effective treatments to prevent its onset, significantly delay its progression, or otherwise positively intervene in the disease course is an international research priority (Posner et al., 2017, p. 22-23). This has been, and continues to be, one of the primary goals of the ABC program and collaborative care team members. Rehabilitation professionals have the opportunity to target brain health by the reduction of modifiable risk factors through physical activity interventions and lifestyle changes (McGough, Kirk-Sanchez, & Liu-Ambrose, 2017). Through this DCE, the gap between therapy and the ABC program was bridged. As a result, this DCE enabled occupational and physical therapy to integrate health promotion into practice for the prevention of dementia and other neurological conditions in older adults at this site (McGough et al., 2017, p. S55). OCCUPATIONAL THERAPY AND BRAIN HEALTH 24 Overall Learning As a learner amongst experienced professionals, effective communication skills were an essential attribute to promote a successful DCE. Throughout the DCE, my written, verbal, and nonverbal communication skills increased significantly. Face-to-face communication with interdisciplinary team members was limited due to a high volume of work demands. Therefore, communication via email was heavily utilized. This allowed interdisciplinary team members to communicate at their earliest convenience. My written communication skills increased significantly through this mode of communication. Verbal and nonverbal communication skills were equally important during the face-toface meetings with interdisciplinary team members, patients, family members, and caregivers. My ability to tailor a conversation to my audience was significantly increased due to variety of people I was addressing on a daily basis. During the DCE, I joined a team of collaborative care team members in a well-established program. In an environment such as this, it was integral to know when to attentively observe and when to actively collaborate. I was consistently attentive, well-dressed, and actively listening to display professional nonverbal communication, regardless of who I was surrounded by. Since face-to-face communication time with all interdisciplinary team members was limited, I quickly learned the importance of utilizing every opportunity to collaborate to the fullest. When communicating with other professionals in the fast-paced environment, my talking points were planned prior to the conversation, and my verbal communication was intended to be efficient, direct, and purposeful. Through collaboration with interdisciplinary team members, I learned about teamwork, leadership, and professional skills, and the importance of these characteristics. In regards to teamwork, I learned that it is essential to be patient and respectful of colleagues time while also OCCUPATIONAL THERAPY AND BRAIN HEALTH 25 actively making an effort to move forward; those two steps did not always go hand-in-hand. My deadlines, goals, and focus were often significantly different than that of my colleagues. However, in numerous situations, it was difficult for me to move forward without their collaboration. This taught me about the skills required to accomplish a task when working as part of a team. It was important to advocate the goals and objectives to colleagues so they were invested, and so they knew what was needed from them. It was necessary to possess professional skills such as organization, efficiency, respect, patience, and communication skills, to promote effective collaboration. Lastly, leadership skills were an essential part of this process, in order to set goals and efficiently accomplish them. I was the primary source of communication between the ABC program and the outpatient therapy clinic during the DCE. There was a significant amount of support and encouragement from both clinics in regard to this DCE. However, due to the additional work demands that the interdisciplinary team members faced, both clinics were reliant on me to effectively communicate and take the steps necessary to establish