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... Supporting Students Facing Occupational Injustice in Higher Education Vaz Dhani, OTS July 28, 2021 A research project submitted in partial fulfillment for the requirements of the Doctor of Occupational Therapy degree from the University of Indianapolis, School of Occupational Therapy. Under the direction of the DCE advisor: Christine Kroll, OTD, MS, OTR, FAOTA Running Head: SUPPORTING STUDENTS FACING OCCUPATIONAL INJUSTICE 1 Abstract Undergraduate and graduate students tend to go unnoticed as a population when experiencing bias or discriminatory incidents on or off-campus, which may manifest as forms of occupational injustice. The purpose of the current project was to develop a program guide that supports and advocates for students' daily functioning and occupational needs when facing bias and discriminatory incidents. Through the guidance of occupational justice principles and the Canadian Model of Occupational Performance (CMOP)the project serves to provide immediately accessible resources for students in higher education that promote occupational engagement, health and well-being, coping strategies, self-advocacy skills, safe spaces, affordable services, and inclusive belonging. Quantitative data analysis and qualitative thematic analysis were the methodological processes selected to approach the project. Administration of both the needs assessment and post-assessment took place via interviews with the internal stakeholders and surveys with the external stakeholders to inform the projects development and execution. The developed project resulted in a website called the University of Indianapolis (UIndy) Student Support Guide, consisting of supportive and resourceful materials that address students' occupational needs when encountering occupational injustice. It is imperative that occupational therapy educators and campus communities use the UIndy Student Support Guide to support the daily functioning needs of their students, especially because of its practicality and easy access online. The website is available at https://sites.google.com/uindy.edu/uindystudentsupportguide/home SUPPORTING STUDENTS FACING OCCUPATIONAL INJUSTICE 2 Supporting Students Facing Occupational Injustice in Higher Education Students in higher education, both undergraduate and graduate, are often overlooked as a population when bias and discriminatory incidents occur on or off-campus. Off-campus incidents may take place within a community on a local, national, or global level. Whether on or offcampus, bias and discriminatory incidents can affect a community's occupations, which can affect each individuals occupations within that community as a ripple effectthis is especially true for students within campus communities. Bias and discriminatory incidents may contribute to negative outcomes such as psychological distress (Cavalhieri, Chwalisz, & Greer, 2019, p. 376; Hwang & Goto, 2008). As a result, students in higher education may suffer from low motivation and decreased academic performance, directly impacting their daily occupational engagement (Benner et al., 2018; Cavalhieri et al., 2019). University-level students may experience occupational injustice due to the nature of bias and discriminatory incidents and their effects on occupations. Occupational injustice occurs when participation in occupation is barred, confined, restricted, segregated, prohibited, undeveloped, disrupted, alienated, marginalized, exploited, excluded, or otherwise restricted (Townsend and Wilcock, 2004b, p. 77). Additionally, the World Federation of Occupational Therapists (WFOT) (2006) declares abuses of the right to occupation may take the form of economic, social or physical exclusion, through attitudinal or physical barriers, or through control of access to the necessary knowledge, skills, resources, or venues where occupation takes place. The aforementioned statement by the WFOT is directly applicable to students in higher education involved in bias and discriminatory incidentsparticularly regarding forms of abuse impacting the right to engage in the occupation of education while on-campus. As a result, SUPPORTING STUDENTS FACING OCCUPATIONAL INJUSTICE 3 utilization of occupational justicean occupational therapy (OT) conceptcan help such students navigate incidents of occupational injustice. Occupational justice is both an existing and emerging construct in OT, specifically within the last two decades (Durocher, Gibson, & Rappolt, 2014; Durocher, Rappolt, & Gibson, 2014; Kinsella & Durocher, 2016; Stadnyk, Townsend, & Wilcock, 2010; Townsend & Wilcock, 2004a, 2004b; Whiteford & Townsend, 2011; Wilcock, 2006; Wilcock & Hocking, 2015; Wilcock & Townsend, 2000). Social justice serves as the foundation for occupational justice the purpose is to highlight social justice issues that humans, or occupational beings, experience through an occupational lens (Kinsella & Durocher, 2016). Occupational justice acknowledges that occupational beings need and want to engage in doing, being, becoming, and belonging through participation in occupations for survival, to connect with others, and to build communities (Nilsson & Townsend, 2010, p. 58). The notion exists because every occupational being has occupational rights regardless of age, ability, gender, social class, or other differences (Nilsson & Townsend, 2010, p. 58). When these occupational rights are affected, three outcomes can occur, affecting an individuals ability to engage in occupations. Nilsson & Townsend (2010) state and define the three outcomes as the following: 1) occupational alienation as social exclusion by restricting a population from experiencing meaningful and enriching occupations; 2) occupational deprivation as social exclusion by restricting a population in diverse contextsfrom participating in occupations that would promote their health and well-being; and 3) occupational marginalization as social exclusion by restricting a population from experiencing autonomy through lack of choice in occupations (p. 58). These three outcomes are prevalent SUPPORTING STUDENTS FACING OCCUPATIONAL INJUSTICE 4 across various contexts in society today, and it is within OTs scope of practice to combat these outcomes to encompass client-centered care. Known as the first occupation-based model to represent client-centered care in the OT field, the Canadian Model of Occupational Performance (CMOP) appropriately complements elements of occupational justice. As a holistic and inclusive model, it views individuals as equally worthy regardless of the personal identities, levels of physical or mental ability, socioeconomic position, or health status one holds (Cole, 2018; Cole & Tufano, 2008). Furthermore, the CMOP also claims that the exchanges between the person, environment, and occupation encourage occupational performance evolution, which is consistent with its humanistic foundation and relation to aspects of occupational justice (Cole, 2018; Cole & Tufano, 2008). Using the CMOP as a guide, this project aims to promote occupational justice for students experiencing bias and discriminatory incidents at the University of Indianapolis (UIndy). Collaboration for developing and implementing the project occurred between the project developer and UIndys Office of Inclusion & Equity (OIE). The OIE serves the entire campus community to integrate inclusive excellence throughout campus (Inclusive Excellence at UIndy, n.d.). The Chief Inclusion and Equity Officer (CIEO) of the OIE, Dr. Amber Smith, developed a strategic plan and framework for inclusive excellence at UIndy called I Belong: Moving Towards Inclusive Excellence. Dr. Smith and other OIE administrators work with faculty, staff, and students to enact I Belong throughout campus via the Inclusive Excellence Matriculation Model (IEMM). The IEMM is a strategic timeline of planned phases to fully integrate inclusive excellence across all aspects of the campus community (Smith, 2020). SUPPORTING STUDENTS FACING OCCUPATIONAL INJUSTICE 5 The current project will occur during the finalization of UIndys Bias Incident Reporting Protocol (BIRP), created by the OIE administrative team. The BIRP developed along with the second phase of the I Belong timeline. The second phase focuses on the strategy development process and will progress through additional stages to completion (analyze, develop, execute, manage are the stages)which highlights the significance of the BIRPs construction (Smith, 2020, p. 3). Under the current timeline phase, the OIE will integrate other related faculty and staff members in various administrative departments to finalize the BIRP into a formal and educational process to mitigate and prevent bias. Although the BIRP targets bias incidents on campus, many bias incidents are not reported or happen off-campus. Whether on or off-campus, bias incidents can affect the campus community's occupations, which can affect individual students' occupations. The purpose of the current project was to support and advocate for students' daily function and occupations in higher education when experiencing bias and discriminatory incidents or when dealing with the BIRP process. Using the CMOP to guide the development of resources to support occupational justice led to creating a web-page of an evidenced-based program guide to implement the purpose. The program guide provides tangibly accessible resources that promote occupational engagement, health and well-being, coping strategies, self-advocacy skills, safe spaces, affordable services, and inclusive belonging. Methods The methodological processes of quantitative data analysis and qualitative thematic analysis (TA) were selected to approach the current project. Quantitative data analysis through application of data collection via Google Forms and Google sheets, as well as descriptive SUPPORTING STUDENTS FACING OCCUPATIONAL INJUSTICE 6 statistics via SPSS (Statistical Product and Service Solutions, Version 28.0.0.0 (190)), were implemented to allow basic summarization of findings and for pattern examination within data sets (Mishra et al., 2019). In addition, due to its ease of accessibility and extensive utility within the social and health sciences, TA was performed to provide an in-depth understanding of the needs and perceptions of the project stakeholders (Braun & Clarke, 2014; Braun & Clarke, 2006). The project developers Institutional Review Board determined that the current project was exempt from review. An overview of the methodological timeline is included in Figure 1. SUPPORTING STUDENTS FACING OCCUPATIONAL INJUSTICE Figure 1 Methodology Flow Chart 7 SUPPORTING STUDENTS FACING OCCUPATIONAL INJUSTICE 8 Needs Assessment A needs assessment was conducted to obtain baseline data, understand the primary needs and perceptions of the stakeholders, and examine the context of the needs to justify the current project. The needs assessment included internal and external stakeholders via a pre-interview for the internal stakeholders and a pre-survey for external stakeholders. The information acquired from the needs assessment guided the development of the current project. Pre-Interview with Internal Stakeholders To qualify as an internal stakeholder, individuals had to be either faculty or staff members within one of UIndys administrative departments. An unstructured pre-interview was performed with Dr. Amber Smith, a primary internal administrative stakeholder, as the Chief Inclusion and Equity Officer (CIEO) of the Office of Inclusion & Equity (OIE). The interview occurred face-to-face on campus in the OIE for approximately 45 minutesconsisting of openended questions and discussion regarding UIndys finalization of the Bias Incident Reporting Protocol (BIRP), social justice policies and definitions, grievance process, Title IX process, student resources, student support services, administrative departments and personnel involved with mitigating bias, and the application of occupational therapy concepts. The insight gained from the internal stakeholder interview informed a survey to further assess the needs of the external stakeholders, the studentsfor whom the current project is focused. Pre-Survey to External Stakeholders Survey Development. The needs assessment was a 16-item pre-survey given to external (student) stakeholders. It was divided into the following categories: Identity (5 items), Bias Incidents (3 items), Daily Functioning & Occupations (4 items), and Support Needs (4 items). SUPPORTING STUDENTS FACING OCCUPATIONAL INJUSTICE 9 The items were designed in the following formats: checkbox selection (5 items), yes or no questions (3 items), multiple choice (1 item), 5-point scale (5 items), and long-answer text (2 items). An introduction was provided at the start of the survey to introduce the project developer, explain the occupational therapy profession, define what occupations are, describe the projects purpose, and express why their feedback would be beneficial to the project. The survey ended with a brief passage informing the plan for the next steps involved in developing the project. Google Forms was used to create the surveyallowing for geographic accessibility, automated data processing, informed consent, and adequate time for respondents to complete the survey. The survey was created by the project developer and peer-reviewed by the project developers advisors, who are both a part of UIndys faculty. See Figure 2 in Appendix A for a copy of the pre-survey. Respondents. Using connections to people and organizations known to the project developer, a snowball sampling method was used to gain as many respondents as possible. The following inclusion criteria were required to receive the pre-survey: 1) be an undergraduate or graduate-level student, and 2) be currently enrolled at UIndy or another college or university within the United States. Initial campaigning efforts for the pre-survey included sending it out to the student communities that UIndy OIE interacts with, all of the UIndy School of Occupational Therapy student cohorts, and students from other universities that the program developer personally knew. Those who met the inclusion criteria were requested to forward the pre-survey to others who also met the inclusion criteria. Procedure. The pre-survey URL link was sent through the following platforms: Email, Text Message, Google Chat, Zoom Chat, GroupMe, and Instagram Messaging. Respondents had SUPPORTING STUDENTS FACING OCCUPATIONAL INJUSTICE 10 an 8-day timeframe from May 10 to May 18, 2021, to complete the pre-survey online. The respondents emails were collected for the post-survey to be sent out once the project was available for students to view and use. A total of 55 respondents completed the pre-survey, consisting of students predominantly enrolled at UIndy (n=36), with the rest being students enrolled at other colleges or universities (n=19) within the United States. Analysis of Needs Assessment Google Forms and Sheets allowed for quantitative data analysis for all pre-survey items that were not in long-answer text format. Excluding the two long-answer text items, the results of 14 items were analyzed in the following pre-survey categories: Identity (5 items); Bias Incidents (2 items); Daily Functioning & Occupations (4 items); and Support Needs (3 items). Both Google services enabled data collection, which was input into SPSS to run descriptive statistics. Pattern examination occurred between the demographic characteristics identified in three items from the Identity category and responses to six items from the other following categories: Bias Incidents (2 items); Daily Functioning & Occupations (2 items); and Support Needs (2 items). Of the six itemstwo items were yes or no questions, and four items were 5-point scale questions. The demographic attributes examined were racial/ethnic group, gender, and sexual orientation. Thematic analysis was conducted in Google Docs by applying coding techniques to analyze qualitative data from the pre-interview and the two long-answer text items in the presurvey. First, grouping repetitive responses with similar wording were identified as codes. These codes were then categorized based on similarities to determine emerging themes within the findings. SUPPORTING STUDENTS FACING OCCUPATIONAL INJUSTICE 11 Project Development Google Sites was used to create the project, a websiteallowing for accessibility in various aspects such as geographic location, user interface, device variety, cost efficiency, and readability. The website was named the UIndy Student Support Guide. It was designed using UIndys colors, Oswald and Helvetica fonts, embedded documents from Google Drive, side and bottom navigation bars, static text boxes, collapsible text boxes, buttons to links, page dividers, and images. The results from the needs assessment informed the division of the website into the following subpages: UIndy Bias Incidents; Anonymous Submission Form; Self-Advocacy Templates; Daily Functioning Support; UIndy Resources; and Other Resources. Each subpage included descriptions, information, and resources constructed by the project developer or pulled from external sources. Google Docs, Forms, and Slides were used to include embedded material produced by the project developer. Adobe PDFs and hyperlinks to websites were used to include embedded material produced by external sources. A Google Analytics account was created and connected to the Google Site, which allows the website owners and collaborators to see real-time user engagement and demographics. The website was created by the project developer, which was peer-reviewed by the project developers advisors, who are both a part of UIndys faculty. Post-Assessment Once the project was developed for viewing, a post-assessment was administered to acquire the external stakeholders suggestions for any modifications to the website, thoughts on if the project met their needs, feedback on what they felt was satisfactory and useful, and SUPPORTING STUDENTS FACING OCCUPATIONAL INJUSTICE 12 anticipation of if they would utilize it. The post-assessment consisted of a post-interview with internal stakeholders and a post-survey for external stakeholders. The responses procured from the post-assessment directed the dissemination of the current project, which UIndy will develop and merge into their main website for usage. Post-Interview with Internal Stakeholders Two unstructured interviews were coordinated with two internal stakeholder teamsone with the UIndy OIE team and the other with the UIndy Marketing and Communications team. The OIE team interview occurred face-to-face on campus in the OIE for approximately 45 minutes. The Marketing and Communications team interview occurred virtually over a videocalling platform, Zoom, for approximately 60 minutes. Both interviews consisted of open-ended questions and discussions regarding constructive feedback and the formalization process of the developed project. Post-Survey to External Stakeholders The post-survey development followed the same methodology as the pre-survey. It was condensed to a 7-item survey to exclusively obtain feedback of the following pre-survey categories relating to the developed project: Bias Incidents, Daily Functioning & Occupations, and Support Needs. The items were designed in the following formats: checkbox selection (1 item), yes or no questions (3 items), 5-point scale (2 items), and long-answer text (1 item). A link to the developed project was provided at the start of the survey. See Figure 3 in Appendix A for a copy of the post-survey. The post-survey URL link was emailed to the 55 respondents who initially completed the pre-survey. They had a 14-day timeframe from June 2 to June 16, 2021, to complete the post- SUPPORTING STUDENTS FACING OCCUPATIONAL INJUSTICE 13 survey online. Out of the 55 respondents from the pre-survey, 56% completed the post-survey equating to 31 respondents. The 31 respondents included students predominantly enrolled at UIndy (n=24), with the rest being students enrolled at other colleges or universities (n=7) within the United States. Analysis of Post-Assessment The analysis of the post-assessment followed the same methodologies as the needs assessment. Google Forms and Sheets allowed for quantitative data analysis of demographic information collected from the pre-survey to apply to the 31 respondents in the post-survey. Excluding the one long-answer text item, the results of the other six items were analyzed. Pattern examination occurred between the same demographic groups and responses to four items within the following post-survey categories: Bias Incidents (2 items) and Support Needs (2 items). Of the four itemstwo items were yes or no questions, and two items were 5-point scale questions. Thematic analysis was conducted to analyze qualitative data from the post-interview and the one long-answer text item in the post-survey. Results Needs Assessment: Quantitative Data Analysis Pre-Survey to External Stakeholders Demographics. All 55 respondents disclosed their demographic information. Three respondents identified as international students. They belonged to the following racial/ethnic groups: 61.8% White; 20.0% Asian, Asian-American, Pacific Islander (AAPI); 14.5% Black/African-American; 1.8% White, Black/African-American, and Mixed; and 1.8% Hispanic. SUPPORTING STUDENTS FACING OCCUPATIONAL INJUSTICE 14 For gender categories, 80% of respondents identified as Cisgender Woman, 14.5% as Cisgender Man, 1.8% as Non-binary, and 1.8% as both Cisgender Woman and Non-Binary. Additionally, 1.8% identified as Cisgender Man while stating they are sort-of detached man, like I kind-of want to flow to non-binary but I'm not there yet. Regarding sexual orientation categories, 78.2% of respondents identified as Heterosexual/straight, 9.1% as Bisexual, 1.8% as Gay, 1.8% as Queer, 1.8% as both Asexual and Queer, 1.8% as both Gay and Queer, 1.8% as both Gay and Lesbian. Additionally, 1.8% identified as Gay, Lesbian, and Queer; and 1.8% stated they appear straight but truthfully pan. For disability, 81.8% of respondents indicated they do not have a disability, 16.4% have an invisible disability, and 1.8% preferred not to say. Descriptive Statistics. 97% of the respondents belonged to the White and Cisgender Woman or Man demographic groups; 79.4% to White and Heterosexual/straight; and 76.4% to Heterosexual/straight and Cisgender Woman or Man. A total of 47.3% of respondents identified within the stated demographic categories. As a result of this overrepresentation within the population, significant patterns developed for items 7, 8, 10, 13, 14, and 15 on the pre-survey which is explained further in the discussion section. Needs Assessment: Thematic Analysis Pre-Interview with an Internal Stakeholder The following are three primary themes that emerged from the pre-interview with a primary internal stakeholder: 1) accountability; 2) presence of policies and procedures; 3) student resources and support services. Accountability. Dr. Amber Smith, the Chief Inclusion and Equity Officer (CIEO) of UIndys Office of Inclusion & Equity (OIE), expressed that everyone has biases. However, not SUPPORTING STUDENTS FACING OCCUPATIONAL INJUSTICE 15 everyone is aware of or educated on their biasescreating a space for bias incidents. She explained a need for accountability with faculty, staff, and students to mitigate them when bias incidents occur. She developed the Bias Incident Reporting Protocol (BIRP) to allow for educational processes, transparency, and formalization to objectively review bias incidents. Presence of Policies and Procedures. Dr. Smith indicated that the locations for policies and procedures surrounding bias incidents are in UIndys Student Handbook and on UIndys internal and external websites. However, they are not easily discoverablehighlighting a need for increased intentional presence and campaigning of the policies and procedures at UIndy, including the BIRP. She also conveyed that the current definitions of bias incidents and discrimination on the OIE website needed to be re-worded from the student's perspective. Student Resources and Support Services. While various departments are available on campus to provide students support, resources, and additional servicesDr. Smith conferred an increased need for more directly available resources supporting the daily functioning of students impacted by bias incidents. She also specified that students struggle both academically and personally during bias incidents. Pre-Survey to External Stakeholders The following are five significant themes that surfaced from the responses to the first long-answer text item in the survey regarding barriers to reporting a bias incident: 1) time and stress; 2) fear and safety; 3) lack of knowledge and resources; 4) lack of trust and understanding; 5) lack of action and support. The following are five significant themes that appeared from the responses to the second long-answer text item in the survey regarding other resources or suggestions for the program guide: 1) safe spaces; 2) emotional support; 3) support from faculty SUPPORTING STUDENTS FACING OCCUPATIONAL INJUSTICE 16 and staff; 4) guidance on reporting bias incidents; 5) diversity, equity, and inclusion resources. For depictions of the thematic analyses for both items, see Tables 19 and 20. Table 19 Are there any barriers to why you would not report an incident? Please explain below. Themes Example Responses Time and stress It just causes a lot of problems, and takes a lot of time, causes anxiety and stress. Fear and safety I think there is always fear of backlash or other negative consequences when reporting these incidents. Lack of knowledge and I feel like there is not a proper resource or number or anything resources that we can use to report these kind of incidents. Lack of trust and Since I don't have any staff members that I am close with, I understanding feel like I don't have a good connection with the school itself so I wouldn't be comfortable enough to report an incident. SUPPORTING STUDENTS FACING OCCUPATIONAL INJUSTICE 17 Lack of action and Feelings of not being taken serious, feeling of being disregard support in severity of incident, thoughts that there will be no repercussions behind the actions. Table 20 Are there other resources or forms of support that you would like to see in this program guide or suggestions for UIndy Office of Inclusion & Equity? Please explain. Themes Example Responses Safe spaces I also think anonymity would be beneficial for in person and virtual safe spaces when people share their thoughts or stories. Emotional support Maybe some sort of validation that we are not alone and our concerns or hurt is worth doing something about (rather than just letting it go). Support from faculty and Professors at UINDY who are willing to hear from students staff going through these things and are willing to provide advice, resources, etc. SUPPORTING STUDENTS FACING OCCUPATIONAL INJUSTICE 18 Guidance on reporting Maybe a step by step guide on how to report a bias incident bias incidents and what to expect as the process moves along so there are no surprises/things we werent expecting to encounter and arent prepared for in the reporting process. Diversity, equity, and Links to national organizations and bias trainings such as inclusion resources micro aggressions workshops. Post-Assessment: Quantitative Data Analysis Post-Survey to External Stakeholders The demographic information for racial/ethnic group, gender, and sexual orientation from the pre-survey was carried over to the 31 respondents in the post-survey due to email collection from the pre-survey. The percentage ratios of the demographic groups were similar from the presurvey, following a continued overrepresentation of the previously mentioned demographic groups. However, the post-survey findings indicated no significant differences found among the demographic categories and survey items. SUPPORTING STUDENTS FACING OCCUPATIONAL INJUSTICE 19 Post-Assessment: Thematic Analysis Post-Interviews with Internal Stakeholders The following are three key themes that transpired from the two post-interviews with internal stakeholders: 1) positive feedback; 2) sustainability and formalization; 3) student accessibility; 4) additional stakeholder involvement. The OIE team, Marketing and Communications team, and project developer all expressed general positive feedback for the current project and contentment with its execution. Hence, they urged immediate planning for sustainability and formalization to broadcast the project on both UIndys internal and external websites, as well as the UIndy mobile application. The Marketing and Communications team denoted that the formalization process includes redesigning the project to match UIndy standardization practices. Both teams communicated considerations to improve student accessibility within the current project, such as providing instructions to navigate embedded documents, changing font size and color, improving visual and tactile accessibility, adding disclaimers, and inserting links to additional UIndy resources. A suggestion made by both teams was to involve additional internal stakeholders at UIndy, such as the OIE Student Team, Title IX Coordinator, and Resident Directors, in the current project. They also suggested emailing the external stakeholders to explain any project changes, the formalization process, and the sustainability plan. Post-Survey to External Stakeholders The following are three prevalent themes that ensued from the responses to the one longanswer text item in the survey regarding any specific changes to be considered before finalizing SUPPORTING STUDENTS FACING OCCUPATIONAL INJUSTICE 20 the program guide: 1) deemed appropriate; 2) accessibility suggestions; and 3) additional resources. For results of the thematic analysis, see Table 21. Table 21 Please state any specific suggestions, additions, and/or removals you would like to see before officially finalizing the guide. Themes Example Responses Positive feedback No suggestions, it looks great! Accessibility suggestions The links at the bottom (home uindy bias incidents other resources etc) are in a small font, somewhat hard to read. Additional resources Maybe put disclaimers so people know what to expect from this guide rather than expecting to find everything in one place. Project Execution Through the information gathered across research and evidence from relevant literature and the analyses of responses from the needs assessment and post-assessment, the execution of the project resulted in a websitethe UIndy Student Support Guide. The data collected through the surveys informed the subpage topics and resources included on the website. SUPPORTING STUDENTS FACING OCCUPATIONAL INJUSTICE 21 Each subpage of the website incorporated resources via informational text, links, or embedded documents corresponding to the pre- and post-identified needs of stakeholders. The UIndy Bias Incidents subpage includes resources such as access to the universitys student handbook, a guide to the BIRP, access to the BIRP, and example scenarios of bias incidents. The student handbook highlights the universitys policies concerning discriminatory and bias-related harassment and social justice; however, the subpage provides a brief overview described from a student perspective. The Anonymous Submission Form'' subpage offers a Google Form where students have a confidential, safe space to submit a story, incident, question, comment, concern, or suggestion to the UIndy OIE without risk for repercussions. The Self-Advocacy Templates subpage presents communication templates to advocate for academic assistance or extensions. The Daily Functioning Support subpage encompasses the following tangible resources and coping tools to support daily life and well-being: a list of journal prompts; coloring sheet packet; gratitude jar activity; self-care planner; list of affirmations; list of daily suggestions; list of phone and tablet applications; and a list of yoga and mindfulness videos, articles, and classes. The UIndy Resources'' subpage provides a summary and access to each of the following UIndy student services: Counseling Center; Crisis Response Team; Disability Services; Fitness and Recreation; Food Pantry Form; Office of Inclusion and Equity; Professional Edge; Student Affairs; Student Concern Form; Student Organizations; and Title IX. The Other Resources subpage provides lists to the following resources: international, national, and local organizations; diversity, equity, and inclusion education; virtual safe spaces; mental health and counseling services or platforms; and relative Instagram accounts to follow. Feedback from the post-assessment also resulted in changes made on the website to improve accessibility and readability for users. Changes applied include adding disclaimers on SUPPORTING STUDENTS FACING OCCUPATIONAL INJUSTICE 22 the homepage and each subpage, adding instructions on accessing embedded content, modifying the font color and size of specific headings, and reformatting the text of hyperlinks. Discussion The purpose of developing the University of Indianapolis (UIndy) Student Support Guide was to provide a program guide that supports university-level students' daily function and occupations when experiencing bias and discriminatory incidents. Internal and external stakeholders influenced the projects development before and after completion via the needs assessment and post-assessment. By conducting the needs assessment, the project developer determined the primary needs of the stakeholders and then developed the program guide to fit those needs. The program guide took the format of a website and was named the UIndy Student Support Guide since it will serve students after finalization. The UIndy Student Support Guide website addressed these needs by providing convenient resources on-demand for student support within the subpages. The project developer derived feedback from the stakeholders by administering the post-assessment to verify if these needs were met on the website. Based on the feedback from both the internal and external stakeholders, the website appropriately met their needs. Before finalizing its dissemination, it underwent minor modifications suggested by secondary internal stakeholders, such as UIndys Title IX Coordinatorto improve web-based low vision accessibility and add on supplementary UIndy resources. By directly incorporating the input of external stakeholdersthe primary end-users of the current projectthe project developer demonstrated validation of their needs and the importance of providing support from an end-user perspective. SUPPORTING STUDENTS FACING OCCUPATIONAL INJUSTICE 23 The project developer utilized the Canadian Model of Occupational Performance (CMOP) to guide the application of occupational justice within the methodology. Under an occupational justice lens, the project developer considered the following aspects of occupational injustice when creating and executing the needs assessment, post-assessment, and project development: occupational alienation, occupational deprivation, and occupational marginalization. The project developer applied the CMOP to occupational justice aspects by designing the interview discussion points, survey items, program guide topics and resources, and program guide format from a client-centered approachspecifically focusing on the nature between the person, environment, and the occupation balance (Cole, 2018; Cole & Tufano, 2008). Viewing the results under the CMOPs lens, the themes found were consistent with relevant literature concerning unfavorable consequences related to bias and discriminatory events. The discovered themes affirmed that adverse outcomes, such as psychological distress and anxiety, affect a students ability to balance their person, environment, and occupations leading to the potential of occupational injustice arising (Cavalhieri, Chwalisz, & Greer, 2019; Hwang & Goto, 2008). Compared to historically underrepresented demographic groups, the needs assessment results demonstrated a significant pattern pointing out the lack of occupational injustice occurring among the following historically overrepresented demographic groups: White, Heterosexual/straight, and Cisgender. Furthermore, the findings indicated a notable pattern distinguishing the mentioned overrepresented groups showing a lesser likelihood of their daily functioning and occupations being affected when occupational injustice occurswhile also exhibiting a higher probability of using on-campus student support services and resources. These results are consistent with current literature indicating that underrepresented racial and ethnic SUPPORTING STUDENTS FACING OCCUPATIONAL INJUSTICE 24 groups, gender identities, and sexual orientations are more likely to experience and be negatively affected by occupational injusticesuch as bias and discriminatory incidentsthan their overrepresented counterparts (Pieterse, Carter, Evans, & Walter, 2010; San & Breen-Franklin, 2019). Conversely, the post-assessment results indicated that all demographic groups largely found the program guide suitable for userevealing successful consolidation of accessibility, advocacy, inclusive belonging, and client-centered design for all student populations in higher education. With supporting evidence from relevant literature and the projects results, the project developer fulfilled the program guides purpose of including intentional resources to promote well-being for university students, while also empowering historically marginalized students. Implications for Practice Occupational therapy (OT) practitioners who work in higher education, such as educators or administrators, have a role in advocating for occupational justice with their OT students. Evidence shows that OT practitioners and students belonging to historically underrepresented demographic groups often undergo isolation, exclusion, marginalization, and stigmatization (Dennis et al., 2020). Due to such consequences from experiencing occupational injusticeOT faculty and staff should employ the program guide to address, decrease, and prevent the adverse effects on current OT students daily functioning and occupational needs. Before the development of the program guide, the University of Indianapolis (UIndy) had minimal access to safe, accessible, and immediate resources to support the daily functioning and occupational needs of students coping with bias and discriminatory incidents that occur on or off-campus. Through issuing the UIndy Student Support Guide website, the campus community can now access all resources in one place, no matter where they are or what device they are on. SUPPORTING STUDENTS FACING OCCUPATIONAL INJUSTICE 25 Although students are considered the primary end-users, it provides a resource for faculty to use in advising students. The project developer suggests that the website be updated and maintained by the Office of Inclusion and Equity (OIE) Student Team with administrative authorization and oversight to maintain the student perspective, which guided the development. The project developer also recommends ongoing communication and cooperation with internal stakeholders to maintain the website within UIndys standardization and legal practices and ongoing feedback with external stakeholders to re-evaluate and address daily functioning and occupational needs. The website URL is https://sites.google.com/uindy.edu/uindystudentsupportguide/home Limitations One limitation of the developed project was the lack of a pre-survey classification item that distinguished between undergraduate and graduate-level students because they may have different occupational needs. A particular limitation was the lack of diversity among external stakeholders, with many identifying with historically overrepresented demographic groups. The limited feedback from historically underrepresented groups may have resulted in unequal influences on the projects development and execution. A significant limitation was that both internal and external stakeholders had little understanding of OTs connection to personal wellbeing and self-care needs. Although the project developer explained what the OT field entails, the internal stakeholders required additional insight into OTs broad scope of practice to understand the projects necessity. In contrast, the external stakeholders found it difficult to comprehend how OT promotes health and well-being while also confronting occupational injusticeas evidenced by the wide range of responses received for survey items asking about daily functioning and occupational needs during bias incidents. SUPPORTING STUDENTS FACING OCCUPATIONAL INJUSTICE 26 Conclusion The client-centered groundwork of occupational justice and the CMOP see individuals as intersectional and diverse occupational beings with occupational rights while embodying elements of social justice. On the contrary, the oppression of occupational rights may result in incidents of occupational injustice to take place. Students in higher education are occupational beings with the occupational right to an education in an academic institution. However, when a bias or discriminatory incident materializes as a condition of occupational injustice, their occupational right to an education is negatively impacted when the academic institution cannot provide the full extent of support and resources necessary. Specifically, at the University of Indianapolis (UIndy), enrolled students had limited access to promptly accessible resources when left to cope with these incidentsfostering occupational injustice. For this reason, the UIndy Student Support Guide website originated to address, advocate, and support the occupational needs of university-level students when bias and discriminatory incidents take place on or off-campus. With free and open access to the website, it is essential and anticipated that the UIndy campus community will reference and utilize the UIndy Student Support Guide for their students' daily functioning and occupational needs affected by occupational injustice. Going forward, UIndy plans to take ownership and translate the developed website to their internal and external websites, mobile application, and social media platforms. SUPPORTING STUDENTS FACING OCCUPATIONAL INJUSTICE 27 References Benner, A. D., Wang, Y., Shen, Y., Boyle, A. E., Polk, R., & Cheng, Y. P. (2018). Racial/ethnic discrimination and well-being during adolescence: A meta-analytic review. The American Psychologist, 73(7), 855883. https://doi.org/10.1037/amp0000204 Braun, V., & Clarke, V. (2006). Using thematic analysis in psychology. Qualitative Research in Psychology, 3(2), 77101. https://doi.org/10.1191/1478088706qp063oa Braun, V., & Clarke, V. (2014). What can thematic analysis offer health and wellbeing researchers? International Journal of Qualitative Studies on Health and Well-Being, 9. https://doi.org/10.3402/qhw.v9.26152 Cavalhieri, K., Chwalisz, K., & Greer, T. (2019). The role of self-efficacy in the relationship between discrimination and health care utilization among college students in the United States. Journal of Health and Social Sciences, 4. https://doi.org/10.19204/2019/thrl6 Cole, M. (2018). Group dynamics in occupational therapy (5th ed.). Thorofare, NJ: Slack Incorporated. Cole, M. & Tufano, R. (2008). Applied theories in occupational therapy: A practical approach. Thorofare, NJ: SLACK Incorporated. Dennis, C., Edwards, A., Erb, M., Gluszek, K., McIlroy, E., & Marko, M. (2020). OT students perceptions of diversity and inclusion. American Journal of Occupational Therapy, 74(4_Supplement_1), 7411510300p1. https://doi.org/10.5014/ajot.2020.74S1-PO6028 SUPPORTING STUDENTS FACING OCCUPATIONAL INJUSTICE 28 Durocher, E., Gibson, B. E., & Rappolt, S. (2014). Occupational justice: A conceptual review. Journal of Occupational Science, 21(4), 418430. https://doi.org/10.1080/14427591.2013.775692 Durocher, E., Rappolt, S., & Gibson, B. E. (2014). Occupational justice: future directions. Journal of Occupational Science, 21(4), 431442. https://doi.org/10.1080/14427591.2013.775693 Hwang, W. C., & Goto, S. (2008). The impact of perceived racial discrimination on the mental health of Asian American and Latino college students. Cultural Diversity & Ethnic Minority Psychology, 14(4), 326335. https://doi.org/10.1037/1099-9809.14.4.326 Inclusive excellence at UIndy. (n.d.). Retrieved March 15, 2021, from https://uindy.edu/inclusion/inclusive-excellence Kinsella, E. A., & Durocher, E. (2016). Occupational justice: Moral imagination, critical reflection, and political praxis. OTJR: Occupation, Participation and Health, 36(4), 163 166. https://doi.org/10.1177/1539449216669458 Mishra, P., Pandey, C. M., Singh, U., Gupta, A., Sahu, C., & Keshri, A. (2019). Descriptive statistics and normality tests for statistical data. Annals of Cardiac Anaesthesia, 22(1), 6772. https://doi.org/10.4103/aca.ACA_157_18 Nilsson, I., & Townsend, E. (2010). Occupational justice-bridging theory and practice. Scandinavian Journal of Occupational Therapy, 17, 5763. https://doi.org/10.3109/11038120903287182 SUPPORTING STUDENTS FACING OCCUPATIONAL INJUSTICE 29 Pieterse, A. L., Carter, R. T., Evans, S. A., & Walter, R. A. (2010). An exploratory examination of the associations among racial and ethnic discrimination, racial climate, and traumarelated symptoms in a college student population. Journal of Counseling Psychology, 57(3), 255263. https://doi.org/10.1037/a0020040 San, S., & Breen-Franklin, A. (2019). Experiences of LGBTQ college students: Identity, health, and participation. American Journal of Occupational Therapy, 73(4_Supplement_1), 7311505116p1-7311505116p1. https://doi.org/10.5014/ajot.2019.73S1-PO3011 Smith, D. A. R. (2020). I belong: Moving towards inclusive excellence (pp. 29) [Executive Summary]. University of Indianapolis. Stadnyk, R., Townsend, E., & Wilcock, A. (2010). Occupational justice. In C. H. Christiansen & E. A. Townsend (Eds.), Introduction to occupation: The art and science of living (2nd ed., pp. 329-358). Upper Saddle River, NJ: Pearson Education. Townsend, E. A., & Wilcock, A. A. (2004a). Occupational justice. In C. H. Christiansen & E. A. Townsend (Eds.), Introduction to occupation: The art and science of living (pp. 243273). Upper Saddle River, NJ: Prentice Hall. Townsend, E. A., & Wilcock, A. A. (2004b). Occupational justice and client-centered practice: A dialogue in progress. Canadian Journal of Occupational Therapy, 71(2), 7587. https://doi.org/10.1177/000841740407100203 Whiteford, G., & Townsend, E. (2011). Participatory occupational justice framework (POJF) 2010: Enabling occupational participation and inclusion. Occupational Therapies without Borders, 6584. SUPPORTING STUDENTS FACING OCCUPATIONAL INJUSTICE 30 Wilcock, A. A. (2006). An occupational perspective on health (2nd ed.). Slack Incorporated. Wilcock, A. A., & Hocking, C. (2015). An occupational perspective on health (3rd ed.). Slack Incorporated. Wilcock, A. A., & Townsend, E. (2000). Occupational terminology interactive dialogue. Journal of Occupational Science, 7(2), 8486. https://doi.org/10.1080/14427591.2000.9686470 Williams, D.A., Berger, J.B., & McClendon S.A. (2005). Toward a model of inclusive excellence and change in postsecondary institutions. Washington, D.C. Association for American Colleges & Universities. World Federation of Occupational Therapists. (2006). Position statement human rights. Retrieved from http://www.wfot.org/AboutUs/PositionStatements.aspx SUPPORTING STUDENTS FACING OCCUPATIONAL INJUSTICE Appendix A Copies of Pre-Survey and Post-Survey Figure 2 Pre-Survey: Student Daily Functioning during Bias Incidents 31 SUPPORTING STUDENTS FACING OCCUPATIONAL INJUSTICE 32 SUPPORTING STUDENTS FACING OCCUPATIONAL INJUSTICE 33 SUPPORTING STUDENTS FACING OCCUPATIONAL INJUSTICE 34 SUPPORTING STUDENTS FACING OCCUPATIONAL INJUSTICE 35 SUPPORTING STUDENTS FACING OCCUPATIONAL INJUSTICE 36 SUPPORTING STUDENTS FACING OCCUPATIONAL INJUSTICE 37 SUPPORTING STUDENTS FACING OCCUPATIONAL INJUSTICE Figure 3 Post-Survey: Student Support Guide Feedback 38 SUPPORTING STUDENTS FACING OCCUPATIONAL INJUSTICE 39 SUPPORTING STUDENTS FACING OCCUPATIONAL INJUSTICE 40  ...

