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The Hybrid Doctor of Physical Therapy Student: A Comprehensive Exploration of Demographics and Decision-Making Factors Submitted to the Faculty of the College of Health Sciences University of Indianapolis In partial fulfillment of the requirements for the degree Doctor of Health Science By: Teresa Bachman, PT, DPT Copyright December 6, 2023 By: Teresa Bachman, PT, DPT All rights reserved Approved by: Laura Santurri, PhD, MPH, CPH, aPHR Committee Chair ______________________________ Kendra Gagnon, PhD, PT Committee Member Associate Professor Johns Hopkins University School of Medicine ______________________________ Elizabeth Moore, PhD Committee Member ______________________________ Accepted by: Lisa Borrero, PhD, FAGHE Director, DHSc Program University of Indianapolis ______________________________ Stephanie Kelly, PT, PhD Dean, College of Health Sciences University of Indianapolis ______________________________ HYBRID DOCTOR OF PHYSICAL THERAPY STUDENT The Hybrid Doctor of Physical Therapy Student: A Comprehensive Exploration of Demographics and Decision-Making Factors Teresa Bachman Department of Interprofessional Health and Aging Studies, University of Indianapolis 1 HYBRID DOCTOR OF PHYSICAL THERAPY STUDENT 2 Abstract Background: Hybrid DPT education has emerged as a model many educators feel holds promise in addressing some of the calls to action in DPT education. Data indicate an increasing number of hybrid DPT programs, yet very little is known about the hybrid DPT student. Purpose: This study aimed to explore hybrid DPT student demographic characteristics, tolerance for ambiguity and perfectionism factors, and key considerations in the students selection of a hybrid DPT program. Method: The study used a quantitative, non-experimental, cross-sectional design with the administration of a Qualtrics survey to explore demographics, student experience, and key considerations data. Data analysis included descriptive statistics to determine measures of central tendency. Results: The median age of the sample was 25 years, with 72.0% females and 29.3% racial minorities. 33.5% of participants were married and 13.5% had children. 54.4% were accepted to more than one program. The median score for tolerance for ambiguity was 23, and the median scores for perfectionism striving and evaluative concerns were 15.2 and 11.4, respectively. The most important considerations in selecting their hybrid DPT program were outcome factors of graduation and employment rates and NPTE pass rates. Conclusion: Hybrid DPT students look very similar to residential DPT students compared to published aggregate data, with main differences in marital status and those with children. New and expanding hybrid DPT programs should consider outcomes as a key driver in student selection of their program. Keywords: entry-level hybrid DPT education, tolerance for ambiguity, perfectionism HYBRID DOCTOR OF PHYSICAL THERAPY STUDENT 3 Acknowledgments Ive dreamed of the day that I would finally sit and write this acknowledgments page. It is hard to believe it is finally here. First, I must give all the glory, praise, and acknowledgment to my Savior, Jesus Christ. Countless prayers have gone up, and He has never failed me! I am truly blessed to be a daughter of the King, badly broken, but deeply loved. None of this would have been possible without the guidance of my amazing dissertation committee, Drs. Laura Santurri, Elizabeth Moore, and Kendra Gagnon. Laura, you have guided me with grace, patience, and an ever-calm presence during this process. Thank you! Elizabeth, your statistical knowledge and patience with me have been a God send. Thank you! Kendra, my colleague, mentor, and friend, I have been blessed beyond measure to have you on this committee. You have challenged me and supported me. Thank you! Together, as a committee, you all have helped me rise to the next level of professional. I am forever grateful. My husband and my boys have been incredibly supportive during this entire process. They have encouraged me, dealt with late nights and early morning working, supported me during my lows, and celebrated with me during the great times. My husband has kept the house running, worked full time, loved and supported me, and dried my tears. Michael, Logan, and Barrett, thank you! Finally, I have to thank my Mom, Angie. They say that a mom is always there for you, and I have found this to be the truth. Thank you, Mom, for raising me to be a strong and independent woman who strives to achieve great things. Thank you for your love and encouragement. I am blessed and grateful. Thank you all! HYBRID DOCTOR OF PHYSICAL THERAPY STUDENT 4 Table of Contents Abstract ........................................................................................................................................... 2 Acknowledgments........................................................................................................................... 3 List of Tables .................................................................................................................................. 6 List of Figures ................................................................................................................................. 7 Chapter 1: Introduction ................................................................................................................... 8 Problem Statement .................................................................................................................... 10 Purpose Statement..................................................................................................................... 10 Research Questions............................................................................................................... 10 Objectives.............................................................................................................................. 11 Significance of the Study .......................................................................................................... 11 Literature Review.......................................................................................................................... 12 DPT Education .......................................................................................................................... 12 History................................................................................................................................... 12 A Call for Change ................................................................................................................. 12 Excellence ............................................................................................................................. 13 The Rise of Hybrid DPT Education ...................................................................................... 15 Data and Outcomes............................................................................................................... 18 Terminology .......................................................................................................................... 19 Student Experience ................................................................................................................... 20 Tolerance for Ambiguity ....................................................................................................... 21 Perfectionism ........................................................................................................................ 23 Chapter 2: Method ........................................................................................................................ 25 Study Type and Design ............................................................................................................. 25 Participants ................................................................................................................................ 25 Data ........................................................................................................................................... 25 Variables ............................................................................................................................... 25 Operational Definitions of Variables.................................................................................... 28 Instruments................................................................................................................................ 28 Tolerance for Ambiguity Scale.............................................................................................. 28 Frost Multidimensional Perfectionism Scale-Brief .............................................................. 29 Procedures ................................................................................................................................. 29 HYBRID DOCTOR OF PHYSICAL THERAPY STUDENT 5 Recruitment ........................................................................................................................... 29 Informed Consent .................................................................................................................. 29 Data Collection ..................................................................................................................... 30 Data Management ................................................................................................................. 30 Statistical Analysis .................................................................................................................... 30 Results ........................................................................................................................................... 31 Discussion ..................................................................................................................................... 32 Characteristic Demographic Profile of Hybrid DPT Students ............................................. 32 Tolerance for Ambiguity and Perfectionism ......................................................................... 34 Key Considerations of Importance in Selection of a Specific Hybrid DPT Program .......... 35 Limitations ................................................................................................................................ 37 Conclusion ................................................................................................................................ 37 References ..................................................................................................................................... 39 Appendix A ................................................................................................................................... 56 Appendix B ................................................................................................................................... 57 Appendix C ................................................................................................................................... 58 HYBRID DOCTOR OF PHYSICAL THERAPY STUDENT 6 List of Tables Table 1: General Demographic Characteristics52 Table 2: Expanded Demographic Characteristics.53 Table 3: Key Considerations in Enrollment in a Specific Hybrid DPT Program.54 HYBRID DOCTOR OF PHYSICAL THERAPY STUDENT 7 List of Figures Figure 1: Percentage of Participants per Regional Location55 HYBRID DOCTOR OF PHYSICAL THERAPY STUDENT 8 The Hybrid Doctor of Physical Student: A Comprehensive Exploration of Demographics and Decision-Making Factors Doctor of Physical Therapy (DPT) educators have been challenged to assess, adapt, and advance educational practices in the ever-changing landscape of health care and graduate education. Over the last decade, commentary with calls to action have been published on issues including student debt to income ratio (Domholdt et al., 2020; Dunn, 2019; Jette, 2016), demand for qualified faculty (Brueilly et al., 2022; Domholdt et al., 2020), physical therapist workforce supply and demand (APTA and APTA Private Practice, 2023; Deusinger & Landers, 2022; Domholdt et al., 2020), declining DPT program applications (ACAPT, 2023; Deusinger & Landers, 2022; Deusinger & Sanders, 2017; Domholdt et al., 2020), the increase in the number of DPT programs (Deusinger & Sanders, 2017; Domholdt et al., 2020) thereby increasing the competition for students, and diversity of PT students and graduates (Domholdt et al., 2020). Considering these issues alone, multiple options to address them could be identified. However, the real challenge is that many of these problems are inextricably connected, and solutions cannot be considered in isolation. In recent years, a new instructional model of education has emerged that many educators feel holds promise in addressing some of the challenges: hybrid DPT education. The first hybrid DPT programs were launched in 2008 (University of St. Augustine for Health Sciences, 2016) and 2011 (Nova Southeastern University, 2011). Both programs were described as flex programs and decelerated the time to a degree. They were characterized by their blended delivery model that combined online and face-to-face instruction with no residential requirements to create flexibility for working students and those otherwise unable to attend fulltime graduate school (Nova Southeastern University, 2011; University of St. Augustine for HYBRID DOCTOR OF PHYSICAL THERAPY STUDENT 9 Health Sciences, 2016). In 2015, the first full-time, fully hybrid DPT program was launched at South College. Like the early flex programs, there was no residential requirement. However, to be responsive to workforce demands and rising concerns about the debt-to-income ratio, this new type of hybrid program accelerated the time to degree to two years (South College, 2021). In 2020, the COVID-19 pandemic rapidly shifted most programs to an online format (Gagnon et al., 2020). Since then, data indicate that at least 10 accredited institutions offer entry-level DPT education, with 25-50% of the program offered remotely and at least six institutions offering more than 50% in a remote method (ACAPT, 2022d). Literature related to hybrid DPT education programs and outcomes is limited. Existing data on hybrid DPT education are derived from case reports that describe hybrid program implementation, outline strategies implemented during the COVID-19 pandemic, and provide some early outcomes (Gagnon et al., 2020, 2022; Ortega et al., 2021). While these studies provide a useful foundation for understanding the characteristics of individual hybrid DPT programs, there is a need to more broadly understand the student experience and outcomes across multiple hybrid programs. Aggregate student demographics and outcomes for graduation rates, licensure examination pass rates, and employment rates for DPT programs are reported annually by CAPTE in the Aggregate Program Data (CAPTE, 2022). These data provide a superficial start to the collection of benchmarking metrics but are limited in their utility as they cannot be separated by program type, describe a narrow set of graduate outcomes, and do not provide information about the student experience. Shields et al. (2018) recognized the limited utility of the data collected by CAPTE and set out to collect a more robust set of data to capture information about student experience. These data included validated tools related to tolerance for ambiguity (TfA), HYBRID DOCTOR OF PHYSICAL THERAPY STUDENT 10 burnout, and perfectionism in their Physical Therapy Graduate Questionnaire (PT-GQ) benchmarking study (Dudley-Javoroski and Shields, 2022). TfA has been widely studied in medical students (Hancock & Mattick, 2020) and identified as a needed trait in DPT students (Craik, 2001; Jette, 2016a). Perfectionism has been correlated to increased stress (Richardson et al., 2022) and negative mental health diagnoses (Bogardus et al., 2022). Perfectionism has been positively associated with developing leadership (Jaworski et al., 2022) and academic achievement (Madigan, 2019). These findings support the need to consider student experience factors of TfA and perfectionism in the metrics of DPT students. However, like all other data, this information is unavailable for the hybrid DPT student. Problem Statement Hybrid DPT programs produced an estimated 1000 graduates this year, with an estimated 3400 students enrolled in hybrid DPT programs in 2023. These numbers will continue to grow as new and expanded hybrid DPT programs emerge. As the DPT education market becomes increasingly competitive, institutions offering hybrid DPT programs must learn to recruit, retain, and support their students effectively. To do this, they must know who their students are and why they chose their specific hybrid DPT education program. Purpose Statement This study aimed to explore hybrid DPT student demographic characteristics and student experience aspects of tolerance for ambiguity and perfectionism. This study also examined key considerations in the student resolution to enroll in a specific hybrid DPT program. Research Questions The following research questions are answered to address the study's purpose. HYBRID DOCTOR OF PHYSICAL THERAPY STUDENT 11 1. What is the characteristic demographic profile of students enrolled in entry-level hybrid DPT educational programs? 2. What is the student experience of tolerance for ambiguity and perfectionism in entrylevel hybrid DPT educational programs? 3. What key considerations impacted students selection of a specific hybrid DPT educational program? Objectives The following objectives are addressed to answer the research questions. 1. Explore the demographic characteristics, such as age, gender, ethnicity, and relationship status of students who enroll in hybrid DPT educational programs, utilizing a newly constructed survey. 2. Explore the tolerance for ambiguity and perfectionism of students enrolled in hybrid DPT programs utilizing the Tolerance for Ambiguity (TfA) scale (Geller et al., 1993) and the Frost Multi-Dimensional Perfectionism Scale- Brief (FMPS-B) (Burgess et al., 2016). 3. Describe key considerations to students selection of a specific hybrid DPT program utilizing a newly constructed survey. Significance of the Study The results of this study provide data that can be used to benchmark hybrid DPT students characteristics and experiences against published aggregate data. This enables institutions that are considering development of a hybrid DPT program to make data-informed decisions regarding the anticipated students and why they would enroll. Ultimately, the results of HYBRID DOCTOR OF PHYSICAL THERAPY STUDENT 12 this study provide the foundation for future studies related to the outcomes of students enrolled in hybrid DPT programs. Literature Review DPT Education History The physical therapy profession has been in the United States since the early 1900s. Initially, six schools offered a post-baccalaureate certificate, awarding those who completed the program the title of Physical Reconstruction Aid (Moffat, 2003). Over the last century, the profession of physical therapy has advanced significantly. Thus, education programs for physical therapy have evolved as well. Education programs have gone from the bachelors degree level in 1978 through the masters degree level in 2008 to the doctorate level by 2015 (Moffat, 2012). Two hundred seventy-three accredited physical therapy programs now confer the DPT degree (CAPTE, 2022). A Call for Change Physical therapist educators have faced challenges throughout the entire history of the profession. These challenges have resulted in growth and changes in physical therapist education, including the progression of education from a certificate to a doctorate. The everchanging landscape of health care and graduate education requires physical therapist educators to assess, adapt continually, and advance administration and educational practices. Recently documented challenges include but are not limited to student debt to income ratio (Dunn, 2019; Jette, 2016b), demand for qualified faculty (Brueilly et al., 2022; Brueilly et al., 2007; Bliss et al., 2018), physical therapist workforce supply and demand (APTA, 2023; Deusinger & Landers, 2022), declining DPT program applications (APTA, 2022; Deusinger & Landers, 2022; HYBRID DOCTOR OF PHYSICAL THERAPY STUDENT 13 Deusinger & Sanders, 2017), an increase in the number of DPT programs (Deusinger & Sanders, 2017; Jette, 2016b), and student/graduate diversity (Nordstrom et al., 2022; Domholdt et al., 2007). Additionally, there are concerns regarding the rising cost of doing business (Jette, 2016b), curricular variation (Jette, 2016b), negative value proposition (Deusinger & Landers, 2022), and defining and achieving excellence in education (Gordon, 2011; Jensen et al., 2017a). All these issues have been discussed in the last 15 years within the APTA Academy of Education (2022) Cerasoli Lectures, with calls to action. However, as discussed by Domholdt et al. (2020), little progress has been seen in most areas. While there may be multiple solutions to address any of the challenges within DPT education, most problems are inextricably connected and cannot be considered in isolation. Healthcare and medical educators have been urged to consider novel education methods and leverage technology to replace outdated methods and improve efficiency in educational delivery (Prober & Khan, 2013; Thibault, 2020.) Leaders in physical therapy education have called for a need to establish excellence in education, unique methods of education, and changes to the curriculum to reduce the cost of physical therapist education, improve efficiencies, and provide flexibility to meet student needs (Gordon, 2011; Graham, 2015; Jette, 2016b; Portney, 2014; Wojciechowski, 2015). Excellence The response to the call for establishing excellence in physical therapist education began with defining excellence (Jensen et al., 2017a; Jensen et al., 2017b). In 2022, ACAPT launched the Center for Excellence in Academic Physical Therapy and formed an advisory committee to support a culture of excellence and reinforce the mission and strategic goals of the organization (ACAPT, 2022a). The definition of excellence and The Excellence Framework was published, HYBRID DOCTOR OF PHYSICAL THERAPY STUDENT 14 and an Institutional Profile Survey was created to collect data around shared challenges, such as building diversity, controlling student debt, increasing the value of education, and addressing shortages of qualified faculty (ACAPT, 2022a). The ACAPT (n.d.) Criteria for Excellence defines excellence as: Excellence is an aspiration rather than a destination characterized by continual improvement. An excellent academic program demonstrates a culture of excellence by continually and intentionally striving to transform learners, advance knowledge, and improve societal health. Excellence in transforming learners, advancing knowledge, and improving societal health is achieved when the academic culture supports the ongoing development and integration of three domains: Inquiry, inclusion, and innovation. Excellence is a multi-faceted construct that respects and supports differences among academic programs while inspiring ongoing self-assessment and growth. (p. 3) The Excellence Framework outlines 12 critical categories to track success (ACAPT, 2022c). Words such as transformative, influential, innovation, risk-taking, collaboration, motivated, engaged, diversity, equity, inclusion, contemporary, adaptive, authentic, and social responsibility are seen throughout the 12 critical categories. Many of these exact words are found in the published literature, including the APTA Academy of Education Cerasoli Lectures (2022), outlining the challenges and suggested solutions in physical therapist education. Additionally, ACAPT (2022b) provides DPT program guidelines to assist programs in striving toward excellence, yet none of these documents operationally define these terms. Achieving excellence in programs may be part of the solution to some of the problems faced in DPT education. However, it is unclear if this work can address the many problems within DPT education without operational definitions to support the implementation. HYBRID DOCTOR OF PHYSICAL THERAPY STUDENT 15 The Rise of Hybrid DPT Education In recent years, a new instructional model of DPT education has emerged that many educators think holds promise in addressing some of the challenges: hybrid DPT education. Distance education, including online and hybrid formats across higher education, has steadily risen since 2014 (Allen et al., 2016). The first hybrid DPT programs were launched in 2008 (University of St. Augustine for Health Sciences, 2016) and 2011 (Nova Southeastern University, 2011). Both programs were described as flex programs that slowed down the time to a degree. They were characterized by their blended delivery model that combined online and face-to-face instruction with no residential requirements to create flexibility for working students and those otherwise unable to attend full-time graduate school (Nova Southeastern University, 2011; University of St. Augustine for Health Sciences, 2016). In 2015, the first full-time, fully hybrid DPT program was launched at South College. Like the early flex programs, there was no residential requirement. However, to be responsive to workforce demands and rising concerns about the debt-to-income ratio, this new type of hybrid program accelerated the time to degree to two years (South College, 2021). In 2020, the COVID-19 pandemic rapidly shifted most programs to an online format (Gagnon et al., 2020). Since then, almost all residential DPT programs have returned to in-person learning. However, research supports the benefits of remote instruction realized during the pandemic (Anderson & Dutton, 2022; Ortega et al., 2022; Plummer et al., 2021), and some programs have chosen to continue with blended instruction in the curriculum. Data indicate that at least 10 accredited institutions offer entry-level DPT education, with 25-50% of the program provided remotely and at least six institutions offering more than 50% in a remote method (ACAPT, 2022d). HYBRID DOCTOR OF PHYSICAL THERAPY STUDENT 16 Hybrid Model of DPT Education. Despite multiple programs now offering a hybrid DPT education model, there is limited published literature related to the model and its ability to address the challenges in DPT education. Most of the literature about hybrid DPT education has been conducted at the individual course level (Adams, 2013; Boucher et al., 2013; Lazinski, 2017; Veneri & Ganotti, 2014; Wassinger et al., 2021). Utilizing a flipped classroom for musculoskeletal DPT education, Boucher et al. (2013) and Wassinger et al. (2021) found improved course outcomes as evidenced by exam scores, and students in both studies were satisfied with the flipped model and most even preferred the method. In another study examining hybrid versus traditional course instruction using computer-assisted learning for a neurologic rehabilitation course, authors found average quiz grades to be improved, and final exam scores were statistically significantly higher in the hybrid group (Veneri & Ganotti, 2014). A study by Lazinski (2017) evaluated student outcomes with performance on practical assessments, online engagement, and student course evaluations for a hybrid one-credit hour lab course for performing surface palpation. Across three cohorts, only one student failed the practical assessment, students exceeded the posting requirement and page views, and qualitative comments related to student satisfaction were skewed in a positive direction. Other published literature on hybrid DPT education pertains to the perspective of students or faculty during the COVID-19 pandemic (Majsak et al., 2022; Neely et al., 2022; Ortega et al., 2021). Ortega et al. (2021) reviewed digital strategies implemented during the COVID-19 pandemic. They reported effective delivery of content, with more research needed on outcomes for the student, program, and community for programs that heavily use digital learning strategies. Majsak et al. (2022) analyzed challenges and faculty concerns about going virtual during the COVID-19 pandemic. This study found that faculty were most challenged with limited contact, HYBRID DOCTOR OF PHYSICAL THERAPY STUDENT 17 increased workload, and learning online technologies (Majsak et al., 2022). The biggest concerns from faculty included fewer hands-on labs, delays in clinical experiences, and safety during oncampus activities (Majsak et al., 2022). Neely et al. (2022) compared student clinical performance for those who received face-to-face education and those who received virtual education. The study results indicated that students in the virtual learning group had lower Clinical Performance Instrument scores and lower ratings from clinical instructors; however, none of the results were statistically significant. These study results must be taken with caution as many factors impacted the implementation of virtual learning during the COVID-19 pandemic. The instructional models explored may be described as emergency remote instruction versus thoughtfully constructed online learning experiences. Thus, the results cannot be generalized to the intentional use of the hybrid DPT education model. Only two studies address a fully hybrid instructional delivery model across a DPT program (Gagnon et al., 2022; Marinas et al., 2022). Marinas et al. (2022) studied students perception of cognitive load and the impact of gender and academic tutoring services on perceptions in an accelerated, blended DPT program. The study found no relationship between cognitive load and gender and a significant difference between students perception of cognitive load for those who received academic tutoring services and those who did not (Marinas et al., 2022). The study did not address whether students perceived a high versus low cognitive load. Gagnon et al. (2022) described the hybrid model implementation and early outcomes of a hybrid DPT education program. The case report provides insight into implementing a hybrid DPT education program inclusive of student affairs, academic affairs, faculty affairs, and institutional affairs (Gagnon et al., 2022). The outcomes of the report indicate that the program has a twoyear mean of 39% minority students enrolled versus the mean of 28% across all DPT programs HYBRID DOCTOR OF PHYSICAL THERAPY STUDENT 18 (Gagnon et al., 2022), suggesting that more than the average number of minority students may enroll in a hybrid DPT education program. Additionally, outcomes showed that most students were very or somewhat satisfied with the program, demonstrated a 96% graduation rate with 36.5% minority graduates, and a 97% ultimate two-year NPTE pass rate (Gagnon et al., 2022). The graduation rate, minority graduation rate, and the ultimate two-year pass rate either equal or exceed the average rates reported by the CAPTE data published in 2021 (Gagnon et al., 2022). There is no literature related to the specific characteristics of students enrolled in hybrid DPT programs or information about the reasons that students enroll in hybrid DPT programs. A study by Ancrum-Smalls et al. (2000) assessed factors of importance for physical therapist applicants choice of program. At the time of the study, there were only residential programs. Respondents rated the degree offered and the accreditation status as very influential (74%) (Ancrum-Smalls et al., 2000). Other factors garnering over 50% response as very influential included perceptions of the programs atmosphere, NPTE pass rate percentages, perceptions of faculty concern for student welfare, tuition costs, first impressions of the program, and distance from home (Ancrum-Smalls et al., 2000). On-campus housing, public transportation availability, student diversity, interaction with/perceptions of program undergraduate advisors, and familiarity with the campus were rated as least influential by 50% of respondents (AncrumSmalls et al., 2000). While this study is dated, it provides some foundation for factors to consider in student enrollment in hybrid DPT education programs. Data and Outcomes There is a lack of universal metrics collected in DPT programs, making it challenging to benchmark and compare program outcomes (Shields et al., 2021). Aggregate Program Data are reported by CAPTE annually (CAPTE, 2022), and ACAPT began reporting the Institutional HYBRID DOCTOR OF PHYSICAL THERAPY STUDENT 19 Profile Survey data in 2022 (ACAPT, 2022d). Neither CAPTE nor ACAPT data separate hybrid data from the aggregate for the program or student. Shields et al. (2018) began a series of studies (Dudley-Javoroski & Shields, 2022; Shields et al., 2021) to create universal metrics for DPT programs. The first study was completed at one university over eight years and utilized a survey based on the metrics and validity of the Association of American Medical Colleges Graduation Questionnaire (Shields et al., 2018). In the second study, the survey was named the Physical Therapist Graduation Questionnaire (PTGQ) (Shields et al., 2021). Data were collected and analyzed across 13% and 26.5% of programs to capture overall satisfaction, curriculum, learning environment, student experience, and student characteristics (Dudley-Javoroski & Shields, 2022; Shields et al., 2021). These three studies provide valuable information for benchmarking, but like CAPTE and ACAPT, there is no separation of data for hybrid programs or students Terminology A unique challenge to studying alternative education methods, especially those that include any online learning component, remains the incongruent terminology (Singh & Thurman, 2019). Various terms, including flipped, blended, online, distance education, and many others, are used interchangeably with the term hybrid. Numerous writings, some peer-reviewed and some not have attempted to provide standardized definitions (Allen et al., 2016; CAPTE, 2021; Malamed, 2010; Saichaie, 2020; Sener, 2015; Singh & Thurman, 2019). In addition, metaanalysis and review studies provide definitions to outline their processes for data collection (AlSamarraie et al., 2020; Cheng et al., 2019; He et al., 2021). Gagnon et al. (2020) utilized the Online Report Card (Allen et al., 2016) to distinguish blended/hybrid courses and programs as 30%-79% online with a minimum of 20% face-to-face. HYBRID DOCTOR OF PHYSICAL THERAPY STUDENT 20 Additionally, Gagnon et al. (2020) referenced the terms outlined by CAPTE (2021) to support working definitions of online, blended, flipped, and traditional instruction. Interestingly, the CAPTE (2021) does not define hybrid instruction but does define blended instruction as a blend of distance education, asynchronous learning, and face-to-face synchronous experiences. CAPTE (2021) does not provide any guidance related to the amount of instruction delivered in distance, asynchronous, and face-to-face synchronously. The reality is that to obtain a proper understanding of the information in the literature related to students in hybrid education, all terms need to be utilized in searching. For this study, the definition of hybrid remained consistent with the seminal hybrid DPT program publication by Gagnon et al. (2020) as a blend of online and face-to-face delivery, with 30-79% of the program delivered online and at least 20% delivered face-to-face. For additional clarity, hybrid programs are referred to as programs that do not require full-time residence or relocation to attend the program. The term residential will be used to reference programs that are not hybrid. This term is not defined in the literature but is defined in this paper as a program that requires full-time residence in a specific geographic location to attend the program. The term residential is chosen over the CAPTE (2021) term traditional because the definition of traditional includes all face-to-face learning experiences in the classroom, lab, or community setting. Given the rise of technology and the shift in educational methods associated with the COVID-19 pandemic, it is unclear if any DPT program meets the working definition of traditional. Student Experience When considering the profile of the entry-level hybrid DPT student, it is essential to look beyond demographics. Demographics and cognitive factors such as grade point average are consistently reported in the literature, but there is a growing body of evidence related to non- HYBRID DOCTOR OF PHYSICAL THERAPY STUDENT 21 cognitive factors (Huhn et al., 2021; Richardson et al., 2022; Roll et al., 2018; Dudley-Javoroski & Shields, 2022; Van Veld et al., 2018). These include emotional intelligence, grit, self-efficacy, TfA, and perfectionism. These factors are studied about outcomes, identifying support mechanisms for students, and as a means of predicting success. To date, these non-cognitive traits have not been included in any of the aggregate data that CAPTE or ACAPT report, but Shields et al. (2018, 2019) began reporting on TfA in their benchmarking studies and subsequently began reporting on perfectionism in the second wave of benchmarking studies (Dudley-Javorski & Shields, 2022). These data have been collected under a section titled Student Experience and included data on burnout, interpersonal reactivity, and empathy. The student experience factors of TfA and perfectionism were selected for this study based on the hypothesis that either trait could impact a students resolution to enroll in a hybrid DPT program and remain consistent with aggregate published data. Tolerance for Ambiguity TfA is a concept that has been studied in healthcare education, with most of the literature derived from medical education (Caulfield et al., 2014; Gaufberg et al., 2018; Geller et al., 1990; Geller et al., 1993; Hancock & Mattick, 2019; Patel et al., 2022; Weissenstein et al., 2014) and a few studies relevant to nursing (Knight et al., 2016; McMahon & Dluhy, 2017; Pressler & Kenner, 2010). The construct of tolerance for ambiguity is difficult to define in the literature. Early research defines it as the tendency to perceive situations that are novel, complex, or insoluble, as sources of threat (Budner, 1962, as cited in Gellar, 1993, p. 990). McClain et al. (2015) also cite Budners work but define ambiguity tolerance as an individuals systematic, stable tendency to react to perceived ambiguity with greater or less intensity (Definition, paragraph 2). HYBRID DOCTOR OF PHYSICAL THERAPY STUDENT 22 Craik (2001) suggests that students need for tolerance for ambiguity in physical therapy education is related to clinical decision-making, growth in knowledge, and professional maturation. Craiks (2001) sentiments are further validated by D. U. Jette (2016b) in the Cerasoli Lecture, Unflattening, where she stated, graduates must make decisions in the face of limited information, ambiguity, and uncertainty (p. 7). Further, graduates must be prepared to work in situations where uncertainty is the norm, and critical thinking and clinical reasoning are the skills needed to overcome uncertainty (D. U. Jette, 2016b). A. M. Jette (2016a) says that a clinician can and often needs to act even in ambiguity. He further states that ambiguity about the effectiveness of physical therapy intervention is never a cause for celebration (p. 134) but promotes asking, studying, and finding answers to questions. Finally, A. M. Jette (2016a) concludes that physical therapy educators know that transmitting ambiguity based on tradition and experience is not helpful and that scientific evidence should be the standard. However, without evidence, embracing ambiguity allows educators and students to know when we know something and when we do not. He advocates for the preparation of students regarding ambiguity and relays that embracing ambiguity is just as important as employing evidence-based practice (A. M. Jette, 2016a). Three studies have examined TfA in DPT students (Dudley-Javoroski & Shields, 2022; Shields et al., 2018; Shields et al., 2021). These studies used the validated Tolerance for Ambiguity (TFA) Scale (Gellar et al., 1993). Results from the first study showed no significant difference in TfA between physical therapists and medical students (Shields et al., 2018). However, both subsequent studies showed a significantly lower TfA among DPT students than medical students. These findings suggested the need to investigate further the optimal levels of HYBRID DOCTOR OF PHYSICAL THERAPY STUDENT 23 TfA for successful outcomes in DPT education and to consider capturing TfA data before matriculating into DPT programs. Perfectionism Perfectionism has been defined in the literature since the mid-twentieth century as demanding of oneself or others a higher quality of performance than is required by the situation (Hollender, 1965, p. 94). The construct was included in the Diagnostic and Statistical Manual of Mental Disorders (DSM) III as a major diagnostic criterion (Frost et al., 1990) and is classified in the present-day DSM-5 as a lower-order facet of compulsivity (Ayearst et al., 2012). Perfectionism is multidimensional, with adaptive and maladaptive outcomes (Hewitt et al., 2003). Additionally, definitions of perfectionistic strivings and concerns were developed from a factor analysis by Frost et al. (1993). Perfectionistic striving consisted of the self-directed pursuit of self-determined high standards without high self-criticism and was associated with positive affect (Frost et al., 1993). Perfectionistic concerns consisted of the drive to obtain unrealistically high standards with excessive self-criticism and doubting self-ability and were associated with negative affect (Frost et al., 1993). Perfectionistic strivings are often grouped with adaptive perfectionism, and perfectionistic concerns are often grouped with maladaptive perfectionism. Meta-analyses have focused on maladaptive outcomes and found that perfectionistic concerns had a positive relationship with multiple psychopathological outcomes (Limburg et al., 2017) and a positive relationship with burnout symptoms (Hill & Curran, 2016). A meta-analysis by Madigan (2019) aimed to determine if perfectionism predicted academic achievement. The study found perfectionistic strivings to have a small to medium positive relationship with academic achievement, and perfectionistic concerns a small negative relationship with academic achievement (Madigan, 2019). HYBRID DOCTOR OF PHYSICAL THERAPY STUDENT 24 The impacts of maladaptive perfectionism have been studied in medical and health profession students and have been correlated with depression, anxiety, and stress (Bogardus et al., 2022; Enns et al., 2001; Henning et al., 2002). Other studies have found positive outcomes of adaptive perfectionism in shaping authentic leadership (Jaworski et al., 2022) and with baseline academic performance expectations and conscientiousness (Enns et al., 2008). Students working toward acceptance into physical therapist education programs may have to compete with others for limited slots in their programs of choice. This inherent competition may lead to perfectionistic tendencies. Richardson et al. (2022) studied perfectionism in entry-level DPT students and found that 41% were adaptive perfectionists and 25% were maladaptive perfectionists. Other literature related explicitly to DPT students and perfectionism groups DPT students with other health professions students (Bogardus et al., 2022; Filipkowski et al., 2021), making it difficult to ascertain if DPT students experience perfectionism with adaptive and maladaptive outcomes more than other healthcare professions students. Dudley-Javoroski and Shields (2022) utilized the FMPS-B in entry-level DPT students. They found that scores were generally higher for perfectionistic strivings than concerns, suggesting that DPT may experience more favorable outcomes related to adaptive perfectionism. Examining the Student Experience factors of TfA and perfectionism tendencies of students who enroll in hybrid DPT education programs may provide helpful information for administrators and faculty about student support services and evaluating outcomes based on these constructs. It is unknown if there is any correlation between TfA and perfectionism with hybrid DPT education program selection. HYBRID DOCTOR OF PHYSICAL THERAPY STUDENT 25 Method Study Type and Design This study used a quantitative, non-experimental study using a cross-sectional design. The survey was conducted online using Qualtrics, an online survey program. The study took place from February 2023 to July 2023. Before participant recruitment, the study was approved by the University of Indianapolis Institutional Review Board. Participants Entry-level Doctor of Physical Therapy (DPT) students were recruited for this study using convenience sampling. Inclusion criteria included students 18 or older currently enrolled in any candidate or accredited hybrid DPT program. Exclusion criteria excluded students in a DPT program outside the United States and students in residential and post-professional programs. It is estimated that 3400 students were enrolled in one of the 19 accredited or candidate for accreditation programs in the United States in the Spring of 2023. Based on a 10% participation rate, the sample size target was 340. To increase the likelihood that the sample would represent the population, all eligible students who completed the survey were included in the study for an estimated maximum of 1,700 participants. Data Variables included student demographics, TfA scores, and FMPS-B scores. In addition, key considerations from the students perspective about enrolling in their specific hybrid DPT program were collected using a 5-point Likert scale. The variables collected are listed and defined below. Variables Variables for student characteristics included HYBRID DOCTOR OF PHYSICAL THERAPY STUDENT 26 age (years), gender (male, female, non-binary, other), sexual orientation (lesbian, gay, bisexual, transgender, queer, heterosexual, other) race (African American/Black, American Indian/Alaskan Native, Asian, Caucasian/White, Hispanic/Latino, Native Hawaiian/Other Pacific Islander, two or more races, unknown, prefer not to answer), highest advanced degree achieved (Bachelors, Masters, Clinical Doctorate, Terminal Doctorate), committed relationship (yes, no) relationship status (married or civil union living together or apart, not married or civil union living together or apart), divorced, widowed, separated, none of these apply (select all that apply) parental status- biological, adopted, foster, or stepchildren (no, no expecting, yes (1, 2, 3, 4 or more)) age of children and in the home or not, in matrix format (one, two, three, four); age of children, preschool (birth to 5 years), elementary (6-13 years), adolescent (14-18 years), adult (19+ years of age); living with you full time (365 days a year), part-time (less than 365 days a year), not living with you), caregiver for someone other than your children (yes, no), person living with you (yes, no), residential location before enrollment in the program- dropdown of states with categorization post data collection as follows (South Atlantic (DE, DC, FL, GA, MD, NC, PR, SC, VA, WV), Middle Atlantic (NJ, NY, PA), East North Central HYBRID DOCTOR OF PHYSICAL THERAPY STUDENT 27 (IL, IN, MI, OH, WI), West North Central (IA, KS, MN, MO, NE, ND, SD), West South Central (AR, LA, OK, TX), New England (CT, ME, MA, NH, RI, VT), Pacific (AK, CA, HI, OR, WA), East South Central (AK, KY, MS, TN), Mountain (AZ, CO, ID, MT, NV, UT, WY), other (write-in), relocation status for the program (yes/no), relocation location- dropdown of states with categorization post data collection as follows (South Atlantic (DE, DC, FL, GA, MD, NC, PR, SC, VA, WV), Middle Atlantic (NJ, NY, PA), East North Central (IL, IN, MI, OH, WI), West North Central (IA, KS, MN, MO, NE, ND, SD), West South Central (AR, LA, OK, TX), New England (CT, ME, MA, NH, RI, VT), Pacific (AK, CA, HI, OR, WA), East South Central (AK, KY, MS, TN), Mountain (AZ, CO ID, MT, NV, UT, WY), other (write-in), name of DPT program currently enrolled in- categorized post-data collection based on unique survey link by the primary researcher (T. B.) acceptance to other hybrid DPT programs (yes, no), acceptance to residential (non-hybrid) DPT programs (yes, no), method of learning about the program (friend/family member, internet search, PTCAS, social media (Instagram, Facebook, Twitter), undergraduate professor/advisor, online advertisement, other (write-in), tolerance for ambiguity (TfA Scale Score), perfectionism (FMPS-B subscale scores) HYBRID DOCTOR OF PHYSICAL THERAPY STUDENT 28 Operational Definitions of Variables Hybrid was defined as a program that blends online and face-to-face delivery; 30-79% of the content is delivered online with a minimum of 20% face-to-face in a physical location together (Gagnon et al., 2020). The concept of tolerance for ambiguity was operationalized using scores obtained on the TfA scale (Geller et al., 1993). Perfectionism was operationalized as the two subscale scores on the FMPS-B (Burgess et al., 2016). Student-reported key considerations of enrollment in a specific hybrid DPT program were defined using a 1-5 Likert, 1 (not important) to 5 (very important), and included university factors: reputation, tuition cost, travel cost, housing cost; program factors: mission, vision, values, program duration, faculty, location; admissions factors: online webinars, pre-admission visits, interactions with the admissions team; outcomes factors: National Physical Therapy Examination (NPTE) first and ultimate (two-year average) pass rates, diversity of study body, graduation rates, employment rates; others: free text write-in space provided. Instruments Tolerance for Ambiguity Scale The TfA scale (Appendix A) measures the tendency to see ambiguous situations as threatening (Budner, 1962, as cited in Geller, 1993). It is comprised of seven questions and utilizes a Likert scale from 1 (strongly agree) to 6 (strongly disagree) (Geller et al., 1993). Summed scores range from 7 to 42, with lower scores demonstrating decreased tolerance and higher scores demonstrating increased tolerance (Geller et al., 1993). The survey has moderate internal consistency ( = .75) and demonstrates construct validity based on the assumption that a self-inventory test is only useful if some overt manifestation of the variable can be strongly related to that test (MacDonald, 1970, as cited in Geller et al., 1993, p. 997). Geller et al. (1993) HYBRID DOCTOR OF PHYSICAL THERAPY STUDENT 29 state that the TfA scale study conducted with physicians on attitudes toward genetic testing reflected behavior correlates of ambiguity tolerance, establishing construct validity. The scale is openly available for use. Frost Multidimensional Perfectionism Scale-Brief The FMPS-B comprises two subscales: evaluative concerns and strivings (Appendix B). Each subscale consists of 4 questions (Burgess et al., 2016). Items are scored on a Likert scale from 1 (strongly disagree) to 5 (strongly agree), and each subscale score is summed separately (Woodfin et al., 2020). Scores on each subscale range from 4 to 20, with higher scores indicating more perfectionistic tendencies. The evaluative concerns scale has a Cronbachs coefficient of = .91, and the strivings scale has a Cronbachs coefficient of = .84, indicating good internal consistency (Tonta et al., 2021). The scale has construct validity with demonstrated concurrent and convergent validity with other similar scales (r = .68-.72) (Burgess et al., 2016). This scale is openly available for use. Procedures Recruitment Participants were recruited via a phone call and email through their DPT program director or program faculty. The primary researcher (T. B.) contacted all accredited or candidate hybrid DPT program directors or faculty to ask for cooperation to disseminate the survey via email to their students. Informed Consent Informed consent was included on the first page of the Qualtrics survey. Participants were required to select yes or no, indicating their understanding of the research project and consent to participate. Participants who selected yes were routed to the surveys first question. HYBRID DOCTOR OF PHYSICAL THERAPY STUDENT 30 Participants who indicated no were routed to a closing page, which thanked them for their consideration. Data Collection Data were collected using a secure Qualtrics survey created by the primary researcher (Appendix C). Before data were collected with the survey, a pilot of the survey was completed utilizing DPTs who had just completed a hybrid DPT program. The survey link was customized for each program participating and was only provided to DPT program directors or faculty who agreed to survey dissemination. The survey link remained open for three months. Two reminder emails were sent to potential participants at four and eight weeks. Students were offered an opportunity to provide their name and email address in a Google Survey, linked at the end of the survey, for inclusion in a drawing for one of ten $25 Amazon gift cards after completion. Participants were also allowed to indicate their interest in being interviewed for phase two of the study. Fraud detection measures, including the prevention of multiple submissions and bot detection, were enabled in the Qualtrics survey software. Data Management All surveys were disseminated to each hybrid program using a unique survey link, and responses were given a unique study identification number for data analysis. The data were downloaded from Qualtrics into a Microsoft Excel file for data cleaning, summing, and calculation of instrument scores. The Microsoft Excel file was password-protected and stored on a password-protected hard drive. Statistical Analysis Statistical tests were run using IBM SPSS Statistics for Windows, Version 28.0 (IBM Corp., Armonk, NY). All statistical tests were two-tailed, and the significance level was set at HYBRID DOCTOR OF PHYSICAL THERAPY STUDENT 31 .05. Normality of interval and ratio data were determined using Shapiro-Wilk tests and visual inspection of Q-Q plots and histograms. Descriptive statistics were used to explore the demographic characteristics of the sample and tolerance for ambiguity and perfectionism scores. Nominal data are reported as frequencies and percentages, and normally distributed interval and ratio data are reported as means and standard deviations. Medians and interquartile ranges are reported for ordinal and non-normally distributed interval and ratio data. Results Thirteen of 19 US hybrid DPT programs, 68%, participated in this study. Four hundred twenty-four participants started surveys, and 379 surveys were more than 50% complete and included in the analysis. The sample included participants from a hybrid DPT program in every regional location in the United States (see Figure 1). The median age of the sample was 25 years (25th percentile = 23, 75th percentile = 29). The general demographic characteristics (gender, race, and education) of the sample are presented in Table 1. Expanded demographic characteristics (sexual orientation, children, relocation, and acceptance into other programs) are presented in Table 2. Of the participants with children (n = 45, 11.8%), 29 (64.4%) had more than one child. The children were primarily preschool age, (n = 38, 84.4%), or elementary age, 22 (48.8%). Twelve (3.2%) participants reported they were caregivers to someone other than their children, and 6 (50%) reported that the person they cared for lived in the same house. Most respondents heard about the program for which they enrolled through an internet search 125 (33%), the Physical Therapist Centralized Application Service 82 (21.6%), or a family/friend/coworker 87 (23%). The least reported methods of hearing about the program included social media 39 (10.3%), undergraduate professor/advising 21 (5.5%), and online advertisement 13 (3.4%). HYBRID DOCTOR OF PHYSICAL THERAPY STUDENT 32 Three hundred and seventy participants completed the TfA and FMPS-B tests. The median score on the TfA was 22 (25th percentile = 17, 75th percentile = 26). The median strivings score on the FMPS-B was 16 (25th percentile = 14, 75th percentile = 18). The median evaluative score was 11 (25th percentile = 8, 75th percentile = 14). Descriptive statistics on key considerations of a students decision to enroll in their specific hybrid DPT program showed program duration, first-time NPTE pass rates, ultimate NPTE pass rates, graduation rate, and employment rate all had a median score of 5, very important. Diversity of the student body had a median score of 3, moderately important. A lab visit before admission had a median score of 2, slightly important. All other factors had a median score of 4, important. Key considerations were collapsed, combining Likert scale ratings of very important and important, as well as ratings of slightly important and not important. See Table 3 for results. Discussion This study is the first to capture data specific to the characteristics and experiences of the hybrid DPT student. Anecdotally, there are many assumptions regarding the student who would choose and be successful in a hybrid DPT program. Some assumptions include hybrid programs increasing the diversity of students, only students who cannot get into a residential program would choose a hybrid program, and assumptions about the quality of students who would be attracted to a hybrid program. Until now, no studies have collected and reported data on the hybrid DPT student to validate those assumptions. Characteristic Demographic Profile of Hybrid DPT Students The characteristic demographics of age, sexual orientation, and racial diversity of the hybrid DPT student appear to be very similar to aggregate data. The median age of the hybrid HYBRID DOCTOR OF PHYSICAL THERAPY STUDENT 33 student was 25 years, and 91.8% reported being heterosexual. This is very close and likely not significantly different than the average age at graduation of 26.2 years and 93.2% heterosexual, as reported in the PT-GQ data by Dudley-Javoroski and Shields (2022). This study found a racial minority population of 28% and a white population of 71%, slightly different from the CAPTE (2022) aggregate data reporting a racial minority population of 30% and a white population of 65%. Early data suggested hybrid DPT programs may increase racial diversity (Gagnon et al., 2022). The differences found in this study compared to the aggregate are small. There appears to be a difference in the marital status and those with children in hybrid DPT students as observationally compared to the aggregate. This study found that 33.5% of students were married and 13.5% had children, compared to 17.5% of students reporting married and 3.8% of students with children reported in the PT-GQ data (Dudley-Javoroski et al., 2022). This equates to approximately twice the number of students in hybrid programs being married and just over 3.5 times the number reporting having children. While it is unknown if this is a statistically significant difference, this seems to be quite a difference. It is hypothesized that people who are married or have children may be more attracted to a hybrid program due to the ability to remain living in a location where they are established, their spouse may be working, their children may be in school, or where they might have support systems in place to help with families while still being able to complete a DPT program. Additionally, this study found a nearly 10% higher population of females at 72% versus 62% in the aggregated data (CAPTE, 2022). This may be due to women, more classically the family caretakers, choosing hybrid programs to further education while still being able to remain home most of the time with their families. Interestingly, less than 20% of participants reported relocating to attend their hybrid DPT program. This may be due to the cost of travel associated with attending face-to-face HYBRID DOCTOR OF PHYSICAL THERAPY STUDENT 34 activities such as orientation and lab immersions or may be due to the location of clinical education placements. Future research on demographic characteristics of hybrid DPT students should focus on obtaining raw data from both hybrid and residential DPT students with a large sample size to complete interferential statistical analysis to determine if actual statistically significant differences exist between the two groups. Additionally, there is a need for qualitative studies to further examine why students with certain characteristics choose hybrid programs. Tolerance for Ambiguity and Perfectionism TfA scores of the hybrid DPT sample were nearly identical to those of the aggregate data available. Participants' median score on the TfA scale was 22 out of 42 available points. This is very similar to aggregate data reported in the PT-GQ of a mean score of 23 (Dudley-Javoroski & Shields, 2022). Only the published studies reporting the PT-GQ data have reported these TfA in DPT students (Dudley-Javoroski & Shields, 2022; Shields et al., 2021). Despite the lack of published data, in recent years, multiple publications have stated the importance of tolerance for ambiguity in DPT students and medical students (Blanton et al., 2020; Hancock & Mattick, 2020). Additional research is needed in this area to determine if the construct of tolerance for ambiguity is different among hybrid DPT students as compared to residential DPT students and to determine if tolerance for ambiguity impacts outcomes for DPT programs and licensure examinations. Like TfA scores, participants in this study scored nearly the same scores on the FMPS-B as the published aggregate data. Data from this study showed a difference of less than .5 points between the two subscales compared to the data collected from the PT-GQ (Dudley-Javoroski & Shields, 2022). This supports the findings from Dudely-Javroski & Shields (2022), which pose HYBRID DOCTOR OF PHYSICAL THERAPY STUDENT 35 that DPT students tend to score higher in the strivings category than the concerns category, suggesting more favorable outcomes towards adaptive perfectionism. Continued research is needed surrounding non-cognitive factors related to student experience and acceptance to DPT programs to determine the impact these factors have on student outcomes. Key Considerations of Importance in Selection of a Specific Hybrid DPT Program Results of this study show that more than half of the participants were accepted into multiple DPT programs and could select the program of their choice. Over 80% of respondents accepted to multiple programs had the option to attend a residential program yet selected a hybrid program. These data suggest that when students have a choice, the majority are likely to choose a hybrid pathway. This is impactful because it puts data behind the rationale for programs to offer the hybrid education pathway and invalidates the assumption that only students who cannot get into residential programs go to hybrid programs. This study examined four categories of potential considerations and their importance in selecting a specific hybrid DPT program. The consideration categories included university factors, program factors, admission factors, and outcome factors. The outcome factors category was shown to have the most important considerations, having 4 out of the top 5 most important considerations. It is not surprising to see these considerations show up in the top 5 because CAPTE requires DPT programs to publish these outcomes on their websites, which makes this data some of the most readily available data to those selecting a program. The only other study examining factors of importance in an applicants choice of program also included the NPTE pass rate percentages as being very influential (Ancrum-Smalls et al., 2000). The other consideration in the top 5 at number 3 was a program consideration of program duration. This is interesting because 87% of participants in this study are from hybrid DPT programs that could be HYBRID DOCTOR OF PHYSICAL THERAPY STUDENT 36 considered accelerated time to degree programs with program completion in 30 months (7 semesters) or less. This suggests that a shorter program duration may be more favorable in students selection of a hybrid DPT program. The admissions factors category included 3 of the least important considerations in selecting a hybrid DPT program, with the number 1 least important- lab visit, number 4interaction with the program, and number 5- online webinar. These findings are important because programs must choose where to spend their recruitment funds. Providing staff and faculty coverage for lab visits, interactions with students, and online webinars can be costly and may be the least effective manner to use funds. Other considerations in the top 5 least important included number 2- diversity of students and number 3- housing cost. Diversity is a common topic of discussion in the recruitment and retention of DPT students; however, it seems that participants rank this as low importance in their selection of a hybrid DPT program. It is important to note that only 29.3% of respondents for this research were racial minorities, which could have impacted the importance of this factor among respondents. Housing costs may be of little importance to students because relocation is not required to complete a hybrid DPT, and only 18% of respondents reported relocating to attend their program. Therefore, the cost of housing in the physical location of the program may not be an important consideration since most participants did not relocate. The least important considerations in this study match several of the least influential factors found in the Ancrum-Smalls et al. (2000) study, with commonalities among student diversity and interaction with the program included. This research study acquired quantitative data on the important considerations for students in selecting their hybrid DPT program. Future studies should aim to collect qualitative data on this subject to determine if there were important considerations that were not listed in this study that had an HYBRID DOCTOR OF PHYSICAL THERAPY STUDENT 37 impact on students decision to enroll in their specific hybrid DPT program. Additionally, research should aim to determine why students choose hybrid programs and residential programs. Limitations There were several limitations to this study. First, this study could only obtain information from approximately 10% of the current hybrid DPT student population, which is a limited sample. A normal distribution of respondents was not achieved. All students from all hybrid DPT programs with current cohorts were invited to participate; however, access to advertise the opportunity to participate in the research was limited by the program's willingness to disseminate the call for participation and the survey link to their students. A second limitation was oversight by the researcher in collecting the specific year of the program that respondents were in during the data collection. Respondents in their first year may have responded differently to student experience questions than respondents in their second year due to a lack of maturation in tolerance for ambiguity and perfectionism. A third limitation of the study was the lack of working definitions within the survey instrument. This left room for misinterpretation of the words used in the key considerations area of the survey. Conclusion This study provides key insight into the characteristics and experiences of hybrid DPT students, benchmarked against national aggregate data. The profile of a hybrid DPT student is similar to the national DPT student population in terms of age, demographics (age, sexual orientation, race/ethnicity), tolerance for ambiguity, and perfectionism. Hybrid DPT students are more likely to be married and/or have children, and the majority are accepted to multiple programs, including residential as well as other hybrid programs. Published graduate outcomes HYBRID DOCTOR OF PHYSICAL THERAPY STUDENT 38 are the most important factor for students when choosing to enroll in their hybrid program. This study lays the foundational work for expanded qualitative studies. 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Internet Journal of Allied Health Sciences and Practice, 19(1), Article 10. https://doi.org/10.3352/jeehp.2018.15.19 Jaworski, M., Panczyk, M., Lenczuk-Gruba, A., Nowacka, A., & Gotlib, J. (2022). The trend of authentic leadership in nursing education: The key role of perfectionism and self-efficacy. International Journal of Environmental Research and Public Health, 19(4), Article 1989. https://doi.org.10.3390/ijerph19041989. Jensen, G. M., Hack, L. M., Nordstrom, T., Gwyer, J., & Mostrom, E. (2017a). National study of excellence and innovation in physical therapist education: Part 2- A call to reform. Physical Therapy, 97(9), 875-888. HYBRID DOCTOR OF PHYSICAL THERAPY STUDENT 46 Jensen, G. M., Nordstrom, T., Mostrom, E., Hack, L. M., & Gwyer, J. (2017b). National study and innovation in physical therapist education: Part 1- Design, method, and results. Physical Therapy, 97(9), 857-874. Jette, A. M. (2016a). In pursuit of the ever-expanding shoreline. Physical Therapy, 96(2), 134135. https://doi.org/10.2522/ptj.2016.96.2.134 Jette, D. U. (2016b). Unflattening. Journal of Physical Therapy Education, 30(3), 4-10. https://doi.org/10.1097/00001416-201630030-00003 Killian C. B., May, F. E., & Moore, E. S. (2022). Statistical Procedures Manual for SPSS. Knight, K., Kenny, A., & Endacott, R. (2016). From expert generalists to ambiguity masters: using ambiguity tolerance theory to redefine the practice of rural nurses. Journal of Clinical Nursing, 25, 11-12. https://doi.org/10.1111/jocn.13196 Lazinski, M. J. (2017). Psychomotor skills, physical therapy, and a hybrid course: A case study. Quarterly Review of Distance Education, 18(4), 5769. Limburg, K., Watson, H. J., Hagger, M. S., & Egan, S. J. (2017). The relationship between perfectionism and psychopathology: A meta-analysis. Journal of Clinical Psychology, 73(10), 1301-1326. Madigan, D. J. (2019). A meta-analysis of perfectionism and academic achievement. Educational Psychology Review, 31, 967-989. Marinas, R., Groff, S., Panesar-Aguilar, S., & Bobbio, T. G. (2022). Students perception of cognitive load in an accelerated DPT program with a blended learning curriculum. Global Journal of Health Science, 14(2), 52-62. Majsak, M. J., Hall, C. A., Kirsch, N. R., Krencicki, D. B., Locke, E., & Hyland, N. (2022). Physical therapy education program faculty challenges, concerns, and priorities during the HYBRID DOCTOR OF PHYSICAL THERAPY STUDENT 47 COVID-19 pandemic: Looking back and moving forward. Journal of Physical Therapy Education, 36(2), 97-106. Malamed, C. (2010, June 6). Glossary of online learning terms. The eLearning Coach. https://theelearningcoach.com/resources/online-learning-glossary-of-terms/ McMahon, M. A., & Dluhy, N. M. (2017). Ambiguity within nursing practice: An evolutionary concept analysis. Research and Theory for Nursing Practice, 31(1), 56-74. https://doi.org/10.1891/1541-6577.31.1.56 Moffat, M. (2003). The history of physical therapy practice in the United States. Journal of Physical Therapy Education, 17(3), 1525. https://doi.org/10.1097/00001416-20031000000003 Moffat, M. (2012). A history of physical therapist education around the world. Journal of Physical Therapy Education, 26(1), 1323. McPoil, T. G. (2019). Is excellence in the cards? Physical Therapy, 99(10), 1281-1290. https://doi.org/ 10.1093/ptj/pzz104 Neely, L., Pabian, P., Darby, A., Tintor, M. Vatnsever, S. & Stock, M. (2022). Examining clinical readiness and performance of student on clinical education experiences: Is there an influence from virtual learning? Journal of Physical Therapy Education, Advance Online Publication. https://doi.org.10.1097/JTE.0000000000000243 Nordstrom, T., Jensen, G. M., Altenburger, P., Blackinton, M., Deusinger, S., Hack, L., Patel, R., Tschoepe, B., & VanHoose L. (2022). Crises as the crucible for change in physical therapist education. Physical Therapy, 102(7), Article pzac055. Nova Southeastern University. (2011, April 7). Nova Southeastern University launches new physical therapy program in the Tampa Bay area. News Wise. HYBRID DOCTOR OF PHYSICAL THERAPY STUDENT 48 https://www.newswise.com/articles/nova-southeastern-university-launches-new-physicaltherapy-program-in-the-tampa-bay-area Ortega, M. A., Marchese, V. G., Zarro, M. J., Film, R. J., Shipper, A. G., & Felter, C. (2021). Digital and blended curriculum delivery in health professions education: An umbrella review with implications for doctor of physical therapy education programs. Physical Therapy Reviews, 27(1), 4-24. https://doi.org/10.1080/10833196.2021.2000286 Patel, P., Hancock, J., Rogers, M., & Pollard, S. R. (2022). Improving uncertainty tolerance in medical students: A scoping review. Medical Education. Advanced online publication. https://doi.org/10.1111/medu.14873 Plummer, L., Kaygisiz, B. B., Kuehner, C. P., Gore, S., Mercuro, R., Chatiwala, N., & Naidoo, K. (2021). Teaching online during the COVID-19 pandemic: A phenomenological study of physical therapist faculty in Brazil, Cyprus, and the United States. Education Sciences, 11(3), Article 130. https://doi.org/10.3390/educsci11030130 Portney, L. G. (2014). 17th Pauline cerasoli lecture: Choosing a disruptive path toward tomorrow. Journal of Physical Therapy Education, 28(3), 4-14. Pressler, J. L., & Kenner, C. A. (2010). Tolerance of ambiguity in nursing academia. Nurse Educator, 35(4), 139-140. https://doi.org/10.1097/NNE.0b013e3181e33813 Prober, C. G., & Khan, S. (2013). Medical education reimagined. Academic Medicine, 88(10), 1407-1410. QualtricsXM. (2022). Fraud detection. Support. https://www.qualtrics.com/support/surveyplatform/survey-module/survey-checker/fraud-detection/ Richardson, M. V., Miller, H., Papa, E., & Santurri, L. (2022). Perfectionism, stress, and the entry-level doctor of physical therapy student: A cross-sectional, observational study. HYBRID DOCTOR OF PHYSICAL THERAPY STUDENT 49 Journal of Physical Therapy Education, 36(1), 9-16. Roll, M., Canham, L., Salamh, P., Covington, K., Simon, C., & Cook, C. (2018). A novel tool for evaluating non-cognitive traits of doctor of physical therapy learners in the United States. Journal of Educational Evaluation for Health Professions, 15(19). https://doi.org/10.3352/jeehp.2018.15.19 Saichaie, K. (2020). Blended, flipped, and hybrid learning: Definitions, developments, and directions. New Directions for Teaching & Learning, 164, 95104. https://doi.org/10.1002/tl.20428 Sener, J. (2015, July 7). Updated e-learning definitions. Online Learning Consortium. Shields, R. K., Dudley-Javoroski, S., Sass, K. J., & Becker Marcie. (2018). Benchmarking the physical therapist academic environment to understand the student experience. Physical Therapy & Rehabilitation Journal, 98(8), 658-669. https://doi.org/10.1093/pgj/pzab229 Shields, R. K., The Benchmarking Research Advances Value in Education Group, & DudleyJavoroski, S. (2021). Benchmarking in academic physical therapy: A multicenter trial using the PT-GQ survey. Physical Therapy & Rehabilitation Journal, 101(12), Article pzab229. https://doi.org/10.1093/ptj/pzab229 Singh, V., & Thurman, A. (2019). How many ways can we define online learning? A systematic literature review of definitions of online learning (1988-2018). The American Journal of Distance Education, 33(4), 289306. https://doi.org/10.1080/08923647.2019.1663082 South College. (2021). Learn more about our doctor of physical therapy program. https://www.south.edu/programs/doctor-physical-therapy/about-us/ Thibault, G. (2020). The future of health professions education: Emerging trends in the United States. FASEB BioAdvances, 2(12), 685-694. HYBRID DOCTOR OF PHYSICAL THERAPY STUDENT 50 Tonta, K. E., Boyes, M., Howell, J., McEvoy, P., & Hasking, P. (2021). Measurement invariance of perfectionism measures in students with and without a history of non-suicidal self-injury. International Journal of Environmental Research and Public Health, 18(190), Article 10171. University of St. Augustine for Health Sciences. (2016, December 28). History. University of St. Augustine for Health Sciences. https://www.usa.edu/about/history-of-university-of-staugustine-for-health-sciences/ Van Veld, R., Slaven, E., Reynolds, B., Shupe, P., &Woolery, C. (2018). First-year doctor of physical therapy students demonstrate change in coping with stress. Journal of Physical Therapy Education, 32(2), 138-144. Veneri, D. A., & Ganotti, M. (2014). A comparison of student outcomes in a physical therapy neurologic rehabilitation course based on delivery mode: Hybrid vs traditional. Journal of Allied Health, 43(4), e75e81. Wassinger, C. A., Owens, B., Boynewicz, K., & Williams, D. A. (2021). Flipped classroom versus traditional teaching methods within musculoskeletal physical therapy: A case report. Physiotherapy Theory and Practice, Advance online publication. https://doi.org/10.1080/09593985.2021.1941457 Weissenstein, A., Ligges, S., Brouwer, B., Maschall, B., & Friederichs, H. (2014). Measuring the ambiguity tolerance of medical students: a cross-sectional study from the first to sixth academic years. BMC Family Practice, 15(6), 1-5. https://doi.org/10.1186/1471-2296-15-6 Woodfin, V., Binder, P. & Molde, H. (2020). The psychometric properties of the frost multidimensional perfectionism scale-brief. Frontiers in Psychology, 11. https://www.frontiersin.org/articles/10.3389/fpsyg.2020.01860/full HYBRID DOCTOR OF PHYSICAL THERAPY STUDENT Wojciechowski, M. (2015). The future of physical therapist education. American Physical Therapy Association. 51 HYBRID DOCTOR OF PHYSICAL THERAPY STUDENT 52 Table 1 General Demographic Characteristics (N = 379) Demographics Gender Male Female Non-binary Race African American/Black American Indian/Alaskan Native Asian Caucasian/White Hispanic/Latino Native Hawaiian/Other Pacific Islander Two or more races Unknown Education Bachelors Masters Clinical Doctorate Terminal Degree n % 104 273 2 27.4 72.0 0.5 18 2 25 268 25 3 33 1 4.7 0.5 6.6 70.7 6.6 0.8 8.7 0.3 313 44 19 3 82.6 11.6 5.0 0.8 HYBRID DOCTOR OF PHYSICAL THERAPY STUDENT 53 Table 2 Expanded Demographic Characteristics (N = 379) Demographics Sexual Orientation Heterosexual LGBTQ+ Relationship Status Committed Not Committed Divorced Separated Married, Living with Spouse Married, Living Apart Not Married, Living with Partner Not Married, Living Apart Children Yes 1 Child 2 Children 3 Children 4+ Children Expecting No Relocation Yes No Accepted to >1 DPT Program Yes No Accepted to a Residential Program Yes No Accepted to a Hybrid Program Yes No Accepted to another Hybrid and a Residential Program n % 347 31 91.8 8.2 281 98 9 1 126 1 71 83 74.1 25.9 2.4 0.8 33.2 0.3 18.7 21.9 45 16 19 8 2 6 328 11.8 4.2 5.0 2.1 0.5 1.6 86.5 69 309 18.3 81.7 206 173 54.4 45.6 171 208 45.1 54.9 67 312 38 17.7 82.3 10.0 HYBRID DOCTOR OF PHYSICAL THERAPY STUDENT 54 Table 3 Key Considerations in Enrollment in a Specific Hybrid DPT Program (N = 379) Key Consideration University Factors University Reputation Tuition Cost Travel Cost Housing Cost Program Factors Program Duration Program Mission Program Vision Program Values Program Faculty Program Reputation Program Lab Location Admission Factors Online Webinar Lab Visit Interaction Outcome Factors NPTE First Time Pass NPTE Ultimate Pass Diversity of Students Graduation Rate Employment Rate Very Important/ Important n % Moderately Important n % Slightly Important/ Not Important n % Median 255 67.3 76 20.1 48 12.6 4 266 217 206 70.2 57.3 54.4 84 92 79 22.2 24.3 20.8 29 70 93 7.6 18.5 24.5 4 4 4 315 224 226 250 292 274 83.1 59.1 59.7 66.0 77.1 72.3 41 83 82 74 48 72 10.8 21.9 21.6 19.5 127 19 22 72 70 54 37 32 5.8 19.0 18.5 14.3 9.7 8.4 5 4 4 4 4 4 229 60.4 94 24.8 55 14.5 4 220 74 214 58.0 19.5 56.4 71 82 76 18.7 21.6 20.1 86 221 87 22.6 58.3 23.1 4 2 4 312 82.4 37 9.8 30 7.9 5 307 81.0 36 9.5 35 9.3 5 174 45.9 87 23 116 30.6 3 323 319 85.2 84.2 29 29 7.7 7.7 26 30 6.8 7.9 5 5 HYBRID DOCTOR OF PHYSICAL THERAPY STUDENT Figure 1 Percentage of Participants per Regional Location 6.3 3.7 9.0 11.1 16.3 14.3 5.8 10.0 23.5 South Atlantic Middle Atlantic East North Central West North Central West South Central New England Pacific East South Central Mountain 55 HYBRID DOCTOR OF PHYSICAL THERAPY STUDENT 56 Appendix A Tolerance for Ambiguity Scale1 Questions 1. It really disturbs me when I am unable to follow another persons train of thought. 2. If I am uncertain about the responsibilities involved in a particular task, I get very anxious. 3. Before any important task, I must know how long it will take. 4. I dont like to work on a problem unless there is a possibility of getting a clear-cut and unambiguous answer. 5. The best part of working on a jigsaw puzzle is putting in the last piece. 6. I am often uncomfortable with people unless I feel that I can understand their behavior. 7. A good task is one in which what is to be done and how it is to be done is always clear. Scale 1: Strongly agree 2: Moderately agree 3: Slightly agree 4: Slightly disagree 5: Moderately disagree 6: Strongly disagree Geller, G., Tambor, E. S., Chase, G. A., & Holtzman, N. A. (1993). Measuring physicians tolerance for ambiguity and its relationship to their reported practices regarding genetic testing. Medical Care, 31(11), 989-1001. https://www.jstor.org/stable/pdf/3766298.pdf?refreqid=excelsior%3A9e0dbfbed02582388990f6afef881c98&ab_seg ments=&origin=&acceptTC=1 1 HYBRID DOCTOR OF PHYSICAL THERAPY STUDENT 57 Appendix B Frost Multidimensional Perfectionism Scale - Brief2 Please circle the number that best corresponds to your agreement with each statement below. Use this rating system: Strongly disagree 1 4 Strongly agree 5 1. If I fail at work/school, I am a failure as a person. 1 2 3 4 5 2. I set higher goals for myself than most people. 1 2 3 4 5 3. If someone does a task at work/school better than me, then I feel like I failed at the whole task. 1 2 3 4 5 4. I have extremely high goals. 1 2 3 4 5 5. Other people seem to accept lower standards from themselves than I do. 1 2 3 4 5 6. If I do not do well all the time, people will not respect me. 1 2 3 4 5 7. I expect higher performance in my daily tasks than most people. 1 2 3 4 5 8. The fewer mistakes I make, the more people will like me. 1 2 3 4 5 2 3 Scoring: Sum items for the following subscales. Do not use a total score. Striving: 2, 4, 5, 7 EC: 1, 3, 6, 8 2 Burgess, A. M., Frost, R. O., & DiBartolo, P. M. (2016). Development and validation of the frost multidimensional perfectionism scale-brief. Journal of Psychoeducational Assessment, 34(7), 620633. HYBRID DOCTOR OF PHYSICAL THERAPY STUDENT Appendix C Entry-level Hybrid DPT Student Profile Survey Standard: Informed Consent (0 Questions) Standard: Purpose and Instructions (1 Question) Block: Demographics (20 Questions) Standard: Key Considerations (6 Questions) Standard: Tolerance for Ambiguity (1 Question) Standard: Perfectionism (1 Question) Standard: Gift Card Opt In (0 Questions) 58 HYBRID DOCTOR OF PHYSICAL THERAPY STUDENT 59 Start of Block: Informed Consent Start of Block: Purpose and Instructions Purpose: The purpose of this survey is to gather the demographic characteristics of students enrolled in entry-level hybrid Doctor of Physical Therapy programs, examine the student experience aspects of tolerance for ambiguity and perfectionism, and identify the key considerations for students when selecting a hybrid DPT program. Instructions: This survey has four sections (Part I- Demographics, Part II- Key considerations in the selection of a hybrid DPT program, Part III- The Tolerance for Ambiguity Scale, and Part IV- Frost Multidimensional Perfectionism Scale-Brief). Please read the instructions above each section for the specifics of answering each section of questions. This survey should take you 15 minutes or less. End of Block: Purpose and Instructions Start of Block: Demographics Please complete the demographic portion of this survey by answering the following questions. HYBRID DOCTOR OF PHYSICAL THERAPY STUDENT Enter your current age in years. ________________________________________________________________ What is your gender? o Male (1) o Female (2) o Non-binary (3) o Let me type- Enter gender below. (7) __________________________________________________ What is your sexual orientation? o LGBTQ+ (1) o Heterosexual (2) 60 HYBRID DOCTOR OF PHYSICAL THERAPY STUDENT How would you describe yourself? o African American / Black (1) o American Indian / Alaskan Native (2) o Asian (3) o Caucasian / White (4) o Hispanic / Latino (5) o Native Hawaiian / Other Pacific Islander (6) o Two or more races (7) o Unknown (8) o I prefer not to answer (9) 61 HYBRID DOCTOR OF PHYSICAL THERAPY STUDENT 62 What is your highest degree earned? o Bachelors (1) o Masters (2) o Clinical Doctorate (Pharm D, Nursing Doctorate, Doctor of Psychology) (3) o Terminal Doctorate (Ph.D., Doctor of Education, Doctor of Veterinary Medicine, Doctor of Engineering, Juris Doctor) (4) Are you in a committed relationship? o Yes (1) o No (2) Skip To: Q28 If Are you in a committed relationship? = No HYBRID DOCTOR OF PHYSICAL THERAPY STUDENT Please select all that apply regarding your relationship. Married or in a civil union, living together (1) Married or in a civil union, living apart (2) Not married or in a civil union, living together (3) Not married or in a civil union, living apart (4) Are you divorced, widowed, or separated? Select all that apply. Divorced (1) Widowed (2) Separated (3) None of these apply (4) 63 HYBRID DOCTOR OF PHYSICAL THERAPY STUDENT Do you have biological, adopted, foster, or stepchildren? o No (1) o No, but I am (or my partner is) pregnant or in the process of adopting (2) o Yes, one child (3) o Yes, two children (4) o Yes, three children (5) o Yes, four or more children (6) Skip To: Q27 If Do you have biological, adopted, foster, or stepchildren? = No Skip To: Q27 If Do you have biological, adopted, foster, or stepchildren? = No, but I am (or my partner is) pregnant or in the process of adopting 64 HYBRID DOCTOR OF PHYSICAL THERAPY STUDENT 65 If you have children, what are the ages of your children, and do they live with you. Select all relevant options below. They do not live with me (1) Preschool (Birth to 5 years) (1) Elementary (6-13 years) (2) Adolescent (14-18 years) (3) Adult Children (19+ years) (4) They live with me parttime (< 365 days a year) (2) o o o o o o o o Are you a caregiver for someone other than your children? o Yes (1) o No (2) Skip To: Q9 If Are you a caregiver for someone other than your children? = No They live with me fulltime (365 days a year) (3) o o o o HYBRID DOCTOR OF PHYSICAL THERAPY STUDENT If you are a caregiver for someone other than your children, does the person you care for live with you? o Yes (1) o No (2) 66 HYBRID DOCTOR OF PHYSICAL THERAPY STUDENT 67 Select the geographical region in which you lived prior to enrolling in your hybrid DPT program. o South Atlantic (DE, DC, FL, GA, MD, NC, PR, SC, VA, WV) (1) o Middle Atlantic (NJ, NY, PA) (2) o East North Central (IL, IN, MI, OH, WI) (3) o West North Central (IA, KD, MN, MO, NE, ND, SD) (4) o West South Central (AR, LA, OK, TX) (5) o New England (CT, ME, MA, NH, RI, VT) (6) o Pacific (AK, CA, HI, OR, WA) (7) o East South Central (AL, KY, MS, TN) (8) o Mountain (AZ, CO, ID, MT, NV, UT, WY) (9) o Other, please specify (10) __________________________________________________ Did you relocate to be closer to the physical facilities of the hybrid DPT program? o Yes (1) o No (2) HYBRID DOCTOR OF PHYSICAL THERAPY STUDENT 68 Skip To: Q24 If Did you relocate to be closer to the physical facilities of the hybrid DPT program? = No Select the geographical region to which you relocated. o South Atlantic (DE, DC, FL, GA, MD, NC, PR, SC, VA, WV) (1) o Middle Atlantic (NJ, NY, PA) (2) o East North Central (IL, IN, MI, OH, WI) (3) o West North Central (IA, KD, MN, MO, NE, ND, SD) (4) o West South Central (AR, LA, OK, TX) (5) o New England (CT, ME, MA, NH, RI, VT) (6) o Pacific (AK, CA, HI, OR, WA) (7) o East South Central (AL, KY, MS, TN) (8) o Mountain (AZ, CO, ID, MT, NV, UT, WY) (9) o Other, please specify (10) __________________________________________________ HYBRID DOCTOR OF PHYSICAL THERAPY STUDENT Were you accepted into more than one DPT program? o Yes (1) o No (2) Were you accepted into another hybrid DPT program? o Yes (1) o No (2) Were you accepted into any residential (non-hybrid) DPT programs? o Yes (1) o No (2) 69 HYBRID DOCTOR OF PHYSICAL THERAPY STUDENT 70 Think back to when you were a DPT applicant. How did you first hear about the DPT program that you chose? o Friend or family member (1) o Internet search (2) o PT-CAS (3) o Social Media (Instagram, Facebook, Twitter) (4) o Undergraduate professor or advisor (5) o Online advertisement (6) o Other, please specify (7) __________________________________________________ End of Block: Demographics Start of Block: Key Considerations Select the level of importance for each key consideration utilizing the 1-5 Likert scale from 1= Not Important to 5= Very Important. HYBRID DOCTOR OF PHYSICAL THERAPY STUDENT 71 Select the level of importance for each key consideration. 1: Not Important (1) University Reputation (1) Tuition Cost (2) Travel Cost (3) Housing Cost (4) o o o o 2: Slightly Important (2) o o o o 3: Moderately Important (3) o o o o 4: Important (4) o o o o 5: Very Important (5) o o o o Select the level of importance for each key consideration. 1: Not Important (1) Program Duration (1) Program Mission (2) Program Vision (3) Program Values (4) Program Faculty (5) Program Location for Onsite Labs (6) 2: Slightly Important (2) 3: Moderately Important (3) 4: Important (4) 5: Very Important (5) o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o HYBRID DOCTOR OF PHYSICAL THERAPY STUDENT 72 Select the level of importance for each key consideration. 1: Not Important (1) 2: Slightly Important (2) 3: Moderately Important (3) 4: Important (4) 5: Very Important (5) Access to Online Webinar Regarding Program (2) o o o o o Pre-Admission Lab Visit (3) o o o o o Direct Interaction with Admissions Team (4) o o o o o HYBRID DOCTOR OF PHYSICAL THERAPY STUDENT 73 Select the level of importance for each key consideration. 1: Not Important (1) 2: Slightly Important (2) 3: Moderately Important (3) 4: Important (4) 5: Very Important (5) National Physical Therapy Exam First Time Pass Rates (1) o o o o o National Physical Therapy Exam Ultimate Pass Rates (2) o o o o o Diversity of the Student Body (3) o o o o o o o o o o o o o o o Graduation Rates (4) Employment Rate (5) In this section, please include any other key considerations that were not listed above and then select the level of importance for each key consideration. 1: Not Important (1) Other, please specify (1) Other, please specify (2) Other, please specify (3) o o o 2: Slightly Important (2) o o o 3: Moderately Important (3) o o o 4: Important (4) o o o 5: Very Important (5) o o o HYBRID DOCTOR OF PHYSICAL THERAPY STUDENT End of Block: Key Considerations Start of Block: Tolerance for Ambiguity 74 HYBRID DOCTOR OF PHYSICAL THERAPY STUDENT Please select the number that best corresponds to your agreement with each statement. Use this rating system: 1 (Strongly agree) to 6 (Strongly disagree). 75 HYBRID DOCTOR OF PHYSICAL THERAPY STUDENT 1: Strongly Agree (1) 2: Moderately Agree (2) 3: Slightly Agree (3) 76 4: Slightly Disagree (4) 5: Moderately Disagree (5) 6: Strongly Disagree (6) It really disturbs me when I am unable to follow another persons train of thought. (1) o o o o o o If I am uncertain about the responsibilities involved in a particular task, I get very anxious. (2) o o o o o o Before any important task, I must know how long it will take. (3) o o o o o o I dont like to work on a problem unless there is a possibility of getting a clearcut and unambiguous answer. (4) o o o o o o The best part of working on a jigsaw puzzle is putting in the last piece. (5) o o o o o o I am often uncomfortable with people unless I feel that I can understand their behavior. (6) o o o o o o HYBRID DOCTOR OF PHYSICAL THERAPY STUDENT A good task is one in which what is to be done and how it is to be done is always clear. (7) o o End of Block: Tolerance for Ambiguity Start of Block: Perfectionism o 77 o o o HYBRID DOCTOR OF PHYSICAL THERAPY STUDENT Please select the number that best corresponds to your agreement with each statement below. Use this rating system: 1 (Strongly disagree) to 5 (Strongly agree). 78 HYBRID DOCTOR OF PHYSICAL THERAPY STUDENT 1: Strongly Disagree (1) 2: Disagree (2) 3: Neutral (3) 79 4: Agree (4) 5: Strongly Agree (5) If I fail at work/school, I am a failure as a person. (4) o o o o o I set higher goals for myself than most people. (5) o o o o o If someone does a task at work/school better than me, then I feel like I failed at the whole task. (6) o o o o o I have extremely high goals. (7) o o o o o Other people seem to accept lower standards from themselves than I do. (8) o o o o o If I do not do well all the time, people will not respect me. (9) o o o o o I expect higher performance in my daily tasks than most people. (10) o o o o o The fewer mistakes I make, the more people will like me. (11) o o o o o HYBRID DOCTOR OF PHYSICAL THERAPY STUDENT End of Block: Perfectionism Start of Block: Gift Card opt In 80  ...