the relationship and meet the objectives. I was surrounded by professionals who encompassed the skills required to be effective leaders, which supported my transition to a leadership role. My advocacy skills significantly improved throughout the DCE. As previously stated, I was the only member from therapy involved in the ABC program. Therefore, I was responsible for advocating for the role of OT and PT to the physicians, collaborative care team members, stakeholders, patients, family members, and caregivers. As previously stated, several of the ABC team members were resistant to occupational therapy as a result of the previous study that was conducted by Callahan et al. (2017). Therefore, I repeatedly advocated for the purpose of the DCE and the role of OT and PT for community dwelling older adults with cognitive impairment, OCCUPATIONAL THERAPY AND BRAIN HEALTH 26 beyond slowing functional decline. The ABC physicians were strongly driven by research, data, and evidence-based practice. Therefore, my ability to incorporate previous research, and articulate and justify its relevance to this DCE and project was essential. Throughout the DCE, I was fortunate to be surrounded by interdisciplinary team members who were evidence-based, ethical, motivating, diligent, and innovative leaders. Through personal research, observation, and collaboration with interdisciplinary team members, my leadership, advocacy, and professional skills have significantly increased. The skills I have gained from this DCE will enable me to be a competent professional and excel in my career as an occupational therapist. OCCUPATIONAL THERAPY AND BRAIN HEALTH 27 References Alzheimers Association. (2017). 2017 Alzheimers disease facts and figures. Retrieved from https://www.alz.org/documents_custom/2017-facts-and-figures.pdf American Occupational Therapy Association [AOTA]. (2014). Occupational therapy practice framework: Domain and process (3rd ed.). American Journal of Occupational Therapy, 68(Suppl. 1), S1-S48. American Psychiatric Association [APA]. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Retrieved from https://books.google.com/books?id=JivBAAAQBAJ&printsec=frontcover&dq=American+Psychiatric+Association.+Diagnos tic+and+Statistical+Manual+of+Mental+Disorders.+Fifth+Edition.+Arlington,+VA:+Am erican+Psychiatric+Association;+2013.&hl=en&sa=X&ved=0ahUKEwi6o8e6draAhWOpFkKHWokCQYQ6AEIMzAC#v=snippet&q=591&f=false Atchison, B. J., & Dirette, D. K. (2012). Dementia. In J. Fraker (Ed.), Conditions in occupational therapy: Effect on occupational performance (4th ed., pp. 99-125). Baltimore, MD: Lippincott Williams & Wilkins. Baumgart, M., Snyder, H. M., Carrillo, M. C., Fazio, S., Kim, H., & Johns, H. (2015). Summary of the evidence on modifiable risk factors for cognitive decline and dementia: A population-based perspective. Alzheimer's & Dementia: The Journal of the Alzheimer's Association, 11(6), 718-726. doi:10.1016/j.jalz.2015.05.016 Boustani, M. A., Sachs, G. A., Alder, C. A., Munger, S., Schubert, C. C., Guerriero Austrom, M., ... & Perkins, A. J. (2011). Implementing innovative models of dementia care: the Healthy Aging Brain Center. Aging & Mental Health, 15(1), 13-22. doi:10.1080/13607863.2010.496445 OCCUPATIONAL THERAPY AND BRAIN HEALTH 28 Callahan, C. M., Boustani, M. A., Schmid, A. A., LaMantia, M. A., Austrom, M. G., Miller, D. K., ... & Hendrie, H. C. (2017). Targeting functional decline in Alzheimer disease: A randomized trial. Annals of Internal Medicine, 166(3), 164-171. doi:10.7326/M16-0830 Callahan, C. M., Boustani, M. A., Unverzagt, F. W., Austrom, M. G., Damush, T. M., Perkins, A. J., ... & Hendrie, H. C. (2006). Effectiveness of collaborative care for older adults with Alzheimer disease in primary care: A randomized controlled trial. Jama, 295(18), 21482157. doi:10.1001/jama.295.18.2148 Callahan, C. M., Sachs, G. A., LaMantia, M. A., Unroe, K. T., Arling, G., & Boustani, M. A. (2014). Redesigning systems of care for older adults with Alzheimers disease. Health Affairs, 33(4), 626-632. doi:10.1377/hlthaff.2013.1260 Cole, M., & Tufano, R. (2008). Applied