... 1 Feasibility Study and Business Model for an ICU Follow-Up Clinic Gracyn Conner Occupational Therapy Department, University of Indianapolis OTD 612: Doctoral Capstone Project Professor Christine Kroll Mentor Brenda Howard May 3rd, 2021 2 Abstract PICS is a condition with long lasting cognitive and physical deficits that impact an ICU survivors independence and quality of life. While there are efforts to prevent the development of PICS, an intervention to help individuals to recover from PICS is warranted. An ICU follow-up clinic is an intervention that could reduce hospital readmission rates and increase a patient's quality of life. ABC staff members identified a need for an ICU follow-up clinic for their patients. An ICU follow up clinic at ABC requires a feasible model backed by evidence based practice and expert approval. Data collected and analyzed from semi-structured interviews, literature review, audiovisual media, and audio works developed 5 themes including clinical team members, clinic form, eligibility, outcome measures, and the purpose of the clinic. Ultimately, the proposed bi-monthly ICU follow-up clinic utilized a telehealth approach and four clinical team members (nurse practitioner, clinical psychologist, pharmacist, and case manager). Those mechanically ventilated for 48 hours or more would be referred to the clinic and complete the SF-36 as a screening tool and outcome measure to be used to determine clinic outcomes. While the proposed clinic does not include an occupational therapist, occupational therapy is warranted for this population and clinical team members should understand its scope of practice. Future implications for the clinic include the development of an in-person clinic, facilitation of peer/family support group, and initiation of ICU diaries. 3 Feasibility Study and Business Model for an ICU Follow-Up Clinic Post Intensive Care Unit Syndrome (PICS) is known as the physical, cognitive, and mental health decline experienced by intensive care unit (ICU) survivors (Fernandes, Jaeger, & Chudow, 2019; Newbill, Abbott, & Tordoff, 2016; Taggart, 2019). Approximately 50% of all patients admitted to the ICU develop post-intensive care syndrome, and often do not return to their previous baseline functioning (Jaffri & Jaffri, 2020). Additionally, one year post-discharge, less than 10% of patients mechanically ventilated for 4 days or more are alive and independent of major functional limitations (Cox et al., 2010). ICU survivors do not only leave the hospital with deficits secondary to their condition, but also with deficits acquired from being in the hospital for long periods of time including hospital-acquired weakness and delirium (Harvey & Davidson, 2016). With the rise in COVID-19 cases, the number of individuals mechanically ventilated for long periods of time has only increased (Lavery et al., 2020). The persistent physical, cognitive, and mental health issues developed with PICS have a significant impact on an individuals daily occupations post ICU stay. These impacts include decreased independence in activities of daily living (ADLs) and instrumental activities of daily living (IADLs) (Hashem et al., 2016; Held & Moss, 2019), increased sleep disturbances (Hashem et al., 2016), negative changes in personal roles and social interactions (Lasiter, 2016; Modrykamien, 2012), and a decline in work or educational status (Heydon, 2020; Miller, 2017). There is a need to address the long-term recovery of ICU survivors post-discharge to increase their overall quality of life. Therefore, the purpose of this capstone project is to develop a feasibility plan and business model for an ICU clinic that may be implemented at a mid-sized hospital. In order to combat the development of PICS during an ICU stay, there is a preventive intervention used named the ABCDEF bundle (Assess and manage pain, Breathing trials and 4 spontaneous awakening, Choice of sedative, Daily delirium monitoring, Early mobility, and Family engagement and empowerment; Colbenson, Johnson, & Wilson, 2019). However, the ABCDEF bundle does not address post-ICU interventions for those who do develop PICS. One solution to address post-ICU complications is an ICU follow-up clinic (Meyer, Brett, & Waldmann, 2018; Schofield-Robinson et al., 2018). The ICU follow-up clinic is relatively undefined and used significantly more in other countries such as the United Kingdom and Australia (Held & Moss, 2019, Stollings & Caylor, 2015; Teixeira & Rosa, 2018). The basis of an ICU clinic includes an interdisciplinary team that conducts follow-up appointments with ICU survivors to implement specialized interventions for those experiencing long-lasting effects from their ICU stay. ICU follow-up clinics are not only being utilized for their impact on patient outcomes but have been suggested to reduce hospital readmission rates and increase the quality of patient outcomes (Feemster, 2018; Held & Moss, 2019). These are important factors to consider with data showing 14% of ICU patients readmit within 30 days of discharge (Kohn et al., 2018). Readmission into the intensive care unit is linked to increased time hospitalized, higher costs, and overall poor outcomes for patients (Ponzoni et al. 2017). The indications for ICU follow-up clinics have increased since the COVID-19 pandemic. Jaffri & Jaffri (2020) suggested that PICS may be the next public health crisis as the COVID-19 crisis stabilizes due to the number of individuals that have required critical care interventions during the pandemic. Those infected with COVID-19 and admitted to intensive care units required on average 10 days of mechanical ventilation, and the use of mechanical ventilation in an ICU increases the likelihood of developing PICS (Grasselli, Zangrillo, Zanella et al., 2020). Nine percent of COVID-19 survivors were readmitted to the same hospital within 60 days of discharge and 1.6% were readmitted more than once (Lavery et al., 2020). Due to the physical, 5 mental, and cognitive impact critical care stays have on an individual, many people require rehabilitation post-discharge. However, there is reduced vacancy in the rehabilitation facilities due to the increasing number of patients needing rehabilitation and due to the additional safety requirements that are essential for COVID-19 (Jaffri & Jaffri, 2020; Kadakia, Nuti, & Gupta, 2020). The ICU staff at a mid-sized hospital located in Indianapolis, referred to in this paper as ABC, has identified a disconnect in the post-ICU care provided to their patients and a desire for practical solution to increase overall patient outcomes. The staff has identified a need and a desire to implement an ICU follow-up clinic. However, implementation would require an indepth look at the feasibility of implementing an ICU follow-up clinic within the hospital. This capstone project addresses ABCs identified need through the development of a feasibility plan and business model for an ICU clinic that may be implemented at ABC. The investigator will develop this project by employing the person-environment-occupation-person (PEOP) model. The PEOP model utilizes a top-down approach and recognizes the dynamic and reciprocal interaction between the individual, their environment, and their occupations (Christiansen, Baum, & Bass, 2011). The model emphasizes the consideration of these three parts and their interactions throughout the entire intervention process (Christiansen, Baum, & Bass, 2011). Additionally, the model provides a 10-step systematic template to develop interventions for large populations. This model is appropriate for the development of the ICU follow-up clinic because, if implemented, it will act as an intervention for these ICU survivors. The purpose of the follow-up clinic intervention is to increase the quality of life for its patients. Therefore, utilizing a model that recognizes and promotes the reciprocal interactions between the person, environment, and occupations to increase quality of life is vital. 6 Once an individual is medically stable, they are discharged from the ICU. Yet, their medical status does not indicate their ability to return home and participate in their daily occupations with the potential new deficits they acquired in the hospital. Therefore, it is necessary to consider how the individual is performing their daily occupations and the barriers they may encounter post-discharge. An ICU follow-up clinic informed by the PEOP model, evidence-based practice, and expert feedback may provide interventions that positively impact ICU survivors quality of life. Methods Ethics This capstone project was submitted for IRB review. Ultimately, this project did not include research of human subjects and did not require IRB approval. Design and Setting To address the feasibility of the ICU clinic, the needs assessment was conducted using a qualitative study design. The data collection and analysis utilized grounded theory methodology. A grounded theory approach allowed for the development of a theory or model that is grounded or based on data and the experiences of stakeholders (Taylor, 2017). Grounded theory processes allow for small sample sizes and a cyclical process for data collection and interpretation (Taylor, 2017). The development of an ICU follow-up clinic model for a specific hospital required constant feedback from a small group of stakeholders. The research was completed with two iterative rounds of data collection, coding, and theoretical sampling with the presentation of a final model to all involved stakeholders. Participants 7 Prior to this capstone project, a group of ICU staff indicated an interest in developing an ICU follow-up clinic. Purposive sampling was used to recruit this group of ICU staff as participants in this project. This project included five participants with advanced ICU knowledge and at least 5 years of experience. Participants included the ICU manager (RN), ICU Educator (RN), ICU Registered Nurse/Psychology Nurse Practitioner Student, ICU Survivor/Nurse Practitioner, and ICU Clinical Nurse Specialist. Data Collection Data collection utilized semi-structured interviews, literature review, audiovisual media, and audio works. Data collection began with an in-depth literature review and a review of current audiovisual media and audio works. The investigator developed interview questions from the literature and media review, and then conducted interviews. After initial interviews, the investigator developed a draft follow-up clinic model, and repeated the initial process. The investigator reviewed new and previously gathered literature and media, developed interview questions, and conducted interviews. The investigator repeated the iterative process twice more and collected all data over a 14 week period between January-April of 2021. Initial interviews utilized a semi-structured format with the purpose of identifying the current consensus of the pre-established ICU staff. The subsequent interview utilized open-ended questions (see table 1) with the purpose of capturing concerns and feedback on the draft ICU follow-up clinic. The investigator interviewed participants two times and each interview lasted between 15-60 minutes. The literature review consisted of peer-reviewed articles within EBSCOHost databases with search terms including ICU, intensive care unit, PICS, postintensive care, post-intensive care syndrome, critical care, critical care clinic, critical care follow up clinic, follow up clinic, covid-19, mechanical ventilation, ICU discharge, readmissions, 8 United States. Lastly, the review included an overview of audiovisual media and audio works. With the novelty of covid-19 follow-up care and the increase in follow-up clinics in the last year, the investigator considered current information that is not readily available in peer-review research at this time. All current media considered was produced or disseminated from a perceived expert in the emerging field who has direct knowledge or experience with follow-up clinics. Table 1 Semi-Structured Interview Questions of Round 1 & 2 Round 1 Interview Questions Round 2 What is your vision for an ICU follow up clinic? What is your thought about the clinic structure? Who would be the best to lead the clinic? Do you have objections to a telehealth clinic? Who would be an integral part of the What are your thoughts on the clinic clinic team? team members? Where should the clinic take place? What do you think about the frequency of the clinic? How often do you see the clinic taking place? What do you see as the biggest challenges to this clinic model? How often should we follow up with Do you have any other feedback patients? about the clinic? What are the biggest barriers you see to this clinic? Data Analysis Data analysis included a process of initial data collection, creation of memos, and coding data to develop themes that guided the model development. Themes in both interviews and literature/media review emerged through a process of selective coding. Selective coding allowed 9 the investigator to reflect on data collected and compare it to published literature to ensure the model developed has a broad understanding (Johnson & Christensen, 2014). For this project, selective coding ensured that the ideas and desires of participants, which guided the model development, did not directly contradict available literature. The investigator analyzed the data collected from two rounds of interviews, literature reviews, and audiovisual media reviews. The investigator transcribed interviews as they occurred, and immediately began the process of creating memos that outlined the key points and ideas discussed with each participant. The investigator reviewed literature and audiovisual materials, captured important quotes, and organized the quotes based on subject. The investigator compiled data from interviews, literature reviews, and audiovisual media reviews and systematically analyzed the data till codes and themes emerged. Following round one of data collection and data analyzing, the investigator developed a draft ICU follow-up clinic business model. Then, round 2 began in which participants provided feedback on the draft model and the investigator completed further literature and audiovisual media review based on participant feedback. Through data analysis of round one and two, themes emerged that guided the development of the clinic model. Results The purpose of this capstone project was to develop a feasibility plan and business model for an ICU clinic that may be implemented at ABC Hospital. The investigator achieved this purpose through iterative rounds of literature review, interviews with experts, and qualitative coding. Throughout iterative rounds, the investigator utilized the PEOP model and its 10-step systematic template to ensure that the proposed clinic ultimately provided quality interventions that increased future patients reciprocal interaction between themselves, their environment, and 10 their occupations. The major themes that emerged from coding data included team members, clinic form, eligibility, outcome measures, and the purpose of the clinic. These themes indicated areas of the model in which the investigator needed to make informed decisions. The results of this project are organized by these major themes. Purpose of the Clinic With no prevailing theory or model for ICU follow-up clinics, the purpose of each clinic is variable. Some clinics are intended to be one-time follow-ups, while other clinics are intended to replace a patients primary care provider for a set period of time. When considering coding results and feasibility of the clinic, a clinic intended to provide quality referrals is most appropriate for ABC hospital. See table 2 for coding results. Table 2 Coding Themes and Corresponding Comments for Round 1 & 2 Theme Purpose of the Clinic Reference Round Comments Participant 1 1 Patients should be able to dictate what services they want or need from the clinic. Participant 2 1 The clinics purpose should increase the chance of the hospital implementing the clinic. Participant 3 1 The clinic should provide various resources for the ICU survivors and their families. Participant 4 1 The clinic should decrease the patients risk of developing future conditions. Participant 5 1 The purpose should be based on other follow up clinics that are succeeding. Teixeira & Rosa, 2018 1 The author suggests that the best structure and feasibility for a followup clinic includes four stages. 1: ICU RN assesses patients independence through a standardized measure. 2. One-two months post-discharge patient participates in a phone screening. 3. Three months after discharge, the patient participates in a follow up clinic and is provided with referrals. 4. Telephone evaluation 12 months post discharge. Mayer, et al., 1 The clinic is designed with intent to transition medical care back to 11 2020 the patient's primary care provider by the end of 1 year. The clinic is open at a minimum of bimonthly and frequently open weekly with capacity to treat up to six patients per session. Bloom et al., 2019 1 One time visit with referrals made as necessary or follow up visit within the clinic. APH Leader, 2021 1 The initial visit is completed where the patient is evaluated. Then the patient completes follow up appointments every 8-12 weeks until the patient is prepared for discharge. The initial visit is conducted. Then one time follow up appointment with referrals as needed. The clinic makes a lot of referrals. Collaboration with outside providers is vital for the purpose of the clinic. The clinic should aim to connect patients with community resources that benefit the patient in the long run. Participant 2 2 The hospital can and sometimes does measure success based on innetwork referrals. Participant 3 2 In-network referrals could be useful when starting the clinic. If the clinic is based on in-network referrals, it is important to measure how often patients are attending those referrals. Clinic Form There are three main forms of clinic presentation in literature and audiovisual media. These include in-person clinics, telehealth clinics, and mobile clinics. In-person clinics are the most prevalent forms of typical ICU follow-up clinics. When considering the coding results and feasibility of the clinic form, a telehealth clinic is the most appropriate clinic form to implement at ABC hospital. See table 3 for coding results. Table 3 Coding Themes and Corresponding Comments for Round 1 & 2 Theme Clinic Form Reference Participant 1 Round 1 Comments There should be a post conference with the clinic team before discharge. After discharge, someone will call and screen the patient. The screen will determine if they will have a video or inperson follow-up visit 12 Participant 2 1 Virtual appointments may be beneficial for those without a lot of support. However, home health could be a resource that the clinic utilizes in some way. Participant 3 1 The follow-up appointment is invaluable and would be hard to complete over the phone. However, too many appointments can be overwhelming. Participant 4 1 An in-person clinic or a telehealth clinic would be appropriate for the services provided as long as the patients needs are met. Participant 5 1 It is important to look at other successful models of follow up care and emulate what works best and input that into the structure of the clinic. Teixeira & Rosa, 2018 1 A large part of the follow-up studies of ICU survivors was performed through telephone contacts and the application of validated and standardized questionnaires and instruments. Rosa et al., 2018 1 Home visits were performed for patients who claimed inability to attend the clinic appointment. Wang et al., 2018 1 Telemedicine appointments may be a cost- and time-effective method for patients that have trouble getting to a hospital-based clinic; however, this has yet to be studied in ICU survivors. APH Leader, 2021 1 In person clinics where patients are assessed by various medical professionals in a carousel system. In this system, the patient sits in one room and each provider individually spends 15 minutes with the patient. The patient goes through a screening process over the phone and then completes an in person appointment. Mayer et al., 2020 1 The clinic is open at a minimum of bimonthly and frequently open weekly with capacity to treat up to six patients per session da Rocha Cabral et al., 2019 1 In contrast, only 14 patients (12.6%) in the ICU recovery program received any outpatient interventions of the ICU recovery program: nine patients (8.1%) used the phone number to contact the team and nine patients (8.1%) attended an ICU recovery clinic appointment. Participant 2 2 Use the NICU Follow Up Clinic as an example Virtual maybe better in order to reach the key market Lun et al., 2020 2 From a physicians perspective, our data suggest that virtual appointments are associated with shorter wait times and appointment times, thus improving our efficiency. The limitations of virtual care are largely related to the inability to physically examine a patient. However, many aspects of the neurological examination can be adapted to be virtually assessed, particularly if screen-sharing is available through the video conference platform. 13 We recognize that its use may be limited by the technological or financial challenges faced by some patients, as it requires a device with access to high-speed internet, speakers, and microphone. Ramdas & Swaminathan, 2021 2 Grouping remote appointments could reduce access fees due to the lower clinician time needed per patient in grouped appointments and could thus make remote appointments more accessible to underprivileged populations. Clinical Team The clinical team for ICU follow-up clinics varies greatly. Some clinical team members include physician, pharmacist, registered nurse, nurse practitioner, case manager, clinical psychologist, occupational therapist, physical therapist, speech therapist, dietitian, and pain management specialist. When considering feasibility and scope of practice of the practitioner, the investigator concluded that the clinic team would include a case manager, pharmacist, nurse practitioner, and clinical psychologist. See table 4 for coding results. Table 4 Coding Themes and Corresponding Comments for Round 1 & 2 Theme Clinical Team Reference Round Comments Participant 1 1 NP/PA/MD should lead the clinic. Other team members should include a social worker, community resource expert, pain management expert, and psychologist. Participant 2 1 The clinic lead should be the person who can make the best referrals/orders. The rest of the team should be made up of individuals to support the clinic lead. There should be a goal to use the least amount of providers when starting the clinic to increase feasibility. Participant 3 1 A NP should lead the clinic. In addition, there should be a palliative care specialist, OT/PT, and a case manager. Participant 4 1 An RN or NP with ICU bedside experience should lead the clinic Participant 5 1 There should be an attending doctor helping to lead the clinic. Mayer, et al., 1 The clinic transitioned to a transdisciplinary approach with the 14 2020 Teixeira & Rosa, 2018 addition of a pharmacist, a physical therapist, and an advanced practice provider. A social worker was added in 2019 to complete the current transdisciplinary team. 1 Consultation in palliative medicine in the context of post-ICU outpatient clinics translates the use of an excellent opportunity to meet the patients many needs, such as psychological concerns, spiritual needs, and better physician-patient, physician-family, and familypatient communication. Home physical therapy rehabilitation program was offered in in addition to ambulatory patient appointments. Intensive care physicians do not usually have health relationships with patients family members or even communicate with family physicians, who are generally familiar with the overall situation of the patient and his/her family. Prinjha, Field, & Rowan, 2009 1 A minority paid for private physiotherapy and this had a significant impact on their financial and personal lives. Wang et al., 2018 1 There is a severe shortage of intensivists in the United States, and therefore utilizing intensivists in post-ICU clinics when they are arguably more-needed in the ICU can be difficult. Further, while intensivists have first-hand experience in patient care within the ICU, they have not been specifically trained in outpatient continuity care and may not be the best staffing choice. da Rocha Cabral et al., 2019 1 Medication reconciliation at the time of ICU transfer was the only intervention from the ICU recovery program completed by both groups because it is considered usual care. P1 Utilized and INSPIRE model with the use of 4 nurses, physical therapist, and psychologist. Utilized an outreach nurse, psychologist, and MD. Utilized a rehab coordinator, psychologist, nurse, and MD. APH Leader, 2021 Utilized psychologist, OT/PT, pharmacist, additional referral for speech/dietitians as needed Downham, 2020 Utilized a physical therapist, clinical psychologist, RN, pharmacist, speech therapist, and dietician. Participant 2 2 The attending NP should have knowledge in critical care. Some patients may not need the pharmacist depending on how soon they were discharged home. Participant 3 2 A clinical team of a clinical psychologist, pharmacist, NP, and case manager seems appropriate. You should have connections with specific providers that can take referrals. 15 Outcome Measures Competent screening tools can act as outcome measures that are needed to appropriately assess the clinics impact on the patient and the facility. With the clinics goal of improving overall health and quality of life, utilizing the Short Form Survey 36 (SF-36) is an appropriate outcome measure the impact with the clinic as well as following the patient's progress. See table 5 for coding results. Table 5 Coding Themes and Corresponding Comments for Round 1 & 2 Theme Outcome Measures Reference Round Comments Participant 3 The case manager should provide help in completing the screening tools with patients. This will help with potential language barriers and cognitive deficits. Participant 4 The screening tools should have a psychological component and not only focus on the physical health of the individual. Downham, 2020 1 Prior to the clinic the patient gets a health questionnaire EQ5D assessment. This informs what they need from the clinic, then the patient gets a post follow up assessment at the end of their treatment. Heydon et al., 2020 1 The questionnaire set consisted of the EuroQol 5-level EQ-5D (EQ5D-5L) Questionnaire, Functional Activities Questionnaire (FAQ), and a novel needs questionnaire regarding their community healthcare service usage and socioeconomic status. Feemster et al., 2015 1 Patients had to have at least two SF-36 scores approximately 1 year apart. To adequately study differences in patient-centered outcomes after hospital admission, it is imperative that premorbid objective assessments of these outcomes are available. da Rocha Cabral, 2019 1 Utilized IES (Impact of Event Scale), HADS (Hospital Anxiety, and Depression) score, the Barthel, and SF-12 (Short-Form of Health Survey Questionnaire). Mayer et al., 2020 1 Utilized Hospital Anxiety and Depression Scale (HADS), Impact of Events Scale- Revised (IES-R), Health-related quality of life (HRQoL), 5D Euro-Quality of Life (EQ-5D-5L), and Montreal Cognitive Assessment (MOCA). 16 Participant 3 2 The SF-36 may be slightly too long. But, does provide a good overview of quality of life. It is important to track the progress of the patient. For example, are they attending their referral appointments and do they have access to all the items they need. Participant 2 2 Integrating the SF 36 into the computer system might be easy to do. You will need someone to explain the scores and outcomes to the patient. Eligibility It is not feasible to follow-up with every patient with an ICU stay, and there is no agreed upon criteria for patients who should be seen by a follow up clinic. Considering the deficits with prolonged mechanical ventilation and feasibility of the clinic, patients would be eligible for the follow-up clinic if they have been mechanically ventilated for 48 hours or more. See table 6 for coding results. Table 6 Coding Themes and Corresponding Comments for Round 1 & 2 Theme Eligibility Reference Round Comments Participant 1 1 Anyone who has had an ICU stay and would like to be seen by the clinic should be seen . Participant 2 1 It should be open to individuals who have been intubated. Participant 3 1 Patients who have been intubated tend to have the greatest deficits. Participant 4 1 It is important to include anyone who has experienced delirium. Heydon et al., 2020 1 Patients were eligible for inclusion if they were mechanically ventilated for a total of 5 or more days and/or the total length of their ICU stay was 7 or more days. Bakhur et al., 2019 1 Patients 18 years old or older admitted to the MICU with shock and/or acute respiratory failure requiring mechanical ventilation for more than 24 hours were included. Teixeira & Rosa, 2018 1 15-20% of ICU patients are mechanically ventilated for 48 hours or more. Cox et al, 2010 1 The most debilitating deficits are noted in patients mechanically ventilated 96 hours or more. 17 APH Leader, 2021 1 Included patients who were mechanically ventilated for 72 hours or diagnoses with ICU delirium. Belfast Health and Social Care, 2020 1 Open to any patients with an ICU stay and available up to one year post discharge. Participant 2 2 48 hours of mechanical ventilation as the criteria is consistent with our hope to extubate patients before the ventilation becomes prolonged. Participant 3 2 48 hours is appropriate for the eligibility criteria. Discussion Through exhaustive literature/audiovisual reviews and interviews, a model was created with the specific needs of ABC and its patients in mind. During an initial participant interview, participant 2 explained the importance of keeping the feasibility of the clinic in mind during its development to increase the likelihood of the clinics implementation. Therefore, throughout the development of this clinic model, the investigator consistently considered the clinics feasibility which impacted the decision making process. This initial model depicts a clinic model backed by literature and expert review which utilizes the least amount of resources required to start an efficient and effective clinic (see Appendix A). Purpose of the Clinic With no prevailing theory or model for ICU clinics, the purpose of each clinic is variable. Some clinics are intended to be one-time follow-ups. While other clinics are intended to replace a patients primary care provider (PCP) for a set period of time (Mayer et al., 2020). A clinic that replaces the patients PCP provides continuity of care and ensures that the care providers have specialized critical care knowledge. However, the implementation of a full clinic that could replace a primary care physician would require a significant increase in staffing and a large dedicated location within the ABC facilities. In contrast, a referral clinic would require fewer 18 resources, provide an opportunity for patients to get specialized care through referrals, and could provide a financial benefit to the network. The investigator determined that the purpose of this clinic is to act as a one-time followup and referral source for patients. This would utilize the least amount of resources required to start the clinic. It would allow the patient to seek out more specialized treatment for their symptoms. This would require clinical team members to be educated on all potential referral sources and when to refer. Additionally, it indicates an implication to find specialized care providers with additional ICU survivor knowledge that the clinic can consistently refer to. Some examples of potential referrals include primary care providers, clinical psychologists, cardiologists, physical/occupational/speech therapists, dietitians, home health services, and pain management specialists. Clinic Form There are three main forms of clinic presentation in literature and audiovisual media. These include in-person clinics, telehealth clinics, and mobile clinics. In-person clinics are the most prevalent forms of typical ICU follow-up clinics. Patients have the opportunity to receive more in-depth physical examinations and therapeutic treatments when appointments are inperson (Bakhru et al., 2019). Unfortunately, in-person follow-up clinics with multiple disciplines are more expensive than typical processes of care (Jensen et al., 2015). Additionally, in-person ICU follow-up clinics are poorly attended due to lack of transportation, distance from the clinic, and financial concerns (Bakhur et al., 2019; Mayer et al., 2020; Wang et al, 2018; Teixeira & Rosa, 2018). There are mobile clinics that provide in-home examinations and services; however, there is little research on their efficacy and cost-effectiveness (Khan et al., 2018; Rosa et al. 2018). Virtual or telehealth appointments have been suggested as a solution to the in-person 19 clinic barriers (Mayer et al., 2020). Yet, virtual appointments pose their own barriers. Completing full physical examinations and providing a typical total follow-up service to the patient is difficult through telehealth (Lun et al, 2020). However, with the increased use of telemedicine due to COVID-19, research has indicated that patients and physicians report higher satisfaction with virtual appointments over in-person visits (Lun et al., 2020; Ramaswamy et al., 2020). Despite the challenges to virtual clinics, ABC has a strong telehealth system that could easily provide the platform needed to support this follow-up clinic. The investigator therefore recommended the ICU follow-up clinic be offered in a telehealth format. Utilizing a telehealth clinic would eliminate the need for a designated clinical space and reduce initial start-up costs. While the quality of the appointment may be downgraded, patients and physicians are satisfied with the care provided during telehealth visits. Employing a virtual system would also combat the major attendance barriers that in-person clinics are facing. Additionally, participants acknowledged the value and potential a virtual clinic could have during the start-up of the ICU follow-up clinic. Clinical Team The clinical team for ICU follow-up clinics varies greatly. Johnathan Downham (2020) interviewed four rehab professionals who worked in ICU follow-up clinics. These rehab professionals had various clinic structures that included various pairings of the following professionals: physician, pharmacist, registered nurse, nurse practitioner, case manager, clinical psychologist, occupational therapist, physical therapist, speech therapist, dietitian, and pain management professional. The participants emphasized the importance of a registered nurse, nurse practitioner, case manager, clinical psychologist, occupational/physical therapist, and 20 added a need for palliative care and an ICU survivor. While each professional listed would provide beneficial care to the patients in the clinic, employing nine individuals to participate in the clinic would result in a high initial start-up cost. Therefore, the investigator reviewed each profession and its scope of practice relative to the ICU follow-up clinic. Informed by a thorough review, the clinical team would consist of four professionals that can provide the most effective and efficient follow-up clinic. These four clinical team members include a case manager, nurse practitioner, clinical psychologist, and pharmacist. The case manager would be responsible for keeping in contact with patients through the recovery process, setting up initial appointments, providing assistance with filling out screening tools if needed, and connecting patients with community resources. The nurse practitioner is responsible for reviewing screening tools, meeting with patients to discuss concerns, making appropriate referrals, and working directly with a physician. The clinical psychologist is responsible for reviewing screening tools, meeting with patients to discuss concerns, making appropriate suggestions, and potentially providing ongoing clinical care. The pharmacist is responsible for reviewing screening tools, reviewing patients current medications, and providing appropriate prescription modifications. The case manager would be in contact with the from discharge until one year post discharge. The case manager would set up the appointments and connect the patient with community resources. Once at the appointment the patient would first be seen by the clinical psychologist who would further explain the purpose of the clinic and review their screening tool relevant to mental health concerns. The psychologist can provide resources for the patient and even continue to provide continued clinical services to the patient if they are interested. The patient would then be seen by the nurse practitioner who would review their screen tools and 21 address any medical concerns they have and provide necessary referrals. The pharmacist would then review the patients medications and address any concerns they may have. The case manager would continue to follow up with the patient to ensure they attend future appointments and receive the suggested care. Outcome Measures Competent screening tools can act as outcome measures which are needed to appropriately assess the clinics impact on the patient and the facility (Feemster et al., 2015). The following outcome measures have been used to assess the effectiveness of ICU follow-up clinics: Hospital Anxiety and Depression Scale (HADS), Impact of Events Scale-Revised (IES-R), Health-related quality of life (HRQoL), 5D Euro-Quality of Life (EQ-5D-5L), Montreal Cognitive Assessment (MOCA), Short-Form of Health Survey Questionnaire (SF-12), Barthel Index, and Functional Activities Questionnaire (FAQ). A table outlining each tool, its purpose, and time to complete is found in Table 2. The components of the outcome measure and its length should be considered when assessing this population. PICS has a significant impact on cognitive functioning (Heydon et al., 2020; Mayer et al., 2020), and this cognitive impact should be considered when assessing appropriate outcome measures to avoid cognitive fatigue during screening. One participant requested that the outcome measure is simple and contains mental health screening. Another participant suggested that patients have an option to complete the screening tools with a professional to ensure the patients comprehension of the tool. The sensitivity and comprehensiveness of the outcome measure is vital to properly assessing outcomes. A participant suggested that the screening tools should be comprehensive so that the clinical team can gather plenty of information in a short period of time. The 22 comprehensiveness of the tool may affect the quality of outcomes. There are some studies that show that ICU follow-up clinics are not effective in improving quality of life. However, these studies lack of evidence may be due to the sensitivity of their outcome measures (Jensen, 2015). Therefore, there is a need for an ICU specific quality of life outcome measurement that can appropriately address the distinct needs of ICU survivors (Jensen, 2015). Until an ICU survivor specific measure is created and validated, an effective, accessible, and comprehensive outcome measure must be used. The effective, accessible, and comprehensive assessment to be utilized in the clinic is the Short Form 36 (SF-36). Before the appointment, patients would complete the SF-36, compile a list of the medications they are taking, and describe any current major quality of life complaints. This SF-36 would act as the screening tool and outcome measure. The SF-36 is a tool that is appropriate for a wide variety of diagnoses and measures health-related quality of life (SRAL, 2015). The SF-36 consists of 8 subscales including physical functioning, role limitation due to physical problems, role limitation due to emotional problems, general health perceptions, vitality, social functioning, general mental health, and health transition (SRAL, 2015). The SF36 would be completed once before the appointment and one year later. The demographics of the patients and outcome measure scores would be compared to measure the impact of the clinic. The outcome data should be reviewed annually to assess the purpose and direction of the clinic. Eligibility Unfortunately, it is not cost-effective to follow-up every patient that admits to the intensive care unit (Teixeira & Rosa, 2018). There are no agreed-upon eligibility criteria for the patients who would receive treatment from ICU follow-up clinics (Ranzani & Jones, 2015). Typically, the eligibility for each clinic is determined by days of mechanical ventilation and/or 23 days spent in the intensive care unit. Approximately 15-20% of ICU patients are mechanically ventilated for 48 hours or more (Teixeira & Rosa, 2018). However, the most debilitating deficits are noted in patients mechanically ventilated 96 hours or more (Cox et al., 2010). Two participants expressed that 48 hours or 72 hours of mechanical ventilation was appropriate for the initial inclusion criteria and suggested that inclusion criteria could change based on needs and outcomes. Those who are mechanically ventilated for 48 hours or more would be referred to the ABC ICU follow-up clinic. These patients would be educated about the clinic prior discharge from the hospital. The clinic would take place bi-monthly in the afternoon with the hopes that it can serve all referred patients and utilize current employees to staff the clinic efficiently. Limitations The main limitation of this feasibility study was the lack of resources and evidence based practice regarding ICU follow-up clinics. These clinics are relatively new and have recently increased in popularity due to COVID-19. Clinic team members should continue to seek out new information about follow-up clinics to ensure their clinic is consistent with evidence based practice. An additional limitation to this study is the lack of direct access to those currently working in ICU follow up clinics. The investigator made efforts to contact many individuals providing direct ICU follow-up clinic care, however, did not receive a response. Impact While the proposed clinic does not contain an occupational therapist, the clinic is based on occupation theory (AOTA, 2020). and provides indication for an emerging area of practice within occupational therapy. The investigator is educated in both occupational therapy and gerontology and utilized that background in the creation of the clinic. The investigator 24 recognized through her research that employing an occupational therapist in the initial and feasible clinic model is not warranted. However, occupational therapy for this population is warranted. Those with PICS are limited in their independence in ADLs and IADLs due to physical and cognitive limitations. Occupational therapists are vital to a patient's success during their recovery from PICS. Occupational therapists provide specific therapy to increase an individual's independence in ADLs and IADLs while considering their person, occupations, and environment. It is important that the referring provider of the ICU follow-up clinic has a strong understanding of the ability and scope of practice of occupational therapists. While the initial clinic does not indicate occupational therapy services, the recovery process for ICU survivors does. Future Implications The presentation of this clinic model is intended to provide a realistic outline for the initial implementation of an ICU follow-up clinic. As the clinic grows, in-person appointments, peer/family support groups, and ICU diaries should be taken into consideration. First, while this clinic has been outlined as a virtual clinic, there is a benefit to having the option to attend an inperson appointment. Virtual clinics do not allow for a full physical examination (Lun et al., 2020), which could be beneficial for ICU survivors. In the future, patients should be able to indicate if they would like a virtual or in-person appointment. Next, it is important to consider that anxiety, depression, and PTSD persist long after admission for a large majority of ICU survivors (Heydon et al., 2020). Experts and ICU survivors have identified support groups as beneficial for the mental health of survivors and their caregivers (Haines et al., 2019; Heydon et al., 2020; Merbitz et al., 2016). Ongoing services and outreach programs facilitated by ABC could impact patient outcomes. Lastly, ICU diaries are constructed by nursing staff while the 25 patient is in the ICU with the intention to fill in the mental/memory 'gaps' that patients experience after discharge (Halm, 2019). Diaries have shown to be the most effective intervention for improving mental health outcomes for ICU survivors (Lasiter et al., 2016). These implications should be considered as the clinic grows. Conclusion The ABC ICU follow-up clinic maximizes feasibility and is backed by evidence based practice and expert approval. The clinics purpose is to act as a referral clinic with the goal of increasing the patient's quality of life and decreasing readmission rates. Patients mechanically ventilated for 48 hours or more would be referred to the clinic. The clinical team would be made up of a nurse practitioner, clinical psychologist, pharmacist, and case manager. The clinic would be held virtually in the afternoon bi-monthly where the patient would interact with all 4 clinical team members. The impact of the clinic would be measured through the SF-36 screening tool provided to patients and through the patients compliance with referrals. The clinic is intended to provide a minimalist approach to be implemented at ABC and should be expanded upon as the clinic grows. 26 References APH Leader. (2021, January 1). Lessons learnt from COVID19: Physiotherapy special from ICU rehab to follow up [Video]. Youtube. https://www.youtube.com/watch?v=FtshKH2KH1s Bakhru, R. N., Davidson, J. F., Bookstaver, R. E., Kenes, M. T., Peters, S. P., Welborn, K. G., Creech, O. R., Morris, P. E., & Files, D. C. (2019). Implementation of an ICU recovery clinic at a tertiary care academic center. Critical Care Explorations, 1(8), e0034. https://doi.org/10.1097/CCE.0000000000000034 Belfast Health and Social Care Trust. (2020, November 9). ICU follow up clinic. [Video]. Youtube. https://www.youtube.com/watch?v=qwRSRdFthP0 Bloom, S. L. A. B., Stollings, J. L. P. F., Kirkpatrick, O. A. B., Wang, L. M., Byrne, D. W. M., Sevin, C. M., MD, Semler, M. W. M. Ms., Bloom, S. L., Stollings, J. L., Kirkpatrick, O., Wang, L., Byrne, D. W., Sevin, C. 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Improving recovery and outcomes every day after the ICU (IMPROVE): Study protocol for a randomized controlled trial. Trials, 19, 1. https://doi.org/10.1186/s13063-018-2569-8 34 Appendix A Access online at: https://drive.google.com/file/d/1przHtsz8SjuhliXWA1RPdeGje9lGRVf0/view?usp=sharing 35 36 37 38 39 40 41  ...