... i YOU ARE SO ARTICULATE: THE PSYCHOLOGICAL IMPACT OF CODESWITCHING AMONG BLACK OR AFRICAN AMERICAN GRADUATE STUDENTS AT PREDOMINANTLY WHITE INSTITUTIONS A Doctoral Dissertation (Defense) presented to the Graduate Department of Clinical Psychology University of Indianapolis In partial fulfillment Of the requirements for the degree Doctor of Psychology Sidney Marie Allen, M.A. DECEMBER 1, 2023 ii YOU ARE SO ARTICULATE: THE PSYCHOLOGICAL IMPACT OF CODESWITCHING AMONG BLACK OR AFRICAN AMERICAN GRADUATE STUDENTS AT PREDOMINANTLY WHITE INSTITUTIONS The signatures below certify that the Doctoral Dissertation (Defense) of Sidney Marie Allen, M.A. has been approved by the Graduate Department of Clinical Psychology of the University of Indianapolis in partial fulfillment of the requirements for the degree Doctor of Psychology Approved: Accepted: _________________________ Mixalis Poulakis, Psy.D. Dissertation Advisor _________________________ John Kuykendall III, Ph.D. Dean, College of Education and Behavioral Sciences _________________________ Kathryn Boucher, Ph.D. Committee Member _________________________ Date _________________________ Charla Davis, Psy.D. Committee Member _________________________ Date iii ABSTRACT This study explored the psychological well-being of Black or African American graduate students at Predominantly White Institutions (PWIs) and the impact of codeswitching from Ebonics to Standard English. Previous literature has shown that Black or African American students, may face challenges at a PWI such as frequent racial tensions and discrimination. The use of codeswitching has also been shown to have negative consequences for Black speakers. Thus, the current study focused primarily on the impact that the use of codeswitching has on individuals who identify as Black or African American graduate students. Through the Consensual Qualitative Research (CQR) method data was collected and analyzed in order to gain insight into this phenomenon. As a part of this study, 12 Black or African Americans who previously obtained an undergraduate degree from a Historically Black College or University (HBCU) and graduated or who were currently attending a PWI at the time of the study were recruited. The results indicated that participants codeswitched at their PWI to avoid challenges such as being misunderstood, not being taken seriously, and being stereotyped. The results supported the notion that codeswitching is a vital tool for Black graduate students to navigate in Predominantly White environments. In terms of psychological implications, the results indicated that psychological stressors such as anxiety, changes to participants' personality (none that align with any specific DSM-5 diagnoses), exhaustion, and masking were present as a result of codeswitching or the use of Ebonics at their PWI. But, in terms of specific mental health comparisons from HBCU to PWI related to codeswitching, there were no significant results. Lastly, the results also suggested that PWIs should create more diversity-related resources, emphasis on graduate student resources through increased funding, and more awareness of codeswitching through discussions, trainings, etc. iv ACKNOWLEDGMENTS I would like to give a special thanks to all those that have supported me throughout this long, hectic, journey. Graduate school including writing this dissertation has not been easy by any means and I truly appreciate my friends, family, and academic support systems. To my father, Anthony Allen I would like to share a special thank you. Thank you for the countless phone calls, always being there to listen to me complain about this paper, and for being my unofficial-official editor. To my mother, Zera Hoosier I would like to express my sincere gratitude for your endless support and for periodically asking me, Did you finish that paper yet? Your reminders and your get things done mentality are what have pushed me to be who I am today. To my sister, Candace Scott I would like to thank you for serving as my forever role model. You have shown me what to and what not to do and I appreciate the life lessons you have given whether I asked for them or not. To my closest friends, Elesha White, Jermaine Grandison, and Dajah Harris, I may not say it all the time but I thank you from the bottom of my heart. Your friendship, random Facetime calls, and pull-ups are what have helped me get through these 5 years. To my advisor, Dr. Poulakis I dont even know where to begin. You have provided unconditional support since the day I interviewed for the PsyD program, and I thank you. I truly appreciate everything you have done from not just checking in on my academics but checking in on me mentally. To my committee members Drs. Charla Davis and Kathryn Boucher, I appreciate you both for putting up with me on this long journey. Dr. Davis, thank you for being more than just a committee member but a friend. Dr. Boucher, thank you for pushing me to think outside the box. v TABLE OF CONTENTS TITLE PAGE ....................................................................................................................... i SIGNATURE PAGE .......................................................................................................... ii ABSTRACT ...................................................................................................................... iii ACKNOWLEDGMENTS ................................................................................................. iv TABLE OF CONTENTS ....................................................................................................v CHAPTER ONE: LITERATURE REVIEW ......................................................................6 Introduction .............................................................................................................6 History of Ebonics and Controversies ...................................................................10 The Ebonics Debate ..............................................................................................13 Codeswitching........................................................................................................14 Perceptions, Reasons, and Implications of Codeswitching ..................................24 Black Students Experiences .................................................................................33 Justification ...........................................................................................................37 Overview and Research Questions ........................................................................40 CHAPTER TWO: METHODS .........................................................................................41 Introduction ...........................................................................................................41 Participants .................................................................................................41 Criteria ..........................................................................................41 Recruitment ...................................................................................43 vi Measures ....................................................................................................43 Demographic Questionnaire .........................................................43 Semi-structured Interview Questions .............................................44 Procedures ..................................................................................................45 CQR Methodology .....................................................................................47 CHAPTER THREE: RESULTS .......................................................................................50 Sample Characteristics ..........................................................................................50 Research Team ......................................................................................................52 Qualitative Data .....................................................................................................53 Domains ....................................................................................................53 Overview of Findings ...........................................................................................53 Domain 1: Motivations for Codeswitching ...............................................54 Domain 2: Ebonics and Standard English ................................................58 Domain 3: Differences among PWIs and HBCUs ....................................62 Domain 4: The Impact of Codeswitching .................................................67 Domain 5: Other Types of Codeswitching ...............................................72 Domain 6: Coping Strategies ....................................................................72 Domain 7: Higher Education Interventions ..............................................73 CHAPTER FOUR: DISCUSSION ...................................................................................78 vii Overview ...............................................................................................................78 Limitations .............................................................................................................90 Implications and Future Research ..........................................................................92 CHAPTER FIVE: CONCLUSION ...................................................................................97 REFERENCES .................................................................................................................99 APPENDICES ................................................................................................................128 Appendix A: Examples of Codeswitching (in general) .......................................128 Appendix B: Recruitment Flyer ..........................................................................129 Appendix C: List of HBCUs ................................................................................131 Appendix D: Demographic Questionnaire...........................................................137 Appendix E: Semi-structured Interview Questions ............................................139 Appendix F: Email ..............................................................................................141 Appendix G: Informed Consent ..........................................................................142 Appendix H: Debriefing Form ............................................................................148 Appendix I: Participant Characteristics ..............................................................150 Appendix J: Domain List ....................................................................................152 Appendix K: Frequency Analysis .......................................................................153 Appendix L: Examples of Ebonics (complied from participant interviews) .......156 6 YOU ARE SO ARTICULATE: THE PSYCHOLOGICAL IMPACT OF CODESWITCHING AMONG BLACK OR AFRICAN AMERICAN GRADUATE STUDENTS AT PREDOMINANTLY WHITE INSTITUTIONS CHAPTER ONE: LITERATURE REVIEW Introduction For centuries, individuals have been enrolling in college and furthering their education. For instance, Harvard University is one of the oldest institutions with it being established in the 1600s (Davis, 2019; The Editors of Encyclopedia Britannica, 2023). While universities such as Harvard have been around for a long time, students from specific backgrounds were not always accepted for enrollment for a multitude of reasons. In particular, Black students have long faced problems in higher education associated with racial climate, Jim Crow laws, economic differences, linguistic discrimination, etc. (Adedoyin, 2022; Hankerson, 2023; Karkouti, 2016). Despite some of these problems, over the years Black and African Americans have still been able to find avenues to enroll and excel in higher education. In the current study, the term Black and African American are used interchangeably. Recently, the undergraduate enrollment rates for African American students have been fluctuating. The Postsecondary National Policy Institute compiled data from the U.S. Department of Education and the National Center for Education Statistics and found that from 2000 to 2010 African American undergraduate enrollment rates increased by 73% (from 1.5 million to 2.7 million) (PNPI, 2020). However, from 2010 to 2018, African American undergraduate enrollment rates decreased by 21% (2.1 million) (PNPI, 2020). From 2018 to 2020, there was an overall decrease in college enrollment regardless of race/ethnicity (Adedoyin, 2022). However, Black individuals continued to see a decrease in enrollment up until 2023 (Marcus, 2023). There 7 are many different reasons for this decrease. However, some have speculated that it was in part due to the 2019 pandemic, financial concerns, and program adaptability (B. Miller, 2020). In more recent years, it has been found that undergraduate college enrollment rates for Black individuals have decreased because of racial trauma in and out of school systems (Edwin & Daniels, 2022). These factors and rates may continue to fluctuate as things change in the world. In addition to undergraduate enrollment rates, from 2000 to 2018, post-baccalaureate enrollment increased by 41% (Hussar et al., 2020). For African American students, from 20002018, post-baccalaureate enrollment increased by 101 % (Hussar et al., 2020). But another fluctuation occurred from 2019 to 2020 as Black/African American graduate student enrollment only increased by 8.1% (Zhou & Gao, 2021). It appears that the rate at which African Americans are enrolling in graduate school is increasing. However, these rates reflect a slow rate of change compared to others (Zhou & Gao, 2021). While the enrollment rates have been changing, the number of African Americans choosing to attend Predominantly White Institutions (PWIs) has also changed (Payne & Suddler, 2014). A PWI is defined as a higher education institution where White people make up 50% or more of the student population (Lomotey, 2010; Setty-Charity, 2022). Dating back to the 70s, Historically Black Colleges and Universities (HBCUs) conferred 35 % of undergraduate degrees and 21% of masters degrees for Black students (Provasnik & Shafer, 2004). But again, these rates fluctuated over the years. For instance, data from the early 2000s stated that many Black students attended PWIs both for undergraduate and graduate school (Aud et al., 2011; M.D. Williams, 2014). By 2008, only 10% of Black graduate students attended HBCUs to pursue their education (Aud et al., 2011). Historically, the data has shown that the number of Black students attending and receiving master's and doctoral degrees from HBCUs has decreased (Provasnik & 8 Shafer, 2004; U.S. Department of Education et al., 2022). More recent data has shown that from 2020-2021, HBCUs only accounted for 5% of conferred masters degrees for Black students (U.S. Department of Education et al., 2022). Furthermore, with a fluctuation in enrollment rates, the experiences of each student are also important. Attendance at a PWI has many different consequences or outcomes for Black or African American students in comparison to White students. In particular, a large number of Black college students come from predominantly Black residential environments and attending a predominantly White environment such as a college can bring about some challenges associated with culture shock (Woldoff et al., 2011). Some of these challenges include but are not limited to, discomfort in adjusting to unfamiliar White environments, segregation, lack of belonging, and a weakened sense of racial identity (Hernandez, 2010; Sinanan, 2012; Woldoff et al., 2011). In particular, a study on Black college students at a rural PWI revealed that Black students who are not socially adjusted to a PWI environment are at an increased risk for disadvantages (Woldoff et al., 2011). This study also included several participant responses that displayed the severity and reality of these challenges such as Blacks have to prove themselves academically first before Whites even respect them a little bit here (Woldoff et al., 2011). Those responses are similar to those within the current study. The adjustment to a PWI has also been studied when it comes to exploring race-related stressors, racial identity, and the overall mental health of African American students. However, much of this research has focused on the adjustment of specifically undergraduate students and their experiences with Black authenticity (Cox, 2020; Eakins & Eakins, 2017; Neville et al., 2004; Payne & Suddler, 2014; Woldoff et al., 2011). In a recent study, researchers found that African American students attending PWIs experience ostracism and lack a sense of belonging 9 (Eakins & Eakins, 2017). However, African American students, have found ways to navigate through such experiences. One experience that has been explored to a certain extent, is African American students experiences with codeswitching between English and Ebonics and the use of codeswitching as a means to navigate through a PWI (Payne & Suddler, 2014). While codeswitching appears as positive way to navigate, it can also come with negative consequences. Some of these negative consequences include but are not limited to decreased social performance and impacts on ones racial-ethnic identity in lieu of performing well in a White value system (PWI) (Payne & Suddler, 2014). Moreover, there are attitudes and perceptions of codeswitching that can impact ones cultural identity. In terms of attitudes and perceptions, it has been found that there are mixed attitudes from Black students towards codeswitching and primarily negative perceptions of codeswitching from White individuals (Bukowski, 2019; Dewaele & Wei, 2014; Durkee & Williams, 2015; Koch et al., 2001; V.A. Young, 2009). Limited research brings to light the individual preferences on the use of codeswitching, attitudes towards codeswitching, and perceptions of codeswitching (Bukowski, 2019; Dewaele & Wei, 2014; Doss & Gross, 1994; Durkee & Williams, 2015; Koch et al., 2001; V.A. Young, 2009). In particular, Doss & Gross looked at the perceptions of Standard English speakers, Black English speakers, and those that codeswitched (1994). In their study, Standard English was not explicitly defined only described as characteristics of White Standard English. However, they did reference Burling (1973) in their work who referred to it as the language of White, Educated, Middle class citizens. Codeswitching speakers were individuals that initially spoke in Standard English and then changed to Black English or the language of African Americans characterized by incorrect grammar, Black vocabulary, and pronunciations that varied from Standard 10 English (Doss & Gross, 1994). From the results, it was found that African Americans from PWIs preferred Standard English speakers over codeswitching speakers and Black English speakers. More specifically, participants rated Standard English speakers as more likeable or having qualities such as being kind, pleasant, open-minded, intelligent, and socially skilled. It was suspected that participants were assigning specific qualities because language served as an indication of cultural identity. Thus, further suggesting that there are negative stereotypes associated with Black English and the belief that certain languages or behaviors can negatively impact ones social mobility (Doss & Gross, 1994). These types of stereotypes and assumptions can lead to negative perceptions of oneself, their own cultural identity, and further influencing the use of codeswitching or Standard English among African Americans, particularly college students. Furthermore, previous research has had a tendency to disregard Black or African American graduate student experiences. It is a fact that research has treated Black students, especially in higher education as a homogenous group and often assumes that all Black students share similar experiences (Adams, 2005; Harper & Nichols, 2008; Steele, 1999; Stewart, 2009). Hence why this study took a qualitative approach to expanding on the individual experiences and implications of codeswitching, the role in which a PWI plays, and examined the psychological well-being of Black or African American graduate students. History of Ebonics and Controversies In discussing the use of codeswitching among African Americans, it is important to examine the language or dialect that is commonly used, known as Ebonics. On January 26th, 1973, Dr. Robert L. Williams created the term Ebonics (Baugh, 2005). It was on this day that the well-renowned African American psychologist coined this term in order to bring light to the 11 pejorative descriptions of the commonly used language of African Americans, Ebonics. As a result of Dr. Williams frustrations with White scholars referring to the African American language as deficient language and slovenly speech, he invited scholars to come together for a discussion on the cognitive and language development of Black children (Yancy, 2011). Those scholarly discussions, brought about the creation of Ebonics through the combining of the words ebony and phonetics. Ebony referring to a deep, lustrous Black, or Black color while phonics or phonetics refers to the science of speech sounds (Ebony, n.d.; Ladefoged, 2023; MerriamWebster, n.d.). Thus, equating to the meaning of black pronunciation, vocabulary, syntax, and structure (R.L. Williams, 1997). The language frequented by African Americans often referred to as Ebonics is also known as African American Vernacular English (AAVE), African American English (AAE), or Black English (BE). For the purposes of this study and to maintain consistency, the term Ebonics was used. Aside from alternative names, the origin of this language is a heavily researched topic (Baugh, 2000; J. Collins, 1999; E.A. Smith, 1978; Sung & Allen-Handy, 2019; Wiley, 2005). Linguists differ in their opinions of where exactly Ebonics originated from. However, there are four hypotheses about the origin that frequently come about in research. These hypotheses are the Creole or Creolist hypothesis, Anglicist hypothesis, Neo-Anglicist hypothesis, and the Substrate hypothesis (Baugh, 2000; McLucas, 2005; Mufwene 2015; Sebba, 1997; Veenendaal et al., 2014; Winford, 2015). The different types of hypotheses show a division in the opinions of linguists as some attribute Ebonics to English origins as a result of African slave interactions, African origins such as the West African language, or even Caribbean or Creole origins (Rickford, 2005; Sebba, 1997). 12 Specifically, the Creole or Creolist hypothesis dates back to 1964 when authors, Beryl Bailey and Bill Stewart expressed that Ebonics stems from a widespread full Creole through the American South (Rickford, 2015). However, the idea that Ebonics descended strictly from Creole has been debunked by modern Creolists (Rickford, 1998; Veenendaal et al., 2014). The refined hypothesis suggests that Ebonics evolved from a Creole-based variety of English (Veenendaal et al., 2014). In particular, during colonization, when Africans from a variety of different countries were transported to North America and became slaves, in order to communicate among their different languages, they developed a pidgin language. This pidgin language was a mixture of West African vocabulary from their original languages and English. (McLucas, 2005). Eventually, as African slaves worked on different plantations, the language further developed into the Creole language that some say was rooted in Gullah (Creole spoken in coastal South Carolina) and evolved towards American English (Mufwene, 2015; Veenendaal et al., 2014). Unlike the Creole or Creolist hypothesis, the Anglicist hypothesis states that Ebonics stems from British dialects (Sebba, 1997). In other words, this hypothesis focuses on Ebonics originating strictly from the English language and excludes any African influence (McLucas, 2005). Similarly, the Neo-Anglicist hypothesis also strays from the notation that Ebonics originated from any type of African influence. However, this hypothesis, in particular, focuses on Ebonics stemming from the English language changing over time. Those who believe in the Neo-Anglicist hypothesis claim that Ebonics is a result of White-American speech, which developed from South White Vernacular English (Veenendaal et al., 2014). Lastly, the substrate hypothesis is in a way a combination of multiple hypotheses. The substrate hypothesis posits that Ebonics is a result of the influence from earlier regional contexts 13 in the U.S. and through the heritage of the original language contact situation (Veenendaal et al., 2014; Wolfram, 2004). More specifically, this language contact situation refers to the language contact between English-like Creole and early settler dialects (Veenendaal et al., 2014). While the substrate hypothesis is a newer theory, researchers have found it to be a better account for the Ebonic language origin given the available data (Kendall et al., 2018; Veenendaal et al., 2014). However, it is important to note that even with current and past data, there are still some limitations. It has even been stated that the origins of the Ebonics language may never be fully understood (Kendall et al., 2018). The Ebonics Debate Years after the term Ebonics was originally coined and hypotheses were formulated, controversy sparked as the topic became focused on literary, cultural, social, and political issues. In particular, the Ebonics debate is commonly referred to as the controversy over the use of Ebonics in school systems (McLaren, 2009). On December 18th, 1996, the Oakland, CA school board made the decision to accept Ebonics as a language and include it as a part of the curriculum to teach Standard English (R.L. Williams, 1997). This decision sparked a controversial debate, as those opposed rejected Ebonics as they were under the assumption that it would allow for substandard speech in the classrooms, further condone slang, and reward failure (R.L. Williams, 1997). Even the African American mayor of Oakland, at the time stated, that there was a commitment to education to include language and math and that a substandard English wouldnt be tolerated (Woo & Curtius, 1996). However, according to Dr. Williams, the actual goal of the Oakland, CA school board decision was to provide African American children with the opportunity to achieve a quality education by incorporating Ebonics. The incorporation of Ebonics into the school system was not to replace the use of Standard English but to allow 14 African American children the ability to navigate through the school system without being penalized for speaking their own language (R.L. Williams, 1997). Along with the rejection of Ebonics in academic settings, controversy is still present when it comes to acknowledging what Ebonics genuinely is and the history of the language. In fact, Ebonics is not equivalent to slang, Urban hip-hop vernacular, or colloquialisms (Thompson, 2000). Slang is defined as unconventional or nonstandard words or phrases often used in a certain way among social interactions (Maurer, 2023). Many have even stigmatized slang over the years (Coleman, 2012). The combination of words forming the term, Urban hip-hop vernacular refers to language or dialect characterized by the cultural movement associated with rap (Light & Tate, 2023). While colloquial from the word colloquialism refers to informal words or expressions from a specific region or demographic (Nordquist, 2020). All of these words obviously have different meanings. But, using these definitions interchangeably with that of Ebonics is to disregard the origins, the purpose, and the importance of Ebonics to Black or African American speakers. In actuality, Ebonics, the language commonly used by African Americans is deeply rooted in African culture and the practices, and themes of the Black church (McLaren, 2009). Codeswitching There is also history and research behind the topic of codeswitching. Codeswitching in simple terms is defined as switching linguistic codes, otherwise known as languages or dialects (Morrison, 2023). It is more specifically defined as shifting between different communication styles based on different cultures or who you are communicating with (Deggans, 2013). It is also important to note that codeswitching or cultural codeswitching can refer to the adjustment of an individuals style such as their physical appearance, the way in which they dress, and their 15 overall expressions of themselves (McCluney et al., 2021; Washington-Harmon, 2020). For example, studies have shown that African Americans will codeswitch by lowering their voice, avoiding wearing not too Black'' hairstyles such as their natural hair, and refraining from wearing baggy clothes (Elkins & Hanke, 2018; Guiffrida, 2003; R. Jones, 2020; Santiago et al., 2021). Instead, they attempt to present as more professional by changing themselves and their appearance to make others feel more comfortable (Santiago et al., 2021). However, for the purposes of this research study, the term codeswitching and relevant literature specifically focused on codeswitching in relation to language and dialect only. See Appendix A for examples of codeswitching (not from participants within this study). In the same way that linguists differ in their views of who, where, and when Ebonics was created, the origins of codeswitching itself are also up for debate. In 1954, Einar Haugen, a sociolinguist claimed to have coined the term, code-switching as a language alternation (I. Harris, 2019). However, language alternation had been recognized since at least the beginning of the 20th century (Hall & Nilep, 2015; I. Harris, 2019). Regardless of the precise definition of codeswitching and its exact origin, there are over 7,000 spoken languages in the world, and the topic of codeswitching has become more prevalent (Michaels, 2019). Beginning in the 1970s, the phenomenon of codeswitching became popular, specifically surrounding the topic of codeswitching among African American students (grade school) and the idea of teaching Standard English (I. Harris, 2019; Morrison, 2023). In the past decade, the topic of codeswitching has also become more prevalent in the media. From the high-profile show, Big Mouth '', the Sundance premiered film Sorry to Bother You, to a variety of empirical articles, people are discussing the phenomenon (Benson, 2001; T. Miller, 2020; Phillips, 2018). However, previous research provides for a very broad scope of codeswitching mainly pertaining to specific 16 topics on bilingualism, multilingualism, or primarily among languages or dialects other than Ebonics (Dewaele & Wei, 2014; Martinez, 2014; McClure & Mir, 1995). A lot of this research expands on the topic of codeswitching from Spanish to English, French to English, and Mandarin Chinese to English (Quin Yow et al., 2017). In particular, there has been extensive research on Spanish-English codeswitching, the awareness of the topic, and the awareness of Spanish-English codeswitching especially in grade school classrooms (Martinez, 2013; Martinez, 2014; Nichols & Colon, 2008). Essentially, researchers have found that Spanish-English speakers in grade school have a general awareness of their switching habits (Martinez, 2013; Nichols & Colon, 2008). But, with encouragement and dialog from teachers, there can be an increased sense of awareness without the loss of culture among students (Martinez, 2013). Although even with self-awareness, others still may have negative attitudes and perceptions. For instance, one of the controversies among switching from Spanish to English is that bilingualism is viewed positively but codeswitching is not (Balam & De Prada Perez, 2017; Mata, 2022). However, some have argued that bilingualism and codeswitching are one and the same or that codeswitching does not exist without having bilingual speakers (Heredia & Altarriba, 2001; Martinez, 2010). The controversy still remains. However, taking into consideration that bilingual means to speak two languages fluently, Ebonics is often left out of the bilingualism versus codeswitching debate (Hamers & Blanc, 2000). Because to be included, Ebonics would have to be viewed as an official language. But, even with the term Ebonics being coined nearly 50 years ago, it is still not recognized as an official language everywhere (ONeil, 1997; R.L. Williams, 1997; Zang, 2020). Thus, potentially creating niche studies that dont fully encompass codeswitching among Ebonics. In fact, much of the current research on the topic of codeswitching from Ebonics to Standard English is either 17 heavily focused on a specific age group, or a particular environment, or the research is simply outdated (McLaren, 2009; R.L. Williams, 1997). For instance, in studies that have observed the use of codeswitching from Ebonics to Standard English, in academia, the focus has been on grade school students and teachers (Godley & Minnici, 2008; Wilson, 2020). One qualitative study, in particular, examined teachers' speech patterns and interactions with students to identify the thought processes behind the choice of codeswitching and its effectiveness in the classroom (Wilson, 2020). In this study, 12 African American teachers were asked about their codeswitching and communications with their students in schools in which the neighborhoods consisted of primarily low to low-middle-income, Black, and Hispanic families (Wilson, 2020). The findings of this study revealed that codeswitching was consistently used among African American teachers for specific teaching tasks and for rapport building. Codeswitching was also found to have created a safe classroom environment and created an environment with a shared understanding (Wilson, 2020). Thus, these findings, provide positive aspects of codeswitching in the classroom setting. Other studies that have focused on the switching from Ebonics to Standard English in grade schools have provided insight into African American students' and teachers' beliefs on codeswitching (Godley & Escher, 2012). More specifically, Godley & Escher explored the perspectives of African American adolescent students in English classrooms and found that most African American students were aware of their own codeswitching habits (2012). In fact, of the 51 students in their study, only 18 said that using both Standard English and AAVE was appropriate in class (Godley & Escher, 2012). Other themes that arose from this study were negative attributes of AAVE (i.e., slang, illiterate, ignorant) and a need for improvement in classrooms (Godley & Escher, 2012). 18 Similarly, in Baker-Bells study, a group of Black or African American 9th graders were asked to read language samples and provide reflections on the speakers/language used in said samples (2019). As a result, the students' reflections on Language A (Black Language sample) revealed words and images such as, disrespectful, sloppy, and bad kids. Meanwhile, the student's reflections on Language B (White Mainstream English sample) revealed words and images such as, proper, white, smart, and good (Baker-Bell, 2019). Similar themes arose in other literature related to codeswitching and the use of Ebonics in grade school. These themes were additional negative conations of Ebonics and the need to acknowledge the significance of Ebonics for African American students (Bohn, 2003; Murphy, 1998; Parmegiani, 2006; Todd, 1997). Thus, establishing that the topic of codeswitching is much more than just an argument over semantics. In addition to the specific topic of codeswitching in grade school, research has also explored codeswitching and the use of Ebonics in academic settings, such as colleges to a certain extent. One study, in particular, examined African American undergraduate students attitudes toward Ebonics and codeswitching (Koch et al., 2001). This study involved 102 African American undergraduate students attending a public university in the Southeastern U.S. Notably, participants werent explicitly identified as PWI students. However, they did attend a university where African Americans only made up 10% of the student population. In the study, they were asked to listen to an audio recording of a male code switcher and later asked to rate the speaker. The results of this study found that when the male speaker spoke using Standard English and the appropriate use of codeswitching the college students gave positive ratings, associated the speaker with a higher socio-intellectual status, and were more inclined to get to know the actual speaker unlike that of the male speaker who spoke using Ebonics and inappropriate 19 codeswitching (Koch et al., 2001). Thus, this study expanded on the existing research on perceptions of codeswitching among African Americans. More importantly, it brought to light the impact of perceptions on an individual. For example, perceptions in terms of psychology, play a large role in how one makes decisions about others, views themselves, and their environment (Cherry, 2023). Psychology has also stated that perceptions can explain how people navigate social environments and can shape behavior, relationships, and identity (Carlson & Barranti, 2016; Cook, 1979). Given that some have provided different or negative perceptions to Black people that codeswitch, it should continue to be explored in the context of an individuals identity and how they navigate in unfamiliar environments. As previously stated, attending a PWI can be an unfamiliar or uncomfortable environment for Black students. Therefore, it is also important to explore the combined topic of language experiences and PWI experiences to see if there are any overlaps or unique experiences. Holliday & Squires did just that in their exploration of the language experiences of Black undergraduate students (2020). In their study, they interviewed 30 Black undergraduates attending PWIs and asked them directly about codeswitching, their linguistic background, language use in/out of the classroom, and how they navigate at their PWI. The results revealed overall themes of linguistic hyperawareness, avoidance of using AAVE in academic settings, and having to mask as a means to navigate scrutiny faced at PWIs (Holliday & Squires, 2020). Other studies examining African American college students and the overall use of codeswitching have found similar themes (Durkee & Williams, 2015; Cox, 2020). Durkee & Williams's overall study looked at links to racial identity including acting White (2015). Acting White as it has previously been studied often refers to African Americans engaging in behaviors perceived to be similar to White culture such as speaking 20 Standard English, performing well in school, or associating with others from different racial/ethnic backgrounds (Durkee & Williams, 2015; Webb & Linn, 2016; Wildhagen, 2011). As such, to avoid acting White Black students codeswitch or go back and forth between Standard English and Black English (Durkee & Williams, 2015). Codeswitching within their study was primarily discussed in order to emphasize that Black youth and emerging adults engage in a wide variety of behaviors such as talking proper to protect their racial/ethnic identity (Durkee & Williams, 2015). Similarly, the use of codeswitching has also been found to be a sign of inauthenticity (Cox, 2020). In fact, much of the codeswitching research focuses on racial identity and authenticity which is discussed in later sections. There are also studies that have looked at codeswitching in academia but on a broader or different level. For instance, a qualitative study similar to that of CQR methodology, on African Americans codeswitching, provided awareness of how interactions and perceptions of language, as educators, can influence students and colleagues of other cultures and races (Bukowski, 2019). In this study, African American male participants with high school, bachelors, or masters level education were interviewed to examine the establishment and reinforcement of perceptions based on social and academic experiences (Bukowski, 2019). The results found that different upbringings based on socioeconomic background, race, and power can directly impact the perceptions of codeswitching and the use of Ebonics among adult African American males (Bukowski, 2019). On a different level, the perceptions of codeswitching from African American male faculty members have also been explored (Hibbler, 2020). More specifically, Hibler explored how codeswitching can be utilized as a means for job promotions. This was done through interviews and focus groups involving 16 African American participants. The results of the study 21 found that a majority of the participants felt that codeswitching improved the trajectory for their career path. In particular, participants reported using codeswitching or speaking in Standard English (accepted language) to be seen as qualified, obtain higher positions, and other advancement opportunities as opposed to changing their vernacular choices and using African American Vernacular (Hibbler, 2020). Again, this emphasizes negative attitudes and perceptions related to the use of Ebonics. As previously mentioned, there are studies on codeswitching among different populations. However, a lot of the research extends only to undergraduate-level students or specifically focuses on one gender. Although, that is not to say that research on codeswitching at the graduate level does not exist. It could in part be due to the perception that graduate students have things figured out and there is an increased need for attention on undergraduate college students, especially when it comes to mental health (Forrester, 2021; Kaler & Stebleton, 2019; Pontius & Harper, 2006). Additionally, graduate students in general, particularly Black graduate students tend to be overlooked in research. Unfortunately, racial minorities such as African Americans in graduate school are underrepresented in research for various reasons (Holloman et al., 2021; Platt & Hilton, 2017). Some of these reasons being the fluctuation in higher education rates, especially for masters and doctoral programs for Black and African Americans. That being said, much of the research on Black graduate students or Black issues, in general, is conducted by Black doctoral students. It has been said that this is due to being trained to focus on gaps in research, desires to help communities, or feeling compelled to research race (Platt & Hilton, 2017). Thus, why some of the limited studies that do focus on codeswitching and those cited within the current study are often conducted by Black individuals and/or Black doctoral students. 22 Again, codeswitching in relation to the use of Ebonics among Black or African Americans at the graduate level has been researched, but the academic/empirical studies are limited (Henfield et al., 2011; Laufer, 2012; Ross et al., 2016; A.D. Smith, 2022; Spencer et al., 2022). Most of the academic/empirical studies available discuss codeswitching in this area but as a secondary topic or it is briefly mentioned within the literature. For instance, A.D. Smith published an interesting article that examined the use of podcasting as a means to avoid the social norms tied to speech and the need to sound collegiate within PWIs (2022). What was interesting was that the author was a Black, female, doctoral student who provided her own experiences as well as scholarly work within her research. In fact, she noted that for her, codeswitching is the process of co-existing in multiple spaces and languages without having professors question her intellect (A.D. Smith, 2022). Aside from her personal experiences, the study overall noted that Black doctoral students can use platforms such as podcasting to confront internalized anti-Blackness, insecurities surrounding the use of their voice, or identities tied to sounding ghetto (A.D. Smith, 2022). But the main focus of the article was on the use of podcasts with limited insights into codeswitching among Black graduate students. In another article, focusing on Black graduate students at the graduate level, it was noted that some found solidarity in codeswitching (Ross et al., 2016). Essentially this article was written to provide recommendations for doctoral education programs in terms of how they can assist their Black graduate students. The authors found themes of low self-esteem, poor selfefficacy, and barriers among Black education doctoral students at PWIs. As a recommendation, the authors found that providing Black students with opportunities to strongly identify with their cultural heritage such as using Ebonics would allow for a decrease in such barriers and problems 23 (Ross et al., 2016). But, its important to note that while this study unlike others focused on Black graduate students, it only mentioned codeswitching once. Similarly, Henfield et al. explored the perceptions of 11 African American counselor education doctoral students at PWIs (2011). Participants were asked what types of issues they experienced in their programs and how they addressed these said issues. Some of the participants noted that in classroom settings they felt challenged or that they would have to over-explain when they spoke. One participant, in particular, stated he switches between his doctoral PWI self and the person who is in touch with his friends and community (Henfield et al., 2011). As a result of the data from the interviews, it was found that from the participants' experiences of barriers and race-related issues, the main way of addressing such issues was assertiveness. Assertiveness in this case meant Black students had to be self-confident, speak up for themselves when professors didnt or wouldnt, and have to prove that they were capable (Henfield et al., 2011; Pfafman, 2020). Again, while this study touched on codeswitching among Black graduate students, the main focus was elsewhere. However, it still emphasizes that the use of Ebonics in PWI graduate programs comes with challenges for Black or African American speakers. Thus, further suggesting that the use Ebonics in PWIs may bring on race-related problems which has already been linked to enrollment rates and psychological challenges. One study even included Black student participants from both post-grad and undergrad programs (Laufer, 2012). This qualitative study used interviews to specifically examine Black students silence in PWIs and perceived stereotypes (Laufer, 2012). Similar to the current study, a thematic coding approach was taken to analyze the data. Among the findings, the majority of the participants perceived that their race, gender, or social class were the reasons why they did not speak out in class. One male doctoral participant, in particular, stated that as a Black man, his 24 friends and professionals of color would critique him for using AAVE and for using highfalutin words (Laufer, 2012). Thus meaning that, whether or not Black students codeswitched or not there were still negative consequences. Once again, while this article provided good insights into the experiences of Black graduate students, the use of codeswitching was not the overall theme. The overall theme was the culture of higher education. The limited research available is still essential in that it illuminates the fact that codeswitching has been a longstanding topic of discussion with many different implications. But clearly, with limitations comes room for growth in terms of further areas to be explored. Perceptions, Reasons, and Implications of Codeswitching For years, codeswitching has been explored and discussed in novels, social media, and academic journals. However, some of the most important research speaks to the specific implications, perceptions, and reasons for codeswitching. Dating back almost 100 years ago, the famous novel, Cane was published in 1923 (Avery, 2023). The 1920s novel painted a picture of the Harlem Renaissance period, demonstrating the complexities of the challenges African Americans faced to include cultural transformations, identity crises, and modern-day codeswitching (Avery, 2023; Dahn, 2012; L. Williams, 2020). In particular, Cane showed readers that Black Americans were frequently changing their modes of communication in order to avoid danger (L. Williams, 2020). Thus, further reflecting that codeswitching has long been impacting Black or African American individuals and needs to be studied. Moving forward, by 1994 there had only been one study to empirically assess African Americans views on African Americans who use codeswitching (Doss & Gross, 1994; Koch et al., 2001). Later in 2001, Koch et al. attempted to rectify the limitations of the 1994 study by using speech samples to examine participants' perceptions (2001). As previously mentioned, they 25 found that participants rated Standard English speakers more favorably than Black English speakers or those who inappropriately codeswitched. Inappropriate codeswitching was defined as someone who violated social norms when they codeswitched. However, researchers at the time of the study stated that future research needed to further examine under what situations African Americans use Black English [Ebonics] and codeswitching, and in what circumstances are those dictated by social norms (Koch et al., 2001). Hence, a gap in research that the current study set out to further examine. Now, refraining from the use of Ebonics and participating in codeswitching is commonly used to be perceived as competent and having a strong character (Billings, 2005; Payne et al., 2000). It may appear as a simple or trivial task to switch from Ebonics to what is known as Standard English. However, the strategy of codeswitching is in fact a linguistic tool, which African Americans use to navigate in a society where they are the racial minority (Greene & Walker, 2004). There is nothing simple about it. Furthermore, the linguistic tool is frequently used by African Americans such that it is almost unconsciously done (Greene & Walker, 2004). In fact, the Pew Research Center found that overall, Black and Hispanic adults and a small number of Whites say they often or at times have the need to change how they talk around others from different races and ethnicities (Dunn, 2019). However, along with examining the perceptions of codeswitching, it is important to examine the reasons for codeswitching and any implications that may follow. Research provides for a multitude of reasons as to why Black or African Americans codeswitch but, as always further exploration can be very beneficial (Boulton, 2016; Foster & Newman, 1989; Matthews, 2006; McCluney et al., 2021; Schau et al., 2007; Warner, 2007). 26 Some of the research on the reasons for codeswitching has focused on workplace codeswitching (McCluney et al., 2021). In fact, it has been found that the three main reasons for codeswitching in the workplace are to increase perceptions of professionalism, avoid negative stereotypes associated with Black racial identity (incompetence or laziness), and to express shared interests with members of dominant groups in order to raise chances of promotions (Carton & Rosette, 2012; Gulati & Carbado, 2004; Kang et al., 2016; McCluney et al., 2021; Melaku, 2019). Researchers also examined the positive and negative outcomes of codeswitching as well as the psychological well-being of those codeswitching, primarily in the workplace. McCluney et al.s study in particular examined the perceptions of codeswitching and evaluations of professionalism. This was done by having White and Black participants listen to an audio recording or an email from a fictitious Black co-worker in a professional field (2021). Among the results, it was found that downplaying ones racial group can create hostility, increase stereotype threat, and contribute to burnout (McCluney et al., 2021). Another study that interviewed Black people employed in high positions (i.e., directors), found that overall codeswitching was used as a survival technique in the workplace and that assimilation was exhausting (Santiago et al., 2021). Among other themes of psychological wellbeing within this study were reports of anxiety, poor sleep habits, feelings of helplessness, impact on interpersonal relationships, and self-doubt. Some participants even reported other implications not specifically related to mental health. For instance, one participant stated that an implication of not assimilating was the risk of losing income (Santiago et al., 2021). While the aforementioned literature focused on workplace codeswitching and assimilation, that is not to say that research on the reasons for codeswitching in other settings 27 such as the classroom or among other specific populations does not exist. In fact, well-executed codeswitching has been found to increase the social status of Black adolescents in academic settings and among peers (Hemmings, 2006). It is important to note that while social status may not seem like a psychological impact, it is. In fact, psychologist, Abraham Maslow posited that a lack of social connection or lack of belongingness can cause personal suffrage and deter psychological growth (Martino et al., 2015). Thus, further questioning whether the lack of wellexecuted codeswitching may lead to a lack of belonging and negatively impact an individuals psychological growth. Additionally, research suggests that youth who identify as Black selectively codeswitch in order to avoid being accused of acting White (Durkee & Williams, 2015; Hemmings, 2006). There are some similarities in the way and reasons why Black youth codeswitch and in the way that Black college students and adults codeswitch. In studies that have examined codeswitching among college students, some of the common reasons for codeswitching discussed were to build social mobility, to construct, and maintain solidarity (Matthews, 2006; Warner, 2007). Thus, providing further evidence that Black people and Black college students codeswitch for a reason and there is meaning behind it. Taking a further look at reasonings, 65 students from diversity-related events were recruited from Miami university (Matthews, 2006). In the study, there were multiple methods to explore participants reasons and understandings of codeswitching and Ebonics. For instance, the participants were given a questionnaire with ranking and open-ended questions about their familiarity and usage of Ebonics, asked to submit an audiotaped recording of a speech from their communication course, and completed an interview. As a result of all of the data, the majority of the participants reported having knowledge of Ebonics but only 37% said it was a valid form of 28 communication. In terms of reasons, 60% of students stated they only used Ebonics with people they are familiar with but 97 % of the students denied using Ebonics with professors (Matthews, 2006). Overall, there was a general theme among participants that codeswitching was a necessity in order to survive in mainstream society. Hence why the current study attempted to expand on the exploration of the settings in which and reasons why Black students codeswitch. When exploring specific reasons and implications of codeswitching it is also important to look at theories such as social learning theory, identity negotiation theory, and functions of Blackness theory (Cross et al., 2002; Cross & Strauss, 1998; Hibbler, 2020; Payne & Suddler, 2014; Ting-Toomey, 2015; Ting-Toomey; 2017). Social learning theory created by Albert Bandura emphasized the idea that learning comes from observing and imitating others' behaviors (Evans & Kelly, 2020; McLeod, 2016). Some have even argued that social learning theory is tied to how people learn a language, language patterns, and motivations to use certain language in certain situations (Bandura,1989; Whitehurst, 1978). Essentially over time as children hear and see words being used, they begin to repeat them and imitate their observations (Bandura, 1989; Skinner, 1957). Thus, similar to the way in which others have argued that Ebonics has been learned. Albert Bandura's social learning theory was further examined in the context of codeswitching in a qualitative study that was primarily used to gain an understanding of how codeswitching uses the structure of language to obtain access to advancement opportunities (Hibbler, 2020). This study, although it focused only on African American male faculty, was guided by Banduras research. The researcher used interviews, questionnaires, and focus groups and found that exposure to codeswitching at an early age taught participants how and when to codeswitch in their later years. One participant even noted that codeswitching was set in stone by 29 their parental figures (Hibbler, 2020). Furthermore, given the sample, it posited the idea that African American males choose their language based on their environment (i.e., working at a PWI) and that early contact with codeswitching can impact the way it is perceived. Thus, in line with social learning theory. Notably within this study, participants also expressed assimilation as a means to overcome negative experiences experienced at their PWI place of employment (Hibbler, 2020). Assimilation also plays a large role in the Identity Negotiation Theory (INT). Under INT, it is assumed that all humans despite cultural background yearn for positive identity affirmation in multiple communication-related settings (Swann & Bosson, 2008; Ting-Toomey, 2017). More specifically, identity in terms of the Identity Negotiation Theory refers to an individuals multifaceted identities including but not limited to culture, ethnicity, SES, sexual orientation, family roles, and personal image (s) (Ting-Toomey, 2015). So, to codeswitch is to often change or suppress your identity and shy away from the negative stereotypes associated with the Black racial identity (McCluney et al., 2021). Again, this is in line with assimilation. Thus, codeswitching refers to the strategy of identity negotiation wherein individuals strive due to an inherent craving for positive identity affirmation in specific communication settings (TingTooney, 2017). In fact, studies have linked codeswitching (in general) to bicultural identity and the negotiation of identities (Toomey et al., 2013; Wentker & Schneider, 2022; Yim & Clement, 2021). Much of the research tying codeswitching in terms of the use of Ebonics and identity negotiation theory primarily consists of student dissertations or theses (S.H. Harris, 2013; Hull, 2020; S. Jones, 2018; Lounsbery, 2014). Among the general codeswitching and INT research (published), a qualitative study was performed to explore bicultural identity and communication strategies among Asian-Caucasian 30 individuals (Toomey et al., 2013). In this study, 12 biracial (Asian-Caucasian) college students were interviewed and asked about their everyday communication patterns, how they felt about their bicultural identity, any conflicts, and resolutions. The results revealed a general theme of conflictual cultural values and participants' urge to keep up with mainstream communications. While many of the participants engaged in codeswitching, they also reported that codeswitching was not an easy process and came with frustrations (Toomey et al., 2013). A summary of the data suggested that codeswitching was tied to identity construction problems, cultural clashes, and feelings of being misunderstood (Toomey et al., 2013). Further establishing that codeswitching can impact ones identity and can lead to further problems. But, given the other data it is also important to explore this area among Black graduate students, another marginalized group that also experiences identity concerns. In terms of identity concerns, it is important to also examine identity construction. But again, the previous research is often among other areas or with participants of ethnicities and races other than Black or African American. For instance, Wentker & Schneider looked at identity construction and codeswitching but in other areas (2022). In fact, they gathered comments and reactions from a Youtube video on common phrases used by Latina mothers to explore how English-Spanish codeswitching is used, how it strengthens identity, and how certain phrases provide for group identity or the need to negotiate. In summary, it was found that codeswitching can reinforce in-group solidarity and is used as an inclusivity tool (Wentker & Schneider, 2022). While this was an interesting view of codeswitching and its link to identity negotiations, it is important to note that this study used written forms of codeswitching. However, another study provided further insights into group solidarity, identity, and codeswitching (Yim & 31 Clement, 2021). In this particular study, 67 Cantonese-English bilinguals in Canada answered questionnaires and it was found that those who identified more with their Asian cultural identity had more positive attitudes toward codeswitching. On the other hand, it was revealed that participants with a strong Canadian identity found codeswitching more difficult and described it as less comfortable and more effortful (Yim & Clement, 2021). This further suggests that codeswitching is tied to identity as well as culture, but it can result in both negative and positive outcomes. The present study aimed to see if these suggestions and results apply to African Americans. Additionally, other theories have been used to better understand codeswitching and the reasons for codeswitching. In a 2014 study that focused on the functions of Black Identity at a PWI, three theories, in particular, were used as the theoretical framework (Payne & Suddler). These three theories were the Standpoint theory, the Black feminist theory, and the functions of Blackness theory (Payne & Suddler, 2014). The Standpoint and Black feminist theory are important as they provide a gender-based conceptualization and posit that previous research has ignored marginalized women and argues that knowledge stems from social position (Borland, 2020; P.H. Collins, 2002; Harding, 1986; Payne & Suddler, 2014). However, the functions of Blackness theory, which was used as the primary conceptualization for the study, is also important in understanding the use of codeswitching. The functions of Blackness theory by Cross and Strauss (1998) and Cross et al. (2002) argued that there are five everyday functional expressions or negotiations of Blackness, with one of them being codeswitching (as cited in Payne & Suddler, 2014). In particular, the fourth function, codeswitching proposes that Black Americans codeswitch in order to fit in within new or different environments or persons in positions of power (Payne & Suddler, 2014). Overall, based on previous research, there are a 32 multitude of reasons for codeswitching such as suppressing one's identity to attempt to fit into different environments (Durkee & Williams, 2015; McCluney et al., 2021; Payne & Suddler, 2014). However, in combination with previous studies on general reasons for codeswitching and the limited research on codeswitching at the graduate level, it is evident that more refined research is necessary. Furthermore, it has been stated that for African Americans to navigate through a White world and still be a person who can be relatable in the hood, many find themselves taking on values of both worlds (Thompson, 2000). To elaborate, codeswitching allows African Americans to navigate through society by paying close grammatical attention, selectively adjusting their style of speech, and downplaying their racial identity (Deggans, 2013; McCluney et al., 2021). Therefore, this not-so-trivial linguistic tool goes beyond simply changing one's tone, but it plays a large role in an individual's identity. In addition to some of the reasons for codeswitching, those who choose to do it or not do it, still face implications and challenges. Some say that neglecting ones linguistic system is one of the most challenging things especially for Black college students (Lewis, 1998). For instance, it has been found that African Americans students language should be recognized, and when it isnt accepted students can lose motivation to learn (Lewis, 1998). Overall, research has found that codeswitching while at a PWI negatively impacts the academic and social performance of some Black students and faculty (Allison, 2008; Feagin, 1992; Ferguson, 2001; Payne & Suddler, 2014; Stanley, 2006). In particular, a study of eight African American professors at a PWI found that among the participant's majority of them codeswitched in order to be seen as professional, credible, and approachable (Allison, 2008). Some participants even reported altering their personality to have successful interactions with 33 White people meanwhile some argued against identity negotiation or codeswitching in order to be their true selves (Allison, 2008). Other studies have revealed negative comments and poor academic achievements from White professors or students based on the use of Ebonics (Feagin, 1992, Ferguson, 2001, Payne & Suddler, 2014; Stanley, 2006). Additionally, because of the potential reasons for codeswitching pertaining to identity, inclusion, avoiding stereotypes, etc., it can cause harm to an individual's mental and emotional health as people may feel inclined to conform, modify, or limit their usual speech (Adikwu, 2020; Payne & Suddler, 2014). Thus, it is vital to explore the potential reasons and implications for codeswitching in more areas. Black Students Experiences Codeswitching is just one of the many things that comes with Black individuals choosing to attend college or graduate school. For years, in the history of the United States, African Americans have experienced hardship in being treated as equals. From the beginning of the Jim Crow era in the late 1800s to the start of the Black Lives Matter Movement in 2013 as a result of the acquittal in the death of Trayvon Martin, the Black community has faced countless acts of racial discrimination at the hands of a system built on segregation (Little, 2015; Winter & Vallano, 2016). In particular, obtaining an education at any level has been a continuous obstacle in the Black community from the fight for desegregation of schools, dating back to the 1700s and into the late 1800s when learning to read and write was considered extremely dangerous due to the harsh punishments at the hands of slave owners (Cornelius, 1983; Evans, 2015; Rasmussen, 2010). In fact, the historical background behind African Americans receiving higher education consists of many obstacles and barriers (Bracey, 2017). In the 1800s the first Black academic 34 institutions, known today as Historically Black Colleges or Universities (HBCUs) were established (Bracey, 2017). The term, HBCU was defined by Congress in 1965, as any historically black college or university that was established prior to 1964, whose principal mission was, and is, the education of Black Americans, and that is accredited by a nationally recognized accrediting agency or association determined by the Secretary [of Education] to be a reliable authority as to the quality of training offered or is, according to such an agency or association, making reasonable progress toward accreditation (Higher Education Act, 2022). At times HBCUs were the only option for an African American to achieve higher education. Up until most of the 20th century, about 90% of African Americans were receiving an education from HBCUs (Kim & Conrad, 2006). This may be in part due to the benefits HBCUs are known for such as providing Black students with an inviting, accepting, and supportive environment as well as promoting personal and psychological development (Bracey, 2017; Cooper, 2017). Additionally, supporters of HBCUs have expressed that these institutions provide for continued educational growth for underrepresented students (Bettez & Suggs, 2012). Along with the opportunities for Black or African American individuals to achieve higher education, by attending an HBCU there is also an opportunity to alleviate stressors associated with attending Predominantly White Institutions and further develop (Van Camp et al., 2009; M.D. Williams, 2014). These alleviating stressors were found when M.D. Williams, a doctoral student examined the experiences of Black doctoral students at PWIs (2014). In her quantitative study, 140 Black/African American doctoral students were given 4 measures: The institutional Integration Scale, The Depression Anxiety Stress Scale, The College Academic Self-Efficacy Scale, and the Scale of Perceived Social Self-Efficacy Scale. Notably, from the sample, 33 individuals obtained their undergraduate degrees from an HBCU. Results from the participant's 35 responses revealed, a significant negative correlation between peer interactions and mental health (depression, anxiety, and stress). There was also a notable difference among the results from those who attended HBCUs vs. PWIs for undergrad. In fact, among the results, it was also found that those who went to HBCUs for undergrad later experienced increased anxiety when they entered graduate school at a PWI (M.D. Williams, 2014). It is important to note that the experiences that African American students encounter at an HBCU are different than at a PWI. In fact, on top of typical college student stressors, Black students attending PWIs can face even more (Cooper, 2017). A study examining the stressors of both African American students from PWIs and HBCUs provided supporting evidence of this. In this study, 101 participants from PWIs and 102 from HBCUs were provided with questionnaires inquiring about their stress and coping skills as well as a demographic questionnaire (Greer & Chwalisz, 2007). The results revealed that there were no overall differences among perceived stress from either group (HBCU students and PWI students). But there was a difference in the responses among minority status stressors. More specifically, the results indicated that African American students attending PWIs experienced more difficulties on campus related to their race which impacted their academic performance. In terms of coping strategies, the results showed that participants from PWIs used avoidance as a primary coping strategy while those from HBCUs tended to use approach coping strategies (Greer & Chwalisz, 2007). Approach coping was referred to as problem-focused coping strategies or seeking social support (Dubow & Rubinlicht, 2011; Greer & Chwalisz, 2007). Thus, further suggesting that Black students attending higher education at PWIs are having less than positive psychological experiences. So much so that, research has also indicated that Black students often have negative experiences 36 related to racism and experience racial microaggressions from not just peers but also staff at PWIs (Cox, 2020; Griffith et al., 2019). In addition to the previously mentioned disadvantages associated with Black students attending PWIs, the issue of authenticity also comes into play again. In fact, through interviews and qualitative surveys, it has been found that Black PWI students are viewed as less authentically Black by Black HBCU students (Cox, 2020). Although, this previous research has brought light to the significant experiences of Black students at PWIs, once again graduate students were not highlighted in these studies. Therefore, this area of literature in combination with codeswitchings impact at predominantly White institutions at the graduate level needs to be investigated. More specifically, because the undergraduate and graduate student experiences can be different, research needs to be done. For many, graduate school can come with more challenging coursework, a change in social environment, increased financial stress, etc. (Cottrell & Hayden 2007; Gardner & Barnes, 2007; Kowarski, 2022). For Black individuals in particular, graduate school and even the idea of attending graduate school can come with its own set of challenges (Alexander & Bodenhorn, 2015; Johnson-Bailey et al., 2009; Leong, 2020; Moses, 1989). As history has shown, there is a theme of Black people experiencing problems in higher education. In looking at graduate school, Johnson-Bailey and colleagues mailed out self-report questionnaires to further examine Black graduate student experiences at PWIs (2009). It is important to note that the participants in this study were alumni of a PWI in the South. The results showed countless acts of discrimination from White students and faculty/staff. The discrimination from the White students was in part attributed to a lack of diversity exposure. Some of the discrimination reported was associated with negative comments regarding 37 Affirmation Action, assumptions of poor writing skills, and racial slurs. Overall, this study suggested that the social experiences of Black graduate students were different than those of undergraduates and those attending HBCUs for graduate school (Johnson-Bailey et al., 2009). In fact, some of the excerpts from Johnson-Bailey and colleagues study were quite disheartening but also emphasized the importance of this phenomenon. Another study with a similar participant sample found that Black graduate students at a southern PWI coped with their personal/emotional adjustment to graduate school with family and friendship support (Alexander & Bodenhorn, 2015). Notably, the 11 participants in this study attended an HBCU for their undergraduate studies. Reports of their adjustment from an HBCU to a PWI revealed psychological distress, lack of support from graduate supervisors, and racial microaggressions (Alexander & Bodenhorn, 2015). The aforementioned factors provide evidence that for Black graduate students at PWIs their negative experiences can be exacerbated. Additionally, to get through their graduate programs Black students are often codeswitching and increasing their psychological distress but dont always have effective coping skills or supportive resources within their PWIs. Justification Furthermore, through a combination of research on U.S. Educational history, the history of Ebonics, experiences of those within the Black community, Black students experiences, and other relevant research, institutions can become cognizant of potential issues and cultivate policies to reflect this phenomenon. In particular, previous studies have further demonstrated that codeswitching among Black or African American individuals in specific environments can have positive and negative outcomes. Thus, for reasons such as codeswitching being characterized as a skill set for survival and making African Americans feel included at school, it is a topic that 38 should not continue to be ignored in research (Washington-Harmon, 2020). Thus far, the majority of the research on codeswitching in terms of the use of language/vocal appearance, among Black or African American individuals has primarily focused on specific age groups such as school-aged children, particular environments such as the workplace, or in higher education such as the pursuit of an undergraduate degree. As evidenced by previous research, codeswitching from what is known as Standard English to Ebonics can result in psychological damage for those who feel inclined to conform or adjust their speech in order to achieve (Adikwu, 2020). Additionally, because the common reasons for codeswitching in other populations are related to racial identity, inclusion, and the avoidance of stereotypes, it is important to evaluate if these same or other reasons apply to those attending graduate school (Adikwu, 2020; McCluney et al., 2021). These are all areas which can also impact ones mental health which is why codeswitching should not just be looked at as a simple tool or an area that doesnt need to be researched. In fact, mental health is vital for humans in order to think, have emotions, and participate in daily activities (World Health Organization, 2018). That being said, codeswitching can be seen as a stress put on people from marginalized identities and it should be on the professional radar (Washington-Harmon, 2020). This is why the current study attempted to provide an in-depth look on the psychological impact of codeswitching from Ebonics to Standard English among Black or African American graduate students, at predominantly White institutions. In particular, this current study expanded on Koch et al.'s, study on the Attitudes toward Black English and Codeswitching by exploring Black students perceptions and feelings towards the act of codeswitching (2001). However, unlike the previous study, this current study took a particular interest in Black graduate students who previously attended HBCUs. 39 In order to add to the research on African American or Black student experiences at predominantly white institutions (PWIs), this study also expanded on Cox's (2020) study, On Shaky Ground: Black Authenticity at Predominately White Institutions, as previously mentioned in the literature review. In short, this study explored not just the attitudes towards codeswitching like the previous study but also brought awareness to the psychological impact of codeswitching among Black or African American graduate students at PWIs. Furthermore, this study added to the infrequent but constantly growing research on underrepresented populations such as Black or African American graduate students. In order to bring awareness and support for African American communities psychologists, this study is justified in that higher education institutions, and their faculty/staff need to be aware of codeswitching itself and the implications it may have on African American or Black students mental health. Along with expanding on studies from the past, this study emulated some of the missions and purposes of specific divisions of the American Psychological Association. In particular, this studys overall purpose is directly related to the purpose statement of The Society for the Psychological Study of Culture, Ethnicity, and Race, a Division of the American Psychological Association, which is to, is to encourage research on ethnic minority issues while concurrently applying psychological knowledge to address these issues (American Psychological Association, n.d.; Society for the Psychological Study of Culture, Ethnicity and Race, n.d.). However, more specifically this study explored the particular issues that African Americans face when altering their vocal appearance, in particular white environments such as Predominantly White Institutions. Additionally, it addressed specific topics of African American graduate students partaking in codeswitching and the impact of codeswitching in university settings, wherein previous research has been lacking. 40 Furthermore, it is important that these topics are acknowledged, explored, and introduced to all societies, in all aspects of psychology. After all, psychology is about describing and understanding behavior (Coon & Mitterer, 2013). Therefore, it is important that not only psychologists but also institutions are aware of the possible psychological turmoil that can be associated with the use of codeswitching and the impact of predominantly white institutions in these situations (Neville et al., 2004). Overview and Research Questions This study used a demographic questionnaire and a semi-structured interview to explore the psychological implications of codeswitching among Black or African American graduate students. Additionally, because the Consensual Qualitative Research (CQR) method used does not focus on the formation of hypotheses, hypothesis testing was not used to evaluate the data (Hill, 2012). Instead, in adhering to the CQR methodology, research questions were used to provide an inductive approach to the data analysis (Hill, 2012). Therefore, the following research questions were proposed: 1) What are the reasons why Black or African American graduate students codeswitch in academic and/or campus settings? 2) How does codeswitching at a PWI impact Black or African American graduate students mental health in comparison to their past HBCU experience? 3) What are the potential challenges Black or African American graduate students experience when codeswitching or refraining from codeswitching at a PWI? 4) In what ways can PWIs become more aware of potential implications surrounding codeswitching among Black or African American graduate students in academic settings? 41 CHAPTER TWO: METHODS Introduction The present study utilized Hills (2012) Consensual Qualitative Research (CQR) methodology. The methodology uses open-ended interviews and relatively small samples, to draw conclusions from the data (Hill, 2012). The method also tends to be used to study personal experiences, attitudes, and beliefs that are not always easy to observe (Hill & Knox, 2021). Therefore, because this study was aimed at exploring the lived experiences of Black or African American graduate students at PWIs, the CQR method was used. In particular, the realities of the participants' experiences add a great deal of importance that numbers cannot justify in the research (Cleland, 2017). More information on the Consensual Qualitative Research method can be found in the Data Analysis section. Participants For this study, a sample of 12 participants was recruited. While CQR methodology suggests a sample of 12 to 15 participants, a lower number of 12 participants was used to avoid having to modify research questions as that could create an overload of data (Hill, 2012). Also, due to recruitment difficulties data collection concluded after the 12th participant. Criteria The participants recruited were adults (18+) of Black or African American descent not including international students. The study of Black international students is still important. However, research has shown that Black international students often have different experiences, cultures, and languages than that of Black or African Americans (Gaun, 2018; Kent, 2007; Mwangi, 2016). Thus, they were excluded from this particular study. The participants were also required to be currently enrolled in or previously graduated from a PWI graduate degree program 42 at the time of recruitment. Notably, the proposed study stated that only participants who were currently enrolled in a PWI graduate program were eligible. However, data collection became very difficult with such inclusion criteria. Thus, after IRB approval it was removed to allow for more successful recruitment. Also, participants were not excluded from the study based on their graduate field of study. However, eligible participants must have attended a Historically Black College or University (HBCU) for their undergraduate degree program. This requirement was in place so that the adjustment experiences among Black or African American students could be better examined by looking at any changes from HBCUs to PWIs. For the purpose of this study, a PWI was defined as a higher education institution where White people make up 50% or more of the student population (Lomotey, 2010; Setty-Charity, 2022). At the beginning of recruitment, it was required that eligible participants must have graduated from their undergraduate degree program within 5 years of the recruitment date. This time frame was suggested in order to avoid the possibility of having too wide of a range of results (Hill, 2012). However, this proved as a hardship during the recruitment process as many individuals did not meet the 5-year time span requirement and it became difficult to find participants. Thus, after careful consideration, it was removed from the inclusion criteria. Based on the low number of 12 participants and the participant sample, this did not appear to change the range of results. Lastly, for CQR studies, participants must be knowledgeable of the phenomenon at hand (Hill, 2012). Therefore, the participants must have had a general knowledge of the meaning of codeswitching in order to participate. The recruitment flyer (See Appendix B) which provided the definition of codeswitching was used as a screening measure for participants' general 43 knowledge of the meaning of codeswitching. The co-investigator also screened for this general knowledge by verbally asking prior to starting the interview process. Recruitment Participants were recruited via flyers and internet postings. The primary method of recruitment was social media platforms such as Facebook and Instagram. Recruitment through specific organizations/research platforms geared toward Black students were also used. Some of these organizations/research platforms were, The Association of Black Psychologists (ABPsi), its subchapters, University Black Student Unions, Black Graduate Student Associations, and African American Student Services. As a part of the recruitment process, it was advertised that compensation would be provided in the amount of $10 per participant, in the form of an Amazon gift card. Measures This study included a demographic questionnaire and a semi-structured interview. The demographic questionnaire allowed for the gathering of background information on each participant. The semi-structured interview allowed for the gathering of specific information related to the phenomenon from each participant. Demographic Questionnaire The demographic questionnaire was used to describe the participants and better analyze the data collected (Allen, 2017). The demographic questionnaire was administered verbally by the co-investigator prior to the semi-structured interview. The responses to the demographic questionnaire were typed and stored on an encrypted flash drive. Responses to the demographic questionnaire were not audio-recorded. 