theories in occupational therapy: A practical approach. Thorofare, NJ: SLACK Incorporated. Csukly, G., Sirly, E., Fodor, Z., Horvth, A., Salacz, P., Hidasi, Z., ... & Szab, . (2016). The differentiation of amnestic type MCI from the non-amnestic types by structural MRI. Frontiers in Aging Neuroscience, 8. doi:10.3389/fnagi.2016.00052 Dawson, N., Judge, K. S., & Gerhart, H. (2017). Improved functional performance in individuals with dementia after a moderate-intensity home-based exercise program: A randomized controlled trial. Journal of Geriatric Physical Therapy. doi:10.1519/JPT.0000000000000128 Farina, N., Rusted, J., & Tabet, N. (2014). The effect of exercise interventions on cognitive outcome in Alzheimer's disease: a systematic review. International Psychogeriatrics, 26(1), 9-18. doi:10.1017/S1041610213001385 OCCUPATIONAL THERAPY AND BRAIN HEALTH 29 Giles, G. M. (2017). Occupational therapys role in adult cognitive disorders. Retrieved from https://www.aota.org/~/media/Corporate/Files/AboutOT/Professionals/WhatIsOT/PA/Fac ts/Cognitive-Disorders-Fact-Sheet.pdf Harvey, P. D., Cosentino, S., Curiel, R., Goldberg, T. E., Kaye, J., Loewenstein, D., ... & Posner, H. (2017). Performance-based and observational assessments in clinical trials across the Alzheimers disease spectrum. Innovations in Clinical Neuroscience, 14(1-2), 30. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5373793/ Hugo, J., & Ganguli, M. (2014). Dementia and cognitive impairment: Epidemiology, diagnosis, and treatment. Clinics in Geriatric Medicine, 30(3), 421-442. doi:10.1016/j.cger.2014.04.001 Jekel, K., Damian, M., Wattmo, C., Hausner, L., Bullock, R., Connelly, P. J., ... & Frlich, L. (2015). Mild cognitive impairment and deficits in instrumental activities of daily living: A systematic review. Alzheimer's Research & Therapy, 7. doi:10.1186/s13195-015-00990 Maskill, L. (2017). Cognitive function in the general population: Maintaining cognitive health in later years. Neuropsychology for Occupational Therapists: Cognition in Occupational Performance, (11). Retrieved from https://books.google.com/books?hl=en&lr=&id=6WbgDQAAQBAJ&oi=fnd&pg=PA177 &dq=rising+problem+of+cognitive+impairment+in+the+US&ots=z3fSg6qwRq&sig=1E WuVoom4jFnJDbiMDVbhWEHHvo#v=onepage&q&f=false McGough, E., Kirk-Sanchez, N., & Liu-Ambrose, T. (2017). Integrating health promotion into physical therapy practice to improve brain health and prevent Alzheimer disease. Journal of Neurologic Physical Therapy, 41, S55-S62. doi:10.1097/NPT.0000000000000181 OCCUPATIONAL THERAPY AND BRAIN HEALTH 30 Posner, H., Curiel, R., Edgar, C., Hendrix, S., Liu, E., Loewenstein, D. A., ... & Harvey, P. D. (2017). Outcomes assessment in clinical trials of Alzheimers disease and its precursors: Readying for short-term and long-term clinical trial needs. Innovations in Clinical Neuroscience, 14(1-2), 22. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5373792/ Rodakowski, J., Saghafi, E., Butters, M. A., & Skidmore, E. R. (2015). Non-pharmacological interventions for adults with mild cognitive impairment and early stage dementia: An updated scoping review. Molecular Aspects of Medicine, 43, 38-53. doi:10.1016/j.mam.2015.06.003 Smallfield, S. (2017). Dementia and the role of occupational therapy. Retrieved from https://www.aota.org/~/media/Corporate/Files/AboutOT/Professionals/WhatIsOT/MH/Fa cts/Dementia.pdf Young, K. W., Ng, P., Kwok, T., & Cheng, D. (2017). The effects of holistic health group interventions on improving the cognitive ability of persons with mild cognitive impairment: A randomized controlled trial. Clinical Interventions in Aging, 12. OCCUPATIONAL THERAPY AND BRAIN HEALTH Figure 1. Physician responses to question one from the survey located in Appendix B. 31 OCCUPATIONAL THERAPY AND BRAIN HEALTH 32 Table 1 Physician Responses for Survey Question Two and Three Physician Physician Response Q1. What type of services not listed above are you interested in occupational/physical therapy providing? P1 P2 P3 P4 After initial assessment creating a home exercise program for patients to maintain function Performative