... Running head: DEVELOPMENT OF A CONSULTING PROGRAM Development of a Consulting Program: Improving Access to Feeding Therapy Services and Increasing Health Literacy for Caregivers of Children with Eating Difficulties Morgan Cole, OTS July 2021 A capstone project submitted in partial fulfillment for the requirements of the Doctor of Occupational Therapy degree from the University of Indianapolis, School of Occupational Therapy Under the direction of the faculty capstone advisor: Alison Nichols, OTR, OTD 1 DEVELOPMENT OF A CONSULTING PROGRAM 2 Abstract Feeding and eating difficulties can occur in typically developing children as well as children with disabilities, which can negatively impact the feeding process and increase caregiver stress. After conducting a needs assessment at Feeding Friends Childrens Feeding Clinic and Therapy Services, it was determined there was a need for increased access to feeding therapy in rural areas, as well as a need to address the lack of accessibility to feeding resources and tools. The purpose of this doctoral capstone project was to provide consultation opportunities and easier access to additional resources for caregivers living in rural areas who have a child with feeding and eating difficulties to improve health literacy and provide a better quality of life for their child(ren). The program included seven handouts, each created to meet a need discovered during the initial needs assessment. The handouts included information pertaining to oral sensory delay, oral motor delay, when to be concerned, difficulty with transitioning, a consent form, intake forms, and how to prepare for a virtual consult. A paper questionnaire was distributed to collect feedback from parents and caregivers on suggestions for the consulting branch, as well as what additional information they might find helpful regarding feeding and eating. To determine if needs were met, a pre- and post-informal interview with the co-owners of Feeding Friends was completed. To examine efficacy of the program once launched, a plan was developed and discussed with both co-owners on how to collect data and continue to gain feedback on the program. Overall, it was determined that the information provided in the consulting branch, as well as additional information had met the needs of the site and both co-owners. DEVELOPMENT OF A CONSULTING PROGRAM 3 Development of a Consulting Program: Improving Access to Feeding Therapy Services and Increasing Health Literacy for Caregivers of Children with Eating Difficulties Introduction Some form of feeding issues can be apparent in around 30% of typically developing children but can increase to 80% in children with developmental disabilities (Mascola et al., 2010). Successful treatment of feeding disorders is often dependent upon initiating a new, and positive, learning experience with eating that involves both the child and caregiver (Greer et al., 2007). Occupational therapists have had a long-standing role in the treatment of feeding and eating problems because of their importance as a primary self-care occupation, and eating is crucial to an individuals health and well-being throughout the lifespan (An, 2013). The purpose of this doctoral capstone experience (DCE) is to create a consulting branch of a pediatric feeding clinic, as well as include additional information on feeding issues, with the goal of increasing health literacy for caregivers and families of children who experience feeding and eating difficulties. Feeding and Eating Pediatric feeding disorders (PFDs) are impaired oral intake that is not age-appropriate, and is associated with medical, nutritional, feeding skill, and/or psychosocial dysfunction (Goday et al., 2019, p. 125). The International Classification of Functioning, Disability, and Health (ICF) framework considers having a holistic understanding when working with PFDs and knowing how they can impact both the psychological and functional characteristics of an individual (Goday et al., 2019). The ICF also highlights how PFDs can include impaired mechanisms, environmental barriers, and facilitators and, most importantly, the impact on participation in daily family and community life (Goday et al., 2019, p. 125). DEVELOPMENT OF A CONSULTING PROGRAM 4 In its simplest form, eating is defined as the ability to keep and manipulate food or fluid in the mouth and swallow it (AOTA, 2014, p. S19). Eating is an essential part of a humans daily occupations that begins at infancy and continues to develop throughout their lifespan (Absolom & Roberts, 2011). Feeding is described as the process of setting up, arranging and bringing food (or fluid) from the plate or cup to the mouth; sometimes called self-feeding (AOTA, 2014, p. S19). Swallowing is defined as moving food from the mouth to the stomach and goes through three phases: the oral, the pharyngeal, and the esophageal (AOTA, 2014, p. S19; Morris & Klein, 2000). For the purposes of this paper, unless otherwise specified, the process of feeding, eating, and swallowing will be referred to as eating. Eating Development The process of developing feeding skills is complex and can be influenced by many factors (Le Rvrend et al., 2014). Eating is a demanding physical task that requires involvement of all the bodys organ systems including the brain, cranial nerves, heart, skeletal muscles, and the vascular, respiratory, endocrine, and metabolic systems (Toomey, 2002). Any issues or impairments that arise involving these systems can have an impact on a childs relationship with food and mealtimes (Morris & Klein, 2000). Children require the experience and developmental readiness to advance their eating skills and once those new eating movements have developed, then they depend on sensory input from their environment, food, and the utensils used during eating tasks (Morris & Klein, 2000). There are multiple barriers that could be limiting the development of a childs feeding skills including structural, physiological, wellness, experiential, and environmental limits (Morris & Klein, 2000). Structural limitations. The development of feeding skills relies on the support from multiple interconnecting systems that each have their own structure, which in turn helps keep the DEVELOPMENT OF A CONSULTING PROGRAM 5 total system at work while eating (Morris & Klein, 2000). During the feeding process, the movement, timing, and coordination of each structure is dictated by neurological programming that is specific to that structural system (Morris & Klein, 2000). Therefore, any changes or limitations of this structural system will influence the other systems and cause problems with an individuals eating (Morris & Klein, 2000). An example of this is when an infant has a cleft lip or cleft palate resulting in an opening in their lip or hard palate, which can then cause limitations in that infants feeding patterns (Morris & Klein, 2000). Physiological limitations. During the process of chewing, multiple physiological factors influence the efficiency of a munch/chew pattern including the number of teeth the child has, occlusion contact area, bite force, ability to control masticatory muscles for efficient contraction, and control of soft tissues to manipulate the bolus and placing of bolus in occlusion area (Le Rvrend et al., 2014). The physiology of eating is also influenced by the neural, hormonal, and neurotransmitter systems that work together to control and monitor the transition of food from one system to the next (Morris & Klein, 2000). Additionally, this involves the respiratory and cardiac systems to assist with feeling comfortable and safe while eating (Morris & Klein, 2000). Aspiration is a common example of a physiological limitation that can occur during eating because it is a result of the upper channels and valves not working well to carry food from the mouth to the stomach (Morris & Klein, 2000). Another frequently seen example of a physiological limitation is gastroesophageal reflux (GER). This can result from the lower esophageal sphincter malfunctioning, which then causes the contents of the stomach to backwash into the esophagus, leading to reflux (Morris & Klein, 2000). Wellness limitations. Wellness limitations cause an individual to lack the balance between their physical, emotional, and spiritual health (Morris & Klein, 2000). These three DEVELOPMENT OF A CONSULTING PROGRAM 6 aspects of an individuals health and wellness are important because they are intertwined and influence both the individuals self-care and overall well-being (Grover, 2018). An example of a wellness limitation can be something as simple as a food or environmental allergy, which may not cause an individual to be sick, but they might not feel well due to the effect their allergy can have on other body systems like respiratory and gastrointestinal (Morris & Klein, 2000). Experiential limitations. Each individual has their own experiences relating to food, eating, drinking, and mealtimes, and some of these experiences are more memorable than others (Morris & Klein, 2000). A common negative experience that children have at a young age is the use of an orogastric or nasogastric tube for feedings (Morris & Klein, 2000). Tube feedings are invasive and can be uncomfortable for children. Therefore, when anything is approaching their nose or mouth, they sometimes determine that this is equally as threatening and uncomfortable as their tube feedings (Morris & Klein, 2000). Environmental limitations. Environmental limitations can include socioeconomic factors or mental-health factors relating to the family (Morris & Klein, 2000). Issues with poverty or inconsistency with mealtimes and caregivers often hinder a childs ability to learn valuable feeding skills (Morris & Klein, 2000). Both caregiver and child enter the feeding environment with set predispositions and abilities that build overtime with every interaction, which can have a negative effect on the childs feeding development if the environment is not consistent or stable (Davis et al., 2006). Eating Concerns Common feeding concerns that are seen during childhood include picky eating or selective eating, food refusal, manifestation of negative affect and negative behavior during eating, exceedingly slow eating, and having a tantrum or angry outbursts during mealtime DEVELOPMENT OF A CONSULTING PROGRAM 7 (Lewinsohn et al., 2005). According to Bernard-Bonnin (2006), About 25% to 40% of infants and toddlers are reported by their caregivers to have feeding problems, mainly colic, vomiting, slow feeding, and refusal to eat (p. 1248). In some cases, parents and caregivers may be unintentionally contributing to the feeding problems their child is experiencing (Lewinsohn et al., 2005). It can be difficult to identify feeding issues considering most children experience them as a result of both medical and behavioral influences (Greer et al., 2007). Impact on Caregiver and Family Feeding and eating problems are one of the most common topics parents discuss with their pediatricians (Gueron-Sela et al., 2011). Increased levels of stress on parents and caregivers can occur when their child has a feeding difficulty, which can result in a strained parent-child relationship and overall negative well-being for both the child and caregiver during their feeding process (Greer et al., 2007). Craig et al. (2003) conducted a study on parental perceptions of gastrostomy feeding and found that parents felt more at ease with this because they were assured that their child was receiving nutrients; however, other concerns were raised such as the negative impact it might have on oral feeding, the stigma around tube feeding and negative public view, possible language difficulties, and overall health and nutrition concerns. Caregivers of children with feeding concerns also feel a personal responsibility for why their child is experiencing these eating difficulties due to the fact that providing nourishment is one of the primary responsibilities for caregivers when their children are young (Craig et al., 2003). Children absorb a great amount of information when they are young, and a lot of their behaviors and actions are modeled by their caregivers behaviors and actions. Therefore, when a caregiver starts to show signs of stress or frustration during mealtime, this visible sign can cause the child to avoid meals even more and DEVELOPMENT OF A CONSULTING PROGRAM 8 continue in a negative cycle until caregivers are given direction and proper intervention for their childs feeding difficulties (Greer et al., 2007). Rural Access to Therapy When theres a lack of healthcare professionals working in rural areas, this will inevitably have an impact on the how individuals with disabilities receive therapy services, as well as how timely and effective those services are (Dew et al., 2013). Early therapy intervention has proven to be beneficial for individuals with a disability, regardless of age, and it improves family and community participation in activities to enhance quality of life (Dew et al., 2013). There are other extrinsic and intrinsic barriers affecting access to therapy services in rural areas. Extrinsic barriers may include the decreased number of community hospitals in remote areas, lack of healthcare specialists in rural areas, decreased incentives for therapists to take on work in rural areas, and rural healthcare policy (Osborne, 2008). Intrinsic barriers decreasing access to therapy in rural areas can involve the cultural perceptions an individual has about their community or personal health, geographical isolation, differences in technology access in rural areas, and an individuals lack of health insurance and low-income status (Osborne, 2008). Telehealth & Consulting According to the Institute of Management Consultancy (IMC), consulting can be defined as the service provided to business, public, and other undertakings by an independent and qualified person (Ajmal et al., 2009, p. 524). Furthermore, consulting is about developing a relationship with the client to offer expertise about a particular issue that the client is experiencing, then providing possible solutions to that problem as well as ways to adapt both the clients internal and external environment in hopes of improving their situation (Dean et al., 2011). Telehealth services are an efficient way for providing consultations to potential patients, DEVELOPMENT OF A CONSULTING PROGRAM 9 so they can gain easier access to care, reduce costs of services, and decrease wait times for those needing immediate therapy services (Renda & Lape, 2018). During therapy sessions, it is important to find what is motivating for each individual client and take that into consideration when using telehealth and a technology design (Burridge et al., 2017). The application of virtual services is continuing to expand with the changing trends in how individuals have access to healthcare including user preference, managing acute and chronic conditions at the right time and place, the movement of care from hospitals to the patients home setting, and the use of mobile devices (Burridge et al., 2017). The key to an effective consultation is a shared commitment to change between the client/caregiver and the consultant, and what that change process entails (DeBoer, 1986; Jaffe & Epstein, 1992; Murray et al., 1993; Rainville et al., 1996). Occupational Therapys Role Occupational therapy (OT) practitioners have advanced knowledge in activities of daily living (ADL) such as an individuals ability to participate in eating (AOTA, 2017). Occupational therapists have the ability to provide comprehensive management of eating problems, as well as provide interventions that focus on facilitating an individuals participation in eating that often involves both the individual and their family or caregiver (AOTA, 2017). OT practitioners are distinctively qualified to address eating difficulties because they look at not only the physiological factors, but also the psychosocial, cultural, and environmental factors involved with these aspects of daily performance (AOTA, 2017, p. 1). Methods Project Site Feeding Friends Childrens Feeding Clinic & Therapy Services is a privately co-owned outpatient pediatric clinic in Indianapolis, Indiana that began providing services in May of 2007 DEVELOPMENT OF A CONSULTING PROGRAM 10 (Find Health Clinics, n.d.). The clinic moved to its current location off of Binford Avenue in 2016. The clinic provides developmental therapy, occupational therapy, physical therapy, and speech therapy through outpatient and early interventionlocally called First Stepsservices. Feeding Friends is one of the premier feeding programs in the greater Indianapolis area and strives to provide therapy services to children of all ages through one-on-one and small group settings (Feeding Friends, 2020). For the remainder of this paper, Feeding Friends Childrens Feeding Clinic & Therapy Services will be referred to as Feeding Friends unless otherwise specified. The OT department at Feeding Friends consists of twelve occupational therapists, all of whom are passionate about providing services to kids and utilizing their own unique treatment styles and various experiences to do so. There are a total of ten speech therapists (STs) working for Feeding Friends who are equally passionate about providing speech therapy to kids. Approximately eighty percent of the kids on the OT caseload at Feeding Friends are being treated for eating difficulties, which includes a variety of diagnoses and conditions at various age ranges. Around sixty percent of the kids on the speech caseload are being treated for eating difficulties. Each OT and ST eating appointment is generally one to two times a week depending on the severity of the eating issue, and last anywhere between 30 and 60 minutes. Typically, children are seen by one therapist; however, some sessions may overlap with other treating therapists. Purpose My primary focus was to develop a program that included consulting and what that entails for Feeding Friends, as well as additional information regarding feeding and eating, to improve health literacy for caregivers and provide a better quality of life for their child(ren). This DEVELOPMENT OF A CONSULTING PROGRAM 11 includes developing a business model with what consulting will look like for Feeding Friends in terms of the delivery, approach, frequency of meetings, allocating time for payments, and more. Additional information will be made available through the Feeding Friends website that includes handouts, feeding tools and devices, professionals typically worked with, and support groups. The purpose of this doctoral capstone project was to provide consultation opportunities and easier access to additional resources for caregivers living in remote and rural areas who have a child with feeding and eating difficulties to help guide them through this process, help them understand what their options are, and let them know that they are not alone. Theoretical Framework The approach of this consulting branch of Feeding Friends is guided by the PersonEnvironment-Occupation-Performance (PEOP) model, including Niklas Luhmanns social systems theory, as well as the sensory integration (SI) and behavioral frames of reference. Person-Environment-Occupation-Performance model. Feeding and eating difficulties are often a result of the childs characteristics (physiological, psychological, sensory-perceptual) the childs environment (internal and external), and the caregivers involved. The PersonEnvironment-Occupation-Performance (PEOP) model demonstrates how the interaction between a persons abilities, the environmental factors involved, and the task demands of certain occupations have a direct influence on performance outcomes (Cole & Tufano, 2008). The PEOP model has a client-centered focus on occupations (valued roles, tasks, and activities) and performance (Cole & Tufano, 2008). This model uses the top-down approach and can assist therapists with identifying enablers and barriers to an individuals occupational performance and participation (Wong & Fisher, 2015). DEVELOPMENT OF A CONSULTING PROGRAM 12 Understanding the interaction between a childs abilities, the environmental factors, and the demands of the task during eating, as well as identifying where there are barriers to successful performance or participation can then be addressed in the intervention process and help enhance the childs role functioning (Cole & Tufano, 2008). For example, for some toddlers, its not the type of food thats causing an eating issue, but rather the size or portion of that food and the higher demand it is requiring from that child to munch/chew and swallow successfully. The presentation of foods is extremely important to ensure the task is possible for that child, so providing smaller portion sizes, as well as smaller bites, will match the childs eating skills and remove the high physical demand of the task. Niklas Luhmanns social systems theory. Luhmanns social systems theory looks at consulting in a non-traditional way with focusing on the boundaries of communication and preventing any unintentional misunderstandings (Mohe & Seidl, 2009). Furthermore, to avoid any miscommunication, Luhmann suggests identifying one individual who is in charge of the contact system, which is the main form of communication between the client and consultant (Mohe & Seidl, 2009). Additionally, this theory utilizes a systemic consulting approach that emphasizes the importance of the client during the consulting intervention process (Mohe & Seidl, 2009). When the client is at the center of the intervention process, then they are responsible for what they decide to do with the input given to them by the consultant (Mohe & Seidl, 2009). Providing consultation options through telehealth is a non-traditional environment, and therefore requires the client to take on more responsibility with the intervention plan in order for there to be success without hands-on treatment from the consultant. Therefore, it is the consultants responsibility to focus on the client and build an effective form of communication DEVELOPMENT OF A CONSULTING PROGRAM 13 and teaching style that will best assist the client so they can have success with the intervention process. For my project, this means describing feeding and eating interventions in a way that the client understands the demands of the task, as well as providing effective examples if needed for further explanation. Following Luhmanns social systems theory, the consulting branch for Feeding Friends will include defining the specific roles of both co-owners in the communication process to ensure organization and increase the success of the session for both client and consultant. Sensory integration frame of reference. Sensory Integration (SI) is based on the way the brain receives sensory input from the environment and organizes it so that the body can respond with action (Cole & Tufano, 2008). This frame of reference is aimed at remediation of the sensory integration challenge, then improving the clients ability to integrate that sensory information by changing the organization of the brain (Cole & Tufano, 2008). Occupational therapists can use this information to develop an intervention plan by identifying the clients sensory needs or intensity of sensation that is specific to each client, then help them normalize their sensory processing needs and produce an adaptive response (Cole & Tufano, 2008). This is true for environmental adaptations as well. To begin facilitating a change for these children with eating difficulties, the OT will need to provide guided sensory input in a context that works best for each child (Cole & Tufano, 2008). For a child to be successful with eating, all the sensory systems must be integrated, as well as the lesser-known senses of balance, body awareness in space, and information received from ones joints (Toomey, 2002). For example, when a young toddler is munching/chewing table foods, their head will naturally move with every munch/chew, so its important for that child to adjust their sense of balance when munching or chewing to be successful with eating table foods (Toomey, 2002). DEVELOPMENT OF A CONSULTING PROGRAM 14 Behavioral frame of reference. The behavioral frame of reference focuses on desired behaviors through defining goals and working toward those goals utilizing skilled instruction, modeling, coaching, and behavioral reinforcement (Cole & Tufano, 2008). The best way to promote desired behaviors is through intermittent positive reinforcement (Cole & Tufano, 2008). Behavior is learned and can be remodeled with reinforcement (Cole & Tufano, 2008). For eating problems, the desired action (eating) requires shaping, which can be done by reinforcing a desired behavior continuously until the child learns the action (Cole & Tufano, 2008). For example, this can be demonstrated with a series of steps that are often used when introducing a new food to kids such as telling them to first smell it, then touch it, and so on until the child gets more comfortable with the new food, with the end goal being they eventually eat the new food. Screening and Evaluation My project began with a needs assessment at Feeding Friends. The assessment included observing multiple feeding sessions for both occupational and speech therapy, as well as conducting unstructured interviews with the speech and occupational therapists on staff in addition to the co-owners of Feeding Friends. Unstructured interviews allow for a more natural conversation than structured interviews because the questions are spontaneous and the interview relies on the social interaction between researcher and informant (Patton, 2002; Zhang & Wildemuth, 2007). Also called informal interviews, unstructured interviews provide more flexibility with questions, allow for in-depth conversation, and increase validity through a deeper understanding of the situation (McLeod, 2014). I utilized a survey methodology in the form of a paper questionnaire to collect feedback from parents and caregivers on suggestions for the consulting branch, as well as what kind of additional information they might find helpful regarding feeding and eating difficulties. This DEVELOPMENT OF A CONSULTING PROGRAM 15 method was chosen because it allowed for a cost-effective and simple process for gaining information from parents/caregivers (Picincu, 2018), and allowed for the opportunity to compare and contrast the information that was collected (Gaille, 2020). The questionnaire was developed based on findings in the literature review and therapist expertise from both co-owners who are a speech and occupational therapist. We developed questions to explore parent/caregiver views on the Feeding Friends website and if they had utilized it before, resources they wish they had access to like handouts or feeding support groups, and recommendations for the consulting branch. The caregiver questionnaire was reviewed by both co-owners before distribution. Based on their feedback, a 6-item questionnaire was finalized that included closed and open-ended questions. See Appendix A for the finalized caregiver questionnaire. The finalized questionnaire was distributed to parents/caregivers of existing eating therapy clients at Feeding Friends, ages 06 with a variety of diagnoses or impairments. Ten questionnaires were distributed, however only four contributors responded. Targeted Population There are two groups of clients that made up the DCE targeted population: the OT and speech therapists at Feeding Friends and the population of children with eating difficulties as well as their family. Results from the needs assessment identified two themes for the clients being served: the need for increased access to feeding therapy in rural and remote areas and the need to address the lack of accessibility to resources and tools through the Feeding Friends website. Implementation Phase A consulting branch of Feeding Friends, as well as additional information about feeding and eating, was developed utilizing telehealth resources created throughout the course of the DEVELOPMENT OF A CONSULTING PROGRAM 16 pandemic. Feeding Friends is looking to expand their services across the state of Indiana, specifically to rural and remote areas to address the lack of feeding services available to individuals in those areas. Part of this development includes creating and implementing handouts with valuable information on feeding and eating difficulties, as well as what to look for during the eating process and when to seek help. Developing handouts. Each handout was created after a thorough review of the literature on that specific topic and relevant information was compiled. Handout topics were decided upon based on the literature, feedback from the caregiver questionnaire, and therapist expertise. Some handouts were formed based on information and resources the speech and occupational therapists had on hand in the clinic, with certain adjustments made to fit each handouts criterion for the project. A rough draft of each handout was created, then reviewed by the occupational and speech therapist co-owners of Feeding Friends. Once the above steps were completed, each handout was re-evaluated again, first by myself and then by both co-owners. Any necessary changes were made, then the revised handouts were piloted by three caregivers who are current clients at the feeding clinic. Verbal feedback was received from all three caregivers who piloted the handouts, and possible changes were discussed among myself and the co-owners of Feeding Friends, and appropriate changes were made after the discussion if necessary. A final needs assessment was conducted to ensure the information on each handout met the needs of the co-owners and potential clients of Feeding Friends. It was determined that no additional handouts or information was needed. This was done in the form of an informal interview with both co-owners of Feeding Friends. DEVELOPMENT OF A CONSULTING PROGRAM 17 Handout details. A total of seven handouts were developed. Each handout was created to meet a need discovered during the initial needs assessment. These handouts were designed to increase health literacy and overall knowledge on feeding and eating difficulties, as well as preparation recommendations for a consultation. The handouts include information pertaining to oral sensory delay, oral motor delay, when to be concerned, difficulty with transitioning, a consent form, intake forms, and how to prepare for a virtual consult. Oral sensory delay. This handout defines oral sensory delay and what are common indicators of a sensory issue. This includes sensory avoidance and sensory seeking behaviors that can be observed during eating tasks. This handout serves to inform parents/caregivers on potential signs and symptoms of oral sensory delay. The oral sensory delay handout can be found in Appendix B. Oral motor delay. This handout defines oral motor delay and common signs to look for during eating tasks that could be indicative of an oral motor delay. It contains safe feeding practices, as well as what can happen as a result of poor oral motor skills. This includes the definitions of dysphasia and aspiration, which are two common terms associated with oral motor delay. Additionally, the handout lists common signs of swallowing problems. The oral motor delay handout serves to inform individuals on what oral motor delays could potentially look like, as well as safe ways to participate in feeding and eating tasks to decrease the likelihood of a problem with swallowing. The oral motor delay handout can be found in Appendix C. When to be concerned. This handout includes two lists of tasks and skills that a child might be struggling with or have not yet developed, which could suggest the need for therapy services. Both lists were already developed and available through the Feeding Friends website DEVELOPMENT OF A CONSULTING PROGRAM 18 under the appropriate therapy provider (occupational, speech, developmental, and physical therapy). For the purpose of this project, we are focusing on the occupational and speech therapists lists. There will be a statement included under the new additional information tab on the website about how to access these lists. The handout that outlines both lists for occupation and speech therapy can be found in Appendix D. Difficulty with transitioning. This handout discusses the correlation between a childs medical history and having trouble with the process of transitioning to new foods whether that transition is from breast/bottle to purees or purees to table foods. It includes common signs that can be observed when working on transitioning to new foods. It also has a list of strategies to attempt to increase success with transitioning. The handout for difficulty with transitioning can be found in Appendix E. Consent form. This form has already been developed for telehealth therapy utilized during the pandemic. The consent form has since been updated due to changes in the regulations regarding the use of telehealth to provide therapy services. As of June 9th, 2021, telehealth services provided by both occupational and speech therapist in the state of Indiana is now permitted. The consent form is an agreement between the therapist and client to freely discuss medical information/history during the sessions. Additionally, the consent form allows for the delivery of early intervention services virtually and that the therapist or First Steps organization is not responsible for any technical issues or security complications. The consent form can be found in Appendix F. Intake forms. The intake forms were also previously developed; however, the co-owners were in the process of revising the questions and information obtained through these forms during my DCE. These forms are given to the parent(s)/caregiver(s) before the evaluation or DEVELOPMENT OF A CONSULTING PROGRAM 19 consultation. Additionally, the forms provide the therapist with comprehensive information about the childs medical history, as well as insurance information, fee for service agreement, attendance policy, and release of information agreement. This allows the therapist to review the forms and gain some understanding of the eating difficulties the child is experiencing before the initial session, so they can ask further questions during the evaluation or consult. The revised intake forms can be found in Appendix G. How to prepare for a virtual consult. This handout includes information for the parent(s)/caregiver(s) on what to attempt before the consultation meeting, so they are better prepared, and in turn help the consult go more smoothly. This handout includes eliminating distractions, being well rested if possible before the consult, and planning the session during a time that the child typically eats a meal or has a snack. The handout regarding how to prepare for a consult can be found in Appendix H. Staff development. To ensure the staff at Feeding Friends developed a good understanding of each handout, a brief training session was held at the clinic. This session provided education and training to both the occupational and speech therapists on staff. Education included an overview of each handout and its purpose, as well as how their clients could benefit from each form. The session involved an open conversation with the therapists and answering any questions or clarifications needed. Since the staff being trained were therapists familiar with eating therapy, only one session was necessary to demonstrate sufficient staff development about the use of each handout and its overall purpose regarding feeding and eating. Additionally, the therapists who attended the session demonstrated verbal understanding of each handout at the end of the discussion. This guaranteed that the therapists had an opportunity to evaluate the handouts and DEVELOPMENT OF A CONSULTING PROGRAM 20 understand the content on each of them. Therapists were given access to the handouts through the Feeding Friends Dropbox. Administration. Administration can be defined as a process of systematically arranging and coordinating the human and material resources available to any organization for the main purpose of achieving stipulated goals of that organization (Amadi, 2008, p. 5). In other words, administration helps a business or organization achieve a set of defined objectives (Amadi, 2008). Occupational therapists as an administrator includes overseeing other occupational therapists in a