44 In this questionnaire, the following participant information was gathered: age, race/ethnicity, gender, sexual orientation, name of undergraduate university, undergraduate degree field of study/degree program, years attended, years since the undergraduate degree was obtained, name of the current university, the current field of study/degree program, year in their graduate program, full-time vs part-time status, and type of degree program. See Appendix C, for a list of HBCUs. Also, as this study did touch on topics related to the Black community and obstacles to obtaining higher education, the participants were also asked about their parent's/guardians level of education and if they are/were first-generation college students. First generation students are defined as students whose parents did not obtain a bachelors degree (PNPI, 2021). See Appendix D for the demographic questionnaire. Semi-structured Interview Questions The semi-structured interview for this study included a total of twenty-one questions split into five sections with interviews lasting anywhere from 15 minutes to 120 minutes. The five sections asked questions related to the following: rapport building, reasons for codeswitching, codeswitching in academic settings, psychological well-being, and diversity/awareness. The first section is important as rapport with participants is one of the main goals of the interview protocol established by Hill (2012). Also, researchers have argued that rapport within conversational or standardized interviews encourages openness to answer questions (Bell et al., 2016). Secondly, participants were asked about their reasons for codeswitching to examine whether or not there were similarities or differences in their reasons as compared to the previous data on other populations (Boulton, 2016; Foster & Newman, 1989; Matthews, 2006; McCluney et al., 2021; Schau et al., 2007; Warner, 2007). The third and fourth sections were created in order to expand on the underlying proposed research question of potential challenges and impacts of the 45 phenomenon. Because an individual's psychological well-being is crucial to their daily functioning and because codeswitching has been previously found to impact ones mental health, this was a vital area to explore (Washington-Harmon, 2020; World Health Organization, 2018). Lastly, the fifth section was created to conclude the semi-structured interview with questions encouraging diversity awareness among research as well as in real-world settings. While these questions are pertinent to the study, all of these questions are not directly based on the literature. One of the luxuries of CQR is that personal experiences can be used as an important source for developing interview questions (Hill, 2012). Therefore, the questions developed for this study were a combination of the personal experiences of the co-investigator and the current literature. See Appendix E for semi-structured interview questions. Procedures The interviews were conducted via a virtual platform called Zoom given the status of the global pandemic (at the time of investigation) and to avoid geographical restrictions (Zoom Video Communications, Inc., 2022). The co-investigator facilitated and conducted all data collection. This was done in order to provide for more consistent interviews. It is important to note that with only one interviewer, there is the limitation of having only the interviewers bias. However, the inclusion of multiple interviewers also poses the limitation of having a wider range of biases (Hill, 2012). Thus, after careful consideration, it was determined that only the coinvestigator would perform the interviews. Notably, the co-investigator was a Black doctoral student who was attending a predominantly white institution at the time of the investigation. Those eligible and interested in participating in the study were asked to respond to the flyer by contacting the investigators via email. The co-investigator then emailed the potential participants a copy of the informed consent and instructions for scheduling an interview. 46 Interview scheduling was done via email scheduling and doodle poll. See Appendix F for the email. Following that, the co-investigator sent the informed consent document (again) to participants via email at least 48 hours prior to the scheduling of their interview. Participants were not asked to provide a wet or electronic signature to indicate their consent. This method was approved by the universitys IRB. Instead, at the beginning of the virtual interview before providing any measures the participants were asked if they had read the informed consent document and to provide verbal consent. The co-investigator then completed the informed consent form. As a part of the informed consent, the participants were made aware that they were free to withdraw consent at any point during the interview, and monetary compensation would still be granted. See Appendix G for the informed consent form. Once informed consent was provided, the participants were screened by having the coinvestigator confirm each criterion with the participant prior to completing any measures. If it was found that the participant did not meet the criteria, they would be politely declined from the study and would not receive compensation. Luckily, this did not occur with any of the participants. After these procedures, both the demographic questionnaire and semi-structured interview were completed. The demographic questionnaire was completed first. There were no specific interventions involved with this study. However, a debriefing form was still emailed to participants following the completion of the semi-structured interview. The debriefing form included a thank you note for their participation, a general overview of the study, and contact information. Additionally, because the semi-structured interview may have prompted feelings of discomfort or embarrassment, mental health resources were also included in the debriefing form. See Appendix H for the debriefing form. 47 Participants data were collected during the scheduled virtual interview. All interviews were audio-recorded via Zoom, manually transcribed, and stored on an encrypted flash drive. Any data obtained from this study remained confidential. Although confidentiality in this study is protected there are specific instances where confidentiality may be broken. The co-investigator was required by Indiana state law to file a report with the appropriate agencies if the information provided indicated child abuse, elderly abuse, harm to the participant, or harm to others. The coinvestigator also had a duty to warn an intended victim, notify the police, or seek hospital-based treatment for participants in such instances. None of these incidents explicitly occurred throughout data collection. Although some participants did reveal mental health concerns for which the co-investigator provided mental health resources. The co-investigator was the only individual with whom participants had direct contact and were personally identifiable to. Participants were not asked to provide their names on the informed consent form, on any questionnaires, or at any point during the audio-recorded interview. They were requested not to provide any identifying information when answering questions. However, some identifying information was shared during the interview, which the co-investigator removed when the audio recording was transcribed. The de-identified transcribed interviews were accessed by the investigators and the research team. The research team then analyzed the data using the CQR method. Consensual Qualitative Research (CQR) The data collected was analyzed using the CQR method which emphasizes the use of a research team. For each transcript, the research team collaboratively came to a consensus in order to form conclusions regarding the meaning of the presented data (Hill, 2012). More information about the research team and how it was formed can be found in the following 48 chapter. Following the formation of the research team, the co-investigator created a domain list. The domain list is a list of meaningful and unique topic areas based on the literature and the transcribed interviews (Hill, 2012). To elaborate, these unique topic areas are areas that represent what the participant said along with what the study was focused on, in this case, codeswitching (Hill, 2012). Later, the research team gathered and discussed in detail each domain. From that discussion, team members came to a consensus on whether or not changes needed to be made to the original domain list. After a thorough discussion, it was found that changes to the original domain list needed to be made. Following the review of the domain list from the research team, the list was then sent to the auditors for another review. The auditors are individuals who review the original research teams work for order, and clarity, expand on original findings, and provide preliminary feedback (Hill, 2012). In this study, the auditors were two doctoral students with previous CQR experience. Once the auditors returned the domain list with feedback, the research team deliberated until a consensus was reached on the finalized domain list. Next, the research team went back and assigned pieces/sentences from the interview data into individual domains (Hill, 2012). Again, the analyzed data gets sent to the auditors, the research team deliberates and accepts or rejects the auditor's feedback, and core ideas are later constructed. Core ideas are simply summaries of what the participants said but in less words (Hill, 2012). The consensus version of the core ideas is later audited, evaluated, and finalized. Lastly, all of the data was taken through a cross-analysis where common themes were identified (Hill, 2012). During this stage, the core ideas were placed into categories or subcategories based on frequency. Categories are common themes that are similar across multiple participants responses within a domain. 49 While subcategories can be more narrow or specific themes within a category. They are often used to better understand the data but are not required within CQR. The frequency was calculated based on the number of participants who have core ideas within each category or subcategory (Hill, 2012). For example, if the category applies to all the participants or all but one, then it is classified as, general. If the category applies to half or more of the participants, then it is classified as, typical. If the category applies to at least two participants but not more than half, then it is classified as, variant (Hill, 2012). The classification of, rare is primarily used in larger samples, but indicates cases of categories applying to one or two participants (Hill, 2012). As with the other stages, the categories were then submitted to the auditors for review. Following the cross-analysis, findings that directly spoke to the research questions, novel findings, findings that contained practical implications, and findings that challenged existing data were reported (Hill, 2012). 50 CHAPTER THREE: RESULTS Sample Characteristics The co-investigator interviewed 12 Black or African American individuals (see Appendix I for a list of the participant characteristics). It is important to note that when asked, What is your race/ethnicity?, eight participants self-identified as Black, two as African American, and two as Black/African American. All of the participants were over the age of 18, but their ages varied from 22 to 41 (M=28.42). They also varied among genders in that there were eight female participants and four male participants. Participants were also asked about their sexual orientation, with the majority identifying as being Straight/Heterosexual. More specifically, ten participants self-identified as being Straight/Heterosexual, one as Gay, and one as Queer. Multiple questions were asked to gain a full picture of their educational backgrounds. First, they were asked the name of the HBCU in which they attended for their undergraduate studies. However, the co-investigator later decided to redact the names of participants' HBCUs to protect their anonymity. Instead, only the region of the participants' HBCUs was reported and used in the individual transcripts read by the CQR team. For instance, eight participants attended HBCUs in the Southeastern region of the United States, three of the participants attended HBCUs in the Mid-Atlantic region, and one attended an HBCU in the Southwestern region. It is important to note that four participants from HBCUs in the Southeastern region of the U.S. attended the same HBCU. Participants undergraduate degrees of study also varied. Most of the participants (N=6) majored in social sciences (e.g., anthropology, psychology, sociology, and diversity studies) during undergrad. Others majored in business (N=3), science (N=2), and math (N=1). The mean number of years passed since a participant graduated from their undergraduate program was 6.3. 51 Participants were also asked questions about their graduate studies. While all the participants were either currently attending or graduated from a PWI, they did not all attend the same university or college. Again, to protect the participants' anonymity, the names of their graduate universities/programs were redacted, and only the regions were reported. The locations of their graduate programs included those from the Midwest (N=3), Southeast (N=2), Southwest (N=2), Western (N=2), Mid-Atlantic (N=1), Mountain Plains (N=1), and the Northeast (N=1). Most of the participants (N=8) were enrolled in or had completed a doctoral program. The other participants (N=4) were enrolled in or had completed a master's program. Some but not all participants had completed a masters degree and were also currently enrolled in/had completed a doctoral program (N=4). However, this information was not explicitly asked within the demographic questionnaire. For those that had already graduated, the mean number of years since a participant had graduated from their graduate program was 7.4. In terms of their graduate field of study, most of the participants (N=7) majored in social sciences (i.e., psychology, sociology, diversity studies). The remaining participants majored in either science (i.e., biology, chemistry, nursing) (N=4) or other (N =1) (i.e., higher education, student affairs). All of those interviewed were enrolled in their graduate programs full-time. Lastly, a question about participants' first-generation status was asked. More than half of the participants were first-generation students (N=7). Among the participants who were not firstgeneration students, the highest degrees their parents earned were masters degrees (N=3) and doctorate degrees (N =2). For relevance and to preserve additional confidentiality, the names of the participant's parents colleges and universities were not reported. However, it is important to note that only one of the participant's parents/guardians attended an HBCU. 52 Research Team In addition to the co-investigator there were also members of the research team that assisted with analyzing the data. The CQR approach does not specifically state who can or cannot be a part of the research team. However, past research teams have consisted of a mixture of masters level students, psychology doctoral students, and professors (Hill, 2012). Also, research teams that consist of individuals with different diversity factors can increase the integrity of the team (Hattery et al., 2022; Hill, 2012). Thus, the co-investigator sought out research team members of similar and different backgrounds. The research team consisted of twenty individuals (not including the principal and co-investigator). There was a mixture of seven undergraduate students, two masters students, ten doctoral students, and one professor. 8 out of the 20 research members had previous CQR research experience. A crash course on CQR analysis was provided to educate all of the team members prior to data being analyzed. In terms of racial diversity, the team consisted of four South Asians, seven Black/African Americans, and nine Caucasian Americans. The majority of the team members were female (14 out of 20). Prior to analyzing any data, the research team met as a group to openly discuss biases, differences, and similarities that may impact analysis. Together, several team members discussed how being a minority, speaking more than one language, only having attended a PWI, or how White privilege may play a role in their biases and how they interpreted the data. After this discussion, the research team was placed in groups. Groups consisted of about 2-3 members with at least one member in each group having previous CQR experience. Following data analysis, members of the research team were also compensated with a $10 Amazon gift card for their time and assistance in analyzing the data. 53 Qualitative Data Domains From the analysis, there was a total of eight domains within this study. As previously stated, domains are broad themes that represent what the participants said (Hill, 2012). Among the domains were: 1) Motivations for codeswitching 2) Ebonics and Standard English 3) Differences among PWIs and HBCUs 4) The impact of codeswitching 5) Other types of codeswitching 6) Coping strategies 7) Higher Education Interventions 8) Other. The 8th domain, of Other included responses that were irrelevant to the current study and tangential responses. Thus, they were excluded and are not reported within the results which is consistent with the CQR method (Hill, 2012). See Appendix J for the domain list. Categories and subcategories were then defined from the core ideas within the domains. Again, categories and subcategories are common themes across the participant's responses that are formed through careful conceptualization and organization (Hill, 2012). A list of the categories, subcategories, and frequencies can be found in Appendix K. Overview of Findings Below is a list of each relevant domain, category, subcategory, and relevant responses from the data. The relevant responses below are either direct quotes from participants' interviews or their core ideas. For example, if in the results the description shows P reported XYZ, this is referring to a core idea or a summary of the participants response. Additionally, the direct quotes may also appear to have grammatical errors, this is intentional. The quotes were not edited for grammar and spelling as it would take away from one of the main points of this study, to explore codeswitching or the adjustment of dialects grammar, etc. 54 Domain 1: Motivations for Codeswitching Participants answered questions about their reasons and motivations for codeswitching in this domain. Three General categories appeared from the data, revealing that most of the responses or motivations for codeswitching were: Based on Setting, For Advantages, and Based on the Racial Makeup of Those Around. From those that said their motivations/reasons for codeswitching were Based on Setting, five Subcategories emerged from the data: Academic/Classroom Settings (General), Being at a PWI (Typical), Comfortable Settings (Typical), Social Settings (Variant), and Professional Settings (Variant). Participant D4 emphasized codeswitching in the classroom as they responded by saying, they are motivated to do it every academic setting which for them included lab and class. In addition to the classroom being a motivating factor, being at PWI also influenced motivations and reasons for codeswitching. For example, Participant F6s core idea stated, P believes that in non-PWI settings, codeswitching is not a necessity. P didnt have to codeswitch at HBCU or at work and could show their authentic self because they were around people that looked like P. Another participant, K11 specifically stated, I was hyper aware uhm and like literally I could be giving a presentation.But as soon as like the VPSA or someone like that stepped in the roomcompletely different [participant name]. Like words got proper, stopped using the slang terms, and the terms we use in Greek life, and you know started talking about theory and you know I had to switch it up. Others clarified that while they were motivated to codeswitch in academic settings, particularly PWIs, there was also another factor among the academic/classroom setting that influenced their motivations. This other factor was interacting with faculty/staff in academic settings. Participants noted that they chose to or were motivated to codeswitch when interacting 55 with faculty/staff in their graduate programs (PWIs) as it would often result in repercussions if they did not. For instance, participant J10 reported, Uhm but for, definitely [codeswitching] for faculty. If I catch myself, I be like, sowhat I meant was, you know and I would catch myself kind of backtracking. Notably, not every participant identified the race of their faculty/staff in their graduate programs. However, the majority of responses indicated that there were a small number of faculty, staff, and students of color in participants' PWIs. These factors and results are also discussed in later sections. For the typical subcategory of comfortable settings, participant A1 stated, I think its like a comfort thing and just recognizing that there are some things that are particular for the social environment that Im in Notably, this subcategory included 7 responses stating that participants were motivated to codeswitch based on being in a comfortable setting. From those that said their motivations for codeswitching were For Advantages, five subcategories emerged from the data: To be Understood (Typical), To Avoid Stereotypes (Typical), To Achieve (Typical), To be Taken Seriously (Variant), and for Mental Health (Variant). Codeswitching for advantages was also a significant motivating factor, as was evidenced by more than 11 responses in this category. Hence why it was labeled as a general category. One of these advantages and typical subcategory was to be understood. Participants emphasized their reasons for codeswitching in order to be understood both verbally as well as empathically. For instance, participant D4 stated, I just feel like I wouldn't be understood. Uhm I don't think I work with people who are racist or think differently about people. I just feel like it'd be it'd be much more translating going on, you know what I mean. Meanwhile, Participant K11s response revealed that, Uhm to be heard and valued I needed to be able to speak that language and at sometimes I needed to be able to translate. 56 Others were motivated to codeswitch in order to avoid stereotypes associated with being Black or African American. Notably, this was a typical subcategory. For example, H8 stated that she codeswitched because I get looked at crazy when I forget. Yes, because theres been a couple of times in class when I forget to codeswitch and people are like [made confused look] or they like assume that like Im the home girland its like no. So yeah thats why I codeswitch. Along with choosing to codeswitch to avoid negative stereotypes, participants also expressed being motivated to codeswitch as they believed it would result in success or achievements. Yet, another typical subcategory. For example, Participant A1 thinks that codeswitching is a strategy used by people who have to follow a particular way of doing things in order to get what they want in life and professional success. Similarly, participant K11 specifically stated, I think it was like I had to do it [codeswitch] in order to survive, achieve, all of those things. And uhm, I dont know, yeah. While it was a variant subcategory, it is still important to note that a small number of responses (2-6) provided evidence that participants' motivation for codeswitching was related to mental health advantages and to be taken seriously. Participant E5 expressed this by stating, different environments are for different things, and it sucks that it has to be that way. But in order for my sane sanity and well-being, it just has to operate like that. From those who said their motivations for codeswitching were Based on the Racial Makeup of Those Around there were no subcategories. It is important to note that this is still a general category even without subcategories. Within this category, participant F6 thinks that society has told them to codeswitch in White settings. More specifically participant F6 stated that, I mean I codeswitch everywhere that Im the only one. The only time that I dont codeswitch is when Im like out with my friends or you know at home around people who look 57 like me. It was not uncommon for the participants to report being the only or one of very few Black individuals in their PWI graduate program. Six typical categories also emerged from the data within this domain, revealing additional motivations for codeswitching from 7-10 responses such as: Role models using Codeswitching, Undergrad Influences, Out of Necessity, Naturally, Ingrained, and No Motivation. Among these categories, participants reported that the reason they codeswitch is because it has been taught either through undergraduate experiences, watching others around them codeswitch, or that it comes naturally. Notably, within the role models using codeswitching category, participant C3 stated, my first experience with like even seeing codeswitching was my mom when should talk at home versus how she had to talk on the phone for work. Or when I would go to work with her and she would sound like a completely different person. And then she kind of taught me that you have to speak a certain way to certain people in order to get things done. Participant K11 also provided many examples of motivations for codeswitching within these typical categories. For example, participant K11 provided many excerpts of watching and listening to their mother codeswitch which motivated them to do the same. Additionally, within the undergrad influences category, participant K11 expressed, our program coordinators [at HBCU], were very hard on us and without saying codeswitching now I realized that they were telling us, we had to codeswitch in order to be successful. Participant K11 also felt that codeswitching has become ingrained and is like a superpower. Among the responses within the naturally typical category were, so, yeah I think its just a natural way of conducting communication from participant A1 and so yeah, so for the most part during undergrad I didn't have to codeswitch as much. And now it just came naturally, where I do it all the time. Like, I said before, you know in any academic setting from participant F6. 58 Others felt they were not motivated to codeswitch but that it was something they did out of necessity. For example, participant J10s core idea even expressed that, P feels that once you have the credentials you can do what you want and not have to codeswitch anymore. More specifically, participant I9 stated, I dont think that I really just had touhm do any codeswitching for that. Notably, participant I9s response was coded as no motivation. Lastly from this domain, three Variant categories emerged from the data. These categories revealed less prevalent motivations for codeswitching such as the Use of codeswitching over time/habit, participants feeling motivated Regardless of the Racial Makeup of Those Around, or simply No reason. Notably, participant I9 said that with age, they have learned more about how to incorporate codeswitching in their academics and identity. While previous responses revealed that participants codeswitched based on the racial makeup of those around, there was still a small number of responses (2-6) that stated the opposite. For instance, Participant L12 reported, codeswitching in academic settings even with Black clients. Meanwhile, some participants provided vague responses to questions within this domain and did not have a particular reason in mind. Hence, participant J10s response of I codeswitch because drumroll [redacted name] I can! It is important to note that the general categories within this domain speak primarily to motivations for codeswitching. Meanwhile, many of the typical categories within this domain speak primarily to reasons for codeswitching. Although, for some this may be viewed as interchangeable but, for research purposes this allowed for more succinct coding. Domain 2: Ebonics and Standard English In this domain, participants answered questions about their personal definitions of Ebonics, Standard English, and Codeswitching. Three General categories appeared from the data 59 which revealed that the majority of the responses were: Neutral descriptions of Ebonics, Positive descriptions of Ebonics, and that Ebonics is tied to African American Culture. From those that provided Neutral descriptions of Ebonics, two subcategories emerged: Dialect (Typical) and Language (Variant). Thus, a significant number of participants (more than 10) described Ebonics as either a dialect or language. In fact, Participant E5 clarified that AAVE has functions and rules, like other languages. Similarly, Participant H8 stated that defining Ebonics is difficult but, it is a dialect among Black people that most Black people no matter where they are from understand. P stated Ebonics is just how Black people talk. From those that provided Positive descriptions of Ebonics, three subcategories emerged: Comfort (Variant), Not Slang (Variant), and Unique (Variant). Notably, there were about 15 responses (some participants provided more than one response) that reflected positive connotations or descriptions of Ebonics, which is significant. Participants such as participant J10 emphasized this as they stated, I feel like its special, unique Others referred to Ebonics as beautiful, comforting, or unique. For example, Participant E5 emphasized that it was comforting by describing Ebonics as a different formatting of English which P finds comforting. P says they are most comfortable with it around their family, neighborhood, or other Black people and misses it in White spaces. From those that stated Ebonics is tied to African American Culture, two subcategories emerged: Slavery (General) and Generational/Family (Typical). This means that the majority of the responses connected Slavery to Ebonics. When asked for clarification, participant G7 expressed, I think that the Ebonics that we know now it certainly has evolved from the broken English of slaves and it has now incorporated our culture, and you know things like that Additionally, participant B2s core idea of, P stated that Black people were taken from the 60 shores of Africa, had their own language, and were then taught a different language which resulted in the creation of a new language with comfortable accents and dialects, added to the above statement. Others such as participant J10 reiterated that Ebonics is taught over time and through generations as they stated, its taught from infancy, right. Its taught from the first time you can speak, you know. Five typical categories also emerged from the data within this domain such as Negative Descriptions of Ebonics, Neutral Descriptions of Standard English, Negative Descriptions of Standard English, Neutral Descriptions of Codeswitching, and Examples. This means that about 7-10 participants answered with such responses. From the Negative Description of Ebonics, one subcategory emerged which was Unprofessional (Variant). All but one response within this category referred to negative descriptions or perceptions of Ebonics as described by others, not the participants. This means that when asked about their definition of Ebonics, about 7-10 participants were often providing others perceptions or White peoples descriptions of Ebonics. For example, when asked How would you define Ebonics or African American Vernacular English? participant F6 responded, It's really more so a thing that you know White people or people with a Eurocentric background would see as slang or as ghetto and things like that. Although, participant L12 provided further insight as they believe that that they have been socialized to think that Ebonics is not a professional language and that the Queens English or proper English is more professional. From the Neutral descriptions of Standard English category, one subcategory emerged which was that it was Related to School (Typical). Essentially, participants were equating Standard English with school, academia, and textbook grammar. The following is a notable 61 exchange with participant H8, to emphasize the differences in descriptions of Ebonics and Standard English: I: Okay. And so, how would you define standard English then? P: Uhmschool taught English. I: Okay. Was that one easier to define then Ebonics? P: Yeah. I was gonna say White people English. Then I was like thats not quite it either. Its school taught English. There were no subcategories for Negative descriptions of Standard English. However, there was a notable response such as: Standard English is what is forced on those who arent from the U.S. and what is expected of others not from here to use just to be accepted and English isnt as standardized as we what want to believe it is from Participant J10. From the Neutral descriptions of Codeswitching, two subcategories emerged: Informal vs. Formal (Variant) and Linguistic Change (Variant). Within this category participants defined codeswitching as a switch between informal and formal languages or linguistic changes. For example, participant C3 stated, codeswitching to me means that I'm switching back and forth between talking in AAVE or talking in English and Participant B2 stated, reminds me of like formal versus informal in language in general. Also, many Examples (another typical category within this domain) of codeswitching and Ebonics were provided within these responses such as what up doe vs hi hows your day going, hey girl & whats poppin, thats how it be, it bes like that, and yo. It is important to note that participants were not explicitly asked to provide examples. Lastly, there were three Variant categories within this domain. These categories were: Positive Descriptions of Standard English, Negative Descriptions of Codeswitching, and 62 Negative Perceptions of Dialects. From the Positive Descriptions of Standard English, there was one subcategory description of Proper (Variant). There were no subcategories for the Negative Descriptions of Codeswitching and Negative Perceptions of Dialects. These categories and subcategories are variant meaning that they were less significant results because they only reflected responses from 2-6 participants. Therefore, it is still important to emphasize that less participants were able to provide positive descriptions of Standard English, Negative Descriptions of Codeswitching, and Negative perceptions of dialects. Domain 3: Differences among PWIs and HBCUs In this domain, participants were asked an array of questions about their PWI experiences, HBCU experiences, professor interactions, etc. Six General categories appeared from the data, which revealed that the majority of the differences were among: Demographics, Racial identity/Culture, Professor Interactions, Social, Support/Resources Available, and Discrimination/Inequities. This meaning that more than 10 participants found at least 6 differences from their HBCU to PWI experience. From those that stated there were differences in demographics, two subcategories emerged: a Low number of Black people at PWI (General) and a High number of Black people at HBCU (Variant). Essentially, more than 10 participants observed demographic differences when comparing their HBCU and PWI experiences. This difference being the number of Black and White students and faculty/staff members. Many of the responses/core ideas were similar to that of participant H8 which was, so, like in my program there's a PsyD and there's a Ph.D. But in that cohort for us when we came in, in 2019 between PsyD there's only three Black people, Ph.D. theres only 3 Black people. So out of the whole cohort, I think theres like 50 of us when we started6 black people and so, it's kind of like in my master's program, in my cohort I was the 63 only black person. The majority of the participants reported being the only or one of few Black people in their PWI graduate program. Participants also emphasized a low number of Black professors in addition to students at their PWIs. In fact, at least five noted not having any Black professors in their graduate program at all. From those that noted Racial Identity/Culture differences, three subcategories emerged: Reinforced at PWI (General), Reinforced at HBCU (Typical), and Worse at PWI (Variant). It is important to note that the majority of the participants felt that their racial identity/culture was reinforced while attending a PWI. One participant (B2) even expressed that since attending a PWI he feels he has an opportunity to do pro-Black things. More specifically, participant B2 stated, and for me, like Black history month yeah like it's definitely something to be celebrated. But always being like not just a [HBCU] but like even when I was a kid I've always went to all Black schools. So you know, its a thing, but it's not like a big deal because we're all Black you know. This is like a regular thing. And I was joking with this person, and I was saying, like, Man you know this is like my opportunity, like being around White like mostly White people or not even just White people like Asians, you know Native Americans whatever all different type of ethnicities and ethnic backgrounds like this is my opportunity to like really do some Black some pro-Black thing. Similarly, when asked about how their racial identity has been impacted since attending a PWI, Participant C3 reported, Ive become more proud, I guess, to be Black. And I really found a sense of meaning in what I do. Meanwhile, a smaller number (7-10), felt that their racial identity/culture was reinforced at their HBCUs. It is important to note that this was a typical subcategory. For instance, participant G7s core idea revealed that they could be themselves at all times during undergrad because they were surrounded by Black culture.and their grad school classmates dont 64 completely know P. Participant L12 specifically stated, I guess like [HBCU] sort of had me so boosted on my racial identity. Like its so central for me, I just love Black people and Black people love me. And then I got into an environment where its like I dont really see Black people. Some (2-6) also described their racial identity/culture as being worse at their PWI. For instance, Participant I9s core idea revealed, their racial identity isnt of the same value at their PWI. In comparison to participants HBCUs, for some, their PWI negatively impacted their racial identity/culture. Participant E5 also spoke of her adjustment: and then going into a predominately white space where you're like Oh, I have to relearn all the survival tactics I learned in high school in order to survive here. And so it was a very, it was just a mind-like bending experience and then you only have the course of a summer to do it. So you're like okay I have to read up on how I have to interact with a majority white population again. So it was weird, it's really weird. From those that noted differences among Professor Interactions, three subcategories emerged: Not good at PWI (General), Good at PWI (Typical), and The Same (Variant). Essentially, participants described an array of positive, negative, and neutral interactions with their professors at their PWIs in comparison to their HBCUs. But a significant number of participants (more than 10) reported that their interactions with their professors were not good at their PWI. Notably, while the questions asked were vague questions about interactions with White faculty/staff, more often than not participants incorporated the use of codeswitching in their responses. For instance, participant K11 described not having to worry about codeswitching at the HBCU level. Participant K11 specifically stated, on campus we were just students, kids on campus. And you know we talked, our professors engaged with us, they understood us, they 65 knew what we were saying. Uhm you know they corrected us with love uhm and it was just a different ethic of care. So, I, even if I got corrected, I still felt like I was being myself.Whereas, you know, in my grad experience it felt punitive, if there was a need for correction. Similarly, participant I9s core idea noted, in comparison to their PWI, professors were more friendly and entertaining at their HBCU. At PWI, P says that they didn't feel their concerns were listened to by a professor. Others like participant L12 made comments such as, ...interactions with White professors are okay but can cause anxiety or feel condescending to describe their interactions with their White professors. It is important to note that not all participants expressed not good interactions with their professors. While the number is smaller, responses from about 7-10 participants indicated that they had good interactions with professors at their PWIs. However, some of these responses did not explicitly state the race/ethnicity of their professors at their PWIs. Participants within this subcategory reported that there were a few White professors that were supportive or that their interactions were decent. For example, participant J10 expressed, the White faculty, you know some of them, have been my greatest supporters and friends. Others (about 2-6) noted that their professor interactions were the same regardless of being at an HBCU or PWI or with White or Black faculty/staff. From those that noted differences in Support/Resources Available, Discrimination/Inequities, and in Social aspects there were no subcategories. In short, a significant number of participants noted a difference in the support and resources that were available when comparing their HBCU to PWI experience. The significant difference was that their PWIs didnt have as many support systems and resources available for students. Notably, participant L12 stated they have been, ...trying to find spaces and support at PWI that resemble 66 the love felt at HBCU. It is also important to note that participants (including L12) noted that these differences may be in part due to being in a graduate program rather than a result of being at a PWI. This was evidenced by the following statement, P reports difficulty in relating to social experiences due to being a grad student but does acknowledge lack of organizations at PWI that were available at HBCU. P was more involved on campus at P's HBCU. But that was not the case for all participants. Another significant category within this domain was the differences among discrimination/inequities faced in PWIs compared to HBCUs. Many participants (more than 10) reported experiences such as being left out of opportunities that White students were being offered, and being treated differently or negatively, which was not their experience at their HBCUs. One response of importance was, P said students at the PWI would often react as if Black students were zoo animals, some type of specimen, or ghetto from participant K11. Another core idea from participant H8, noted P feels that times at their PWI were rough because they were dealing with racial inequities which made her miss her HBCU because they didn't have those issues. At P's PWI people didn't have the same experience as her and made comments such as I sympathize but that's not my people whose bodies [Black people being killed] is on social media". Three Typical categories also emerged from the data which revealed additional differences such as Academic, Size/Location, and General Differences. Among these typical categories participants discussed academic differences such as more race-related discussions in the curriculum at HBCUs compared to PWIs, the size/location of the schools impacting experiences, and simply that there are general differences. In terms of differences among 67 size/location, participant J10 stated, P believes the composition of students and the amount of students was a difference among the HBCU vs PWI experience. One Rare category emerged from the data which was that there were no differences. This means that one participant out of twelve stated that their experiences were basically the same at both their HBCU and their PWI. It is important to note that the general categories within this domain speak primarily to the differences associated with the racial makeup of the different school settings (HBCU vs PWI). Among the typical categories are differences primarily related to overall institutional differences such as academic courses offered, the size/location of institutions, and general differences regardless of HBCU vs PWI status. Domain 4: The Impact of Codeswitching In this domain, participants were asked an array of questions about their experiences with codeswitching including but not limited to reactions from others, discriminatory responses, and personal feelings. Five General categories appeared from the data which revealed that the majority of the participants stated there were Challenges, Negative Experiences, Positive Experiences, an Impact on identity/authenticity, and a change in their codeswitching habits as a result of The Impact of Codeswitching. From those that reported Challenges, there were three subcategories: Internal/Personal (General), External/Dealing with others (General), and With the act of Codeswitching (Typical). As this study primarily focused on the impact of codeswitching it is extremely important to emphasize the data and responses within this domain and its categories and subcategories. A significant number of participants (more than 10) reported Internal/Personal challenges associated with codeswitching such as masking, feelings of exhaustion, and having to dim 68 themselves down so as to not threaten others. Among the internal/personal general subcategory, participant K11 expressed, Im kinda like selling my soul to the devil. Like, and so its like, that dual like uhmwhat does Dubois call it? A dual consciousness, where its like Im aware of this, but its like when, when I want something, when I need something, it's just a reaction that just turns on.But it's also like one of those uhh, I would say I almost at sometimes, at some points weaponize it to get what I want. Participant G7 also stated it can be stressful. That a lot of times there are so many internal processes going on for students of color that you, you know you dont see before they even walk in a room. Meanwhile more than 10 participants within this category also reported External challenges or challenges of Dealing with others. Essentially, participants were describing challenges maintaining relationships (with peers and faculty/staff) as a result of having to codeswitch all of the time or refrain from codeswitching (when around peers) or having to overexplain themselves to people who didnt understand Ebonics. A notable response from participant J10 stated: honestly, even if I do codeswitch or I dont codeswitch its insulting for you to feel like you have the right to say anything to me about any of that. Participant C3 provided another perspective of this challenge by saying, so it [codeswitching] kind of like hinders my relationships at home if I cant codeswitch. But then the same thing here [PWI] if I start talking like I do at home. Lastly, within this category, a smaller number of participants (2-6) reported challenges with the act of codeswitching itself. The responses revealed problems such as having to remember when/where to codeswitch, having to switch back and forth, and having to find the right words. Notably, participant C3 stated, Its almost hard now for me to even codeswitch 69 like back to AAVE sometimes like it takes me a minute because I have to stay in regular English so long. From those who reported Negative Experiences, there were 2 subcategories: Perceived (General) and Actual (General). Of the reported Perceived Negative Experiences, the participants stated that they would be perceived differently or negatively if they didnt codeswitch in their PWI grad program. Many of these negative perceptions were associated with participants having low intelligence, being seen as ghetto, and otherwise stereotyped. Notably, in response to not codeswitching participant G7 expressed that, I think they [White professors/students] might perceive me as less professional and maybe even less educated, even though, like we know, on paper, we all have the same level of education. But I think that may be the perception. There may also be a perception of wondering if I got where I am because of some type of like affirmative action or some type of concessions like that. Because I think people do make a lot of judgments about people, based on how they speak. Of the reported Actual Negative Experiences many of the participants stated inappropriate or negative responses/reactions from students/faculty at their PWI when they did not codeswitch or when they used AAVE. For some this resulted in them talking less, others simply didnt care. Notably, participant J10 described a look or expression of confusion from faculty at their PWI when P [J10] doesn't codeswitch. More specifically J10 stated, its a face, its never words, who you know, where theyll feel uhm bold enough to say it to me. But, its a look of like what just happened, Im so lost, Im so confused. Similarly, Participant H8s core idea stated, P hasn't experienced discrimination based on use of Ebonics from PWI faculty but often gets side-eyed from students. 70 From those who reported Positive Experiences, there were two subcategories: Actual (General) and Perceived (Variant). Among the responses stating Actual Positive Experiences, the participants stated they have not experienced any discrimination because of their lack of codeswitching or use of AAVE at their PWI. Although, among half of the responses noted that participants had not experienced discrimination yet or that they dont experience discrimination because they codeswitch well. Notably participant E5 stated, Ive always been codeswitching in class and with professors. So I haven't had that moment, I guess not like a slip up a moment of like genuineness when I am speaking that [Ebonics], and be discriminated against. No. In terms of the few participants (two), that reported Perceived Positive Experiences, participants did not think they would experience any discrimination if they didnt codeswitch or if they used AAVE. For those that reported an Impact on Identity/Authenticity, there were no subcategories. The responses revealed that participants (more than 10) felt inauthentic or that they were changing themselves when they had to codeswitch at their PWI. Although, it is important to note that some participants reported that their racial identity was not impacted but that their authenticity was impacted. Notably, participant E5s core idea stated, P feels they are changing themselves when they codeswitch and it sucks because she can't be her genuine self. P feels fine most of the time because AAVE isn't her identity. Meanwhile, Participant K11s core idea stated, P feels that he was being inauthentic when he was codeswitching at his PWI but not that he was changing himself because it was conscious. Similarly, participant G7 said, what I felt like is, I was only presenting one part of myself. And that's why I feel like the people my Grad school cohort, my friends from Grad school, they don't really know the full me. So yeah I don't feel like I was changing, who I was but definitely not being my full self. 71 For the category Codeswitching Habits there were no subcategories. The responses revealed that codeswitching is in fact a habit for participants but one that participants arent always aware of. Others noted that their codeswitching habits changed or increased throughout their time in graduate school. Notably, Participant J10s stated, I think it [codeswitching] was definitely more frequent in my, in my Grad program. cause you almost didnt want to come off as a fraud, right. You got to deal with that imposter syndrome, you have, you know. Additionally, Participant K11 described their codeswitching habits a little differently such as if you think about all of that work that you have to do to codeswitch and fit in and then think about the fact that you do it so much that it becomes habit like, you talk about like inherited trauma and like just things that we don't see that and you know, it's really crazy! Two typical categories appeared from the data which revealed that 7-10 participants responded with Neutral Experiences or that there were No challenges/Impact based on their use of codeswitching. From those who reported Neutral Experiences, there were no subcategories. Many of the responses simply stated that there were differences in the way other White faculty/students responded to participant's codeswitching but there was no description of whether this was negative or positive. From the responses that stated, No Challenges/Impact, there were no subcategories. Participants that stated no challenges/impact reported responses such as its not a big deal, I wouldnt care if other White students or professors perceived P differently, it hasnt impacted me, or P doesn't have many challenges when codeswitching in the classroom because P has done it since childhood and it's natural. Lastly, one Variant category of Change noticed by others came from this domain. There were no subcategories. But the responses revealed that for a small number of participants (2-6), their Black friends often noticed or pointed out when they codeswitched which wasnt always a 72 positive experience. Notably, Participant C3s core idea stated, P stated not personally noticing that they changed themselves when codeswitching until a friend saw them speak AAVE versus English. Meanwhile, Participant K11 specifically stated, ...if you start codeswitching at home theyre gon be like, why are talking like that, whats wrong with you like cause you went to college you think I have experienced this Domain 5: Other Types of Codeswitching In the current study, participants were not explicitly asked about other forms of codeswitching outside of language. Thus, these results will not be discussed in detail. However, responses associated with other forms of codeswitching still came up. One General category appeared from the data which revealed that the majority of the participants also spoke of General Appearance when it came to other forms of codeswitching. Within this category, three subcategories also emerged: Clothing (Typical), Hair (Variant), and Clothing and Hair. Two Variant categories also appeared from the data which revealed additional forms of codeswitching such as Non-Verbals and Writing. Domain 6: Coping Strategies In this category, participants were asked questions about their mental health in graduate school, coping with race-related stressors experienced at their PWI, and their coping strategies as it pertained to dealing with the repercussions of codeswitching. Although, some participants only responded with their overall coping strategies. One general category appeared from the data which revealed that the majority of the participants utilized Support Systems as a means of coping. From this category, five subcategories emerged: POC Specific Support (General), Family (Typical), Financial Support (Variant), Religious/spiritual (Variant), and Academic (Variant). Notable responses revealed that participants turned to other people of color, family 73 members, prayer, and academic advisors for support. For example, participant J10 mentioned, I think that is what really is what really sustained me was, I would say faith, friends, definitely, my family as it pertained to managing mental health in graduate school and participant K11s core idea revealed, P stated P wanted to get far away from Ps PWI and be around people of color in order to heal because it was traumatizing. Similarly, participant B2 responded that they coped with race-related stressors at PWIs by, hanging around Black people. Few responses (2-6) also revealed that Financial support helped alleviate stressors associated with graduate school and made them feel safe. Financial support was not specifically mentioned as a means to cope with the repercussions of codeswitching. Seven typical categories also emerged within this domain. These categories revealed additional forms of coping from 7-10 participants such as Lack of Adequate Coping, Self Care, Therapy, Socializing, Lessons Learned, Emotion Regulation, and Finding Safe Spaces. From the responses showing a lack of adequate coping, there was one subcategory of Drugs/Alcohol (Variant). Notably, two participants reported using alcohol or marijuana to cope with racerelated stress experienced at their PWI. There were also other notable responses such as P coped with race-related stressors at their PWI by finding people he could trust, safe spaces where he could breathe, or where he didn't have to codeswitch from participant K11 and from J10, P stated that being able to learn how to talk and express how you feel helped P cope with racerelated stress at PWI. P stated that in Black culture people are trained to keep everything in. Domain 7: Higher Education Interventions In this category, participants were asked questions about how their PWI grad program could improve, if there were any diversity-related educational resources already available, and if Ebonics should be accepted in higher education. Four general categories appeared from the data 74 which revealed that there is a need for more awareness of codeswitching, a Lack of diversityrelated resources at the PWI/Need for improvement, a Need for overall institutional change, and that participants feel that AAVE should be accepted. A significant number of participant responses indicated that there needs to be more awareness of codeswitching in PWIs. In fact, 11 participants noted in some way shape, or form that codeswitching is not currently discussed or at least not in-depth at their PWIs and that there is a lack of understanding of codeswitching as well as its impacts among users. For instance, participant E5 stated, I think it would be important for them [PWI faculty/students] to know or understand that just because someone speaks it [Ebonics] doesnt mean that theyre unintelligent. And just because you would say that you would feel comfortable with someone speaking it doesn't mean that they would be comfortable speaking it around you. So don't expect for them to speak it around you Among the significant number of responses that stated there is either a lack of diversityrelated resources or a need for improvement at participants' PWIs, it is important to note the nonverbal responses as well. In almost all of the interviews when asked if participants PWIs have diversity-related resources in place, participant's responses consisted of laughter. The laughter was often followed by a response of no or a description of a lack of emphasis on diversityrelated resources in their PWI. For example, participant H8 responded, I dont mean to laughNo! Whew girl but they try. Uhm absolutely not. They have a DEI program they're starting, I think that, like a student on the board and like something else, but like no Others reported that the diversity-related resources that are in place are only geared toward undergraduates. As a recommendation, all participants stated that there needs to be a change at the institutional level. This change would include, recognizing that Black people are not 75 homogenous, ensuring that institutions across the board are supportive, changing recruitment procedures, including Black history in all areas of higher education, etc. As a specific recommendation, K11 stated, ...PWIs need to come to terms with the fact that when you recruit students, you recruit their authentic selves and this needs to be welcomed. Additionally, Participant I9 feels that higher ed needs to be changed to be more accommodating, especially for first-generation students. In terms of the significant responses that indicated that AAVE should be accepted in PWIs, all but one participant agreed. Among those who stated AAVE should be accepted, they believed Black students should be allowed to express themselves without consequences. Additionally, participants such as Participant B2, believes that AAVE should be accepted at Ps school because it isn't derogatory. P believes that not accepting AAVE should be frowned upon because it is the use of someone's comfortable way of speaking. While many were for AAVE being accepted, participants were still aware that this may not be the case as evidenced by participant G7s response, ...but I think that, realistically, we still have to codeswitch because it's not going to be accepted in certain arenas, no matter what. Two typical categories also emerged from this domain: Need for faculty change/specific training and that there were diversity-related resources currently in place at the PWI. 7-10 participants recommend that there be a change among faculty or specific training at their PWI. In terms of a faculty change, participants noted that they would like to see a heterogeneous staff or hear more from diverse voices. More specifically, participant J10 s core idea expressed that, P thinks that the HBCU to PWI experience is a specific shift that should be talked about and if not it's a disservice to those students experiences. P thinks that codeswitching, diverse voices, and language, should be essential and integrated into the curriculum. In terms of having more 76 specific training, the participants in this category stated that faculty/staff need to have diversityspecific training to understand that Black students experiences are different than White students and that they can experience challenges associated with racial identity and language. In particular, participant K11 thinks there should be training for faculty on differences including language or anything outside of the White world. It is also important to note that only seven responses revealed that there were diversity-related resources already in place at participants PWIs, two of which were reiterations from the same participant. Three variant categories also emerged from this domain revealing that, there is a need for better funding of diversity-related resources, codeswitching should be accepted, and Codeswitching shouldnt be accepted. Notably, 2-6 participants suggested that there be increased funding for diversity-related resources because graduate programs are currently not doing so or are having students put in extended efforts to get things done or funded. On the other hand, participant D4, believes that increased funding and research opportunities for Black students at HBCUs would help increase diversity at PWIs. Also, within this category, a small number of participants (three) stated that codeswitching should be accepted in PWIs. However, some also argued that codeswitching shouldnt be accepted for reasons such as people of color shouldnt be required to do such in academic, public, and corporate settings. For example, participant L12 stated, codeswitching shouldn't be an obligation or requirement. But for a lot of Black students, it feels like it is. Because we're worried about how youll perceive us. So a remedy to this is being willing to accept us for who we are not trying to force us to present in this way that's consistent with what is a pristine proper person based on White supremacists ideologies. Just be willing to accept us. Create that space, and then we won't feel like we have to codeswitch. 77 Lastly, there was one Rare category within this domain that suggested that AAVE shouldnt be accepted due to reasons of cultural appropriation. In particular, participant D4 stated, I do not want it accepted in my school. Cause I don't White people walking around using AAVE. It looks ridiculous and I'm a big proponent of Antiuhmm cultural appropriation. So you know if we got ridiculed at a point and time for speaking how we speak and so now that like we are starting to become more accepted in White settings. I wouldn't care for them to start picking up on our language. Because they don't understand the history behind it, they dont have the cultural ties to it. So, no I dont. Selfishly, I would not want AAVE to be accepted at my PWI. 78 CHAPTER FOUR: DISCUSSION Overview The purpose of this study was to gain a better understanding of what it means to codeswitch (from Ebonics to Standard English), any possible implications to an individual's identity, any possible psychological implications, and how PWIs can be more cognizant of this phenomenon. In particular, the author examined the experiences of Black or African American individuals who attended an HBCU for their undergraduate studies and graduated or were currently attending a PWI for their graduate studies. Previous research provided evidence that Black students have long faced differences and difficulties in terms of their experiences and mental health when attending or choosing to enroll in higher education at a PWI (Eakins & Eakins, 2017; Karkouti, 2016; Payne & Suddler, 2014; Woldoff et al., 2011). Some of these differences and difficulties were in part associated with having to shift linguistic codes depending on the speaker's environment, otherwise known as codeswitching (Deggans, 2013; Morrison, 2023). This is in part why many Black individuals have chosen to attend HBCUs (Bracey, 2017; Cooper, 2017). However, for those wanting to further their education via graduate school, HBCUs are not always an option for various reasons (i.e., financial concerns and program availability) (B. Miller, 2020; Rogers, 2008; Upton & Tanenbaum, 2014). Hence why some of those same students that attended an HBCU for undergrad went onto a PWI for graduate school. The combination of the implications of codeswitching and the experiences of Black students in higher education sparked interest among researchers. Research has also provided evidence that when exploring the experiences of students in higher education, graduate students are often left out. When graduate students have been included in research, it has been found that 79 they often receive fewer resources than undergraduates (Forrester, 2021; Kaler & Stebleton, 2019). But, for Black graduate students in particular, they are often both underrepresented and overlooked (Holloman et al., 2021; Stone et al., 2018). Thus, instead of simply looking at Black undergraduates, this study added an additional layer or demographic factor to exploreBlack graduate students at PWIs. Therefore, Consensual Qualitative Research (CQR) methods were used for this study to capture the richness of participants' experiences, attitudes, beliefs, and perceptions (Hill, 2012). The interviews provided relevant and informative information for interpretation. In terms of the interpretation and discussion of the results, when the terms, generally, typically, and variably are used it is in reference to CQR terminology. Overall, participants varied in terms of their reasons or motivations for codeswitching. However, general categories indicated that participants were motivated based on the setting they were in, if they saw it as being advantageous, or based on the racial make-up of those around them. More specifically, participants seemed to be motivated to codeswitch if they were in academic/classroom settings, around White people or another race (other than their own), or to put themselves in more favorable positions. As the participants were all graduate students or post-graduates, codeswitching in academic/classroom settings referred to participating in research labs, communicating with committee members, giving presentations, attending meetings, practicum, student events, and within classes. Participants were also all from PWIs, which is notable, as they found being around White people or another race a significant motivating factor to codeswitch as well. In terms of the favorable positions that participants noted being a general reason for codeswitching, this entailed many things. The data indicated that most but not all participants (typical category) codeswitched so that they could be successful, understood, and to avoid stereotypes. 80 Thus, these results are similar to previous literature findings that state that Black individuals tend to codeswitch to avoid stereotypes and to experience inclusion or increase social mobility (Adikwu, 2020; Matthews, 2006; Payne & Suddler, 2014; Warner, 2007). The specific findings shed light on the factors that influenced codeswitching among Black graduate students, with a focus on their experiences within predominantly White spaces, particularly academic settings. These findings provide valuable insights into the reasons behind codeswitching behaviors, specifically within the context of Black individuals in higher education. Furthermore, academic settings such as graduate school are already known to be challenging but for Black students, these challenges can increase due to discrimination, personal/emotional adjustments, etc. (Alexander & Bodenhorn, 2015; Johnson-Bailey et al., 2009; Leong, 2020; Moses, 1989). Thus, as indicated by the current data Black graduate students being surrounded by White people or in White settings codeswitch to decrease their potential challenges such as not being understood (verbally and empathically), being stereotyped as uneducated or unprofessional, and to present as professional or different to succeed in such settings. An important piece that the results also add to the literature is that a number of Black graduate students were also motivated to codeswitch at their PWI based on their undergraduate experience, having codeswitching modeled for them, and felt that it was now ingrained in them (Typical categories). Participants expressed that they did not feel inclined to codeswitch at their HBCUs. However, they also expressed that their HBCU professors, undergraduate internships, and experiences within The Divine Nine sororities and fraternities taught them to codeswitch in White settings in order to be successful. Notably, The Divine Nine refers to nine National PanHellenic Council (NPHC) organizations that were founded for the betterment of Black men and women during a time of racial isolation on PWI campuses (NAACP, 2023; NPHC, 2023). 81 Thus, suggesting that HBCUs play a role in influencing ones frequency to codeswitch at the PWI graduate level. Furthermore, these results support both the social learning theory and identity negotiation theory (INT) (Evans & Kelly, 2020; Hibbler, 2020; McLeod, 2016; TingToomey, 2015). In particular, social learning theory posits that language and motivations to use certain languages are learned from observations and imitating others behaviors (Bandura, 1989; Evans & Kelly, 2020; McLeod, 2016; Whitehurst, 1978). Meanwhile, INT posits that codeswitching is done as a means to seek positive identity affirmation or change ones identity to avoid negative stereotypes (Ting-Toomey, 2015; Ting-Toomey, 2017). Therefore, from the data, it is indicated that codeswitching for Black graduate students attending PWIs is learned from HBCU experiences, observing role models (including family), and is used to suppress facets of Black identity. In terms of the participants' understanding behind codeswitching and the language they use, the data indicated that Ebonics is tied to African American Culture by ways of slavery or through different generations (general category). Overall, participants noted that as a result of Africans being forced into slavery, having to learn a new language while also being reprimanded for reading and writing in English resulted in another branch of English or the formation of Ebonics. This suggests that Ebonics does, in fact, have significant historical ties to Black people, which can be argued as a reason not to devalue it or its speakers. Although this debate has been had time and time again, these results are here to emphasize that this topic should not be taken lightly as it affects many (R.L. Williams, 1997). Participants even provided positive or neutral descriptions of Ebonics and emphasized that it is a dialect/language and not a form of slang (general category). The emphasis on Ebonics not being a form of slang contradicts some previous studies that suggested that individuals 82 (including Black people) had negative attributions or definitions of Ebonics (Baker-Bell, 2019; Godley & Escher, 2012; Koch et al., 2001). Notably, among the current data, there was a smaller number of participants that provided negative descriptions of Ebonics (Typical) and an even smaller number that provided positive descriptions of Standard English (Variant). In fact, participants used words such as unprofessional to negatively describe Ebonics. But that was the participants' definition of Ebonics as described by others (i.e., how non-Ebonics speakers or White people would define Ebonics). Participants also provided examples of Ebonics during the interview process which can be found in Appendix L. In terms of definitions of Standard English, participants primarily referred to it as grade-school-taught English or proper English. This consistent with previous literature that has suggested that Standard English is considered more appropriate, especially in class settings (Durkee & Williams, 2015; Godley & Escher, 2012). In looking at differences among academic settings, participants noted many differences between their HBCU and PWI experiences. These differences were among demographics, their own racial identity, professor interactions, discrimination/inequities experienced, social aspects, and the amount of support/resources available (all general categories). The data indicated that, in comparison to HBCUs, PWIs had a low number of Black people including staff, faculty, and students, which is not new to the literature. However, the data also indicated that PWIs actually reinforced participants' sense of culture and racial identity. More specifically, being at a PWI provided participants with more opportunities to display their Blackness or be aware of their racial identity. Based on the responses, this was in part due to participants wanting to bring more attention to their race as this wasnt necessary at their HBCU, show faculty/students at their PWI that they arent another stereotype, or because they had an increased awareness of racial issues 83 due to their new predominantly White environment. This adds to the literature as it has previously been emphasized that PWIs provide primarily negative experiences for Black students and negatively impact their racial identity (Hernandez, 2010; Sinanan, 2012; Woldoff et al., 2011). However, this was not the case for all participants in terms of their identity and authenticity when it came specifically to codeswitching at their PWI (discussed in later sections). The differences among professor interactions at participants PWIs compared to their HBCUs is a notable difference. The majority of the responses revealed that participants did not have good interpersonal relationships or interactions with their professors at their PWI. Specifically, many of them expressed negative interactions, such as White professors at PWIs disregarding participants' accomplishments, viewing them as aggressive, and setting unrealistic expectations in comparison to their White student counterparts. This is consistent with literature that has found that White professors tend to make negative comments or give out poor academic evaluations to Black students based on their use of Ebonics (Feagin, 1992; Ferguson, 2001; Payne & Suddler, 2014; Stanley, 2006). For this study in particular, it resulted in students experiencing anxiety, feeling as if they were being punished, and not feeling the same type of love experienced by professors at their former HBCU. Although it is important to note that two participants expressed negative interactions also from the few Black professors at their PWI. Additionally, there was also a significant difference among discrimination and inequities experienced at HBCUs in comparison to PWIs. The data revealed that participants experienced more discrimination from students, faculty, and staff at their PWI in comparison to their HBCU. Although it is important to note that not all participants reported discrimination or inequities based on the use of codeswitching. Some reported other instances, such as being mistaken for other Black people, not being afforded the same opportunities as White students, experiencing 84 harsher disciplinary action, and hearing negative or discriminatory comments about their race. One participant suggested that the reason White students at their PWI were discriminatory or looked at Black students as if they were specimens, was because they were never afforded the opportunity to be around Black people before. This is similar to Johnson-Bailey et al.s study results that showed multiple instances of discrimination from White students, faculty, and staff at a PWI which was in part attributed to the lack of diversity exposure (2009). In terms of social differences and differences among support/resources, HBCUs appeared to provide more than PWIs. Specifically, participants noted that HBCUs expected students to maintain leadership roles, encouraged them to find social support, and to be involved in the community. Thus, with these expectations, the HBCUs provided social outlets and support for their students. According to participants, this was not the case at PWIs as the majority of the social supports and resources were geared toward undergraduate students. This is consistent with the limited research available on graduate students and mental health (Kaler & Stebleton, 2019). In fact, the literature has found that the needs of graduate students have been overlooked and resources (i.e., mental health resources, economic resources, etc.) are heavily focused on undergraduate students or non-marginalized groups (Kaler & Stebleton, 2019; Pontius & Harper, 2006). Participants also explained that the lack of resources and social outlets could have been due to the COVID-19 pandemic. The COVID-19 pandemic has been found to increase social isolation, decrease in-person interactions, and altered the availability and safety of university extracurricular activities (Finnerty et al., 2021; Son et al., 2020). The responses to the codeswitching-related questions are particularly relevant to this study. As previously noted, codeswitching has been studied in limited environments many of which yielded negative responses from participants (Bohn, 2003; Godley & Escher, 2012; Koch 85 et al., 2001; Murphy, 1998; Parmegiani, 2006; Todd, 1997). Participants from the current study highlighted their many challenges as a result of codeswitching (general category). From the results, some of the most challenging were the internal and external impacts of codeswitching (general subcategories). Many of the participants revealed psychological stressors such as anxiety, changes to their personality (none that align with any specific DSM-5 diagnoses), feelings of exhaustion, and masking. In terms of anxiety-related symptoms, participants reported feeling worried about how White faculty/staff or students would perceive them for their codeswitching skills or having to know when and where to codeswitch. As previously mentioned, perceptions can guide ones behavior, personality, and identity (Carlson & Barranti, 2016; Cook, 1979). While participants did not report being diagnosed with a personality disorder as a result of codeswitching, there were reports of notable changes to their personalities. In fact, participants reported a challenge of withholding their true personality when codeswitching at their PWI. Two participants specifically reported that codeswitching at their PWI brought on a challenge of having to put on a mask all of the time. It was stated that masking made them feel uncomfortable but made others (White people) feel comfortable. Thus, adding on to Holliday & Squires study which also noted that Black students were masking and codeswitching as a means to navigate scrutiny faced at their PWIs (2020). But, unlike their study, the current study revealed results from graduate students, not undergraduate students. Participants also reported feeling exhausted, tired, or drained as a result of the complexities of codeswitching constantly. One participant even associated codeswitching with trauma and self-harm. Notably, previous studies have not explicitly associated codeswitching with trauma or any trauma-stressor-related disorders. Additionally, the current results are 86 somewhat inconsistent with other studies that have explored codeswitching in various environments (i.e., workplace, grade school). Other studies have revealed psychological symptoms or problems such as poor sleep habits, feelings of helplessness, self-doubt, and hostility (McCluney et al., 2021; Santiago et al., 2021). All of those psychological symptoms or problems were not mentioned in the results of the current study. Although, there are still some similarities between the psychological well-being responses of this study and others such as the reports of conflict in interpersonal relationships, burnout, and increased anxiety. Additionally, Santiago et al.s, study specifically discussed that assimilation by means of codeswitching in the workplace is exhausting, similar to reports within the current study (2021). The results also emphasized external challenges or challenges when it came to dealing with others (general subcategory). These challenges included difficulties communicating with others who may not understand Ebonics at PWIs, difficulties maintaining relationships on campus, having to frequently explain Ebonics, and fighting negative assumptions about Ebonics speakers. Thus, in line with another study, where participants described an issue of their doctoral program as having to over-explain when they spoke (Henfield et al., 2011). Furthermore, codeswitching, or the lack thereof also indicated both positive and negative responses from other people/listeners (general categories). The data showed that as a result of codeswitching at PWIs, participants faced negative experiences (general subcategory). These negative experiences included uncomfortable tensions in academic settings, being side-eyed, or not being accepted due to their use of Ebonics. The data also showed that even if participants did not report lived negative experiences, they reported perceived negative experiences (general subcategory) if they did not codeswitch. Many perceived that White students or faculty/staff would look at them as less than, uneducated, or that their PWI had low standards if they didnt 87 codeswitch. Hence, the reason why some participants chose to codeswitch or refrain from the use of Ebonics at their PWI. Those who stated positive experiences (general category) they simply expressed that they havent experienced any discrimination based on their lack of codeswitching at their PWI, yet or that they codeswitched well enough not to experience discrimination. Another general category revealed that codeswitching did in fact impact participants' identity and authenticity while at their PWI. Many felt that they werent being true to themselves, or they were inauthentic when codeswitching at their PWI. The participants' change in self and inauthenticity was also noticed by others/peers as reported by participants, which for some brought on a further sense of inauthenticity. These results add to previous research on authenticity experienced at PWIs (Cox, 2020; Neville et al., 2004; Payne & Suddler, 2014; Woldoff et al., 2011). It has previously been found that Black students who attend PWIs are often viewed as less authentically Black by Black students who attended HBCUs (Cox, 2020). However, the current results suggested that participants (Black PWI students) viewed themselves as inauthentic when others (Black family members, HBCU alumni/colleagues, Black friends) noticed their codeswitching. It was not solely due to the fact that they were in attendance at a PWI. In terms of other forms of codeswitching, the results revealed that participants also described changing their general appearance (general category). The data showed that there was also a small number of participants who described changing their writing as a form of codeswitching (variant category). This suggests that because of the small number of participants that described writing as a form of codeswitching that there may not be a significant difference in this form of codeswitching at HBCUs vs PWIs as compared to verbal codeswitching. 