tasks that help determine financial capacity (e.g. check writing) Driving assessment or other aspects of home safety Computer simulated driving evaluation Q2. What challenges have you faced in referring a patient for OT/PT services at Eskenazi Health? P1 P2 P3 P4 Transportation, patient motivation and buy in, patient compliance and completion I know very little about the programs Largest obstacle was the requirement for the patient to make the appointment. Sometimes need a home-based assessment as home safety an important issue Have not tried to refer OCCUPATIONAL THERAPY AND BRAIN HEALTH Appendix A. Terminology. Mild Neurocognitive Disorder: 1) Modest cognitive decline in one or more cognitive domains, based on: a) Concern about mild decline, expressed by individual or reliable informant, or observed by clinician. b) Modest impairment, documented by objective cognitive assessment. 2) No interference with independence in everyday activities, although these activities may require more time and effort, accommodation, or compensatory strategies. 3) Not exclusively during delirium. 4) Not better explained by another mental disorder. Major Neurocognitive Disorder: 1) Significant cognitive decline in one or more cognitive domains, based on: a) Concern about significant decline expressed by individual or reliable informant, or observed by clinician. b) Substantial impairment, documented by objective cognitive assessment. 2) Interference with independence in everyday activities. 3) Not exclusively during delirium. 4) Not better explained by another mental disorder. Specify one or more etiologic subtypes, due to: 1) Alzheimers disease 2) Cerebrovascular disease (Vascular Neurocognitive Disorder) 3) Dementia with Lewy Bodies (Neurocognitive Disorder with Lewy Bodies) 33 OCCUPATIONAL THERAPY AND BRAIN HEALTH Appendix A. Terminology. 4) Parkinsons disease 5) Huntingtons disease 6) Traumatic Brain Injury 7) HIV Infection 8) Prion Disease 9) Another Medical Condition 10) Multiple Etiologies Cognitive domains: 1) Complex attention 2) Executive functioning 3) Learning and memory 4) Language 5) Perceptual-motor/visuospatial function 6) Social cognition 34 OCCUPATIONAL THERAPY AND BRAIN HEALTH 35 Appendix B. Physician Survey Questions. 1. Listed below are components of assessments utilized in occupational and physical therapy to identify deficits in function. Which components would you find of value, as an addition to your new patient evaluation? Please check all that apply. Balance Static/dynamic balance Gait quality/speed Fall Risk Strength/Endurance Manual Muscle Testing- upper/lower body Grip Strength Pinch Strength Coordination Range of motion- upper/lower body Gross motor- upper/lower body Fine Motor Functional Mobility and Indication of Fall Risk Static/dynamic balance Gait quality/speed Durable medical equipment/assistive devices Community vs. home ambulation Activities of Daily Living Performance-based Functional status of activities applicable to patient Time required to complete Safety awareness Level of assistance required vs. level of assistance available Fear of Falling/ Falls Efficacy Perception of balance/stability during ADLs Perceived awareness of safety Pain Numerical pain scale At rest/with activity Relation to mood and participation in ADLs, IADLs, social activity, physical activity, sleep, etc. All of the Above None of the Above OCCUPATIONAL THERAPY AND BRAIN HEALTH 36 Appendix B. Physician Survey Questions. 2. What type of services not listed above are you interested in occupational/physical therapy providing? {Open-ended} 3. What challenges have you faced in referring a patient for OT/PT services at Eskenazi Health? {Open-ended} OCCUPATIONAL THERAPY AND BRAIN HEALTH 37 Appendix C. Brain Care Bundle General Tips Sheet https://drive.google.com/file/d/1lfL0stZRDucqlWto1tg_X0ycSiY4QY2Q/view?usp=sharing Appendix D. Brain Care Bundle Endurance Sheet https://drive.google.com/file/d/1WdcvltM70ERmSiGNgD87N1jm3-GJVCLT/view?usp=sharing Appendix E. OT/PT Referral Sheet https://drive.google.com/file/d/1ul8-emQs21J6I1x-odWutT_qg0q1BUBA/view?usp=sharing  ...