department and are responsible for program planning, management, policy development and budget separation, educating the staff and clients, and personnel management (What is OT, 2021). During my doctoral capstone experience, I was able to utilize and acquire many of the traits associated with being an effective administrator to ensure the success of the program. I increased my knowledge not only in eating interventions but in program planning and development. I successfully educated the Feeding Friends staff on the purpose of each handout and benefits of the consulting branch. In addition to utilizing both co-owners of Feeding Friends, I also included the occupational and speech therapists on staff throughout the phases of this project to help contribute to the development of the program and overall goal for their business. Four additional skills that I often utilized throughout the development of the program included communication, flexibility, leadership, and organization. Communication played a major role in the development of the program, especially in the implementation phase to ensure consistency among the staff at Feeding Friends. I remained flexible with the direction that the program was going, as well as changes that were made or suggested throughout the DCE. I also DEVELOPMENT OF A CONSULTING PROGRAM 21 demonstrated flexibility regarding meeting times with the co-owners and staff at Feeding Friends, since their schedules are all different and they change frequently in an outpatient setting. I conducted an educational training session for the staff demonstrating the value and importance of the program, as well as the handouts. My leaderships skills were tested due to the everchanging schedules of the co-owners and staff and having to take initiative to establish times to discuss the program. I stayed focused and organized throughout the DCE and program development, which gave me the chance to make the most of my time when I had the opportunity to discuss topics with the co-owners or other staff. All of these skills and traits allowed me to effectively assume the role of an administrator and successfully implement the consulting branch, as well as additional information on feeding and eating. Results Program Evaluation Once each problem had been identified and addressed during the implementation phase, I began to evaluate the program. I repeated an informal interview with the co-owners of Feeding Friends to discuss the finalized product and ensure the materials included in the program met the needs of both clients. Additionally, a plan was developed and discussed with the co-owners on how to assess efficacy of the program once implemented. Project outcomes. After conducting the final informal interview, it was determined that the information had met the needs of the site and both co-owners. This included an easy way to sign up for a consult either virtually or in person with one of the co-owners, forms and handouts with important information regarding feeding and eating difficulties, how to prepare for a virtual consult, feeding support groups, feeding devices/tools with picture examples and the resources that the Feeding Friends typically uses to find those devices/tools, and a statement about the DEVELOPMENT OF A CONSULTING PROGRAM 22 importance of teaming and a list of healthcare professionals that Feeding Friends typically works with. Since Feeding Friends will be implementing the program after Im no longer on site, both co-owners have been educated on how to examine efficacy of the program once implemented. First, we discussed possible ways to collect data on the new sections of the website once it is launched. This included setting up a way to monitor how many people access either the additional information or the consulting branch on the website. By doing this, it would allow the co-owners to keep track of the number of views that occurred on those two tabs. Additionally, the co-owners plan to record the number of consults they accumulate through the website and whether the consult was virtual or in-person. Collecting this data will help determine the effectiveness of the program and if it is expanding Feeding Friends business. Next, a trial run of the new Feeding Friends website was discussed and agreed upon. The co-owners plan to utilize two of the four caregivers who responded to the caregiver questionnaire and have them perform the trial run of the new website, as well as two of the therapists on staff at Feeding Friends. This ensures that both targeted populations will review the information before it is launched and address any final concerns or suggestions that they might have. There is also a plan to develop a handout for potential clients to fill out before a consultation along with the consent form and intake forms. This handout would ask for brief information such as name, date of birth, contact information, diagnosis, reason for referral, other services being received or have received, do you want the consult to be virtual or in-person, and how did you hear about Feeding Friends. Again, by asking how these individuals heard about Feeding Friends, this would allow for the co-owners to see the most consistent way that caregivers and families are seeking therapy services from DEVELOPMENT OF A CONSULTING PROGRAM 23 Feeding Friends. Whether its from the website, a physician, word of mouth, Facebook, or other resources. Societal Need Around 25% to 40% of infants and toddlers are reported by their caregivers to have feeding problems such as colic, vomiting, slow feeding, and refusing to eat (Bernard-Bonnin, 2006). Through my DCE, I address the societal need regarding the lack of access to feeding therapy services and how that is impacting both the child and caregiver or family. I addressed this need through the development of a consulting branch, as well as including additional information on feeding and eating. I created handouts to educate caregivers and provide assistance to therapists during their feeding intervention process, as well as assist caregivers in preparation for a virtual or in-person consultation. All of this will help increase health literacy and overall knowledge on feeding and eating difficulties. Ideally, this will provide easier access to feeding therapy services and decrease the effects that eating difficulties can have on both the child and the caregiver/family, therefore reducing the societal challenge of pediatric feeding disorders (PFDs). Quality Improvement To ensure quality improvement of the project was sustained, continuous adjustments and evaluations were completed throughout each phase of the DCE. During the evaluation phase, both the Feeding Friends staff and caregivers of clients were encouraged to discuss what their needs were and any suggestions regarding the consulting branch or additional information that was going to be added to the Feeding Friends website. After completion of the evaluation phase, a few minor suggestions were discussed and implemented during the implementation phase. This included the possibility of holding group feeding therapy opportunities in a central location for DEVELOPMENT OF A CONSULTING PROGRAM 24 the individuals in remote and rural areas, in order to capture more people at one time. The implementation phase continued with no other issues identified. After evaluating the program again, I met with the co-owners of Feeding Friends one final time to ensure no further issues arose and all suggestions had been addressed; no additional issues were identified. Sustainability Sustainability of the program is probable given that both co-owners and the additional occupational and speech therapists on staff are familiar with virtual sessions and have been using telehealth services for over a year now. Additional steps have also been taken to ensure sustainability such as completion of the training session on the handouts prior to implementation of the program to warrant consistency among therapists. Electronic versions of the handouts will be available through the Feeding Friends Dropbox, also a hardcopy version of each handout is available in the staff office to all therapists at the clinic. Copies of those handouts can be made as needed. By providing possibilities on how to examine efficacy of the program once it is launched, this further assists with sustaining the program after I am no longer on site. Discussion and Overall Learning During my entire doctoral capstone experience I gained a great deal of knowledge and experience that will help me become a better future OT practitioner. This includes learning how to develop and implement a program successfully, as well as advancing my clinical skills. I have expanded my knowledge regarding pediatric occupational therapy, specifically related to children with eating difficulties. I was able to learn new strategies when addressing difficult child behaviors, also methods to use when involving the caregiver(s)/parent(s) in the intervention process or treatment session. Additionally, I was exposed to a variety of diagnoses and DEVELOPMENT OF A CONSULTING PROGRAM 25 impairments and developed a better understanding of how that might affect a childs oral motor development or eating habits. In addition to increasing my knowledge base, I have been able to grow professionally as well. I was able to observe flexibility during a treatment session and with daily scheduling. I watched the benefits of teamwork among co-workers, as well as working with additional healthcare professionals to provide the best care for each child. Additionally, I witnessed effective communication, the importance of evidence-based practice, and the value in building rapport. Many of these experiences work hand in hand together to create a positive work environment and accomplish tasks. Effective Communication Throughout my DCE, I had multiple opportunities to observe and interact with other healthcare professionals in addition to the clients I worked with. Particularly in a healthcare setting, working together with an interprofessional team allows for different perspectives and different aspects of health to provide the best treatment plan for the client (Eaton et al., 2017). Effective communication is a critical part of obtaining success and reaching the desired goal(s) when working with members of an interprofessional team (Shoham et al., 2016). I was able to engage in written communication, as well as verbal and nonverbal communication during my doctoral capstone experience. Additionally, it was important for me to stay aware of my body language and how I was stating things during verbal communication to ensure I was remaining professional, and my demeanor was true to what I was attempting to communicate. Occupational therapists need to have good communication to ensure patient satisfaction, adherence to treatment, and an overall positive health outcome (Borghi et al., 2016). For example, an occupational therapist can utilize their questioning skills to build an occupational DEVELOPMENT OF A CONSULTING PROGRAM 26 profile for that client, which includes acquiring information about the clients medical history, daily activities they participate in, what interests and values they have, what does their support system look like if they have one, and what are their desired goals or outcomes for therapy. Completing an occupational profile is an important part in creating an effective treatment plan/intervention for the client. Building rapport is another important aspect when working in a professional health setting because it creates a sense of trust between the therapist and client. Therefore, occupational therapists need to utilize good communication skills in order to build that rapport and develop a healthy relationship with the client (Price, 2017). In a pediatric setting, it was not only important for me to build rapport with the clients that I was seeing, but also with their caregiver(s). A lot of the children I was working with were too young or sometimes unable to communicate their experiences with me, so I needed to be able to effectively communicate with their caregiver to gain that information and understand what goes on in that childs daily life. Overall, there were three key parts of communication that I learned and was able to further develop during my doctoral capstone experience. First, I realized the importance of good verbal and non-verbal communication when interacting with others such as an interprofessional team, the client, or the clients caregiver(s). This will also assist in building a positive relationship during the therapy process and allow for optimal treatment and intervention. Second, building confidence when speaking to others can lead to better confidence overall in both my communication skills and therapeutic knowledge, which allows me to feel confident when sharing my ideas and thoughts about a client. I will continue to improve in this aspect through practice. And third, when working with other healthcare professionals and participating in collaborative work, this can help produce the best treatment plan and outcomes for the client. DEVELOPMENT OF A CONSULTING PROGRAM 27 Development of Leadership and Advocacy Skills I have utilized and developed many professional, leadership, and advocacy skills throughout the different stages of this DCE. Leadership skills. I was able to increase my knowledge and experience regarding eating difficulties, development and implementation of a program, and increasing my communication skills. By taking on the role of a leader in certain aspects of this doctoral capstone experience, I was able to self-direct myself and further develop my confidence and initiation skills. I improved my collaboration skills with other disciplines including physical therapists, speech therapists, and developmental therapists by communicating with them outside of therapy sessions. Additionally, I increased my knowledge and experience with professional writing and research. By continuing to grow and develop my leadership skills, among other skills, I will develop into a better future OT practitioner. Advocacy skills. According to the third edition of the Occupational Therapy Practice Framework (OTPF), Occupational therapy practitioners can indirectly affect the lives of clients through advocacy (AOTA, 2014, S11). Advocacy supports health, well-being, and occupational participation at the individual or systems level (AOTA, 2014, S30). During this DCE, I had the opportunity to advocate for the OT profession, my clients at Feeding Friends, my program development, and myself. When advocating for the OT profession, this included educating the clients families, as well as the staff at Feeding Friends. I was able to educate both parties on the purpose of OT, especially when addressing feeding and eating. This helped me gain experience with advocating, which allowed me to better describe the OT profession and enhance my explanation after each discussion. DEVELOPMENT OF A CONSULTING PROGRAM 28 I advocated for my clients at Feeding Friends, including those who were experiencing eating difficulties and those who were not. I educated and collaborated with clients and their families to ensure the best care was provided and everyones goals were being met. Additionally, I provided education to families and caregivers on how they can advocate for their child(ren) to receive the benefits and accommodations that are available to them in order to improve their participation in occupations. This included discussing possible equipment and tools available to them, community-based services available where they lived, and insurance benefits/restrictions. Although I did not have the opportunity to discuss the impact of eating difficulties with the public, I often discussed the topic with caregivers during sessions or in between sessions whenever the topic was brought up. In addition to some of the handouts that were developed regarding oral sensory delay, oral motor delay, when to be concerned and seek a referral to therapy, and difficulty with transitioning are all ways to increase advocacy and awareness of eating difficulties. I advocated for the consulting program, along with additional information on feeding and eating, by initiating conversations with the co-owners of Feeding Friends, other staff members, and families of clients. After the program was developed, I educated both the occupational and speech therapists on the handouts developed, the purpose of the program, and how to advocate for its use. Additionally, I collaborated with the co-owners to develop a plan for implementation and examining efficacy of the program once I am no longer on site. During my doctoral experience, I had multiple opportunities to advocate for myself. I reached out to therapists about opportunities that benefit my learning experience and increase my knowledge about pediatric OT. This included observing multiple treatments and evaluations performed by different therapists including occupational, speech, and developmental therapists. I DEVELOPMENT OF A CONSULTING PROGRAM 29 had the opportunity to observe a different setting that incorporated equine-assisted therapy, which involved activities with horses. Advocating for myself allowed me to grow professionally and further develop my leadership, communication, and advocacy skills. I also encountered barriers to my growth and development of these skills, however, I was able to overcome those barriers to complete my program and become a better professional and future OT practitioner. Summary Throughout my experience at Feeding Friends, I was able to accomplish many things. This includes evaluating, interpreting, and resolving some of the needs of Feeding Friends by creating a consulting program that can be easily implemented and maintained once I am no longer at their site. I was able to gather additional information for the Feeding Friends website, which included developing relevant handouts, providing suggestions for eating devices/tools as well as the links for where you find those devices/tools, and specify feeding support groups in and around Indianapolis. I also expanded Feeding Friends eating therapy opportunities and increased health literacy for potential feeding clients. I have developed many skills and abilities during this DCE experience and have grown both professionally and as a future OT practitioner. I have advanced my clinical skills and experiences through this DCE opportunity and feel that it has not only helped me prepare to become an occupational therapist but has also allowed me to grow as an individual. DEVELOPMENT OF A CONSULTING PROGRAM 30 References Absolom, S., Roberts, A. (2011). Connecting with others: The meaning of social eating as an everyday occupation for young people. Journal of Occupational Science, 18(4), 339-346. 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International Journal of Telerehabilitation, 10(1), 3-14. doi: 10.5195/ijt.2018.6244. Shoham, D. A., Harris, J. K., Mundt, M., & MCGaghie, W. (2016). A network model of communication in an interprofessional team of healthcare professionals: A cross-sectional study of a burn unit. Journal of Interprofessional Care, 30(5), 661-667. doi: 10.1080/13561820.2016.1203296 Toomey, K. (2002). Feeding strategies for older infants and toddlers. Pediatric Basics, 311. DEVELOPMENT OF A CONSULTING PROGRAM 35 What is OT? (2021, March 12). The University of Tennessee Health Science Center. Retrieved from https://www.uthsc.edu/health-professions/occupational-therapy/about/what-isot.php#:~:text=Occupational%20therapists%20in%20the%20administrator,profit%20shel ter%20for%20the%20homeless. Wong, S. R. & Fisher, G. (2015). Comparing and using occupation-focused models, occupational therapy in health care. Occupational Therapy in Health Care, 29(3), 297315. doi: 10.3109/07380577.2015.1010130 Zhang, Y. & Wildemuth, B. M. (2007). Unstructured interviews. The University of Texas School of Information, University of Texas at Austin. Retrieved from https://www.ischool.utexas.edu/~yanz/Unstructured_interviews.pdf DEVELOPMENT OF A CONSULTING PROGRAM Feeding Friends 36 Appendix A Finalized Caregiver Questionnaire Childrens Feeding Clinic and Therapy Services, Inc. Phone (317) 284-1166 --- Fax (317) 284-1559 --- Email: feedingfriends@hotmail.com Caregiver Questionnaire Feeding Friends is looking to expand their services across the state of Indiana, specifically to rural and remote areas. Theres a lack of healthcare professionals working in rural areas and this is negatively impacting how individuals receive therapy services, as well as how timely and effective those services are. Feeding Friends plans to create a consulting branch for individuals seeking a consult for feeding and eating difficulties. Additionally, we are trying to grow our website by including additional information on feeding equipment, handouts, and update our annual paperwork. Feeding Friends values any feedback or recommendations regarding our website, annual paperwork, and future consultation branch. 1. Have you used the Feeding Friends website before? If so, what did you like about it? Any recommendations for the website? 2. Are there any handouts regarding feeding information that you wish you had access to? 3. Would you benefit from having additional information about common adaptive equipment/devices used with feeding difficulties, as well as the resources where you can obtain that equipment? 4. Would you like information on feeding support groups? If you already utilize a feeding support group, if you dont mind sharing, which one(s)? 5. Do you know anyone who would benefit from a consultation from Feeding Friends but cannot complete the consult at the clinic due to distance, medical concerns, etc.? 6. Is there any advice you could provide for the consulting branch if you needed services but did not live in the area or could not come in person? DEVELOPMENT OF A CONSULTING PROGRAM Feeding Friends Appendix B Oral Sensory Delay Handout Childrens Feeding Clinic and Therapy Services, Inc. Phone (317) 284-1166 --- Fax (317) 284-1559 --- Email: feedingfriends@hotmail.com Oral Sensory Delay The mouth tissues perceive sensory information such as the taste, temperature, and texture of food. Some children can have a feeding aversion to how foods feel or taste. Common Signs of Oral Avoiding Behaviors - Refusing entire categories of food - Avoids certain texture of foods - Difficulty with new foods - Gags, chokes or drools often - Difficulty using a straw - Refusing to eat foods that touch - Refusing to touch or explore foods - Crying during mealtimes Common signs of Oral Seeking Behaviors - Strong brand preference - Craves certain foods - Prefers spicy or hot foods - Bites frequently - Bites/Chews nails - Mouths non-food items - Chews furniture, toys, pencils, etc 37 DEVELOPMENT OF A CONSULTING PROGRAM Feeding Friends 38 Appendix C Oral Motor Delay Handout Childrens Feeding Clinic and Therapy Services, Inc. Phone (317) 284-1166 --- Fax (317) 284-1559 --- Email: feedingfriends@hotmail.com Oral Motor Delay The suck-swallow-breath pattern in infants may be poorly developed. Muscles of the tongue, jaw and lips may be weak with underdeveloped chewing patterns. Common Signs of Oral Motor Delay - Poor lip closure or latch - Weak sucking/chewing skills - Overstuffing/pocketing food - Limited tongue movement - Immature chewing pattern - Difficulty transitioning from bottle to table foods - Coughing or choking - Low intake of food (child may not consume enough calories because it takes so long to eat) Safe feeding practices A swallowing problem means that one or more of the phases of swallowing are not functioning well, also call dysphagia. Dysphagia can interfere with a safe swallow which can cause aspiration. Aspiration is the term used to describe food or liquid entering the airway. Most often, when aspiration occurs you will see the following signs. However, a child can silently aspirate (fluid/foods going into the lungs without coughing or choking) Common signs of Swallowing Problems - Coughing during and following eating/drinking problems - Unexplained low-grade fevers - Sneezing following eating - Reoccurring respiratory infections and/or pneumonia - Choking during mealtimes - If infant, bottle or breast refusal, pulling away from nipple - Noisy or wet upper airway sounds and/or poor voice quality (hoarse, weak, wet) during and following eating/drinking - Difficulty with food transitions (puree to solids) - Poor saliva control - Poor chewing skills - Multiple swallows to clear bolus (residue left on posterior portion of tongue) - Poor weight gain - Nasal regurgitation DEVELOPMENT OF A CONSULTING PROGRAM 39 Appendix D When to be Concerned Handout When your child might need to be referred to Occupational Therapy. Fine Motor/Gross Motor/Play Skills If your child is only using one hand to complete tasks If your child is not being able to move/open one hand/arm If your child is uncoordinated or displays jerky movements during activities If your child is over or under-shooting the intended object when reaching If your child is not using the appropriate force to complete a task (too rough/gentle) If your child has fisted hands past 6 months If your child is not bringing hands to midline by 10 months of age If your child is not releasing an object deliberately by 12 months of age If your child is not scribbling on paper by 15 months of age If your child is not imitating writing lines by 26 months of age If your child is not using scissors by 30 months of age If your child is not able to dress themselves by 4 years of age If your child has difficulty engaging in this tactile play If your child is constantly in motion If your child is fearful of movement If your child covers their ears to avoid sound If your child likes to crash into or push objects, furniture, and other people If your child is not able to feed themselves with their fingers or with a spoon by 12 months of age When your child might need to be referred to Speech Therapy. Receptive (understanding of language) Your child does not respond to their name Your child does not follow age-level directions (1 step 18-24 months, 2 step related 2430 months, 2 step unrelated 30-36 months) Your child does not identify body parts or common objects/pictures Your child has limited play with toys Expressive (spoken language) Your child does not babble or jabber (0-18 months) Your child is not able to combine words in phrases (24-36 months) Your child uses words and/or phrases but is not functional in their language use Your child has a limited use of actions, adjectives and pronouns (27-36 months) Your child expresses extreme frustration or negative behavior DEVELOPMENT OF A CONSULTING PROGRAM 40 Articulation/Speech (how clearly your child is understood) Your child uses the same sound attempt for most words Your child demonstrates labored speech or will grope for words Your child has a limited ability to combine syllables in words/phrases Your child is unintelligible (24 months 50%, 36 months 80%) Your child has delayed age-level sounds (p/b/m/n/t/d/h/w/y) Your childs vocal quality is nasally or raspy Orally Your child drools a lot, shirt is wet, need to keep a bib on your child during non-mealtime Your child keeps his/her mouth open (mouth breather) DEVELOPMENT OF A CONSULTING PROGRAM 41 Appendix E Difficulty with Transitioning Handout Feeding Friends Childrens Feeding Clinic and Therapy Services, Inc. Phone (317) 284-1166 --- Fax (317) 284-1559 --- Email: feedingfriends@hotmail.com Difficulty with Transitioning Infants and children with a history of gastrointestinal difficulties (reflux, constipation, delayed gastric emptying), food allergies, and/or developmental delays may experience increased difficulty transitioning from breast/bottle to purees and table foods. Common Signs of Problems with Transitioning: - Refusing the spoon - Immediately spitting food out - Etc. Try These Strategies: - Use spoon to present a preferred food (applesauce, yogurt) - Use spoon to stir or draw with a puree on tray or table; encourage imitation - Allow time for child to get comfortable with the puree and interact with spoon and/or puree before presenting a bite - Present the spoon to lips and keep it there until child open mouth for it - Remain calm and use a soothing voice; limit verbal cues and and use brief statements like bite or more yogurt - Provide praise after taking a bite, opening mouth, etc. whether it was independently taken or adult led - Keep mealtimes fun! - Allow for messy play with food as this helps with sensory development and to prevent oral aversion - Limit cleaning of the face and avoid scraping lips with the spoon to clean off excess food DEVELOPMENT OF A CONSULTING PROGRAM Feeding Friends Appendix F Consent Form Handout Childrens Feeding Clinic and Therapy Services, Inc. Phone (317) 284-1166 --- Fax (317) 284-1559 --- Email: feedingfriends@hotmail.com 42 DEVELOPMENT OF A CONSULTING PROGRAM Feeding Friends 43 Appendix G Intake Forms Childrens Feeding Clinic and Therapy Services, Inc. Phone (317) 284-1166 --- Fax (317) 284-1559 --- Email: feedingfriends@hotmail.com Section I: Patient Information Date______________ Name: _____________________________________________ Prefer to be called: __________________________ Phone: (______) _________________ Date of Birth: _______________ Primary Address: _____________________________City:_______________State:_________Zip_____________ Secondary Address: __________________________________City:_______________State:_________Zip_______________ Child Resides with: _____ Both Parents _____ One parent (please name:________________________) Person to contact in case of emergency: ___________________________________ Phone: ___________________ Email Address: __________________________________________ Primary Physician: ______________________________ Phone: (______) ________________ Section II: Insurance Information Policy Holder: _______________________________DOB:_______________Relationship to Patient: ________________ Address: ________________________________________City:_______________State:_________Zip:_______________ Social Security # ________________________ Name of Employer: _______________________ Insurance Company: _____________________________ Insurance Co. Phone: _____________________________ ID#:_________________________ Group #:______________________ Plan/Program Name: ______________________ ------------ DO YOU HAVE ANY ADDITIONAL INSURANCE? Yes No IF YES, COMPLETE THE FOLLOWING Name of Insured: ____________________________ DOB: _______________ Relationship to Patient: ________________ Address: _________________________________________City:_______________State:_________Zip:_______________ Name of Employer: ____________________________________________ Insurance Company: _____________________________ Insurance Co. Phone: _____________________________ ID#:_________________________ Group #:______________________ Plan/Program Name: _____________________ Parent/Guardian 1. Name: _________________________________________ Relationship to Patient: __________________ DOB: ________________ Social Security #: ______________________ Address: _______________________________________ City: ____________________ State: _______ Zip: ___________ Phone: ________________________________ Email address: _____________________________ 2, Name: _________________________________________ Relationship to Patient: __________________ DOB: ________________ Social Security #: ______________________ Address: _________________________________________ City: ____________________ State: _______ Zip: _________ Phone: ________________________________ Email address: ____________________________ DEVELOPMENT OF A CONSULTING PROGRAM Section III: 44 Medical Release of Information The above information is true to the best of my knowledge. I authorize my insurance benefits to be paid directly to Feeding Friends, Inc. I understand that I am financially responsible for any balance. I also authorize Feeding Friends, Inc. or the insurance company to release any information required to process my claims. Insurance Subscribers Signature: __________________________________ Date: ____________________ HIPAA/FERPA HIPAA is a Federal law that requires companies to maintain strict confidentiality for client information specifically the clients private health information (PHI). I have reviewed and understand Feeding Friends Inc.s HIPAA policy, including how my PHI may be shared, stored, and displayed. I understand my HIPAA rights. Insurance Subscribers Signature: __________________________________ Date: _______________________ FERPA is a Federal law that protects the privacy of student education records and gives parents certain rights with respect to their childrens education records. Since we often receive education documents, we are required to protect these documents as well. I understand my FERPA rights. Insurance Subscribers Signature: __________________________________ Date: _______________________ I have read HIPAA and FERPA; however I choose to waive my rights and continue to allow Feeding Friends Inc. to access all medical records of the above patient. Insurance Subscribers Signature: __________________________________ Date: _______________________ Fee for Service Agreement This agreement stands between Feeding Friends Childrens Feeding Clinic and Therapy Services, Inc. and the patient listed below for the duration of the current year. Please initial by each line to indicate understanding and agreement. _____Feeding Friends Childrens Feeding Clinic and Therapy Services, Inc. will assist the patient in the filing of insurance claims if we are in-network with the provider. Please remember the only services eligible for insurance reimbursement are occupational/physical/speech and language therapies. Unfortunately, developmental therapy is ineligible for insurance reimbursement. _____It is understood by both the insurance subscriber and Feeding Friends Childrens Feeding Clinic and Therapy Services, Inc. that if the therapy fees are not covered under the patients insurance plan, the insurance subscriber will be responsible for payment of these service fees. As a reminder, the patients family is responsible for monitoring the number of visits allowed per coverage year and must notify their therapist AND the front office immediately if the limit has been exceeded to discuss continuing services. DEVELOPMENT OF A CONSULTING PROGRAM 45 ____We will file your therapy services through Medicaid if we have received your insurance information to complete an authorization. You are responsible for notifying Feeding Friends if you are using Medicaid insurance in other therapy locations. Medicaid will often not pay for multiple therapy sites for the same service. If Medicaid does not cover your claims, you will be responsible for payment of these fees. ____We will continue to use telehealth services as appropriate. Insurance companies vary with their allowance of these services. We will work with you to determine if your insurance company will allow telehealth. Families are responsible for payment if the telehealth services are not covered. ____The insured will be responsible for notifying Feeding Friends Childrens Feeding Clinic and Therapy Services, Inc. when there is a change in insurance coverage. If new insurance information is not provided in a timely manner, the family will be responsible for unpaid services due to lack of timely filing. Per our contracts with our insurance companies, we must submit claims within 30 days. In addition, families will be charged $20.00/claim if we must refile claims due to new coverage. Parent Signature/Date: ____________________________________________________________________ Childs Name___________________________ DEVELOPMENT OF A CONSULTING PROGRAM 46 Feeding Friends Childrens Feeding Clinic and Therapy Services, Inc. Phone (317) 284-1166 --- Fax (317) 284-1559 --- Email: feedingfriends@hotmail.com Attendance Policy (CLINIC) Feeding Friends Childrens Feeding Clinic and Therapy Services, Inc. is committed to proving quality and consistent care of your child. We want your child and family to achieve the goals and outcomes that you have decided upon. In order for this to happen, we need consistent care and therapy time so that we can assist you in making these great changes in your child. Below is our attendance policy for all therapy services offered through Feeding Friends, Inc. Please initial to indicate that you understand the policy. ____If you need to cancel therapy services, we would appreciate a 24-hour notice. Although, we do understand that illnesses are unpredictable, the earliest notification possible will allow us greater flexibility in rescheduling your appointment. ____If a family cancels within 2 hours of the scheduled appointment time, this therapy visit will be considered a no show appointment. The only exception to this rule will be if your childs appointment is prior to 10 am. Three no -show appointments will lead our therapists to discharge your child from our services. ____ If a family cancels therapy without attempts to reschedule the appointment 4 times within a 3-month period, the therapist reserves the right to fill your spot and a new day and time will be assigned to you. ____If your family plans an extended time off from therapy services due to illness, hospitalization, or vacation, you will need to notify your provider. Your therapy time may not be held by the provider. ____If your therapist needs to cancel or reschedule an appointment due to illness or vacation, we will reschedule with you at a time that is convenient for both the family and therapist. If a therapist will not be able to provide services for greater than two weeks in a row, we will offer a substitution therapist to cover your childs services. Please sign below indicating that you understand Feeding Friends Childrens Feeding Clinic and Therapy Services attendance policy. ________________________________________ Parent signature and Date ________________________________________ Childs name _______________________________________ Therapist Signature and Date DEVELOPMENT OF A CONSULTING PROGRAM 47 Feeding Friends Childrens Feeding Clinic and Therapy Services, Inc. Phone (317) 284-1166 --- Fax (317) 284-1559 --- Email: feedingfriends@hotmail.com Release of Information I, _____________________ agree that Feeding Friends Childrens Feeding Clinic and Therapy Services, Inc. can relay information about my child, _____________________ in the following manner: Voice Mail Message Using the following #s: Text Message Using the following #s: Email At the following address(es): I, _____________________ agree that Feeding Friends Childrens Feeding Clinic and Therapy Services, Inc. can release information about my child, _____________________ in regards to his/her progress and skills observed by any of our therapists. Feeding Friends Childrens Feeding Clinic and Therapy Services, Inc. may establish contact with the following: Name: Phone #: 1. ____________________________________________ ______________________ 2. ____________________________________________ ______________________ 3. ____________________________________________ ______________________ 4. ____________________________________________ ______________________ (continue on the back if necessary) _______________________________________________ ______________________ Parent/Guardian Signature Date Photography Release I, ___________________________, give permission for Feeding Friends Childrens Feeding Clinic and Therapy Services, Inc.to use photographs of my child, _____________________ for the purpose of marketing both in paper publications and internet use and for the purpose of (history, journaling, scrapbook, etc.). _______________________________________________ Parent/Guardian Signature ______________________ Date DEVELOPMENT OF A CONSULTING PROGRAM 48 Feeding Friends Childrens Feeding Clinic and Therapy Services, Inc. Phone (317) 284-1166 --- Fax (317) 284-1559 --- Email: feedingfriends@hotmail.com Directions to Feeding Friends 6330 E. 75th St., Suite 206, Indianapolis, IN 46250 From Greenwood Area: 1-465 E to Shadeland Ave/ 56th Street Exit 40. Keep left to take Shadeland Ave/ 1-465 N ramp. Keep Left to merge onto N Shadeland Ave. Turn left onto E 75th Street then turn Right on Knue then Right again before the Railroad Tracks. Suite 206 will be directly in front of you. From Carmel/ Zionsville/Westfield Area: 1-465 S to 1-69 S via Exit 37A toward Binford Blvd/Indianapolis. Take a Right onto E 75th Street then Right on Knue then Right again before the Railroad Tracks. Suite 206 will be directly in front of you. From Fishers/Noblesville Area: IN-37 to 1-69 S towards Binford Blvd/Indianapolis. Take a Right onto E 75th Street then Right on Knue then Right again before the Railroad Tracks. Suite 206 will be directly in front of you. Leaving Feeding Friends heading towards Greenwood: East on E 75th Street towards Binford Blvd to Right on N. Shadeland. Keep Left for ramp for I-465 S DEVELOPMENT OF A CONSULTING PROGRAM 49 Appendix H How to Prepare for a Virtual Consult Handout Feeding Friends Childrens Feeding Clinic and Therapy Services, Inc. Phone (317) 284-1166 --- Fax (317) 284-1559 --- Email: feedingfriends@hotmail.com How to Prepare for Virtual Consult: Try to limit distractions o o o o o Put pets up Remove any additional electronics from room Set up meeting at dinner table or where mealtime typically takes place Set up in a room away from other children/siblings If needed, utilize toys that are used during mealtimes only Be well rested o Try to get a good nights rest before the consult o If possible, plan session after the childs naptime Plan the session during a time that your child typically eats a meal or snack o This will provide the greatest opportunity for the therapist to observe your childs eating habits and/or concerns  ...