88 Additionally, the results revealed that participants coped with such challenges in various ways (i.e., self-care, therapy, socializing, emotion regulation, finding safe spaces, etc.). As this study included a particular demographic group (HBCU & PWI students), the results enhanced previous studies that have looked at coping strategies among Black PWI students versus Black HBCU students (Dubow & Rubinlicht, 2011; Greer & Chwalisz, 2007). In previous research, it was found that PWI students primarily used avoidance as a coping strategy while HBCU students primarily use problem-focused coping strategies or sought social support (Dubow & Rubinlicht, 2011; Greer & Chwalisz, 2007). The present study found that the primary coping skill reported was the utilization of support systems (general category) particularly with people of color (general subcategory). Thus, suggesting that participants were further influenced by their HBCU undergraduate experiences even in a new setting such as a PWI for their graduate studies. The use of avoidance as a coping strategy which was previously found to be used among Black PWI students, was not substantiated within the current study. Although, a smaller number of participants did report a lack of adequate coping strategies (Typical category) such as the use of drugs/alcohol (Variant subcategory) as a means of coping with race-related stressors and codeswitching. As previously mentioned, another big proponent of research is to bring awareness to the issue and provide recommendations for improvements. This study, in particular, aimed also to provide recommendations to higher education institutions on how to better care for their Black graduate students who have previously been forgotten about. The results suggested that awareness of codeswitching, acceptance of Ebonics, improvement of diversity-related resources, and an overall institutional change were the main recommendations for change (all general categories). In particular, participants would like White students, staff/faculty, and the entire 89 PWI to take the time to learn about codeswitching. The results indicated that most White individuals at participants' PWIs seldom heard Ebonics being used in academic settings because participants were codeswitching so often. Additionally, participants suggested that there not just be an awareness of what codeswitching is but also the challenges it poses for Black students when they are inclined/forced not to speak the language they are most comfortable in. These results add to the literature as there are countless studies on codeswitching from Spanish to English in academia but less on codeswitching from Ebonics to Standard English in academia. The results and recommendations from the Spanish to English studies are still congruent with the present study. Essentially, researchers have found that when teachers encourage and normalize codeswitching, it can increase students critical language awareness and identity (Martinez, 2013). Thus, they have to know about it [codeswitching] in order to encourage and normalize it. A few participants within the current study even discussed Spanish to English codeswitching when suggesting that Ebonics should be accepted in PWIs. However, the acceptance of Ebonics in schools has been a long-standing debate (McLaren, 2009; R.L.Williams, 1997; Woo & Curtius, 1996). It wasnt even agreed upon by all participants in the current study. Among those who agreed that Ebonics should be accepted in their PWI provided various reasons to support their argument, as did those from the historic Ebonics debate in Oakland, CA (R.L. Williams, 1997). For instance, within the current study it was suggested that acceptance of Ebonics would allow for a better atmosphere for Black students and, let Black students express themselves freely and authentically. It was also stated that Ebonics is a normal form of language and that it is not derogatory or ghetto. Thus, very much in line with Dr. Williams's argument within the Ebonics debate. In fact, he suggested that acceptance would allow African American students to achieve a quality education and the ability to navigate through the school system without being 90 penalized for speaking their own language (R.L. Williams, 1997). The results of the current study are very different from the opposing responses within the historic Ebonics debate which suggested that acceptance would allow for substandard speech in classrooms, condone slang, and reward failure (R.L. Williams, 1997; Woo & Curtius, 1996). Although, one participant within the current study explicitly stated that Ebonics should not be accepted for fear of cultural appropriation by White counterparts (rare category). While this response was rare, it is still very important as it highlights the reality of what could potentially happen if Ebonics becomes accepted by all in PWI settings. Acceptance may not be ideal, thus suggesting there is a strong reason to gate-keep Ebonics. Notably, the results also showed that while a few participants PWIs have diversityrelated resources in place, most do not, or the resources are very limited. Thus, further perpetuating instances of discrimination, decreased cultural competency, and creating a less than safe environment for Black graduate students. This is also in line with the results of a similar study that found that countless acts of discrimination were in part due to the lack of diversity exposure at a PWI in the South (Johnson-Bailey et al., 2009). Participants in the current study would actually like to see increased funding for diversity-related resources (variant category) and for Black graduate students in particular, as much of the current funding goes toward other areas such as undergraduates. This result further emphasizes that much of the current funding and resources are geared towards undergraduates or non-minority studentsagain leaving them out of the discussion (Kaler & Stebleton, 2019; Pontius & Harper, 2006). Limitations Like any research study, there are also certain limitations that should be acknowledged and considered. Some of this study's limitations are in data collection and with the proponents of 91 the CQR methodology. For instance, in the current study data collection concluded at 12 participants to avoid an overload of data. However, even with 12 participants, there was still an overload of data as shown by lengthy interview times and multiple categories and subcategories. Further discretion should have been taken during the recruitment and interview process to either minimize the participant sample to 10 or to have a stricter interview time length (<120 minutes). Although limiting the participant sample to less than 12 would have differed from the CQR methodology. In addition to a large sample, the current study also consisted of quite a large research team. Typically, CQR research teams consist of about 4-12 members (Hill, 2012). This studys research team had 20 members with varying levels of experience and from an array of backgrounds. While the diversity of the research team can be seen as a strength, having such a large number of people can also be a weakness. The weakness being that a larger research team can mean a wider range of biases that could have impacted data analysis. Additionally, given that this study involved team members reading transcripts of two Black people (interviewer & interviewee) speaking informally and at times using Ebonics, another limitation was posed. At times during the analysis process, terms/transcribed conversations were not always well understood by non-Black research team members. Thus, the meanings of certain responses could have been lost in the core ideas stage. While this may be considered a minor limitation of the study, it is important to note that both auditors, who were of African American descent, demonstrated meticulous attention to detail during the auditing process. The co-investigator was also readily available during analysis to answer questions from the team members about meanings of phrases. 92 Additionally, there was only one interviewer throughout the interview process. Thus, there was a risk of interview bias. However, a semi-structured interview was used to decrease potential bias. Semi-structured or structed interviews are often used in an attempt to limit bias (Shah, 2019; J. Young et al., 2018). But one cannot completely eliminate all bias within research. Lastly, multiple keywords (i.e., codeswitching, code-switching, Black, African American, authenticity, etc.) were used to compile the literature review for this study. Throughout the literature review, gaps in the research were noted. However, it is important to acknowledge that extensive access to literature databases served as a limitation in this study as well. Implications and Future Research Given what is known from the data and results within this study, many things should be different moving forward. Even with the previously mentioned limitations, this study provided qualitative evidence that Black graduate students do in fact face many challenges, including psychological challenges as a result of codeswitching at their PWIs. The overall themes related to psychological well-being were: anxiety, changes to personality (none that align with any specific DSM-5 diagnoses), exhaustion, and masking. But these impacts and challenges are going unnoticed by White staff, faculty, and students. This is in part due to Black graduate students codeswitching or refraining from using Ebonics so often at their PWIs to avoid negative consequences. When White staff, faculty, and students are noticing glimpses of codeswitching from Black graduate students they are at times responding with negative reactions such as sideeying, or potentially perceiving them as less than, uneducated, or that their PWI has low standards. Previous research has already suggested codeswitching in general for Black people poses its own challenges. However, this study illuminated these challenges in a different light and environment. These results indicated a need for academics and White faculty, students, and 93 staff at the graduate level to acknowledge that there is nothing simple about having to switch back and forth between a language you are most comfortable with to one that is either uncomfortable, unfamiliar, or comes with negative consequences. In terms of future interventions for said problems, the participants provided an array of their own ideas. These recommendations and interventions should be carefully reviewed and considered for implementation in current higher education institutions, particularly at PWIs. In order to increase awareness of codeswitching, participants suggested that PWI faculty, staff, and students learn what codeswitching is, acknowledge the fact that codeswitching is a skill, and to not expect African Americans to codeswitch or use Ebonics. In short, there needs to be more discussions about codeswitching and its implications among those at PWIs the same way diversity is so called emphasized. One participant even noted that it should be talked about the same way people are now discussing imposter syndrome. This could be done through regularly scheduled and required seminars and interactive workshops at PWIs. However, these should be provided as proactive measures rather than reactive measures. An established fact is that graduate students of color, including Black graduate students, commonly encounter racism and discrimination within their academic programs (Brunsma et al., 2016). Despite this common knowledge and the increase of hate crimes motivated by race, PWIs and individual departments have often waited until after a traumatic event has occurred to acknowledge the problem, take action or have lacked intentional actions (Brunsma et al., 2016; Garibay et al., 2019; National Center for Education Statistics, 2023; Schwartz, 2019). For instance, in 2020, the murder of an unarmed Black man, George Floyd sparked performative action from White people and institutions (Hess, 2022). This is similar to how other racially charged incidents across the U.S. have resulted in mandatory diversity trainings in hopes of change (Dobbin & Kalev, 2018). All 94 of that being said, seminars and workshops created to promote the awareness of codeswitching need to be considered as proactive measures. As previous incidents have shown, discussing serious matters such as the psychological impact of codeswitching should not be a one-time discussion. Nor should such awareness only be considered after a Black graduate student, reports being discriminated against or worse for the use of their language, Ebonics. Further research should also explore how these interventions can best be implemented and the efficacy of them. Furthermore, as codeswitching and being at PWI for participants brought up feelings of inauthenticity this is another area for exploration. Future research may want to take a further look at how Black graduate students cope with these challenges in the long term. Also, further exploration of whether said coping strategies, as mentioned within this study such as support systems of color are actually effective or if they simply serve as an avoidance mechanism. Taking it a step further but also looking back, it would be important to examine individual upbringing, attachment styles, beginning teachings of Ebonics, and the roles played in adult codeswitching. Future studies could take a more quantitative or mixed method approach by also including validated coping strategies scales, adult attachment style questionaries, and additional mental health screeners. This would allow for further evaluation of the psychological impacts of codeswitching and more valid results. The participants also shared their experiences of facing challenges and notable differences during their transition from an HBCU to a PWI. Interestingly, it was observed that HBCUs, particularly at the undergraduate level, seemed to offer more resources for their students compared to PWIs at the graduate level. It would be valuable for future research to delve into this transition further, exploring areas such as adjustment disorders, student engagement, academic challenges, and more. It would also be valuable for future studies to include a group of 95 participants from undergraduate programs at PWIs and HBCUs as well as a group of participants from graduate programs at PWIs and HBCUs. This would allow for a closer look at the transition from multiple stages. Essentially, this could provide a clearer picture of the undergraduate to graduate transition while also exploring different codeswitching experiences. Additionally, as previously discussed, for many participants, they were the only or one of few Black students in their program, cohort, or class. Notably, majority of the participants within the current study were in social science related fields. It would be important to examine whether or not these results also pertained to Black students in other fields such as STEM. This would be a vital area to explore as the STEM field is a primarily White dominated field (Fry et al., 2021). Participants also noted a low number of Black faculty within their PWIs which further impacted their codeswitching habits. Thus, it would be important for PWIs to take a further look into their recruitment and retention rates and question why Black students or faculty do not feel inclined or comfortable to attend or remain at their institutions. Because as indicated from this study and in previous studies, a lack of diversity contributes to increased racial tensions and negatively impacts ones identity and authenticity. These negative impacts are another layer for those in research and academia to consider when it comes to addressing challenges related to diversity. Lastly, the results also indicated that many PWIs had a lack of diversity-related resources including funding. Thus, making the implementations of these potential interventions difficult. As a solution, PWIs should consider increasing funding and resources related to the inclusion of Black graduate students, awareness of the implications of codeswitching, and acceptance of Ebonics but with sensitivity as to avoid cultural appropriation. This could entail reallocating university funding from others such as university athletics as it is already a billiondollar industry (Zimbalist, 2023). This could also include increasing scholarships for Black 96 graduate students, which could in turn lead to an increase of Black graduate student enrollment, which could further cultivate a sense of belonging and make Black students feel more comfortable using Ebonics. Although, with a proposed increase in Black graduate students an increase in Black faculty at PWIs may also be beneficial and provide both entities with a sense of support and belonging. Participants even suggested a change in the faculty and an overall institutional change at their PWIs such as creating a more heterogenous staff, having more staff of color, and practicing inclusion of the whole student. 97 CHAPTER FIVE: CONCLUSION To reiterate, the current study has provided vital results about the psychological implications of codeswitching at predominantly White institutions. In short, there were 4 overall research questions instead of specific hypotheses for which the data set out to answer: 1) What are the reasons why Black or African American graduate students codeswitch in academic and/or campus settings? 2) How does codeswitching at a PWI impact Black or African American graduate students mental health in comparison to their HBCU experience? 3) What are the potential challenges Black or African American graduate students experience when codeswitching or refraining from codeswitching at a PWI? 4) In what ways can PWIs become more aware of potential implications surrounding codeswitching among Black or African American graduate students in academic settings? The data provided a multitude of answers to the first question. In short, Black or African American graduate students codeswitch or refrain from speaking Ebonics in academic settings if there are no Black people around or to seek advantages (i.e., to be understood, to avoid stereotypes, to achieve, or to be taken seriously). These results suggest that codeswitching for Black graduate students is done as a means to avoid challenges in White classroom settings. This also suggests that codeswitching is an important and vital tool for Black graduate students to navigate in predominantly White environments. The results also answered the second research question in that, codeswitching was found to be utilized more in PWIs in comparison to HBCUs. Further, the results indicated that Black students had significant negative experiences including mental health challenges while attending a PWI graduate school less than reported at their HBCU undergrad. But, in terms of a specific mental health comparison related to codeswitching, there were no significant results. This means 98 that, while Black graduate students at PWIs codeswitched more than they did at their undergraduate HBCUs the responses did not yield specific results in terms of their mental health comparisons in relation to codeswitching, specifically. Essentially, based on participant responses it was difficult to decipher a specific comparison as many of the responses were generalized or vague in this area. However, the 3rd research question did pose important information about Black graduate students' codeswitching experiences at their PWIs. In summary, the results suggested that Black graduate students experienced a great deal of psychological stressors as a result of codeswitching or the use of Ebonics at their PWIs. This further provides evidence that codeswitching for Black graduate students at PWIs poses problems of discrimination and acceptance. 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Retrieved May 31, 2021, from https://www.pbs.org/speak/seatosea/americanvarieties/AAVE/worldscollide/ Woo, E., & Curtius, M. (1996, December 20). Oakland School District Recognizes Black English. Los Angeles Times. https://www.latimes.com/archives/la-xpm-1996-12-20-mn11042-story.html World Health Organization. (2018, March 30). Mental health: strengthening our response. WHO. Retrieved April 29, 2021, from https://www.who.int/news-room/factsheets/detail/mental-health-strengthening-our-response Wyatt, T. A., & Seymour, H. N. (1988). The Implications of CodeSwitching in Black English Speakers. Equity & Excellence in Education: University of Massachusetts School of Education Journal, 24(4), 1718. https://doi.org/10.1080/0020486870240406 Yancy, G. (2011). The scholar who coined the term ebonics: A conversation with Dr. Robert L. Williams. Journal of Language, Identity and Education, 10(1), 4151. https://doi.org/10.1080/15348458.2011.539967 Yim, O., & Clment, R. (2021). Acculturation and attitudes toward code-switching: A bidimensional framework. International Journal of Bilingualism, 25(5), 13691388. https://doi.org/10.1177/13670069211019466 Young, J., Rose, D. C., Mumby, H. S., Benitez-Capistros, F., Derrick, C. J., Finch, T., Garca, C., Home, C., Marwaha, E., Morgans, C., Parkinson, S., Shah, J., Wilson, K. A., & Mukherjee, N. (2018). A methodological guide to using and reporting on interviews in 127 conservation science research. Methods in Ecology and Evolution, 9(1), 1019. https://doi.org/10.1111/2041-210x.12828 Young, V. A. (2009). Nah, We Straight: An Argument Against Code Switching. JACEP, 29(1/2), 4976. https://www.jstor.org/stable/20866886 Zang, B. (2020, July 23). Is African American Vernacular English a Language? Encyclopedia Britannica. https://www.britannica.com/story/is-african-american-vernacular-english-alanguage Zhou, E., & Gao, J. (2021). Graduate enrollment and degrees: 2010 to 2020. Washington, DC: Council of Graduate Schools. Zimbalist, A. (2023, March 18). Analysis: Who is winning in the high-revenue world of college sports? PBS NewsHour. https://www.pbs.org/newshour/economy/analysis-who-iswinning-in-the-high-revenue-world-of-collegesports#:~:text=The%20Facts%3A,among%201%2C100%20colleges%20and%20universi ties. Zoom Video Communications, Inc. (2022). Zoom Meeting (Version 5.13.0) [Software]. 128 APPENDICES Appendix A Examples of Codeswitching (in general) Examples of codeswitching between African American Vernacular (Ebonics) and Standard English are listed below (Redd & Webb, 2005 as cited in Gresham, 2014): She seen him yesterday vs. She saw him yesterday. He be here tomorrow vs. He will be here tomorrow. We gon win vs. We are going to win. He finna go vs. Hes about to go. He be steady talkin vs. He keeps talking on and on. He bin finish vs. He has already finished. They is some crazy folk, you was right. Vs. They are some crazy folks, you were right. Additional examples of the method of codeswitching are listed below (R.L. Williams, 1997): 1. Standard English: Mark the toy that is behind the sofa. 2. Ebonics: Mark the toy that is in back of the couch. 1. Standard English: Point to the squirrel that is beginning to climb the tree. 2. Ebonics: Point to the squirrel that is fixing to climb the tree. 129 Appendix B Recruitment Flyer Recruitment is for research purposes This research project has been approved by the University of Indianapolis Institutional Review Board (IRB) Approval Date:11/18/2021 Approval Number: 01529 SEEKING VOLUNTEERS FOR DISSERTATION RESEARCH We are seeking 12 to 15 Black or African American graduate students or former graduate students who are or have attended a predominantly White institution (PWI) to help with research on the psychological impact of codeswitching. The overall purpose of this study is to observe individual graduate student experiences when codeswitching at PWI to include the examination of race-related stressors, perceptions, identity, and mental well-being. Additionally, this study seeks to bring awareness and support for Black/African American communities, psychologists, and higher education institutions, by providing research on potential implications codeswitching may have on Black/African American students mental health. Participants will complete a demographic questionnaire form and an audio-recorded virtual interview. You are eligible to participate in this study if you meet the following criteria (please read carefully): Identify as Black or African American Non-international student Current graduate student or have completed a graduate degree program at a Predominately White Institution (PWI) o A PWI is defined as: A higher learning institution where the student enrollment includes 50 % or more of White or Caucasian students Earned an undergraduate degree from a Historically Black College or University (HBCU) o An HBCU is defined as: Any historically Black college or university that was established prior to 1964, whose principal mission was, and is, the education of Black Americans, and that is accredited by a nationally recognized accrediting agency or association determined by the Secretary of Education to be a reliable authority as to the quality of training offered or is, according to such an agency or association. Have general knowledge of codeswitching o Codeswitching for the purposes of this study is defined as: the switching from the linguistic system of one language [Standard English] or dialect to that of another [Ebonics, African American Vernacular, African American English] Engage in codeswitching Speak English Must be 18 years of age or older Willing to be audio-recorded for the interview 130 The entire study will take approximately 1 hour of your time (in one visit). You will receive compensation for completing the study, in the form of a $10.00 gift card. Please email the principal investigator (Dr. Mixalis Poulakis) at poulakism@uindy.edu or the coinvestigator (Sidney Allen, M.A.) at smallen@uindy.edu if you are interested in participating or have any questions. The study will take place on a virtual platform. 131 Appendix C List of HBCUs (The hundred-seven, 2018). Alabama A&M University Alabama State University Albany State University Alcorn State University Allen University American Baptist College University of Arkansas at Pine Bluff Arkansas Baptist College Barber-Scotia College (Not currently accredited) Benedict College Bennett College Bethune-Cookman University Birmingham-Easonian Baptist Bible College (Not recognized by the U.S. Department of Education as an HBCU) Bishop State Community College Bluefield State College Bowie State University Carver College (Not recognized by the U.S. Department of Education as an HBCU) Central State University Charles Drew University of Medicine and Science (Not recognized by the U.S. Department of Education as an HBCU) 132 Cheyney University of Pennsylvania Claflin University Clark Atlanta University Clinton College Coahoma Community College Concordia College, Alabama (closed 2018) Coppin State University Delaware State University Denmark Technical College Dillard University University of the District of Columbia Edward Waters College Elizabeth City State University Fayetteville State University Fisk University Florida A&M University Florida Memorial University Fort Valley State University Gadsden State Community College (Valley Street campus) Grambling State University Hampton University Harris-Stowe State University Hinds Community College at Utica 133 Hood Theological (Not recognized by the U.S. Department of Education as an HBCU) Howard University Huston-Tillotson University Interdenominational Theological Center J. F. Drake State Technical College Jackson State University Jarvis Christian College Johnson C. Smith University Johnson C Smith Theological Seminary (Not recognized by the U.S. Department of Education as an HBCU) Kentucky State University Knoxville College (Not currently accredited ) Lane College Langston University Lawson State Community College LeMoyne-Owen College Lewis College of Business (closed 2013) The Lincoln University Lincoln University Livingstone College University of Maryland Eastern Shore Meharry Medical College Miles College 134 Miles School of Law (Not recognized by the U.S. Department of Education as an HBCU) Mississippi Valley State University Morehouse College Morehouse School of Medicine Morgan State University Morris Brown College (Not currently accredited) Morris College Norfolk State University North Carolina A&T State University North Carolina Central University Oakwood University Paine College Paul Quinn College Payne Theological (Not recognized by the U.S. Department of Education as an HBCU) Philander Smith College Prairie View A&M University Rust College Saint Paul's College (closed 2013) Savannah State University Selma University Shaw University Shelton State Community College- C A Fredd Campus Shorter College 135 Simmons College of Kentucky South Carolina State University Southern University at New Orleans Southern University at Shreveport Southern University and A&M College Southwestern Christian College Spelman College St. Augustine's University St. Philip's College Stillman College Talladega College Tennessee State University Texas College Texas Southern University Tougaloo College H. Councill Trenholm State Community College Tuskegee University University of the Virgin Islands Virginia State University Virginia Union University Virginia University of Lynchburg Voorhees College West Virginia State University 136 Wilberforce University Wiley College Winston-Salem State University Xavier University of Louisiana 137 Appendix D Demographic Questionnaire 1. What is your current age? 2. What is your race/ethnicity? 3. What gender identity do you most identify with? 4. What is your sexual orientation? 5. What is the name of the HBCU you attended for your undergraduate degree program? 6. What was your field of study in undergrad? (please select the best fit) a) Aviation (e.g., aviation technology, aeronautical science, and air traffic management) b) Art (e.g., visual arts, graphic design, drama/theatre, music, and art history) c) Business (e.g., accounting, entrepreneurship, marketing, finance, and economics) d) Science (e.g., biology, chemistry, nursing, and astronomy) e) Social Science (e.g., anthropology, psychology, sociology, and diversity studies) f) Political Science (e.g., public administration, international relations, and law) g) Communication (e.g., mass communications, journalism, and sports communication) h) Math (e.g., applied mathematics, statistics, and data analytics) i) Engineering (e.g., mechanical engineering, chemical engineering, and civil engineering) j) Other (please list only if your field of study does not fit best within any of the above categories) 7. How many years ago did you graduate from your undergraduate and/or graduate degree program? 8. What is the name of the PWI you are currently enrolled in for your graduate degree or graduated from? 9. Are you currently enrolled or were you enrolled as a full-time or part-time student? program? 10. Is or was your graduate degree program a masters or doctoral-level degree 138 11. If you are currently enrolled in a graduate program, what year are you in your program? 12. What is or was your field of study in your graduate program? a) Aviation (e.g., aviation technology, aeronautical science, and air traffic management) b) Art (e.g., visual arts, graphic design, drama/theatre, music, and art history) c) Business (e.g., accounting, entrepreneurship, marketing, finance, and economics) d) Science (e.g., biology, chemistry, nursing, and astronomy) e) Social Science (e.g., anthropology, psychology, sociology, and diversity studies) f) Political Science (e.g., public administration, international relations, and law) g) Communication (e.g., mass communications, journalism, and sports communication) h) Math (e.g., applied mathematics, statistics, and data analytics) i) Engineering (e.g., mechanical engineering, chemical engineering, and civil engineering) j) Other (please list only if your field of study does not fit best within any of the above categories) 13. Are you a 1st generation college student? (please answer yes or no) A 1st generation college student is a student whose parents or guardians have not obtained a bachelors degree a) If not, what universities did your parents/guardians attend? b) If not, what is the highest degree your parents/guardians have earned? 139 Appendix E Semi-structured Interview Questions Rapport Building Questions 1. How would you compare your experience at your HBCU to your experiences while attending a PWI? a) Academics? Campus social life? 2. How do you or did you manage your mental health while in graduate school? Reasons for Codeswitching Questions 3. How would you define Ebonics or African American Vernacular English (AAVE)? 4. How would you define Standard English? 5. How would you define codeswitching? 6. Why do you codeswitch? 7. Has codeswitching become a necessity for you? If so, why? Codeswitching in Academic Settings Questions 8. How are/were your interactions with your White professors compared to your Black professors, if you have/had any in your graduate program? 9. In what academic settings do you/did you partake in codeswitching? 10. What are some/were some challenges you face(d) when codeswitching in the classroom setting? 11. How did your codeswitching habits change from undergrad to graduate school? Psychological Questions 12. Do you think that you codeswitch unconsciously (or codeswitch without realizing it)? 140 13. Do you feel that you were changing who you were when you were codeswitching at your PWI? 14. How has your racial identity been impacted since attending a PWI? 15. Have you experienced any discrimination based on your use of Ebonics or lack of codeswitching in the classroom or in interactions with faculty at your PWI? 16. How do you feel that other students or professors of European/White origin will perceive you if you dont codeswitch? 17. How do you/did you cope with any race-related stress experienced at your PWI? Diversity/Awareness Questions 18. What kind of historical ties do you think Ebonics have to African American culture, if any? 19. Whats something you would like to share with the faculty or students at your current or past PWI, about codeswitching that you think is important for them to know/understand? 20. Do you think Ebonics, AAVE, AAE, or Black English should be accepted in your school? 21. Do you feel that your graduate program has placed an emphasis on diversity-related educational resources? 141 Appendix F Email Hello, Thank you for your interest in this study. Please read the Informed Consent document attached to this email. If you are still interested and would like to participate please click this LINK (hyperlink to doodlepoll) to schedule your interview. Best, Sidney Allen, M.A. 142 Appendix G Informed Consent Informed Consent Minimal Risk UIndy Study # 01529 Study Version: 1 Study Version Date: 11/18/2021 Informed Consent Form (ICF) Version: 1 ICF Version Date: 11/18/2021 University of Indianapolis University of Indianapolis KEY INFORMATION FOR POTENTIAL RESEARCH PARTICIPANTS We are attempting to gather data on Black or African American graduate student experiences of codeswitching at Predominately White Institutions (PWIs) and any potential psychological implications. In particular, this study looks at individuals who previously attended historically Black colleges or universities (HBCUs) and will examine their experiences surrounding codeswitching, racial identity, discrimination, and overall mental health. Additionally, this study seeks to bring awareness and support for Black/African American communities, psychologists, higher education institutions, by providing research on potential implications codeswitching may have on Black/African American students mental health. We are looking for participants who identify as Black or African American, non-international graduate students or alumni, who engage in codeswitching, speak English, and are at least 18 years of age. Please see the recruitment flyer for additional eligibility requirements. Participants will be completing a demographic questionnaire and a semi-structured interview. The demographic questionnaire consists of 11 questions. While the semi-structured interview consists of 21 questions. The semistructured interview will be audio-recorded using a digital audio recording device. The administration of the demographic questionnaire and the semi-structured interview will take approximately 1 to 2 hours. There is minimal risk involved with this study. In particular, feelings of discomfort or embarrassment may be elicited due to questions pertaining to psychological well-being, racial identity, and discrimination. However, mental health resources will be provided to participants once the interview concludes or following early termination of participation. There are no direct benefits to participants. Although, in appreciation, participants will receive a payment in the form of a $10.00 gift card following the completion of the study. Participation in this study is completely voluntary, and there is no obligation to participate. If you would still like to participate, please read the information below before continuing 143 CONSENT TO PARTICIPATE IN RESEARCH STUDY "You Are So Articulate": The Psychological Impact Of Codeswitching Among Black Or African American Graduate Students At Predominantly White Institutions Study Principal Investigator (PI): Mixalis Poulakis, Psy.D. UIndy Email: poulakism@uindy.edu UIndy Telephone: (317) 788-6141 or 800-232-8634 x6141 Study Co-Investigator: Sidney Allen, M.A. UIndy Email: smallen@uindy.edu Mixalis Poulakis, Psy.D. and Sidney Allen, M.A. from the College of Applied and Behavioral Sciences (formerly School of Psychological Sciences) at the University of Indianapolis (UIndy) are conducting a research study. Your participation in this research study is voluntary. Why is this study being done? The study was designed to explore the psychological well-being of Black or African American graduate students at Predominately White Institutions (PWIs) and the impact of codeswitching. The primary focus will be on what it means to codeswitch, any possible implications to an individuals identity, any possible psychological implications, and how PWIs can be more cognizant of this phenomenon. The results of this study will bring awareness and support for Black/African American communities, psychologists, and higher education institutions, by providing research on potential implications codeswitching may have on Black/African American students mental health. What will happen if I take part in this research study? If you volunteer to participate in this study, the researcher will ask you to do the following: You will need to meet all criteria as specified in the recruitment flyer You will need to read this informed consent form (ICF) in its entirety and ask any questions you have about the study. You will be required to give your voluntary, informed consent verbally to participate in this study and the co-investigator will sign the ICF in person or electronically to document that consent was received. You will need to provide your availability via the online Doodle poll link sent out by the coinvestigator in order to schedule your virtual interview. The interview will take place on a 144 virtual platform such as zoom. This will be agreed upon mutually with you and the coinvestigator. You will complete a 13-item demographic questionnaire which will be administered verbally during your scheduled interview but, responses will not be audio recorded. The questionnaire will ask you about your educational background as well as general background information (i.e. age, gender, etc.). You will be interviewed about your reasons for codeswitching, your mental health, your experiences at your HBCU/PWI, and your thoughts on diversity awareness. This interview will be conducted by the co-investigator. The administration of the interview will take approximately 1 to 2 hours depending on the length of responses. This virtual interview will be audio recorded. How long will I be in the research study? Participation will take a total of about 1-2 hours to be completed in one sitting. Are there any potential risks or discomforts that I can expect from this study? The risks and discomforts of this research study are minimal. Although, due to the nature of some of the interview questions feelings of discomfort or embarrassment may be elicited. In particular, you will be asked personal questions pertaining to your racial identity, discrimination, and psychological well-being. The intention of this study is not to make you feel uncomfortable. However, if questions arise, that make you feel uncomfortable, you have the right to end your participation at any time. Additionally, mental health resources will be provided to you once the interview concludes or following the early termination of your participation. Are there any potential benefits if I participate? You will not directly benefit from your participation in the research. The results of the research may aid in the research on ethnic minority issues by applying psychological knowledge to address current issues. Will I be paid for participating? You will receive a $10.00 gift card for your participation. The gift card will be distributed electronically via email. Will information about me and my participation be kept confidential? The results of this study may be published in a scholarly book or journal, presented at professional conferences or used for teaching purposes. However, only aggregate data will be used. Personal identifiers will not be used in any publication, presentation or teaching materials. 145 Any data obtained from this study will remain confidential. The co-investigator is the only individual with whom you will have direct contact and be personally identifiable to. You will not be asked to provide your name on the informed consent form, any questionnaires, or at any point during the audio-recorded interview. You will be requested not to provide any identifying information when answering questions. However, if you do state any identifying information during the interview, the co-investigator will remove any identifiable information when the audio recording is being transcribed. Also, during the interview, you will be reminded not to provide any identifiable information. All documents obtained to include the audio-recorded interview responses will be labeled with an unidentifiable code and stored on an encrypted flash drive. The co-investigator and primary investigator will be the only individuals with access to the encrypted flash drive. Other researchers on the research team will only have access to the de-identified transcripts of the interview during the data analysis phases. Everyone on the research team is obligated to maintain confidentiality. Although, your confidentiality in this study is protected there are specific instances where confidentiality may be broken. The investigators are required by Indiana state law to file a report with the appropriate agencies if information is provided indicating child abuse, elderly abuse, harm to yourself, or harm to others. The investigators also have a duty to warn an intended victim, notify the police, or seek hospital-based treatment for you in such instances. Additionally, because all documents and materials obtained will be labeled with an unidentifiable code, none of your personal information will be connected to any of the data. All communication through email or phone will be destroyed after all interviews have been completed. All copies of the audio recordings will be destroyed following the dissertation defense. All other documents to include demographic information, consent forms, and transcribed interviews will be destroyed after three years as recommended by the University of Indianapolis Institutional Review Board. Will the data from my study be used in the future for other studies? It is possible that de-identified data from this study could be used for future research or shared with other researchers for use in studies, without additional informed consent. De-identified means that any codes and personal information that could identify you will be removed before the data is shared. Will my data be shared in any other way? Your interview will be transcribed and shared with the research team during the data analysis phase. However, the research team will only have access to the de-identified transcription. No personal information will be transcribed or shared with the research team. The research team typically consists of graduate and undergraduate students who are obligated to maintain confidentiality of the de-identified transcripts. What are my rights if I take part in this study? 146 You can choose whether or not you want to be in this study, and you may withdraw your consent and discontinue participation at any time. Whatever decision you make, there will be no penalty to you, and no loss of benefits to which you were otherwise entitled. You may refuse to answer any question/s that you do not want to answer and still remain in the study. You have the right to listen to the audio recording and request immediate disposal of the file and withdrawal of your participation. Who can I contact if I have questions about this study? The Research Team: If you have any questions, comments or concerns about the research, you can talk to one of the researchers. Please contact: Principal Investigator: Mixalis Poulakis, Psy.D. School/Department/Division: College of Applied Behavioral Sciences Telephone: (317) 788-6141 Email: poulakism@uindy.edu Co-Investigator: Sidney Allen, M.A. School/Department/Division: College of Applied Behavioral Sciences Email: smallen@uindy.edu The Director of the Human Research Protections Program (HRPP): If you have questions about your rights as a research participant, or you have concerns or suggestions and you want to talk to someone other than the researchers, you may contact the Director of the Human Research Protections Program, by either emailing hrpp@uindy.edu or calling 1 (317) 781-5774 or 1 (800) 232-8634 ext. 5774. How do I indicate my informed consent to participate in this study? If you consent to participate in this study, then you affirm that you satisfy inclusion criteria and your consent is voluntary. You do not need to sign this, or any other document to indicate your consent. To indicate your voluntary consent and proceed with the questionnaire and interview, please respond when the co-investigator asks for verbal consent at the beginning of the interview. You will be given a copy of this information to keep for your records. 147 SIGNATURE OF PERSON OBTAINING CONSENT Name of Person Obtaining Consent Signature of Person Obtaining Consent Date 148 Appendix H Debriefing Form Minimal Risk UIndy Study # 01529 Study Version:1 Study Version Date:1 Informed Consent Form (ICF) Version:1 ICF Version Date:11/18/2021 Principal Investigator: Dr. Mixalis Poulakis, Psy.D School/Department/Division: College of Applied Behavioral Sciences Telephone: (317) 788-6141 Email: poulakism@uindy.edu Co-Investigator: Sidney Allen, M.A. School/Department/Division: College of Applied Behavioral Sciences Email: smallen@uindy.edu DEBRIEFING FORM FOR PARTICIPATION IN RESEARCH ACTIVITIES Study Title: "You Are So Articulate": The Psychological Impact Of Codeswitching Among Black Or African American Graduate Students At Predominantly White Institutions Thank you for participating in this study. The overall purpose of this study is to explore the psychological well-being of Black or African American graduate students at Predominantly White Institutions (PWIs) and the impact of codeswitching. Over the years, the number of Black or African American students attending graduate school at HBCUs has decreased. Thus, many have enrolled in graduate school at PWIs which has come with its own challenges. This study will observe the experiences of Black or African American graduate students attending/have attended PWIs and any challenges they may face surrounding codeswitching, racial discrimination, identity, and overall mental health. The investigators invited adults of Black or African American descent, currently attending/have attended a PWI for graduate school, obtained an undergraduate degree from an HBCU, have a general knowledge of codeswitching, engage in codeswitching (from Ebonics to Standard English), speak English, and are willing to be audio-recorded for the semi-structured interview. Also, in this study, you were asked to provide demographic information verbally. The results of this study will be used to encourage research on ethnic minority issues while concurrently applying psychological knowledge to address these issues. The responses you 149 provided will also be useful in providing insight on any impacts of codeswitching among Black or African Americans to universities and mental health providers. Also, as the semi-structured interview may prompt feelings of discomfort or embarrassment, a list of mental health resources is provided below. Thank you again for your participation in this study! If you have any further questions, please contact the principal investigator or coinvestigator. Additionally, if you have questions or concerns about your rights and welfare as a research participant, please contact the Director of Human Research Protections Program at 317781-5774 or 1-800-232-8634 or via email at hrpp@uindy.edu Mental Health Resources University of Indianapolis Student Counseling Center (for Uindy Students only) - 317-788-5015 Marion County Crisis Hotline (for Indiana residents) - 317-251-7575 Indiana Minority Health Coalition (for Indiana residents) - 317-926-4011 Suicide Prevention Life Line - 1-800-273-TALK (8255) National Organization for People of Color Against Suicide - http://nopcas.org/ IM ALIVE (online crisis network) - www.IMALIVE.org National Alliance for the Mentally Ill (NAMI) - 1-800-950-NAMI (6264 - INFO@nami.org 150 Appendix I Participant Demographics 1 Age 22 23 24 25 26 30 33 35 41 2 3 4 5 6 7 Race/Ethnicity Black African American Black/African American Gender Female Male Sexual Orientation Straight/Heterosexual Gay/Homosexual Queer Region of HBCU Southeast Mid-Atlantic Southwest Undergraduate Field of Study Social Science Business Science Math Region of PWI Midwest Southeast Southwest # of participants 2 1 1 2 1 1 1 2 1 M=28.42 8 2 2 8 4 10 1 1 8 3 1 6 3 2 1 3 2 2 151 8 9 10 11 12 13 Western Mountain Plains Mid-Atlantic Northeast Graduate Field of Study Social Science Science Other Enrollment Status Full-time Part-time Years since obtaining an undergraduate degree 1 2 2.5 3 4 5 9 13 14 18 Years since obtaining a graduate degree (if already graduated) 2 7 8 12 2 1 1 1 7 4 1 12 0 2 1 1 2 1 1 1 1 1 1 M= 6.3 1 1 2 1 M=7.4 First generation Status First generation Non First generation 7 5 Parent/guardians higher education institution PWI HBCU 4 1 152 Appendix J Domain List Domai n# 1 Domain Name Definition Motivations for codeswitching - 2 Ebonics and Standard English - 3 Differences among PWIs and HBCUs 4 The impact of codeswitching 5 Other types of codeswitching 6 Coping strategies 7 Higher Education Interventions 8 Other Motivations for codeswitching (not negative impacts of codeswitching) Settings to codeswitch in Reasons why participants codeswitch - - Specifying conditions for codeswitching (relationships, people, etc.) Historical ties Participants quoting specific phrases Participants explaining Ebonics Examples of Ebonics Definition of Ebonics Definition of Standard English Differences among PWIs and HBCUs (not related to codeswitching) Number of Students of Color Interactions with professors of POC vs non POC Differences among campus social life Resources Examples of school experiences (including curriculum) Changes from undergrad to grad school Specific examples and comments on thoughts, feelings and related to the domain Impacts on racial identity Discrimination based on non-codeswitching/use of Ebonics Negative comments from students Negative comments from professors negative or positive impacts of codeswitching Results/outcomes of codeswitching Others reactions or perceptions if P codeswitches (based on actual experiences) Codeswitching of appearance Discussions of clothing Changes of mannerisms -Coping strategies related to codeswitching - Coping strategies not related to codeswitching (general ways of maintaining mental health, dealing with differences from pwi vs hbcu, surviving PWI, etc.) - Reports of not coping Recommendations for higher education Diversity-related resources Aspirational ideals Things institutions should not do Things institutions should change Acceptance or non-acceptance of Ebonics irrelevant stuff 153 Appendix K Frequency Analysis Domain, Category, and Subcategory Frequency 1 Motivations for Codeswitching Based on Setting Academic/Classroom Settings Comfortable Settings Being at a PWI Social Settings Professional Settings For Advantages To be understood To Avoid Stereotypes To Achieve To be taken Seriously Mental Health Based on Racial Makeup of Those Around Role models using Codeswitching Undergrad Influences Out of Necessity Naturally Ingrained No Motivation Regardless of Racial Makeup of those around Use of Codeswitching overtime/habit No Reason General General Typical Typical Variant Variant General Typical Typical Typical Variant Variant General Typical Typical Typical Typical Typical Typical Variant Variant Variant 2 Ebonics and Standard English Neutral Description of Ebonics Dialect Language Positive Description of Ebonics Comfort Not Slang Unique Ebonics is tied to African American Culture Slavery Generational/Family Negative Description of Ebonics Unprofessional Neutral Description of Standard English Related to School General Typical Variant General Variant Variant Variant General General Typical Typical Variant Typical Typical 154 Negative Description of Standard English Neutral Description of Codeswitching Informal vs Formal Linguistic Change Examples Positive Description of Standard English Proper Negative Description of Codeswitching Negative Perceptions of Dialects 3 Differences among PWIs and HBCUs Demographics Low number of Black people at PWI High number of Black people at HBCU Racial identity/culture Reinforced at PWI Reinforced at HBCU Worse at PWI Professor Interactions Not good at PWI Good at PWI The same Social Support/Resources Available Discrimination/Inequities Academic Size/Location General Differences No differences 4 The Impact of Codeswitching Challenges Internal/Personal External/Dealing with others With the act of codeswitching Negative Experiences Perceived Actual Positive Experiences Actual Perceived Impact on Identity/Authenticity Codeswitching Habits Neutral Experiences No Challenges/Impact Change noticed by others 5 Other Types of Codeswitching General Appearance Typical Typical Variant Variant Typical Variant Variant Variant Variant General General Variant General General Typical Variant General General Typical Variant General General General Typical Typical Typical Rare General General General Typical General General General General General Variant General General Typical Typical Variant General 155 Clothing Hair Clothing & Hair Non Verbals Writing 6 Coping Strategies Support Systems POC Specific Support Family Financial Support Religious/Spiritual Academic Lack of Adequate Coping Drugs/Alcohol Self-Care Therapy Socializing Lessons Learned Emotion Regulation Finding Safe Spaces 7 Higher Education Interventions Need for more awareness of Codeswitching AAVE Should be accepted Lack of Diversity-Related Resources at PWI/Need for Improvement Need for Overall institutional change Need for faculty change/specific training Diversity Related Resources currently in place at PWI Need for Better Funding of Diversity Related Resources Codeswitching Should be Accepted Codeswitching Shouldnt be Accepted AAVE Shouldnt be Accepted Typical Variant Variant Variant Variant General General Typical Variant Variant Variant Typical Variant Typical Typical Typical Typical Typical Typical General General General General Typical Typical Variant Variant Variant Rare 156 Appendix L Examples of Ebonics & codeswitching (compiled from participant responses) Hey girl whats poppin whats good Thats how it be It bes like that yo Oh Im just chillin vs Im either relaxing or I am taking a break What up doe vs hi, hows your day going  ...

... THE EFFECTS OF INTERNALIZED WEIGHT STIGMA ON THE PERCEPTIONS OF OTHERS A Doctoral Dissertation Presented to The Graduate Department of Clinical Psychology University of Indianapolis in partial fulfillment of the requirements for the degree Doctor of Psychology Victoria Silvati, M.A. November 2023 THE EFFECTS OF INTERNALIZED WEIGHT STIGMA ON THE PERCEPTIONS OF OTHERS This is to certify that the Doctoral Dissertation of Victoria Silvati has been approved by the Graduate Department of Clinical Psychology of the University of Indianapolis in partial fulfillment of the requirements for the degree of Doctor of Psychology Approved: Accepted: ____________________________ Erin M. Fekete, Ph.D. Dissertation Advisor ____________________________ John Kuykendall III, Ph.D. Dean College of Education and Behavioral Sciences ____________________________ Samantha Gray, Ph.D. Committee Member _________________________ Date Dr. Kathryn Boucher, Ph.D. Committee Member November 3, 2023 ____________________________ Date INTERNALIZED WEIGHT STIGMA ON THE PERCEPTION OF OTHERS iii Abstract Women are held to high societal standards regarding weight, and when they deviate from the ideal, others may negatively stereotype and discriminate against them. This stigma may become internalized as individuals endorse and attribute negative weight-based stereotypes and attitudes to themselves. Internalized weight stigma negatively affects ones body image and psychological well-being, but little research examines how it influences the perception of others. An onlinebased Qualtrics study using a convenience sample of female undergraduate students was conducted (n = 156). Participants were randomly assigned to complete 3 writing prompts meant to illicit feelings of internalized weight stigma or a neutral writing prompt. Participants were shown one of four vignettes, accompanied by an avatar describing a woman with normal weight, overweight, obesity, and severe obesity. Following the presentation of the vignettes, all participants were asked to complete a variety of measures assessing their stereotypes, desire for social distance, social comparisons, and demographic information. A series of 2x4 factorial ANOVAs were conducted. Overall, the findings from this study partially support the initial hypothesis that participants would endorse greater antifat attitudes toward the target with higher BMIs; however, they desired less social distance from the target with normal weight than the target with obesity or severe obesity. Also, individuals who wrote about internalized weight stigma made fewer downward social comparisons toward the target in comparison to those who wrote about their daily routine. Results from this study may suggest that the participants experienced higher levels of empathy due to their own internalized weight stigma, which impacted their beliefs and behaviors toward others. Future research should continue to explore how internalized weight stigma may impact the perception of others. INTERNALIZED WEIGHT STIGMA ON THE PERCEPTION OF OTHERS iv Acknowledgements First, I want to express my deepest appreciation to my advisor, Dr. Fekete, for her invaluable patience and feedback throughout the entirety of this project. I am also extremely grateful for both Dr. Gray and Dr. Boucher, my dissertation committee members, who generously provided additional support and expertise. The completion of this project would not have been possible without the endless love and encouragement from my family and friends. Thank you for fueling my drive to learn and igniting my passion to redefine beauty standards as a way to allow all individuals to feel confident and beautiful. INTERNALIZED WEIGHT STIGMA ON THE PERCEPTION OF OTHERS v TABLE OF CONTENTS TITLE PAGE.i SIGNATURE PAGE.....ii ABSTRACT.....iii ACKNOLWEDGEMENTS.iv TABLE OF CONTENTS......v LIST OF TABLES.....viii INTRODUCTION.........1 Societal Ideals of Weight...............1 Stereotypes/Prejudice Against Obesity.........2 Weight Discrimination/Weight Stigma.....5 Internalized Weight Stigma ......7 Social Comparisons.........10 Ingroup/Outgroup Bias........12 The Present Study....17 METHOD19 Participants..19 Procedure.....19 Measures..20 Writing Prompts.....21 Vignettes....22 Comprehension and Attention Check Questions...........22 INTERNALIZED WEIGHT STIGMA ON THE PERCEPTION OF OTHERS vi Manipulation Check Question...23 Social Distance...24 Antifat Attitudes.25 Social Comparisons...26 Demographics....26 Analysis Plan...27 Power Analyses......27 Preliminary Analyses.....27 Main Analyses...28 RESULTS....29 Participant Characteristics...29 Manipulation Check.....29 Quantitative Analysis of Manipulation......29 Qualitative Analysis of Manipulation31 Preliminary Data Analyses..31 Assumptions...31 Main and Interactive Effects of Vignette and Writing Condition..32 Covariates..37 Main and Interactive Effects of Vignette and Writing Condition Including Covariates.....38 DISCUSSION..........39 Main Effects of Vignette Condition....39 Main Effects of Writing Condition..44 INTERNALIZED WEIGHT STIGMA ON THE PERCEPTION OF OTHERS vii Interactive Effects of Vignette and Writing Condition...47 Limitations...48 Strengths..49 Implications and Clinical Applications...51 Conclusion...53 REFERENCES54 APPENDICES.75 APPENDIX A: Informed Consent..76 APPENDIX B: Study Measures..80 APPENDIX C: Vignettes88 APPENDIX D: Writing Prompts.93 INTERNALIZED WEIGHT STIGMA ON THE PERCEPTION OF OTHERS viii LIST OF TABLES Participant Demographics......30 Main and Interaction Effects on Social Distance Scale.....33 Main and Interaction Effects on Seating Distance Task34 Main and Interaction Effects on Antifat Attitudes.36 Main and Interaction Effects on Social Comparison.37 Correlations Between BMI and Dependent Variables...38 INTERNALIZED WEIGHT STIGMA ON THE PERCEPTION OF OTHERS 1 The Effects of Internalized Weight Stigma on the Perception of Others Societal Ideals of Weight Although the prevalence of obesity has significantly increased in recent years, the pressure for women to remain thin and fit has continued. Women are still held to high societal standards regarding their weight, size, and body type. Thin ideals have been persistent because the media has suggested that very slim women are more popular and successful (Alley & Scully, 1994; Gustafson et al., 1999). The emphasis on beautiful, slender women in the media shows that society tends to objectify womens bodies, putting an emphasis of worth on physical appearance, which trumps the importance of any other characteristic (Fredrickson & Roberts, 1997). Thin ideals are still present today; however, current societal ideals also emphasize a new fit and muscular physique. A study involving female college students found that participants gave higher attractiveness ratings to a thin, muscular woman than to images of the same woman with muscles edited out (Betz et al., 2019). These results show an emergence of an athletic ideal that pressures women to increase muscle mass while remaining thin. The media paints this body type as healthier because it adds the idea of exercise into a womans routine but is arguably more difficult for the typical woman to achieve than just extreme thinness (Garvin & Damson, 2008). Images in the media are often presented with negative messages that objectify women, induce guilt, and promote dieting and restraint, which can all harm a womans body image and satisfaction (Betz et al., 2019; Bozsik et al., 2018). Negative outcomes can occur when current societal standards for female beauty emphasize thinness and muscularity to a level that is impossible for women to achieve (Tiggemann & Slater, 2003). The increase in both slender and muscular images in the media starkly contrasts the rising prevalence of overweight and obesity and can contribute to body INTERNALIZED WEIGHT STIGMA ON THE PERCEPTION OF OTHERS 2 dissatisfaction as women compare themselves to the ideal. In fact, 72% of women have reported substantial body dissatisfaction when comparing themselves with thin ideals (Fiske et al., 2014). In addition, exposure to this new form of the thin muscular ideal has recently been associated with greater physique anxiety, body dissatisfaction, negative mood, eating disorders, psychological disturbances, and lowered self-esteem (Betz et al., 2019; Bozsik et al., 2018; Garvin & Damson, 2008). Due to the emphasis on maintaining a thin and muscular ideal, individuals tend to hold negative attitudes toward individuals who deviate from these norms. Thus, these negative attitudes can become the basis for discrimination against those with overweight and obesity, which can lead to increased distress and lower body satisfaction. Interestingly, these negative attitudes are even present in individuals with overweight and obesity, but little research has focused on why this may occur. One reason may be that their internalization of attitudes and perceptions regarding weight standards (i.e., internalized weight stigma) may influence their attitudes and judgments toward others. Thus, the present study aims to examine how an individuals own feelings of internalized weight stigma may influence judgments about individuals of different weight categories. Stereotypes/Prejudice Against Obesity Individuals with overweight and obesity are often negatively stereotyped and commonly experience prejudice and discrimination. Stereotyping is fundamental to cognition because it serves to organize and structure ones knowledge about the world. By categorizing classes of stimuli into like groups, individuals can organize the vast array of stimuli they encounter daily (Bodenhausen et al., 2011). These social categories allow individuals to develop a sense of identity, belonging, and connection to or alienation from others (Hornsey, 2008). Social INTERNALIZED WEIGHT STIGMA ON THE PERCEPTION OF OTHERS 3 categories can help one infer an individuals goals and intentions, what skills and knowledge they possess, and what general personality traits they are likely to exhibit (Bodenhausen et al., 2011). Biases can be perpetuated when previous experiences and knowledge lead the individual to believe their attitudes are appropriate. For example, if individuals encounter others with overweight and obesity that they perceive negatively, they are likely to continue to attribute these negative traits to the entire category of individuals. Individuals that believe these stereotypes to be true tend to perceive all those with overweight and obesity negatively. Considerable evidence indicates that individuals in the United States who are overweight or obese, particularly women, are often negatively stereotyped (Smith et al., 2007; Meadows & Calogero, 2018; Seacat et al., 2009). One reason people attribute negative personality characteristics to individuals with obesity is that they are seen as being responsible for their weight (Puhl & Heuer, 2010). Research has documented harmful weight-based stereotypes suggesting that individuals with overweight and obesity are lazy, ugly, unhappy, unintelligent, unsuccessful, socially isolated, lack self-discipline, and are noncompliant with weight loss treatment (Major et al., 2012; Puhl & Heuer, 2010; Puhl, & Brownell, 2006; Smith et al., 2007). Some research suggests that women with obesity are perceived as less sexually skilled and unattractive when compared to their thin counterparts, but this same effect was not found for men (Smith et al., 2007). Another study found that college students rated heavier women as relatively unattractive, unlikely to date, and unworthy of attractive partners compared to normal weight women (Boyes & Latner, 2009). All these negative stereotypes against women with overweight and obesity may be worsened by the media. The media can exacerbate negative weight-related attitudes and can adversely affect individuals with obesity (Vartanian et al., 2014). Stigmatizing portrayals of people with obesity INTERNALIZED WEIGHT STIGMA ON THE PERCEPTION OF OTHERS 4 are common in television programs, movies, cartoons, and commercials (Puhl & Heuer, 2009; Wang et al., 2004). The media consistently ridicules overweight characters and stereotypically portrays them as less likely to have friends or date, and more likely to be shown eating or be the target of jokes (Greenberg et al., 2003). These stereotypical depictions of people with overweight thus affect individuals perceptions about being overweight and obesity in general. Research shows a positive association between media exposure and expressions of weight stigma (Latner et al., 2007). In addition to negative portrayals of individuals with overweight and obesity in entertainment media, 72% of individuals who are overweight or obese are depicted in online news photographs in a stigmatizing way (Heuer et al., 2011). The news media reinforces perceptions that bodyweight is within personal control, which serves to justify stereotypes and prejudice as an acceptable response to obesity (Puhl & Heuer, 2010). Research shows that the media disproportionately emphasizes that an individual is responsible for their own obesity and chooses to ignore how external factors play a role in obesity (Kim & Willis, 2007). This perpetuates the belief that weight is controllable. Therefore, people tend to hold others, and sometimes themselves, responsible for being overweight or obese. Believing that weight is controllable assumes that individuals who are overweight lack the motivation and responsibility to lose weight, but they could escape the stigmatized group if they wanted to. According to Frederick and colleagues (2020), it becomes easier to stigmatize people when they possess a trait viewed as unfavorable and within personal control. Furthermore, since weight is often perceived as being within an individuals control, it is likely that empathy for those with overweight and obesity decreases while antifat attitudes increase (Teachman et al., 2003). The large number of individuals exposed to stigmatizing portrayals of overweight and INTERNALIZED WEIGHT STIGMA ON THE PERCEPTION OF OTHERS 5 obesity may partially explain the pervasive discrimination and stigma directed toward this group. Weight Discrimination/Weight Stigma Individuals who are overweight or obese are frequent targets of weight stigmatization (Andreyeva et al., 2008; Puhl & Heuer, 2010). Carr and Friedman (2005) found that individuals in the highest obesity categories were 40-50% more likely to report discrimination than their normal weight peers. In fact, weight stigma ranks among the most common types of discrimination, including ageism, racism, and sexism (Andreyeva et al., 2008). However, weight stigma differs significantly from these other forms of discrimination. Discriminatory acts against one who is overweight or obese are often blatant and can be justified as a way of motivating individuals to lose weight, making it more socially acceptable than other forms of discrimination (Major et al., 2012; Tomiyama, 2014). However, weight stigma hinders weight loss and may actually cause weight gain (Tomiyama, 2014; Vartanian et al., 2014). Additionally, there have been marked gender differences in weight stigma and discrimination. For example, although research has found that about 40% of men report experiences of weight stigma, women typically report experiencing stigma at lower BMIs than do men (Himmelstein et al., 2018; Puhl et al., 2008). Weight stigma may be worse for women than men because cultural norms emphasize stricter body ideals for women than for men. This may lead to high rates of body dissatisfaction and greater likelihood of having internalized weight stigma in women (Azarbad & Gonder-Frederick, 2010; Himmelstein et al., 2018; Purton et al., 2019). Weight discrimination has been documented in places of employment settings and healthcare facilities (Andreyeva et al., 2008). In places of employment, a structural bias emerges when individuals with overweight and obesity apply for jobs. There is a large body of INTERNALIZED WEIGHT STIGMA ON THE PERCEPTION OF OTHERS 6 experimental evidence on hiring decisions finding that when employers were given fictional job applications with identical qualifications, applicants with obesity were less likely to be hired than applicants with normal weight (Giel et al., 2010). Furthermore, gender appears to interact with weight in making these decisions. For example, one study found that normal weight males and females had a significantly higher chance of being hired than females with obesity. Additionally, if both job applicants were obese, the male with obesity had a significantly higher chance of being hired in comparison to the female with obesity (Giel et al., 2012). These structural biases can be detrimental to ones ability to get and maintain a decent job, which could explain why women with obesity tend to be lower in socioeconomic status, making less money than their nonobese counterparts (Azarbad & Gonder-Fredrick, 2010). In addition, doctors, obesity specialists, and other healthcare providers have all been found to hold negative attitudes toward, spend less time in appointments, and provide less health education with individuals who are overweight or obese in comparison to normal-weight patients (Azarbad & Gonder-Fredrick, 2010; Diedrichs & Barlow, 2011; Puhl & Heuer, 2010). The commonality of weight-based discrimination can be harmful to ones financial situation and physical and psychological wellbeing, which hinders the ability to foster positive interpersonal relationships. Weight stigmatization also occurs within close interpersonal relationships, including those with friends and family members. The most reported experiences by individuals with overweight or obesity have been negative verbal comments from family members, friends, and romantic partners (Cossrow et al., 2001; Vartanian et al., 2014). In addition, other research shows that individuals with overweight and obesity experience verbal harassment while exercising and going out in public, a lack of dating opportunities, and mistreatment from friends (Cossrow et al., 2001). Taken together, these situations may make it difficult for an individual INTERNALIZED WEIGHT STIGMA ON THE PERCEPTION OF OTHERS 7 with overweight or obesity to maintain interpersonal relationships, seek medical help, or incorporate exercise into their daily routine. An additional form of weight discrimination is the desire for social distance from an individual who is overweight or obese. Social distance can occur either through direct actions of rejection, shunning, or avoidance of the target and can occur when individuals deviate from societal norms (Crandall, 1994; Link & Phelan, 2001; Maddox et al., 1968). Most research regarding social distance has been examined within the context of mental illnesses. However, recent research has expanded this literature to individuals with overweight and obesity (Angermeyer et al., 2004; Vartanian et al., 2015). People with obesity frequently find themselves distanced from or avoided by others in public situations. For example, one study found that viewing targets with obesity were associated with more negative attitudes, negative stereotypes, and a greater desire for social distance from the target (Vartanian et al., 2015). Another study found that as the weight of female adolescents increased, the more they reported that their peers did not hang out with them, ignored them, and would not sit with them at lunch or in class (Pearce et al., 2002). Due to experiencing discrimination across many domains, an individual with overweight or obesity is likely to face increased distress and internalize their negative weight-based experiences. Internalized Weight Stigma Internalized weight stigma is the degree to which one endorses weight-based negative stereotypes and attributes them to themselves. It occurs because of an individuals experience with weight discrimination and their perceptions of stereotypes about people with overweight and obesity (Ratcliffe & Ellison, 2013). Ratcliffe and Ellison (2013) suggest that weight stigma becomes internalized in several ways. First, negative external judgments become internalized INTERNALIZED WEIGHT STIGMA ON THE PERCEPTION OF OTHERS 8 through a process of self-judgment. This self-judgment then influences how the individual interacts with other individuals and their environment. More specifically, individuals with overweight and obesity draw from real-life experiences to make predictions about how others view them, which influences how they view themselves. This relationship between external devaluation and internal evaluation can become self-perpetuating (Ratcliffe & Ellison, 2013). Second, internalized weight stigma is also influenced by attentional processing, or the way in which individuals recall stigmatizing experiences. A field perspective involves recalling an event through ones own eyes, whereas an observer perspective involves recalling an event from the perspective of a spectator (Ratcliff & Ellison, 2013). If an individual recalls a stigmatizing event from an observer perspective, it has a more negative impact on psychological well-being than using a field perspective (Lau et al., 2009). The tendency to recall adverse events from an observer perspective may prolong its negative effects and maintain anxiety about past social events where an individual felt excluded from society or a group (Lau et al., 2009). Internalized weight stigmatization is often associated with higher levels of depression and anxiety (Durso & Latner, 2008). Moreover, internalized weight stigma and its association with anxiety can lead to avoidance of activities associated with daily functioning, including feeling afraid to travel, uneasiness in crowds, and feeling self-conscious with others (Friedman et al., 2008). As an individual with overweight or obesity chooses to avoid these situations, the opportunity to obtain evidence that disconfirms their belief about others opinions of themselves reduces. This serves to perpetuate their negative self-perception and how they believe others view them. Finally, it is likely that negative mood and low self-esteem, which result from experiences of weight stigma, can increase the likelihood that negative attitudes become INTERNALIZED WEIGHT STIGMA ON THE PERCEPTION OF OTHERS 9 internalized (Ratcliffe & Ellison, 2013). The psychological distress induced by weight stigma forces individuals to adopt coping mechanisms to react to these stressors. Encountering negative comments or assumptions from others is associated with increased negative self-talk, which can maintain low self-esteem and body dissatisfaction (Puhl & Brownell, 2006; Puhl & Heuer, 2010; Rodriguez et al., 2016). Further, the more frequently one internalizes weight stigma, the greater ones body image concern, body shame, depression, anxiety, and stress (Durso & Latner, 2008). Individuals who have internalized weight stigma may also hold strong beliefs about and attach a disproportionate amount of importance to their weight (Ratcliff & Ellison, 2013). This extreme focus on weight leads them to disregard their positive attributes, which perpetuates negative selfevaluation. Internalized weight stigma also impacts general health and eating behaviors. Higher levels of internalized weight stigma have been found to be associated with severe eating disturbances (Durso & Latner, 2008; Latner et al., 2013). In general, humans tend to increase their food intake, particularly of high fat and high sugar foods often labeled as comfort foods when exposed to stress (Epel et al., 2001; Adam & Epel, 2007). Although these episodes of overeating might initially ameliorate negative emotions, they have also been shown to elicit feelings of shame, perpetuating cortisol release and leading to excess weight gain (Tomiyama, 2014). This shows that obesity itself is a significant factor in predisposing and maintaining internalized weight stigma in both men and women (Ratcliffe & Ellison, 2013). Although men and women of all weight categories experience internalized weight stigma, research suggests that the experience of internalized weight stigma may be different for men and women (Himmelstein et al., 2019; Puhl et al., 2017). Moreover, research shows that internalized weight stigma increases as BMI increases (Puhl et al., 2017; Ratcliffe & Ellison, 2013) but that INTERNALIZED WEIGHT STIGMA ON THE PERCEPTION OF OTHERS 10 women are more likely to internalize weight stigma and have more psychological impairment in comparison to men (Boswell & White, 2015; Puhl et al., 2017). For example, one study found that women who are overweight tend to report that they feel less attractive than other people because of their weight, and heavier women did not believe they were up to the standard of what their current partner wanted in an ideal relationship (Boyes and Latner, 2009). Taken together, these results suggest that internalizing weight stigma affects an individuals life in numerous ways including behaviorally, emotionally, and psychologically. Less attention, however, focuses on how ones internalized weight stigma may influence their feelings about others with overweight and obesity. However, frequent stigmatization from others that becomes internalized can lead individuals with obesity to hold prejudices and weightbased stereotypes (Ratcliffe & Ellison, 2013). Further, individuals with internalized weight stigma may use downward social comparisons to protect their self-esteem, increasing antifat attitudes toward others (Lew et al., 2007; OBrien et al., 2007). Additionally, the lack of ingroup preference for individuals with overweight or obesity might lead them to hold more negative attitudes about others in the same BMI category (Durso & Latner, 2008; Latner et al., 2013). Therefore, just as internalized weight stigma influences ones negative attitudes about themselves (Durso & Latner, 2008), it may also influence their negative feelings toward others with overweight and obesity. Social Comparisons Internalized weight stigma may influence how individuals perceive others with overweight and obesity through social comparisons. In fact, viewing idealized media, such as images of fashion models, induces social comparisons which becomes a stable way individuals compare themselves to others (Betz et al., 2019). Social comparison theory suggests that INTERNALIZED WEIGHT STIGMA ON THE PERCEPTION OF OTHERS 11 individuals will instinctively engage in upward and downward social comparisons to determine their own worth and value (Festinger, 1954). When individuals compare themselves to others who are superior to them on one dimension, they make an upward social comparison. In contrast, when individuals compare themselves to others who are inferior to them in one dimension, they make a downward social comparison. Research has shown that upward social comparisons typically increase negative self-evaluation, which decreases both body satisfaction and selfesteem (Lew et al., 2007). In contrast to upward social comparisons, downward social comparisons tend to increase positive self-evaluation and increase body satisfaction and self-esteem (Lew et al., 2007). Downward social comparisons can be critical for individuals with internalized weight stigma to reduce their negative emotions and attitudes they hold toward themselves (OBrien et al., 2007). When one uses a downward social comparison to regulate their internalized weight stigma, they might compare themselves to someone with a higher BMI and attribute negative stereotypes to the target. Engaging in downward social comparisons instead of upward comparisons can regulate womens body and weight satisfaction, anxiety about ones appearance, the desire to lose weight, and increase positive self-evaluation (Lew et al., 2007). For example, Brown et al. (1992) found that female college students perceived themselves as more attractive when they were asked to compare themselves to an image of an unattractive woman than when they had to compare themselves to an attractive woman. By comparing oneself to someone who is seen as physically inferior because of their weight, an individual is likely to increase their self-esteem but might develop and enhance negative cognitions and feelings about individuals with overweight and obesity in general. Over time, this process builds stronger implicit associations between those with overweight or obesity INTERNALIZED WEIGHT STIGMA ON THE PERCEPTION OF OTHERS 12 and negative attributes, such as greater dislike for those with higher BMIs and greater belief that these individuals lack willpower and self-control (OBrien et al., 2007). Choosing to use a downward social comparison instead of an upward comparison technique can counterbalance a self-image threat by generating a positive experience in the place of a negative one (Lew et al., 2007). This strategy allows the individual to focus on positive aspects of the self rather than negative ones to maintain self-esteem when they experience internalized weight stigma. However, downward social comparisons are to the detriment of others, which can increase antifat attitudes and negative stereotypes about those with higher BMIs. In sum, those who experience internalized weight stigma may be more prone to using downward social comparisons to make themselves feel better, which may further exacerbate negative attitudes toward others. Ingroup/Outgroup Bias Ones own internalized weight stigma may also negatively affect individuals perceptions of overweight and obesity due to ingroup/outgroup biases. Individuals with marginalized social identities such as race, gender, and ethnicity typically have a strong sense of identification with their ingroup and show a preference for others perceived to be in the same social group (ingroup) versus those from another group in which they do not belong (outgroup) (Lam & Seaton, 2016). When one has a strong sense of belonging, members of these stigmatized groups are more likely to be motivated to reject the stereotype corresponding to their group (Devine, 1989). Most of the time, affiliation with a specific group is central to an individuals self-concept and self-esteem, and they identify strongly with their social identities (Tajfel, 1978). In addition, research has found that ingroup bias is related to increased trust, group cohesion, cooperation, and increased loyalty, pride, and commitment to the ingroup (Dunne, 2018). However, individuals with INTERNALIZED WEIGHT STIGMA ON THE PERCEPTION OF OTHERS 13 overweight typically do not have a strong sense of identification with their ingroup (Puhl & Heuer, 2010; Schwartz et al., 2006). One reason for this may be that, unlike other social identities, such as race or gender, individuals with overweight typically wish that they were not categorized as overweight, and instead, seek to escape it (Major et al., 2012; Puhl & Heuer, 2010). Another reason for the lack of ingroup bias among those with higher BMIs is that as overweight and obesity have become more common in the United States, individuals may perceive being overweight as the new normal. This anchoring effect occurs because individuals use the weight of others to decide what resembles normal weight and only view people above this threshold as overweight (Robinson & Kirkham, 2013). Indeed, a considerable amount of people with overweight and obesity misjudge their weight and believe that they are a healthier weight than they truly are (Robinson & Kirkham, 2013). For example, only one in five adult Americans would be classified as obese based on self-reported weight, yet more than one in four based on objectively measured weight (Sturm, 2003). Individuals with overweight might hold negative attitudes toward themselves and others with overweight or obesity because of both experienced and internalized weight stigma, which contributes to the lack of cohesion within their ingroup (Essien et al., 2020; Wang et al., 2004). It is known that when one is a member of a stigmatized group, they are often the object of ridicule or negative stereotypes, which can further negatively impact self-esteem (Ratcliffe & Ellison, 2015). Since, unlike other social identities, those with overweight or obesity are usually blamed for their weight status, they may be more likely to internalize these beliefs about themselves and others in the same weight category, leading to outgroup preference (Meadows & Calogero, 2018; Rudman et al., 2002). When one has internalized weight stigma, they endorse the negative INTERNALIZED WEIGHT STIGMA ON THE PERCEPTION OF OTHERS 14 stereotypes, and believe them to be true (Durso et al., 2011), which may attribute to the lack of ingroup preference seen in