... POLICY, ADVOCACY, AND DIVERSITY IN OT A Doctoral Capstone Experience with Federal Affairs at The American Occupational Therapy Association (AOTA): Policy, Advocacy, and Diversity Angella Chen August 2021 A research project submitted in partial fulfillment for the requirements of the Doctor of Occupational Therapy degree from the University of Indianapolis, School of Occupational Therapy. Under the direction of the faculty capstone advisor: Dr. Beth Ann Walker, Associate Professor Abe Saffer, Senior Legislative Representative at AOTA 1 POLICY, ADVOCACY, AND OT 2 Abstract Background: This doctoral capstone experience took place at the American Occupational Therapy Association (AOTA), a national organization for the profession of occupational therapy. The capstone student worked with the senior legislative representative from the Federal Affairs Division of the AOTA for 14 weeks. The primary function of the Federal Affairs division is to advocate for occupational therapy on the congressional level, especially federal policy that affects the practice of occupational therapy. Purpose: This capstone experience aims to determine the Federal Affairs Divisions needs and create an action plan according to them. Method: The design of this doctoral capstone project began with a semi-structured interview to collect preliminary data on relevant needs from the Senior Legislative Representative and the Federal Affairs team in achieving the goals during the 117th Congress. As a result of the needs assessment, an action plan with objectives was developed. Efforts were assessed using the Goal Attainment Scale to measure progress. Results: The results of this capstone include the enhancement in the knowledge of public policy, legislative processes, policy advocacy, and facilitating the introduction of the Allied Health Workforce Diversity Act. The capstone student also delivered several products as outcomes of this experience including One-pagers, Talking Points, action alert statements, letters of support, a comic strip in summer school guidelines, resources for COVID-19 recovery, and an advocacy module. Conclusion: The capstone student produced several legislative supporting documents to assist in moving bills forward in Congress and created a new AHWD one-pager indicating current problems regarding the lack of diversity in allied health professions. This experience also POLICY, ADVOCACY, AND OT indicates the importance and necessity of occupational therapy students and practitioners participation in public policy. The paper concludes by suggesting implementing an immersive learning experience in the program curriculum. Keywords: occupational therapy, policy, advocacy, legislative, workforce, diversity 3 POLICY, ADVOCACY, AND OT 4 Importance of Policy Advocacy for Diversity in Occupational Therapy Public policy for many people is a difficult concept to grasp; it is established from collective decisions by governmental agencies that include plans and actions to be undertaken toward mutual goals within a society (Jacobs, & McCormack, 2019; Lencucha, & ShikakoThomas, 2019; World Health Organization [WHO], n.d.). Policy has pervasive impacts on the practice of occupational therapy, it not only defines the scope of practice and also shapes the environment of clients everyday lives (Lencucha, & Shikako-Thomas, 2019; Osman et al., 2020). According to the Occupational Therapy Practice Framework; Domain and Process 4th ed. (OTPF-4) (American Occupational Therapy Association [AOTA], 2020-b), occupational justice is defined as a justice that recognizes occupational rights to inclusive participation in everyday occupations for all persons in society, regardless of age, ability, gender, social class, or other differences (p. 11). Occupational therapists have the obligation to recognize occupational injustice from the individual, group, and population perspectives as well as have the responsibility to advocate for undeserving and minority populations through taking actions toward policy advocacy to support and facilitate participation in meaningful occupations during day-to-day lives (AOTA, 2020b). Therefore, it is important to ensure that occupational therapists understand the processes of public policy and actively participate in policy advocacy to empower clients engagement in daily occupations and advance the profession as a whole (Jacobs, & McCormack, 2019). According to AOTAs 2019 Workforce and Salary Survey, the percentage of occupational therapy practitioners identifying themselves as African American/black in the United States is 3%, and those identifying as Hispanic/Latino is 3.9% (AOTA, 2020a). The only racial minority group that has more than 5% are practitioners who are Asian/Pacific Islander, POLICY, ADVOCACY, AND OT 5 which is approximately 6.3% (AOTA, 2020a), and this presentation of occupational therapists does not reflect on the client population that many practitioners encounter every day (AOTA, 2021). Studies have indicated the lack of representation and cultural awareness in healthcare professionals might, directly and indirectly, increase the health disparities among minority populations and the key to solve the issue is to not only increase practitioners cultural awareness but also expand workforce diversity (Augsberger et al., 2015; Cohen et al., 2002; Jang et al., 2019; Marrast et al., 2014; Saha et al., 2000; Walker et al., 2012; Ye et al., 2012). The primary purpose of this doctoral capstone experience with AOTAs Federal Affairs is to understand and learn the processes of public policy, advocacy, and lobbying. Additionally, to facilitate the process of introduction and passage of the Allied Health Workforce Diversity Act of 2021, a bill that aims to promote a more diversified workforce among allied health professions. Literature Review Public Policy and Occupational Therapy Occupational therapy is a profession that uses a unique lens to analyze a persons engagement of daily occupations within the environment, therefore, when it comes to public policies occupational therapists can offer a different point of view to address individuals needs and wants to enhance participation in meaningful occupations and promote social justice to enable individuals engagement within society (Bailliard et al., 2020; Osman et al., 2020). Policy is the fundamental structure that shapes occupational therapy practice as well as the lives of many clients; however, it is often a periphery concern in the education and practice of occupational therapy and frequently ignored during the legislative process (Lencucha & Shikako-Thomas, 2019; Osman et al., 2020). Lencucha and Shikako-Thomas (2019) conducted a POLICY, ADVOCACY, AND OT 6 scoping review to examine and identify how public policies are addressed in occupational therapy literature, the results showed many studies describe the impact of policies on occupational therapists practice. For example, the rehabilitation and habilitation policies that affect occupational therapists ability to provide services within specific settings such as mental health and preventative promotion in communities, and the business-oriented reimbursement policies that partake in many practitioners decision-making process during practices (Lencucha & Shikako-Thomas, 2019). On the other hand, policy has an influence on clients on both micro and macro-level including family, community, health care, and social justice, such as the accessibility of health care in the rural area (Ghorbanzadeh et al., 2020), the ability to obtain health insurance for low socioeconomic or minority communities (Buchmueller, & Levy, 2020), and the social injustice that can hinder clients participation in everyday occupations (Bailliard et al., 2020; Jacobs, & McCormack, 2019; Osman et al., 2020). What is Advocacy? Advocacy is defined as the actions that speak in favor of or support/defend on behalf of the interests of others (Jacobs, & McCormack, 2019). According to OTPF-4, advocacy is putting efforts toward the promotion of occupational justice directly to empower clients for occupational participation (AOTA, 2020b), and occupational therapists have the opportunity to advocate for both the clients and the profession from everyday practice to systematic levels (AOTA, 2020b; Jacobs, & McCormack, 2019). Additionally, national and state professional organizations such as American Occupational Therapy Association (AOTA) and Indiana Occupational Therapy Association (IOTA) advocate on behalf of the causes that impact its members to assure that occupational therapy is included in the policies that influence the scope of practice, POLICY, ADVOCACY, AND OT reimbursement, and accessibility. Advocating for occupational therapy is one of the most important elements throughout the processes of policy-making (Jacobs, & McCormack, 2019). According to Hart and Lamb (2018), there are three levels of advocacy including daily practice, professional, and systems that an occupational therapy practitioner can employ to promote the value of occupational therapy. Within the daily practice, an occupational therapist can demonstrate advocacy using client-centered and occupation-based interventions to promote clients occupation performance, in addition, a practitioner can advocate through daily documentation to payer organizations considering this is the primary method that many stakeholders such as insurance companies learn about occupational therapy (AOTA, 2020b; Hart, & Lamb, 2018; Jacobs, & McCormack, 2019). On the professional level, an occupational therapy practitioner can advocate for the profession both inside and outside of work settings addressing unmet needs, challenges, and build alliances with other disciplines toward the same goals (Jacobs, & McCormack, 2019). For example, an occupational therapist provides feedback to managers to update the template for occupational therapy evaluation to include new CPT codes and participate in town council meetings to promote community engagement for individuals with disabilities (AOTA, 2020b; Jacobs, & McCormack, 2019). A practitioner can participate in systems-level advocacy by maintaining involvement in local, state, and national professional organizations as well as building connections with elected officials to voice concerns when there is an issue that could affect the profession (AOTA, 2020b; Bailliard et al., 2020; Jacobs, & McCormack, 2019). Allied Health Workforce Diversity Act of 2021 In 2007, AOTA released a Centennial Vision to guide the future of the profession and celebrate the 100th anniversary of occupational therapy in 2017, the vision stated we envision 7 POLICY, ADVOCACY, AND OT 8 that occupational therapy is a powerful, widely recognized, science-driven, and evidence-based profession with a globally connected and diverse workforce meeting society's occupational needs (AOTA, 2007, p. 613). AOTA presented the vision 2025 in 2016, which was developed based on the Centennial Vision to further lead the profession beyond 2017, they established a pillar of equity, inclusion, and diversity to increased the inclusion and diversity within the profession, additionally, they developed a pillar of accessible to promote culturally appropriate services to clients from diverse background (AOTA, 2017). While occupational therapy practitioners have frequent encounters with clients from diverse backgrounds, within the United States, the profession is predominantly composed of white (85%) and female (91%) practitioners, which does not reflect the communities these practitioners serve (AOTA, 2020a; Taff, & Blash, 2017; Whitla et al., 2003). Evidence has shown a more diverse workforce and student population can increase creativity and the sense of belonging while bringing positive influence to the organization as well as improving the quality of occupational therapy services to many underserved populations (Taff, & Blash, 2017). Research studies indicated that many Asian Americans tend to be reluctant to seek health professionals help due to the discomfort and discrimination caused by the lack of culturally appropriate practice in healthcare, which inevitably increased the health disparity among this population (Augsberger wt al., 2015; Simon et al., 2018; Ye et al., 2012). Additionally, a cross-sectional study conducted by Marrast et al. (2014) found that patients from underrepresented and minority populations tend to seek non-white physicians; black, Hispanic, and Asian physicians are more likely to provide services to patients with lower income or cover by Medicaid, indicating the importance of increasing workforce diversity to address inequalities POLICY, ADVOCACY, AND OT 9 in healthcare as well as decrease health disparities among minority populations (Marrast et al., 2014). Allied Health Workforce Diversity Act of 2021 (AHWD) is legislation focused on promoting workforce diversity by increasing opportunities for individuals from racial and ethnic minorities and underrepresented populations amount allied health professionals including occupational therapy, physical therapy, speech-language pathology, audiology, and respiratory therapy (AOTA, 2021). AHWD is a bipartisan bill that provides grants to allow higher education programs to attract, recruit, and retain students from diverse backgrounds. It promotes a more diverse workforce within allied health professions to help address shortages of providers while improving the ability of the health care workers to effectively address the needs of all Americans especially in the post-COVID era and increase healthcare accessibility to minority populations in the United States. The profession of occupational therapy prides itself in promoting individuals participation in everyday meaningful occupations and with the push of this legislation, the profession will be able to receive additional funding designated for increasing the diversity within the profession. This bill also corresponds with the AOTAs Centennial Vision to meet society's occupational needs by diversifying the workforce (AOTA, 2007; AOTA, 2020b; AOTA, 2021). Model and Frame of Reference This capstone experience/project was guided by the combined logic model, a model that was created and modified by Gen and Wright in 2013. This model provides a visualized road map to stakeholders with the information that shows the connections between inputs, activities, and outcomes of intended results and goals (Community Research, 2020; Gen & Wright, 2013; WK Kellogg Foundation, 2004). The original logic model has been primarily used in program POLICY, ADVOCACY, AND OT 10 evaluation (WK Kellogg Foundation, 2004), however, Gen and Wright (2013) found this model has been applied by multiple organizations as a foundation to understand the process of policy advocacy. The authors developed this combined logic model with the inclusion of the theory of change and the original logic model to adapt for the policy advocacy engagement (Gen & Wright, 2013). In addition to the combined logic model, the capstone student will use the Coalition of Occupational Therapy Advocates for Diversity (COTAD) framework to guide the process of advocacy for diversity within the profession of occupational therapy throughout the capstone experience. The COTAD board members developed the COTAD framework in 2015; it uses a multi-faceted approach to promote diversity within the profession as well as provides guidance to advocate for people from diverse backgrounds (Wilson et al., 2015). This framework included three tiers: person, group, and population and within each tier, some strategies help with fostering diversity in occupational therapy (Coalition of Occupational Therapy Advocates for Diversity [COTAD], 2021; Wilson et al., 2015). The capstone student will use the strategies akin to the advocacy aspect of the personal, group, and community outreach categories from the framework as guidance for the project (COTAD, 2021; Wilson et al., 2015), which aligns with the objectives of this capstone experience to advocate for occupational therapy in Congress and promote the introduction and passage of the Allied Health Workforce Diversity Act of 2021. Methods Needs Assessment Jacobs and McCormack (2019) suggested the importance of increasing engagement in public policy and understanding the role of occupational therapists as an advocate at the policy level. Additionally, Lavis (2006) indicated the necessity of building connections with policymakers, for the clients and professional practices. It is crucial for occupational therapists to POLICY, ADVOCACY, AND OT 11 maintain relationships with decision-makers to ensure occupational therapy is included in the discussions and promote the profession by continuous advocacy (Osman et al., 2020). The needs assessment of this doctoral capstone experience utilized a one-on-one semi-structured interview to collect data on relevant needs from the Senior Legislative Representative of the Federal Affairs Division at AOTA to best assist the Federal Affairs team to achieve the goals and advocate for the profession of occupational therapy during the 117th Congress. Measurement of Outcomes In addition to the semi-structured interview with the Senior Legislative Representative and activity analysis of this capstone experience, the capstone student used the Goal Attainment Scale (GAS) to measure the outcomes of this capstone project. GAS is an individualized measurement with a criterion-referenced approach to assessing an individuals progression of goals (Hurn, Kneebone, & Cropley, 2006; Roach, & Elliott, 2005; Shirley Ryan Abilitylab, 2020). The capstone student created a GAS table (table A2) with all expected outcomes and examined them at the 10th week of the capstone experience in order to ensure the fulfillment of the goals and objectives. The Combined Logic Model The capstone student followed the steps from Gen and Wright (2013) to create the combined logic model for this capstone project at AOTA. The desired outcome of this capstone experience includes learning public policy, legislative process, and policy advocacy, collecting evidence and participating in committee hearings regarding COVID and advocating for the AHWD, SISP, and school OT. The inputs of the combined logic model include the necessary conditions for policy advocacy (Gen & Wright, 2013). The inputs for this capstone project including the capstone students willingness to increase awareness regarding lack of diversity POLICY, ADVOCACY, AND OT 12 within the profession of occupational therapy, the opportunities to connect with stakeholders and work with AOTAs Senior Legislative Representative, and utilization of AOTAs existing resources (AOTA, 2021; Jacobs, & McCormack, 2019). The definition of activities category of the combined logic model is the concerted actions done in advocacy that are meant to affect policy processes (Gen & Wright, 2013, p.18). The activities during this capstone include attending hill meetings and Political Action Committees (PAC) events, networking, advocating and preparing supportive documents for legislations, guidelines for school reopening, and advocacy module of the Diversity, Equity, and Inclusion (DEI) Toolkit. The impacts category is defined as the outcomes resulting from the activities and actions taken by the advocates to impact public policy and make society change (Gen & Wright, 2013). The impacts of this capstone project are to promote a more diverse workforce and decrease health disparities among minority populations, to increase awareness and advocate for funding in supporting SISP in school, and to include occupational therapy in relevant bills for the benefits of memberships. See Table A1 for the roadmap of the combined logic model for this capstone project. Results Results of Needs Assessment The results of the needs assessment interview indicate the need for creating an evidencebased synthesized two-sided one-pager for hill staffers to learn and better understand the importance of the Allied Health Workforce Diversity Act and support the bill as co-sponsors in the Congress. The one-pager will include the information from a recently published article in the Journal of the American Medical Association, statistics/data from the National Institute of POLICY, ADVOCACY, AND OT 13 Health, the Centers for Disease Control and Prevention, and various research articles, and the rationale of the importance of a diverse workforce and why the policymakers should support this bill. In addition to the one-pager, the capstone student will work on reviewing, creating, and updating supporting documents to promote the introduction and passage of AHWD in the 117th Congress. Additionally, the capstone student will have opportunities to be involved in educational-related policy advocacy such as the Individuals with Disabilities Education Act (IDEA) and the Elementary and Secondary Education Act (ESEA) to increase awareness of SISP and related services in school settings. Furthermore, the capstone student will have the opportunity to collaborate with AOTAs grassroots leader and Diversity, Equity, and Inclusion (DEI) committee members to develop an advocacy module to promote advocacy for diversity and inclusion. To have resources accessible to use when needed, the capstone student will also work with the AOTAs Practice team to create resources and guidelines associated with school reopening and summer school for practitioners, parents, and children to use. Objectives and Plan for Deliverables The primary objectives of this doctoral capstone experience are to demonstrate in-depth knowledge in advocacy, legislative process, and public policy for the profession of occupational therapy from a federal level and to produce legislative documents to support bills relevant to occupational therapy. In addition, with the opportunities to involve and provide assistance throughout the process of the introduction and passage of the Allied Health Workforce Diversity Act of 2021 to promote a more diverse workforce among allied health professionals. The objectives and deliverables are listed below: To facilitate the introduction and passage of the Allied Health Workforce Diversity Act (AHWD) during the 117th Congress POLICY, ADVOCACY, AND OT 14 A brand new version of synthesized one-pager with additional evidence that shows the importance of AHWD and includes the recently published research article from the Journal of the American Medical Association (JAMA), this is the capstone students primary project for this experience Update and revise previous AHWD One Pager with up-to-date evidence and language Modify Talking Points document and include up-to-date language and supporting evidence Update the action alert statement for AOTA Legislative Action Center Create a letter of support template and survey form for program directors Attending meetings and collaborating with allied health coalition members Schedule and attend hill meetings with Senators/Representatives office staff to advocate and ask support for AHWD To increase awareness and promote Specialized Instructional Support Personnel (SISP) in school and create resources for school re-opening National Alliance of Specialized Instructional Support Personnel (NASISP) National SISP Appreciation Week Attendance of hill meetings Coalition meetings and discussion School re-opening and summer school resources guide: comic stripe creation POLICY, ADVOCACY, AND OT 15 To collect evidence and attend Senate and House committee hearings regarding COVID long haul and recovery to advocate for OT in the post-pandemic era To learn policy advocacy and collaborate with the AOTA grassroots leader to create an advocacy module that will be included in the Diversity, Equity, and Inclusion (DEI) Toolkit Outcomes Allied Health Workforce Diversity Act One-pager. A legislative one-pager can be utilized as a summarized information sheet for policymakers and their staff members to understand the issue and/or topic that needs their attention. It is an effective method to tell a story and facilitate conversation on the target issue with a legislator or a staffer (Public Knowledge, 2015). A one-pager typically includes background information, evidence-based supports, statistics/data, and solutions or actions that policymakers should take (Public Knowledge, 2015). While working on introducing the AHWD to the 117th Congress, the Journal of the American Medical Association (JAMA) published an article that not only supported our bill but provided statistical data on the problems that AHWD could solve. Therefore, the legislative representative and the capstone student decided to utilize the information from this recently published article and create a new one-pager that tells a story regarding the current problems and how AHWD can be the solution. This new version of the one-pager was created on a shared Google Doc between the legislative representatives and the capstone student. After multiple discussions and meetings with the Federal Affairs team, the capstone student started the document with an outline to ensure all the problems were addressed then used Google Scholar and EBSCO databases to complete a preliminary search on the most recent evidence. After the preliminary search, the capstone POLICY, ADVOCACY, AND OT 16 student used the relevant articles tab on Google Scholar to do a thorough search on the topic to strengthen our argument. Once the literature search was done, the capstone student started the construction of the one-pager (Imagine A1). After repetitive meetings and conversations with the legislative representative, the capstone student was able to finalize the document to a 3-page report from a 10-page paper and then utilize the information to create an infographic to visualize the argument. After the one-pager and the infographic were done, the documents were sent to AOTAs Creative Service and Copyediting department for final editing and approval before publishing on the website for members to use. The final products can be used by other allied health professional organizations to increase awareness of the AHWD in Congress and they also will be distributed to legislators and staffers after each hill meeting. Other legislative supporting documents. In addition to the JAMA one-pager, the capstone student also revised the original AHWD One-pager from 116th Congress as an additional supporting resource for the bill (Imagine A2). Furthermore, the capstone student updated the Talking Points document (Imagine A3) for AOTA members to use when meeting with their members of Congress to advocate for AHWD. The student also modified the action alert statement (Imagine A4) in the Legislative Action Center so that members of AOTA will receive notification to support this bill. In order to receive more support from program directors, the student created a letter of support template and survey form (Imagine A5) and will be sent out by the senior legislative representative at AOTA once the bill moves forward in the process. Resources for School Re-opening NASISP. The senior legislative representative that the capstone student worked with at AOTA is also a co-chair of the National Alliance of Specialized Instructional Support Personnel (NASISP), therefore, the student had opportunities to attend hill and coalition meetings for the POLICY, ADVOCACY, AND OT 17 passage of the Resolution of 2021 National SISP Appreciation Week as well as advocating for more funding and resources for Specialized Instructional Support Personnel (SISP) in school. The outcome of our advocacy was that the Senate Resolution (S.Res.180) was passed on April 27th, 2021, which designated the week of April 26 through April 30, 2021, as National Specialized Instructional Support Personnel Appreciation Week. School re-opening and summer school guidelines. While working on SISP resolution, the capstone student had the opportunity to work with several members from the Practice Division at AOTA to create a comic strip that was included in the practice guideline regarding summer school. The purpose of this guideline was to provide resources for practitioners, parents, and children to return to school post-pandemic. This comic strip was created for the children who may need to attend summer schools due to the pandemic and the intent for the comic is to provide rationales for kids to understand that summer school is not a punishment but an opportunity to learn and have fun. The resources can be found on AOTAs website and this is the link to the comic strip: https://www.aota.org/-/media/Corporate/Images/Practice/OT-KidsSummer-Programs-Comic.jpeg COVID-19 Long Haul Studies have shown that the demands for rehabilitation will continue to increase as the COVID-19 confirmed cases continue to decrease, in addition, the evidence have shown that occupational therapy is needed for the survivors to return to their previous functional level (Daynes, Gerlis, & Singh, 2021; De Biase, et al., 2020). Due to the pandemic, there were plenty of hearings and meetings on the hill to discuss the plan for the aftermath of the pandemic, and AOTAs legislative representatives must engage with the members of Congress and make sure that occupational therapy is included in the bills that address post-pandemic plans and fundings. POLICY, ADVOCACY, AND OT 18 The capstone student helped the Federal Affairs team to collect evidence regarding COVID-19 and occupational therapy in order to persuade the policymakers that occupational therapy is necessary in the post-pandemic era. The capstone student also attended several committee hearings about the COVID long hauler and their recovery to learn the direction of the current administration on this topic so that AOTAs Federal Affairs team can prepare for it. Advocacy Advocacy is core to the occupational therapy profession, yet, the lack of engagement in policy advocacy leads to a feeling of disconnect between public policy and clinical practice. This capstone experience provided opportunities for the capstone student to participate and engage in policy advocacy on the hill. At the beginning of the experience, the capstone student was required to learn the language that people commonly use in the political field before communicating with the elected offices for meetings and other requests. Then, the capstone student was able to attend multiple hill meetings, PAC, and fundraising events to speak with members of Congress and their legislative assistant for specific topics such as the introduction of AHWD and the resolution of national Specialized Instructional Support Personnel Appreciation Week. Before the hill meetings, the capstone student had to learn the background of the topic or bill as well as to conduct a literature search to obtain the most recent supporting information for advocacy and lobbying. For example, we had a meeting with the legislative assistant from representative Bobby Rushs office with an anticipation that the Representative would continue being a Democrat lead sponsor for the AHWD. Before the meeting, we had to collect and prepare up-to-date evidence regarding health disparities among underrepresented populations and the importance of increasing diversity and cultural competency in the healthcare workforce to strengthen our argument and the significance of passing the AHWD. Furthermore, the POLICY, ADVOCACY, AND OT 19 capstone student also prepared an elevator pitch to provide perspectives and points of view as a minority student in occupational therapy to advocate for the AHWD. In addition to hill meetings, the capstone student participated in several coalition meetings for the collaboration of pushing the AHWD into the 117th Congress as well as advocating for additional funding and more SISP in school. With the frequent participation in these coalition meetings, the capstone student was able to capture the concept of networking and the importance of using appropriate communication styles to work together while advocating for the profession of occupational therapy within the coalition. Furthermore, the capstone student collaborated with the Grassroots leader at AOTA to create an advocacy module that will be included in the DEI Toolkit to increase awareness and promote participation in policy advocacy. The capstone student is unable to provide the link to the module this date since it is currently under review and will be published with the next section of the DEI toolkit on AOTA. Throughout the process of creating the advocacy module, the capstone student was able to learn directly from the Grassroots leader and participated in Political Action Committees events to raise funds in supporting elected officials who supported and helped the profession of occupational therapy in the Congress. Legislative Process and Public Policy The United States Constitution states "all legislative Powers herein granted shall be vested in a Congress of the United States, which shall consist of a Senate and House of Representatives (U.S. Const. art. I, 1). The legislative process is commonly known as difficult to understand and one of the best ways to learn is through first-hand experiences. The doctoral capstone student learned the legislative process through working with a lobbyist from AOTA. Legislation begins with an idea and when it is ready, the individual or the organization POLICY, ADVOCACY, AND OT 20 finds a member of Congress to sponsor the bill (U.S. House of Representatives., n.d.). Once the bill is introduced, it will be assigned to a committee for a detailed study, then if it is approved the bill will be placed on schedule to be discussed, amended, and voted on the Congress floor (Congress.gov., n.d.; U.S. House of Representatives., n.d.). After it is passed by both House and Senate, there will be a conference committee composed with both chambers members to conclude a final version of the bill and return to the House and Senate for final approval before sending it to the President for signature or veto the bill (Congress.gov., n.d.; U.S. House of Representatives., n.d.). Within each of these legislative steps, a legislative representative or a lobbyist must involve and continue pushing and advocating for the organizations best interest so the bill has a chance to pass when being voted on the floor. The capstone student had an opportunity to be involved in these small steps throughout the capstone experience. Many supporting documents are required to have the most up-to-date research to support the argument for a specific issue or bill, the capstone student assisted in the preparation of these documents including one-pager, talking points, action alert statements, letters of support, and press release. The AHWD was introduced to the Senate in the last (116th) Congress, however, the process was postponed due to COVID and later on failed to continue in the Congress. Therefore, the capstone student was able to utilize previous documents as examples and used Google Scholar as a primary search engine and EBSCO database for more in-depth research. Once the literature search was done, the capstone student then modified and added the latest evidence onto the existing documents and sent it to AOTAs Copyediting department for final approval before publishing on the AOTAs website. The capstone student was able to produce more than 10 different documents throughout this capstone experience, which helped the student to learn and practice the policy language as POLICY, ADVOCACY, AND OT 21 well as strengthening research skills and providing a different viewpoint to the Federal Affairs team as an occupational therapist. Outcome Measurement After the completion of the one-pager and the infographic for the AHWD, the capstone student reviewed the Goal Attainment Scale (GAS) that was created at the beginning of the experience with the site mentor. After careful evaluation of the objectives and goals (table A2), the site mentor and the capstone student concluded that all the listed goals were achieved. The capstone student was able to produce a new AHWD one-pager and an additional infographic for AOTA to use as a resource when advocating for the passage of the AHWD with a policymaker or a staffer. Discussion/Implication The process of legislation can be long, unpredictable, and difficult to perceive, this may prevent engagement in policy advocacy for many occupational therapy practitioners (Jacobs, & McCormack, 2019). However, professional inputs from practitioners are necessary to shape and develop good health policies (Jacobs, & McCormack, 2019). This capstone experience provided a different aspect of policy advocacy from a team of lobbyists and advocates that dedicated their time advocating the profession of occupational therapy on the hill. Participation in hill meetings and events is beneficial for the student to understand the art of policy advocacy and grasp the concept of political dynamics. Opportunities to attend and involve in various meetings also provided the student a chance to use a professional lens to provide recommendations from an occupational therapy practitioner to both lobbyists and hill staffers. In addition to the advocacy and legislative process, the engagement in creating and modifying legislative supporting documents provided a hands-on experience for the capstone student. The ability to work on the POLICY, ADVOCACY, AND OT 22 official documents enhanced the students skills in using appropriate policy language to persuade policymakers from a professional point of view. The collaboration with other professionals for the Allied Health Workforce Diversity strengthened the students communication techniques and leadership experiences, which are the essential skills for practitioners to have. Additionally, the focus of this capstone experience on the introduction and passage of the Allied Health Workforce Diversity helped the student understand although policy change wont happen overnight, it is important to continue advocating and voice the concerns so the policymakers recognize the needs of their constituents. This bill raises awareness and initiates a change to improve the lack of diversity among allied health professions. The creation of the new one-pager provides a succinct report to policymakers and the general public, it addresses the urgency of having a more diverse workforce, especially in the post-COVID era. Political astuteness is an awareness and understanding of legislative and policy processes, and political skills (Primomo, 2007, pp. 260). In 2017, students from a Doctor of Nursing Practice (DNP) program in Virginia attended a series of events and worked with members of Congress for a week on Capitol Hill as experiential learning to increase awareness and participation in policy advocacy (Eaton, & Hulton, 2018). The results of this experiential learning indicated increased confidence and knowledge in healthcare policy advocacy (Eaton, & Hulton, 2018). After a 14-week immersive learning experience with AOTAs Federal Affairs Division, the capstone student has increased self-confidence when discussing healthcare policy with legislators and obtained networking skills for not only advocacy but future connections. The capstone student suggests that occupational therapy programs could implement a more intensive learning experience that is similar to the nursing programs to increase students and practitioners political astuteness and advance the profession on the federal level. Furthermore, POLICY, ADVOCACY, AND OT 23 AOTA and occupational therapy programs should take more actions to promote and encourage students to apply for opportunities to work at AOTA with the Federal Affairs team to have an indepth experiential experience to participate in the legislative process and policy advocacy from the congressional level. Conclusion The purpose of this experience was to determine the Federal Affairs Divisions needs and create an action plan according to their needs as well as learning the processes of legislation, policy advocacy, and public policy with firsthand experience. The results of this experience indicate that engagement from occupational therapy students and practitioners in public policy is necessary and it is important for us to understand the legislative process to effectively participate in policy advocacy. The capstone student also produced several legislative supporting documents to assist in moving legislation forward in Congress. Furthermore, the creation of the new AHWD one-pager indicates current problems regarding the lack of diversity in allied health professions as well as rationals for members of Congress to support this bill. While this experience indicates that the understanding of policy and advocacy on the federal level is still a difficult concept to operationalize, it provides an example of the benefits of experiential learning and can encourage occupational therapy programs to design a more immersive experience to ensure students understand public policy and legislative process to enable and increase the participation in policy advocacy and advance the profession on the federal level. POLICY, ADVOCACY, AND OT 24 References American Occupational Therapy Association. (2007). AOTAs Centennial Vision and executive summary. American Journal of Occupational Therapy, 61(6), 613-614. American Occupational Therapy Association. (2017). Vision 2025. American Journal of Occupational Therapy, 71 (3), 7103420010. American Occupational Therapy Association. (2020-a). AOTA 2019 Workforce and salary survey. American Occupational Therapy Association. American Occupational Therapy Association. (2020-b). Occupational therapy practice framework: Domain and process (4th ed.). American Journal of Occupational Therapy, 74(Suppl. 2), p 1-87. American Occupational Therapy Association. (2021). The Allied Health Workforce Diversity Act introduced in the 117th Congress. Retrieved from https://www.aota.org/Advocacy-Policy/Congressional-Affairs/Legislative-IssuesUpdate/2021/Allied-Health-Workforce-Diversity-Legislation-Introduced.aspx Augsberger, A., Yeung, A., Dougher, M., & Hahm, H. C. (2015). Factors influencing the underutilization of mental health services among Asian American women with a history of depression and suicide. BMC health services research, 15(1), 542. Bailliard, A. L., Dallman, A. R., Carroll, A., Lee, B. D., & Szendrey, S. (2020). Doing occupational justice: A central dimension of everyday occupational therapy practice. Canadian Journal of Occupational Therapy, 87(2), 144-152. Buchmueller, T. C., & Levy, H. G. (2020). The ACAs Impact On Racial And Ethnic Disparities In Health Insurance Coverage And Access To Care: An examination of how the POLICY, ADVOCACY, AND OT 25 insurance coverage expansions of the Affordable Care Act have affected disparities related to race and ethnicity. Health Affairs, 39(3), 395-40 Coalition of Occupational Therapy Advocates for Diversity. (2021). COTAD Framework. Retrieved from https://www.cotad.org/about Cohen, J. J., Gabriel, B. A., & Terrell, C. (2002). The case for diversity in the health care workforce. Health Affairs, 21(5), 90-102. Community Research. (2020). Logic model and theory of change. Retrieved from https://whatworks.org.nz/logic-model/ Congress.gov. (n.d.). The legislative process: Overview. Retrieved from https://www.congress.gov/legislative-process Daynes, E., Gerlis, C., & Singh, S. J. (2021). The demand for rehabilitation following COVID19: A call to service providers. Physiotherapy. De Biase, S., Cook, L., Skelton, D. A., Witham, M., & Ten Hove, R. (2020). The COVID-19 rehabilitation pandemic. Age and ageing, 49(5), 696-700. Eaton, M. K., Hulton, L. J. (2018, April 19-21). Health Policy Institute (HPI): Capitol hill experiential learning to gain political astuteness [Paper presentation]. Nursing Education Research Conference, Washington D.C., U.S.A. https://sigma.nursingrepository.org/bitstream/handle/10755/623863/Eaton_Info_89566.p df?sequence=2 Gen, S., & Wright, A. C. (2013). Policy advocacy organizations: A framework linking theory and practice. Journal of Policy Practice, 12(3), 163-193. POLICY, ADVOCACY, AND OT 26 Ghorbanzadeh, M., Kim, K., Ozguven, E. E., & Horner, M. W. (2020). A comparative analysis of transportation-based accessibility to mental health services. Transportation research part D: transport and environment, 81, 102278. Hart, E. C., & Lamb, A. J. (2018). Mindful Path to Leadership Module 4: A mindful path to advocacy. Bethesda, MD: AOTA Press. Hurn, J., Kneebone, I., & Cropley, M. (2006). Goal setting as an outcome measure: a systematic review. Clinical Rehabilitation, 20(9), 756-772. Jacobs, K., & McCormack, G. L. (Eds.). (2019). The occupational therapy manager. Bethesda, MD: AOTA Press. Jang, Y., Yoon, H., Park, N. S., Rhee, M. K., & Chiriboga, D. A. (2019). Mental health service use and perceived unmet needs for mental health care in Asian Americans. Community mental health journal, 55(2), 241-248. Lavis, J. N. (2006). Research, public policymaking, and knowledge translation processes: Canadian efforts to build bridges. Journal of Continuing Education in the Health Professions, 26(1), 37-45. Lencucha, R., & Shikako-Thomas, K. (2019). Examining the intersection of policy and occupational therapy: A scoping review. Canadian Journal of Occupational Therapy, 86(3), 185-195. Marrast, L. M., Zallman, L., Woolhandler, S., Bor, D. H., & McCormick, D. (2014). Minority physicians role in the care of underserved patients: diversifying the physician workforce may be key in addressing health disparities. JAMA internal medicine, 174(2), 289-291. POLICY, ADVOCACY, AND OT 27 Osman, A., Webber, C., Oliel, S., Couture-Lavoie, K., Lencucha, R., & Shikako-Thomas, K. (2020). Engagement of occupational therapy organizations with public policy: A qualitative analysis. Canadian Journal of Occupational Therapy, 87(5), 354-363. Primomo, J. (2007). Changes in political astuteness after a health systems and policy course. Nurse Educator, 32(6), 260264. Public Knowledge. (2015). Navigating capitol hill and tips for creating one-pagers. Retrieved from https://www.publicknowledge.org/documents/navigating-capitol-hill-and-tips-forcreating-one-pagers/ Roach, A. T., & Elliott, S. N. (2005). Goal attainment scaling: An efficient and effective approach to monitoring student progress. Teaching Exceptional Children, 37(4), 8-17. Saffer, A. (2020, August). COVID-19 pandemic adds new urgency, momentum to passing the Allied Health Workforce Diversity Act. OT Practice, 25(8), 9. Saha, S., Taggart, S. H., Komaromy, M., & Bindman, A. B. (2000). Do Patients Choose Physicians Of Their Own Race? To provide the kind of care consumers want, medical schools might be able to justify using race as an admissions criterion. Health affairs, 19(4), 76-83. Shirley Ryan Abilitylab. (2020). Goal Attainment Scale. Retrieved from https://www.sralab.org/rehabilitation-measures/goal-attainment-scale Simon, M. A., Tom, L. S., Leung, I., Taylor, S., Wong, E., Vicencio, D. P., & Dong, X. (2018). Chinese immigrant women's attitudes and beliefs about family involvement in women's health and healthcare: A qualitative study in Chicago's Chinatown. Health equity, 2(1), 182-192. POLICY, ADVOCACY, AND OT 28 Taff, S. D., & Blash, D. (2017). Diversity and inclusion in occupational therapy: Where we are, where we must go. Occupational therapy in health care, 31(1), 72-83. U.S. Const. art. I, 3. U.S. House of Representatives. (n.d.). The legislative process. Retrieved from https://www.house.gov/the-house-explained/the-legislative-process Walker, K. O., Moreno, G., & Grumbach, K. (2012). The association among specialty, race, ethnicity, and practice location among California physicians in diverse specialties. Journal of the National Medical Association, 104(1-2), 46-52. Whitla, D. K., Orfield, G., Silen, W., Teperow, C., Howard, C,, & Reede, J. (2003). Educational benefits of diversity in medical school: A survey of students. Academic Medicine, 78, 460466. Wilson, S., Anvarizadeh, A., Drazen, C. H., Holland, DAndre, Kwebetchou, N., Smith, C. R., & Skowronski, J. (2015). Diversity in the workforce. OT Practice, 11, 19-21. WK Kellogg Foundation. (2004). WK Kellogg Foundation logic model development guide. WK Kellogg Foundation. World Health Organization. (n.d.). Health topics: Health policy. Retrieved from https://www.euro.who.int/en/health-topics/health-policy/health-policy Ye, J., Mack, D., Fry-Johnson, Y., & Parker, K. (2012). Health care access and utilization among US-born and foreign-born Asian POLICY, ADVOCACY, AND OT 29 Appendix Table A1 Doctoral Capstone Experience with Federal Affairs at AOTA POLICY, ADVOCACY, AND OT 30 Table A2 Goal Attainment Scale for Capstone Experience Goals -2 (Less than -1 (Not quite expected) achieved) 0 (Achieved the goal) +1 (Slightly exceeded +2 (Much more the expectation) than expectation) I will have the ability to start an advocacy Unable to start conversation with a an advocacy policymaker 70% of conversation the time to be able to be a policy advocate. Able to start an advocacy conversation 50% of the time Able to start Able to start an an advocacy Able to start an advocacy conversation advocacy conversation conversation 90% of 70% of the 80% of the time the time time To demonstrate professional leadership skills by developing a 30 No second to 1 minute demonstration elevator pitch on the in leadership purpose and importance of occupational therapy Able to develop an elevator pitch for OT but not enough information deliver Able to develop 30 seconds to 1 minute elevator pitch for OT with sufficient information Create a synthesized one-pager for AHWD Nothing with a focus on the created JAMA article Created an expected oneCreated a onepager with pager with some minimal evidenceinformation based and limited resources to resources support the argument Improve networking skills through Less than 3 collaborating and No connection connections educating other has made have made professionals on the purpose of occupational therapy Made more than 5 connections and demonstrate good networking skills Able to develop a 30 second to 1 minute elevator pitch for OT with sufficient info and able to deliver the pitch with enough selfconfidence Develop and deliver an elevator pitch for OT in specific topics and issues to match with the purpose One-pager created Created a one-pager with strong with fair among of upevidence and clear to-date evidence-based argument to research support AHWD Made 8+ connections and demonstrate the ability to collaborate with them Made 10+ connections and demonstrate the ability to collaborate, educate, and advocate for OT POLICY, ADVOCACY, AND OT 31 Create the advocacy module Develop and create the with collaboration Develop and advocacy module and and deliver the create the utilize resources at product to the advocacy AOTA to collaborate AOTA Practice module with expertises Team for dissemination to the public Collaborate and create advocacy module for AOTA Practice team to No module is better support them made on educating occupational therapy practitioners and students Start to develop and create but not finish Provide assistance including updating the one-pager, engagement statement, letters of support, creation of Google form, and No progress advocate the bill to made policymakers to facilitate the introduction of the Allied Health Workforce Diversity Act of 2021 into the 117th Congress. Involve in all the process including communication between the Provide assistance with coalition, advocate Involve in the Provide additional involvement the bill to process but no assistance as such as using congressman, actual help needed connections to advocate update resources, for the bill letters of support, engagement statement, and press release POLICY, ADVOCACY, AND OT Imagine A1 New Version of AHWD One-pager 32 POLICY, ADVOCACY, AND OT 33 POLICY, ADVOCACY, AND OT Imagine A2 AHWD Original One-Pager 34 POLICY, ADVOCACY, AND OT Imagine A3 AHWD Talking Points 35 POLICY, ADVOCACY, AND OT Imagine A4 AHWD Action Alert Statement https://cqrcengage.com/aota/app/write-a-letter?0&engagementId=511842 36 POLICY, ADVOCACY, AND OT Imagine A5 Letter of Support Template and Survey Form for Program Directors 37 POLICY, ADVOCACY, AND OT 38  ...

... 1 Co-occupations of Supplementary Grandparents and their Grandchildren Gabrielle Castor, Rachel Cole, Kylie Harper, Stephanie McElhaney December 17, 2021 A research project submitted in partial fulfillment for the requirements of the Doctor of Occupational Therapy degree from the University of Indianapolis, School of Occupational Therapy. Under the direction of the research advisor: Lucinda Dale, EdD, OTR, CHT, FAOTA 2 A Research Project Entitled Co-occupations of Supplementary Grandparents and their Grandchildren Submitted to the School of Occupational Therapy at University of Indianapolis in partial fulfillment for the requirements of the Doctor of Occupational Therapy degree. By: Gabrielle Castor, Rachel Cole, Kylie Harper, Stephanie McElhaney Doctor of Occupational Therapy Students Approved by: Lucinda Dale EdD, OTR, CHT, FAOTA Research Advisor 12/17/2021 Date Accepted on this date by the Chair of the School of Occupational Therapy: Kate E. DeCleene Huber, OTR, MS, OTD Chair, School of Occupational Therapy Date 3 Abstract Objective: The purpose of this study was to understand the lived experiences of supplementary grandparents with their grandchildren during co-occupations. Methods: The researchers enrolled eight grandmothers and one grandfather, with grandchildren ages six months to 21 years. Using a phenomenological design, the researchers gathered data through surveys, individual semi-structured interviews, and a focus group interview. Researchers completed individual and collective coding to identify themes. Results: Participants varied in age, employment status, marital status, and proximity to their grandchildren, extending from 10 minutes to more than two hours. Findings revealed that participation in co-occupations between grandparents and grandchildren enhanced their relationship and encouraged an active lifestyle of grandparents. Grandparents also experienced physical and cognitive demands during co-occupations, prompting modifications to preserve participation. Grandparents described the purpose of co-occupations as having fun, teaching, and learning from grandchildren. The results indicated that co-occupations were influenced by grandparents employment status, the age of the grandchildren, the health of the grandparent, the relationships between parents and grandparents, and the proximity to grandchildren. As grandchildren aged, the grandparents roles in co-occupations shifted from active participants to observers and supporters. Conclusion: The findings of this study can help occupational therapy practitioners understand the benefits and challenges associated with co-occupations of grandparents and grandchildren. 4 Co-occupations of Supplementary Grandparents and their Grandchildren With increasing life expectancies and growing numbers of dual-worker households, grandparents are playing a more prominent role in the lives of their grandchildren (Mansson, 2016, p. 136). Grandparents make up 18% of the worlds 7.6 billion people. Of these, 1.4 billion people, 58% of grandmothers and 49% of grandparents, provided grandchild care in the past year (Triado et al., 2014). Grandparents provide a range of assistance from visits, occasional care, and transportation, to full care (Ludwig et al., 2007). With a large population of grandparents occupations involving grandchildren, adequate research is necessary to understand these lived experiences. Occupations are defined in the OTPF as daily life activities in which people engage that are influenced by client factors and performance skills (American Occupational Therapy Association (AOTA), 2014, p. S1). Throughout the literature, grandparents are defined by the amount of time they spend with their grandchildren or the responsibilities they have in their role. Roles are defined in the Occupational Therapy Practice Framework (OTPF) as sets of behaviors expected by society and shaped by culture that provide guidance in selecting activities (AOTA, 2014, p. S8). In their systematic review, Kinsner et al. (2017) categorized grandparent care as skipped generation, multigenerational, and babysitters. In the skipped generation arrangement, grandparents serve as the childs primary caregiver because the parents are absent. In another systematic review, Kim et al. (2017) defined this arrangement as custodial grandparenting. Grandparents in the multigenerational arrangement share the household and caregiving responsibilities with the parents. Grandparents who do not live with the grandchild and provide sporadic care are considered to be a part of the babysitting arrangement (Kinsner et al., 2017). In comparison, Kim et al. (2017) defined a grandparent who provides care for children of parents who work or study 5 as supplemental. Similarly, Triado et al. (2014) labeled grandparents who help balance work and family for dual-earner couples as auxiliary grandparents Supplementary, or auxiliary, grandchild care providers not only provide convenient caregiving but also relieve financial burdens (Villar et al., 2012). Chamie (2018) explained that grandparents in the United Kingdom save their children more than $70 billion annually in childcare costs. In the current study, researchers focused on individuals who fulfilled the role of supplemental grandparents. Not only do supplementary grandchild care providers benefit their families, but they also benefit their own health and life satisfaction. Moore and Rosenthal (2015) found that satisfaction with grandchild care positively correlated with grandmothers life satisfaction. According to the Role Enhancement Theory, individuals with multiple roles may have better health compared to those with only a few roles to fulfill, providing those with additional roles a sense of usefulness, competency, and control in later life (Di Gesa et al., 2015). Triado et al. (2014) found that grandparents who provided auxiliary grandchild care identified their role as a source of positive emotions and an opportunity to establish and reinforce affective links, as opposed to as a burden (p. 123). Whereas additional responsibilities can be more rewarding, researchers suggested through the Socioemotional Selectivity Theory that as individuals age, they become more emotionally selective with their relationships (Mansson, 2016). Mansson (2016) proposed that grandparents chose to keep interactions they perceived as personal and meaningful, specifically the grandparent-grandchild relationship. By examining what grandparents perceived as the best part of their role, Mansson (2016) found that grandparents identified mutual grandparentgrandchild affection and shared activities as the most enjoyable. He defined these shared grandparent-grandchild activities, or co-occupations, as joint events in which the grandparent 6 and grandchild are actively engaging simultaneously, such as playing games and assembling puzzles (Mansson, 2016). Co-occupations are defined as occupations that are shared with others and involve active participation from both or all people (AOTA, 2014, p. S6). In the supplementary grandparent role, grandmothers reported that co-occupations with their grandchildren were meaningful and contributed to their well-being (Ludwig et al., 2007). The purpose of this study was to understand the lived experiences of supplementary grandparents with their grandchildren during co-occupations. Using a phenomenological approach, the researchers answered the research question: How do supplementary grandparents experience co-occupations with their grandchildren? Literature Review Researchers conducted a narrative literature review, using the Johns Hopkins Nursing Evidence-Based Practice Research Evidence Appraisal Tool to determine the quality of the literature and chose only high or good quality articles for the literature review (Dang & Dearholt, 2017). To assess the quality of the literature review manuscript, the researchers used the Scale for the Assessment of Narrative Review Articles (Baethge et al., 2019). The researchers searched gray literature and used the Academic Search Complete, CINAHL, and MEDLINE databases to conduct single database searches to find full-text articles written in English. Researchers used the following keywords in conjunction with Boolean operators and and or: child care, grandparenting, supplementary care providers, grandparents, quality of life, supplemental grandchild care, psychological well-being, supplementary grandparents, well-being, occupation, interventions, occupational therapy, noncustodial grandparents, shared activities and cooccupations. 7 In a thematic synthesis, Van Leeuwen et al. (2019) examined the meaning of quality of life (QoL) to older adults and defined QoL as a dynamic relationship between objective and subjective, and positive and negative influences, with health as the most important element. In Bernardo et al. (2014), older adults described QoL as being healthy, keeping busy, feeling satisfied with life, preserving interpersonal relationships, and receiving support. In contrast, Fullen (2019) found older adults well-being to be positively associated with giving support to others, rather than receiving social support. Llobet et al. (2011) found the main reasons for better QoL to be health, family, and social relationships, and the ability to adapt. Older adults adapted to bodily changes by being more attentive to the task at hand, changing how the task was performed, using technology or adaptive equipment, obtaining help from other people, or eliminating the task (Wright St. Clair et al., 2011, p. 89). As they aged, older adults redefined health in terms of ability rather than the absence of illness (Van Leeuwen et al., 2019, p. 21). Good health, the most important element of QoL, appeared to facilitate older adults ability to participate in occupations, take care of themselves, perform household tasks, and communicate (Van Leeuwen et al., 2019). To understand occupations in the context of everyday living, Wright St. Clair et al. (2011) analyzed the routines and experiences of older adults. They found that when asked about aging, older adults preferred to talk about occupations they found purposeful, such as contributing to family members. Van Leeuwen et al. (2019) identified some of the meaningful occupations of older adults as caring for others and engaging in social activities. Although Van Leeuwen et al. (2019) did not study relationships of grandparents with grandchildren, the authors found that older adults described caring for others as a meaningful occupation. Danielsbacka et al. (2019) used the Survey of Health, Ageing, and Retirement in Europe (SHARE) to investigate associations between grandparenting and subjective well-being. 8 SHARE contained five measurements of grandparents health, including self-rated health, life satisfaction, the meaning of life scores, depressive symptoms, and limitations with activities of daily living (ADL) (Danielsbacka et al., 2019, p. 194). The only significant negative association found by the researchers was between the grandparents subjective well-being and ADL limitations. These findings suggested that lower well-being is correlated with physical barriers and limitations to daily activities during grandchild care (Danielsbacka et al., 2019). Grandparents who provided more than 30 hours of supplementary grandchild care weekly were inclined to suffer adverse health consequences that are similar to custodial grandparents (Triad et al., 2014). In regard to the negative consequences of caregiving, Triado et al. (2014) found that the effects could be dependent on the types of care tasks and responsibilities the grandparent assumes. Instrumental care tasks, such as home maintenance and meal preparation, involved a large workload and were viewed as less enjoyable than other tasks. The perceived difficulty of the tasks, or even the problematic behavior of the grandchild, was associated with lower health and satisfaction (Triado et al., 2014). These consequences may be attributed to the commonality that grandparents providing intensive supplementary grandchild care participate in more instrumental tasks that require more work as opposed to less strenuous leisure activities (American Occupational Therapy Association, 2014). Triad et al. (2014) concluded that only the intensity of care predicted poorer perceived health. However, Kim et al. (2017) also found that grandparents who care for grandchildren reported feeling younger. In addition, Kinsner et al. (2017) concluded that grandparents who babysit grandchildren experience health benefits such as exercise and fewer functional limitations (p. 7). In contrast to physical health concerns, Chan et al. (2019) found that grandparents who serve as full-time caregivers encountered more psychosocial challenges despite the emotional 9 rewards of providing for their grandchildren. Grandparents psychological stress was associated with additional caregiving responsibilities, insufficient social support, and relationship tensions with the grandchilds parents (Chan et al., 2019). Additionally, grandparents who provided highintensity care experienced more negative effects on their psychological health than those who provided low-intensity care (Kim et al., 2017). In their systematic review, Kim et al. (2017) concluded that although some studies show statistically significant relationships between supplementary, or low-intensity, grandchild care, and psychological well-being, more research needed to be conducted to confirm the positive relationship. The researchers attributed the differences in findings to the complex attributes of each situation, such as length of time spent on childcare, financial outcomes, and the relationship with the parents of the grandchildren (Kim et al., 2017). Focusing on psychological aspects, researchers examined how the loss of meaningful occupations due to caregiving impacted grandparents well-being. Ludwig et al. (2007) found that full-time caregiver grandmothers experienced a loss of occupational balance, normal routine, and life satisfaction compared to less involved caregivers. As a time-consuming obligation, caring for a grandchild prevented grandparents from engaging in their preferred activities (Triado et al., 2014). In contrast, less-involved, supplementary grandmothers did not notice a loss in their everyday occupations, but rather a gain of a new role. Sixty-six percent of grandmothers reported that being a grandmother was one of the top three roles in their life (Ludwig et al., 2007, p. 48). In addition, Moore and Rosenthal (2015) found that the feeling of personal growth in the role of grandparent was associated with satisfaction and better psychological health. The grandparent-grandchild relationship contributes positively to the grandparents overall life satisfaction (Mansson, 2016). Co-occupations enhanced emotional closeness in the 10 grandparent-grandchild relationship (Mansson, 2016). Further illuminating the importance of cooccupations, Moore and Rosenthal (2015) found the frequency of activities with grandchildren was positively correlated with the life satisfaction of grandmothers rather than the number of hours spent with grandchildren. Researchers found that grandmothers and grandfathers prefer to engage in different grandparent-grandchild activities. Grandmothers reported cooking, shopping, and playing board games, whereas grandfathers reported engaging in outdoor activities, such as sports (Mansson, 2016). As opposed to co-occupations, Villar et al. (2012) focused on the experience of grandparents in their caregiver role and found that grandparents performed occupations for the purpose of assisting and filling a gap for the parents. Grandparents mainly described the circumstances of their role as providing help when maternity leave ended, for work-related tasks, leisure activities, and emergencies (Villar et al., 2012). Despite not acknowledging shared activities, all of the participants viewed their role as highly satisfactory and more relaxed than when they raised their own children (Villar et al., 2012). A review of the literature shows that researchers have studied the effect of grandparenting on QoL and well-being of grandparents, the impact of caregiving for grandchildren on chronic health conditions of grandparents, occupations restricted by caregiving responsibilities of grandparents with grandchildren, and stressors related to caregiving by grandparents for grandchildren. Researchers have focused more on grandparents who fulfill a custodial role rather than a supplementary role with their grandchildren, and have also focused more on occupations of grandparents in contrast to co-occupations of grandparents with grandchildren. To address a gap in the literature, researchers in the current study focused on the experiences of supplemental grandparents during co-occupations with their grandchildren. Methodology 11 Study Design The researchers studied the lived experiences of supplementary grandparents with their grandchildren during co-occupations using a phenomenological design. Participants The participants met inclusion criteria if they identified as a grandparent of an adopted, biological, or step-grandchild, and were English speaking. Participants were excluded if they had legal guardianship of their grandchildren. Instruments Online Survey- Google Forms The researchers developed an online survey to collect demographic information about the grandparents and their grandchildren. According to Portney and Watkins (2009), surveys can be a valuable source of data for identifying participant characteristics. Researchers solicited expert feedback from 13 faculty, with more than 100 years of combined experience in direct client care or teaching in occupational therapy, to ensure validity and feasibility of the survey questions; experts did not recommend changes to the survey (Cresswell & Poth, 2018). The survey included age and gender of the participants, their partners, their children, their grandchildren, level of education, marital status, proximity to their grandchildren, and frequency of time spent with grandchildren (See Appendix A). Individual Interviews The researchers developed 10 interview questions to be asked during individual semistructured virtual interviews. Researchers solicited expert feedback from the same faculty panel that reviewed the online demographics survey to ensure validity with the interview and focus group questions (See Appendix C). Based on the feedback, researchers added questions to collect 12 data related to expectations of the grandparenting role. Additional questions were added to address the impact of the COVID-19 pandemic on the co-occupations of grandparents and their grandchildren. Focus Group Interview The researchers developed 13 questions to guide the focus group, combining descriptive questions along with grand tour questions to understand the lived experience of supplementary grandparents and their grandchildren during co-occupations (See Appendix C). According to Spradley (1979), a grand tour question is a type of descriptive question that simulates an experience and encourages participants to talk about a specific scene. Procedures Institutional Review Board The Institutional Review Board granted approval for the study conducted at a university in the Midwest. Training Researchers trained for data collection by reviewing procedures for conducting a focus group and individual interviews using the recommendations of Liamputtong (2011). Recruitment and Enrollment Using purposeful sampling, the researchers recruited nine supplementary grandparents to participate in the study through the use of email announcements and recruitment flyers. Palinkas et al. (2015) described purposeful sampling as the identification and selection of groups or individuals who are especially knowledgeable or experienced with a phenomenon of interest (p. 2). Prospective participants contacted the principal investigator (PI) with their interest through phone or email communication. The PI sent each participant a digital informed consent 13 outlining the purpose, procedures, risks, benefits, and rights involved with participating in the study. All participants provided verbal consent to the study and were given a copy of the informed consent for their records. All participants understood that their participation was voluntary and could choose to stop at any point of the research. Data Collection Researchers prioritized the health and safety of all individuals throughout the duration of the study. Due to COVID-19, researchers conducted virtual interviews instead of planned faceto-face interviews to be in compliance with university policies and the Center for Disease Control (CDC) recommendations. Participants completed an online survey through Google Forms about demographics and time spent with grandchildren. Researchers then conducted individual semi-structured interviews lasting about an hour on a virtual platform (phone call or Zoom). Two researchers were present during interviews and additional questions were asked based upon feedback from participants. Upon review of the initial interview, researchers developed individualized follow-up questions to ask during a second virtual semi-structured interview. Participants were encouraged to virtually share and explain photographs or videos of their grandchildren or activities with grandchildren during individual interviews. Seven of the participants answered questions about grandparenting during a focus group with other grandparents using Zoom. Hollis et al. (2002) recommended that researchers limit focus groups to six to 10 participants in order for interactions and conversations to be managed effectively. The focus group lasted an hour and fifteen minutes and took place after the completion of individual interviews. Liamputtong (2011) suggested conducting a focus group 14 within one and a half hours to prevent a decrease in participants attention while allowing enough time for participants to warm up to the conversation and to encourage discussion. Otter.ai- Audio recording and transcription service The researchers utilized Otter.ai, a smart note-taking application, to record and transcribe interviews. Otter.ai identified speakers and highlighted key phrases used within the interviews. The researchers kept audio recordings of the interviews in a protected and shared folder in the Otter.ai app to easily access and review when needed. Virtual Meeting Platforms The researchers conducted the interviews through Zoom or phone calls depending on participants preferences. The focus group was completed through Zoom, an online video conference software that allowed the participants to share video and audio feedback with all researchers and other focus group participants. All data and analyses were stored in a password-protected Google folder for data storage. The researchers downloaded each participant-verified transcription from individual interviews and the focus group. The researchers added numbered lines to the individual and focus group transcripts for increased readability and consistency across the research team. Data Analysis Data collection and analysis occurred concurrently during a 12-week academic semester (Cresswell & Poth, 2018). Data were collected until saturation was achieved (Creswell & Poth, 2018). The researchers scheduled interviews with time in between to allow for member checking and analysis of data (Cresswell & Poth, 2018). Cresswell and Poth (2018) explain that data analysis in qualitative research involves organizing the data, coding and organizing themes, representing the data, and forming an interpretation of them (p.181). The researchers began 15 analysis of the data individually by reading all transcripts to familiarize themselves with the content as a whole. Cresswell and Poth (2018) suggest that scanning the data as a whole prior to coding allows the researcher to gain an understanding of the content without the increased complexities of coding (p. 187). Researchers completed individual coding of the interviews and focus group to identify themes and patterns within the data. Memos, and individual and collective codes were maintained by researchers to form an audit trail to enhance validity (Cresswell & Poth, 2018; Portney & Watkins, 2009). Cresswell and Poth (2018) explain how writing memos and taking notes throughout data analysis helps track the development of ideas and, in turn, increases the credibility of the data analysis process (p.189). The researchers combined all independent codes in a protected master codebook using Google Sheets to have a central, all-inclusive location to track the emergence of themes and patterns within the data. Cresswell and Poth (2018) endorse the value of a codebook stating the codebook articulates the distinctive boundaries for each code and plays an important role in assessing inter-rater reliability among multiple coders (p. 190). Researchers ensured triangulation through multiple researchers, multiple data collection methods, and multiple sources of data to enhance internal validity and credibility of data interpretation (Kolb, 2012; Portney & Watkins, 2009). The researchers met weekly to collectively analyze, condense, and organize the codes into well-defined and distinct themes. The researchers used MindNode (2021) to create a visual mind map of the major themes and subthemes found during data analysis to represent and display findings in a more organized manner. The researchers continued the interpretation of their findings through ongoing discussions involving comparisons to the literature. 16 Results Eight grandmothers and one grandfather ranging from 53 to 78 years of age participated in the study. Seven of the original nine participants attended the focus group. Participants had a differing number of grandchildren, ages of grandchildren, and driving distance from their grandchildren (See Appendix A). Common themes that emerged from the data among all of the participants included: co-occupations for the purpose of fun and teaching, impact of grandchild demographics on co-occupations, occupations of grandparents, demands of role, and role and relationships with parents and grandparents. The researchers condensed the major themes that emerged from coding into a visual representation (See Appendix B) using the application, Mind Node. Co-occupations Grandparents described fun and teaching as the two main purposes of co-occupations with their grandchildren. Fun co-occupations included riding bikes, visiting parks, coloring, playing ball, and looking for animals or bugs. Some co-occupations spanned several days and required advanced planning. For example, Participant 9 shared that she and her husband have a Grampops camp in the summer when the grandchildren come for as long as they can . . . to do all kinds of stuff. In contrast, grandparents also described participating in co-occupations with a single grandchild. Participant 9 elaborated on celebrating birthdays by taking each of [the grandchildren] for a birthday date and having time with each by herself to hear about events happening at school and with their friends. Participants also preferred their home environment for co-occupations with their grandchildren as it eliminated distractions and focused attention on their time together. Participant 6 described their preference of environment: 17 I think I just love having them into our house because we're kind of on our turf and they're more likely to be focused on exactly what we're doing. I mean that's sort of a selfish thing because, for instance, if were at the lake, there are all kinds of kids to play with and they're swimming so I'm sort of interacting with them but it's a big group thing so I don't have them one-on-one. So I would say we always cherish those moments when we kind of just have them to ourselves. Family events were also mentioned as fun co-occupations that included spending holidays together, going on vacation or traveling with grandchildren, and having dinner at each others house frequently. Participant 6 described concentrated togetherness during long weekend getaways to the lake house. During co-occupations, grandparents and grandchildren each fulfilled the role of teacher. When grandparents were teachers, grandchildren learned about family history, character development, life skills, and formal education. Grandparents told stories about relatives and growing up. Participants commonly described the desire to leave a legacy with their grandchildren. Participant 5 shared using ancestry.com to understand her family history, prior to taking her grandson to the cemetery: Our favorite thing to do is go to the cemetery . . . I don't get to do it very often with my [grandson] because it's too far away . . . but that's an example of storytelling in a place that means something to you. Participant 5 also elaborated on teaching about family through story-telling: I grew up on all of those stories from grandparents and talking about our relatives and that's just what we do. And, I'm excited about sharing that history with the grandkids, and my son loves it. 18 Additionally, participants used co-occupations for teaching character building in their grandchildren through reading books about faith or going to church, discussing how to treat others, teaching manners, and being aware of others feelings. Participant 6 shared, We have actually had a lot of conversations about social justice and politics. Other recurring methods of character building used by grandparents included playtime and intentionally watching movies with characters who demonstrated qualities viewed positively by grandparents. Participant 2 described using playtime as an opportunity to talk about being kind and sharing those kinds of character qualities that we would like to see in her. Grandparents additionally taught their grandchildren how to perform instrumental activities of daily living and leisure activities such as doing laundry, unloading the dishwasher, playing in the ceramic studio, visiting a museum, teaching tasks around the house (e.g., cleaning, dusting, vacuuming), fishing, teaching about and playing musical instruments, taking care of animals, and building a birdhouse. Participant 1 shared that her grandson liked to cook and bake with her and she [taught him] how to measure and all of those things. Throughout the participants reports, co-occupations with the purpose of teaching centered around home maintenance and hobbies. Grandparents engaged in co-occupations for the purpose of teaching through formal education and helping their grandchildren with homework. Participant 6 shared that she was helping with e-learning one day a week and fills in if other peoples days dont work out. Participants also engaged in co-occupations for the purpose of teaching through informal education by taking their grandchildren to the library, assisting with getting to and from school, teaching how to do sudoku, and reading books with their grandchildren. 