those with overweight and obesity (Rudman et al., 2002). In turn, these negative beliefs about themselves may become externalized and lead individuals to adopt antifat attitudes toward others with overweight and obesity, as those with internalized weight stigma may perceive others in their ingroup as negatively as they view themselves. Indeed, weight biases are prevalent in individuals with normal weight and overweight. Research shows that individuals with overweight do not tend to hold more favorable attitudes toward others with overweight or obesity and tend to report similar levels of antifat attitudes toward individuals who are overweight (Durso & Latner, 2008; Latner et al., 2013; Teachman et al., 2003). For example, a study by Rudman et al. (2002) showed that participants who were overweight held negative associations about others with overweight, and participants with the highest BMIs showed the least automatic preference for their group. Moreover, participants who were overweight also favored those with normal weight over those with overweight or obesity. In contrast, other stigmatized groups, such as individuals who were Jewish or Asian, showed more automatic ingroup bias (Rudman et al., 2002). Another study found similar results by randomly assigning participants to appear obese by wearing a fat suit or normal weight by wearing regular clothes and then instructed them to walk across a college campus. They found that participants who wore the fat suit reported more antifat attitudes than the control group, further exemplifying that individuals with overweight and obesity hold antifat attitudes (Incollingo Rodriguez et al., 2016). However, a study recently found that individuals with higher BMIs may have higher levels of sympathy toward others with obesity and, in turn, have a lower desire for social distance and fewer antifat attitudes (Sikorski et al., 2015). Other studies have also found similar INTERNALIZED WEIGHT STIGMA ON THE PERCEPTION OF OTHERS 15 results that BMI may be inversely related to implicit antifat attitudes. For example, individuals with higher BMI were found to display lower levels of implicit antifat attitudes in comparison to those with lower BMI; however, the level of explicit and implicit antifat attitudes was relatively high regardless of weight class (OBrien et al., 2007). Interestingly, this article looked at the role of physical appearance comparisons on implicit antifat attitudes and found that the more one makes appearance-related comparisons, the higher their implicit antifat attitudes. This could explain why the article found that BMI was inversely related to implicit antifat attitudes as those with overweight and obesity may be more likely to use downward comparisons to maintain selfesteem. It is also important to note that these studies examined how experienced, rather than internalized, weight stigma was related to social distance and antifat attitudes. Internalized weight stigma is associated with an increase in shame and negative attitudes toward the self, and therefore could become externalized when judging others (Durso & Latner, 2008; Ratcliffe & Ellison, 2013). Further, the more frequently one internalizes weight stigma, the greater their depression, anxiety, and stress (Durso & Latner, 2008), which all could affect the way they perceive others. Individuals also might experience higher levels of self-blame due to believing the stereotypes to be true by and might attribute this to other individuals with overweight which may lead to a decrease in empathy, and increase in antifat attitudes (Meadows & Calogero, 2018). There has also been research suggesting that the extent to which someone identifies as overweight or obese may explain their ingroup/outgroup preference. Phenotypic prototypicality refers to the degree to which an individuals appearance resembles a prototypic member of the group (Davies et al., 2016). Although this term is usually used to explore racial identities, it INTERNALIZED WEIGHT STIGMA ON THE PERCEPTION OF OTHERS 16 could have implications for weight class identification. For example, those who are overweight and have higher similarity to the overweight category may be more likely to identify with their ingroup. However, when someone is on the low end of the overweight category, they may show higher similarity to the normal weight category, identifying more strongly with this group, even if their BMI indicates they are classified as overweight. Essien, Otten, and Degner (2020) found that participants with overweight more strongly preferred individuals with normal weight relative to those with overweight, the lower their self-reported weight status. These higher levels of outgroup favoritism occurred partly because participants who reported being less typical for their group were also less likely to identify with that group fully. This could partially explain why some studies have found higher ingroup bias among those with higher BMIs since they are more likely to identify with their specific weight class. This lack of ingroup preference among individuals with overweight and obesity may perpetuate the stigma of obesity. Therefore, outgroup members may be more persuasive in continuing these negative stereotypes and antifat attitudes. Taken together, experiencing weight discrimination and stereotypes can lead an individual to internalize these beliefs about themselves. This internalization of cultural standards may contribute to the negative evaluation of others with obesity (Klaczynski et al., 2004). While internalized weight stigma may negatively influence ones attitudes toward themselves, it may also influence their beliefs about others with overweight and obesity. The use of downward social comparisons may be used to maintain self-esteem and body satisfaction after experiencing internalized weight stigma. However, it may also increase stereotypes and antifat attitudes about others who are overweight or obese (OBrien et al., 2007). Furthermore, the lack of ingroup bias seen in individuals with overweight and obesity further enhances these antifat attitudes and may INTERNALIZED WEIGHT STIGMA ON THE PERCEPTION OF OTHERS 17 influence how individuals perceive others with overweight or obesity. It is known that internalized weight stigma affects how individuals perceive themselves (Boyes & Latner 2009; Durso & Latner, 2008; Latner et al., 2013); however, there is little research on how it affects the perceptions of others. The Present Study The present study will use a vignette paradigm to examine how activating participants feelings of internalized weight stigma influence their perceptions, attitudes, and behaviors toward individuals with normal weight, overweight, obesity, and severe obesity. A wealth of research has examined how experiences of weight stigma affect an individuals perception of themselves, along with their own physical and psychological well-being (Giel et al., 2012, Puhl & Heuer, 2010; Diedrichs & Barlow, 2011). Research has also examined the stereotypes that people hold towards individuals with overweight and obesity (Major et al., 2012; Puhl & Brownell, 2006; Puhl & Heuer, 2010; Smith et al., 2007). However, a paucity of research has examined how an individuals own internalized weight stigma may influence the stereotypes they have towards individuals with overweight, obesity, and severe obesity. Understanding how ones own internalized weight stigma may influence how individuals perceive others may provide potential avenues to decrease weight stigma and antifat attitudes. It is hypothesized that there will be a main effect of the targets BMI, such that the participants stereotypes, attitudes, and behaviors toward a female vignette target will become more negative as the BMI of the woman in the vignette increases. Specifically, compared to a vignette target with normal weight, participants will have more antifat attitudes towards, make more downward social comparisons about, and desire more social distance from the vignette targets who have overweight, obesity, or severe obesity. Secondly, it is hypothesized that there INTERNALIZED WEIGHT STIGMA ON THE PERCEPTION OF OTHERS 18 will be a main effect of internalized weight stigma. Compared to individuals who write about a neutral topic, participants who write about their own internalized weight stigma will have more antifat attitudes towards, make more downward social comparisons about, and desire more social distance from the vignette target, regardless of the BMI of the vignette. Finally, it is hypothesized that there will be an interaction between participants internalized weight stigma and the BMI of the target. Specifically, it is expected that activating participants internalized weight stigma will exacerbate the negative ratings of participants as the BMI of the target increases. INTERNALIZED WEIGHT STIGMA ON THE PERCEPTION OF OTHERS 19 Method Participants Participants were a convenience sample recruited from SONA, the undergraduate research subject pool at the University of Indianapolis. To be eligible for this study, participants must have been over the age of 18 and been able to read and respond to an online questionnaire in English. Further, only women were eligible to participate in this study as research has found that both actual and internalized weight stigma may be experienced differently for women and men (Azarbad & Gonder-Frederick, 2010; Himmelstein et al., 2018; Purton et al., 2019). Individuals who were pregnant or had ever been diagnosed with an eating disorder were excluded from this study. All study procedures were approved by the Human Research Protections Program at the University of Indianapolis, and participants were treated in accordance with APA ethical principles. The total number of participants in this study was 193. However, 37 participants were removed because 1) they did not answer the attention check question correctly (n = 17) or 2) they did not answer the comprehension question correctly (n = 20). Thus, the final sample size for this study was 156. Procedure Prior to beginning the study, individuals completed a set of questions screening them for eligibility using the SONA prescreen feature. Only eligible individuals had the option to sign up for the study. Eligible individuals who were interested in participating in the study followed a hyperlink to an online survey powered by Qualtrics. Upon starting the study, the individual was asked to read an online informed consent document that described their rights as a participant. Individuals were not allowed to advance to the next screen unless they consented to participate in INTERNALIZED WEIGHT STIGMA ON THE PERCEPTION OF OTHERS 20 the study. Any individual who did not consent to participate was directed to the end of the survey and thanked for their time. After the informed consent process, participants were randomly assigned to one of two writing conditions. Participants in both groups were asked to complete three brief writing prompts for three minutes each, rather than being asked to write about one prompt for several minutes. Participants in the experimental group were asked to engage in three writing prompts designed to make them think about their own existing internalized weight stigma. Participants in the control condition were asked to engage in three neutral writing prompts. After completing the writing prompts, all participants completed a manipulation check and then were randomly assigned to one of four vignette conditions with a picture and description of a fictional woman named Emily who was 1) normal weight, 2) overweight, 3) obese, or 4) severely obese. Participants were not able to proceed to the next screen until 60 seconds had elapsed to ensure they read the entire vignette. After reading the vignette, participants completed a questionnaire containing a series of measures assessing their demographics and feelings about the woman depicted in the vignette. In addition, participants were asked to answer comprehension and attention check questions to ensure that they read the vignettes and engaged in the study. Any participants who did not correctly answer the comprehension or attention check questions were excluded from the analyses. After completing the survey, participants were thanked for their participation and given credit in SONA. Measures A copy of all measures, vignettes, and writing prompts that were used in this study can be found in Appendix B, C, and D, respectively. INTERNALIZED WEIGHT STIGMA ON THE PERCEPTION OF OTHERS 21 Writing Prompts Participants in the experimental group were asked to spend three minutes responding to writing prompts designed to make them reflect on their own internalized weight stigma. These writing prompts were derived from the control condition of the Neff et al. (2020) selfcompassion mindstate induction. First, the participant was asked to think about a particular situation in which they felt self-conscious about their weight or body image for one minute. The participant was also reminded that their responses were completely anonymous, that their writing was confidential, and not to worry about spelling, sentence structure, or grammar. Next, they were given three writing prompts and asked to write for three minutes total. They were told that if they finished before the time was up, they should go back and elaborate on the details of what they already wrote. The following writing prompts were provided for the experimental group: 1) Please write about what exactly is occurring in this situation regarding your weight or body image. Try to be as descriptive as possible. 2) Please write about who is involved in the situation if it involves more than just you. Please describe the people involved with as much detail as possible, even if you are the only one (in this case, describe yourself). 3) Please write any words that have been spoken in the situation, either what you have said to yourself, what other people have said to you, or what you have said to other people. Please use as much detail as possible. Participants in the control condition were prompted to respond to three neutral writing prompts in relation to their schedule on a normal day. The three neutral writing prompts were displayed in the same manner as the experimental writing prompts. Participants were asked to think about a typical day in their life for one minute before the writing prompts appeared on the next page. The following writing prompts were provided for the control group: 1) Please write about your morning routine. What do you do when you first wake up in the morning? Describe INTERNALIZED WEIGHT STIGMA ON THE PERCEPTION OF OTHERS 22 your activities in as much detail as possible. 2) Please write about your afternoon routine. What do you do during the middle of the day? Describe your activities in as much detail as possible. 3) Please write about your evening routine. What do you do at nighttime? Describe your activities in as much detail as possible. Vignettes Participants were randomly assigned to one of four vignette conditions. Each vignette contained information about a woman in her 20s named Emily, who just moved to Indianapolis and was looking for new friends. The vignette included her height, weight, BMI, age, location, occupation, and a list of hobbies. The vignettes were identical except for one factor, namely Emilys weight/ BMI. Weight and BMI were manipulated in each vignette to represent four different weight statuses: normal weight (BMI = 21.5), overweight (BMI = 26.9), obesity (BMI = 34.3), and severe obesity (BMI = 46.9). In addition, an avatar of Emily was provided with each case. Before displaying the vignette, the participants were told that Emily created an avatar to accurately represent herself. The same avatar was used in each photograph to control for variation of attractiveness and physical features, and body shape and weight were manipulated using a photoshop application. In developing the four vignettes, careful consideration was made to maximize internal, external, and construct validity (Evans et al., 2015). Specifically, the vignettes were no longer than 500 words and followed a narrative, story-like progression. Each vignette followed a similar structure, utilized uniform language and identifying information, and maintained neutrality concerning sociocultural variables. Comprehension and Attention Check Participants were asked to answer a comprehension and attention check question regarding the vignette. The comprehension question was intended to ensure the participant read INTERNALIZED WEIGHT STIGMA ON THE PERCEPTION OF OTHERS 23 and understood the vignette they were presented with. Specifically, after reading the vignette, participants were asked, What did Emilys mom teach her how to do when she was a kid? a) play sports, b) cook and bake, c) play the guitar, or d) dance. Any participant who did not correctly answer this question (e.g., cook) was excluded from the analyses. In addition, an attention check question was added to the Modified Weight Bias Internalization Scale to determine if participants were attentive and engaged in responding to the questionnaire. This question asked participants to select five as the response option. Any participant who did not select the correct response to this attention check was excluded from the analyses. Manipulation Check To evaluate the effectiveness of the writing prompt on activating internalized weight stigma, participants completed the Modified Weight Bias Internalization Scale (WBIS-M; Pearl & Puhl, 2014) immediately after they completed the writing prompts. The WBIS-M consists of 11 items based on the original Weight Bias Internalization Scale (Durso & Latner, 2008). However, the WBIS-M was developed to assess internalized weight stigma across all weight categories instead of in individuals with overweight and obesity. Responses were rated on a 7point Likert scale ranging from 1 (strongly disagree) to 7 (strongly agree). Item responses were averaged to produce a mean score, with higher scores indicating higher internalized weight stigma. WBIS-M has high internal consistency and strong construct validity (Pearl & Puhl, 2014). In the present study, the mean amount of internalized weight stigma was 3.31 (SD = 1.5, range = 1.00-6.91, = 0.95). INTERNALIZED WEIGHT STIGMA ON THE PERCEPTION OF OTHERS 24 Social Distance Social distance was measured using a modified version of the Bogardus Social Distance Scale (Bogardus, 1925) and an online social distance task. The Social Distance Scale measured participants attitudes towards being in a social situation with the vignette target using items adapted from the Bogardus Social Distance Scale. Although first designed to measure prejudice against different races, the items used in this scale are generalized and can therefore be applied to any social group (Wark & Galliher, 2007). The wording of each item was altered slightly to reflect the context of the present study by using the name Emily in place of group member. Example items from this measure include: How would you feel about renting a room in your home to someone like Emily? and How about as a worker on the same job as someone like Emily? Each of the items was rated on a 4-point Likert scale ranging from 0 (definitely willing) to 3 (definitely not willing). Since two of the items ask the participant to think about their feelings about having their child marry or be babysat by Emily, the sentence If you dont actually have children currently, think about future children was added to these questions to make them relevant to college-aged students. Participants responses were summed to produce a total score ranging from 0 to 21, with higher scores indicating higher desired social distance. The scale has high internal consistency reliability and good convergent and construct validity (Johnstone & Grant, 2019). The mean social distance reported in the present study was 2.10 (SD = 2.9, range = 0-12, = 0.92). In addition to the Bogardus Social Distance Scale, participants completed an online Seating Distance Task (Macrae et al., 1994). Historically, the seating task has been done in person instead of online. Participants enter a room where another participant who is really a confederate is already seated. The participants are simply asked to choose a seat, and social INTERNALIZED WEIGHT STIGMA ON THE PERCEPTION OF OTHERS 25 distance is determined by how far the participant chooses to sit from the target. Recent research has found that an online version of the seating distance task is also effective at measuring desired physical distance from a target (e.g., Vartanian, 2015). In the online task, participants were shown an image of a rectangular table with seven seats, with the seat that the target is sitting in marked. The participants then had to decide which seat they would like to take for themselves. The seat in which the participant chose for themselves was coded as follows: one seat away from the target was coded as 1; two seats away from the target was coded as 2; and three seats away from the target was coded as 3. Higher scores reflect a greater desire for social distance (Vartanian, 2015). The mean social distance reported on this task in the present study was 1.40 (SD = 0.61, range = 1-3). Antifat Attitudes The short form of the Fat Phobia Scale (FPS; Bacon et al., 2001) was used to measure antifat attitudes toward the target vignette. The FPS is a 14-item measure scored on a five-point semantic differential scale. Each item contains two adjectives to describe fat people that are bipolar opposites (e.g., secure, insecure). The adjectives are measured on a scale from 1 to 5. For the present study, the directions were changed from asking participants to describe fat people to asking them to describe the target, Emily. Item responses were averaged to produce a mean score, with higher scores reflecting higher antifat attitudes about Emily. The Fat Phobia Scale short form demonstrates excellent reliability, construct and concurrent validity, and correlates highly with the original 50-item Fat Phobia Scale (Bacon et al., 2001; Yuker et al., 1995). The mean amount of antifat attitudes reported in the present study was 32.05 (SD = 5.6, range = 16-53, = 0.79). INTERNALIZED WEIGHT STIGMA ON THE PERCEPTION OF OTHERS 26 Social Comparisons The Social Comparison Scale (Allan & Gilbert, 1995) was used to measure participants self-perception of social rank and relative social standing. This scale examined participants judgments concerned with rank, attractiveness, and how well participants thought they fit in with others in society. One modification was made to the instructions of the scale. Specifically, instead of comparing themselves to other people in general, the prompt was altered so the participants make comparisons of themselves in relation to Emily. Participants rated themselves along a ten-point scale for each of the 11 items from 1 (inferior) to 10 (superior) in comparison to Emily. For example, a rating of three would mean the participant saw themselves as inferior to Emily, a rating of five (in the middle) indicates they are about equal, and a rating of 7 indicates they believe they are somewhat superior to Emily. Items were summed to create a total scale score, with high scores representing superiority, or greater use of downward social comparisons. This scale has been found to have good reliability with Cronbach alphas of 0.91 and 0.90 with student populations (Allan & Gilbert, 1995). The mean amount of social comparison reported in the present study was 62.09 (SD = 14.5, range = 11-103, = 0.89). Demographics Participants completed questions regarding demographic characteristics, including their age, gender, race/ethnicity, self-reported height (inches), and self-reported weight (pounds) to determine BMI. Participants also selected their perceived weight status by responding to a multiple-choice question with answers ranging from 1 (very thin) to 5 (very heavy). INTERNALIZED WEIGHT STIGMA ON THE PERCEPTION OF OTHERS 27 Analysis Plan Power analysis An a priori power analysis using G*Power 3.1 was conducted to determine how many participants were needed for a 2 x 4 between-subjects design to be fully powered to detect significant results if significant results are present. It was determined that a minimum sample of 237 was required to achieve a 0.80 power level when anticipating a medium effect size and using p < 0.05 levels of significance (Faul et al., 2007). Using the current sample size of 156, it was determined that the actual power to detect a medium effect size was 0.65, and the power to detect a large effect was 0.98. Thus, the current study was slightly underpowered to detect small or medium effects, but the sample size was sufficient to detect a large effect. However, the study would likely benefit from a larger sample size, as most effect sizes in behavioral science research fall between small and medium (Schfer & Schwarz, 2019). Preliminary Analyses Participants responses to the internalized weight stigma writing prompt were analyzed using the Linguistic Inquiry and Word Count (LIWC) program as another manipulation check to ensure that participants engaged in the writing prompt and wrote about a topic related to weight stigmatization. The LIWC dictionary is composed of over 12,000 words and phrases divided into categories to assess various psychosocial constructs (Boyd et al., 2022). LIWC is the gold standard in software for analyzing word use that works by counting words in a text and calculating the percentage of words in the given text that fall into a specific category (Boyd et al., 2022). This analysis used to ensure that participants engaged in the writing prompt and wrote about a topic related to weight stigmatization. INTERNALIZED WEIGHT STIGMA ON THE PERCEPTION OF OTHERS 28 Main Analyses To test the hypotheses, a between-subjects 2x4 factorial ANOVA (i.e., two-way ANOVA) was conducted. A factorial ANOVA is an extension of the one-way ANOVA that allows for the examination of two independent variables on a continuous dependent variable. A factorial ANOVA was the best test for the proposed hypotheses because it allows for the examination of both main and interaction effects (Field, 2013). The main effect is the effect of one independent variable on the dependent variable while ignoring the effect(s) of all other independent variables. Because this study includes two independent variables, it has the potential to have two main effects. In contrast to the main effect, an interaction effect occurs when the effect of one independent variable on the dependent variable changes as a result of different levels of another independent variable (Field, 2013). Using a factorial ANOVA to analyze these data assessed if there is an interaction effect between internalized weight stigma and the BMI of the target in the vignette on the dependent variables. INTERNALIZED WEIGHT STIGMA ON THE PERCEPTION OF OTHERS 29 Results Participant Characteristics Efforts were made to recruit a diverse sample; however, the population of the University of Indianapolis is 65.3% White, with 25% of the enrollment from international students and students of color. Table 1 presents the demographic characteristics of the participants (N = 156) in the current study. Participants average age was 20.10 (SD = 3.8, range = 18-57). The majority of the participants in this sample identified as non-Hispanic (87.8%). Most of the participants in this study identified their race as White (75%) followed by Black (12.8%), Asian (4.5%), Biracial/Multiracial (2.6%), and American Indian/Alaska Native (1.3%). Several participants preferred not to answer (1.2%) or chose other for their race (2.6%). Participants BMI was calculated using the self-reported height and weight provided by participants. The average BMI was 25.99 (SD = 7.15, range = 15.35-54.86). Most of the participants BMI fell in the normal weight category (53.2%), followed by overweight (17.3%), obese (12.2%), severely obese (11.5%), and underweight (5.8%). Participants average perceived body size was 3.01 (SD = 0.81, range = 1 (very thin) to 5 (very heavy)). Manipulation Check Quantitative Analysis of Manipulation An independent samples t-test was conducted to compare the average internalized weight stigma reported by participants in the internalized weight stigma writing condition (n = 83) to the average internalized weight stigma reported by those in the neutral writing condition (n = 73). Levenes test for equality of variances was non-significant, thus equal variances can be assumed. The t-test was statistically significant, with the internalized weight stigma writing condition group (M = 3.64, SD = 1.5) reporting higher internalized weight stigma than the neutral writing INTERNALIZED WEIGHT STIGMA ON THE PERCEPTION OF OTHERS 30 condition (M = 2.93, SD = 1.5), t(154) = -2.98, p = 0.003, 95% CI [-1.18, -0.24], d = 0.48. These results suggest that the writing condition was effective at inducing feelings of internalized weight stigma. Table 1 Participant Demographics N % 19 137 12.2 87.8 117 20 2 7 4 2 4 75.0 12.8 1.3 4.5 2.6 1.2 2.6 8 83 27 19 18 5.2 53.2 17.3 12.2 11.5 M SD Age 20.12 3.81 BMI 25.99 7.12 Perceived Weight Status 3.01 0.81 Ethnic Background Hispanic or Latino Not Hispanic or Latino Race White Black or African American American Indian or Alaska Native Asian Biracial/Multiracial Prefer not to answer Other BMI Category Underweight Normal Weight Overweight Obese Severely Obese INTERNALIZED WEIGHT STIGMA ON THE PERCEPTION OF OTHERS 31 Qualitative Analysis of Manipulation The Linguistic Inquiry and Word Count (LIWC) software was used to analyze word use on participants responses to the internalized weight stigma and neutral writing prompts to ensure that participants appropriately interacted with the writing prompts. Those who wrote about experiences with internalized weight stigma used a higher percentage of emotion and weight-related terms (0.22%; 2.37%) in comparison to those who were in the neutral writing prompt group (0.00%; 0.08%). Further analysis showed that those in the internalized weight stigma group used a higher percentage of words related to happiness (0.13%) than sadness (0.07%) in comparison to the neutral writing group (0.00%, 0.00%). Preliminary Data Analyses Assumptions Before conducting the analyses, the data were examined to assess the assumptions associated with a factorial ANOVA. All of the dependent variables were measured on a continuous level, both independent variables consisted of two or more categories, there was an independence of observations, and no significant outliers were observed in the data. Two of the dependent variables, antifat attitudes and social comparison, were normally distributed. However, both scales measuring social distance were positively skewed. The skewness of the social distance scale was found to be 1.34 and 1.27 for the seating distance task indicating that the distributions were right-skewed. Because the skewness was relatively low, the variables were not transformed (Field, 2013). Levenes test was used to evaluate the assumption of homogeneity of variance for all variables. None of the Levenes tests were significant, indicating that the assumption of homogeneity of variance was not violated. Finally, multicollinearity was not INTERNALIZED WEIGHT STIGMA ON THE PERCEPTION OF OTHERS 32 violated as the two independent variables, vignette condition and writing condition, are theoretically not correlated with one another. Main and Interactive Effects of Vignette and Writing Condition Social Distance Scale A between groups factorial analysis of variance (ANOVA) was used to investigate the effects of vignette and writing condition on social distance. As shown in Table 2, the ANOVA revealed a statistically significant main effect for the vignette condition F(3, 148) = 2.72, p = 0.047, p2 = 0.05. However, no significant main effects were found for the writing condition F(1, 148) = 3.51, p = 0.063, p2 = 0.02. Further, no significant interaction effect was found between vignette and writing condition F(3, 148) = 0.76, p = 0.517, p2 = 0.02. Pairwise comparisons revealed no significant difference in the social distance desired between participants in the overweight (M = 1.94, SE = 0.48, p = 0.818) and obese vignette conditions (M = 1.80, SE = 0.40, p = 0.818), and between participants in the overweight and severely obese vignette conditions (M = 1.70, SE = 0.47, p = 0.719). Further, there were no significant differences in the desired social distance for those participants in the obese condition and participants in the severely obese condition. However, contrary to what was predicted, participants in the normal weight vignette condition (M = 3.35, SE = 0.48, p = 0.039) desired more social distance from the target than participants in the overweight vignette condition. Similarly, participants in the normal weight vignette condition desired more social distance from the target than participants in the obesity and severe obesity conditions. INTERNALIZED WEIGHT STIGMA ON THE PERCEPTION OF OTHERS 33 Table 2 The Main and Interaction Effects on Social Distance Scale M(SE) Vignette Condition Normal Weight Overweight Obese Severely Obese Writing Condition Control IWS Vignette x Writing Condition Control Normal Weight Overweight Obese Severely Obese IWS Normal Weight Overweight Obese Severely Obese F 2.72 Partial Eta Squared 0.52 p 0.047 3.35(0.48) 1.94(0.48) 1.80(0.40) 1.70(0.47) 3.51 0.23 0.063 0.76 0.015 0.517 2.63(0.33) 1.77(0.31) 3.60(0.72) 2.73(0.72) 2.52(0.59) 1.65(0.63) 3.10(0.63) 1.15(0.63) 1.07(0.54) 1.75(0.70) Social Distance Seating Task As shown in Table 3, no significant main effects were found for the vignette condition, F(3, 148) = 1.63, p = 0.185, p2 = 0.03) or writing condition, F(1,148) = 0.01, p = 0.931, p2 = 0.00 on the seating distance task. Further, no significant interaction effect was found between the vignette and the writing condition, F(3,148) = 0.61, p2 = 0.01. INTERNALIZED WEIGHT STIGMA ON THE PERCEPTION OF OTHERS 34 Table 3 The Main and Interaction Effects on Seating Distance Task M(SE) Vignette Condition Normal Weight Overweight Obese Severely Obese Writing Condition Control IWS Vignette x Writing Condition Control Normal Weight Overweight Obese Severely Obese IWS Normal Weight Overweight Obese Severely Obese F 1.63 Partial Eta Squared 0.03 p 0.185 1.56(0.10) 1.24(0.10) 1.42(0.09) 1.36(0.10) 0.01 0.00 0.931 0.61 0.02 0.607 1.40(0.07) 1.39(0.07) 1.47(0.16) 1.33(0.16) 1.39(0.13) 1.40(0.14) 1.65(0.14) 1.15(0.14) 1.44(0.12) 1.31(0.15) Antifat Attitudes As shown in Table 4, the ANOVA for antifat attitudes revealed a statistically significant main effect for the vignette condition, F(3, 148) = 3.72, p = 0.013, p2 = 0.07. However, results revealed no significant main effect for the writing condition, F(1, 148) = 1.45, p = 0.230, p2 = 0.01. Finally, there was no significant interaction between the vignette and writing conditions, F(3, 148) = 2.07, p = 0.107, p2 = 0.04. Post hoc analyses revealed that participants expressed fewer antifat attitudes toward the target in the normal weight vignette condition (M =29.63, SE = 0.92, p = 0.002) than participants INTERNALIZED WEIGHT STIGMA ON THE PERCEPTION OF OTHERS 35 in the obesity vignette condition (M = 33.39, SE = 0.77, p = 0.002). Similarly, participants in the normal weight vignette condition expressed fewer antifat attitudes toward the target than the participants in the severe obesity vignette condition (M =33.06, SE = 0.91, p = 0.009). However, participants in the normal weight condition did not differ in the amount of antifat attitudes expressed toward the target when compared to participants in the overweight vignette condition (M =31.90, SE = 0.92, p = 0.084). There were also no significant differences found in participants antifat attitudes toward the target in the overweight vignette and the obese vignette and between participants in the overweight vignette and the severely obese vignette. Finally, no significant effects were revealed for participants antifat attitudes toward the target in the obese vignette condition and the severely obese condition. INTERNALIZED WEIGHT STIGMA ON THE PERCEPTION OF OTHERS 36 Table 4 The Main and Interaction Effects on Antifat Attitudes M(SE) Vignette Condition Normal Weight Overweight Obese Severely Obese Writing Condition Control IWS Vignette x Writing Condition Control Normal Weight Overweight Obese Severely Obese F 3.72 Partial Eta Squared 0.07 p 0.013 29.63(0.92) 31.90(0.92) 33.39(0.77) 33.06(0.91) 1.45 0.01 0.230 2.07 0.04 0.107 32.53(0.64) 31.47(0.60) 29.07(1.4) 33.80(1.4) 34.74(1.1) 32.50(1.2) IWS Normal Weight Overweight Obese Severely Obese 30.20(1.2) 30.00(1.2) 32.04(1.0) 33.63(1.4) Social Comparison For the model examining social comparison, the ANOVA revealed a statistically significant main effect for the writing condition F(1, 148) = 5.61, p = 0.019, p2 = 0.04. However, there was no significant main effect for the vignette condition, F(3, 148) = 0.32, p = 0.808, p2 = 0.01. Additionally, the interaction effect between the vignette and writing condition was not significant F(3, 148) = 1.22, p = 0.305, p2 = 0.02. Contrary to what was predicted, post hoc analyses (Table 5) revealed that participants who wrote about a neutral topic made more INTERNALIZED WEIGHT STIGMA ON THE PERCEPTION OF OTHERS 37 downward social comparisons (M = 65.06, SE = 1.7, p = 0.019) than participants who wrote about their own internalized weight stigma (M = 59.50, SE = 1.6, p = 0.019). Table 5 The Main and Interaction Effects on Social Comparison M(SE) Vignette Condition Normal Weight Overweight Obese Severely Obese 64.17(2.5) 60.84(2.5) 62.32(2.0) 61.80(2.4) Writing Condition Control IWS 65.06(1.7) 59.50(1.6) Vignette x Writing Condition Control Normal Weight Overweight Obese Severely Obese IWS Normal Weight Overweight Obese Severely Obese F 0.32 Partial Eta Squared 0.01 p 0.808 5.61 0.04 0.019 1.09 0.02 0.354 0.33 0.01 0.801 70.53(3.7) 62.33(3.7) 62.78(3.0) 64.60(3.2) 57.80(3.2) 59.35(3.2) 61.85(2.8) 59.00(3.6) Covariates To assess for possible confounding relationships between the outcome variables and the participants BMI and perceived body size, bivariate correlations were conducted for each outcome variable. As shown in Table 6, bivariate correlation analyses revealed significant relationships between social comparison and BMI (r = -0.36, p < 0.001) and between social comparison and perceived weight status (r = -0.39, p < 0.001). There were no other significant INTERNALIZED WEIGHT STIGMA ON THE PERCEPTION OF OTHERS 38 relationships between participants BMI and perceived body size and social distance, antifat attitudes, and social comparison. Table 6 Correlations Between BMI and Dependent Variables Variables 1. 2. 3. 4. 5. BMI Social Distance Antifat Attitudes Social Comparison Perceived Body Size 1 2 3 4 5 -0.11 -0.14 -0.36 0.80 0.29 0.13 0.03 0.25 -0.10 -0.39 Main and Interactive Effects of Vignette and Writing Condition Including Covariates All analyses were repeated using BMI and perceived body size as covariates to examine how adding covariates changed the pattern of results. ANCOVAs were utilized to allow for the inclusion of covariates in the model. Because perceived body type and BMI were highly correlated (r = 0.80, p < 0.001), they were examined separately as covariates. When BMI was used as a covariate, there were no appreciable differences in the findings except for one. Specifically, the significance of the main effect of writing condition on social comparison was reduced to marginal significance F(1, 147) = 3.72, p = 0.056, p2 = 0.03. However, the mean level of downward social comparisons was still lower in the group who wrote about a weight stigmatizing experience (M = 60.01, SE = 1.5) compared to the group who wrote about a neutral experience (M = 64.32, SE = 1.6). When perceived body type was used as a covariate, there were no appreciable differences in the findings. INTERNALIZED WEIGHT STIGMA ON THE PERCEPTION OF OTHERS 39 Discussion This study used a vignette paradigm to examine how activating participants own internalized weight stigma influenced their perceptions of a target with differing weights. The results partially supported the first hypothesis that participants would express fewer antifat attitudes toward the vignette with normal weight than the vignette with obesity and severe obesity. However, contrary to what was predicted, participants desired more social distance from the target who was normal weight compared to the target who was shown as overweight, obese, or severely obese. Also, inconsistent with hypothesis two, participants who wrote about a neutral topic made more downward social comparisons than those who wrote about a weightstigmatizing situation. Furthermore, the findings did not support the hypothesis that the two independent variables, vignette condition (i.e., weight of target) and writing condition (neutral versus internalized weight stigma), would interact and exacerbate the negative ratings of the target. Main Effects of Vignette Condition on Antifat Attitudes, Social Distance, and Social Comparison Antifat Attitudes The findings from this study are consistent with previous literature, demonstrating that individuals express greater antifat attitudes towards others as their BMI increases (Boyes & Latner, 2009; Major et al., 2012; Puhl & Heuer, 2010; Smith et al., 2007). Since weight is often perceived as being within an individuals control, empathy for those with overweight and obesity tends to decrease, while antifat attitudes increase (Teachman et al., 2003). As such, believing that weight is controllable assumes that individuals with heavier weights lack the motivation to lose INTERNALIZED WEIGHT STIGMA ON THE PERCEPTION OF OTHERS 40 weight, making it easier to stereotype them (Frederick et al., 2020; Puhl & Heuer, 2010). These feelings may be exacerbated by the media as it depicts individuals with overweight and obesity in a stigmatizing way, while continuing to emphasize images of successful women who are thin and muscular (Alley & Scully, 1994; Kim & Willis, 2007; Heuer et al., 2011). However, the emphasis of thin images in the media starkly contrasts the increasing commonality of individuals in the United States who are overweight, which may lead to an increase in antifat attitudes towards individuals with normal and heavier weights. Interestingly, participants did not differ in their antifat attitudes toward the vignette targets with normal weight and overweight. One reason for this may be that according to the National Health and Nutrition Examination Survey (NHANES) 30.7% of the United States is now considered to be overweight and 42.4% have obesity (2021). By 2030, 81% of men and 75% of women are projected to be overweight or obese (Wang et al., 2020). Thus, individuals may perceive overweight as the new normal weight, only viewing people above this threshold as overweight or obese (Robinson & Kirkham, 2013). This anchoring effect may contribute to a lack of ingroup bias that is typically seen among those with higher BMIs as many people of higher weights believe they are healthier weights than they truly are (Robinson & Kirkham, 2013). Similarly, participants did not differ in the antifat attitudes toward the vignette targets who were overweight and obese and between the vignette targets who were obese and severely obese. A recent study found that individuals of higher BMIs may have higher levels of empathy or sympathy toward others with obesity, leading to fewer antifat attitudes and higher ingroup preference (Sikorski et al., 2015). Previous research has also found that individuals tend to poorly categorize people into correct BMI categories, which may have influenced the results INTERNALIZED WEIGHT STIGMA ON THE PERCEPTION OF OTHERS 41 (Easton et al., 2017; Robinson & Kirkham, 2013; Sturm, 2003). For example, one study found that only 6.1% of individuals with obesity and 41% of those who were overweight correctly identified themselves as such (Easton et al., 2017). There may not be much noticeable difference between individuals with normal weight or overweight, or between individuals with obesity and severe obesity. However, there is a much more noticeable difference between those with normal weight and obesity or severe obesity. Social Distance Inconsistent with previous literature, participants desired more social distance from the target in the vignette condition with normal weight than in the vignette with overweight, obesity, and severe obesity. This finding was surprising given that research typically finds that discrimination and the desire for social distance are positively related to BMI (Angermeyer et al., 2004; Carr & Friedman, 2005; Vartanian et al., 2015). One explanation for this could be that because participants experienced high levels of antifat attitudes toward the target with higher BMIs, feelings of empathy or pity were activated. Empathy may reduce prejudice toward stigmatized groups in multiple ways. For example, higher empathy levels may reduce blame attributed to others for their weight, increase outgroup evaluations, and decrease anxiety toward others (Batson & Ahmad, 2009; Galinsky & Ku, 2004; Pettigrew & Tropp, 2008). Therefore, even if participants viewed the target in the vignette as someone in an outgroup, they may have perceived them more positively than if they did not experience empathy. Individuals who are perceived as not being responsible for their weight or trying to be healthy, are more likely to elicit pity and less likely to provoke disgust than individuals who are seen as responsible for their weight, potentially reducing avoidance or social distance toward larger-bodied individuals (Beames et al., 2016; Black et al., 2014; Weiner, INTERNALIZED WEIGHT STIGMA ON THE PERCEPTION OF OTHERS 42 1996). As such, it would be important for future research to examine empathy and pity as potential mediators of the relationship between BMI, antifat attitudes, and social distance. It is also important to note that most of the participants in this study were undergraduate psychology majors, which may impact their behavioral intentions when presented with stigmatizing information. It is possible that due to their major, these students may have a better understanding of their own biases in making judgments. One study that examined empathy levels among students found that helping profession majors, such as psychology, showed statistically significant higher empathy than those students pursuing a degree in STEM, Economics, or Political Science (Olsen & Gebremariam, 2020). As such, the psychology students empathy levels may have impacted their stereotyping and discriminatory behavior. Participants in the overweight, obese, and severely obese conditions did not differ from each other in their desire for social distance. This was inconsistent with the first hypothesis that the desire for social distance would increase as BMI increased. It is likely that the nuanced differences between overweight, obese, and severely obese are not as noticeable as one may believe. These difficulties in differentiating between BMI categories may be due to the increasing number of individuals with overweight and obesity in the United States. For example, although a majority of individuals in the United States are overweight or obese, they tend to not accurately classify themselves into the correct BMI categories (Easton et al., 2017). One study also found that the highest prevalence of misperceived BMI categorization was among individuals in the overweight BMI category, in which 56% of participants fell in the overweight range, but only 38% of participants perceived themselves as overweight (Coulson et al., 2006). This study did not find a significant difference between the vignette group on the outcome measure of the seating distance task. It is interesting that these findings were not INTERNALIZED WEIGHT STIGMA ON THE PERCEPTION OF OTHERS 43 parallel to the findings for the social distance measure. Previous research has found that responses on the social distance measure are significantly correlated with responses on the seating distance task (Vartanian et al., 2015). However, in this study, the responses between them were not correlated (r = 0.16; p = 0.050), which questions the measures validity in this study. Furthermore, the participants may have been aware of what the seating distance task was measuring and chose to act in a way that was socially acceptable. Future research in this area may aim to include a measure of social desirability to determine its influence on participants responses. It is also possible that the inconsistent findings between vignette group on the social distance seating task might be explained by a mediator. For example, a study examined the role disgust plays in social distance and found that disgust mediated the relationship between a targets BMI and desire for social distance (Vartanian et al., 2015). Also, disgust and contempt have been found to explain the relationship between blame and desired social distance toward individuals with obesity (Wirtz et al., 2015). As feelings of disgust and contempt may increase the desire for social distance, other emotions may decrease the desire for social distance. Previous correlational research has found a negative association between feelings such as affection, enthusiasm, comfortability and desire for social distance from individuals with obesity (Magallares, 2017). It is possible that ingroup and outgroup preference play a role in the likelihood that a participant experiences these positive and negative emotional states, and future research should continue to examine their impact on the desire for social distance. Social Comparison The present study did not find any significant differences between the targets BMI and participants social comparisons toward the target. This is interesting given that individuals tend INTERNALIZED WEIGHT STIGMA ON THE PERCEPTION OF OTHERS 44 to instinctively compare themselves to others to determine their own worth (Festinger, 1954). Those with higher BMIs are typically seen as inferior and having less favorable characteristics than those with normal weight (Major et al., 2012; Puhl & Heuer, 2010; Puhl, & Brownell, 2006; Smith et al., 2007), making them a prime target for downward social comparisons if an individual wishes to increase their self-esteem. Engaging in social comparisons may be influenced by an individuals goals. If the goal of engaging in social comparison is self-improvement, an individual will use an upward comparison; however, if the goal is self-enhancement, they may use downward (Wood, 1989). It is possible that participants may have compared themselves to the target on non-appearance dimensions such as intelligence, education level, personality characteristics as a way to increase their self-esteem without expressing negative feelings toward the target. This type of comparison allows an individual to focus on other valued aspects of the self, apart from appearance, which counterbalances self-image threats and creates a positive experience in its place (Lew et al., 2007). By comparing themselves to the target on non-appearance dimensions in which the participant felt superior, they also simultaneously place less importance on physical characteristics, such as body shape and size. As a result, the participants may have been less inclined to negatively evaluate the target based on outward appearance alone. Future research should continue to examine alternative social comparisons as a way to regulate self-esteem and decrease antifat attitudes. Main Effects of Writing Condition on Antifat Attitudes, Social Distance and Social Comparison Social Comparison INTERNALIZED WEIGHT STIGMA ON THE PERCEPTION OF OTHERS 45 Contrary to what was predicted, participants who wrote about a neutral topic made more downward social comparisons than those who wrote about internalized weight stigma. This suggests that, compared to individuals in the internalized weight stigma writing condition, individuals in the neutral writing condition compared themselves to the target in the vignette and felt superior to the target, regardless of their weight. This finding is surprising, given that previous research has discovered that downward social comparisons may have a protective effect for individuals experiencing internalized weight stigma (Lew et al., 2007; OBrien et al., 2007). Although downward social comparisons are seen to be helpful to counterbalance a threat to ones self-esteem and self-concept, it may be difficult to actually engage in downward social comparisons. It is possible that individuals who wrote about a neutral writing prompt felt more positively toward themselves than those who wrote about internalized weight stigma due to the negative emotions people experience as a result of internalized weight stigma. These same negative emotions were not elicited for the neutral writing prompt group, which likely led them to feel superior toward the target on one or more domains, resulting in more downward social comparisons. Antifat Attitudes and Social Distance This study did not find any significant differences between the internalized weight stigma writing condition and the neutral writing condition on participants antifat attitudes. It is known that frequent experiences with weight stigmatization can become internalized and lead others to hold antifat attitudes (Ratcliffe & Ellison, 2013). Contrary to previous research that found links between internalized weight stigma and outgroup preference (Meadows & Calogero, 2018; Rudman et al., 2002), the results from this study show that although participants who wrote about weight stigma actually experienced greater levels of internalized weight stigma, these INTERNALIZED WEIGHT STIGMA ON THE PERCEPTION OF OTHERS 46 feelings were not projected onto the target. Other studies have also found that participant BMI is inversely related to implicit antifat attitudes, leading to an ingroup preference (OBrien et al., 2007). It is possible that the participants recognized their own negative reactions to writing about a time when they experienced internalized weight stigma and did not want others to feel the same way, leading to ingroup cohesion. Although ingroup and outgroup preference is typically examined through social identities, it is possible that participants who wrote about a weight stigmatizing experience viewed the target as someone who may have also experienced weight stigma, regardless of BMI, making the target a member of their ingroup. This finding has great clinical implications as ingroup preference leads to a stronger sense of identity, increased self-esteem and trust, and the ability to reject stereotypes associated with their group, all of which are central to combat the negative effects of internalized weight stigma (Devine, 1989; Dunne, 2018; Tajfel, 1978). When one has internalized weight stigma, they endorse the negative stereotypes, and believe them to be true, which is associated with low self-esteem and body dissatisfaction (Puhl & Brownell, 2006; Puhl & Heuer, 2010). As such, participants may have recognized their negative feelings toward themselves, and instead of externalizing these beliefs to others, were actually more motivated to reject the stereotypes corresponding to their ingroup. It would be important for future research to use measures examining participants levels of ingroup and outgroup biases to assess their impact on antifat attitudes and desire for social distance. The present study also did not find any significant effects on writing condition and social distance or seating distance task. The lack of significant findings show that the desire for social distance may not be directly impacted by experiences of internalized weight stigma. It is possible that the relationship is mediated by participant BMI and in-group bias. For example, although INTERNALIZED WEIGHT STIGMA ON THE PERCEPTION OF OTHERS 47 internalized weight stigma increases with BMI, some research has found that individuals with higher BMIs desire less social distance from others with overweight and obesity, revealing an ingroup bias (Sikorski et al., 2015). Due to the increasing number of individuals in the United States who are overweight or obese, it is possible that individuals have common interactions with individuals with bigger bodies and are able to actively discredit stereotypes against them. Research has also found that one of the most effective ways to decrease the desire for social distance is positive social contact with members of the marginalized group (Dunaev et al., 2018; Koball & Carels, 2015). It is important for future research to continue to explore the different avenues that may decrease the desire for social distance, such as in-group preference. Interactive Effects of Vignette and Writing Conditions on Antifat Attitudes, Social Distance, and Social Comparison Overall, no significant interaction effects emerged for the hypothesis that activating a participants internalized weight stigma would exacerbate the negative ratings of antifat attitudes, desire for social distance, and social comparison toward the targets as the BMI of the target increased. The current study was slightly underpowered to detect small or medium effects, which increases the probability of a Type II error (Christley, 2010). As such, the likelihood of detecting an interaction effect, where they truly was one, was reduced, and thus may explain the lack of results. It is also possible that participants own BMI also played a role in the way individuals rated the targets. Unfortunately, the sample size and distribution of participants into each weight category was too small to analyze data using a 3-way interaction. This would be a potential avenue to explore in the future as research has shown that experiences of internalized weight stigma increases as BMI increases (Puhl et al., 2017; Ratcliffe & Ellison, 2013). Although some research has suggested that individuals with higher BMIs experience sympathy toward others INTERNALIZED WEIGHT STIGMA ON THE PERCEPTION OF OTHERS 48 with overweight and obesity (Sikorski et al., 2015), other studies have found that they express high levels of antifat attitudes (Durso & Latner, 2008; Teachman et al., 2003). Also, adding BMI as a third independent variable may lead to significant effects due to the outgroup bias seen within this population. Limitations The present study has several limitations that should be acknowledged. First, the study utilized a convenience sample of undergraduate students recruited from a psychology research subject pool. The majority of participants were students between the ages of 18-22, and all were female. Thus, the homogeneity of the sample limits the generalizability of the results. It is known that men experience weight stigma and internalized weight stigma, although they experience them differently (Himmelstein et al., 2019; Puhl et al., 2017). For example, women experience stigma at lower BMIs than men and are more likely to experience negative psychological effects as a result (Boswell & White, 2015; Himmelstein et al., 2019, Puhl et al., 2017). As such, it would be important to add to the limited research on internalized weight stigma and men to see if it may affect the perception of others in similar or different ways. Second, there was a lack of diversity in the sample of this study as a majority of participants were White and fell into the normal weight category. If there were equal distributions across race, BMI category, and perceived body weight, differences within and between groups could have been explored. For example, research has found that racial differences play a role in stigmatization of individuals with obesity. Latner and colleagues (2005) found that African Americans and Asians perceived others with obesity in a better light than Whites. As such, it could be interesting for future research to explore how a more diverse sample may have impacted the results. INTERNALIZED WEIGHT STIGMA ON THE PERCEPTION OF OTHERS 49 A third limitation to the present study was the use of a visual avatar in place of real photographs. The use of avatars is becoming increasingly popular in online communication. Previous communication research has found that people make inferences and judgments about another based off their avatars, which may continue to affect their behaviors in the future (Nowak, 2015). However, the process of making social inferences based on an avatar or the actual image of a human may be different. Although sparse, a few research studies have included photographs that have been manipulated to alter the body weight of the individual to assess weight stigma (Hebl & Xu, 2001). It would be important for future research to compare the use of avatars to real photographs to better understand weight stigma and weight discrimination based on visual cues. Strengths Although the present study has limitations, it adds to the current literature in novel ways. First, to our knowledge, this is one of the first studies that examines how internalized weight stigma influences biases towards others with heavier weights using a vignette paradigm. Most studies examine the negative impact of internalized weight stigma on the individual who experiences it. For example, previous research focuses on the behavioral, emotional, and psychological effects of internalized weight stigma and has found that it is associated with higher levels of anxiety and depression, body dissatisfaction, and severe eating disturbances (Durso & Latner, 2008; Latner et al., 2013; Puhl & Brownell, 2006). Continuing to understand the overlap between internalized weight stigma and weight biases held by individuals with higher weights can provide further information on decreasing antifat attitudes and weight-based discrimination. Second, this study used visual images to accompany a written vignette to ensure that participants accurately envisioned the targets weight and BMI. This is particularly important in INTERNALIZED WEIGHT STIGMA ON THE PERCEPTION OF OTHERS 50 the United States as overweight and obesity have become more common, leading individuals to only perceive others over a certain threshold as overweight or obese (Robinson & Kirkham, 2013). Furthermore, written vignettes are commonly used to assess stigma. Previous research has found that participants blamed targets less for their weight when using a written stimulus in comparison to visual stimuli (e.g., videos and images). As such, providing a visual image in combination with a written stimulus addressed these methodological issues. Lastly, most research studies that have included visual stimuli to assess weight stigma utilize stereotypical (i.e., eating, emphasizing abdomen/lower body region, not shown as professionals/in professional clothing) or counter-stereotypical (i.e., walking, lifting weights, doing yoga) images (Dunaev et al, 2018; Heuer et al., 2011; Myre et al., 2020). As such, the addition of neutral avatars to accompany written vignettes provides a new addition to the research. Using neutral images instead of stereotypical or counter-stereotypical media provides less information about the target and allows for greater interpretation from the participant. This may address a gap in the research that compels the participant to make more inferences about the targets behaviors and personality characteristics that are not discussed in the vignette or shown in the avatar. Additionally, this study used an experimental design, the gold standard for research, which strengths the results of the study. Participants were also randomly assigned to control and experimental groups which controls for extraneous variables and continues to decrease the potential for biased results. Furthermore, due to the methodological design of this study, causal implications can be made with more confidence between BMI and antifat attitudes, such that as BMI of a target increases it causes antifat attitudes to also increase. As such, the current study builds upon previous research using experimental designs to examine antifat attitudes and allows future research to continue to examine the validity of the current results. INTERNALIZED WEIGHT STIGMA ON THE PERCEPTION OF OTHERS 51 Implications and Clinical Applications Although a wealth of interventions have been conducted to reduce weight stigma and negative attitudes toward individuals with overweight and obesity (Breithaupt et al., 2020; Griffiths et al., 2018; Levin et al., 2018; Talumaa et al., 2022), it continues to be a prevalent issue. The findings from this study continue to emphasize the need to address the effects of internalized weight stigma on an individuals psychological and physical well-being. As the frequency of individuals with overweight, obesity, and severe obesity continues to increase across the world, clinicians will need to better understand how to treat patients who have experienced weight stigma or who have internalized weight stigma. This is important for practicing clinicians to understand when working with larger bodied individuals. Clinicians need to understand the impact of weight related biases and internalized weight stigma. Furthermore, it is imperative that they recognize their own biases and how this may influence their approach to therapy with heavier bodied clients. Recognizing and examining ones beliefs allows a clinician to identify the assumptions they hold and be able to actively change them. This includes a continual need for self-examination and feedback from others to promote understanding and acknowledgment of ones biases to promote a positive therapeutic experience. Utilizing specific theoretical orientations that emphasize self-esteem and strengths may be especially important when working with clients with higher BMIs. Specifically, using concepts from positive psychology may help to increase positive experiences and relationships, and increase character strengths and virtues, thus improving self-esteem (Peterson, 2009). Acceptance and Commitment Therapy (ACT) has gained recent attention in the weight stigma research due to the desire to increase psychological flexibility in how one experiences cognitions INTERNALIZED WEIGHT STIGMA ON THE PERCEPTION OF OTHERS 52 and emotions related to their physical appearance (Hayes et al., 2006). Regardless of the theoretical orientation, clinicians should ensure to provide a facilitative, growth-producing environment that will allow the client to move toward self-understanding and reconstruct how they view themselves, which may lead to an increase in self-efficacy and self-esteem, and decrease body image concerns (Cooper, 2013). On a larger scale, policies need to be implemented to protect individuals who are overweight and obese from continued discrimination and weight bias. Although weight-based discrimination is legal in the United States, few states and cities have begun to pass legislation prohibiting weight-based discrimination (Pomeranz, 2008). With the exception of these areas, individuals have no means for seeking legal action after enduring weight discrimination in the workplace as civil rights laws (1970) are limited to prohibiting discrimination based on race, ethnicity, color, religion, and sex. Not only does weight bias negatively impact emotional and physical health, but it can also lead to social or economic disparities in the workplace especially, contributing to increased stress across various areas of an individuals life. Knowing the pervasive negative impacts that experienced and internalized weight stigma has on a majority of the population in the United States, it would be helpful to adopt a weightinclusive approach, such as Health at Every Size (HAES) to health and wellness. The Health at Every Size approach may be imperative to individuals with internalized weight stigma as it focuses on body acceptance, physical health, and living a meaningful lifestyle (Bacon & Aphramor, 2011; Robinson, 1999; Robinson, 2005). Unlike other health-related programs that emphasize weight loss as their main goal, HEAS focuses on ensuring the overall well-being of the individual, regardless of their body size and shape (Robinson, 2005, Hunger et al., 2020). Moreover, this approach may help individuals reject weight-based stereotypes and increase self- INTERNALIZED WEIGHT STIGMA ON THE PERCEPTION OF OTHERS 53 esteem through body positivity and acceptance. Data collected from this study highlights the importance of examining the effects of internalized weight stigma on the perception of others as a way to decrease weight-related stigma and discrimination. Conclusion Weight stigmatization and internalized weight stigma are immensely intertwined but often studied separately. Studying how an individuals internalized weight stigma may perpetuate weight bias, stereotypes, and discrimination toward others contributes to the complex body of research on weight stigma. Although participants in this study felt negatively toward the target with higher weights, they did not discriminate at higher rates. 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Sage Publications, Inc. INTERNALIZED WEIGHT STIGMA ON THE PERCEPTION OF OTHERS Appendices 75 INTERNALIZED WEIGHT STIGMA ON THE PERCEPTION OF OTHERS Appendix A: Informed Consent 76 INTERNALIZED WEIGHT STIGMA ON THE PERCEPTION OF OTHERS 77 College of Applied Behavioral Sciences KEY INFORMATION FOR POTENTIAL RESEARCH PARTICIPANTS Your consent is being sought for research regarding participants' thoughts, attitudes, and perceptions about themselves and others. Your participation in this research is voluntary and will take a total of about 15 minutes. After engaging in a brief writing exercise, you will be asked to read a description of a person and then will answer a series of questionnaires regarding your thoughts, attitudes, and feelings about yourself and the person depicted in the vignette. It is possible that you may experience slight emotional discomfort when engaging in the writing prompts and responding to some of the questionnaires, but you are free to skip any questions you do not wish to answer. You will receive .25 SONA credits for your participation in this research study. If you choose not to participate in this study, there are alternative assignments available on SONA that you may choose to complete. CONSENT TO PARTICIPATE IN RESEARCH STUDY Thoughts, Attitudes, and Perceptions of People Study Principal Investigator (PI): Erin, Fekete, Ph.D. UIndy Email: feketee@uindy.edu UIndy Telephone: (317) 788-8030 Study Co-Investigator: Victoria Silvati UIndy Email: silvativ@uindy.edu Erin Fekete, Ph.D. and Victoria Silvati, M.A. from the College of Applied Behavioral Sciences at the University of Indianapolis (UIndy) are conducting a research study. Why is this study being done? This study is being done to gain a better understanding of how individuals form thoughts, attitudes, and perceptions about others. What will happen if I take part in this research study? If you volunteer to participate in this study, the researcher will ask you to do the following: Provide consent to participate in the study. INTERNALIZED WEIGHT STIGMA ON THE PERCEPTION OF OTHERS 78 Complete a brief writing exercise. Read a vignette about a person. Complete a series of brief questionnaires regarding your thoughts, attitudes, and perceptions about yourself and the person in the vignette. How long will I be in the research study? Participation will take a total of approximately 15 minutes on one occasion. Are there any potential risks or discomforts that I can expect from this study? It is possible that some participants may feel uncomfortable when they participate in the writing exercise or when they answer some of the questions in this study. If you experience any emotional and/or psychological discomfort as a result of participating in this study, you can contact the Principal Investigator, Dr. Erin Fekete, at feketee@uindy.edu (317) 788-8030 or the University of Indianapolis Student Counseling Center (317) 788-5015. Are there any potential benefits if I participate? You will not directly benefit from your participation in the research. However, the results of the research may provide information that could help professionals and researchers have a better understanding of how we develop attitudes and perceptions about others. What other choices do I have if I do not wish to participate? If you choose not to participate in this study, you may participate in alternative assignments on SONA, such as critiquing a research article. Please reach out to the SONA administrator if you have questions about these alternatives. Additionally, individual instructors may offer other alternatives to participating in a research study; you should review your course syllabus or reach out to the instructor of the course to learn more about these alternatives. Will I receive course credit for participating? If you sign up and participate in the study via the SONA system, you will receive .25 credits. Will information about me and my participation be kept confidential? Yes, we are not collecting personal identifiers. The results of this study may be published in a scholarly book or journal, presented at professional conferences, or used for teaching purposes. Only aggregate data will be used. There will be no way to identify you or your data. Will the data from my study be used in the future for other studies? INTERNALIZED WEIGHT STIGMA ON THE PERCEPTION OF OTHERS 79 It is possible that data from this study could be used for future research or shared with other researchers for use in studies without additional informed consent. What are my rights if I take part in this study? You can choose whether or not you want to be in this study, and you may withdraw your consent and discontinue participation at any time. Whatever decision you make, there will be no penalty to you and no loss of benefits to which you are otherwise entitled. You may refuse to answer any question/s that you do not want to answer and still remain in the study. Whom can I contact if I have questions about this study? The Research Team: If you have any questions, comments, or concerns about the research, you can talk to one of the researchers. Please contact: o Study Principal Investigator (PI) and Faculty Sponsor: Erin Fekete, Ph.D. o UIndy Email: feketee@uindy.edu UIndy Telephone: (317) 788-8030 o UIndy Co-Investigator: Victoria Silvati, UIndy Email: silvativ@uindy.edu The Director of Human Research Protections Program (HRPP): If you have questions about your rights as a research participant, or you have concerns or suggestions and you want to talk to someone other than the researchers, you may contact the Director of the Human Research Protections Program, by either emailing hrpp@uindy.edu or calling 1 (317) 781-5774 or 1 (800) 232-8634 ext. 5774. How do I indicate my informed consent to participate in this study? If you consent to participate in this study, then you affirm that you satisfy inclusion criteria, and your consent is voluntary. To indicate your voluntary consent and proceed with the questionnaire, select one of the following options: I voluntary consent to participate in this study. I do NOT consent to participate in this study. INTERNALIZED WEIGHT STIGMA ON THE PERCEPTION OF OTHERS Appendix B: Study Measures 80 INTERNALIZED WEIGHT STIGMA ON THE PERCEPTION OF OTHERS 81 Modified Weight Bias Internalization Scale (WBIS-M) Please rate your agreement with the following items on a scale of 1-7(1=strongly disagree; 7 = strongly agree) Rating 1-7 1. Because of my weight, I feel that I am just as competent as anyone. 2. I am less attractive than most other people because of my weight. 3. I feel anxious about my weight because of what people might think of me. 4. I wish I could drastically change my weight. 5. Whenever I think a lot about my weight, I feel depressed. 6. I hate myself for my weight. 7. My weight is a major way that I judge my value as a person. 8. Please select somewhat agree (5) as the answer to this question. 9. I dont feel that I deserve to have a really fulfilling social life, because of my weight. 10. I am OK being the weight that I am. 11. Because of my weight, I dont feel like my true self. 12. Because of my weight, I dont understand how anyone attractive would want to date me. INTERNALIZED WEIGHT STIGMA ON THE PERCEPTION OF OTHERS 82 Bogardus Social Distance Scale Definitely willing 0 1. 2. 3. 4. 5. 6. 7. How would you feel about renting a room in your home to someone like Emily? How about being a worker on the same job with someone like Emily? How would you feel having someone like Emily as a neighbor? How about having someone like Emily babysit your children for a couple of hours? (if you dont have children currently, think about future children) How about having one of your children marry someone like Emily? (if you dont have children currently, think about future children) How would you feel about introducing Emily to someone you are comfortable with? How would you feel about recommending someone like Emily for a job working for a friend of yours? Probably willing 1 Probably not willing 2 Definitely not willing 3 Score INTERNALIZED WEIGHT STIGMA ON THE PERCEPTION OF OTHERS Seating Distance Task This is an image of a table with 7 chairs around it. The red chair is where Emily has decided to sit. Please choose the number above the seat that you would choose to sit in yourself. 1 2 3 4 5 6 83 INTERNALIZED WEIGHT STIGMA ON THE PERCEPTION OF OTHERS 84 Fat Phobia Scale Listed below are 14 pairs of adjectives. For each adjective pair, please mark the bubble closest to the adjective that you feel best describes Emily. Industrious Has will power Unattractive Poor self-control Slow Having no endurance Inactive Strong Self-sacrificing Likes food Shapely Overeats Secure High self-esteem o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o Lazy No will power Attractive Good self-control Fast Having endurance o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o Active Weak Self-indulgent Dislikes food Shapeless Undereats Insecure Low self-esteem INTERNALIZED WEIGHT STIGMA ON THE PERCEPTION OF OTHERS Social Comparison Scale Please mark the number at a point which best describes the way in which you see yourself in comparison to Emily. In relationship to Emily, I feel: Inferior 1 2 3 4 5 6 7 8 9 10 Superior Incompetent 1 2 3 4 5 6 7 8 9 10 More competent Unlikeable 1 2 3 4 5 6 7 8 9 10 More likeable Left out 1 2 3 4 5 6 7 8 9 10 Accepted Different 1 2 3 4 5 6 7 8 9 10 Same Untalented 1 2 3 4 5 6 7 8 9 10 More talented Weaker 1 2 3 4 5 6 7 8 9 10 Stronger Unconfident 1 2 3 4 5 6 7 8 9 10 More confident Undesirable 1 2 3 4 5 6 7 8 9 10 More desirable Unattractive 1 2 3 4 5 6 7 8 9 10 More attractive An outsider 1 2 3 4 5 6 7 8 9 10 An insider 85 INTERNALIZED WEIGHT STIGMA ON THE PERCEPTION OF OTHERS 86 Demographics How old are you? (slide the bar to indicate your appropriate age) 18-100 What is your gender? (check one) o Male o Female o Transgender Female o Transgender Male o Non-Binary/Gender Non-Conforming o Other o Prefer Not To Answer Which of the following best describes your racial/ethnic background? o Hispanic or Latino (A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture of origin, regardless of race) o Not Hispanic or Latino What race do you most identify with? (Check one) o White (A person having origins in any of the original peoples of Europe, the Middle East, or North Africa) o Black or African American (A person having origins in any of the black racial groups of Africa) o American Indian or Alaska Native (A person having origins in any of the original peoples of North and South America, including Central America, and who maintains tribal affiliation or community attachment) INTERNALIZED WEIGHT STIGMA ON THE PERCEPTION OF OTHERS 87 o Asian (A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam) o Native Hawaiian or Other Pacific Islander (A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands o Biracial/Multiracial o Prefer not to answer What best describes your body size? (Check one) o Very thin o Thin o Average o Heavy o Very heavy Self-reported Height (Open response) Self-reported Weight (Open response) INTERNALIZED WEIGHT STIGMA ON THE PERCEPTION OF OTHERS Appendix C: Vignettes 88 INTERNALIZED WEIGHT STIGMA ON THE PERCEPTION OF OTHERS 89 Normal Weight Vignette Name: Emily Age: 20 Hair Color: Brown Eye Color: Brown Height: 5 feet, 4 inches Weight: 125 BMI: 21.5 Hi! My name is Emily and I just recently moved to the Indianapolis area for college. I am a student at University of Indianapolis and Im studying Psychology. I am interested in learning what other interesting things there are to do in the area besides watching sports. I dont know many people in the area yet, so I am excited to meet new friends and engage in new social experiences. I enjoy spending time with my family, reading mystery novels, going for walks in the park, and exploring new places. Growing up, my mom taught me how to cook and now I love cooking and baking for my friends, so if you are a foodie, we will get along! I also love listening and dancing to live music of all kinds. There is nothing better than going out with friends, listening to music, and trying new food at different restaurants. As adventurous as I might be, I will never be one to pass up a night in with my friends, wearing pajamas, ordering a pizza, and watching good movies. INTERNALIZED WEIGHT STIGMA ON THE PERCEPTION OF OTHERS 90 Overweight Vignette Name: Emily Age: 20 Hair Color: Brown Eye Color: Brown Height: 5 feet, 4 inches Weight: 157 BMI: 26.9 Hi! My name is Emily and I just recently moved to the Indianapolis area for college. I am a student at University of Indianapolis and Im studying Psychology. I am interested in learning what other interesting things there are to do in the area besides watching sports. I dont know many people in the area yet, so I am excited to meet new friends and engage in new social experiences. I enjoy spending time with my family, reading mystery novels, going for walks in the park, and exploring new places. Growing up, my mom taught me how to cook and now I love cooking and baking for my friends, so if you are a foodie, we will get along! I also love listening and dancing to live music of all kinds. There is nothing better than going out with friends, listening to music, and trying new food at different restaurants. As adventurous as I might be, I will never be one to pass up a night in with my friends, wearing pajamas, ordering a pizza, and watching good movies. INTERNALIZED WEIGHT STIGMA ON THE PERCEPTION OF OTHERS 91 Obese Vignette Name: Emily Age: 20 Hair Color: Brown Eye Color: Brown Height: 5 feet, 4 inches Weight: 200 BMI: 34.3 Hi! My name is Emily and I just recently moved to the Indianapolis area for college. I am a student at University of Indianapolis and Im studying Psychology. I am interested in learning what other interesting things there are to do in the area besides watching sports. I dont know many people in the area yet, so I am excited to meet new friends and engage in new social experiences. I enjoy spending time with my family, reading mystery novels, going for walks in the park, and exploring new places. Growing up, my mom taught me how to cook and now I love cooking and baking for my friends, so if you are a foodie, we will get along! I also love listening and dancing to live music of all kinds. There is nothing better than going out with friends, listening to music, and trying new food at different restaurants. As adventurous as I might be, I will never be one to pass up a night in with my friends, wearing pajamas, ordering a pizza, and watching good movies. INTERNALIZED WEIGHT STIGMA ON THE PERCEPTION OF OTHERS 92 Severe Obesity Vignette Name: Emily Age: 20 Hair Color: Brown Eye Color: Brown Height: 5 feet, 4 inches Weight: 273 BMI: 46.9 Hi! My name is Emily and I just recently moved to the Indianapolis area for college. I am a student at University of Indianapolis and Im studying Psychology. I am interested in learning what other interesting things there are to do in the area besides watching sports. I dont know many people in the area yet, so I am excited to meet new friends and engage in new social experiences. I enjoy spending time with my family, reading mystery novels, going for walks in the park, and exploring new places. Growing up, my mom taught me how to cook and now I love cooking and baking for my friends, so if you are a foodie, we will get along! I also love listening and dancing to live music of all kinds. There is nothing better than going out with friends, listening to music, and trying new food at different restaurants. As adventurous as I might be, I will never be one to pass up a night in with my friends, wearing pajamas, ordering a pizza, and watching good movies. INTERNALIZED WEIGHT STIGMA ON THE PERCEPTION OF OTHERS Appendix D: Writing Prompts 93 INTERNALIZED WEIGHT STIGMA ON THE PERCEPTION OF OTHERS 94 Writing Prompts Experimental Writing Prompts First, think about a particular situation in which you felt self-conscious about your weight or body image. Think about this situation for one minute, and then you can proceed to the next page where you will be asked to write in detail about this situation. 1) Please write about what exactly is occurring in this situation regarding your weight or body image. Try to be as descriptive as possible. 2) Please write about who is involved in the situation if it involves more than just you. Please describe the people involved with as much detail as possible, even if you are the only one involved (in this case describe yourself). 3) Please write any words that have been spoken in the situation, either what you have said to yourself, what other people have said to you, or what you have said to other people. Please use as much detail as possible. Control Writing Prompt First, think about a typical day in your life, what you do daily. Think about your everyday routine for one minute, and then you can proceed to the next page where you will be asked to write in detail about your daily activities. 1) Please write about your morning routine. What do you do when you first wake up in the morning? Describe your actions in as much detail as possible. 2) Please write about your afternoon routine. What do you do during the middle of the day? Describe your actions in as much detail as possible. 3) Please write about your evening routine. What do you do at nighttime? Describe your activities in as much detail as possible.  ...