19 It was evident that co-occupations also involved grandchildren teaching grandparents. Grandparents reported learning how to use social media applications (TikTok) and online computer software. Additionally, grandparents learned how to take selfies, perform new dance trends, and participate in geocaching. Beyond learning skills, the participants described how their grandchildren taught the value of life moments. Participant 9 stated, Our grandchildren teach us and remind us [of] just the innocence, and the joy that they see in little things, and just remind us about what's important in life. Impact of Grandchild Demographics on Co-Occupations Participants commonly noted that the demographics of their grandchildren impacted the relationship and time spent with them during co-occupations (See Appendix A). When grandchildren were younger, grandparents noted there was more of a focus on developmental activities like vocabulary, communication, and tummy time. Participants also noted that cooccupations were easier when younger grandchildren no longer needed to be carried. Participants 7 and 8 described purposefully seeking out frequent co-occupations with their younger grandchildren, stating weve done grandparents' day at school with them . . . when they were younger, we took every opportunity and we were there. Additionally, Participant 9 intentionally attended activities with young grandchildren, anticipating the impact of grandchildren aging, stating Well, they're young enough that they, I mean, basically, they just love everything we do with them. And I'm sure that's going to stop when they get older. So we're taking full advantage of it while we can. As they aged, grandchildrens interests changed, making it more challenging for grandparents to find mutually enjoyable co-occupations. Participants described that older grandchildren engaged in less play with the grandparents and were less interactive; more thought 20 was required to choose co-occupations with the older grandchildren. A recurring response from grandparents was that their role in co-occupations shifted from active participants to more observers and supporters as grandchildren aged. Participants 7 and 8 shared examples of grandchildren attending college and job interviews, as contrasted by sporting events that grandparents could watch. Participant 5 shared, I'm mostly an observer now cause they're in sports and things like that and swimming and, you know, dancing and all that kind of stuff so I'm usually just watching. Participant 2 elaborated on the reduced availability of grandchildren for co-occupations due to involvement in sports or other activities, stating: They're doing baseball or basketball, they're practicing piano and, you know, all kinds of stuff that they do though in golf. And then when they're done with it, they're still playing it. So, there's you know a lot of time that they spend doing extra things which is good, but doesn't leave a lot of extra time. Participants explained how co-occupations with grandchildren differed based on the gender of the grandchild. Granddaughters were more interested in less physically demanding activities such as playing dress-up, making jewelry, and styling each others hair. In contrast, grandsons had more physical energy and wanted to play sports, run around, and wrestle. Grandsons were also interested in toys such as transformers, cars, and video games, more so than granddaughters. Participant 9 summarized the difference between granddaughters and grandsons, sharing: We have four granddaughters, and two grandsons, and they are very different. The granddaughters like to play dress up, play with each other's hair, have me play with their hair, braid it and do all kinds of things and make jewelry, just a lot of girly things, paint 21 each other's nails. The boys, on the other hand, are wrestling on the floor, about five minutes after they get here running around like crazy children. Proximity had an impact on co-occupations and time spent with grandchildren. Being close to grandchildren allowed for random visits and more time with them. Participant 6 described the effects of living closer to grandchildren, stating, We can buzz over there at a moment's notice. It's helpful to be close. In contrast, she explained that with the grandchild who lived further away she has to just spend the whole day as opposed to spending a few hours each time. Participant 2 shared that proximity makes it easy and on a nice day she can just pick [the grandchildren] up and do a walk. For Participant 9, demands of the parent role impacted co-occupations with grandchildren. She stated, we have two special needs boys at home. And so that is the biggest thing that interrupts our time with our grandkids. Numbers and ages of grandchildren also influenced how grandparents spent their time with grandchildren during co-occupations. For example, some grandparents reported having too many grandchildren to fit everyone in a single vehicle. Others reported that younger grandchildren needing car-seats posed a challenge when planning travel. Occupations of Grandparents The participants employment status included two full-time workers, two part-time workers, one volunteer, two retired participants, and three with no history of employment. Participant 3, who worked part-time as a barista at Starbucks, indicated that her wonky schedule posed challenges to engaging in co-occupations with her grandchildren during her workweek. Participants who were retired had more time to dedicate to their grandchildren than they did when they were still working. Not only did participants have more time when they 22 retired, but they also had more energy for the [grand]kids now. More time and energy in retirement translated to Participant 6 helping with schoolwork during the COVID-19 pandemic as she stated, theres no way [she] could help with the grandchildren during e-learning if [she] was still working full-time. Participant 1 described the mixed emotions of full-time work interfering with spending time with grandchildren: [My job] makes [spending time with grandchildren] a little bit harder and maybe it's because of the impact psychologically . . . you're limited to doing something that takes away a little bit of your freedom, your ability to make your own decision. Participant 2 described prioritizing co-occupations with grandchildren over personal occupations, saying, We have put some of our extra activities on hold, things that arent essential. Many of the grandmother participants noted that their husbands still worked. As a result, the time and types of co-occupations the grandfathers shared with their grandchildren were different than those of the grandmothers. Participant 9 explained: So now [my husband] doesn't get his own day [with the grandchildren]. But he's hopefully two years away from retirement. And that's a really big thing he's hoping, you know, to crash all of our Grammy days. And there have been occasions where if we can get him to come home for lunch, it just doesn't work out very well because he's got a really high-pressure job. So for Christmas, we do experiences instead of gifts. And so we have done some things where he took the grandsons to Home Depot to build a birdhouse. And then I did you know, on a different occasion, I did things with the girl. So occasionally he does, but it's not a weekly thing. Like I mean, I have Grammy day every week. He doesn't get to do that. Demands of Role 23 Physical and Health Demands The impact of physical health and abilities on participation in co-occupations with grandchildren was a recurring theme. A positive impact on participants physical health included the exercise they experienced during many co-occupations shared with their grandchildren. Participant 1 shared, I do a lot of running, and he's [five-year-old grandson] keeping me active in terms of my physical ability with doing that. Participant 4 described the importance of being proactive with physical health in order to participate in co-occupations with her grandchild, age two, by explaining, I understand I have to do some work to keep going. But, yeah it's like if you don't then you can't do things with your grandchild. Some grandparents described reduced physical abilities during co-occupations such as difficulty lifting or rocking young grandchildren. Participant 1 stated, I'm older. It's hard to get up and down and all of that stuff but I do it. Other participants described fatigue and pain after co-occupations such as playing kickball and running around the yard with their grandchildren. Physically challenging aspects of the role were more pronounced for grandparents with chronic health conditions, as noted by Participant 9: It has a pretty big impact on it because it's something I don't think about until there's a problem but a few weeks ago, I had plantar fasciitis . . . we were playing kickball and I could hardly run and chase the ball or the kids. And that's one of the first times that it struck me that [my health] definitely has a big impact. I also have polymyalgia, which is kind of like fibromyalgia, it comes and goes and Im on medicine for so right now its fine. It affects my shoulders a lot . . . Anyway, there were times when my shoulders and knees hurt so bad that I couldn't get down on their level or pick them up when they were 24 little. And thankfully, I don't deal with that right now. But yeah, it definitely has an impact. Participants indicated several adaptations or modifications they made to preserve cooccupations with their grandchildren; these modifications were a direct result of grandparents physical limitations and younger grandchildrens limited tolerance for prolonged activity. One grandfather bought memberships to the Childrens Museum and Zoo to allow for more frequent visits of shorter durations at a reduced cost. Participant 6 described challenges with driving at night, resulting in modifications to spend time with grandchildren. Participant 1 shared, If I'm babysitting at their house and then having to drive home. I would, I'd have to stay the night there. So, but we have lots of sleepovers. Emotional and Cognitive Demands Grandparents recognized that co-occupations were opportunities for creating memories with grandchildren, one aspect of the emotional experience of co-occupations with grandchildren. Participants wanted to be remembered by being faithful, a role model, and a strong, happy, and caring person. Many participants wanted to be remembered by how much they loved their grandchildren and the time they spent together, rather than by gifts or money. Participant 9 shared: That is something I think about a lot. I hope they will remember the time that I spent with them not any money I spent on them or you know, I guess gifts you know, we just don't do that much that many gifts but, but that they will remember, you know, special times that we had all together and with each one by themselves too. Additionally, participants described the emotional experience of co-occupations using words such as love, pure joy, appreciative, thankful, and really fun. By participating in co- 25 occupations, the participants believed they enhanced their relationships with their grandchildren and improved their emotional well-being. Participant 7 described the bond his grandson had with his grandmother [Participant 8] stating, I have to tell you that he and his grandma have a bond that's unbelievable, he would do anything. He comes over, works on his computer, takes care of her in ways that even her own children didnt. Although participants reported many positive emotional experiences of co-occupations, they also admitted to negative experiences associated with co-occupations. Some described grandparenting as stressful, overwhelming, or frustrating; paradoxically, they also indicated missing their grandchildren when away from them. Some grandparents also noted the lack of resources on grandparenting, unlike the resources available for parenting, as a source of frustration. Additionally, feeling older resulted in unique emotional challenges as the participants found it harder to relate to their grandchildren. Grandparents found it emotionally challenging to hear a grandchild cry at doctor appointments or help a grandchild adjust to having a bad day. Participant 6 described the degree to which this can cause emotional challenges by saying if they're not happy then we're not happy. In addition to emotional challenges, cognitively challenging aspects of co-occupations such as a lack of understanding or interest in technology and helping with homework or elearning were described as most difficult. Participant 9 mentioned that participating in cooccupations in heavily trafficked areas with their grandchildren made it mentally challenging to "keep track of six little ones." Participant 2 shared that being around water required extra vigilance because [grandchildren] dont understand the hazards and they want to just be in the middle of it. Mentally challenging aspects of co-occupations included keeping the 26 grandchildren off their phones, not allowing them to play video games, and getting the younger grandchildren to take naps. Demands due to COVID-19 Pandemic COVID-19 had an impact on many aspects of co-occupations with grandchildren. Socially, COVID-19 resulted in fewer outings, no hugging grandchildren, distancing, limited location options for co-occupations, and straining the mental health of participants and families. The grandparents were more careful in their activities and in respecting the wishes of the parents. Participant 8 shared, Right now, you know we cant hug or touch, and that is a real problem for me as a grandmother. As a result of the pandemic, grandparents described more frequently spending time outside and finding new games, wearing a mask, and helping with e-learning were new aspects of co-occupations resulting from the pandemic. In contrast, traveling with grandchildren and participating in indoor activities decreased in frequency. Authoritative Demands A recurring aspect that participants identified as non-preferred was acting as a nanny or caregiver to their grandchildren during co-occupations. Participant 2 shared that as time spent with grandchildren increased, so did the non-preferred aspects of the grandparent role: I dont really want to be the parent, you know, I wanted to enjoy being a grandparent, but I just have them enough that we know that we will obviously be more involved in the structure and discipline. Participant 6 shared, the frustration is sometimes [the grandchildren] don't always listen to us. And so we do spend some time reminding them that were their grandparents, and they need to listen and not always push back. Whereas the participants did not prefer to take on 27 the authoritative role that accompanies caregiving, they acknowledged the responsibility that came with the supervisory role. Role and Relationships with Parents and Grandparents In regard to expectations of the grandparent role during co-occupations, Participant 9 shared, I just didn't have any idea how much I was gonna love being with them, and they are pure joy. I loved them all instantly. And it's so much different than raising your own kids. Participant 6 stated, I honestly thought people really exaggerated about how wonderful it is to be a grandparent. But once I became a grandparent, I mean, it really is just the best thing ever . . . it really just exceeded my expectations. In comparison to the parent role, the participants experienced less stress and worry in their supplemental grandparent role. Grandparents described themselves as more patient, more present, less distracted or stressed, and more purposeful during co-occupations with their grandchildren. Grandparents stated that the reduced responsibility in raising the grandchildren allowed them to be more easy-going relative to their experience in the parenting role. Participants 7 and 8 stressed that there were boundaries to their role as grandparents: The one thing that's really important to remember. And we have tried to do this. And that is being involved with your grandchildren is a great thing. And we really enjoyed them. At the same time, we are not their parents, and some of the stuff, between parents and grandchildren, and their children is none of our damn business. and we need to try to walk away from those things and not interfere. Because we are not the children's parents. And that's important, I think. Yeah, they've got to do the parenting. Grandparents described communication as an important aspect of their role and relationships with grandchildren during co-occupations. Grandparents communicated with their 28 grandchildren frequently and often daily, depending on the age of and distance from their grandchildren. The forms of communication included facetime, in person, phone calls, and through the grandchildrens parents. Living in close proximity also enabled Participants 7 and 8 to walk over to their house and knock on the door, wave at the window, and leave. Participant 6 relied on facetime with her grandchildren due to distance and indicated she would love to be texting them or emailing the two older ones, but their parents really don't encourage them. With younger grandchildren, the parents would just face the phone to [the grandchild] so I [could] see what [they are] doing. I just kind of watched [them] play. Grandparents described age as a communication barrier; some grandchildren were too young to use a phone whereas others were too old and had their own lives. Although participants described many positive aspects of the grandparent role during cooccupations, some potentially negative or challenging aspects were related to discipline. Participants varied in their opinions on discipline, but some believed discipline was necessary if they wanted the grandchildren to try new foods, if they needed a reminder to listen, or if they needed to stop running. Grandparents also shared that the parents acted on their behalf. Participant 8 stated, If they didnt respond how my daughter thought they should then she would take them aside and talk to them. When asked about the role of the grandparents in disciplining, Participant 1 reported she doesnt sweat the small stuff and is a little bit more lackadaisical. Further, Participant 9 shared that when a person is in the parent role, they have to worry about the rest of life. Participants 7 and 8 stated, We are there to be grandparents. I have never, that I recall, ever said a harsh word of discipline to any of my grandchildren. That's their parents job. Some indicated they felt comfortable disciplining their grandchildren; however, others expressed they didnt feel comfortable without the parents present or deferred to 29 parents to discipline. Participant 9 also indicated she never gives advice without asking [the parents] and respected the parents wishes in regard to disciplining the grandchildren. In general, participants described that a good relationship with the parents made it easier for the family to participate in co-occupations. Grandparents used words such as easy, strong, blessed, trusting, appreciated, close, and proud to describe their relationship with the parents. Participant 2 stated, [they] had a mutual respect and love for each other. The positive relationship between the grandparents and parents allowed for more ease in regard to access to and frequency of co-occupations between grandparents and grandchildren. Participant 9 further elaborated on the importance of gaining parental approval for co-occupations: We don't do anything that the parents don't want us to do. I think that is a really big factor because they wouldn't want us to have [the grandchildren] if we went behind their back, or we did things that they didn't want them doing. Despite the positive aspects, the relationship between the grandparents and parents also presented some challenges that impacted the relationship between grandparents and grandchildren. Participants agreed that they often resolved problems with the parents for the sake of the grandchildren. Participant 5 elaborated stating they attempt to not hold grudges or bad mouth. Other challenges in the relationship with the parents that impacted co-occupations were due to grandparents having a previous role of custodial grandparent, excessive work demands, absence of a parent due to the military, or parents having their own lives. A recurring response about the relationship with the parents revolved around the importance of daughter/daughter-in-law relationships. Participants agreed that relationships with daughters-in-law had more of an impact because it could influence the number and duration of opportunities for co-occupations with their grandchildren. Participant 6 shared, I feel really 30 grateful right now that I have two daughters because I think it's easier to be the grandparents of the daughters children. The relationship with the daughter, in contrast to the relationship with the daughter-in-law, provided grandparents with increased comfort in reaching out to see the grandchildren. Participant 6 elaborated, If you're a mother-in-law you don't want to step on your [daughter-in-laws] toes, where, you know, my daughters feel free to speak their mind. Participants believed that daughter relationships positively influenced the frequency and ease of engagement in co-occupations with their grandkids, due to increased comfort with it being their own daughter. Many participants indicated needing to work harder at establishing a good relationship with their daughters-in-law, compared to their sons-in-law, to engage in cooccupations with their grandchildren. Discussion Found throughout the data, participants indicated that co-occupations enhanced the relationship between the grandparent and grandchild and that co-occupations contributed to the grandparents emotional well-being. Similar to the findings of Ludwig et al. (2007) and Mansson (2016), grandparents described co-occupations as being the most enjoyable aspect of the relationship and contributing to emotional closeness (Ludwig et al., 2007; Mansson, 2016). Moreover, the grandparents in the current study described their relationships with their grandchildren as meaningful, similar to the older adults in studies by Bernardo et al. (2014) and Llobet et al. (2011) whose QoL was linked to interpersonal relationships. Participants in the current study supported findings from Moore and Rosenthal (2015) that satisfaction with grandchild care and frequency of co-occupations positively impacted their life satisfaction. However, the researchers in the current study additionally found how grandparents have learned and continued developing through participation in co-occupations with their grandchildren, 31 acknowledging improvements in patience, joy and appreciation for the seemingly insignificant moments, and technology use. Danielsbacka et al. (2011) utilized self-rated health, life satisfaction, the meaning of life scores, depressive symptoms, and limitation with activities of daily living (ADL) as measurements to explore the association between grandparenting and subjective well-being. Although the researchers did not focus on co-occupations of grandparents and grandchildren in their quantitative study, they found a correlation between physical limitations with ADLs and lower subjective well-being (Danielsbacka et al., 2011). The participants in this current study reported ADL limitations during co-occupations such as the inability to drive in the dark and reduced physical capacity when playing outside and carrying grandchildren. Likewise, the findings of the current study were consistent with Wright et al. (2011) in that grandparents focused on describing co-occupations they enjoyed, while focusing less on challenges or difficulties they experienced during co-occupations with their grandchildren. Fullen (2019) noted that older adults with positive outlooks on life were more likely to participate in preventative health behaviors. Similarly, in the current study, all participants had positive outlooks about their role as a grandparent, however, only a few mentioned that engagement in co-occupations increased their likelihood to participate in preventative health behaviors. Partially consistent with findings from Kim et al. (2017) and Kinsner et al. (2017), grandparents reported that participation in co-occupations between grandparents and grandchildren encouraged an active lifestyle of grandparents, but the current study also indicated that co-occupations occasionally led to feelings of aging in grandparents due to inability to use technology or understand content to help teen-age grandchildren with homework. Physical barriers such as feeling exhausted when caring for their grandchildren, difficulty balancing 32 memory and physical demands, not being able to drive grandchildren at night due to aging, and decreased vision in the dark, made the participants feel older. The participants in the current study recognized that they were providing assistance and understood the benefits of their role to the families of their grandchildren, but never identified it as the primary reason for providing care and engaging in co-occupations. This finding contrasts with those of Chamie (2018) and Villar et al. (2012), who reported grandparents tended to provide more financial and caregiving assistance to families, such as help when maternity leave ended, and for work-related tasks, leisure activities, and emergencies. Unlike Fullen (2019), grandparents in the current study did not describe receiving support from children or grandchildren as motivation for providing childcare. Instead, they focused on the enjoyment they received during co-occupations when they served as a resource to children and grandchildren, and in spending time with grandchildren. In Triado et al. (2014), grandparents who provided high-intensity care experienced more negative effects on their psychological health than those who provided low-intensity care. On the contrary, participants in the current study talked primarily about physical stress related to the age of the child, not necessarily psychological stress. The psychological stress reported by grandparents in the current study was more related to concerns for safety, discipline, and missing the childrens presence. Contradicting values between grandparents and parents also contributed to psychological stress during co-occupations such as eating meals together. In addition, in the current study, stress surrounding the impact of the relationship between grandparents and parents, specifically with daughters and daughters-in-law, on co-occupations and frequency of co-occupations was mentioned. The current study showed unique findings that participants believed a positive relationship with daughters and daughters-in-law increased their ability to 33 participate in co-occupations with their grandchildren more than the relationship with sons and sons-in-law. Villar et al. (2012) found that all of the grandparents viewed their role as highly satisfactory and more relaxed than when they raised their own children in the role of a parent. Similarly, grandparents in the current study discussed feeling that their role as grandparents was more lackadaisical than when they were parents. Participants in the current study reported satisfaction in their role through the feelings of joy and pride during co-occupations with grandchildren. Although grandparents enjoyed their role, they reported having non-preferred roles as caregivers and disciplinarians when they spent an increased amount of time with their grandchildren. This finding is consistent with an observation by Chan et al. (2019) that psychological stress was associated with additional caregiving responsibilities. Grandparents in the current study reported that they did not always feel comfortable with disciplining their grandchildren without parents approval and identified that discipline presented differently as their grandchildren aged. The researchers in the current study found that proximity to grandchildren influenced the co-occupations of the grandparent and grandchild. Grandparents who lived closer to their grandchildren reported more opportunities to participate in co-occupations, a finding consistent with Villar et al. (2012). Additionally, new findings included the impact of the age of grandchildren on co-occupations. As grandchildren aged, the grandparents roles in cooccupations shifted from active participants to observers and supporters. Some grandparents reported missing co-occupations they participated in when their grandchildren were younger, but also expressed excitement to watch their grandchildren age and experience life milestones such as weddings. Although the co-occupations changed, the grandparents in the current study never 34 indicated less satisfaction with the role, unlike Triado et al. (2014) who found providing care for older grandchildren was less rewarding for grandparents. Conclusion Researchers focused on understanding the lived experiences of supplemental grandparents with their grandchildren during co-occupations. They found that co-occupations enhanced the relationship between the grandparent and grandchild, contributed to the grandparents emotional well-being, and encouraged an active lifestyle of grandparents. Grandparents also experienced physical and cognitive demands during co-occupations, prompting modifications to preserve participation. Age of and proximity to grandchildren impacted types of co-occupations performed. As grandchildren aged, the grandparents roles in co-occupations shifted from active participants to observers and supporters. The focus of this study may have limited the sample of participants to those who enjoyed and wanted to talk about their role as grandparents. Although the participants also discussed some negative aspects of co-occupations, they may have been more inclined to describe positive views. In addition, the study was designed prior to the COVID-19 pandemic and data collection occurred concurrently with the pandemic, therefore the discussions were more shifted towards the effects of the pandemic. Due to the virtual environment of the focus group and individual interviews, participants may have not felt comfortable with sharing details relating to negative experiences, limiting a full understanding of the lived experiences of grandparents during cooccupations with grandchildren. Experiences during co-occupations of grandparents unable to use technology were not represented because of the exclusion criteria for the study. Lastly, all but one participant was a grandmother, therefore grandfathers were underrepresented. 35 Due to the preponderance of studies of parent-child co-occupations, researchers should focus investigations on grandparent-grandchild co-occupations. Additionally, researchers should emphasize in-person interviews and expand to include more grandfathers. Participants briefly discussed how the age of grandchildren impacted co-occupations, but the differences in the grandparenting role based on the age of grandchildren should be studied further. Researchers also did not ask grandparents if participating in co-occupations yielded health benefits, therefore, it could be that these benefits, or preventative health behaviors, were under-reported, warranting investigation. Conversely, research regarding the mental and physical challenges of grandparents as influenced by the age of grandchildren is recommended to fully understand the lived experiences of supplemental grandparents during co-occupations. The findings of this study can help occupational therapy practitioners anticipate and understand the benefits and challenges associated with co-occupations of grandparents and grandchildren. Understanding the demands of co-occupations can lead to modifications to maintain co-occupations and the valued role of being a grandparent. 36 References American Occupational Therapy Association. (2014). Occupational Therapy Practice Framework: Domain and process (3rd ed.). American Journal of Occupational Therapy, 68(Suppl. 1), S1S48. http://doi.org/10.5014/ajot.2014.682006 Baethge, C., Goldbeck-Wood, S., & Mertens, S. (2019). SANRAa scale for the quality assessment of narrative review articles. Research integrity and peer review, 4(1). https://doi.org/10.1186/s41073-019-0064-8 Bernardo, E. M., Sanchez, C. S., & Vicario B. P. (2014). Perception of the quality of life of a group of older people. Revista de Enfermagem Referncia, 4, 7381. https://doi.org/10.12707/RIII1314 Chamie, J. (2018, September 4). Increasingly indispensable grandparents. Retrieved from https://yaleglobal.yale.edu/content/increasingly-indispensable-grandparents Chan, K. L., Chen, M., Lo, K. M., Chen, Q., Kelly, S. J., & Ip, P. (2019). The effectiveness of intervention for grandparents raising grandchildren: A meta-analysis. Research on Social Work Practice, 29(6), 607-617. https://doi.org/10.1177/1049731518798470 Cresswell, J. W., & Poth, C. N. (2018). Qualitative inquiry & research design (4th ed.). Sage. Dang, D., & Dearholt, S. L. (2017). Johns Hopkins Nursing Evidence-Based Practice, Third Edition: Model and Guidelines (3rd ed.). Sigma Theta Tau International. Danielsbacka, M., Tanskanen, A. O., Coall, D. A., & Jokela, M. (2019). Grandparental childcare, health, and well-being in Europe: A within-individual investigation of longitudinal data. Social Science & Medicine, 230, 194-203. https://doi.org/10.1016/j.socscimed.2019.03.031 37 Di Gessa, G., Glaser, K., & Tinker, A. (2015). The health impact of intensive and nonintensive grandchild care in Europe: New evidence from SHARE. The Journals of Gerontology Series B: Psychological Sciences and Social Sciences, 71(5), 867-879. https://doi.org/10.1093/geronb/gbv055 Fullen, M. (2019). Defining wellness in older adulthood: Toward a comprehensive framework. Journal of Counseling and Development, 97, 62-74. https://doi.org/10.1002/jcad.12236 Hollis, V., Openshaw, S., & Goble, R. (2002). Conducting focus groups: Purpose and practicalities. British Journal of Occupational Therapy, 65(1), 2-8. https://doi.org/10.1177/030802260206500102 Kim, H.J., Kant, H., & Johnson-Motoyama, M. (2017). The psychological well-being of grandparents who provide supplementary grandchild care: A systematic review. Journal of Family Studies, 23(1), 118-141. https://doi.org/10.1080/13229400.2016.1194306 Kinsner, K., Parlakian, R., & MacLaughlin, S. (2017). Grandparents who care: Literature review. Zero to Three. https://www.zerotothree.org/resources/1997-grandparents-whocare-a-literature-review Kolb, S. (2012). Grounded theory and the constant comparative method: Valid research strategies for educators. Journal of Emerging Trends in Educational Research and Policy Studies, 3(1), 83-86. Liamputtong, P., (2011). Focus group methodology: Principles and practice. Sage Publications. Llobet, M. P., Avila, N. R., Farrs Farrs, J., & Canut M. T. L. (2011). Quality of life, 38 happiness and satisfaction with life of individuals 75 years old or older cared for by a home health care program. Revista Latino-Americana De Enfermagem, 19, 467475. Ludwig, F. M., Hattjar, B., Russel, R. L., & Winston, K. (2007). How caregiving for grandchildren affects grandmothers meaningful occupations. Journal of Occupational Science, 14(1), 40-51. https://doi.org/10.1080/14427591.2007.9686582 Mansson, D. H. (2016). The joy of grandparenting: A qualitative analysis of grandparents, Journal of Intergenerational Relationships, 14(2), 135-145. https://doi.org/10.1080/15350770.2016.1160738 MindNode. (2021). IdeasOnCanvas GmbH (Version 2021.1.2) [Mobile application software]. Retrieved from https://www.mindnode.com Moore, S. M., & Rosenthal, D. A. (2015). Personal growth, grandmother engagement and satisfaction among non-custodial grandmothers. Aging & Mental Health, 19(2),136-143. https://doi.org/10.1080/13607863.2014.920302 Palinkas, L. A., Horwitz, S. M., Green, C. A., Wisdom, J. P., Duan, N., & Hoagwood, K. (2015). Purposeful sampling for qualitative data collection and analysis in mixed method implementation research. Administration and Policy in Mental Health, 42(5), 533544. https://doi.org/10.1007/s10488-013-0528-y Portney, L. G., & Watkins, M. P. (2009). Foundations of clinical research: Applications to practice (3rd ed.). Pearson Education Inc. Spradley, J. (1979). Asking descriptive questions. The Ethnographic Interview (1st ed.). Wadsworth Group. Triad, C., Villar, F., Celdrn, M., & Sol, C. (2014). Grandparents who provide auxiliary 39 care for their grandchildren: Satisfaction, difficulties, and impact on their health and wellbeing. Journal of Intergenerational Relationships, 12(2), 113-127. https://doi.org/10.1080/15350770.2014.901102 Van Leeuwen, K. M., Van Loon, M. S., Van Nes, F. A., Bosmans, J. E., De Vet, H. C. W., Ket, J. C. F., Widdershoven, G.A.M., & Ostelo, R. W. J. G. (2019). What does quality of life mean to older adults? A thematic synthesis. PLoS ONE, 14(3). https://doi.org/10.1371/journal.pone.0213263 Villar, F., Celdrn, M., & Triad. (2012). Grandmothers offering regular auxiliary care for their grandchildren: An expression of generativity in later life? Journal of Women and Aging, 24(4), 292-312. https://doi.org/10.1080/08952841.2012.708576 Wright St. Clair, V. A., Kerse, N., & Smythe, E. (2011). Doing everyday occupations both conceals and reveals the phenomenon of being aged. Australian Occupational Therapy Journal, 58, 88-94. https://doi.org/10.1111/j.1440-1630.2010.00885.x 40 Appendix A Table 1 Grandchildren Demographics Participant Total Number of Grandchildren Age Range of Grandchildren (years) Proximity to Grandchildren 1 2 0.5 - 5 10- 30 min 2 2 0.5 - 2 <10 min 3 2 2-7 <10 min 4 1 2 2+ hours 5 8 5 - 14 <10 min; 60 min; 2+ hours 6 3 4 - 11 30 min; 75 min 5 17 - 21 <10 min 5 5 - 10 30 min 7 8 9 Note. Participants 7 and 8 are married and share the same grandchildren. 41 Appendix B Mind Mapping of Emerging Themes Note. Visual representation of major themes and sub-themes found throughout data analysis. 42 Appendix C Individual Interview Questions: 1. Describe a favorite or special activity with your grandchild (grandchildren). 2. Describe a least favorite activity with your grandchild (grandchildren). 3. (Before the coronavirus pandemic,) what activities do you wish you could do more with your grandchild (grandchildren)? 4. Does your relationship with your grandchilds (grandchildrens) parents make it easier or harder to spend time with your grandchild (grandchildren)? How so? 5. (Before the coronavirus pandemic,) how do you keep up communication with your grandchild (grandchildren)? 6. How does your employment status impact your relationship and the time you spend with your grandchild (grandchildren)? 7. How does the distance you live from your grandchild (grandchildren) impact the time you spend with your grandchild (grandchildren) and the activities you participate in together? 8. Tell us more about what your expectations of becoming a grandparent were? How did this differ from your current experience as a grandparent? 9. Describe how your experiences with your grandchild (grandchildren) have been the same or different as a result of the coronavirus. 10. If you are interested in sharing a picture, you can hold it up to the screen to show us. Can you tell us about the picture you shared? OR Can you describe a photo of you and your grandchild (grandchildren)? Focus Group Interview Questions: 43 1. Share a story about a time you learned something as a result of spending time with your grandchild (grandchildren). 2. Tell us about a typical day with your grandchild (grandchildren) outside. 3. Tell us about a typical day with your grandchild (grandchildren) inside. 4. Tell us about a day that would not be so typical. 5. Describe the most physically challenging part about spending time with a grandchild (grandchildren). Contrast that with the most mentally challenging part about spending time with a grandchild (grandchildren). 6. How has your role as a grandparent changed as your grandchild (grandchildren) has aged? 7. Tell us about what interrupts time spent with your grandchild (grandchildren)? 8. Describe some of the conversations you have with your grandchild (grandchildren). 9. Describe some of the locations where you and your grandchild (grandchildren) spend time. 10. Describe a time when you wished the day would not end when you were with your grandchild (grandchildren). What about a time when it did not end soon enough? Signature: Email: decleenek@uindy.edu  ...