... Mindfulness-Based Interventions During Play for Parents of Children with Down Syndrome: Two Case Studies Dr. Alison Nichols, OTR, Samantha Trench, Serena Good, Caroline Stone, Marissa Cavanaugh, Carissa Anderson, Caitlyn Naghdi, Krystal Scott December 15, 2023 A research project submitted in partial fulfillment for the requirements of the Doctor of Occupational Therapy degree from the University of Indianapolis, School of Occupational Therapy. Under the direction of the research advisor: Alison Nichols, OTR, OTD A Research Project Entitled Mindfulness-Based Interventions During Play for Parents of Children with Down Syndrome: Two Case Studies Submitted to the School of Occupational Therapy at the University of Indianapolis in partial fulfillment for the requirements of the Doctor of Occupational Therapy degree. By Alison Nichols, OTR, OTD, Samantha Trench, Serena Good, Caroline Stone, Marissa Cavanaugh, Carissa Anderson, Caitlyn Naghdi, Krystal Scott Occupational Therapy Doctorate Students Accepted on this date by the OTD Program Director: 12/15/23 Alison Nichols, OTR, OTD OTD Program Director Associate Professor of Occupational Therapy Date Abstract Parents of children with disabilities are known to experience stressful or anxious feelings in their role as both parents and caregivers but it is less known about what, if any, effective strategies may be used to reduce these feelings. The following study aimed to explore the use of mindfulness-based interventions (MBI) for parents of a child with a disability and consider the effects these may have on stressful or anxious feelings experienced by those parents during parent-child play interactions. Parents with a child with a disability included in the study met the following inclusion criteria: parents must be at least 18 years of age with a child with a disability between the ages of two and twelve and must be English-speaking. This study was conducted virtually in the format of a researcher-led focus group. To assess the effectiveness of the mindfulness strategies provided, follow-up surveys were conducted six weeks post-intervention, and qualitative data was collected through audio transcripts. One theme identified in the followup survey responses was the positive effects of mindfulness techniques during parent-child play in public or private settings. Based on the follow-up survey results, both participants expressed positive experiences and decreased instances of stressful or anxious feelings using mindfulness techniques. Limitations of the study include a limited sample size indicated by only having two participants who both identify as female and mothers to a child with Down syndrome, lack of standardized assessment tools, and participants located in the same geographical location. Implications for future studies and practice include the effects of prolonged use of mindfulness techniques on the anxiety of caregivers and parents of children with diversified diagnoses. Keywords: Down syndrome, play, caregivers, anxiety, mindfulness Mindfulness-Based Interventions During Play for Parents of Children with Down Syndrome: Two Case Studies When raising a child, parents typically will encounter physical, emotional, and financial stressors. When raising a child with a disability, these are amplified and may lead to parents experiencing increased anxious feelings. As described by Nichols et al. (2021), parents of a child with a disability experience anxious feelings from stressors, which may include low socioeconomic status, loss of a family member, or parenting a child with a disability, among many others (p. 3). These anxious feelings have the potential to penetrate every aspect of the parents life, impacting their ability to engage in meaningful occupations and sustain current levels of satisfaction and quality of life. Anxious feelings experienced by parents may also impact playful interactions with their children. Romn-Oyola et al. (2018) explained that playfulness is a relationship-based phenomenon and an important factor for the development of social relationships between children and their main caregivers (p. 2). The purpose of this study is to address the significant gap in the literature on resources or strategies and their effects on parents who experience stressful or anxious feelings during parent-child play interactions. Play Play is the primary occupation of children and is displayed in multiple forms across various settings including imaginative, physical, group, and individual. Play provides critical support for optimal child development. According to Tamm and Skr (2000), play has been viewed as an all-encompassing activity through which a child develops skills in self-awareness, communications, and socialization (p.174). Play is recognized by the United Nations High Commission for Human Rights (2022), as a right of every child (Article 31.1). Play teaches children important motor, cognitive, and social skills as well as creativity and self-confidence which are skills required throughout life (Romn-Oyola et al., 2018, p.1). However, it may be more difficult for children with disabilities to engage in play as their play is often described as skill-based with a focus on therapeutic intervention rather than exploration and discovery (Parham & Fazio, 2007). Due to this focus on therapeutic intervention, these children could be missing out on essential experiences afforded by unstructured free play. Down Syndrome According to the Centers for Disease Control and Prevention (CDC, 2023), Each year, about 6,000 babies born in the United States have Down syndrome. This means that Down syndrome occurs in about 1 in every 700 babies (How Many Babies Are Born section). Down syndrome is the most common genomic disorder of intellectual disability and is caused by trisomy of Homo sapiens chromosome 21 (Antonarakis et al., 2020, p. 2). Like all children, children with Down syndrome (DS) have unique characteristics and individualized needs that may change throughout their lifespan. De Weger et al. (2021) mention that it is common for children with DS to have developmental delays impacting multiple developmental processes, such as vulnerabilities in motor, cognitive, language, social and attentional domainsall aspects of adaptive behaviour (pp. 1-2). According to Antonarakis et al. (2020), the social stigma around the diagnosis of DS and the inability to fit within cultural norms are barriers to successful community engagement of individuals with DS. The impact of developmental barriers and social stigmatism surrounding DS not only the well-being and quality of life of the child but also those of their caregiver. Parental Well-Being Many parents who care for children with disabilities experience anxiety, stress, and other psychological symptoms (Rani et al., 2014). These low-level feelings of anxiousness, tension, fear, and distress are caused by the everyday demands and stressors involved in caring for children with disabilities. A study by Hedov et al. (2000) concluded that mothers of children with Down syndrome had much lower self-reported ratings of vitality and mental health than mothers of neurotypically developing children. While numerous parents of children with disabilities seek coping strategies and social support to manage anxious feelings and distress, some parents still experience clinically significant levels of anxiety and/or depression (Martin et al., 2019, p. 980). It is crucial to address parental distress experienced by caregivers of a child with a disability because poor parental well-being can have a negative effect on both quality of life and functional performance. Research indicates that parents of children with disabilities who report having anxious feelings typically have difficulty interacting with their children, particularly through play (Nichols et al., 2021). One research study by Rani et al. (2014) evaluated anxiety levels and coping strategies in mothers of children with cerebral palsy. In the discussion, it was found that parenting stress was related to the mothers style of interaction with their childrenwhich means that a high level of maternal stress interferes with the mothers effectiveness for engaging in quality interaction with their children (Rani et al., 2014, p. 248). In other words, parental anxiety and stress significantly affected parent-child interactions. Moreover, the study found that there was a strong association between parenting stress and interaction style suggests the need for therapists to develop and implement interventions to enhance the quality of mother-child interaction along with other rehabilitation services for children with disabilities (Rani et al., 2014, p. 248). For parents dealing with anxious feelings and stress when interacting with children with disabilities, rehabilitation services may be useful to improve levels of satisfaction and quality of life (Rani et al., 2014). Caregivers experiencing a decrease in well-being resulting from anxious feelings may benefit from mindfulness-based interventions that are accessible and usable in the home. Mindfulness Mindfulness is a psychological practice that allows an individual to become increasingly aware of the internal and external factors that surround them. Keng et al. (2011) also describes mindfulness as awareness and nonjudgmental acceptance of ones moment-to-moment experience (p. 2). The application of mindfulness to psychological health has been proven to be an effective solution in relieving worry, fear, stress, and anxiety in various situations (Keng et al., 2011). Therefore, a strategy that mentally re-engages the parents back to the present moment when playing with their child may be a beneficial approach when taught correctly. A review by Creswell (2017) demonstrates that mindfulness interventions can improve mental and physical health, cognitive and affective factors, and interpersonal outcomes (p. 508). The research indicates there are consistent findings on the benefits of mindfulness-based interventions for parents of children with disabilities. Sarang et al. (2020) demonstrated that mindfulness-based interventions specifically benefited parents of children with ASD, specifically concerning anxiety symptoms and parental stress. Similarly, Burke et al. (2017) and Neece et al. (2019) also demonstrated mindfulness benefits for parents of children with intellectual and developmental disabilities or delays including improvements in personal well-being, advocacy skills, professional relationships, children's services, reactivity, and being present in the moment. Overall, the findings related to Mindfulness-Based Interventions (MBI) have demonstrated a positive effect on the parents to whom they were administered. As previously described, mindfulness-based practices have become more mainstream in recent decades. Though popular, there is still limited research on the impact of mindfulness- based practice in occupational therapy. As reported by Nichols et al. (2021), parents of children with disabilities have demonstrated increased parental stress which can present as difficulty with being in the moment with their children, specifically during play. A mindfulness approach would be beneficial to help parents develop strategies to be present in the moment at any point with simple mindfulness-based exercises and tasks. These tools are meant to provide relief from stress, not add to the parents responsibilities; therefore, it will be imperative to emphasize to parents both the simplicity of mindfulness along with its effectiveness. Model The chosen model for this study is the Model of Co-Occupation, created by Pickens and Pizur-Barnekow (2009). This model focuses on three categories of interrelated social occupations: parallel occupations, shared occupations, and co-occupations. Of these three, we will be specifically focusing on co-occupations, which require two or more people to be active agents during the occupation. As mentioned above, play for a child with a disability can look different, often requiring the caregiver to be more actively engaged with the child during play. Pickens and Pizur-Barnekow (2009) talk about the importance of co-occupations between mothers and children as imperative to the childs growth and development (p. 151). Play is a critical co-occupation between a child and caregiver, where both are actively engaged. Pickens and Pizur-Barnekow (2009) also make a proposition specifically toward children with disabilities, writing, Impairment or disability across the lifespan may influence how cooccupation is manifested and co-occupation has the potential to influence disability outcomes'' (p. 154). Understanding that co-occupations for children with disabilities may be different than typically developing children supports the need for understanding what these differences may look like. These understandings can lead to how we can better support caregivers in being successful in engaging in play with their children. This model provides support for the importance of co-occupations between children and caregivers, along with addressing that these co-occupations can look different due to a disability. Occupational Therapists Role Occupational therapists primary goal is to help clients engage in their chosen occupations. When aspects of an individuals life, such as activities of daily living (ADL) or instrumental activities of daily living (IADL) are impacted by anxious thoughts and feelings, occupational therapists provide extensive support and treatment to these individuals. While occupational therapists do not diagnose anxiety, occupational therapists play an important role in helping clients with anxious feelings manage their symptoms and minimize the overwhelming impact on the clients occupational performance. In this study, anxious feelings experienced by parents were the predominant barrier identified while participating in the co-occupation of play with their child. Play has an integral role in the development of children across all developmental domains and is the primary occupation for a child. While the literature indicates that parental anxiety is occurring while parents play with their child with a disability, there are little to no interventions focused on helping reduce anxiety during play. The purpose of this study is to explore the effectiveness of utilizing a mindfulness-based intervention that is focused on the co-occupation of play, specifically when looking at parental coping skills, self-efficacy, and anxious feelings. Method Participants For this study, parents who have a child with a disability were recruited. The parents were required to be at least 18 years old, with a child or children with a disability between the ages of two and twelve years old. All participants were required to speak English. To recruit participants, we reached out via email, posted flyers at local Indianapolis occupational therapy clinics, and advertised on various social media accounts. We recruited two participants who were each the mother of a child with Down syndrome, ages six and eleven. This study (#10676) was approved by the University of Indianapolis Human Research Protection Program (HRPP). Study Design The study was guided by the following questions: Is MBI a useful tool to decrease parents anxious feelings during play with their child? We hypothesized that MBI will provide effective coping mechanisms for parents and decrease anxious feelings during play. The study design consisted of caregiver recruitment, followed by virtual delivery of mindfulness-based interventions for caregivers, and concluded with a virtual post-intervention survey after six weeks. Measures and Procedures Before the session, both participants received a sample mindfulness breathing activity to try with their child and a video discussing the basic concepts of mindfulness. The researcher-led session was completed virtually in a single session format and lasted approximately one hour (see Figure 1). Participants were asked open-ended questions by researchers to gain insight into their levels of stress and anxious feelings experienced during play, how mindfulness activities impacted them and their anxious feelings, and the feasibility of using these techniques during play. Researchers first conducted the 5-4-3-2-1 mindfulness activity (see Appendix) that could be used by participants when playing with their children. This activity incorporated grounding techniques, meant to lower stressful or anxious feelings during play. Follow-up questions regarding the grounding techniques were asked by the researchers to reflect on how participants could incorporate the mindfulness approach into their everyday routines. Following this activity, the researchers introduced a self-compassion practice and discussion that allowed participants to reflect on their emotions, recognition, and reflection. At the end of the session, participants reflected on the feelings they experienced while playing with their child, the impact mindfulness has on their stress and anxiety levels, and how these techniques could be incorporated into their daily lives and, more specifically, during play. After the session was complete, the participants were provided with an evidence-based practice journal article called Healing Parent-Child Relationships Through Mindfulness (Smith, 2021). This article was provided to the participants as a resource, showing the benefits of mindfulness and several activities that parents can engage in with their children. The participants were also provided with a link to additional mindfulness activities to be used on their own for them to gain more experience with mindfulness-based practices. These activities can be found in the Appendix. Six weeks after the researcher-led session was completed, participants received a virtual survey to assess the carryover of mindfulness techniques and how mindfulness has since impacted their daily lives. Within the survey, participants were asked about their perspectives on the mindfulness-based exercises that they were requested to complete before the session with their child. Figure 1 Mindfulness Curriculum for the Virtual Session Data Analysis Qualitative data were collected through the transcriptions of the audio recording of the intervention session. Due to the limited number of participants, the research team decided to focus primarily on the responses from one participant. Researchers analyzed her responses to the semi-structured interview questions provided during the session. After the responses from the first case study were examined, researchers compared them to the responses found in the second case study. Differences between the two participants were then highlighted and described. The follow-up survey was completed by both participants six weeks after the initial session. Researchers collected qualitative and quantitative data to address the carryover of mindfulness activities in the home and their effectiveness. Once the responses were submitted, researchers analyzed the results to determine similarities and differences between the participants responses. Findings Case Study 1 (Sharon & Sabrina): Sharon is the mother of Sabrina, an 11-year-old child with Down syndrome. Although Sharon had previous exposure to mindfulness before the intervention session, she expressed her excitement to learn more about how to incorporate mindfulness-based interventions into her and Sabrinas routines. Specifically discussing her play with Sabrina, Sharon stated, I definitely probably struggle with that more in the area of play and engaging with my child. Like sometimes I really have to think with so much going on. It's hard to stay in the moment. Sharon mentioned being distracted by her phone or cleaning commonly takes attention away from Sabrina while they play. Though these are her more typical distractions, Sharon describes her solution of focusing on Sabrina and, the pride and joy that I feel with all the stuff that she's doing. That's usually my grounding piece. Sharon described herself as a perfectionist which can be specifically seen in feelings of guilt surrounding play if its not therapeutic enough. On the other hand, being a part of a local Down syndrome parent organization has helped Sharon to let go of other unspecified parenting mistakes. Overall, Sharon responded positively to the mindfulness interventions performed in the session but did not think the pre-session breathing activity was as successful in comparison to other intervention ideas provided. The main issue Sharon addressed was the lack of compliance from Sabrina when attempting the activity together. During the 5-4-3-2-1 activity, Sharon reported feel[ing] more relaxed and in a better mood. One aspect of the 5-4-3-2-1 activity Sharon did not like was the five things she saw section because she felt her surroundings were cluttered, and this increased her anxious feelings because she was now thinking of all the other things she should be doing instead. Additionally, Sharon enjoyed the Self-Compassion experience, stating that self-compassion can be used to create a more positive and mindful environment. Sharon is only raising one child, Sabrina, and she explains that she has nothing to compare it to. From years 0-4, she was still coming to terms with the diagnosis, but each year she feels that she experiences an increase in personal growth. Sharon states that she has: A lot more compassion when it comes togiving people grace and stopping to smell the roses and just likeenjoying the slow route, I guess. And without Sabrina, I would never have been okay with the pace of my current lifeso it makes me a lot more patient with other people and what they're going through. When asked about self-compassion, Sharon explained that comparing her own family with other families is the hardest thing she deals with. Because the Down syndrome community is very tight-knitwe have an amazing community especially compared to other disability group(s). There are families in ourcommunity whose kids are like academically light years beyond where my daughter is, and they're younger than my daughter and they're doing all of these therapies every single day and their parents don't work and basically homeschool them in addition to all the stuff they do at school. Regarding play, Sharon feels that she does a great job letting Sabrina participate in play like a typically developing child and does not make play activities therapy-based. During the self-compassion activity, Sharon and Lola both showed physical signs of emotion during the activity. Sharon explained that she does not give herself enough positive selftalk. There is a lot to balance required as a mother, and for Sharon, her job is a large stressor and distraction. Another instance where Sharon feels she struggles with anxious feelings is out in public. She states, I think my most anxious and stressful time with Sabrina is when other people are around. She also indicated that, I want perfection out in public and as a result, that's probably when I look my worst as a parent. Sharon feels the pressure to be successful and good and put on a good show in public. Sharon also says there are times that she cannot understand what Sabrina is saying, and this results in frustration for both parties. The guilt Sharon feels from these occurrences ties back to the fear that she did not put her in the right, best, or earliest speech therapies she could have. It is seen through the session results that both participants experience a lot of stress for similar or different reasons. In the follow-up survey, Sharon marked the following as stressors present during play: (a) thinking about other things I should be doing, (b) wanting to avoid play, and (c) thinking about potential delays of your child. Sharon commented that she used mindfulness techniques once a day, with the 5-4-3-2-1 Exercise, the STOP Exercise, and additional activities from the mindfulness activities link (see Appendix) being the most beneficial. When asked about the effect on parent-child relationships, Sharon stated, When I am calm and less stressed, I am a better mom. Additionally, she stated, I was amazed at how impactful it was even thinking back to an issue that had happened previously. It helped me realize that taking a moment, in the moment, to give myself grace can be so freeing, when referring to the value mindfulness has added to her life. Case Study 2 (Lola & Lyle) Lola is a single mother to her 6-year-old child Lyle, who has Down syndrome. In comparison to Sharons self-perspective, Lola views herself as less emotional. She expresses that like Sharon, she focuses on putting more of her effort into her child rather than into herself. Lola explained to researchers how good it felt to let go of emotions during the activities completed. There were some notable differences between Sharon and Lola. One of these concerns was that Lola experiences worries about other kids mistreating her son. She gives an example that there was one boy who was really sweet and another little boy came making fun of Lyle, and I was getting anxiety just from really watching the other kids. Another difference is Lola faces difficulty at home with Lyles defiant behavior which causes her to experience anxious feelings as opposed to Sharons anxious feelings in public places. Another large concern from Lola is that she cannot physically manhandle him to do what he needs to do for fear that she will harm him or herself. Lola lastly expressed that her biggest challenge with her son comes during transitions of activities. In the follow-up survey, Lola explained that her stressors during play with her child include: (a) hurting or being hurt by her child, (b) feelings of frustration, and (c) thinking about potential delays of her child. Lola stated that she integrated mindfulness-based interventions, more specifically breathing work and observation activities, once a day. The most impactful intervention completed during the session was the Self-Compassion Exercise. Lola felt it was reaffirming to her as a mother and reminded her of the accomplishments and goals she is meeting every day. Discussion Impact of Mindfulness on Play and Routines Romn-Oyola et al. (2018) report that play is the primary occupation for children and interaction influences the parent-child relationship. Promoting these interactions can have a systemic impact on this necessary relationship, reducing the likelihood of anxious feelings experienced by parents during play with their children with a disability. The goal of the researcher-led session was to help parents combat these stressors by incorporating mindfulness activities into their day. Our findings support the use of these mindfulness techniques during play, whether that is in a public or private setting, as it provides the ability to alleviate stressful and anxious feelings experienced by the parents. Based on the follow-up results, both participants practiced mindfulness once a day, adding value to their lives through feelings of being refreshed and/or liberated. Responses to Specific Mindfulness Activities Parents perceptions and experiences of mindfulness-based activities determine how effective mindfulness practices will be (Bazzano et al., 2015). In research with children with disabilities, mindfulness-based techniques have shown that parents can intentionally attend to their child's problematic behavior, improve satisfaction with parenting skills and interactions with their children, and reduce the stress associated with caring for their children (Bazzano et al., 2015). Our findings highlight how parents of children with Down syndrome perceive mindfulness as part of their everyday routine, particularly playing with their children. We propose that to improve interactions during play with their children and decrease caregiver stress, mindfulness-based techniques may enhance intentional awareness in parent-child relationships. After completing a mindfulness exercise, participants indicated they were feeling more relaxed and in a better mood. Incorporating mindfulness-based techniques into a daily routine has been shown to have many benefits, as many parents report that mindfulness practice has helped them slow down, notice impulses before they act, really listen to their children, and come to a more relaxed and peaceful state of mind when they interact with their children (Neece et al., 2019, p. 13). As with Neece et al. (2019), participants in our study noted that even though changing their routine to do mindfulness activities with their child throughout the day was different and took more time, it helped parents improve perceptions of their child's behavior and reduce overall stress. In the follow-up surveys, both participants found the mindfulness exercises helpful and relieving their anxieties during play and interactions with their child. One participant reported that the Self-Compassion exercise was most beneficial to her as it helped to create a relaxing, calm environment, and she was able to fully engage in mindful thinking. Similarly, the other participant exhibited positive feelings after completion of the Self-Compassion activity as it allowed her to let go of her emotions throughout the activity. The Self-Compassion activity had the most impact on the participants as it reaffirmed their primary roles as mothers, which allowed them to build compassion for themselves as well as build resilience, equanimity, and determination. Self-Compassion Though self-compassion was not originally a focus of this study, it came to be a large barrier that the parents reported facing daily. Self-compassion is defined as being touched by and open to ones suffering, not avoiding or disconnecting from it, generating the desire to alleviate ones suffering and to heal oneself with kindness (Neff, 2003, p. 87). A lack of selfcompassion can cause parents to experience additional anxious feelings. The parents in this study were more worried about themselves and their performance as a parent than they were about their children. Additionally, Stenz et al. (2022) looked at self-compassion in parents who had children with psychological disorders and found that increasing self-compassion can reduce the stress that these parents experience daily. As demonstrated in the virtual intervention session, mindfulness can be a means for encouraging parents to engage in self-compassion. As noted in the results, there was an obvious emotional release following the self-compassion activity that was viewed by the participants as an overall positive experience. A parents internalized expectations can lead to an overwhelming amount of pressure to be successful with little room for error. Self-compassion directly addresses the need for patience and grace for parents for them to have the same attitude of patience and grace toward their children. Willards (2017) work guided our self-compassion activity and states, I work to be a good parent, and I may not be perfect, but I am a good-enough parent (p. 154). Self-compassion is addressing the root problem of unrealistic expectations in parents to alleviate anxious feelings that may present during play. Anxious Feelings Previous research explains that parents of children with disabilities encounter anxious feelings throughout their daily lives from stressors beyond their control (Nichols et al., 2021). Additionally, Sarang et al. (2020) found that MBI interventions provided benefits to parents of children with disabilities by decreasing anxious feelings. Within our study, the parents reported anxious feelings when trying to enforce appropriate behavior both in the home and in public, as well as play in public settings. The collected qualitative data in our study is supported by the findings of Sarang et al. (2020) as the parents responded positively to the MBI activities by stating feelings of relaxation and improved mood at the conclusion. Limitations A limitation of the current study includes a limited sample size indicated by only having two participants who both identify as female and mothers to a child with Down syndrome. By only having mothers participating in the study, limitations in gender differences are present in the responses. Both participants focused on how stress and anxiety impact their psychological view of themselves specifically as mothers. This sample was also narrowed because both children of the participants have a diagnosis of Down syndrome. The participants for the case studies were also from the same geographical area which limits the ability to generalize the results. Another limitation of this study is the limited follow-up with participants after the conclusion of the initial session. The follow-up survey was provided to participants six weeks after the initial session, limiting this study to a short time frame for mindfulness impacts to influence both the parents and their children. By not gathering data with an extended time frame or through additional follow-up interactions, support for the impacts of mindfulness on play and routines was limited to initial effects. Therefore, generalized effects on the anxious feelings of participants long-term are not fully understood in the scope of this study. Lastly, while gathering the data, researchers did not utilize standardized assessment tools. The data collected was primarily qualitative self-reporting obtained during the virtual session and through the completion of a researcher-developed follow-up survey. These methods of data collection are limited due to relying on how much the participants are willing to disclose through conversation and self-reporting measures. There is an underrepresentation in the literature on parents of children with disabilities and how mindfulness interventions provide benefits specifically during play. Future recommendations for assessing this population include a larger, more diverse sample size. This may include fathers or foster parents, children with different diagnoses, caregivers from different locations, and more diversity in race, ethnicity, age, education, and socioeconomic status of parents. Including the children of the participants in a session may provide a view of parent-child interactions and anxious feelings that may arise specifically during play, as well as help participants better understand how to incorporate the child into mindfulness-based activities. It is recommended to continue using a virtual platform to assist with participant recruitment and follow-up interactions including additional sessions and surveys. Conclusion The findings of this study indicate that mindfulness-based activities for parents of a child with a disability can decrease anxious feelings during the co-occupation of play. We observed both a positive physical and emotional impact on caregivers during the virtual mindfulness session. Both participants indicated in the follow-up survey that at least three, if not all, of the mindfulness-based activities completed with researchers were advantageous to them. It would be beneficial for future studies to examine mindfulness-based intervention strategies and their effect on anxious feelings experienced by caregivers with a more quantitative measure of anxiety during play. It may also be beneficial to examine the effects of prolonged use of mindfulness techniques on the anxious feelings of caregivers. The scope of occupational therapy includes addressing mental health and dimensions of well-being that may negatively impact an individuals everyday roles and task completion. Play is viewed as an important co-occupation between parent and child for both individuals. Therefore, addressing the influence of anxious feelings on play for parents addresses multiple aspects within the scope of occupational therapy. 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Parenting stress and self-compassion in parents of children with and without psychological disorders. The Family Journal, 31(2), 308313. https://doi.org/10.1177/10664807221123557 Tamm, M., & Skr, L. (2000). How I play: Roles and relations in the play situations of children with restricted mobility. Scandinavian Journal of Occupational Therapy, 7(4), 174-182. Willard, C. (2017). Raising resilience: The wisdom and science of happy families and their thriving children. Sounds True. Appendix Mindfulness-Based Activities Provided to the Participants Title of Activity Description Self-Compassion Letter to Self Sit in a comfortable setting and think through the details of a difficult parenting situation, reflecting on that moment. When thinking of this time, remind yourself, you are a good-enough parent and all parents struggle. Take a few more grounding breaths, recognizing any physical or emotional feelings that arise. Grounding and Centering Exercise Find a comfortable, quiet space. Stand up and notice the feeling of the ground beneath your feet. Slowly shift your weight back and forth and bring awareness to this sensation. Begin to notice how this shift in weight affects your legs, hips, and lower stomach. S.T.O.P. Exercise S.T.O.P. is an acronym standing for Stop what you are doing, Take a few deep breaths, Observe your bodys physical and emotional sensations, and Proceed with what you were doing once you feel grounded. Feel Your Hand Activity Sit in a comfortable position and close your eyes. Take your right hand and stroke your left hand for a few seconds. Switch hands. Continue to repeat this process for several minutes to help bring yourself to reality. Name a Goodie This activity can be completed within a group of individuals or alone. Participants go around the circle naming something that is good or positive in their life (ex. A smell, something they had to eat recently, getting engaged, etc.). Remember what you pick does not have to be positive for everyone. Adult Coloring Find an adult mindfulness coloring page or create your own to color. Pay attention to your senses as your are coloring- what you see, hear, smell, feel, and taste. To increase the sensory experience, you may add scented oils or markers, food, beverages, or music. One Big Mindfulness Day Set aside one day every week to focus on mindfulness activities that help you feel grounded. These activities can vary from person to person, or even day to day. Candle Study Exercise Light your favorite scented or unscented candle and observe how the flame flickers. Complete this for five to ten minutes, allowing your mind to wander and observing the thoughts that drift through. Gratitude Scavenger This activity can be completed alone or with your child. During this Hunt activity, there are numerous things to be searching for including: something you enjoy first thing in the morning, something that makes you happy, something you enjoy playing with, your favorite game to play, a place you feel the most comfortable, etc. Walking Meditation Find a walking path where you will not be disturbed. Take ten-fifteen steps or propel yourself twenty to forty feet and stop, breathing for as long as you need. When ready, repeat this movement and focus on making small, slow movements. During these slow movements, observe one or more sensations that you would normally take for granted. It is okay for your mind to wander during this mediation. Adjustments can be made to this daily walk to fit the individuals needs for that day. Acceptance of Thoughts and Feelings Sit in a comfortable place and focus on your breath. Allow your mind to wander, noticing each thought that passes by. Guide your attention back to the sensation of breathing and bring a quality of compassion to your awareness. As you become aware of various bodily sensations that arise, shift your attention to these sensations briefly. Acknowledge the comfort or discomfort that surfaces and begin to differentiate yourself from your thoughts and feelings. Without judgment, label the thought or feeling and move on. Remind yourself you are not what those thoughts or feelings convey to you. Mindfulness Parenting Tool Kit The mindfulness tool kit is something you and your family can create together that will include various mindfulness activities you and your family enjoy. There is not a limit on how many activities are needed, just make sure they are meaningful and beneficial. The Body Scan Find a comfortable and quiet place to complete this activity. It can last anywhere from five to thirty minutes depending on the style you choose. A typical body scan will have you lying on your back and focusing on different parts of your body at a time, starting from your feet and slowing making its way to your head. Morning Page Every morning when you wake up write whatever comes to mind. What you write does not have to be creative or have any structure as long as it is helpful and meaningful to you. Three-Minute Breathing Space Find a comfortable and quiet space to help you relax and feel grounded. During these three-minutes, you will start with closing your eyes and thinking about what you are doing. Bring your attention to your breathing, making sure to take deep breaths in through your nose and out through your mouth. Shift your attention to how your body feels and focus on the environment around you. Who Am I Beyond My Formatted questions are provided, focusing on self-reflection. Anxiety Reflection These questions have you list positive characteristics about yourself, activities you do and do not enjoy, describe which relationships in your life are most important to you and why, and what you feel like you are best at.  ...

... Examining Occupational Therapists Perception of Efficacy in Telehealth During the COVID-19 Pandemic Lauren Gandhi, Samantha Rich, Alexandria Dattilo, Karlie Hamilton, Kirstin Krause, Eric Meyers, Brynn Shallenberger December, 2023 A research project submitted in partial fulfillment for the requirements of the Doctor of Occupational Therapy degree from the University of Indianapolis, School of Occupational Therapy. Under the direction of the research advisor: Lori Breeden, EdD., OTR Examining the occupational therapy perception of efficacy in telehealth A Research Project Entitled Examining Occupational Therapists Perception of Efficacy in Telehealth During the COVID-19 Pandemic 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 Lauren Gandhi, Samantha Rich, Alexandria Dattilo, Karlie Hamilton, Kirstin Krause, Eric Meyers, Brynn Shallenberger Doctor of Occupational Therapy Students Accepted on this date by the OTD Program Director: 12/7/23 Alison Nichols, OTR, OTD OTD Program Director Associate Professor of Occupational Therapy Date 2 Examining the occupational therapy perception of efficacy in telehealth 3 Examining the Occupational Therapy Perception of Efficacy in Telehealth During the COVID-19 Pandemic Lauren Gandhi, Samantha Rich, Alexandria Dattilo, Karlie Hamilton, Kirstin Krause, Eric Meyers, Brynn Shallenberger School of Occupational Therapy, University of Indianapolis Author Note Lauren Gandhi, School of Occupational Therapy, University of Indianapolis, https://orcid.org/0000-0002-7104-5084 Samantha Rich, School of Occupational Therapy, University of Indianapolis, https://orcid.org/0000-0002-5513-5100 Alexandria Dattilo, School of Occupational Therapy, University of Indianapolis, https://orcid.org/0000-0001-7847-2460 Karlie Hamilton, School of Occupational Therapy, University of Indianapolis, https://orcid.org/0000-0002-5072-3720 Examining the occupational therapy perception of efficacy in telehealth Kirstin Krause, School of Occupational Therapy, University of Indianapolis, https://orcid.org/0000-0003-2775-6599 Eric Meyers, School of Occupational Therapy, University of Indianapolis, https://orcid.org/0000-0001-8905-4037 Brynn Shallenberger, School of Occupational Therapy, University of Indianapolis, https://orcid.org/0000-0001-6645-6607 4 Examining the occupational therapy perception of efficacy in telehealth 5 Abstract Background: During the COVID-19 pandemic, clients relied on telehealth to gain access to health care services. As telehealth continues to be used it is important to understand how to implement quality sessions. This study aimed to identify practitioner needs related to the development of telehealth skills. Methods: Participants included occupational therapy practitioners who used telehealth in practice. Snowball sampling was used to recruit participants for semi-structured interviews. Thematic analysis of the interview transcription resulted in categories which were a focus of discussion during interviews. Findings: Data analysis led to five thematic categories. These were: Telehealth barriers and benefits, Telehealth value on a scale, Logistics of the telehealth transition, Client readiness for telehealth participation, and Educating caregivers and supporting their participation via telehealth. Conclusion: The information revealed through this study supports occupational therapy practitioners in their understanding of how service delivery can change with telehealth. Considering ways to modify occupational therapy practice could make telehealth an effective tool instead of an inadequate alternative to in person delivery. Examining the occupational therapy perception of efficacy in telehealth 6 Examining the Occupational Therapy Perception of Efficacy in Telehealth During the COVID-19 Pandemic During the COVID-19 pandemic, telehealth was an option for individuals to gain access to health care services without risking exposure to the virus. In Indiana, OT practitioners had no history using telehealth until Governor Eric Holcomb issued an executive order, authorizing its use (Exec. Order No. 20-13, 2020). The American Occupational Therapy Association (AOTA) identified telehealth as a valid delivery method of occupational therapy services and provides occupational therapists with resources for telehealth (Cason et al., 2013). As healthcare systems continue making adjustments to practice during a pandemic occupational therapists may continue to use telehealth as it allows flexible scheduling and practitioner satisfaction with interventions (Hoel et al., 2021). Traditionally, the physical engagement of occupational therapists with their clients was viewed as essential to providing occupational therapy services (Dahl-poplizio et al., 2020); during the pandemic, in-person interventions were less possible, which forced many practitioners to learn to adapt their strategies using trial and error rather than a traditional evidence based approach (Dahl-poplizio et al., 2020). OT practitioners expressed frustration with the use of telehealth as a delivery method during the pandemic and many experienced barriers to providing effective interventions (Breeden et al., 2023). The COVID-19 pandemic created an emergency use situation and practitioners felt under-prepared to perform well using telehealth as a means of service delivery (Hoel et al., 2021). Our methodology is based on a phenomenological approach, however, the adoption of telehealth by practitioners was examined through the lens of social constructivism (Amineh & Asl, 2015). Social constructivism explains the ways individuals create meaning from their Examining the occupational therapy perception of efficacy in telehealth 7 experiences based on interactions with other people and the environment around them (Amineh & Asl, 2015). The meaning practitioners derive from their experiences with telehealth as a rehabilitation tool can be influenced by their positive and negative interactions. The purpose of this qualitative study was to examine occupational therapists perceptions of using telehealth during the COVID-19 pandemic. This study aimed to identify occupational therapy practitioner needs related to the development of telehealth skills. This study aimed to make recommendations about the direction of continuing education for telehealth to allow practitioners a smoother transition into OT service delivery in the virtual world. Key Words: Telehealth, Occupational Therapy, COVID-19 Telehealth is the use of audio and video equipment to provide healthcare-related services over a virtual platform (What is telehealth, n.d.). Occupational therapy is the use of rehabilitative services to increase participation in daily living, often through the physical manipulation of the environment and/or the client during treatment sessions (Definition of occupational therapy practice for the aota model practice act, n.d.). Literature Review Between 2012-2019, prior to the COVID-19 pandemic, most telehealth users were those who lived in rural populations (Chu et al., 2021). Although people in rural populations increased their use of telehealth during the COVID-19 pandemic, the greatest increase during this time was found in urban populations (Chu et al., 2021). Telehealth use increased in all age categories since 2019, but the biggest increase was seen in older adults aged 65+, likely due to restrictions during the COVID-19 pandemic for this high risk age group (Chu et al., 2021). Examining the occupational therapy perception of efficacy in telehealth 8 There were many perceived barriers to the switch to telehealth use. According to Iacono et al. (2016), the majority of OT practitioners surveyed were hesitant to use telehealth due to the risk of poor client-therapist relationships. Difficulties were also identified with supervising patients and privacy concerns (Rortvedt, 2019). Technical difficulties, lack of physical contact, caregiver involvement, and lack of universality for all patients were reported as perceived barriers of the use of telehealth (Dahl-popolizio et al., 2020). Abbott-Gaffney & Jacobs (2020) found internet reliability, lack of physical contact, lack of licensure portability across states, and inappropriate referrals as barriers. Additionally, client factors such as finances and caregiver assistance, and workplace needs associated with updated technology and tech support were identified as barriers to using telehealth (Goel et al., 2022). Access to technology and funding were also identified as perceived barriers (Hoel et al., 2021). Although there were many barriers identified, there were also benefits that came with the use of telehealth. Worboys et al. (2017) found that the majority of occupational therapists surveyed were satisfied with telehealth services and found ease of equipment use and appropriate audio quality. Of the occupational therapists surveyed, 83% expressed that they were able to satisfactorily and competently assess patients (Worboys et al., 2017). Schedule flexibility was also identified as a perceived benefit (Rortvedt, 2019). Proffitt et al. (2021) reported that occupational therapists perceived the lack of traveling out to clients as a benefit of telehealth. Occupational therapists perceived an increased correlation between telehealth use and safety as well as reasonable employer expectations as benefits (Hoel et al., 2021). Abbott-Gaffney & Jacobs (2020) reported efficiency, student engagement, and comfort as perceived benefits to telehealth. Goel et al. (2022) identified that for patients with spinal cord injuries, telehealth was Examining the occupational therapy perception of efficacy in telehealth 9 beneficial for access to care, safety, carryover of care, and patient education in activities of daily living and instrumental activities of daily living. Occupational therapists have identified several diagnostic groups that have benefitted from telehealth during the pandemic. These included: patients with hand injuries (Worboys et al., 2017), patients with spinal cord injuries (Goel et al., 2022), pediatric settings (Dahl-popolizio et al., 2020), patients with developmental delays (Dahl-popolizio et al., 2020), and school settings (Abbott-Gaffney & Jacobs, 2020). Based on the perceived benefits and barriers to the efficacy of telehealth, this type of practice delivery is perceived as a productive tool for specific populations. More research is needed on individual capabilities of clients in order to determine if using telehealth is appropriate for treatment. Although perceptions of benefits and barriers to telehealth have been examined, there are no clear conclusions of efficacy. There is a gap in the literature that prevents us from moving beyond the general mechanics of telehealth practice and examining how OT practitioners manage the challenges. This study examined the experience of success and failure within telehealth practice to identify practitioner needs and better prepare future practitioners for this method of service delivery. Methods Study Approach/Design The study was guided by a phenomenological approach, which gathers individuals experiences of the same phenomenon and the meaning of those experiences to the individuals (Creswell & Poth, 2018). The phenomenological approach seeks out key elements common in most, or all, of the individuals experiences of a phenomenon (Creswell & Poth, 2018). This Examining the occupational therapy perception of efficacy in telehealth 10 study aimed to analyze the data by looking at the interactions the participants had with their environment, employers, peers, and clients, through telehealth. The data was viewed through the lens of social constructivism. Social constructivism was used to analyze qualitative data by theorizing that people make meaning in their reality by interacting with their environment and the people around them (Amenineh, R. & Asl, H., 2015). We demonstrated trustworthiness through member checking, analysis of reflexivity journals, and the use of an audit trail (Krefting, 1991). Participants Six occupational therapy practitioners were interviewed as participants in this study. An occupational therapy practitioner was an occupational therapist or an occupational therapy assistant with no minimum of practice experience in the field. The occupational therapy practitioners were required to have used telehealth at least once. Participants were recruited using social media and snowball sampling (Patrick, et al., 1998). We placed recruitment posts on CommunOT and other OT discussion boards, OT Hub and groups on Facebook, as well as local professional association meetings. Procedures Six participants from multiple occupational therapy settings were interviewed in-depth regarding their experiences in telehealth. We used field notes, member checking, and reflexivity journals from their interviews to insure trustworthiness (Krefting, 1991). Data Collection Researchers used semi-structured interviews to obtain in-depth information from each participant (Alshenqeeti, 2014). The interviews allowed participants to explain topics in their own voice, as well as for the interviewer to ask clarifying questions and access complete Examining the occupational therapy perception of efficacy in telehealth 11 answers; semi-structured interviews also allowed for the interviewer to dig deep into topics that a structured interview cannot (Alshenqeeti, 2014). A second researcher was present during interviews to manage the audio recording and take field notes (Krefting, 1991). The study was determined to be exempt by the institutional review board at the University of Indianapolis. Informed consent documents were not signed by participants as it would have been the only identifying information connecting the participants to the study. Prospective participants were informed that their participation was voluntary, and they were free to end their participation at any time. Data from the interview (recordings and transcription) were stored in a password protected computer in a locked office. Recordings were deleted after transcription was completed. Any identifying information from the recordings was given an alias during transcription. Each member of the research team reflected on and disclosed any bias they had for telehealth, the participants, and the project in general through reflexivity journaling. An audit trail was maintained during transcription and data analysis. Both measures were taken to increase trustworthiness. Data Analysis To guide our qualitative thematic analysis, we used the phases laid out by Braun & Clark (2006). The phases are as follows: familiarizing yourself with your data generating initial codes searching for themes reviewing themes defining and naming themes Examining the occupational therapy perception of efficacy in telehealth 12 producing the report (Braun & Clarke, 2006) Transcription occurred by two members of the research team who were not present during the interview. This transcription occurred within 24 hours, and analysis of the transcript, adequate to allow member checking, began within one week (Alshenqeeti, H., 2014). Working in pairs, researchers began coding interview transcripts and came to an agreement on codes. Following, the entire team cross compared codes for consistency. Groups of two from the research team individually coded transcripts and then compared codes together. Finally, the team came together and collaborated on a final code for the transcripts (member checking) (Krefting, 1991). Once coding was complete, memoing focused on the coded quotes as representation of action within the experience being shared. Using a dry erase board, concept maps of memos provided a visualization of participants' telehealth experiences. Findings Thematic analysis of interview transcripts led to five thematic categories regarding the use of telehealth during the COVID-19 pandemic: telehealth barriers and benefits telehealth value on a scale logistics of the telehealth transition client readiness for telehealth participation caregiver education and participation Telehealth Barriers and Benefits The interviews yielded patterns of reported barriers and benefits of telehealth practice among participants. As a benefit, Participant 5 (P5) reported experiencing professional growth while practicing Am I grateful for the things I have learned from experiences it brought? Examining the occupational therapy perception of efficacy in telehealth 13 Yeah. I do. I think Im a better therapist (P5). Additionally, another benefit that participants expressed was telehealth promoted occupation-based treatments, which was useful for functional task carryover. P5 discussed that they used more occupation-based treatment during telehealth use when they were required to go bagless and rely on what the patient had in their home to perform interventions. P5 said, I wouldve probably tried bagless soonerit kind of forces you to [be more flexible]. Participant 6 (P6) shared an example of their use of occupation-based treatment and explained that during the holidays, a patient needed to switch from an in-person session to telehealth due to poor weather. P6 shared their experience of providing occupation-based care by building their session around wrapping holiday gifts: It was really great because it was something [the patient] got to do for his grandkids and something he had always kind of done where he actually got to participate more that yearit was great cause it allowed me to see a whole bunch of different functions at the same time and really really be a purposeful activity, and that was not a mimic of something. Participants noted barriers to accomplishing a successful telehealth session. Participant 2 (P2) reported that a lack of hands-on access contributed to patients becoming distracted by other family members who were present during sessions. Often during the lockdown period parents were managing multiple children in the homes during a telehealth OT session. The same participant stated, ...during COVID their kids couldnt go anywhere else, cause daycares were closed, schools were closed. And so they're trying their best to pay attention they were doing the best they could. These types of recurring distractions for clients and caregivers led to practitioners feeling that they could not control the treatment environment well enough to provide effective treatment. Another barrier discussed throughout the interviews was that using Examining the occupational therapy perception of efficacy in telehealth 14 telehealth led to increased time for the evaluation process. P6 stated, I have yet to figure out how to do an assessment verbally. Furthermore, some evaluations were deemed by participants as a poor fit for virtual practice. P6 shared: [It] takes a skilled eye to then do it over camerahow can I have them do a nine hole peg test, to stack some blocks, the dynamometer, the pinch gauge, you know those things, the range of motion, that stuff I cant fill out remotely. These identified benefits and barriers left participants presenting their telehealth experience as inferior to traditional treatment but better than clients receiving no treatment at all. Telehealth value on a scale Patterns surfaced across participants including preparation, skepticism, and success or a lack thereof when utilizing telehealth. The patterns revealed a perception that telehealth was a better alternative for clients to receive services versus not at all. As pandemic protocols evolved, healthcare practitioners developed an awareness that virtual sessions needed to be intentionally managed. Participant 3 (P3) offered, I dont think zoom will ever go away now, its here to stay you have to adapt. P2 suggested that the abrupt shift to telehealth during the pandemic left them feeling like a new practitioner or student again. However, P5 was grateful for the experiences telehealth brought, and believes that they are a better therapist because of it. P6 explained that although building rapport is difficult over the computer, it is getting better and people are getting more comfortable. P6 also noted that the home environment is a safer space for the client and may give more insight into actual functioning than what is seen in the clinic. Some participants are still skeptical of virtual delivery and they do not see telehealth as productive as in-person care. P2 states Im assuming though if I were doing real techniques with them then after a few [telehealth] visits, we would get it, whereas maybe it wouldve only Examining the occupational therapy perception of efficacy in telehealth 15 taken me one [visit] in person. P6 explained their reasoning for patients that are well vs. poorly suited for telehealth: As we weigh modalities and other things, theyve all got pieces and roles and have parts where its more appropriate than others. They closed with this statement: As long as I think we keep the patient at the center, so patient-centered care, and you take a look at it as a way of, is this a tool that helps them or doesnt help them and how can we modify and adjust it? Then thatll serve us fine with any kind of new technology that comes through. So you keep that at your center and the center of what you do and, you know, being an OT, and the rest falls into place. Based on their experiences with using telehealth, practitioners feel that telehealth visits were better than patients not receiving care, but traditional in-person occupational therapy is better than telehealth. Logistics of the Transition Some participants shared the idea that a lack of leadership during this telehealth transition revealed a stagnation in their organizations which limited care overall. In this case systemic stagnation refers to their healthcare system experiencing a bottleneck in the flow of providing occupational therapy services after evaluations were conducted. The inability of the healthcare system to transition quickly and keep up with the demands of an unexpected healthcare crises was limiting to the provision of care. This became evident during the pandemic as healthcare providers quickly transitioned to online care. Participant 1 (P1) stated, It was just like were closing Friday and were starting telehealth, you know? For some, leadership stepped in and made this transition easier. P2 stated: Yeah they're really great about giving us such training about changing stuff. Of course, everybody has pitfalls and things get forgotten, and things like that. But this is definitely, Examining the occupational therapy perception of efficacy in telehealth 16 the company is on top of it. And they're sending things out ahead of time, which is really nice. Leadership from companies during the transition to telehealth was crucial for practitioners to provide quality care to patients. Participants who experienced a lack of leadership from their companies felt limited in providing care. An OT practitioner working in early intervention described ample use of telehealth for evaluation, but insufficient care providers to provide interventions. P5 described their experience: You know, an assessment team can see if you see four families a day for five days a week, youve seen 20 families. But then its 20 different families, and its another 20 families the next week, and another 20 families the next week. Where if youre seeing them ongoing, you may have those 20 slots but only 20 families. So in a month, Im seeing 20, theyre seeing, you know, what, 80. Transitioning to telehealth exacerbated this organizations disparity between evaluating and providing interventions for an exponentially growing list of clients. They expressed frustration with healthcare leadership to appropriately balance staffing allowing the provision of care to stagnate. Client Readiness The interviews also produced patterns that considered the clients readiness or lack thereof as influencing the success of telehealth sessions. Participants reported better outcomes with preparation of the client prior to the session either by the occupational therapist or through the client's engagement. P1 mentioned that they would drop things off on client porches, and their advice to the caregiver was to come up with as many, like, generic activities [to keep] in your toolkit as possible. P1 also mentioned the workload that goes into planning virtual sessions Examining the occupational therapy perception of efficacy in telehealth 17 may have slowed productivity, saying, I was only really seeing initially I would say two or three kids a day because besides their 45 minute treatment session, there was so much work going into the planning processes. Participants reported that parents began creating toolkits of things that could be beneficial for therapy sessions for their kids. P5 stated: I had one mom I was working with in person that got really excited about some of the stuff we were doing and then she would be at dollar tree or she would be at Walmart and see something and she would be like I wanna try this one! OT practitioners were forced to take a more active role in preparing their clients prior to treatment through the physical delivery of materials and through communication with caregivers. Caregiver Education and Participation Caregiver education and participation came up a number of times during practitioner interviews. Analysis revealed that when an occupational therapist did not have the ability to work hands-on with their clients, it seemed to create a sense of pressure for the caregiver to take on the therapist role during sessions. P3 noted, It is a lot more work for [caregivers]. P1 discussed how clients did not want to listen to their caregivers during sessions, saying, If the kid needed the parental support during their sessionthe kid doesnt really want to listen to the parent. That was, that was difficult. Participants noted they felt that telehealth supported caregiver education and impacted client progress. One participant discussed how caregiver education was completed during their sessions: I had a baby doll that I could use. Um its a training baby doll that we use for training clinicians, um, but I had one that I could kind of show them what I wanted them to do as well but yeah theres a lot of showing, a lot of a lot of tries. And then sometimes it just didnt go well. Examining the occupational therapy perception of efficacy in telehealth 18 P5 noted, Requiring [caregivers] to be more involved, I think, has been a benefit as well in terms of carryover. Furthermore, The parents who are getting down and dirty getting with the kid are the ones who make the best progress. When caregivers were properly educated, the participants reported that it increased the opportunity for them to be involved with the clients treatment which supported the clients overall progress. After analyzing the participants experiences using telehealth, five themes were identified. Benefits to telehealth were that it promoted professional growth and occupation-based treatments, which was useful for functional task carryover outside of therapy sessions. Barriers to telehealth were that a lack of hands-on access contributed to patients becoming distracted during treatment sessions. Telehealth was seen as better than nothing, but in-person was still preferred; some contributing factors were feelings of skepticism, preparedness, and success or not. Company leadership made a difference to our participants on whether telehealth was perceived as successful or not. The participants that had a supportive leadership team that provided them with structure and guidelines had a smoother transition into telehealth. For others, there was a stagnation in care due to a lack of leadership. Clients readiness or lack thereof influenced the success of telehealth sessions. Furthermore, when practitioners felt they had a strong company leadership they were able to prepare the client for sessions better. When an occupational therapist did not have the ability to work hands-on with their clients, it seemed to create a sense of pressure for the caregiver to take on the therapist role during sessions. Additionally, telehealth was found to support caregiver education and increase caregiver participation which impacts client progress and carryover in the home. Examining the occupational therapy perception of efficacy in telehealth 19 Discussion Findings consisted of five themes regarding telehealth use throughout peak COVID-19 pandemic. In comparing our themes to the current literature, we found additional support for many of our findings with a few exceptions. Telehealth Barriers and Benefits Data analysis revealed barriers and benefits to practicing telehealth secondary to COVID. One of the barriers practitioners identified was the lack of ability to physically guide clients during an intervention, which led to practitioners feeling they could not adequately control the treatment environment. Lack of physical contact with clients is reported as a barrier to treatment due to the information physical contact provides during evaluations, like joint end feel with range of motion (Rortvedt & Jacobs, 2019; Wittmeier et al., 2022). Our findings are supported by Rortvedt & Jacobs (2019) as participants reported they saw hands-on evaluation as the best way to assess a clients physical characteristics. Not having hands-on evaluations with patients, therapists were challenged to go outside of their normal practices in order to provide the most effective care. Another barrier identified by our participants was inefficiency with telehealth evaluations, which influenced overall productivity. Practitioners explained that evaluations took much longer during telehealth use if the evaluations were deemed valuable at all (Wittmeier, et al., 2022). Researchers reported athletic trainers did not find evaluations via telehealth as a useful practice due to their reliance on hands-on access to clients (Winklemann et al., 2020). Difficulty conducting evaluations over telehealth is a barrier supported by the current literature and our participants responses. Examining the occupational therapy perception of efficacy in telehealth 20 The final barrier our participants identified was the increased distractions to clients coming from family members. This barrier was influenced by the lack of hands-on access to clients, as it led to practitioners feeling ineffective without physical intervention. This theme is not supported or refuted by literature as a barrier, but participants reports suggest a relationship between distractions to clients and the lack of hands-on access to clients that practitioners experienced. Participants identified professional growth as a benefit of using telehealth. This idea is supported in the literature through reported challenges of using telehealth, which led to professional growth through expanding practitioners creativity and critical thinking (Wittmeier et al., 2022). Researchers found that therapists experienced professional growth through learning new skills and improved on existing skills, like coaching and teaching, especially with families of clients (Wittmeier et al., 2022). Through the opportunities telehealth provided for occupation-based care, our participants found better functional skill carryover as a benefit as well. Wittmeier et al. (2022) reported OT and physical therapy (PT) practitioners appreciated the benefit of seeing clients interact with their home environments. Some therapists reported it was easier to make recommendations based on what families had available in their homes (Wittmeier et al., 2022). Though therapists experienced professional growth through the use of telehealth and appreciated an increased use of occupation-based intervention, the lack of hands-on access, client susceptibility to distractions, and increased evaluation efficiency left participants concluding that while telehealth is better than receiving no treatment at all, it is inferior to traditional treatment. Telehealth value on a scale Examining the occupational therapy perception of efficacy in telehealth 21 Participants offered that while telehealth sessions were better than nothing, in-person sessions were preferred. Findings in this study are consistent with previous research. Physicians expressed skepticism with the lack of in-person evaluations; their main concern was the lack of in-person evaluation increasing the chance of missing symptoms and negatively affecting treatment (Goldberg et al., 2022). The reduced in-person treatment session had physicians concerned with missed signs and symptoms (Goldberg et al., 2022). This is consistent with our findings where the concern of reduced in-person care altered the treatment and intervention strategies. A second study that interviewed orthopedic physicians and athletic trainers also identified skepticism with the success of telehealth (Winklemann et al., 2020). Researchers found that the lack of hands on and in-person interaction increased skepticism of successful sessions (Winklemann et al., 2020). Researchers found that physicians expressed concern with telehealth not providing comparable care to patients virtually (Alqahtani et al., 2022). Clinicians in a mental health setting were skeptical when starting to use telehealth, finding a preference for in-person interactions with their clients over telehealth (Lynch et al., 2021). Despite overarching skepticism of the use of telehealth in practice, many providers agree the role of telehealth is beneficial in reaching clients although find it better than no contact for care at all. Overall, the current research confirms that clinicians prefer telehealth over clients not receiving treatment, but not as much as they prefer in-person sessions. Logistics of the Transition Participants in this study identified logistics of telehealth and organizational leadership regarding the telehealth transition as directly impacting service delivery. Hoel et al. (2021) found that for many providers, successful use of technology was hindered by limited knowledge of online platforms and procedures to organize telehealth delivery. Hoet et al. conducted a similar Examining the occupational therapy perception of efficacy in telehealth 22 study in which many respondents stated that they did not receive proper guidance during the urgent transition to virtual therapy. This supports the finding that organizational leadership was seen as making a difference when it came to the quality of services. In a qualitative study by Lynch et al. (2021), participants noted there was good conservation of care and they were able to successfully adapt the sessions to the individual client to produce better flexibility of the session time and duration. To maintain continuity of care and maintain HIPAA compliance, the administration developed resources and provided training to the clinicians (Lynch et al., 2021). The perception of leadership effectiveness, and its relationship to the transition to a telehealth platform is an opportunity for further research; however both topics were meaningful to participants in this study. Client Readiness Participants believed their sessions were more effective when they prepared the client prior to the occupational therapy telehealth session. The literature reflects that while some researchers found that preparation of the client led to more personalized care, others suggested that having the client prepare prior to the session might not be very effective (Goldberg et al., 2022; Hughes et al., 2020). Participants receiving telehealth cognitive-behavioral therapy (CBT) felt better about doing telehealth therapy when the clinician communicated the purpose of the activities (Hughes et al., 2020). In the current study the theme of preparing the client for the session is consistent with this previous literature. Goldberg et al. (2022) interviewed physicians who worked with the geriatric population who reported the need to retrain staff, or rely on volunteers to provide more pre-visit preparation and orientation to patients. Furthermore, physicians found no changes in digital literacy for older adults in use of telehealth (Goldberg et Examining the occupational therapy perception of efficacy in telehealth 23 al., 2022). Preparation of the client was identified by occupational therapy practitioners in this study as an important part of a successful session. Clinicians noted issues they faced when using telehealth included technology issues, human error with technology, changes in the environments of those involved with the session, how to transition techniques to be used virtually, and how to maintain regulations virtually (Waller et al., 2020). Some of the ways clinicians found they were able to alleviate issues with telehealth was having the client prepare by: having the equipment to write down information ready, preparing the device the client will use for the session, checking their ability to connect through their internet, having a safe space to participate in that is private, limiting distractions, and sending information prior to the session (Waller et al., 2020). Caregiver Education and Participation Caregiver education and participation in telehealth has been studied in previous research. Karlsen et al. (2018) examined the experiences of older adults and affirmed the theme regarding increasing pressure on caregivers: Family caregivers reported that [telehealth] eased their concern for a time. However, they felt increased responsibility which led to ambivalent feelings between wanting to comply with the older adults desire to live at home and the stress and concern this caused (p. 1300). Although caregivers were able to check in on the older adults during telehealth sessions, telehealth ended up increasing their stress. When an occupational therapist does not have the ability to be hands-on with their clients, it seemed to create a sense of pressure for the caregiver(s). Examining the occupational therapy perception of efficacy in telehealth 24 Another theme that was affirmed through the research was that caregiver participation increased progress for the client: active participation of the caregivers was considered critical to the success of the telehealth experience (Fergus et al., 2021, p. 162). Furthermore, the telehealth delivery of service seems to enhance the empowerment and buy-in of the patient/caregiver resulting in improved outcomes and carryover for PT (Fergus et al., 2021, p. 159). Previous research supports the importance of caregiver participation and education based on it supporting the clients overall progress. Conclusion Findings of this study provide insight into occupational therapy practitioners perceptions of telehealth use during the COVID-19 pandemic. This study identified practitioner needs related to the development of telehealth skills. Recommendations for practice include that employers develop and integrate training for practitioners to create consistent telehealth guidelines to support virtual practice. Additionally, this study identified that there may be a lack of efficacious evaluations suitable for virtual practice. Practitioners interviewed for this study were unaware of existing literature about evaluations in virtual practice. Furthermore, practitioners should prepare themselves for telehealth practice through existing evidence, continuing education, and understanding the practice guidelines that affect the provision of telehealth. Future research should include examining the psychometric properties of assessment tools when implemented virtually, as well as the design of interventions that better fit the virtual practice realm. Additionally, telehealth-specific training should be developed to ensure therapist competency in practice via telehealth. Examining the occupational therapy perception of efficacy in telehealth 25 Acknowledgements We thank the participants for their time and for providing stories of their experiences using telehealth during the COVID-19 pandemic. We also acknowledge Dr. Penelope Moyers for her support and encouragement during the early stages of our study. Examining the occupational therapy perception of efficacy in telehealth 26 References Abbott-Gaffney, C., & Jacobs, K. (2020). Telehealth in school-based practice: Perceived viability to bridge global ot practitioner shortages prior to COVID-19 global health emergency. 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... 1 Educational Interventions for Managing Ethical Problems in Occupational Therapy: A Survey Brenda Howard, Payton Berger, McKayla Hendricks, Allison Moll, Erin Rusconi, Abigail Shamdin, Julia Swindeman, and Zoe Cochran December 2023 A research project submitted in partial fulfillment for the requirements of the Doctor of Occupational Therapy degree from the University of Indianapolis, School of Occupational Therapy. Under the direction of the research advisor: Brenda Howard, DHSc, OTR, FAOTA EDUCATIONAL INTERVENTIONS FOR MANAGING ETHICAL PROBLEMS 2 A Research Project Entitled Educational Interventions for Managing Ethical Problems in Occupational Therapy: A Survey 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: Dr. Brenda Howard, DHSc, OTR, FAOTA, Payton Berger, McKayla Hendricks, Allison Moll, Erin Rusconi, Abigail Shamdin, Julia Swindeman, and Zoe Cochran Accepted on this date by the OTD Program Director: Alison Nichols, OTR, OTD OTD Program Director Associate Professor of Occupational Therapy 12/13/23 Date EDUCATIONAL INTERVENTIONS FOR MANAGING ETHICAL PROBLEMS 3 Abstract Moral distress is a prevalent issue among healthcare professionals. Little is known about how to mitigate moral distress within the field of occupational therapy, but ethics education may reduce its impact by providing practitioners with tools for managing ethical problems. The purpose of this study is to explore the impact of ethics education on managing ethical problems among occupational therapy practitioners within the first five years of practice. Specifically, the investigators looked at the type of ethics education that occupational therapy practitioners received and how helpful they found it. This study used a pre-existing survey dataset that was collected in the Spring of 2020. Questions included what ethical problems practitioners have encountered, ethics education they have received, how much they believed each kind of education helped them manage ethical problems, and how confident they felt responding to ethical issues in practice. Researchers analyzed data by using Spearmans rho and Kendalls Tau-b to evaluate the influence of the type of education on the level of helpfulness. Practitioners reported that the most helpful ethics education types were classroom discussions and case studies; fieldwork mentorship, informal discussions, and experience; continuing education; and informal discussions with colleagues. Practitioners relied on personal experience, common knowledge, past education, supervisors, mentors, and colleagues within their organizations to manage ethical problems. They were confident in their ability to manage ethical problems, access the AOTA Code of Ethics and State Practice Act, and find setting policies pertaining to ethics. They were not confident in finding written resources or filing an ethics complaint. This study will add to the current literature by evaluating the effect of ethical education and how helpful it is when occupational therapy practitioners are faced with ethical problems in the workplace. Keywords: Moral distress, ethics education, occupational therapy EDUCATIONAL INTERVENTIONS FOR MANAGING ETHICAL PROBLEMS 4 Educational Interventions for Managing Ethical Problems in Occupational Therapy: A Survey Moral distress is prevalent in healthcare (Penny & You, 2011), including the profession of occupational therapy (OT; Penny et al., 2014). There is very little literature that discusses occupational therapy ethics education in the United States (US), and very little literature explores what type of education helps practitioners manage ethical problems (Dieruf, 2004). However, if practitioners are able to manage ethical problems, their moral distress may decrease (Bushby et al., 2015; Drolet, 2018). Morley, Bradbury-Jones, et al. (2021) defined moral distress as, The psychological distress that is causally related to a moral event (p. 2). When moral distress is not properly addressed, there is a decrease in job satisfaction that has the potential to lead to negative mental health outcomes in both patients and workers (Smallwood et al., 2021). The fact that moral distress negatively impacts patient care warrants careful consideration of interventions to reduce moral distress in occupational therapy practitioners. Much of the available literature on interventions for mitigating moral distress focuses on managing the emotions and trauma accompanying moral distress, not how to directly address the ethical issue at the root of the moral distress. These interventions include breathing techniques, yoga, self-reflection, and meditation (Patronis & Staffileno, 2021). Furthermore, there is no available literature that discusses education on how to prevent moral distress for occupational therapy assistants, a population that faces moral distress but does not have their experiences in relation to moral distress documented in the literature (Penny, 2019). Because moral distress is a prevalent issue among occupational therapy practitioners, there needs to be a better understanding of how entry-level occupational therapy and occupational therapy assistant programs might mitigate moral distress by intervening through education. EDUCATIONAL INTERVENTIONS FOR MANAGING ETHICAL PROBLEMS 5 The purpose of this study was to explore the impact of ethics education on managing ethical problems in practice among occupational therapy practitioners within the first five years of practice. Specifically, investigators examined the formats and types of ethics education that occupational therapy practitioners received and how helpful they found these types of education to be for managing ethical problems in practice. In addition, this study explored the relationships between ethics education and confidence in skills for ethical problem-solving. Lastly, the researchers examined what additional support new occupational therapy practitioners have perceived to help resolve ethical problems in practice. This study adds to the very limited body of literature on occupational therapy practitioner education for ethical problem-solving in the US. Investigators used a pre-existing survey data set (Howard et al., 2023) with quantitative analysis to explore the impact of education on managing ethical problems (see Appendix A for survey questions). Literature Review A limited number of studies inside and outside of the US have investigated ethics education for occupational therapists. Kanney et al. (1996) investigated how occupational therapy coursework prepared students for ethical problems in fieldwork and practice in the US. This dissertation sought to understand whether having ethics education in coursework or practice experience made a difference in moral reasoning. The study sampled nine occupational therapy programs regarding entry-level ethics education and moral reasoning. A comparison between beginning students, senior students, and practicing practitioners who had graduated in the past two years showed no statistical significance regarding education and moral reasoning (Kanney et al., 1996). Dieruf (2004) looked at the change in the fields of occupational therapy and physical therapy and how the advancements in technology and managed care could lead to more ethical EDUCATIONAL INTERVENTIONS FOR MANAGING ETHICAL PROBLEMS 6 problems. The investigators used the Defining Issues Test (DIT) to measure moral reasoning among physical therapy and occupational therapy students. The results showed that the current education the students were receiving was not enhancing their moral development (Drieuf, 2004). The authors emphasized that without proper ethics education, students would not be properly prepared for clinical practice. Educational programs that focused on how to handle ethical problems demonstrated the potential to decrease moral distress among practitioners. Penny and You (2011), in a cross-sectional study, collected data from students in a 5-year program and found that an entry-level occupational therapy education program may have helped prepare practitioners for moral reasoning. Similarly, Howard et al. (2020) found that fieldwork education may have contributed to improved moral reasoning patterns in entry-level occupational therapy and physical therapy students. These studies have shown that while there has been a need to decrease moral distress among practitioners, it has been difficult to determine how education may help. Within the US, there has not been a consensus on a specific educational ethics program that is beneficial for practitioners. Researchers have additionally investigated moral distress and the impact of ethics education in occupational therapy outside of the US. Kinsella et al. (2008) investigated ethical tensions among new graduates in occupational therapy in Canada. They discovered students were afraid to speak up about ethical tensions they experienced during fieldwork and out in practice and thought a lack of ethical education may have been the reason for their fear (Kinsella et al., 2008). Geddes et al. (2008) investigated in Canada whether moral reasoning schema and patterns were impacted by ethics training prior to graduation. The research team conducted a 6-year longitudinal study that followed six cohorts of occupational and physical therapy students. EDUCATIONAL INTERVENTIONS FOR MANAGING ETHICAL PROBLEMS 7 After the study concluded, they found there was no significant impact of the educational ethics training on the graduates moral judgment (Geddes et al., 2008). VanderKaay et al. (2018) studied the impacts of online ethics education modules and found that clinician-educators who participated in the study reported a sustained increase in ethics knowledge and an intent to incorporate strategies to explicitly address ethics within the context of their work with student occupational therapists (p. 10). This study presented a specific educational program through a module that showed positive outcomes in increasing ethics knowledge. In a study done in Canada, researchers looked at 25 occupational therapy and physiotherapy programs and analyzed the content of their courses (Hudon et al., 2014). The study found that the terms ethics/ethical were found in 75% of OT and 71% of PT course descriptions (Hudon et al., 2014). While the programs do have courses that discuss ethics, it is not known what content is taught or how much time is spent on ethics-related content. While little research indicated how ethics education prepared occupational therapy students to face ethical problems in practice, studies in other healthcare professions have examined types of ethics education and their usefulness. Investigators from the nursing profession have examined the use of ethics education to mitigate the prevalent risk of facing moral distress (Krautscheid et al., 2017). Many nurses have not taken action against morally distressing issues due to a lack of external resources, fear, uncertainty, and more. The common solution that has been discussed is adding ethics education into the nursing curriculum. Bong (2019) proposed that adding ethical talking points to every unit in schooling would allow for an open and informal conversation regarding moral distress. Curriculum changes are critical for preparing nurses to enter the field and be prepared for ethical problems. By changing the curriculum, programs would create a comprehensive, sustainable approach for teaching the EDUCATIONAL INTERVENTIONS FOR MANAGING ETHICAL PROBLEMS 8 future of the nursing workforce how to prevent and manage moral distress (Krautscheid et al., 2017, p.318). Therefore, by creating a universal curriculum on ethics, programs can better prepare their students for potential issues in the future. Multiple studies have evaluated the use of ethics education after experimenting with potential ethics curricula in collegiate healthcare programs. One education program saw a significant decrease in nursing students reported measures of moral distress after being introduced to two types of stressful situations in a 30-minute lecture and then evaluating a morally distressing scenario (Monteverde, 2016). On the other hand, Bilgen et al. (2018) found that students believed they had developed morals and ethical standards before attending university, from experiences they had growing up, but thought clinical practice experiences were better at enhancing those morals than lectures and assignments. In addition to curricular changes internal to a profession, interprofessional education scenarios were studied. In a systematic review, Guraya and Barr (2018) found that interprofessional education was vital to client-centered and high-quality care and contributed to ethical practice. Nichols et al. (2021) created an interprofessional education (IPE) day that brought nursing, midwifery, and law students together while Seidlein et al. (2021) allowed for collaboration between nursing and medical students. In both studies, there was a positive impact on the students' ethical understanding, and the experience allowed them to have an idea of how the other professional students would interpret the scenario (Nichols et al., 2021; Seidlein et al., 2021). Seidlein et al. (2021) found that the students believed the session should have been longer since the material was complicated. These two studies demonstrated the potential for ethics education in interprofessional scenarios and the benefit of interacting with students from other professions when interpreting these scenarios. EDUCATIONAL INTERVENTIONS FOR MANAGING ETHICAL PROBLEMS 9 Healthcare practitioners have benefited from post-professional continuing education in the management of ethical issues to reduce moral distress. Allen and Butler (2016) discussed the impact of ethics education on critical care nurses who were experiencing moral distress. The intervention included using the American Association of Critical-Care Nurses (AACN) 4 As Model, communication, personal action plans, and ethical reasoning skills (Allen & Butler, 2016). Nurses were able to use the skills that they learned during their educational training to reduce their moral distress. The 4 As Model was also used with a group of critical care nurses in Iran in the form of an educational workshop. Researchers found that the model was successful in reducing moral distress among nurses (Molazem et al., 2013). While the ethics education that was given to the nurses did reduce their moral distress, it did not prevent the cause of the moral distress. The most common sources of moral distress were a continuation of life support, witnessing false hope, and continuing patient care despite little hope. While these situations cannot always be prevented, the education taught the nurses ethical reasoning skills that they could use in practice, ultimately relieving some of the moral distress that nurses face (Allen & Butler, 2016). While this intervention was successful for nurses, further research is needed to determine the effectiveness of educational interventions for reducing moral distress for other health professionals. Multiple interventions aimed at reducing moral distress among healthcare workers have been introduced. Investigators looked at nurses and doctors within an intensive care unit and implemented the following interventions: moral empowerment programs, end-of-life educational programs, reflective exercises through individual narrative writing or group reflective debriefing, multidisciplinary case debriefing, meetings integrated into clinical practice, and moral resiliency training (Imbulana et al., 2021). Researchers found that there was no significant evidence to EDUCATIONAL INTERVENTIONS FOR MANAGING ETHICAL PROBLEMS 10 show that these interventions prevented or reduced moral distress. Morley, Field, et al. (2021) completed a systematic review to look at moral distress interventions among nurses. The following interventions were examined: facilitated discussions, self-reflection, narrative writing, multidisciplinary rounds, specialist consultation service programs, intervention bundles, and education interventions (Morley, Field, et al., 2021). Out of the sixteen articles included in the systematic review, seven reported a reduction in moral distress. The authors suggested that more effective interventions would need to be more flexible and adaptable to each individuals needs. Ethics rounds have been recommended as an intervention to reduce moral distress in occupational therapy practitioners (Erler, 2017). During these rounds, practitioners would be able to prepare for emerging ethical issues. Erler (2017) noted that during the ethics rounds, the environment should be professional, give a voice to underserved populations, and identify themes and triggers (Erler, 2017). By implementing these ethical rounds into practice, organizations would affirm that ethics were valued and addressed. Ethics rounds would allow for open communication, support, and preparation for ethical problems that could arise (Erler, 2017). By preparing for these ethical problems and having other people to talk to and learn from, the hope is that moral distress would be mitigated. A variety of educational programs have provided indirect interventions to address moral distress; that is, these interventions did not address the moral distress directly but rather the emotional sequelae experienced by a practitioner when encountering moral distress. Patronis and Staffileno (2021) used a Mindful Moment program that consisted of 20-minute sessions of yoga, self-reflection, and meditation among nurses. Irwin et al. (2020) offered resilience training to new graduate nurses. This training educated nurses on factors that lead to an increase in resilience and techniques that could be used in daily practice. These techniques included EDUCATIONAL INTERVENTIONS FOR MANAGING ETHICAL PROBLEMS 11 interventions such as journaling, reflection, and gratitude. Sawyer et al. (2021) used the intervention of the RISE program. The RISE program was eight weeks long and was used as a psychoeducational group intervention for nurses. It focused on four different components including resilience, insight, self-compassion, and empowerment. Finally, Bevan and Emerson (2020) held their educational session based on Frierean conscientization. They held three, four-hour sessions of critical reflection, motivation, and action as an educational intervention for nurses, which resulted in participants feeling more confident and empowered when it came to speaking up regarding ethical issues (Bevan & Emerson 2020). The interventions in these studies were intended to mitigate moral distress when dealing with ethical problems and did not give strategies for working through ethical problems in practice. The literature has been limited regarding preventing and managing moral distress stemming from ethical problems among occupational therapy practitioners especially in the US. Moral distress has had the potential to lead to negative mental health outcomes in both patients and healthcare workers, which has been especially apparent during the COVID-19 pandemic (Smallwood et al., 2021). The increase in moral distress experienced by healthcare workers during COVID-19 has led to an increased risk of anxiety, depression, post-traumatic stress disorder, and burnout, (Smallwood et al., 2021, p. 1). Without proper interventions, there could be a threat to workforce longevity and the safety of patients. Education has the potential to lead to a higher level of confidence when facing ethical problems (VanderKaay et al., 2018). This study adds to the literature by addressing which formats and types of educational interventions occupational therapy practitioners reported that help address ethical problems and increase confidence in ethical problem-solving, thereby reducing moral distress. EDUCATIONAL INTERVENTIONS FOR MANAGING ETHICAL PROBLEMS 12 Methods Study Approach The purpose of this study was to explore the impact of ethics education on managing ethical problems in practice among occupational therapy practitioners within the first five years of practice. This study utilized a dataset previously collected in the Spring of 2020 (Howard et al., 2023). In this quantitative cross-sectional, nonexperimental survey, 125 occupational therapists and occupational therapy assistants who had passed the NBCOT exam within the previous five years answered questions regarding ethical problems they had encountered, ethics education they have received, how much they believed each kind of education helped them manage ethical problems, how confident they felt responding to ethical issues in practice, and what they relied on for ethical problem-solving strategies. Researchers analyzed responses descriptively regarding educational formats and types and its helpfulness in managing ethical problems; and correlated confidence in ethical problem-solving to having received the types of education perceived to be the most helpful. Ethics This study was reviewed by the University of Indianapolis Human Research Protections Program Institutional Review Board and determined to be not human subjects research. No personal identifiers were collected in the survey. Participant Characteristics Target Demographics, Inclusion/Exclusion Criteria Participants included in the original dataset of this study were occupational therapy practitioners who passed the NBCOT within the past 5 years. Exclusion criteria included individuals who were not occupational therapists or occupational therapy assistants, and those EDUCATIONAL INTERVENTIONS FOR MANAGING ETHICAL PROBLEMS 13 not practicing in the field of occupational therapy. Investigators excluded participants who completed less than 80% of the survey. Procedures Sampling Procedures In collaboration with NBCOT, investigators sent a mass email to a sample of people who recently passed the NBCOT exam within the past 5 years. NBCOT also advertised the survey on social media sites. Investigators stratified the sample to obtain responses from occupational therapy practitioners in all regions of the US. Investigators originally sent the survey to 3,600 occupational therapists and 1,200 occupational therapy assistants. Due to the low return rate, investigators sent the survey to an additional 2,000 occupational therapy practitioners and 1,000 occupational therapy assistants via email (Howard et al., 2023). Sample Size, Power, and Precision Investigators calculated the needed sample size to achieve statistical significance, using G*Power 3.1.9.4 (Faul et. al., 2009). With correlation set at 0.3, alpha error of probability of .05, and power set at 0.95, a sample size of 115 participants was needed to calculate Kendalls Tau-b and Spearmans rho. Overall, 163 individuals completed the demographic portion of the survey; 125 individuals remained after the removal of incomplete responses. Therefore, the study was adequately powered. Instrumentation This present study utilizes previously collected survey data (Howard et al., 2023). Investigators created a survey using principles from Forsyth and Kviz (2006) and Stein et al. (2013). Researchers asked several University of Indianapolis School of Occupational Therapy faculty members and an expert on survey research to review the questions in the survey using the EDUCATIONAL INTERVENTIONS FOR MANAGING ETHICAL PROBLEMS 14 Cognitive Validity Method (Willis, 2004) to increase the validity of the survey. The researchers then edited the questionnaire to improve clarity and quality. For full survey questions, see Appendix A. Analysis For this current study, investigators analyzed the portions of the survey addressing ethics education in the classroom, on fieldwork, and with continuing education after post-entry level education using descriptive statistics (counts and percents) to determine most commonly reported formats and types of ethics education, which of these participants perceived as most helpful, confidence in ethical problem-solving, and what ethical problem-solving strategies they relied on when managing ethical problems in practice. Since the data were nonparametric for all variables (Shapiro-Wilk results 0.05), researchers used nonparametric tests of Kendalls Tau-b and Spearmans rho to correlate types of ethics education to confidence in ethical problem-solving. Results Of the 125 participants who completed the survey, 23.2% had passed the NBCOT exam less than one year prior, 44% had passed the NBCOT one to under three years prior, and 32.8% had passed the NBCOT three to five years prior to this survey. The mean age of the responding 123 participants was 30.8 and the median age was 28. The youngest participant was 23 and the oldest was 64. Ninety-two percent of the participants were female, 4.8% were male, one participant was a trans male, 2 identified as non-binary, and 1 preferred not to answer. Of the 125 participants, 108 were white, 4 were black or African American, 3 were biracial/multi-racial, 3 preferred not to answer, and 2 were other. When asked about ethnicity, 5.6% were Hispanic or Latino, 91.2% were not Hispanic or Latino, and 3.2% preferred not to answer. See Table 1 for demographic characteristics of the sample. EDUCATIONAL INTERVENTIONS FOR MANAGING ETHICAL PROBLEMS Table 1 Demographic Characteristics of Sample Variable (n Responding) Years since NBCOT (125) Less than 1 year 1 to under 3 years 3 to 5 years 29(23.2) 55(44) 41(32.8) Certification (125) Occupational Therapist Occupational Therapy Assistant 104(83.2) 21(16.8) OT Degree Obtained (104) Masters Doctoral 63(60.6) 41(39) OTA Degree Obtained (21) Associates 21(100) n(%) Region of entry-level degree obtained (125) West (Washington, Oregon, California, Montana, Idaho, Wyoming, Nevada, Utah, Colorado, Arizona, and New Mexico 21(16.8) Midwest (North Dakota, South Dakota, Nebraska, Kansas, Minnesota, Iowa, Missouri, Wisconsin, Michigan, Illinois, Indiana, and Ohio) 47(37.6) North East (New York, Pennsylvania, New Jersey, Vermont, New Hampshire, Massachusetts, Connecticut, Rhode Island, Maine) 25(20) South (Texas, Oklahoma, Arizona, Louisiana, Kentucky, Tennessee, Mississippi, Alabama, Georgia, Florida, South Carolina, North Carolina, Virginia, West Virginia, Maryland, Delaware) 31(24.8) Hawaii, Alaska, Puerto Rico, Washington D.C. and US Territories Outside the US Region of current practice (125) 1(0.8) 15 EDUCATIONAL INTERVENTIONS FOR MANAGING ETHICAL PROBLEMS West (Washington, Oregon, California, Montana, Idaho, Wyoming, Nevada, Utah, Colorado, Arizona, and New Mexico 33(26.4) Midwest (North Dakota, South Dakota, Nebraska, Kansas, Minnesota, Iowa, Missouri, Wisconsin, Michigan, Illinois, Indiana, and Ohio) 33(26.4) North East (New York, Pennsylvania, New Jersey, Vermont, New Hampshire, Massachusetts, Connecticut, Rhode Island, Maine) 15(12) South (Texas, Oklahoma, Arizona, Louisiana, Kentucky, Tennessee, Mississippi, Alabama, Georgia, Florida, South Carolina, North Carolina, Virginia, West Virginia, Maryland, Delaware) 40(32) Hawaii, Alaska, Puerto Rico, Washington D.C. and US Territories Outside the US 4(3.2) Area of primary practice (125) Children and Youth Mental Health Rehabilitation & Disability Productive Aging Emerging & non-traditional Academic Administrative/managerial Not working in OT Other 41(32.8) 5(4) 55(44) 13(10.4) 2(1.6) 1(0.8) 1(0.8) 3(2.4) 4(3.2) Years in Current Practice Setting (125) Less than a year 1 to under 3 years 3 to 5 years Other 46(36.8) 51(40.8) 26(20.8) 2(1.6) Age (123) Mean Median Youngest Oldest 30.8 28 23 64 16 EDUCATIONAL INTERVENTIONS FOR MANAGING ETHICAL PROBLEMS Gender (125) Male Female Trans male Non-binary Prefer not to answer 17 6(4.8) 115(92) 1(0.8) 2(1.6) 1(0.8) Primary Race (125) White Black or African American Asian/Pacific Islander Biracial/Multi-racial Prefer not to answer Other 108(86.4) 4(3.2) 5(4) 3(2.4) 3(2.4) 2(1.6) Ethnicity (125) Hispanic or Latino Not Hispanic or Latino Prefer not to answer 7(5.6) 114(91.2) 4(3.2) Didactic Ethics Education Formats and Types Table 2 contains the ethics education formats and types that entry-level occupational therapists and occupational therapy assistants reported they received in didactic, fieldwork, and post-certification education. Participants reported that dedicated face-to-face ethics courses were the most helpful. Ethics content interwoven throughout the curriculum was the most common type of education content received by participants. Entry-level occupational therapy practitioners reported receiving various ethics education types, with the majority (94.3%) receiving lecture-based education. Ethical case studies were reported as the most helpful type of education, with a mean of 2.56 out of a total possible of 3 on a Likert-type scale. See Table 2. EDUCATIONAL INTERVENTIONS FOR MANAGING ETHICAL PROBLEMS 18 The most common types of ethics education participants received on Level II Fieldwork included first-hand experiences with ethical dilemmas and discussions with fieldwork educators regarding those experiences. Participants reported that the most helpful types of education on fieldwork were an informal discussion with fieldwork educators or occupational therapy interprofessional colleagues (62%). Another helpful education type was experiences with clients during fieldwork involving ethical problems, with a mean of 2.48 out of a possible 3 on a Likert-type scale. See Table 2 for reporting of responses with a mean of two or more out of three on the Likert-type scale for helpfulness. Table 2 Ethics Education Formats and Types in Didactic, Fieldwork, and Continuing Education Ethics Education Descriptions Entry-Level Ethics Education Format Entry-Level Ethics Education Types Item* (n responding) n (%) **Helpfulness mean(median) 114(95.2) n=109 2.46(3.0) Dedicated face-to-face ethics course (n=121) 96(79.3) n= 94 2.53(3.0) Ethics lecture (n=123) 116 (94.3) n=111 2.38 (2.0) Formal classroom discussion with cohort classmates about ethics (n=123) 115 (93.5) n=110 2.51(3.0) Reading assignment (n=122) 109 (89.3) n=105 2.33 (2.0) Ethics case studies (n=123) 105 (85.4) n=100 2.56(3.0) Ethics content interwoven throughout the curriculum (n=120) EDUCATIONAL INTERVENTIONS FOR MANAGING ETHICAL PROBLEMS Informal discussion (n=121) 103 (85.1) n=99 2.42(2.0) Ethical problem-solving guide, steps, or resources (n=123) 100 (81.3) n=97 2.50(3.0) 80 (65) n=80 2.39(2.0) Ethics role playing (n=122) 80 (65.6) n=81 2.43(3.0) Interprofessional education experience in the classroom regarding ethics(n=121) 62 (51.2) n=58 2.48(2.5) Informal discussion with OT colleagues in fieldwork setting regarding ethics (121) 75(62) n=72, 2.54(3) Experience with clients in fieldwork settings involving ethical issues or problems (121) 73(60.3) n=68, 2.48(3) Read an occupational therapy professional article on ethics (n=121) 70 (57.9) n= 66 2.20 (2.0) Ethics exam (n=123) Fieldworks Ethics Education Types Ethics Education Since Initial OT Certification 19 *In your entry-level (classroom) education, which of the following types of ethics education did you receive? ** If you did receive this type of education, how well did it help you learn to resolve ethical problems you have encountered in practice? 1 = did not help; 2 = helped somewhat; 3 = helped a great deal. Ethics Education Since Initial Occupational Therapy Certification Seventy participants reported reading an article on ethics since their initial occupational therapy certification, which was somewhat helpful (x = 2.2 out of 3). EDUCATIONAL INTERVENTIONS FOR MANAGING ETHICAL PROBLEMS 20 Ethical Problem-Solving Strategies Table 3 contains what the participants rated they relied on the most to decide on a course of action. These participants reported that the following were relied on the most: common knowledge, personal experiences, talking to a supervisor, past education to identify, assess, and offer resolutions, and talking to a colleague. See Table 3 for more information. Table 3 Ethical Solving Strategies Item* (n responding) Relied on common knowledge (120) Relied on Mean(median)** 4.20(4.0) Relied on personal experience (120) 4.04(4.0) Relied on past education to identify, assess, offer resolution (119) 4.03(4.0) Talked with a supervisor (119) 4.03(4.0) Talked with a colleague within the organization/setting (120) 3.6(4.0) Looked up laws (licensure act, third party payor rules, etc.) (120) 3.06(3.0) Looked up policies and procedures (120) 3.05(3.0) Talked with a mentor within the organization/setting (120) 3.03(3.0) Looked up a Code of Ethics (120) 2.85(3.0) Looked up other resource materials (120) 2.85(3.0) Talked with a colleague outside the organization/setting (120) 2.8(3.0) Talked with a mentor outside the organization/setting (120) 2.56(2.0) Enrolled in continuing education (120) 1.93(1.0) EDUCATIONAL INTERVENTIONS FOR MANAGING ETHICAL PROBLEMS Talked with an ethics committee member or members (119) 1.59(1.0) Other (please write in) (34) 1.29(1.0) 21 * Which items OTP relied on to decide on a course of action when experiencing ethical problems. ** When encountering an ethical problem in practice, how much did you rely on each of the following to decide on a course of action to resolve the ethical problem? (1 = none at all; 2 = a little; 3 = a moderate amount; 4 = a lot; 5 = a great deal) Relationship between Ethics Education and Confidence in Skills Investigators explored the relationships between ethics education and confidence in skills for ethical problem-solving by correlating the Confidence scale (10 items) to specific types of ethics education. Investigators first analyzed confidence items using Cronbachs alpha to determine if these items could be totaled into a scale and analyzed together. Cronbachs = .842 for the 10 items, indicating good internal consistency. Investigators then analyzed the correlation between the confidence scale and ethics education items to determine if there was a relationship between ethics problem-solving confidence and specific types of ethics education. Investigators used both Kendall's Tau b and Spearmans rho statistics due to the small sample size and nonparametric nature of the data, and to compare the results between these two nonparametric tests. Investigators included only items with 10 or more in each group, per the requirements of the statistical test (Field Study Council, n.d.). Tables 4, 5, and 6 contain the significant results from these correlations. Results indicated a significant but low-strength correlation between ethical problem-solving confidence and ethics education items listed. Table 4 Didactic Education: Significant Correlations between Question Items and Ethical Problem-Solving Confidence Total Scale Variable* (n responding) Kendalls Tau B Spearmans Rho EDUCATIONAL INTERVENTIONS FOR MANAGING ETHICAL PROBLEMS 22 Significance (p<.05) Correlation Coefficient** Significance (p<.05) Correlation Coefficient Ethics content interwoven throughout the curriculum (116) .048 0.155 .047 0.185 Informal discussion with cohort classmates about ethics (112) 0.003 0.236 0.003 0.283 Ethics exam (110) 0.041 0.164 0.040 0.196 Ethics case studies (119) 0.008 0.204 0.007 0.244 Ethics role playing (110) 0.000 0.289 0.000 0.346 Interprofessional education experience in the classroom regarding ethics (106) 0.003 0.245 0.002 0.293 Professional conference session related to ethics while in OT school (107) 0.012 0.193 0.017 0.231 EDUCATIONAL INTERVENTIONS FOR MANAGING ETHICAL PROBLEMS Professional development discussion with mentor or advisor related to ethics (110) 0.003 0.222 0.005 23 0.265 *Question: In your entry-level (classroom) education, which of the following types of ethics education did you receive? **Correlation coefficients are interpreted as: 0 - 0.20 = negligible; 0.20 - 0.40 = low; 0.40 0.60 = moderate; 0.60 - 0.80 = high; 0.80 - 1.00 = very strong correlation. Table 5 Fieldwork Education: Significant Correlations between Question Items and Ethical Problem-Solving Confidence Total Scale Variable* (n responding) Significance (<.05) Kendalls Tau B Significance Ethical problem-solving guide, steps, or resource (114) 0.006 Correlation Coefficient** 0.205 Significance (<.05) Spearmans Rho Significance Correlation Coefficient 0.009 0.245 *Question: In your entry-level (classroom) education, which of the following types of ethics education did you receive? **Correlation coefficients are interpreted as: 0 -0.20 = negligible; 0.20 - 0.40 = low; 0.40 0.60 = moderate; 0.60 - 0.80 = high; 0.80 - 1.00 = very strong correlation. Table 6 Ethics Education Since Entering Practice: Significant Correlations between Question Items and Ethical Problem-Solving Confidence Total Scale EDUCATIONAL INTERVENTIONS FOR MANAGING ETHICAL PROBLEMS Variable* (n responding) 24 Significance Kendalls Tau B Significance Spearmans Rho Significance (p<.05) Significance (p<.05) Correlation Coefficient Correlation Coefficient** Ethics continuing education taken as required by the state licensing board (117) 0.002 0.228 0.003 0.272 Ethics continuing education taken for workplace/setting (119) 0.015 0.182 0.017 0.218 Ethics continuing education taken for a specialty certification (113) 0.001 0.262 0.001 0.314 Ethics continuing education sought on own (119) 0.008 0.190 0.013 0.227 Reading an interprofessional article on ethics (115) 0.013 0.188 0.016 0.224 *Question: In your entry-level (classroom) education, which of the following types of ethics education did you receive? **Correlation coefficients are interpreted as: 0 -0.20 = negligible; 0.20 - 0.40 = low; 0.40 0.60 = moderate; 0.60 - 0.80 = high; 0.80 - 1.00 = very strong correlation. Items not included for correlation analysis were: ethics content interwoven throughout the curriculum, ethics readings, ethical problem-solving guide, formal classroom discussion, ethics training separate from orientation, postgraduate ethics course, organizational ethics committee or consultation, and formal mentorship. These items did not meet the statistical assumptions for EDUCATIONAL INTERVENTIONS FOR MANAGING ETHICAL PROBLEMS 25 correlation analysis (i.e., did not have 10 or more participants in each group). Discussion Education In didactic education, role-playing was considered to be most helpful, followed by IPE classroom experiences and mentorship discussions. The lowest ranked type was ethics exams. The results reflect that hands-on education for ethical problem-solving was perceived as more helpful. These results are similar to those found in studies that included role-playing and scenario-based education (Bilgen et al. 2018; Monteverde, 2016). This finding may be because studying for examinations is more memorization-based, while educational experiences give students more active participation in acquiring and solidifying knowledge. It is important to note that this discrepancy could also be due to the differences in preferred student learning styles. The results of this study suggest it may be helpful to prioritize ethics education in didactic and post-graduate education rather than in fieldwork. Placing a greater focus on role-playing, IPE discussions, and mentorship discussions during class time could be beneficial in increasing the percentage of occupational therapists perceived ability to address ethical problems. These results align with findings that IPE events within didactic education allow for a broader understanding of other professional students ethical reasoning (Nichols et al., 2021; Seidlein et al., 2021). The reason behind the effectiveness of these interventions over others could be explained by the higher use of active learning and problem-solving as well as the opportunity to gain others perspectives and ideas through discussions. Fieldwork The results revealed that certain experiences during fieldwork helped improve preparedness for ethical problems. The fieldwork experiences that practitioners perceived as EDUCATIONAL INTERVENTIONS FOR MANAGING ETHICAL PROBLEMS 26 helping the most included informal discussions with fieldwork educators and interprofessional colleagues, gaining experience with managing ethical issues, having a mentorship with a fieldwork educator or other individual, and having an ethical problem-solving guide, theory, steps, or method to follow. These findings align with the positive response from ethics rounds during the work week that allow practitioners to discuss ethical problems (Erler, 2017). However, only problem-solving guides were found to be statistically significant when correlated with ethical problem solving confidence.. This may be because students can take the time to look at these resources on their own, away from stressors. It may be difficult for students to find ethical education on fieldwork helpful because they are focused on learning skills and engaging in their setting. Ethics Education Since Certification Regarding education for new practitioners, many resorted to finding ethics education on their own. This could be because they had more time or witnessed more ethical problems and needed to seek education independently. Less than half of the respondents reported having to complete continuing ethics education required by their state or practice setting. If more states or practice settings have this requirement, it may help promote continuing education regarding ethics. Another form of ethics education since certification that respondents found helpful was informal mentorships. Informal mentorships allow individuals to talk about ethical dilemmas with people in the same field. People may have found this helpful because mentors often give advice based on similar life situations, offering insight towards the practitioners experiences. Practitioners noted that reading ethics articles was a popular form of continuing education regarding ethics, however they are often inaccessible to practitioners.. EDUCATIONAL INTERVENTIONS FOR MANAGING ETHICAL PROBLEMS 27 Practitioners would be better informed on ethics if there were an easier way to access these articles to use for their continuing education units (CEUs). With the incentive of CEUs, more practitioners may access ethics articles and be informed about up-to-date ethics research in the field of occupational therapy. More articles, combined with more intuitive ways to access them, could increase the likelihood that practitioners would read articles about ethics after their initial education. This educational strategy may help mitigate or reduce moral distress in practitioners by educating them on what to do if these situations occur.. It is important to note that some ethical situations are hard to prepare practitioners for such as specific dilemmas related to a global pandemic. This is why it is important for practitioners to have a base knowledge in mitigating moral distress, not just specific scenarios. In this instance, case studies may not be as beneficial to understanding how to mitigate moral distress in cases one cannot always predict. This explains why it is important to focus on other areas of didactic education and fieldwork education to further prepare practitioners. Recommendations for Research The current study helped reveal certain gaps in ethics education and can be used to suggest recommendations for future research on the topic. First, research could explore the effectiveness of an ethics mentorship program during fieldwork for mitigating moral distress. It would be beneficial to further examine if preparedness for ethical problem-solving through didactic education helps to mitigate moral distress. A longitudinal cohort study exploring didactic education with ethical problem-solving and their confidence levels would be helpful for educators to understand the effectiveness over time. Implications for Occupational Therapy Practice With the most significant intervention from this study being ethical continuing education, EDUCATIONAL INTERVENTIONS FOR MANAGING ETHICAL PROBLEMS 28 followed by state-required continuing education and continuing education sought out on your own, this study reflects the need for occupational therapy practitioners to consider taking more CEUs regarding ethics education. As newly practicing occupational therapists gain experience, ethical problems will certainly occur. Registering for CEUs focused on ethical problem-solving could help practitioners reflect on their experiences with ethical problems and consider what they could have done differently. This also would help practitioners prevent ethical problems and manage them appropriately and more effectively. Limitations Limitations included a small sample size that could have impacted the results and self-selection bias due to practitioners choosing whether they wanted to participate in the study. This survey took place during the second month of the COVID-19 pandemic, which could have impacted results. Because of the uncertainty created by the pandemic, practitioners may have experienced more recent ethical problems that prompted them to respond to the questionnaire. Conclusion Occupational therapy practitioners consistently experience ethical problems within the first five years of practice. This study aimed to explore the impact of ethics education on managing ethical problems among occupational therapy practitioners within the first five years of practice. Researchers met this aim through a survey and analyzed the different types of education experienced and how that education correlated with confidence in managing ethical problems. Correlations between education formats and types, such as hands-on education, IPE discussions, and mentorships, and practitioners confidence when managing ethical problems reflected the most benefit. Researchers recommend using these techniques as instructional activities in preparation for managing ethical problems. Implications for practice include more EDUCATIONAL INTERVENTIONS FOR MANAGING ETHICAL PROBLEMS 29 support for ethical problem management during fieldwork, ethics mentorships, continuing education, and ethics rounds in practice. Further research is recommended to explore the effectiveness of ethics education on confidence levels with ethical problem-solving. EDUCATIONAL INTERVENTIONS FOR MANAGING ETHICAL PROBLEMS 30 References Allen, R. & Butler, E. (2016). Addressing moral distress in critical care nurses: A pilot study. International Journal of Critical Care and Emergency Medicine, 2(2), 1-6. https://doi.org/10.23937/2474-3674/1510015 Bevan, N. A., & Emerson, A. M. 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Interprofessional health-care ethics education for medical and nursing students in Germany: An interprofessional education and practice guide. Journal of Interprofessional Care, 36(1), 144-151. https://doi.org/10.1080/13561820.2021.1879748 Smallwood, N., Pascoe, A., Karimi, L., & Willis, K. (2021). Moral distress and perceived community views are associated with mental health symptoms in frontline health workers during the COVID-19 pandemic. International Journal of Environmental Research and Public Health, 18(16), 3-15. https://doi.org/10.3390/ijerph18168723 Stein, F., Cutler, S., & Rice, M. (2013). Clinical research in Occupational Therapy (5th ed.). Clifton Park, NY: Delmar. VanderKaay, S., Letts, L., Jung, B., & Moll, S. E. (2018). On-line ethics education for occupational therapy clinician-educators: A single-group pre-/post-test study. Disability and Rehabilitation, 41(23), 28412853. https://doi.org/10.1080/09638288.2018.1473510 Willis, G. B. (2004). Cognitive interviewing: A tool for improving questionnaire design. SAGE Publications. EDUCATIONAL INTERVENTIONS FOR MANAGING ETHICAL PROBLEMS 35 Appendix A Survey Questions Demographics Questions Answers How many years ago did you complete your initial NBCOT certification for your current occupational therapy practice title? Less than 1 year 1 to under 3 years 3 to 5 years 6 or more years I do not have an initial NBCOT certification What is your current or most recent occupational therapy practice NBCOT certification? Occupational Therapy Assistant Occupational Therapist I am not, and have never been, and NBCOT-certified occupational therapy practitioner What degree did you obtain to become an occupational therapy assistant? Associates Bachelors What degree did you obtain to become an occupational therapist? Masters Doctoral In what region did you obtain your entry-level degree for your current practice level? West (Washington, Oregon, California, Montana, Idaho, Wyoming, Nevada, Utah, Colorado, Arizona, and New Mexico) Midwest (North Dakota, South Dakota, Nebraska, Kansas, Minnesota, Iowa, Missouri, Wisconsin, Michigan, Illinois, Indiana, and Ohio) Northeast (New York, Pennsylvania, New Jersey, Vermont, New Hampshire, Massachusetts, Connecticut, Rhode Island, Maine) South (Texas, Oklahoma, Arizona, Louisiana, Kentucky, Tennessee, Mississippi, Alabama, Georgia, Florida, South Carolina, North Carolina, Virginia, West Virginia, Maryland, Delaware) Hawaii, Alaska, Puerto Rico, Washington D.C and US Territories Outside the US In what region do you currently practice? West (Washington, Oregon, California, EDUCATIONAL INTERVENTIONS FOR MANAGING ETHICAL PROBLEMS 36 Montana, Idaho, Wyoming, Nevada, Utah, Colorado, Arizona, and New Mexico) Midwest (North Dakota, South Dakota, Nebraska, Kansas, Minnesota, Iowa, Missouri, Wisconsin, Michigan, Illinois, Indiana, and Ohio) Northeast (New York, Pennsylvania, New Jersey, Vermont, New Hampshire, Massachusetts, Connecticut, Rhode Island, Maine) South (Texas, Oklahoma, Arizona, Louisiana, Kentucky, Tennessee, Mississippi, Alabama, Georgia, Florida, South Carolina, North Carolina, Virginia, West Virginia, Maryland, Delaware) Hawaii, Alaska, Puerto Rico, Washington D.C and US Territories Outside the US In which of these settings do you currently primarily practice? Please choose one. Children & Youth Health & Wellness Mental Health Rehabilitation & Disability Productive Aging Work & Industry Emerging & non-traditional Academic Administrative/managerial Not working in OT Other How long have you been practicing in your current primary practice setting (at your current practitioner level)? Less than a year 1 to under 3 years 3 to 5 years Other What was your previous primary practice setting, prior to your current employment? Children & Youth Health & Wellness Mental Health Rehabilitation & Disability Productive Aging Work & Industry Emerging & Non-Traditional Academic Administrative/ managerial Not working in OT EDUCATIONAL INTERVENTIONS FOR MANAGING ETHICAL PROBLEMS 37 No previous practice setting/ have been in my current practice setting since entry into the profession Other In what region was your previous practice setting (prior to your current employment)? West (Washington, Oregon, California, Montana, Idaho, Wyoming, Nevada, Utah, Colorado, Arizona, and New Mexico) Midwest (North Dakota, South Dakota, Nebraska, Kansas, Minnesota, Iowa, Missouri, Wisconsin, Michigan, Illinois, Indiana, and Ohio) Northeast (New York, Pennsylvania, New Jersey, Vermont, New Hampshire, Massachusetts, Connecticut, Rhode Island, Maine) South (Texas, Oklahoma, Arizona, Louisiana, Kentucky, Tennessee, Mississippi, Alabama, Georgia, Florida, South Carolina, North Carolina, Virginia, West Virginia, Maryland, Delaware) Hawaii, Alaska, Puerto Rico, Washington D.C, Military, and US Territories Outside the US No previous practice setting/ have been in my current setting since entry to the profession How long did you practice in your previous practice setting (prior to your current employment)? Less than 1 year 1 to under 3 years 3 to 5 years N/A No previous practice setting Other What is your age? What is your gender? Male Female Trans male Trans female Non-binary Prefer not to answer Other (please write in) What do you consider to be your primary race? White/ Caucasian Black or African American Asian/ Pacific Islander American Indian/ Alaskan Native EDUCATIONAL INTERVENTIONS FOR MANAGING ETHICAL PROBLEMS 38 Biracial/Multi-racial (please write in) Prefer not to answer Other What is your ethnicity? Hispanic or Latino Not Hispanic or Latino Prefer not to answer Ethics Preparation Questions Format Options In your entry-level (classroom) education, which of the following formats or ethics education did you receive? If you did receive this format of education, how well did it help you learn to resolve ethical problems you have encountered in practice? Dedicated face-to-face ethics course In your entry-level (classroom) education, which of the following types of ethics education did you receive? If you did receive this type of education, how well did it help you learn to resolve ethical problems you have encountered in practice? Ethics Lecture Dedicated online ethics course Ethics content interwoven throughout the curriculum Other (please describe) Reading assignment(s) about ethics Ethical problem-solving guide, steps, or resource Formal classroom discussion with cohort classmates about ethics Informal discussion with cohort classmates about ethics Sub Questions Answer Options Did you receive this format of ethics education in your entry-level (classroom) education? Yes No Not sure If yes: How well did this type of education help you learn to resolve ethical problems you have encountered in practice? Did not help Helped somewhat Helped a great deal Did you receive this format of ethics education in your entry-level (classroom) education? Yes No Not sure If yes: How well did this type of education help you learn to resolve ethical problems you have encountered in practice? Did not help Helped somewhat Helped a great deal EDUCATIONAL INTERVENTIONS FOR MANAGING ETHICAL PROBLEMS 39 Ethics exam Ethics case studies Ethics role playing Interprofessional education experience in the classroom regarding ethics Interprofessional education experience outside of the classroom regarding ethics Professional conference session related to ethics while in OT school Participation in a student organization session while in school related to ethics Professional development discussion with mentor or advisor related to ethics Other (please write in) In your Level II Fieldwork clinical practice education, which of the following types of ethics education did you receive? If you did receive this type of education, how Ethics reading assignment while at fieldwork site Yes No Not sure Ethics training in fieldwork orientation Did you receive this type of ethics education in your clinical practice education/Level II Fieldwork? Ethics training session in fieldwork If yes: How well did this type of education Did not help Helped somewhat EDUCATIONAL INTERVENTIONS FOR MANAGING ETHICAL PROBLEMS well did it help you learn to resolve ethical problems you have encountered in practice? that was separate from orientation Attendance at an ethics committee meeting or participation in an informal or formal ethics case consultation Mentorship with fieldwork educator regarding ethics Mentorship with another individual within the fieldwork setting regarding ethics Informal discussion with OT colleagues in fieldwork setting regarding ethics Informal discussion with interprofessional colleagues in fieldwork setting regarding ethics Experience with clients in fieldwork setting involving ethical issues or problems Ethical problem solving guide, steps, or resource Formal ethics rounding in the fieldwork setting help you learn to resolve ethical problems you have encountered in practice? 40 Helped a great deal EDUCATIONAL INTERVENTIONS FOR MANAGING ETHICAL PROBLEMS 41 Other (please write in) Since becoming initially certified as an OT practitioner, which of the following types of ethics education did you receive? If you did receive this type of education, how well did it help you learn to resolve ethical problems you have encountered in practice? Read an occupational therapy professional article on ethics Read an interprofessional or non-professional article on ethics Completed ethics continuing education required by state/territory license Completed ethics continuing education required by my practice setting Completed ethics continuing education required by a professional association or specialty certification Completed ethics continuing education that I sought on my own Completed a post-graduate level course on ethics at a college or university Participation in an organization's ethics committee or ethics consultation service Sought formal ethics mentorship Did you receive this type of ethics education since becoming initially certified? Yes No Not sure If yes: How well did this type of education help you learn to resolve ethical problems you have encountered in practice? Did not help Helped somewhat Helped a great deal EDUCATIONAL INTERVENTIONS FOR MANAGING ETHICAL PROBLEMS 42 Sought informal ethics mentorship Other (please write in) Understanding and Confidence with Ethical Problem Solving Prompt Please rank the following statements on a scale from "I am not confident" to "I am highly confident." Statement I can adequately manage ethical problems in my current practice setting. I understand how to use an ethical problem solving theory, guide, steps, or other method to help work through ethical problems in practice. I know where to find and access the AOTA Code of Ethics. I know where to find my state or territory's occupational therapy practice act. I know where to find my practice setting's policies and/or procedures, and/or other resources, related to ethical problem management or resolution. I know how to bring an ethics issue before an ethics committee at my facility, in my state, and/or with my national association I know where to get written resources on solving ethical problems. I know where to find Scale Options I am not confident that I am able to do this. I am unsure that I am able do this. I am neutral regarding whether I am able to do this. I am confident that I am able to do this. I am highly confident that I am able to do this. EDUCATIONAL INTERVENTIONS FOR MANAGING ETHICAL PROBLEMS individuals within my work setting with whom I can discuss ethical problems. I know where to find individuals outside of my work setting with whom I can discuss ethical problems. I know where to find continuing education regarding ethics. Other (please write in) When encountering an ethical problem in practice, how much did you rely on each of the following to decide on a course of action to resolve the ethical problem? Relied on personal experience A great deal A lot Relied on common A moderate amount knowledge A little None at all Relied on past education to identify, assess, offer resolutions Talked with a supervisor Talked with an ethics committee member or members Talked with a mentor within the organization/setting Talked with a colleague within the organization/setting Talked with a mentor outside the organization/setting Talked with a colleague outside the organization/setting Looked up policies and procedures 43 EDUCATIONAL INTERVENTIONS FOR MANAGING ETHICAL PROBLEMS Looked up laws (licensure act, third party payor rules, etc.) Looked up a Code of Ethics Looked up other resource materials Enrolled in continuing education Other (please write in) Is there anything else you would like to tell us about the ethical problems you have experienced since becoming initially certified? (For example - tell us your story! What was the ethical problem? What did you do? Did you experience moral distress? Did you find resolution? Are you holding on to that moral distress or do you have lingering self-doubt about whether you did the "right" thing? How have ethical problems and challenges impacted your practice?) 44  ...

... 1 A Well Kept Secret, Identifying Facilitators and Barriers to Occupational Therapy Referral by United States Cancer Healthcare Professionals Olivia Witteborg, Korrin Schalhamer, Morgan Jones, Alexandria Gilley, Cara Murphy, Taylor Brown, Rachel Graves December 2023 A research project submitted in partial fulfillment for the requirements of the Doctor of Occupational Therapy degree from the University of Indianapolis, School of Occupational Therapy. Under the direction of the research advisor: Katie Polo DHS, OTR, CLT-LANA 2 A Research Project Entitled Title: A Well Kept Secret, Identifying Facilitators and Barriers to Occupational Therapy Referral by United States Cancer Healthcare Professionals Submitted to the School of Occupational Therapy at the University of Indianapolis in partial fulfillment for the requirements of the Doctor of Occupational Therapy degree. Morgan Jones, Korrin Schalhamer, Olivia Witteborg, Alexandria Gilley, Cara Murphy, Taylor Brown, Rachel Graves OTS Katie Polo DHS, OTR, CLT-LANA Accepted on this date by the OTD Program Director: Alison Nichols, OTR, OTD OTD Program Director Associate Professor of Occupational Therapy Date 12/13/23 3 TABLE OF CONTENTS TABLE OF CONTENTS.................................................................................................................. 3 SCOPING REVIEW......................................................................................................................... 5 Scoping Review...........................................................................................................................5 Methods....................................................................................................................................... 7 Data Extraction and Synthesis...............................................................................................8 Inclusion/Exclusion Criteria..................................................................................................9 Procedures to Address Trustworthiness and Credibility....................................................... 9 Results....................................................................................................................................... 10 Theme 1: Oncologist's Perspectives on Rehabilitation....................................................... 11 Theme 2: Personal Characteristics of Patients.................................................................... 12 Theme 3: Characteristics of Cancer.................................................................................... 12 Theme 4: Multidisciplinary Coordination and Communication......................................... 13 Discussion................................................................................................................................. 14 Limitations...........................................................................................................................15 Implications......................................................................................................................... 16 Conclusions............................................................................................................................... 16 PHASE II RESEARCH STUDY.................................................................................................... 18 Research Abstract......................................................................................................................18 Introduction............................................................................................................................... 19 Methods..................................................................................................................................... 20 4 Research Team.....................................................................................................................20 Research Design.................................................................................................................. 20 Participants.......................................................................................................................... 21 Data Analysis...................................................................................................................... 22 Credibility and Trustworthiness.......................................................................................... 22 Results....................................................................................................................................... 23 Participants.......................................................................................................................... 23 Findings............................................................................................................................... 23 Barriers to Referral.............................................................................................................. 23 Participant Context.............................................................................................................. 26 Knowledge of Patient Client Factors & Side Effects.......................................................... 31 Visual Diagram....................................................................................................................32 Discussion................................................................................................................................. 32 Limitations...........................................................................................................................34 Practice Implications........................................................................................................... 35 Conclusion.................................................................................................................................36 REFERENCES................................................................................................................................37 APPENDIX A................................................................................................................................. 43 APPENDIX B..................................................................................................................................46 APPENDIX C..................................................................................................................................48 5 SCOPING REVIEW Scoping Review The number of people living with or beyond cancer (LWBC) is rising, from 15.5 million in this decade, to 20 million in the next (Alfano et al., 2017). Cancer survivorship is defined as the span of time between diagnosis until the end of life (Loh & Jonsson, 2016). With a survival rate of 67% overall, there is a large percentage of people who live with the side effects of cancer and medical treatments throughout their entire lifetime (Siegel et al., 2020). A diagnosis, as well as treatment for cancer, can lead to a range of short-term, long-term, and late-onset symptoms (Alfano et al., 2017). Cancer impacts physical, cognitive, and emotional aspects of life as well as other important body processes and functions through the harsh treatments necessary to rid the body of the cancer cells (Baxter et al., 2017). Treatments can cause one or more side effects including pain, fatigue, impairment in emotional functioning, anxiety, depression, insomnia, and body image (Loh & Jonsson, 2016). More consequences of cancer treatment can be balance and mobility problems, bladder and bowel issues, communication difficulties, cognitive problems, etc. (Alfano et al., 2017). These limitations, or side effects, can interfere with the patient's ability to be functional at work and participate in lifelong activities (Alfano et al., 2017). Although cancer treatments are used to save lives, survivors are left with physical and psychosocial complications that can prevent engaging in everyday life activities and can result in a compromised quality of life (Baxter et al., 2017). These effects can make it hard for individuals LWBC to continue with their typical daily activities such as going back to work, self-care, leisure, social activities, etc. (Alfano et al., 2017). 6 Cancer is recognized as a chronic condition that has a draining impact on areas in a patient's life (Loh & Jonsson, 2016), which requires care beyond a medical standpoint. However, there is a lack of survivorship care including rehabilitation that can prolong the physical, cognitive, and emotional side effects of cancer (Baxter et al., 2017). Therefore, a broader psychosocial-emotional and occupational functioning model of care is needed, throughout the cancer continuum, that addresses occupational participation for reengaging with work, daily activities, and leisure (Loh & Jonsson, 2016). With the side effects of cancer negatively impacting an individual's quality of life, the use of rehabilitation including occupational therapy (OT), physical therapy (PT), and speech therapy (SLP) can help to reduce these impacts and improve the function of the individual (Stout et al., 2021). Cancer rehabilitation is defined as restoring the level of independence and functional ability that one had before cancer (Pergolotti, 2014). The ability to resume the performance of daily activities, work, and engagement in meaningful activities after cancer continues to be overlooked in rehabilitation (Loh & Jonsson, 2016). The need for cancer survivorship rehabilitation is evident; however, many rehabilitation professions including OT are underutilized (Pergolotti, 2014). Physician unawareness and poor communication between fields lead to a lack of referrals needed to access care (Pergolotti, 2014). Evidence supports the use of rehabilitation to treat physical, cognitive, and performance impairments to manage oncology treatment-related symptoms (Stout, 2021). With the absence of screening and monitoring cancer patients for rehabilitation services, many of these symptoms and problems go unaddressed. Routine screening and referrals to rehabilitation services should be implemented across all oncology settings (Alfano et al., 2017). For individuals LWBC, OT addresses health, well-being, and participation to enhance length and quality of life (Loh & Jonnsson, 2016; American Occupational Therapy Association 7 [AOTA], 2020). Utilizing this holistic approach, the person is focused on as a whole, rather than the isolated aspect, which addresses all aspects of cancer effects (AOTA, 2020). With the known benefits that OT can provide, there is a need to understand why services are underutilized in those LWBC, including exploring barriers to OT referral. Currently, researchers are conducting a systematic review exploring reported barriers to cancer rehabilitation from health care professionals' point of view; however, results are not yet determined (Cadmus-Bertram & Douglass, 2021). Understanding barriers provides background information on the referral process, though they do not improve utilization. Exploring supports provides implementable solutions to the overall problem of the lack of referrals to rehabilitation services for people LWBC (Boyden et al., 2010). The purpose of this systematized literature review is to explore the factors surrounding referral to OTfrom healthcare providers in cancer care that include barriers as well as support to referral. The specific question used to guide this literature review is, "In cancer healthcare professionals, which factors influence the referral of individuals LWBC to rehabilitation services throughout their survivorship continuum?" The objective is to address why individuals LWBC are not receiving referrals to rehabilitation as well as what strategies can be implemented to receive referrals in the future. Methods The Model of Occupational-Participation for Cancer Survivorship (MOPCS), is an emerging model of survivorship care, augmented by the International Classification of Functioning (ICF) by the World Health Organization, that addresses the gap in the provision of services that focuses on the resumption of life occupations and engagement in meaningful activities throughout the survivorship continuum (Loh & Johnson, 2016). The MOPCS 8 incorporates a number of critical areas for persons LWBC, such as distinguishing between health issues prior to cancer, health conditions throughout the disease, and health conditions after cancer has been eradicated (Loh and Johnson, 2016). The use of the MOPCS assisted in organizing thinking with regard to article inclusion for the supports and barriers of cancer rehabilitation referrals throughout the survivorship continuum. Data Extraction and Synthesis To begin the search process, a systematized approach was used that followed a sequential procedure with the elements of a systematic review including comprehensive searching, leveling of articles, quality assessment, and bias reporting. A grey literature search was conducted through PROSPERO and Trip Database. In collaboration with an expert in systematic reviews, a faceted search of indexed databases including; PubMed, CINAHL, Academic Search Complete, Medline, and PsychInfo was conducted. A hand search was used to accompany the original searches of Medline. The search criteria were bound by referral, the one main search term, followed by an extensive list of cancer, rehabilitation, and medical professional sub-terms. Filters were used to narrow the search which included 'date-range', 'language', and 'subject heading'. The search included all publications since 2011. We extracted data in order to compare and understand the presented outcomes. The full list of search terms used is listed below in Table 1. Database search results were collected and imported into Zotero (Version 5.0, 2021) software before transferring into Rayyan software where exclusion and inclusion criteria were handled (Ouzzani et al., 2016). The results from each search device were gathered, collected, and reviewed for duplicate entries. All citations and abstracts were reviewed by at least two independent reviewers. All citations that were accepted by the reviewers were included in a full-text review which was conducted by at 9 least two of the same reviewers. Through both screening processes, a third reviewer handled and resolved any disagreements. Inclusion/Exclusion Criteria Studies were included if they (1) include persons living with/or beyond cancer, (2) include any age, race, and gender, (3) were in English, (4) include barriers and/or supports to referrals, (5) any international articles written in English, and (6) include one or more key terms. We excluded studies not reported in English, any studies prior to 2011, and if there was a lack of focus on cancer survivorship. Quality Assessment and Analysis In this systematized review, we analyzed the study sample, population, and setting, the level of evidence, and the quality rating. We described the level of evidence by using the Johns Hopkins Evidence-Based Practice Model which includes five levels of appraisal, as indicated in Table 2. Articles classified as levels 1-3 were used for the purposes of this review to reduce bias in the outcomes. Procedures to Address Trustworthiness and Credibility Researchers started using an audit trail at the beginning of the study that included index tracking of initial and final coding, and notes on decision-making to increase dependability and confirmability (Creswell, 2013). Collectively, the research team engaged in continual reflexive thinking by considering and challenging how biases and past experiences might influence data interpretation (Creswell, 2013). Additionally, both the first and last authors (K.P. & K.L), experienced qualitative researchers that performed the data analysis in the first Israeli study, did not actively code data for this study. They did supervise the other researchers during the analysis process so as to not influence or bias results from the first to second study. Various types of data were collected to assure triangulation and establish credibility including video recordings, transcriptions, and field notes from focus group discussions (Creswell, 2013). Member Checking 10 occurred at the end of each focus group, by having note takers summarize discussions to the participants for changes, additional comments and for confirmability and to support credibility (Creswell, 2013). Results A database search was conducted, yielding a total of 862 articles that were imported into Zotero (Version 5.0, 2021) for deduplication, identifying 154 duplicate articles. There were 708 articles from database searching and 59 articles from hand-searching methods that were imported into the Rayann software for manual appraisal (Ouzzani et al., 2016). Due to the inclusion criteria, 657 articles were excluded and 53 articles were assessed for eligibility to answer the PICOT question. Fifteen articles met the full inclusion criteria from the database search. This process is outlined in the PRISMA Flow Chart depicted in Table 1, and Appendix G includes the article title, leveling of evidence, and findings relevant to this review as shown in Table 2. In total, 15 articles were assessed for bias risk using the Risk of Bias table for Randomized Controlled Trial (RCT) and Non-RCT, as well as the Risk of Bias table for Before-After (Pre-Post) Studies with No Control Group (Higgens et al., 2016; National Heart Lung and Blood Institute, 2014). There were 12 articles that demonstrated low bias risk (Oldenburg et al., 2020; Marshall et al., 2019; Mousten et al., 2015; Silva et al., 2020; Nwosu et al., 2012; Wadhwa et al., 2018; Mertens et al., 2017; Low et al., 2018; Schenker et al., 2014; Johnston et al., 2021; Mousten et al., 2019; Feld et al., 2019), two articles demonstrated moderate bias risk (Weaver et al, 2018; Johnson et al., 2010), and one article demonstrated high bias risk. (Maiwald et al., 2021). Four emerging themes including (1) the oncologists' perspectives on rehabilitation, (2) personal characteristics of patients, (3) characteristics of cancer (4) multidisciplinary communication, were consistently found to be related to referral to rehabilitation. All of the 11 articles included in this review were related to referral to palliative care, and the database search revealed that there is little to no research related to the referral of patients LWBC to other areas of rehabilitation services. Theme 1: Oncologist's Perspectives on Rehabilitation Seven articles focused on the oncologist's perspective of rehabilitation. There were five articles that were Level III qualitative studies (Johnson et al., 2011; Nwosu et al., 2012; Weaver et al., 2018; Feld et al., 2019; Schenker et al., 2014), one was a Level IV quantitative (Meritens et al., 2017), and one was a Level III case-control (Oldenberg et al., 2020). One of the barriers found was that many oncologists believed the care they were providing was sufficient, and they could treat the patients' needs on their own without any rehabilitation services (Weaver et al., 2018; Feld et al., 2019). Doctors claimed to have established a rapport with patients and knew the extent of their issues, but patients were most likely uninformed throughout treatment leading to a lack of knowledge of referral (Johnson et al., 2011; Nwosu et al., 2012). This has led to the idea of physicians' concern about burdening patients with extra treatment as they worry the patient might feel overwhelmed (Feld et al., 2019). Authors from three articles indicated that physicians do not want individuals to experience or feel abandoned during treatment: one article was Level IV quantitative, one was a Level III multisite qualitative interview study, and one was Level III qualitative. Oncologists tend to worry about how patients will feel neglected throughout their treatment and how it could affect them (Schenker, 2014), even though these services can help with the transition to end-of-life care (Meritens 2017). 12 Theme 2: Personal Characteristics of Patients Three articles found personal characteristics, including race, age, gender, education level, and socioeconomic status (SES) influenced the rate of referral to palliative care. All three articles were Level 3 articles; one was a quantitative study, one was a population-based cohort study, and one was a quantitative retrospective cohort. One quantitative study revealed Black patients were less likely to receive palliative referrals than white patients (Lee et al, 2021). Researchers of a population-based cohort study demonstrated younger patients were more likely to be referred than older individuals and females received more referrals than males (Mosuten et al, 2015). Data from the same study showed those with higher levels of education had a higher rate of referral than those with lower levels of education (Mosuten et al, 2015). Additionally, researchers of a quantitative retrospective cohort study found there was a disparity in both referrals to palliative care and attendance of services between members of low and high-socioeconomic-status groups. Members of lower SES received fewer referrals and were less likely to attend than their higher SES counterparts (Dalton et al, 2019). Theme 3: Characteristics of Cancer Five articles found that various characteristics of cancer, including specific symptoms, type of cancer, and stage of disease were related to patients' referral to rehabilitation services: two were Level III qualitative studies, one was a Level III Quantitative Retrospective Cohort study, one was a Level III retrospective review, and one was a Level III mixed-method study. Researchers from these articles indicated that various symptoms, including nausea or vomiting, pain, gastrointestinal difficulties, and difficulty breathing were viewed by physicians as a reason to refer patients to palliative care (Johnson et al., 2010; Feld et al., 2019). 13 Malnourishment was a specific symptom that was related to earlier referral to palliative care than other symptoms patients experienced, as well as significant weight loss (Silva et al, 2020). In addition to symptoms prompting physician referral to palliative care, the stage of cancer a patient was diagnosed with was also related to referrals. Patients with stage III and IV tumors were more likely to be referred to palliative care than patients with stage I or II tumors (Silva et al, 2020), and patients who received a cancer diagnosis two or more years prior were more likely to be referred than those who received a diagnosis more recently (Wadhaw et al., 2018). Specific types of cancer, such as breast cancer, were more likely to be referred to palliative care earlier than other types of cancer (Low et al, 2018; Wadhaw et al, 2018). Theme 4: Multidisciplinary Coordination and Communication Six articles indicated that there was a lack of multidisciplinary coordination and inter-service communication between oncology professionals and rehabilitation services: one was a Level II case-control study, one was a Level II mixed methods study, three were Level III qualitative studies, and one was a Level III mixed methods study. An overarching finding from these studies was that there was insufficient communication between the professionals involved in caring for those LWBC, and the benefits of collaboration with other disciplines were not viewed to be worth the difficulties (Maiwald et al., 2021; Low et al., 2018). A barrier to referral noted by two studies was that oncologists were not educated on the benefits that rehabilitation services may provide their patients nor the aspects that may qualify a patient for rehabilitation (Schenker et al., 2014; Nwosu et al., 2012). The authors of the two articles demonstrated a potential lack of formal education on rehabilitation services within medical programs (Weaver et al., 2018; Oldenburg et al., 2020). There was a low percentage of 14 students in pediatric oncology fellowship programs who reported being required to have a rotation in palliative care services (Weaver et al., 2018). Additionally, students in medical school reported a lack of confidence in referring patients to rehabilitation services in terms of qualifications for rehabilitation and the benefits it can provide (Oldenburg et al., 2020). Discussion This systematized review considered the literature regarding the barriers and supports of referral of patients LWBC to rehabilitation services. Palliative care was found to be a prominent area of referral for patients LWBC compared with other rehabilitation services, such as physical or occupational therapy. There is strong evidence characterizing the barriers to referrals due to the oncologists' views or beliefs on the subject. These barriers include a lack of knowledge (87.6%) and awareness (85.6%) of the cancer rehabilitation services and how they can benefit a patient throughout their treatment (Yang et al., 2014). These findings support the evidence from previous articles indicating these barriers prevent a patient from receiving optimal treatment. There is limited evidence supporting the idea of lessening the burden on patients to prevent them from thinking the oncologist gave up on their treatment. There is strong evidence indicating that personal characteristics (including race, age, gender, education level, and socioeconomic status) contribute to lower rates of referral and subsequent poorer health outcomes for those with cancer (Lee et al, 2021, Mosuten et al, 2015). These findings suggest personal biases of providers who refer influence the rate of referral. Although it was found these characteristics hinder referral, previous literature did not find them to be a barrier to referral specifically, despite the indication that these characteristics resulted in 15 general poorer health outcomes for those with cancer (Halpern et al., 2016). These poor outcomes could be related to a lack of referral. There is strong evidence in the literature that the characteristics of cancer are a barrier to referral to rehabilitation services for patients LWBC. The diagnosis, prognosis, and symptoms of cancer were specific factors previously found in research to be barriers to referral (Hui et al., 2016; Lattanzi et al., 2010). These findings support the evidence from this systematized review and may indicate that patients who have early stages of cancer, good prognosis, or lack specific symptoms are overlooked when referring to rehabilitation services. There was not any previous research indicating multidisciplinary coordination and communication as a barrier to referral to rehabilitation for those LWBC. However, the evidence from this review demonstrates that six articles addressed multidisciplinary coordination and communication as a common barrier to referral. One specific barrier noted in these articles includes insufficient communication between healthcare professionals regarding the treatment plan and patients' status. This novel theme should therefore be explored further in research to determine the impact it might have on the referral of patients to rehabilitation services. Limitations Limitations of the systematized review include the design and methodology of the individual studies. The articles were primarily Level 3, which is a lower level of evidence, and there were no Level 1 articles (Higgens et al., 2016; National Heart Lung and Blood Institute, 2014). Despite this limitation, all but one article were found to be high quality, justifying their inclusion in this review. Several measures were taken to ensure comprehension of search strategies, however, it is possible that relevant studies were overlooked, creating a publication selection bias. 16 Additionally, a few of the studies included specific groups in their sample, therefore limiting the generalizability to the larger population of oncology. Some examples of these specific groups include samples from large academic medical sites (Feld et al., 2019), well-developed palliative care programs (Schenker et al., 2014), or areas with cultural taboos surrounding palliative care (Low et al., 2018). The oncologists' perspectives regarding the referral of individuals LWBC to rehabilitation services within these studies may not generalize to the overall population of oncologists. Implications Referral to rehabilitation services is hindered by a variety of factors that lead to subsequent underutilization of rehabilitation services across the cancer care continuum. Further research is needed to determine how to improve rates of referral. No existing literature indicates when referral to rehabilitation services should be implemented to produce effective outcomes. Additionally, this review indicated a novel theme of referral. This should be further examined in future literature since it is a novel finding. Research guided by an occupational-based theory could be beneficial in discovering where in the cancer care continuum rehabilitation referral would yield the most advantageous results for people living with and beyond cancer. Conclusions Referral to rehabilitation services is underutilized across the cancer care continuum for individuals LWBC. Barriers to referral include cancer care providers' lack of education about OT services, personal characteristics (sociodemographic characteristics) of patients, characteristics of patient's cancer, and lack of multidisciplinary communication. These barriers are supported by other literature reviews. However, multidisciplinary communication was not found as a barrier to referral in other literature reviews and is considered a novel finding. Further education and 17 research could aid in the reduction of barriers to referral for rehabilitation services for those LWBC. 18 PHASE II RESEARCH STUDY Research Abstract Those living with and beyond cancer (LWBC) have psychosocial and physical complications, compromising their quality of life (QoL). Occupational therapy (OT) offers a unique service promoting health, well-being, participation, and QoL. However, it has been revealed that OT services are underutilized in oncology care. Phase II of this international study explores the perspectives of healthcare professionals working with persons LWBC regarding the role of OT in oncology, as well as supports and barriers to OT referral. Data was collected through four focus groups with 17 participants. A multiple explanatory case study and a grounded theory approach were used to analyze data. Four overarching themes emerged, including "support for OT referral, knowledge of patient client factors & side effects, barriers to OT referral, and participant context," along with ten sub-themes. The limitations of this research may impact generalizability and depth, such as a predominance of female participants. Future research should examine the impact of education on OT scope of practice on OT referral and recruit participants in diverse ways to address limitations. Addressing system barriers and advocating for the scope of OT may lead to more OT referrals in oncology. Keywords: Cancer, referrals, OT, barriers, supports 19 Introduction Cancer is now considered a chronic condition for many people, which can impact returning to function, participation, and quality of life (Hunter et al., 2017). While cancer treatments' primary focus is to eliminate cancer and prolong one's life, survivors often face residual physical and psychosocial complications that lead to a compromised quality of life (Baxter et al., 2017). There is a strong need for rehabilitation services, specifically occupational therapy (OT), for those living with and beyond cancer (Baxter et al., 2017). Many individuals LWBC that are both in treatment or remission can experience adverse symptoms that influence their overall occupational performance and quality of life. The goal of OT is to maintain and restore function, reduce symptom burden, optimize independence, and improve the quality of life (Alfano et al., 2017). Rehabilitative and OT services are underutilized in oncology care despite the growing evidence and recommendations to regularly screen for the need for these services (Baxter et al., 2017; Stout et al., 2020). Currenlty, there is a paucity of literature surrounding the referral process to OT in cancer care. To support proper referral practices, other healthcare professionals in cancer care need to understand the role of OT and the indications for appropriate referrals (Oldenburg et al., 2017). A lack of referral can stem from a lack of knowledge regarding OT's role in oncology and the lack of communication between providers and employers. These professionals can help coordinate work-based programs with cancer rehabilitation for optimal effectiveness (Alfano et al., 2017). Some barriers that exist that impact referral to rehabilitation and OT services include a lack of knowledge of rehabilitation services by referral sources, understanding in who is appropriate for referral, a lack of rehabilitation services in oncology-based institutions or nearby 20 communities, and a lack of infrastructure supporting an easier referral process (Pergolotti et al., 2019). The purpose of this study was to investigate the perspectives of healthcare professionals in the United States who work with individuals LWBC regarding OT involvement in cancer care. Additionally, an overarching aim was to outline the current barriers and facilitators influencing referrals to OT during and after cancer treatment. The specific aims of this study were to explore the perspectives of healthcare professionals in the United States regarding 1) the role of OT in cancer care, 2) the need for OT services for cancer patients, 3) the current barriers to OT referral, and 4) what is needed to optimize referral. Methods Research Team This study was conducted by seven graduate students studying OT at the University of Indianapolis while receiving support from two experienced qualitative researchers. Of our four focus groups, two were led by student Taylor Brown, one was led by student Alexandria Gilley, and one was led by researcher and data collector Khawla Loubani. All researchers were female and received training through a data analysis research course. Student researchers did not have any relationships established with participants prior to the commencement of the focus groups. At the beginning of the focus group, the scheduled interviewer explained their participation alongside Dr. Katie Polo in this research project. Dr. Katie Polo served as the principal investigator of this research study. Research Design The research coordinators conducted a study using a multiple explanatory case study, allowing compelling evidence to be formed from each case and compared for analysis (Yin, 21 2018). The exempt review was processed through Helsinki, the primary institution's IRB in Israel, and the University of Indianapolis IRB entered into a reliance agreement for data collection in the United States. All participants were asked to give consent to participate through Qualtrics. Participants Researchers utilized purposive sampling methods, including professional contacts and recruitment by phone, email, flier, social media, and word of mouth. This type of sampling method allows the researchers to select individuals and sites that can provide information, as well as participants that relate to the reason for the study and the research problem (Creswell, 2013). Participants consisted of those who met the following criteria: (1) currently working in oncology or cancer care, (2) professional as a nurse, oncologist, social worker, or physician's assistant, and (3) located within the United States. Our goal was to conduct four focus groups consisting of four to six participants, because this number is ideal for identifying themes and conducting a cross-case theme analysis (Creswell, 2013). Data Collection Data was collected through four focus groups, consisting of four to five participants. An interview guide consisted of ten open-ended scripted questions; see Appendix B for details. Open-ended questions in the interview guide allowed the interviewees to open up and share their responses (Creswell, 2013). Other data sources included Qualtrics survey and team member field notes taken during the focus groups. The focus groups were recorded and transcribed verbatim via Zoom and Google Meets. There were no repeat interviews. The timing of the interview discussions averaged 33 minutes with a range of 30-36 minutes. Multiple research team members reviewed the focus group transcripts for accuracy. All participants completed a Qualtrics survey, including a consent form, before the start of the focus groups and demographic questions. 22 Data Analysis Data was analyzed for this case study using a grounded theory approach, which includes three stages: (1) open coding to identify key elements, (2) axial coding to identify relations between the elements, and (3) selective coding to create propositions and a theory to explain the relations (Strauss & Corbin, 1990). During open coding, transcripts from the focus groups were used to form codes or categories, which then formulated a codebook. This codebook allows detailed descriptions, themes, and interpretations of the data (Creswell, 2013). Seven researchers coded the data. Analysts and coders learned proper procedures for data analysis research through a data analysis research course. The data analysis process was supervised by two experienced qualitative researchers. The researchers individually coded the data from the focus groups, followed by collaborative coding in a group setting to derive themes with a consensus of at least five researchers. Data saturation was reached near the end of the second to last transcipt. Demographic data were analyzed using IBM SPSS Version 28 (IBM Corp., Armonk, NY). Credibility and Trustworthiness The use of multiple types of data collection, such as interview questions, detailed transcripts, and observations, permits the extensive amount of data collected from each focus group to be analyzed in great depth (Creswell, 2013). The research team used continual reflexive thinking throughout the process to assist in preventing personal biases thus increasing objectivity. Two experienced qualitative researchers reviewed and supported the data analysis process to ensure dependability and confirmability. Triangulation was used to establish credibility; the group collected various data methods such as video recordings, transcriptions, and field notes (Creswell, 2013). Note takers performed member checking by summarizing discussions to the participants 23 for to confirm intent of discussions, supporting credibility and confirmability (Creswell, 2013). The writers of the study described the participants and setting in detail which enables readers to transfer information to other settings, allowing for increased transferability (Creswell, 2013). Results Participants We recruited 17 professionals for this study: three oncologists, five nurse navigators, six nurses, and three social workers aged 30 to 66 years old. Participants' work experience ranged from 1 to 40 years. Demographics collected from the participants include age, gender, profession/specialization, practice state, prior referral to OT, possible collaboration with OT, and how collaboration with OT occurs. Participant demographics are shown in Table 1. Findings Four overarching themes emerged with subsequent subthemes. The theme support for OT referral consisted of subthemes (a) integration of OT into oncology; (b) knowledge of occupational performance; (c) knowledge of the scope of OT practice; and (d) ideas to support referral. The second overarching theme was knowledge of patient client factors and side effects. Theme three, barriers to referral, includes subthemes (e) insufficient awareness/knowledge of OT; (f) system barriers; (g) clinic barriers; and (h) patient barriers. The final theme, participant context, was separated into subthemes (i) profession; and (j) experience, interaction, and collaboration with OTs. Barriers to Referral Participants explained what is currently inhibiting the lack of referrals to OT in the oncology process. They were asked to describe their knowledge of the scope of OT, and several participant responses revealed a lack of understanding of the profession of OT and the role of OT 24 within oncology. One participant was able to provide a limited description of OT, saying I would say in general occupational therapy isobviously a form of therapyfocusing on those signed motor skills versus the big muscle groups and bone.[and] job related movement. A common topic of discussion was how PT and OT tend to get intertwined in that PT is more commonly known for their scope of practice. A participant shared, I think I kind of intermix PT and OT a little bit. If I was asked to really give a specific difference and who they see I probably wouldn't get it correct. Many expressed there is often confusion around the true description of the profession. One participant explained: You know I think, I think OT is a well-kept secret. Unfortunately, I think it's that you all don't market yourselves very well. Everybody knows what PT is. Everybody knows that. Unless we have something really specific, if somehow we happen to get referred to an occupational therapist, we don't know half of what you all do. You have a lot to offer but nobody knows you're nobody knows you're around. Participants expressed barriers in the system, especially regarding the insurance process for receiving OT services. Patients may not be able to afford all of the services, which can limit the treatment they can receive. A participant stated: We pretty aggressively hate on cancer centers of America they do this queen for a day system, where they have, you see a nutritionist, a PT, an OT, a chiropractor, etc. You know, they have to see all these different subspecialties and then make you individually bill for all of them. And the patient actually can't afford to go to all those subspecialists. So it's got a bad reputation in cancer for that reason. That, you know, we try to do everything under one roof as much as we can. 25 A prominent sub-theme is that clinics have difficulty making referrals due to other priorities, or oncologists might be unsure which service to refer to. A participant shared, We refer to physical therapy as a start, then occupational therapy as a second step or a parallel. Individuals mentioned that it would be helpful to delineate clearly who handles what in the intervention process. It was also mentioned how physicians have several patients to see on a day-to-day basis and often do not even think of OT at the moment as a referral option. A participant reported: I'll just be really honest, clinic, clinics are busy. Physicians are having trouble seeing a lot of patients. The nurses, unfortunately, unless they've been tuned in the nurses, don't think of it. And I think they just haven't been exposed enough. Oncologists also have to make referrals to these services, which can inhibit it from happening due to other priorities. Individuals voiced their opinion, The biggest barrier was the oncologists. We shouldn't wait on giving someone a service that is necessary while they're getting treatment but it was definitely in my experience an afterthought. Participants also shared how there may be a lack of OTs in the clinic, eliminating the ability to refer altogether. Patients often undergo several treatments at a time, which can drain their energy levels. Participants expressed how the universal trait of all cancer patients is fatigue and overwhelmingly tiring on a physical, emotional front. Patients also may not have the time or money to add other services to their schedule on top of what they are already doing. There may be a limited appointment window for these individuals, and adding another service can be overwhelming. A participant shared, I think oftentimes when the patient is in the throes of treatment, it's hard for them to think about adding an additional appointment. It was found that patients may also be more reserved when it comes to the need for OT or PT services and want to just focus on one treatment at a time. But it seems more times than not patients are so focused, driven on one treatment to the next, which, that's their reality 26 right now is Hey, I need to do this to get to the next step. Do this chemo. Do a CT. Let's see how it is. A participant explained how a lot of this can be due to a lack of awareness and resources on the patient side. Patients do not realize what else can help them as they are hyper-focused on other treatments. A participant explained: Some patients think that they've been through so much that they don't realize that they don't have to be in this kind of state; they can actually improve afterward as well some patients are thinking that this is their new normal. So we do want them to be able to do as much as they can on their own and improve. The individuals expressed barriers limiting referrals to OT during the cancer survivorship continuum. Participants expressed a lack of awareness or knowledge of OT, patient barriers, and how clinics tend to have other priorities in the referral process. Participant Context Participants expressed varied levels of context for OT. All participants had some knowledge of OT as a profession based on their personal experiences, professional interactions, and collaboration with OTs. Personal experience with OT included knowing occupational therapists or OT students and/or use of OT services for themself or a family member. A participant reported, My son was in OT when he was small so I'm familiar with that... then my sister is in OT school. So she often has to create different tools for people in certain situations. So that's what I know. Participant context of OT also came from professional interaction and collaboration with OTs. Most of the participant context of OT came from professional experiences working with OTs. Participants reported having knowledge of OTs' work with sensory processing disorders in pediatric settings and some knowledge of OTs' role in oncology. One participant stated, I do know the OT I worked with most closely when I was at radiation oncology. She 27 helped a lot with neuropathy issues and lymphedema issues. Additionally, a participant shared her experience with OTs helping patients post-mastectomy and post-node removal patients regain upper extremity function, By working with the OT clinics, she was able to regain function, you know, have a sleeve that fit gets fitted for one actually, you know, regained use of her dominant arm, which was a huge deal for her. Most participants relied on personal contact with OT as their source of knowledge for the scope of practice through family members receiving OT services rather than professional experience and being educated on OTs presence and role in their setting. Support for Referral Participants expressed their current understanding of the purpose of OT as it relates to the oncology setting. The subtheme of knowledge of OT scope of practice was delineated into partial knowledge and sufficient knowledge based on participants' descriptions of the services OT provides. Some responses indicated that participants had only partial knowledge of the scope of OT, focusing on side effects in patients resulting from oncology treatment or the cancer process. The participants mentioned several side effects that might prompt referral to OT in their settings, including weakness, fine motor difficulties, fatigue, and peripheral neuropathy. It was also noted that referrals to OT are made to address the long-term side effects that cancer or oncology treatments may yield. One participant stated, I refer to OT mostly for peripheral neuropathy and kind of assistance with tools like that... Generally, just again, trying to kind of assist with activities of daily living type things. But probably the neuropathy is the biggest referral. Participants mentioned fatigue and neuropathy multiple times, though these are a small part of the OT scope of practice. Other participants provided more details regarding why they might refer to OT services within the oncology setting, indicating a sufficient knowledge of the scope of OT practice. It was noted that the side effects from cancer or oncology treatments often impact 28 patients' daily activities, and a few participants discussed how specific side effects might relate to occupational performance deficits observed in patients. The participants demonstrated adequate knowledge of the profession of OT while also indicating an understanding of the impact that cancer treatments may have on their patient's overall function and engagement in occupations. It was reported that the impact of side effects was most often seen in patients' abilities to engage in activities of daily living and to function safely within the home environment. One participant stated: OT is a type of rehabilitation it's closely related to physical therapy but focuses more on task-oriented or real goal-specific things as opposed to generalizing strength training, for example, spoon use after stroke or swallowing efficiency, things like neuropathy or fatigue in cancer as opposed to the goal of having a general physical goal where like 30% of use back actually, having a focused goal with like an ADL purpose. A few participants expressed a deeper understanding of the scope of OT within the oncology setting through the relation of side effects to occupational performance deficits. It was also noted that participants used clinical experiences to describe how side effects impacted the occupational performance of oncology experience, and this application of knowledge provides support for referral to OT based on the integration of knowledge and experience with patients. This second subtheme, knowledge of occupational performance, was also separated into partial or sufficient knowledge of occupational performance. Partial knowledge was signified by the description of side effects loosely tied to occupational performance, while sufficient knowledge involved comments describing the impact of side effects on patients' occupations. One participant explained, I mean neuropathy can be as little as discomfort and walking or as much as writing with the pen or buttoning their shirt for balance issues. The side effect that was emphasized as 29 having a substantial impact on cancer patients was fatigue, as well as subsequent shortness of breath and weakness. These factors were noted to affect the functioning of the participants' patients negatively, and participants expressed that assistive devices are helpful in combating these side effects, indicating support for referral to OT services in those situations. Additionally, a few participants pointed out that it can be challenging to directly obtain information about changes in daily functioning from the patients. It was mentioned that family members often provide insight into the impact that side effects have on patients' daily lives. The participants' understanding of how to obtain information about patients' occupational performance supports the referral process, as it guides them in asking questions to the family members and the patients. One participant described this scenario, saying: I feel the family is usually where we hear that from. Usually, the family will say things like, you know I'm worried about them falling, um they're not eating like they should, they're not bathing well on their own, um they're not as active. So I feel like it's usually the family who will first make a comment about just their decrease in functioning. Another prominent subtheme in support of OT referral is the integration of OT in oncology. The participants discussed processes currently in place at their facilities that promoted OT involvement in oncology patient care. It was expressed that many participants try to ask patients about any side effects that they might be experiencing to identify the need for OT services earlier. Several participants also mentioned that their facilities incorporated inpatient OT into the care plan so that patients could receive OT services while still in the hospital, as it was noted that appointments in outpatient following the hospital stay may be difficult for patients to attend for various reasons. One of the participants worked as a breast surgeon in a facility that had a revital 30 program, which included an automatic referral as a part of the post-surgery protocol. The participant further described the program: So for me, we do refer all the post-surgical patients. And then we send them back during their survivorship period from my perspective because I'm the surgeon if they have continued range of motion issues and really the big thing we focus on is lymphedema. Other participants mentioned that their facilities schedule OT evaluations alongside other services to reduce the need for patients to attend multiple appointments. It was noted that a new protocol had recently been enacted in which OTs would come into the infusion clinic to assess the need for OT while patients were simultaneously receiving other treatments. The participant at this facility stated: So we recently have really tried to make use of our partnership with one of our local groups that we refer to a couple of times in this conversation and so what I have agreed to do with them, that group is to have them actually, physically come into the clinic in our infusion room and do some assessing, talking to the patients directly without, you know, kind of with an agreement that if they see something, then they'll say something to us and we'll refer based on that. So, just kind of an extra set of professional eyes. They know what they're looking for, or what they're listening for in conversations. In addition to identifying current processes supporting OT referral, the participants provided several suggestions to increase the referral of oncology patients to OT. This subtheme to support OT referral includes ideas to simplify and streamline the process of OT referral, as well as reduce the burden of OT appointments for patients. Several participants mentioned that coupling OT with other services, such as infusions or chemotherapy, could increase the utilization of OT services since it would address the issue of patients having multiple weekly appointments. It was also 31 stated that providing co-treatments with PT may be beneficial for the same reason of reducing patient burden. A common suggestion among participants was to provide more specific outlines of what OT can contribute to the oncology process, such as through evidence-based case studies. One participant explained: Yeah, I think like you mentioned case studies where it's outside the box, and we know the general overview of what you do. But there's a lot more to it and when we see that, then it helps to think "Oh my gosh. Yeah, this patient I can use that." Creating more specific resources for healthcare providers may increase confidence in their knowledge of OT scope of practice, which in turn can further increase referrals to OT services. Knowledge of Patient Client Factors & Side Effects Participants named many cancer treatment side effects that reduced patient occupational performance. Although client factors vary per client and are influenced by type of cancer, a typical client factor discussed by participants was fatigue. General fatigue inhibits patients from participating in the occupations they did prior to treatment, reduces performance, and interferes with socialization. One participant noted: One of the biggest issues is always fatigue, across the board is the fatigue, the energy loss. I think it's very dependent though on the cancer as well because if you're talking about head and neck cancer or you're talking about prostate cancer I mean it's very different. A participant, who is a practicing surgeon, stated loss of motion and sensory changes occur as a result of cancer-related surgeries, like mastectomies and lymph node removals. These client factors reduce mobility and interfere with client function. Multiple participants reported weakness and lethargy as culprits for decreased occupational performance: 32 I've had a couple of patients who just have a lot of weakness afterward and need to regain that strengthThe weakness had caused her to lose activity as well. So she was even having some shortness of breath and things because she just hadn't been as mobile as she should have been. Some client factors are long-term and impede client functioning after treatment is complete. Participants expressed that fatigue, chemo brain, and neuropathy or pain often persist and interfere with occupational performance after treatment concludes. This theme highlights a need for interventions to improve occupational performance for cancer patients during and after treatment. The client factors and side effects noted by participants (fatigue, weakness, sensory changes, loss of range of motion, cognitive changes, pain, lymphedema) fall under OT's scope of practice. Visual Diagram A visual diagram was developed to capture the interrelated conditions (subthemes) and interconnections of the supports and barriers to OT referral in oncology care, as noted by the focus group participants, see Figure 1. While supports and barriers were prominent in this research study, it was also essential to understand the relationships between participant context, knowledge of client factors, and solutions to support referrals. The diagram simulates using the participant context and their knowledge of client factors to create solutions to support referrals. This will trickle into using the wrecking ball to knock down the barriers, shown as the brick wall, most commonly reported by the participants to increase referral to OT. Discussion The current study was part of a more extensive international study between researchers in both Israel and the USA that explored the perspectives of healthcare professionals regarding the 33 barriers and facilitators of OT referral for persons living with or beyond cancer. The current study had four aims: 1) to explore the perspectives of healthcare professionals in the USA regarding the role of OT in cancer care, 2) to explore healthcare professionals' knowledge of the need for OT services for cancer patients, 3) to understand the current barriers for referrals to OT from healthcare professionals' perspectives, and 4) to explore what is needed from healthcare professionals perspective to optimize referral of patients to OT. The outcomes of this study have provided further evidence that there is room for improvement in the referral of OT in oncology care in the United States. Through multiple focus groups, four themes were commonly observed; support for referral, barriers to referral, knowledge of patient client factors/side effects, and participant context. Participants throughout the focus groups explained their prior experiences with OT referral in oncology care while also describing briefly what OT services provide for oncology care. This information produced the subthemes "Integration of OT in Oncology" and "Knowledge of the Scope of OT Practice." The subtheme "Knowledge of the Scope of OT Practice" comprised two types of knowledge: partial knowledge and sufficient knowledge. An intersection between the theme "knowledge of patient client factors/side effects" and the subtheme "knowledge of occupational performance" was identified a few times throughout data analysis, indicating that some participants inadvertently had partial knowledge about how patient side effects from cancer cause a decline in occupational well-being and performance. The other intersection that commonly arose throughout our data analysis was between "knowledge of patient client factors/side effects" and the subtheme "knowledge of the scope of OT practice". The results from this intersection show most participants had partial knowledge of the scope of OT 34 practice due in part to the experiences and side effects their patients experienced in cancer treatments. The current literature supports the findings of this study. Previous researchers identified the underutilization of OT services in oncology care regardless of growing evidence for the need for rehabilitative services. Data from this study found an underutilization of referrals to OT services for patients LWBC for a variety of reasons (Baxter et al., 2017; Stout et al., 2020). The primary reason for this lack of referral is a lack of understanding of OT's scope of practice and role within oncology. This finding is supported by previous literature which argues that healthcare professionals must understand OT's role in oncology to support proper referral practices (Oldenburg et al., 2017; Alfono et al., 2017). Data from this study indicates that the lack of occupational therapists available in outpatient oncology clinics and integrated into inpatient oncology settings is a barrier to OT referral. This indication is supported by Pergolotti et al.(2019), who cite the lack of services in oncology-based institutions or nearby communities as a barrier to referral. The current literature did not discuss patient barriers that directly impact referral to OT. Data from this study cites lack of time and resources as patient-specific barriers that prevent referral to OT. Many participants discussed patients being inundated with follow-up appointments and time, transportation, and patient energy as deterrents for referral. Limitations The limitations of this research may impact generalizability and depth. The predominant participation of individuals from the nursing field, with a scarcity of medical doctors such as oncologists and surgeons, introduces a possible bias that restricts the applicability of findings to a broader medical context. The overrepresentation of female participants adds another layer of 35 limitation, potentially skewing the results if gender-related nuances exist in the topic under investigation. However, data saturation was achieved by the end of the third focus group due to having consistent data over multiple samples to conclude. The use of Google Meets as a platform, combined with a group setting, may have inadvertently constrained the participants from freely expressing conflicting views or opinions that involve professionals from other disciplines. This limitation could compromise the diversity of perspectives essential for a comprehensive understanding of the subject matter. As such, it is crucial to acknowledge these constraints when interpreting the study's outcomes and to recognize the need for more diverse and extensive participant inclusion in future research endeavors. In addition, it is possible that focus group members felt unable to state opinions in a group setting due to having multiple professions or colleagues present. To offset this possible limitation, member checking was completed at the end of each focus group in which note-takers discussed the findings to allow for additional comments and changes and confirmability and credibility (Creswell, 2013). Practice Implications Throughout our interviews with oncology professionals, a common topic of underrepresentation and weak marketing of the OT profession was mentioned. Marketing allows professionals and consumers to function together and increase consumer satisfaction with products and services. This could increase understanding and knowledge of the scope of OT practice to improve referrals. A way to achieve this would be to create resources describing OTs' roles and services for other healthcare professionals to reference daily. These resources could also model methods of proper referral through the provision of patient examples detailing which symptoms warrant OT referral, as well as a list of clinics with available OT practitioners in the area. 36 Future research should further examine and explore the impact of education for OT referral sources surrounding OTs scope of practice. Specifically, if referral sources received education to OT services, does this impact referral rate and access to OT services. Future studies should recruit in different ways and for a more extended period of time to gain more oncology professionals' perspectives to address the limitations of the current study's results. Addressing barriers to referral, including streamlining referral processes and easing the burden of multiple appointments for patients, as well as providing training and resources regarding the scope of OT and indications for referral may lead to more OT referrals. Conclusion This study highlighted prominent themes discussed among oncology professionals regarding barriers and facilitators of OT referrals. There are barriers to OT referral within the oncology setting related to oncology providers' lack of knowledge of services, lack of education on referral processes, and lack of accessible therapy services. These findings are supported by previous literature; however, this study also contributes novel information concerning patient-specific factors noted as barriers to the OT referral process. Education regarding the scope of practice of OT through OT based case studies will address initial barriers to OT referral within oncology settings. 37 References Alfano, C. M., Kent, E. E., Padgett, L. S., Grimes, M., & de Moor, J. S. (2017). Making cancer rehabilitation services work for cancer patients: Recommendations for research and practice to improve employment outcomes. PM&R, 9. https://doi.org/10.1016/j.pmrj.2017.06.019 American Occupational Therapy Association. (2020). Occupational therapy practice framework: Domain and process (4th ed.). American Journal of Occupational Therapy, 74(Suppl. 2), 7412410010. https://doi.org/10.5014/ajot.2020.74S2001 Baxter, M. F., Newman, R., Longpr e, S. M., & Polo, K. M. (2017). 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Corporation for Digital Scholarship. 43 Appendix A Table 1 Demographic data Participant 1 Age Education (Yrs.) level 47 MD Profession Med Specialization Practice Years in Collab. Active / Department Setting cancer care with OT Referral to OT Breast Academy 15 Yes (often) Yes Clinical Commun 23 No No Research ity 40 Yes Yes Surgeon 2 66 MA Nu Coordinator 3 60 BA Nu Thoracic Other Oncology (sometimes) Nurse Navigator 4 65 MA Nu Registered Other 40 No No Manager, Commun 4 No Yes Nursing ity 24 No Yes Nurse Abstractor 5 35 Associates's Nu Services 6 54 Associate's plus a year towards BSN Nu Primary Commun Clinic Nurse ity 44 7 45 BA Nu Clinic Nurse Commun 1 No No ity 8 - - Med Oncologist - - - - 9 - - Nu - - - - - 10 30 MA SW Oncology Hospital 4 No Yes Social Worker 11 56 MA SW Social Worker Hospital 7 No No 12 38 MD Med Medical Hospital 7 Yes Yes Oncologist 13 36 MA SW (sometimes) Program Commun Manager ity 8 No No 14 54 BA - - - - - - 15 49 BA Nu Nurse Commun 15 No Yes Navigator ity Breast Hospital 10 Yes Yes 16 43 Associate's Nu Navigator 17 47 Med Nu Mean (SD) Mean BA =4 Nurses- Median (SD) (23.5%) 10 (IQR) = MA= 5 (58.8%) N% 48.43 (29.4%) - (sometimes) - - Hospital= 4 (23.5%) Commun Median Yes = 4 Yes = 8 (47.1%) (IQR) (23.5% ( No= 5 (29.4%) ity= 6(35.3%) 10 (7-23) - No= 9 (52.9%) - 45 (11.3 MD = 2 Social 1) (11.8%) workers 3 Rang Associate=3 (17.6%) (5.9%) e= (17.6%) MD =3 Other=2 (17.6%) (11.8%) 30-66 Academy =1 Note. Three participants had missing demographic data. We attempted to contact them after the interviews to complete the missing information but were unable to reach them. All participants were women, except participants 8 and 12 were men. Med=Medicine; Nu=Nursing; SW=Social Work. 46 Appendix B Table 2 Interview Guide Interview Guide Study Aims Interview Questions Relating to Aims Aim 1: Explore the perspectives of healthcare What do you know about occupational professionals regarding the role of therapy in general? occupational therapy to the care of cancer What do you know regarding occupational patients. therapys role in oncology? Aim 2: Explore healthcare professionals How does cancer affect your patients daily knowledge of the need for occupational functioning and activities of daily living therapy services for cancer patients. (ADL)? What are the signs and/or indicators to refer your patients to occupational therapy? What limitations in your patients daily functioning might prompt you to refer to occupational therapy? What kind of functional impairments do your patients have? How does cancer affect patients daily functioning/routines? 47 Aim 3: Understand the current barriers to What are the reasons that cancer patients occupational therapy referrals from healthcare are not referred to occupational therapy? professionals perspectives. Aim 4: Explore what is needed to optimize What do you think is needed to optimize referrals to occupational therapy. the referral of your patients to occupational therapy? Additional Questions Is there anything else you would like to share? Note. The interview guide is sectioned into two different columns; the left colum indicates the studys specific aims while the right colum indicates interview questions that correspond to the study aims. 48 Appendix C Figure 1 Visual Diagram of Supports and Barriers of Referral to Occupational Therapy  ...

... Using an Occupational Therapy Lens to Explore the Role of Grandparenting: A Thematic Synthesis Abigail Crouse, Kaitlin Goedde, Jonathan Guan, Emma Magee, Adrienne Numbers, and Aryn Snyder December 19, 2023 A research project submitted in partial fulfillment for the requirements of the Doctor of Occupational Therapy degree from the University of Indianapolis, School of Occupational Therapy. Under the initial direction of the research advisor: Dr. Lucinda Dale, EdD, OTR, CHT, FAOTA Reviewed by: Dr. Beth Ann Walker, PhD, MS, OTR, FAOTA Using an Occupational Therapy Lens to Explore the Role of Grandparenting A Research Project Entitled Using an Occupational Therapy Lens to Explore the Role of Grandparenting: A Thematic Synthesis 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 Abigail Crouse, Kaitlin Goedde, Jonathan Guan, Emma Magee, Adrienne Numbers, and Aryn Snyder Accepted on this date by the OTD Program Director: 12/20/23 Alison Nichols, OTR, OTD OTD Program Director Associate Professor of Occupational Therapy Date 2 Using an Occupational Therapy Lens to Explore the Role of Grandparenting 3 Approximately 70 million grandparents constitute one-third of the U.S. adult population in 2017, marking a significant 24 percent increase since 2001 (Bulletin, 2017). Baime (2023) highlights a significant demographic trend in recent U.S. Census data revealing that approximately 7.1 million American grandparents cohabit with their grandchildren under 18, with 2.3 million actively assuming caregiver responsibilities. The growth of caregivers role reflects the expanding influence that grandparents have on their families and communities (Bulletin, 2017). Across the lifespan, the bond between grandparents and grandchildren yielded a positive influence enhancing their engagement in meaningful occupations, diverse roles, and enriching relationships (Harmon et al., 2022). Grandparents play a significant role in upholding the emotional vitality of their relationships with grandchildren, as asserted by Bangerter and Waldron (2014). Their assumed responsibility in this regard stems from the unique insights they develop into family dynamics, which shape the grandparent-grandchild (GP-GC) relationship. Mansson (2016) emphasized the significance of exploring this dimension in academic literature, not solely for the welfare of grandparents benefiting from these relationships but also in light of the changing societal dynamics driven by factors like diverse family structures, increased life expectancies, a rise in dual-worker households, and elevated rates of family breakdown. The grandparents role is exemplified by the growth of supplementary grandchild care in the United States in recent decades, as documented by Kim et al. (2017). The increased frequency of interaction between grandparents and their grandchildren was attributed to not only the considered role of grandparents but also the extended life expectancy of grandparents (Bengtson, 2001). In 2022, multigenerational households surged to 4.7 percent of all households in the United States, with nearly 35 percent of grandparents in such households taking on the primary caregiving role, particularly those aged 60 and over (Saxena & Brotherson, 2022). Consequently, Using an Occupational Therapy Lens to Explore the Role of Grandparenting 4 as Kim et al. (2017) pointed out, grandparents will likely face increasing demands for supplementary childcare in the future. The distinctive challenges faced by both grandparents and grandchildren offer occupational therapy (OT) practitioners the chance to develop and execute initiatives and services that cater to their occupational requirements enabling therapists to fill generational gaps in kinship families and empower them with resources for a successful transition into a multi-generational household (Romsdal & Wavra, 2021). Baker and Silverstein's typology for grandparent care distinguishes between providing supplementary childcare for working parents and offering custodial care when adult children are unable to raise their own children (Baker et al., 2008). Chan (2023) expanded on this, illustrating the diverse caregiving roles of grandparents ranging from occasional caregivers in non-co-resident households to co-parenting supplementary caregivers in multigenerational households and even becoming custodial caregivers in skipped-generation households. Stephens (2020) noted that over 50 percent of caregivers in grandparent-headed households are aged 45 to 59, and fewer than 10 percent are those aged 70 or older. The roles undertaken by grandparents can evolve as they adapt to the evolving needs of their growing grandchildren and the shifting dynamics of family life, such as geographic proximity, age considerations, and the pursuit of personal development (Bangerter & Waldron, 2014; Stephens, 2019). Chan (2023) defined supplementary caregivers as providing care between 10 and 29 hours weekly or staying overnight, often engaging in co-parenting or childcare within multigenerational households. Bangerter & Waldron (2014) highlighted variations in traditional family roles with some grandparents acting as enjoyable companions and others engaging in long-distance grandparenting. In comparison, the term grandfamilies, defined by Freeman et al. (2019), is a family structure where grandparents co-reside and undertake custodial caregiving. Using an Occupational Therapy Lens to Explore the Role of Grandparenting 5 As a result, fundamentally unique experiences included grandparents viewing their role as a second chance at parenting and actively engaging in family maintenance (Bangerter & Waldron, 2014). Fifty-five percent of grandparent caregivers have been the primary caretakers for three or more years, emphasizing the long-term nature of their responsibilities (Stephens, 2020). In a related context, Freeman et al. (2019) noted that in contrast to conventional families, grandparent caregivers often indicate diminished family cohesion and heightened intra-family strain, contributing to a more complex communicative environment. Many factors contributed to grandparents taking on such responsibilities including abandonment, incarceration, divorce, limited childcare options, unemployment, as well as health and mental health challenges (Tracy et al., 2022). Dennis and Brewer (2016) added that the custodial role extends into children's adulthood with grandparents continuing to provide financial and emotional support. Chan (2023) described that the grandparent-grandchild (GP-GC) relationship could have a positive or negative impact on the grandparent, which aligns with the Role Enhance and Strain Theory; these theories combined can help explain the diverse roles of grandparents. Relationship enhancement or strain can influence the other roles grandparents play in their family and community (Luo et al., 2012). This concept of influence aligns well with the Life Course Theory, which acknowledges that one family member can be influenced over time by intrinsic and extrinsic factors such as society, culture, life events, phases of life, location, and passage of time (Jones et al., 2019; Lersch, 2023). Those factors interlock and cause changes in other family members' lives (Elder, 1998). Scholars historically have used Life Course Theory to understand the interconnectivity of family members as they progress through life (Bengtson & Allen, 1993). The relationships between family members across generations refer to the term intergenerational solidarity. The Family Systems Theory suggests that families consist of subsystems and Using an Occupational Therapy Lens to Explore the Role of Grandparenting 6 emphasizes interrelationships among family members within the family system (Bowen, 1966). The subsystems are contained in a broader social context, and these impact the functioning of the grandchildren (Crosnoe & Elder (2002). According to Freeman et al. (2019), children in grandfamilies maintain important connections to family, community, and culture, recognizing their grandparents as sources of positive influence and contributors to an improved quality of life. Mansson (2016) suggested that encouraging children to spend time with their grandparents not only benefits the children but also provides parents with insights into ensuring their own parents' happiness and well-being. Consequently, it is common for parents to actively endorse and facilitate interactions between their children and grandparents recognizing the multifaceted benefits arising from these intergenerational relationships (DAstous et al., 2013). According to Stephens (2019), grandchildren with college-educated grandparents exhibited higher levels of literacy and math skills upon entering formal schooling compared to those whose grandparents had attained a high school education or less. In an attempt to identify reciprocal benefits, Mansson (2016) noted that grandparents felt a sense of fulfillment and connection within their role as a grandparent. The identified mutual investment towards the GP-GC relationship also significantly contributed to the overall beneficial experience for both populations. Bangerter and Waldron (2014) found that consistent communication between a grandparent and grandchild positively influenced maintaining their intimate relationship, specifically for long-distance GP-GC relationships. Additionally, Marcus (2017) identified the pertinent benefit of grandchildren developing a positive attachment relationship with multiple figures. Overall, the crucial role of a grandparent was noted through the positive benefits, including fostering relational closeness through shared activities, providing Using an Occupational Therapy Lens to Explore the Role of Grandparenting 7 social support, and family satisfaction throughout the relationship (Bangerter & Waldron, 2014). Grandparents' dedication provides children with valuable elements like time, love, compassion, and a sense of family, enriching the lives of those who might otherwise lack familial support (Dennis & Brewer, 2016). Alongside the numerous beneficial outcomes for a GP-GC relationship, research also identified various negative outcomes and stressors for both the grandparent and grandchild. With a shift in the caregiving role, additional stressors brought onto grandparents may be exacerbated by the uncertainty of the duration of care, including financial strain, mental wellness, and physical well-being of the family, which may ultimately cause elevated stress and depressive symptoms for grandparents and behavioral-emotional distress for the grandchild (Tracy et al., 2022). According to Freeman et al. (2019), older caregivers, particularly grandparents in caregiving roles, often encounter financial challenges, with approximately 20 percent reporting income levels below the poverty line, further indicating a likelihood of living in financial hardship. Additional stressors as the grandparent engaged in a caregiver role included increased time demands, sleep deprivation, challenges associated with aging, a shift in previous parenting methods, and intergenerational issues related to technology use and assisting with homework (Wood et al., 2016). Overall, older adult caregivers, particularly grandparents, may face a higher vulnerability to psychological difficulties, including feelings of social isolation, depression, and stress (Freeman et al., 2019). It is important to note that children raised in a custodial family with grandparents have increased rates of depression or anxiety when compared to grandchildren raised in parental family setups (Freeman et al., 2019). In specific scenarios where a grandchild is placed under the care of a grandparent due to parental neglect or abuse, the upheaval in conventional family roles Using an Occupational Therapy Lens to Explore the Role of Grandparenting 8 may cause distress among grandchildren and other family members, ultimately adding to the caregiving challenges faced by custodial grandmothers (Tracy et al., 2022). Throughout the intricacies involved in the establishment of grandfamilies, the research noted triggers for stress and trauma experienced by both grandparent caregivers and their grandchildren (Freeman et al., 2019). Overall, significant life events, school commitments, peer relationships, and geographic separation from a grandchild can result in relationship shifts, including the possibility of decreased emotional closeness between the grandparent and grandchild (Bangerter & Waldron, 2014). Kim et al. (2017) found that Asian and European countries and the United States have observed an increase in supplementary care of grandchildren. In American Indian communities, the raising of grandchildren operates outside legal adoption or guardianship, with an estimated 100,000 grandparents raising grandchildren under the age of 18 (Dennis & Brewer, 2016). As American Indian grandparents balanced sole custody, they faced poverty, limited access to resources, and physical limitations (Dennis & Brewer, 2016). In research done by Stephens (2020), African-American grandparents were more likely to guide their grandchildren on topics of behavior, faith, and culture compared to their White and Mexican-American counterparts, which led to their grandchildren valuing their teachings throughout adolescence and adulthood. Compared to the African American community, the Latino culture, which is typically a close-knit family structure, grandparents are typically involved in the upbringing of grandchildren, with many grandparents residing nearby and providing part-time caregiving (Xie et al., 2018). Occupational therapy, as a discipline, is grounded in the belief that meaningful engagement in various activities is pivotal for health and well-being (Harmon et al., 2022). OT Using an Occupational Therapy Lens to Explore the Role of Grandparenting 9 practitioners therapeutically employ everyday life activities with their clients to enhance or enable their participation by leveraging their understanding of the dynamic relationship between the client, their involvement in meaningful activities, and the surrounding context (Occupational Therapy Practice Framework, 2020). Understanding external factors, such as a clients role or family dynamic, allows an OT to create goals and interventions with a holistic approach that is client-centered and meaningful to the client (Gentry et al., 2018). We see this from a global perspective as the World Federation of Occupational Therapy (Sinclair, 2019) acknowledges that diversity and culture remain at the top of their agenda due to the undoubted impact that both have on the client. OT practitioners can leverage their expertise to address the unique challenges within kinship families, bridging generational gaps and facilitating a successful transition into multi-generational living (Romsdal & Wavra, 2021). Therefore, the purpose of this study was to explore the literature to determine the benefits and challenges associated with grandparenting in various cultures and identify implications for occupational therapy practice. Methodology Considering the extensive range of OT practices, encompassing the delivery of personalized and excellent care for individuals potentially identifying as grandparents, the researchers sought a methodology that could offer comprehensive contextual insights into a diverse array of experiences highlighted in qualitative studies (Walker et al., 2016). A thematic synthesis is a qualitative method that seeks to derive conclusions by identifying common themes across diverse studies (Lucas et al., 2007). Thematic synthesis involves extracting data, coding themes line by line, creating descriptive codes, exploring similarities and differences among these codes to categorize them into descriptive themes, and generating analytical themes in alignment with the research question (Thomas & Harden, 2008). Using an Occupational Therapy Lens to Explore the Role of Grandparenting 10 Researchers initially conducted a systematic review of the literature available via the EBSCOhost database. Inclusion criteria included cohort studies of level III, qualitative studies of mixed methods or mixed quantitative meta-synthesis studies, and articles consisting of grandparent or grandchildren participants with no age limit. Exclusion criteria omitted level I systematic reviews and meta-analyses, level II quasi-experimental studies, practice guidelines, quality improvement, program evaluations, case reports, mixed-method studies, and articles written in non-English languages. The researchers search strategy was performed in a coordinated and collaborative manner as each researcher utilized specific key terms (Table 1) through a systematic approach of the following databases within EBSCOhost: CADTH, CINAHL, Cochrane Library, Ebsco eBooks, ERIC, Grey Literature, Google Scholar, PEDro, Prospero, PubMed, Medline, OTSeeker, System Review Data Repository. The researchers yielded a total of 3,259 articles. Table 1 Key Search Terms Searched in Databases Key search terms Shared experience and grandparent Multicultural and grandparent or grandchild Activities and grandparents Shared experience and grandchild Multicultural and grandparents or grandchildren Activities and grandchild Interpersonal relation and grandparent or grandchild Money and grandparents Play and grandparents/grandchildren Interpersonal relations and grandparents or grandchildren Financial and grandparents Quality time and grandparents/grandchildren Social participation and grandparent and grandchild Communicate and grandparent or grandchild Shared experience and grandparents Using an Occupational Therapy Lens to Explore the Role of Grandparenting 11 Interaction and grandparents/grandchildren Social participation and grandparents and grandchildren Communicate and grandparents or grandchildren Co-occupation and grandparents/grandchildren Play or games and grandparent or grandchild Multilingual and grandparents or grandchild Engagement and grandparents/grandchildren Play or games and grandparents or grandchildren Multilingualism and grandparents or grandchildren The researchers exported the articles from the databases into Zotero, which allowed researchers to download, organize, annotate, cite, and share articles amongst the research team members (Zotero, n.d.). Of 3,259 articles, 46 were duplicates, resulting in a pool of 3,213 articles to be reviewed. Once all duplicates were deleted, the researchers exported articles into Rayyan, a free web tool that speeds the process of screening literature by allowing researchers to select studies and remove bias from the review through a blinding process to prevent viewing others' work (Rayyan, 2023). One researcher had control over this tool and was able to enable and disable blind viewing. The researchers enabled blind viewing while the titles and abstracts of the 3,213 articles were reviewed independently. Once the researchers completed this process, the researchers disabled the blind viewing setting yielding 517 articles categorized as in conflict. To resolve disagreements about including or excluding articles, the research team discussed each article, and 46 articles were added based on majority agreement. At this stage, the exclusion criteria was updated by eliminating articles published before 2012, resulting in the exclusion of 98.6% (3,131) articles. Forty-six articles were appraised using the Johns Hopkins Evidence-Based Practice Model for Nursing and Healthcare Professionals (Dang et al., 2021). The researchers engaged in a peer-reviewing process after each researcher individually appraised their assigned articles. If the researchers experienced disagreements, the entire research team discussed the relevancy of the Using an Occupational Therapy Lens to Explore the Role of Grandparenting 12 article with advice provided by the principal investigator, who made the final decision to include or exclude the article. As a result of the appraisal process, nine articles were included in the analysis. Data extraction The researchers used the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) as guidance during the process of selecting and appraising studies for effectively synthesizing data (PRISMA, 2020). Data extracted included the demographics of the target population and the relationship between grandparent and grandchild, such as custodial versus supplemental. Findings related to the purpose of the study to identify the benefits and challenges associated with grandparenting and relevant implications for practice were extracted for further analysis. Researchers utilized a constant comparative approach to analyze the texts of each article through which common themes and concepts were identified by simultaneously labeling, coding, and analyzing (Taylor & Bogdan, 1998). First, the research team received training regarding thematic synthesis, analysis techniques, and constant comparison strategies. Articles were divided amongst the research team in preparation for synthesis to identify commonly shared themes and concepts. Initially, each researcher read the introduction of their respective article by free line-by-line coding. Afterward, the research team reviewed and organized the free codes into constructive themes according to relevance for the study. The codes and categories were continuously discussed amongst the researchers until a majority consensus was established to omit bias and decrease impulsive categorization. The themes revealed through this process included beneficial factors related to overall wellness, negative factors affecting wellness, grandparent-headed households, grandparents as caretakers, cultural relevance, types of roles, Using an Occupational Therapy Lens to Explore the Role of Grandparenting 13 educational and spiritual resources, increased engagement in grandparenting, and decreased engagement in grandparenting. Researchers also explored the relevancy of data to the profession of occupational therapy. Next, the researchers read the results, findings, discussion, and conclusion section of their respective articles to identify relevant data related to the prior themes. Sentences relevant to the purpose of the study were extracted and categorized based on benefits, challenges, or implications for practice. Once compiled, extracted data was inputted into Chat Generative Pre-trained Transformer (ChatGPT) to identify common themes. ChatGPT is a language model developed by OpenAI designed for conversational purposes (ChatGPT, 2023). Capable of generating replies varying from human-like responses to text prompts, the ChatGPT software was developed on massive amounts of data, which allows the responses to understand context, generate coherent text, and perform a variety of language-related tasks (ChatGPT, 2023). The themes constructed by ChatGPT were reviewed by the research team to confirm the accuracy and relevance of the study. A constant comparison approach was used across ChatGPT-generated data points in order to form categories and concepts. Findings Among the nine articles included in our study, researchers enrolled participants from populations that consisted of African American, Lakota Elders, Asian, White, Hispanic, Native, and Latino. The age range of grandparents across the nine studies was 36-98 years. Three studies provided evidence about grandmothers and their grandchildren; six studies provided evidence about grandmothers, grandfathers, and their grandchildren. Of the nine articles reviewed (Table 2), five researchers studied grandparents who fulfilled the supplemental role; five researchers studied grandparents who fulfilled the custodial role. Using an Occupational Therapy Lens to Explore the Role of Grandparenting 14 Table 2 Articles Included in Analysis Author (Date) D'Astous, et al. (2013) Freeman, et al. (2019) Xie, et al. (2018) Tracy, et al. (2022) Purpose of Study Research Design Sample Demographics Discovering the Qualitative range of Semi-Structured engagement of intergenerational interview relationships in families with a child with Autism Spectrum Disorder (ASD) 14 grandparents How do grandparent caregivers describe their cognitions and behaviors in regards to communication with their grandchildren? Qualitative 21 grandparents (17 female, 4 male) What are Latino grandparents perceptions of and attitudes toward the way children spend their leisure time, and in particular LTPA? Qualitative Analyze online journals written over four weeks by grandmothers raising Qualitative 129 grandmothers Journal prompts and online Ages ranging from 36-76 years Semi-structured interviews Braun and Clarkes 6-step process for thematic analysis Focus group interviews Type of Grandparent Supplementary (8 grandmothers, 6 grandfathers) Age ranges between 56-81 years Caucasian descent in the United States Custodial Age ranges between 4074 years 51% Caucasian, 22% Black, 20% Hispanic, and 3% Asian United States 53 grandparents of 40-70 years Supplementary Grandchildren of 2 12 years old Latino descent Low income within Los Angeles County, United States 21.7% Black, 10.9% Custodial Using an Occupational Therapy Lens to Explore the Role of Grandparenting Stephens (2019) Bangerter & Waldron (2014) Mansson (2016) Dennis & Brewer (2016) grandchildren questionnaires Hispanic, 6.9% Bi/Multiracial 6.9% Asian 0.78% Native American 0.78% United States Examined how African American grandmothers caring for their grandchildren promoted literacy for themselves and the children in their care. Qualitative 8 grandmothers Semi-structured interviewing Age ranges between 46-70 years In what ways does the closeness of GP-GC relationships change throughout the grandchild's adolescence? Qualitative 35 grandparents Semi-structured interviews with retrospective interview technique with constant comparative method Age ranges between 60-82 years What do grandparents perceive as the best part about being grandparents? Qualitative 104 grandparents (84 female, 20 male) The central focus of this research is to gain an understanding of the experience of Lakota elders raising Qualitative 25 grandparents (20 female, 5 male) Interviews Age ranges between 55-98 years Criterion-based and snowball sampling Descriptive-pheno menology Open-ended survey questions Six-step thematic analysis 15 Custodial African American descent within the United States Supplementary Majority caucasian descent in the United States Supplementary Age ranges between 60-91 years Majority caucasian descent and married in the United States American Indian descent Custodial Using an Occupational Therapy Lens to Explore the Role of Grandparenting grandchildren Stephens (2020) The purpose of this study was to understand the methods of informal learning for human capital used by Black grandmothers caring for their grandchildren in rural communities 16 Living in South Dakota Qualitative 10 grandparents Basic interpretive inquiry Age ranges between 44-78 years Semi-instructed interview Custodial African American women, in a rural community within the United States Benefits Associated with Grandparenting Three qualitative themes of positive outcomes between GP-GC relationships can be identified from the provided excerpts across different studies: education for custodial grandparents, communication and pride, and physical and emotional support. These themes collectively highlight the multifaceted roles that grandparents play in the lives of their grandchildren, encompassing education, faith, communication, support, and the nurturing of positive relationships across generations. Education for Custodial Grandparents Within education for custodial grandparents, four subcategories emerged: attachment to social networks and educational development, intergenerational learning and reciprocation, custodial grandparent involvement in Parent-Teacher-Student Associations (PTSA) and educational engagement, and faith literacy development. Custodial grandmothers became attached to social networks within and outside of school. The attachment to social networking systems contributed to resources for assisting Using an Occupational Therapy Lens to Explore the Role of Grandparenting 17 grandchildren in learning and development, reducing high school dropout rates, and providing support for their grandchildren when they were treated unfairly. A vested interest in the educational development of grandchildren was shown. Intergenerational learning and reciprocation of learning were evident between older and younger generations. Informal learning activities led to collaborative activities, group discussions, and expanded social relationships. Learning transferred between generations was found to strengthen the Black family. Custodial grandparent involvement in PTSA and their grandchilds educational development was valued and contributed to intergenerational learning. Participation in PTSA activities provided resources to enable custodial grandmothers to gain skills to guide their grandchildrens learning. Custodial grandmothers were highly motivated to learn about their children's school experiences. Through participation in PTSA activities, the utilization of human capital in the context of informal learning was employed for intergenerational learning due to collaborative efforts between intergenerational learners (grandmothers and grandchildren), and members of a system working together to advance the well-being of the grandchildren. When individuals, like grandmothers taking care of their grandchildren, participate in opportunities to acquire human capital, particularly within a sociocultural setting, they establish connections with networking systems comprising other parents, students, educators, counselors, and principals. These connections facilitate the occurrence of more informal learning opportunities, fostering increased interactions and learning experiences for both the grandmothers and their grandchildren. Black grandmothers were deeply rooted in their religious beliefs and served as guides in imparting spiritual direction to both their children and grandchildren. Faith literacy development of grandchildren was enhanced through participation in activities such as Sunday school, Using an Occupational Therapy Lens to Explore the Role of Grandparenting 18 Vacation Bible School, and Bible study. Grandmothers were found to use the Bible and other religious education materials to enhance their grandchildren's reading skills and contribute to their moral development. This resulted in these children acquiring improved capabilities to conduct themselves effectively when away from home. Communication and Pride Within communication and pride, four subcategories were identified: community leadership and support, communication practices, long-distance relationships and technology, and mutual affection and pride. Community leadership and support are evidenced by care and concern for the broader communities' children and elders providing leadership, guidance, and assistance with food in resource-limited environments. The living Lakota values, including generosity and commitment to family, also support the subcategory of community leadership and support. Communication practices emphasized by grandparents include listening, dialogue, emotional discussions, openness, and allowing questioning. These practices are also supported by structured communication activities for stability and consistency in grandchild upbringing. Communication practices include improved resources, acquired wisdom, and increased emotional maturity, which contribute to refined communication. Long-distance relationships and technology are supported by grandparents who actively engage in relationship maintenance practices for long-distance relationships. Technology, such as texting and social media, helps sustain close relationships over time. Lastly, the subcategory of mutual affection and pride is evidenced by grandparents' enjoyment of mutual affection and shared activities with grandchildren. Pride in grandchildren, children, and their accomplishments is a fundamental aspect of the GP-GC relationship. Using an Occupational Therapy Lens to Explore the Role of Grandparenting 19 Physical and Emotional Support. Latino grandparents who perceived the benefits of physical activity on a grandchilds physical and mental health supported leisure-time physical activity directly and indirectly. Grandparents overall were found to provide emotional support and nurturance for parents and grandchildren. Closeness and contact between parents and grandparents were found to enhance positive relationships. Challenges Associated with Grandparenting Four qualitative themes of challenges associated with GP-GC relationships were identified from the provided excerpts across different studies: challenges with custodial grandparenting, complex stress, struggles in promoting health habits, and decline in closeness during adolescence and long-distance relationships. Challenges with Custodial Grandparenting Custodial grandparents often rely on limited resources when raising their grandchildren. Despite grandparents' motivation to support their grandchildren due to the cultural values of family and caring for future generations, they continue to face many challenges due to the nature of their responsibilities. Grandparents take on the responsibility due to reasons such as substance abuse, neglect, parents seeking employment and educational opportunities, and accidental deaths. Complex Stress Some grandparents face complex, stressful situations related to child trauma, unstable conditions with biological parents, and emotional and behavioral issues in grandchildren. Legal custody conflicts with birth parents and navigating complex family dynamics create stress for grandparents. Behavioral and emotional problems in grandchildren, challenges with the grandchilds parents, financial strain, concerns for the grandchilds future health, worry about Using an Occupational Therapy Lens to Explore the Role of Grandparenting 20 adult children, social isolation, and navigating complex judicial systems are stressful and have a negative influence on the well-being of grandparents. Struggles in Promoting Healthy Habits The struggles in promoting healthy habits are evidenced by grandparents being the role models in promoting grandchildrens leisure-time physical activity. Some grandparents struggle to modify sedentary behaviors through verbal communication. Grandparents also use unhealthy foods as an incentive for physical activity, which may encourage unhealthy eating. Decline in Closeness During Adolescence and Long-Distance Relationships The decline in closeness during adolescence and long-distance relationships is evidenced by the decline attributed to growing independence and engagement with peers and adults. Relational closeness often declines due to life changes, moving away, or the grandparent's limited involvement in family life. Family disruptions, such as conflicts over financial support or drug abuse, were also found to contribute to estrangement. Grandparents described the relationship as "one-sided" with their grandchildren, with their efforts to communicate not being reciprocated, resulting in grandparents longing for deeper connections. Implications for Occupational Therapy Five qualitative themes of possible implications for practice were revealed from the analysis: faith literacy, culture, support, and outreach interventions, grandparents' roles and communication, and training and education. Faith Literacy Within the theme of faith literacy, two subcategories emerged: collaboration for faith literacy-based adult education and intergenerational learning through faith literacy. There is a need to facilitate collaboration among adult educators, researchers, and students of adult Using an Occupational Therapy Lens to Explore the Role of Grandparenting 21 education to establish best practices for grandmothers and older adult learners in informal education programs, using faith literacy as a foundation for diverse teaching and learning opportunities. Implementing faith literacy activities as a significant component in intergenerational learning would enable grandmothers and grandchildren to acquire skills that build on existing competencies, opening doors to further learning opportunities. Culture Within the theme of culture, three subcategories emerged: promoting Latino grandparents involvement, cultural healing approaches, and addressing the unique needs of African-American Grandmothers. Designing interventions to empower Latino grandparents in supporting their grandchildrens leisure-time physical activity will promote Latino grandparents involvement with their grandchildren. Additionally, providing information on the benefits of physical activity, local resources, and the development of intergenerational programs for physical activity will aid in involvement. In approach to cultural healing, recognition of the need for mental health services that incorporate cultural healing approaches will address the unresolved grief and loss within the community. Lastly, investigating and addressing the unique needs of African-American grandmothers caring for grandchildren in rural communities by engaging them in informal learning activities for knowledge development demonstrates the importance of education for both caregivers and children. Support and Outreach Interventions Within support and outreach interventions, three subcategories were identified: outreach of behavioral and mental health support, support services and interventions, and supporting grandparents of children with disabilities. It is important to implement outreach efforts by behavioral and mental health services to provide concrete support and tools for managing family Using an Occupational Therapy Lens to Explore the Role of Grandparenting 22 dynamics in grandfamilies. Grandparents would benefit from the necessary support to address emotional, behavioral, and developmental issues in children. Also, interventions to assess and alleviate stresses related to transitions and parental instability will support custodial grandparents in raising grandchildren, including navigating social and economic challenges. It is important to support grandparents of children with disabilities by providing accurate information to grandparents regarding their grandchild's disability, enhancing understanding and support. Lastly, fostering inclusion in family activities and expressing appreciation will strengthen intergenerational relationships within families with a child with a disability. Grandparents Roles and Communication Within the theme of grandparents roles and communication, three subcategories emerged: acknowledging grandparents contribution, communication practices in grandfamilies, and recognizing grandparent caregivers roles. The efforts of grandparents should be recognized as a vital service to the community. It is important to acknowledge grandparents' contribution to maintaining family stability and providing financial and emotional support to their grandchildren. By recognizing grandparents roles, we gain insights into aging caregivers' reflections on overall family communication. This reflection will allow for a better understanding of grandparents' roles within grandfamilies, which is required to develop communication strategies and practices that align with the second-chance parenting phenomenon. Lastly, it is important to recognize grandparent caregivers multifaceted role as parents, teachers, and heads of households. Overall, these efforts will support adult educators in understanding and addressing the responsibilities placed on grandparent caregivers while also incorporating culturally relevant instruction and scaffolding strategies. Training and Education Using an Occupational Therapy Lens to Explore the Role of Grandparenting 23 Within the theme of training and education, four subcategories were identified: interprofessional education and collaboration, strengthening PTSA and collaborative approaches for custodial grandparents, family-centric approaches in health care, and behavioral parent training for grandfamilies. There is an increasing need for interprofessional education and collaboration, particularly as more grandmothers assume the role of primary caretakers, emphasizing the importance of interdisciplinary approaches to address complex family needs. For example, PTSA and collaborative approaches can be strengthened within schools by broadening the membership to include various professionals beyond parents and teachers. It is also necessary to promote collaborative approaches across professions to effectively meet the complex needs of families with custodial grandparents. Family-centric approaches in health care need to approach grandparents from a family context, providing population-specific training on conducting family assessments for grandmothers raising grandchildren. It is important to address various familial relationships and offer support for managing these relationships. This can be done by developing behavioral parent training for custodial grandfamilies and programs to teach grandparents and the grandchild's parents co-parenting skills. Interventions for grandparents and grandfamilies need to be tailored to the needs of different generations within grandfamilies, such as considering diverse age groups. Discussion The purpose of this study was to explore the literature to determine the benefits and challenges associated with grandparenting in various cultures and explore implications for the practice of occupational therapy. Researchers found that grandparents engaging in meaningful custodial or supplementary roles can lead to considerably beneficial outcomes for not only the grandparents but also the grandchildren. Using an Occupational Therapy Lens to Explore the Role of Grandparenting 24 Our findings show that custodial grandmothers are motivated to learn about their grandchildrens school experiences and education through their involvement in PTSA. This included actively participating in PTSA activities to acquire skills to guide their grandchildren's learning. Our research noted the value of PTSA and how its social aspects can promote intergenerational learning within GP-GC relationships. Intergenerational learning and reciprocation between older and younger generations also contribute to positive outcomes in our findings (Stephens, 2020). This encompasses informal learning activities, which lead to collaborative activities, group discussions, and expanded social relationships (Stephens, 2020). Alongside formal and informal learning, OT practitioners are equipped to provide educational programs necessary to facilitate interpersonal and social skills (Marton & Stewart, 2020). For instance, OT practitioners can provide supplementary services for grandchildren eligible for Individualized Education Plans (IEPs) developed by grandfamilies and professionals within the school services (Generations United, 2023). Furthermore, grandfamilies can seek out the assistance or skilled services of OT practitioners when needing extra classroom support necessary for optimal learning (Marton & Stewart, 2020). Specifically, school-based OT practitioners can prompt physical and mental wellness by addressing the physical, cognitive, psychosocial, and sensory components of the grandchilds performance (American Occupational Therapy Association, 2017). By doing so, OT practitioners will not only promote the overall well-being of the grandchild through client-centered care but will also provide the necessary educational concepts through grandfamily-centered care necessary for grandparents to maintain such support outside of the PTSA (Marton & Stewart, 2020). In addition to providing support for grandchildren, our findings show that grandparents also provide emotional support and nurturance for parents (DAstous et al., 2013). It is shown Using an Occupational Therapy Lens to Explore the Role of Grandparenting 25 that closeness and contact between parents and grandparents enhance positive relationships (DAstous et al., 2013). Very few research studies have focused on the coping strategies necessary to address emotional barriers and support within the grandfamily dynamic. However, the few studies that have been conducted duly noted the very few resources available to support grandfamilies (Wood et al., 2016). A successfully effective OT practitioner should not only assess and identify the emotional and supportive needs of grandfamilies but also identify the appropriate resources the grandfamilies require for prolonged maintenance (Wood et al., 2016). For instance, intergenerational programming within the context of OT can effectively provide support through meaningful participation in co-occupations, including shared physical, emotional, and volitional engagement (Harmon et al., 2022). Whether through meaningful intergenerational interventions or educational programs, successful OT practitioners should assess, address, and provide grandfamilies with the appropriate tools and resources to facilitate or maintain support and nurturance (American Occupational Therapy Association, 2020). We found that brimming with mutual affection and engaged in shared activities, grandparents revel in the pride derived from their grandchildren, children, and their own accomplishments, making it a fundamental and cherished aspect of the GP-GC relationship (Mansson, 2016). Moore and Miller (2007) paralleled these findings by suggesting that African American grandparents facing diverse challenges while raising their grandchildren gain a substantial amount of psychological rewards, which heightens their gratification, sense of usefulness, and growing pride. Henderson et al. (2017) revealed that among Native People residing in a rural Arctic climate, pride was a significant factor contributing to the joy experienced by grandparents in the upbringing of their grandchildren. Therefore, evidence supports that overcoming the challenges and having pride in their grandparenting role has the Using an Occupational Therapy Lens to Explore the Role of Grandparenting 26 potential to not only enrich the GP-GC relationship but also improve the overall well-being of the grandparent. Recognizing the advantages of physical activity for the well-being of their grandchildren, Latino grandparents actively endorse and provide support for their leisure-time physical pursuits, fostering both physical and mental health benefits directly and indirectly (Xie et al., 2018). On the contrary to fostering healthy habits, Pankhurst et al. (2019) found in their survey of supplementary grandparents in Southern Australia that discretionary treats are a valuable part of the GP-GC relationship that is strategically used by grandparents to identify themselves as uniquely different from other family members. Williams et al. (2021) and Moestue & Huttly (2008) concluded that the grandparents level of education directly correlates to the level of the grandchilds health. Although the physical activities and rewards that grandparents choose to share with their grandchildren have an impact on the grandchilds health, ultimately, the higher the level of education of the grandparent, the higher the level of health the grandchild is likely to have. Providing support and sharing time were important benefits to the role of grandparenting. Stephens (2019) described grandmothers' pivotal role in supporting grandchildren during challenging times through faith literacy development and attachment to social networks and educational development. Additionally, shared time in activities such as faith literacy, Sunday school, and Bible study, were found to also enhance reading skills and moral development in grandchildren (Stephens, 2020). Attachment to networking systems contributed to resources that assisted grandchildren learning in development reducing overall high school dropout rates (Stephens, 2019). Leitao et al. (2023) added that OT practitioners can facilitate grandparents engaging in custodial or supplemental roles by directly supporting the use of spirituality Using an Occupational Therapy Lens to Explore the Role of Grandparenting 27 necessary for further holistic support of either client-centered or grandfamily-centered care. Alongside values and beliefs, spirituality is listed as an important client factor in the Occupational Therapy Practice Framework (American Occupational Therapy Association, 2020). Thus, OT practitioners should consider spirituality as an essential aspect of practice as it plays a significant role in influencing not only an individuals motivation, but also their overall well-being, health, and engagement in meaningful activities (Leitao et al., 2023). An important and positive aspect of the relationship between grandparents and grandchildren is communication. Communication practices emphasized by grandparents include listening, dialogue, emotional discussions, openness, and allowing questioning (Freeman et al., 2019). Structured communicated activities should be encouraged to provide stability and consistency in a grandchild's upbringing (Freeman et al., 2019). In addition, improved resources, acquired wisdom, and increased emotional maturity positively contribute to more refined communication between grandparents and grandchildren (Freeman et al., 2019). Examining communication practices among grandparent caregivers, Dennis and Brewer (2016) focused on elders, particularly women, showcasing their dedication to caring for the community's grandchildren. Despite resource limitations, these elders provide leadership, guidance, and assistance, embodying Lakota values within a challenging economic context. Freeman's (2019) study reinforced the importance of meaningful dialogue and structured communication within grandfamilies. Our study notes positive behavioral adjustments among grandchildren, attributing these improvements to enhanced resources and emotional maturity resulting from effective communication strategies. When considering OT practices and the facilitation of meaningful GP-GC communication, OT practitioners can be valuable agents of resources by providing tailored interventions, education, and support necessary to meet the needs of both the Using an Occupational Therapy Lens to Explore the Role of Grandparenting 28 grandparents and grandchildren (Romsdal & Wavra, 2021). An assessment of determining the exact need should be developed to provide the necessary resources needed to produce and maintain positive and meaningful communication. Specifically, OT practitioners are equipped to facilitate social skills training sessions for either grandparents or grandchildren (American Occupational Therapy Association, 2020). Lakota elders epitomize significant leadership and dedication to the overall well-being of their community, especially the children, by providing guidance and crucial food support within environments with meager resources (Dennis & Brewer, 2016). Amidst limited resources, the elders embody the enduring values of the Lakota people, marked by generosity and an unwavering commitment to family, as highlighted by Dennis and Brewer in 2016. Similarly, Lazaro et al. (2023) uncovered that a significant number of grandfathers in Southern Malawi are integral in the support, development, and transmission of knowledge and values to their orphaned grandchildren whom they have adopted and unconventionally raised due to their parents death. In their investigation of the social identity of grandparents within the United States, Neikrug (2000) proposed that grandparents who are deeply engaged and actively involved can exert a profound influence in mentoring younger individuals with disabilities. Taking on the roles within their families and community allows grandparents to have a continued influence on the culture and future of their community. In the realm of intergenerational relationships, the role of grandparents in the upbringing and support of their grandchildren is a multifaceted and dynamic one. Our findings show that despite facing socio-economic challenges, elders are motivated by cultural values centered on family and their commitment to future generations, prompting them to take on the responsibility of raising their grandchildren (Dennis and Brewer, 2016). This altruistic commitment becomes Using an Occupational Therapy Lens to Explore the Role of Grandparenting 29 even more crucial in situations where substance abuse, neglect, parental pursuit of employment and education, or accidental deaths lead grandparents to assume caregiving roles (Dennis and Brewer, 2016). Peterson (2018) supports grandparents experiencing emotions of worry for several reasons, including lack of caregiver options, the possibility of a child being placed in government systems, or if the child has a sudden health crisis. Despite raising grandchildren in a context of limited resources, grandparents are motivated to support their grandchildren due to the cultural values of family and caring for future generations (Dennis & Brewer, 2016). Peterson (2018) adds that grandparents also choose themselves over other relatives due to age, familial and career responsibilities, and overall inability to provide care. As grandparents raise a grandchild, resilience and a positive perspective overcome the challenges and stressors they experience (Hayslip et al., 2019). Expanding on this, the research completed by Freeman et al. (2019) looked into the intricate dynamics within grandfamilies, revealing a prevalence of child trauma stemming from unstable conditions during the time grandchildren spent with their birth parents. Families can often face significant stress due to common emotional and behavioral issues such as depression, anxiety, attachment disorders, and attention-deficit/hyperactivity disorder (Freeman et al., 2019; DAstous et al., 2013; Tracy et al., 2022). In previous research done by Doley et al. (2015), it was found that 23 percent of custodial grandparents reported their grandchild having high levels of emotional problems and 29 percent with hyperactivity. Our findings show that stressors for grandparents include behavioral and emotional problems in grandchildren, challenges with the grandchild's parents, financial strain, concerns for the future health of the grandchild, social isolation, and navigating complex judicial systems (Freeman et al., 2019; DAstous et al., 2013; Tracy et al., 2022). Outside research by Hayslip et al. (2019), similarly states that grandparents' Using an Occupational Therapy Lens to Explore the Role of Grandparenting 30 stressors such as being poor, minority status, or problematic family relationships also cause distress and disadvantages. Our study found that grandparents experience conflict when navigating family dynamics with the birth parents regarding the custody of the grandchild in relation. Other difficult family dynamics can include negotiating troubling parental behaviors that impact their relationships with both the parent and the grandchild, adding further layers to their caregiving responsibilities (Tracy et al., 2022). Xies et al. (2018) findings contribute to the narrative by exploring how grandparents, through role modeling, attempt to promote their grandchildren's leisure-time physical activity. Research by Bell et al. (2022) found that custodial grandmothers did so by limiting sedentary activity, including their grandchild in healthy lifestyle activities, and building a positive relationship with food. Our findings show that custodial grandparents face challenges in modifying sedentary behaviors through verbal communication, and some grandparents resort to using unhealthy food as incentives, raising concerns about potential impacts on children's eating habits. Bell et al. (2022) also note that despite the grandmother's motivation to promote healthy lifestyles, they could not role model engagement in physical activities. Bangerter & Waldrons (2014) investigation shifts the focus to changes in relational closeness with grandparents and grandchildren, noting approximately one-third of long-distance grandparents experience this during adolescence. Within our study, factors such as the child's growing independence, engagement with a broader social network, and life changes experienced by both parties were found to contribute to this decline. Family disruptions, including conflicts over financial support or drug abuse, were found to further strain the relationship, leading to estrangement. According to Charenkova and Gevorgianiene (2018) relocated grandparents, such as when grandparents transition to a nursing home, led to significant deterioration in Using an Occupational Therapy Lens to Explore the Role of Grandparenting 31 relationships, emotional closeness, and overall satisfaction. At times, the relationship is described by grandparents as "one-sided," with efforts to communicate not reciprocated by adolescent grandchildren (Bangerter & Waldron, 2014). Duflos (2022) supports our findings by stating the key factors that predict the closeness of a GP-GC relationship include age, physical and mental health, frequency of contact, educational level, and overall encouragement from parents. Implications for Practice For best practice and client-centered care, OT practitioners need to acknowledge the diverse responsibilities of grandparent caregivers as potentially including the roles of parent, teacher, and household head because individuals who encompass these roles are more adept at providing support through both meaningful assistance (Tracy et al., 2022). Our study indicates such acknowledgment from facilitative agents including, but not limited to, OT practitioners who provide strategically meaningful approaches that can create an overall positively beneficial impact upon both the grandparents and grandchildren (Stephens, 2019). Hayslip et al. (2019) support how increased attention to the complexity of the family structure and stressors within a grandfamily will help practitioners understand the challenges of raising a grandchild and influence them to bring in resources to support them. Approaching grandparent caregivers from a family contextual viewpoint, OT practitioners should consider the relationships grandparents have within their family. By having a deeper understanding of such contextual factors, OT practitioners will have an opportunity to address any barriers or challenges with increased effectiveness (Generations United, 2023). With the consideration of meaningful interventions, OT practitioners are equipped to provide skilled services and resources for not only grandparents Using an Occupational Therapy Lens to Explore the Role of Grandparenting 32 but also grandchildren; thus, highlighting the importance of additional research to understand the diverse needs of grandfamilies across different generations (Tracy et al., 2022). In addition, grandparents raising grandchildren necessitate mental health outreach, encompassing concrete support for managing family dynamics and access to essential respite care and support groups. Within recognition of their pivotal role in stabilizing families and communities, OT practitioners should address unresolved emotional issues through culturally appropriate interventions addressing unresolved grief and loss within the community and exploring traditional practices and innovative methods for community healing (Dennis & Brewer, 2016). Xu et al. (2022) note that custodial grandparents often face barriers when finding resources and services for their grandchildren, including mental health services. Lack of resources was found to reduce the overall quality of life in grandchildren, resulting in increased risk for future adversities (Xu et al., 2022). By understanding the caregiving roles of grandparents, OT practitioners can develop new resources to support the needs of clients, including older adults (grandparents) and children (grandchildren). Research done by Fox et al. (2022) supports that strength-based interventions will aid in grandparent self-efficacy and social support, ultimately increasing grandfamily resilience and outcomes. This can include implementing behavioral and mental health services outreach efforts to provide concrete support and tools for managing family dynamics within grandfamilies. Hayslip et al. (2019) outlined the need to continue understanding the various cultural differences among grandfamilies as there is limited research and resources to support them. Cox (2018) specifically advocated for the role of policy as a support for grandparent-headed households, stating that policy plays a significant role in the types of support and resources provided, ultimately contributing to some grandparents' reluctance to find resources. OT Using an Occupational Therapy Lens to Explore the Role of Grandparenting 33 practitioners can use skills as advocates when recognizing and acknowledging diverse populations and their cultures. Specific cultural implications of recognizing Latino grandparents include designing interventions to empower in support their grandchildren's leisure-time physical activity (Xie et al., 2018). Also, providing current information on local resources and benefits for physical activity and developing new intergenerational programs to better support Latino grandparents' involvement (Xie et al., 2018). According to Shovali et al. (2019) within Latino culture, grandparents are highly respected and an integral part of the family system. As summarized by Cox (2018), culture guides family systems, relationships, and child-raising practices. As suggested by our findings, it is important to support cultural values when providing necessary resources and consider family contexts when advocating for the role of policy in custodial grandparents or understanding the impact within family dynamics (Stephens, 2020; Cox, 2018). Our findings highlight the importance of faith literacy within intergenerational learning, collaboration, and learning opportunities for grandparents with their grandchildren. Specifically, we found that implementing faith literacy activities is a significant component in intergenerational learning, enabling grandmothers and children to acquire skills that build on existing competencies, which may open doors to further learning opportunities (Stephens, 2020). Allana et al. (2017) found that grandparents struggled to maintain their faith practices on top of their day-to-day responsibilities. Despite the noted difficulties, grandparents and educators note the need to introduce spirituality earlier in a grandchild's life (Allana et al., 2017). A need is recognized to strengthen PTSA within schools by broadening the membership to include various professionals beyond parents and teachers. OT practitioners have the skills to provide diverse support, such as environmental modifications, behavioral strategies, and Using an Occupational Therapy Lens to Explore the Role of Grandparenting 34 educational guidance for teachers, grandparents, and grandchildren by advocating for necessary accommodations through IEPs (American Occupational Therapy Association, 2017). In addition, promoting collaborative approaches across professions to effectively meet the complex needs of families with grandmothers as primary caretakers (Stephens, 2020). Shovali et al. (2019) suggested that an increase in grandparent confidence through community resources aided in higher academic performance in their grandchildren. Xu et al. (2022) found insufficient school support and accessible resources for custodial grandchildren, overall impacting their academic success. School systems can aid in establishing supportive services, such as IEPs, to augment grandparents' efforts in raising grandchildren in order to promote increased educational engagement. OT practitioners can aid this process by developing interventions to assess and alleviate stresses related to transitions and parental instability. OT practitioners should engage in collaborative approaches alongside not only custodial grandparents and educators but also with additional facilitative agents involved in supportive services, such as behavioral therapists or speech-language pathologists. Additionally, IEPs developed through a collaborative approach by both involved family members and broader professionals have been noted to have increased effectiveness (Curro et al., 2022). By identifying, supporting, and advocating for the specific needs of the grandchild, both the grandparents and PTSA will have the effective ability to meet the complex needs of the collective family as a whole. In conclusion, there are significant motivations, challenges, and varied dynamics within the GP-GC relationship, emphasizing the need for a nuanced understanding of these relationships and the factors that shape them. Our findings highlight the complex dynamics and challenges faced by grandparents in various caregiving situations, shedding light on the motivations, stressors, and difficulties encountered in raising and maintaining relationships with their Using an Occupational Therapy Lens to Explore the Role of Grandparenting 35 grandchildren. Outside research aids in the understanding of continued research and implications for practice amongst OT practitioners, educators, and other healthcare professionals. This knowledge is invaluable for OT practitioners, offering insights that can inform evidence-based practices and enhance the effectiveness of interventions. 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