... Running head: HEALING HORSESHOES Doctoral Capstone Written Project: Healing Horseshoes Elizabeth A. Brock January 19, 2021 A research project submitted in partial fulfillment for the requirements of the Doctor of Occupational Therapy degree from the University of Indianapolis, School of Occupational Therapy. Under the direction of the faculty mentor: Taylor McGann, OTR, MS, OTD 1 HEALING HORSESHOES 2 Healing Horseshoes Elizabeth Brock, OTS, PCBIS University of Indianapolis HEALING HORSESHOES 3 Abstract Autism spectrum disorder (ASD) is a developmental disability that presents deficits in communication and social participation (Vanessa & Simmonds, 2018). For children diagnosed with ASD, their occupational engagement increased after participating in equine-assisted therapy (Grockien et al., 2018; Llambias et al., 2016). The purpose of this literature review is to explore the research on the role of an occupational therapy (OT) practitioner within The Equine Assisted Growth and Learning Association (EAGALA) interdisciplinary team, the effectiveness of equine-assisted therapy, and the benefits of equine-assisted therapy to the ASD population. Healing Horseshoes is a doctoral capstone experience (DCE) project that aims to develop and advocate for an OT practitioners role in EAGALAs interdisciplinary team at BC Stables and Training Center Missouri, USA. The purpose of this study was to investigate potential relationships between OTs role in the EAGALA model, specifically to investigate potentially expanding the populations EAGALA serves. There was a positive clinical relationship between OT and EAGALA found in the data. Participants viewed the addition of an OT practitioner to the EAGALA interdisciplinary model to be beneficial, increase the populations they serve, and some would potentially hire or support the hire of an OT practitioner. HEALING HORSESHOES 4 Healing Horseshoes A horse is like a mirror to your soul. Like a mirror, a horse does not flatter but reflects an individuals emotions such as aggression, anxiousness, confidence, etc. Horses are prey animals, making them hypervigilant to their environment; therefore, they have developed a keen awareness of non-verbal communication (Notgrass & Pettinelli, 2015). Horses share several similarities to humans; thus, their behavior easily translates to the individuals current situation (Notgrass & Pettinelli, 2015). Allowing individuals to work through their emotional problems with a horse is therapeutic and it creates opportunities for self-growth and learning (Notgrass & Pettinelli, 2015). EAGALA is a global association that uses an interdisciplinary team approach that provides psychotherapy and personal development incorporating horses (Equine Assisted Growth and Learning Associations [EAGALA], 2018). Lee et al. (2020) found individuals diagnosed with functional or cognitive impairments could meaningfully engage and find purpose from their therapy experiences under the EAGALA model. The EAGALA model is appropriate for a single participant, family, or group (EAGALA, 2018). The EAGALA team model consists of a minimum of an equine specialist and a mental health professional (EAGALA, 2018). The EAGALA model encourages the participant(s) to lead the session while the facilitators, the mental health professional and equine specialist, are observing the participant and not directing them (EAGALA, 2018). All sessions within the EAGALA model take place on the ground, the participant(s) do not complete mounted activities or ride (McNamara, 2017). The facilitators will set-up an activity for the participant(s) and the horse to complete without any guidance, directions, roles, etc. This set-up promotes the participant(s) to engage and communicate with the horse directly. The facilitators only relay feedback to the participant(s) based on their observations of the horses interactions and the HEALING HORSESHOES 5 participant(s). Allowing the participant(s) to guide the session encourages self-awareness followed by self-reflection leading to new insights and behavioral changes within the participant(s) (Notgrass & Pettinelli, 2015). The equine specialist has professional experience and training in horse behavior and psychology (Notgrass & Pettinelli, 2015). The equine specialist and mental health professional work together to translate the horses behavior and the participant(s) pattern of behaviors throughout the activity to the participants current life situation. Upon completing the activity, the mental health professional guides the participant(s) in working through their emotional and/or mental barriers that are prevent their progress towards their life goals (Notgrass & Pettinelli, 2015). The equine specialist will continue to set-up appropriate activities to encourage further progression toward the participants goals as needed (Notgrass & Pettinelli, 2015). Researchers found participants reported resolution of deep issues that clients were unable to solve through traditional talk-based therapies (Notgrass & Pettinelli, 2015). The purpose of this literature review is to explore the research on the role of an OT practitioner within an EAGALA interdisciplinary team, the effectiveness of equine-assisted therapy, and the benefits of equine-assisted therapy to the ASD population. Upon reviewing the literature, researchers did not find OT practitioners addressing individuals mental health through equine-assisted therapy services. Therefore, the purpose of this study was to investigate potential relationships between OTs role in the EAGALA model, specifically to investigate potentially expanding the populations EAGALA serves. HEALING HORSESHOES 6 Literature Review Occupational Therapy Equine-assisted therapy is within the scope of practice for an OT practitioner; however, it is still considered an emerging area of practice due to limited research (Baker, 2015). OT practitioners are skilled professionals in several medical conditions, allowing them to treat a diverse population with equine-assisted therapy. OT practitioners conduct an occupational profile and evaluation to gather a holistic picture of the client while building rapport with their client (Baker, 2015). The OT practitioner and client work alongside one another to establish client-centered goals (Baker, 2015). To best help the client meet their goals, the OT practitioner modifies the clients environment to promote functionality, independence, and safety (Baker, 2015). All sessions include evidence-based interventions, and the OT practitioner administers an outcome measure to track the clients progress toward their goals (Baker, 2015). OT aims for a holistic approach including not only the client but their family too. Equine-assisted therapy provided an overall more positive family dynamic that was beneficial to all parties involved in the study (Vanessa & Simmonds, 2018). Vanessa and Simmonds (2018) conducted a study from the parents perception to understand the positive and/or negative impacts their children experienced after participating in equine-assisted therapy. Parents reported several levels of psychosocial benefits for themselves and their children (Vanessa & Simmonds, 2018). Parents reported an increase in their childs engagement and calmness while on the horse, which was uncommon for their diagnosis of ASD (Llambias et al., 2016). The childs engagement in the session increased because the therapy horse served as a primary motivator (Grockien et al., 2018). The child was statistically significantly more motivated to engage in future therapy sessions after attending at least three HEALING HORSESHOES 7 sessions prior (Grockien et al., 2018). For example, a child diagnosed with a medical condition from a young age has potentially received typical OT within a clinic for several years. Equineassisted therapy provides a change in scenery for the child while still offering the therapeutic benefits of OT. OT practitioners and their clients benefit from implementing equine-assisted therapy into their sessions (Grockien et al., 2018; Llambias et al., 2016; Vanessa & Simmonds, 2018). The child and their family members had a positive experience when their OT incorporated equine-assisted therapy (Grockien et al., 2018; Llambias et al., 2016; Vanessa & Simmonds, 2018). Further research is needed to solidify the current findings and move equine-assisted therapy out of an emerging practice area. Future research is also necessary to find therapeutic benefits for children diagnosed with ASD receiving equine-assisted therapy from an OT practitioner working under the EAGALA model. Population at Risk Autism spectrum disorder is a developmental disability that presents with deficits in communication and social participation (Vanessa & Simmonds, 2018). This population is at risk for psychosocial difficulties throughout their life, impeding their ability to live independently, find employment, and relationships (Vanessa & Simmonds, 2018). Children diagnosed with ASD are at risk for occupational deprivation (Little et al., 2014, cited in LeVesser & Berg; Rodger & Umaibalan, 2011). For children diagnosed with ASD, their occupational engagement increased after participating in equine-assisted therapy (Grockien et al., 2018; Llambias et al., 2016). Children diagnosed with ASD and who participated in equine-assisted therapy were functioning with higher levels of self-regulatory abilities which allowed for increased positive behaviors (Vanessa & Simmonds, 2018). Children diagnosed with ASD presented with reduced HEALING HORSESHOES 8 hyperactive behaviors and irritability after engaging in equine-assisted therapy (Gabriels et al., 2015). Vanessa & Simmonds (2018) found that children diagnosed with ASD thrived in an environment that they felt secure and comfortable because they were rooted in routines, habits, and behaviors (Vanessa & Simmonds, 2018). Humans rely heavily on verbal and non-verbal communication which is difficult for those diagnosed with ASD (Anderson & Meints, 2016). A therapy horse can deliver clear non-verbal communication that is easy to understand for child diagnosed with ASD (Anderson & Meints, 2016). The child and the horse communicate directly with one another (Anderson & Meints, 2016). Direct communication allows the child to receive simultaneous feedback, facilitating increased awareness of oneself and behaviors (Anderson & Meints, 2016). Children diagnosed with ASD increased their social interactions with peers and diverged from routine activities after participating in equine-assisted therapy. Grockien et al. (2018) reported children diagnosed with ASD in their study had increased patience, confidence, autonomy, and communication skills after engaging in equine-assisted therapy. Overall, several researchers have found evidence to support the use of equine-assisted therapy with the ASD population. Equine-Assisted Therapy Equine-assisted therapy involves the use of a horse as the therapy animal during the session. Vanessa and Simmonds (2018) found a horse to be an appropriate therapy animal for children diagnosed with ASD because of their perceived nonjudgmental and accepting nature. A horse can encourage positive behaviors such as respect, compliance, and open communication (McNamara, 2017, cited in Masini, 2010; Ratliffe & Sanekane, 2009). The positive effects of human and equine interactions were statistically significant (Gabriels et al., 2015). Researchers HEALING HORSESHOES 9 described an animal in a therapy session as a social lubricant between the therapist and child, allowing more self-disclosure due to an increase in the childs comfort level (Wilson et al., 2017, cited in Friesen, 2010; Levinson, 1969). Specifically, children that participated in equine-assisted therapy under the EAGALA model had improved aggression, anxiety, behaviors towards peers, and attention (Harvey et al., 2020). Childrens attention and time of engagement in the therapy increases in therapy sessions that include a horse compared to a therapy session without a horse (Llambias et al., 2016). The horses body warmth and rhythmic gait provide a calming effect to the children riding (Gabriels et al., 2015). Trzmiel et al. (2019) found children diagnosed with ASD benefited from equineassisted activities and therapy. Children diagnosed with ASD had increases in their functional mobility after participating in equine-assisted therapy (Grockien et al., 2018; Trzmiel et al., 2019). Trzmiel et al. (2019) found children diagnosed with ASD had increases in their trunk stability after engaging in equine-assisted therapy. A child diagnosed with ASD also had psychosocial gains after participating in equine-assisted therapy, such as reduced aggression and improved social integrative skills (Trzmiel et al., 2019). Vanessa and Simmonds (2018) found the childs social participation and ability to regulate their emotions improve after participating in equine-assisted therapy. Overall, the researchers supported mental, physical, and occupational benefits from engaging in equine-assisted therapy (Vanessa & Simmonds, 2018). There is limited research in the area; therefore, some researchers are still not convinced that there is enough research to support human-animal interactions (Lanning et al., 2014). Healing Horseshoes Healing Horseshoes is a DCE project that aims to develop and advocate for an OT practitioners role working within EAGALAs interdisciplinary team at BC Stables and Training HEALING HORSESHOES 10 Center located in Missouri, USA. BC Stables and Training Center already provides EAGALA services and has a third-party mental health professional that travels in for their sessions. EAGALA organizations typically offer their services to participants with substance use disorders, trauma, and abuse (Buck, Bean, & Marco, 2017). However, the EAGALA model can serve additional populations with the correct professionals on their interdisciplinary team. The training center has the capability to provide services to other populations; however, equine specialists and mental health professionals are not licensed to provide therapy to children with ASD or other medical conditions. Several organizations providing equine-assisted services refer to their business as equine-assisted learning or coaching facility to avoid insurance and the need for referrals (Wood et al., 2020). OT practitioners can offer their expertise to these already established EAGALA organizations to expand the populations they serve. By hiring an OT practitioner, the business will be able to offer its services through insurance, potentially attracting new populations through referrals. However, there is a lack of knowledge on OT as a profession; therefore, OT practitioners need to advocate for their skills to increase referrals. In return, more children diagnosed with ASD or any other medical condition will have opportunities for meaningful occupations through their participation in equine-assisted therapy services. Occupational therapy is a holistic profession that helps people across the lifespan independently engage in activities in their daily life that are meaningful to them, also known as occupations (American Occupational Therapy Association [AOTA], 2021). OT practitioners serve diverse populations across the lifespan, including all EAGALAs current populations (AOTA, 2021). OT practitioners currently perform hippotherapy services, which include primarily physical disabilities but fail to address mental health disabilities. The EAGALA model HEALING HORSESHOES 11 offers OT practitioners an opportunity to utilize an equine-assisted therapy model to address mental, emotional, social, psycho-social, and physical conditions that are common barriers to the clients ability to engage in their meaningful life occupations. Advocating and developing a program for an OT practitioners role within the interdisciplinary team can provide opportunities for EAGALA organizations to increase the diversity in the populations they serve such as children diagnosed with autism spectrum disorder (ASD). This population is at risk for occupational deprivation due to their limited opportunities to participate in occupations as typically developing children (Little et al., 2014, cited in LeVesser & Berg; Rodger & Umaibalan, 2011). Children diagnosed with ASD experience a lack of available opportunities to engage in meaningful occupations (Little et al., 2014, cited in LeVesser & Berg; Rodger & Umaibalan, 2011). The ASD population would benefit from having greater access to meaningful occupations. To improve access for children diagnosed with ASD or any other complex diagnosis to EAGALA resources, a trained and knowledgeable medical professional such as an OT is required. OT practitioners have expertise in activity analysis, skilled observation, and environmental modifications that encourage maximal participation for several populations. Creating a position for an OT practitioner starting at BC Stables and Training Center, as well as EAGALA organizations will increase accessibility to equine-assisted therapy for children diagnosed with ASD to increase their engagement in meaningful occupations. If other EAGALA organizations followed suit, more children diagnosed with ASD would have more opportunities for occupational engagement. Children diagnosed with ASD did not have the same availability to meaningful occupations as typically developing children their age; therefore, the children experienced occupational deprivation (Llambias et al., 2016). Children diagnosed with ASD had HEALING HORSESHOES 12 decreased accessibility to equine-assisted therapy services; consequently, they were unable to benefit from the services or develop their experiences into a meaningful occupation as typically developing children could (Grockien, Dovidaitien, Kerzien, & Stankeviius, 2018; Llambias et al., 2016). There is a need for more equine-assisted therapy programs such as Healing Horseshoes, to advocate and offer their services to children diagnosed with ASD to reduce occupational deprivation in the ASD population. Model of Human Occupation I have chosen the Model of Human Occupation (MOHO) to guide the direction of the DCE project, Healing Horseshoes. The MOHO is a valid occupation-based model for children diagnosed with ASD (Cole and Tufano, 2008). An OT practitioner can use the MOHO to understand the clients volition, habituation, and performance capacity to increase their occupational engagement (Cole and Tufano, 2008). OT practitioners can use the MOHO within Healing Horseshoes to understand how the environment contributes to the clients motivation to participate, behavioral patterns, and functional performance (Cole and Tufano, 2008). For Healing Horseshoes to be sustainable, the program must utilize the MOHO and the occupational therapy practice framework (OTPF) to determine the clients occupations, habits, intrinsic motivators, performance skills and patterns, and the context/environment (American Occupational Therapy Association [AOTA], 2014; Cole and Tufano, 2008). Therefore, the OT practitioner can use the MOHO to understand how to adapt the environment to meet the clients needs to facilitate new skills and increase their occupational performance by incorporating equine-assisted OT. According to the MOHO, client motivation is the key to occupational engagement, and past researchers found using a horse within therapy sessions to be highly motivating for clients HEALING HORSESHOES 13 (Baker, 2015; Cole & Tufano, 2008). Notgrass & Pettinelli (2015) found the child and the horse formed a meaningful bond within the EAGALA model; therefore, the horse becomes an intrinsic motivator to the child. Researchers found that children demonstrated increased participation in the therapy sessions because the child found it personally rewarding to interact with the horse (Notgrass & Pettinelli, 2015). Children diagnosed with ASD do not have the same availability to meaningful occupations as typically developing children their age (Llambias et al., 2016). Therefore, the MOHO is an appropriate choice for guiding Healing Horseshoes through program development and advocacy so that children diagnosed with ASD can engage in meaningful occupations. Methodology I conducted a quantitative research study to investigate potential relationships between OT and the EAGALA model. I hypothesized a positive relationship and improved benefits for EAGALA organizations if they created a role for OT practitioners within their interdisciplinary team. Also, I hypothesized that EAGALA organizations with OT practitioners might expand their services to populations facing occupational injustice, such as children diagnosed with ASD. Deductive reasoning was applied to test the hypothesis on the benefits of adding an OT practitioner to the EAGALA interdisciplinary team. A survey-based questionnaire was developed to send out to participants to test the hypothesis. Participants To collect relevant data, I required participants to be associated or knowledgeable with the EAGALA model, an EAGALA organization, equine services, OT or hippotherapy within the local community. I did not set any exclusion criteria for age, gender, ethnicity, or religion. I utilized the EAGALA website to locate local EAGALA organizations. I obtained potential HEALING HORSESHOES 14 participants contacts and contacted potential participants that met inclusion criteria through email and phone. I explained the purpose of the DCE project and the questionnaire to the potential participants. Individuals responded to my email with their preferred email address if they were interested in participating in the questionnaire and study. I emailed the questionnaire to those willing participants. I emailed the questionnaire to ten potential participants; however, only six participants returned it completed. I obtained data from equine specialists, mental health professionals, and EAGALA business owners from four various local EAGALA organizations. Setting This study took place at BC Stables and Training Center located in Fair Grove, MO. I conducted the study in January of 2021. All participants were associated with EAGALA organizations within one hundred miles of BC Stables and Training Center. I determined a onehundred-mile radius so that data collected was generalizable to the local community members perceptions on the topic. Healing Horseshoes was developed to be implemented in Fair Grove, MO; therefore, the community members input is beneficial to the programs success. Also, the coronavirus disease 2019 (COVID-19) restrictions were in place during the study. Therefore, communication with the participants was completed virtually due to COVID-19 restrictions. Measure After receiving permission of exempt study approval by the University of Indianapolis Human Research Protections Program, quantitative design was utilized to investigate possible relationships between OT and the EAGALA model. The questionnaire was designed online through Google forms. The questionnaire was made up of nine questions, two open-ended and seven closed-ended questions. I designed questions that were non-bias and easily understood by the participants (See Appendix A). HEALING HORSESHOES 15 I designed questions one and two (See Appendix A) to gather demographic and background information on the participants business and professional title. I used questions one and two to determine if participants met inclusion criteria. Question three (See Appendix A) was designed to gather information on the participants professional experience working under the EAGALA model. I created this question to explore the relationship between the participants experience level and their opinion of adding occupational therapy to the interdisciplinary team. Question four and seven (See Appendix A) were binary questions designed to gather the participants knowledge of OT. The participant required a general understanding of OT to fully understand the benefits of adding an OT to the EAGALA interdisciplinary team. Question five (See Appendix A) was set up to have a list of options with multiple answers to assess the participants knowledge of the populations OT practitioners can serve in. Questions six, eight, and nine (See Appendix A) used Likert scales to collect quantitative data for analysis. I designed questions six and eight (See Appendix A) to explore if participants believed OT practitioners would be beneficial on the EAGALA interdisciplinary team. If the participants believed it would be beneficial, I wanted to investigate the potential of hiring or supporting the hire of an OT practitioner. Lastly, question nine (See Appendix A) was created to capture how comfortable participants would be when working with a child diagnosed with ASD. Disabilities often have a social stigma, which can potentially play a role in occupational injustice secondary to the equine-assisted organizations not feeling comfortable offering services to this population. The survey was distributed to the participants via email through Google forms. I distributed ten surveys and received six fully completed surveys from participants. Data Analysis HEALING HORSESHOES 16 I received six questionnaires from participants. I analyzed the data using Google Forms and Microsoft Excel. I did not remove any data secondary to all questionnaires being fully completed. I collected ordinal, categorical, and text data from the questionnaire responses. I used Microsoft Excel to organize the data and created figures that represent my findings. I analyzed each question separately to determine relationships between occupational therapy and the EAGALA model, the EAGALA model and ASD, and OT practitioners role within the EAGALA interdisciplinary team upon analysis of the data. Results I ran descriptive statistics on the data received by six participants. I analyzed each question separately and used figures to interpret the data. As illustrated in Figures 1 and 2, the participants included two licensed professional counselors, a CEO, and three horse training professionals from four various businesses/companies. Figure 1 Questionnaire Question 1: What Is the Name of Your Company or Business? 17%, (n = 1) 17%, (n = 1) BC Stables and Training Center 17%, (n = 1) True North Equus 50%, (n = 3) Figure 2 Zero2Sixty Performance Coaching Simple Gifts Counseling HEALING HORSESHOES 17 Questionnaire Question 2: What Is Your Professional Title? Horse Trainer 33%, (n = 2) 50%, (n = 3) CEO Licensed Professional Counselor 17%, (n = 1) The participants experience level ranged from no experience to five or more years working under the EAGALA model. As shown on Figure 3, 33.3% (n = 2) of participants reported five or more years, 33.3% (n = 2) of participants reported less than a year, 16.7% (n = 1) of participants reported three to five years, and 16.6% (n = 1) of participants reported no experience. Figure 3 Questionnaire Question 3: How Long Have You Worked Under the EAGALA Model? HEALING HORSESHOES 18 17%, (n = 1) Less than a year 33%, (n = 2) 1-2 years 3-5 years 5 years or more 33%, (n = 2) N/A 17%, (n = 1) When I asked participants familiarity with OT, 66% (n = 4) of the participants reported being familiar with OT profession, while 33.3% (n = 2) reported not being familiar as shown in Figure 4. Figure 4 Questionnaire Question 4: Are You Familiar with Occupational Therapy? 33%, (n = 2) Yes 67%, (n = 4) No HEALING HORSESHOES 19 Five participants scored 100% on question five because they correctly selected all six practice areas applicable to OT. However, one participant scored 83.3% because they chose options except psychosocial (see Figure 5). Figure 5 Questionnaire Question 5: Select All Areas That Apply to Occupational Therapy Number of Practice Areas Selected by Participants 6 100%, (n = 6) 100%, (n = 6) 100%, (n = 6) 100%, (n = 6) 100%, (n = 6) Trauma Mental Health 83%, (n = 5) 5 4 3 2 1 0 Physical Social Emotional Psychosocial Occupational Therapy Practice Areas Note. All six practice areas are related to occupational therapy. As illustrated in Figure 6, all participants rated the benefit of having an OT within the EAGALA team model an eight or higher on a zero Likert scale, representing not beneficial and ten representing highly beneficial. Specifically, 66.7% (n = 4) of participants rated a ten, 16.7% (n = 1) of participants rated a nine, and 16.7% (n = 1) of participants rated an eight (see Figure 6). Figure 6 Questionnaire Question 6: On a Scale 1-10, Rate How Beneficial it Would be to Have an Occupational Therapist Within the EAGALA Team Model HEALING HORSESHOES 20 Number of Participants 6 5 67%, (n = 4) 4 3 2 17%, (n = 1) 1 17%, (n = 1) 0 If an OT practitioner were added to the participants EAGALA team, 83.8% (n = 5) of participants believed they would be able to expand the populations an EAGALA team could serve, while 16.7% (n = 1) of participants did not (see Figure 7). Figure 7 Questionnaire Question 7: Would you Be Able to Expand the Populations That You Serve by Having an Occupational Therapist on Your EAGALA Team? 17%, (n = 1) Yes 83%, (n = 5) No HEALING HORSESHOES 21 However, when asked to rate the likelihood of hiring or supporting the hire of an OT on their EAGALA team with a zero Likert scale, representing not likely and ten representing highly likely. On question eight, 33.3% (n = 2) of participants rated a ten, 16.7% (n = 1) of participants rated a nine, 33.3% (n = 2) of participants rated a three, and 16.7% (n = 1) of participants rated a one (see Figure 8). Figure 8 Questionnaire Question 8: On a scale of 1-10, Rate How Likely Would You Be to Hire (or Support the Hire of) an Occupational Therapist on Your EAGALA Team 6 Number of Participants 5 4 3 2 1 0 33%, (n = 2) 33%, (n = 2) 17%, (n = 1) 1 Not Likely 17%, (n = 1) 2 3 4 5 6 7 8 9 10 Highly Likely Lastly, participants used a Likert scale on question nine to rate how comfortable they would feel offering EAGALA services to children diagnosed with ASD. One represents not comfortable, and ten represents highly comfortable. As shown in Figure 9, 16.7% (n = 1) of participants who rated a ten, 16.7% (n = 1) of participants rated a nine, 16.7% (n = 1) of participants rated a six, 16.7% (n = 1) of participants rated a two, and 33.3% (n = 2) of participants rated one (see Figure 9). I then set to interpret the data and discuss any relationships found within the data. HEALING HORSESHOES 22 Figure 9 Questionnaire Question 9: On a scale of 1-10, Rate How Comfortable You Would Feel Offering EAGALA Services for Children Diagnosed with Autism Spectrum Disorder (ASD) Number of Participants 6 5 4 3 2 33%, (n = 2) 1 17%, (n = 1) 17%, (n = 1) 17%, 17%, (n = 1) (n = 1) 0 Discussion To understand occupational therapys role within the EAGALA team model I have analyzed and interpreted the data. I have identified positive relationships in the data that support my hypothesis; there are still several unanswered questions. I interpreted the results of each question on the questionnaire as well as, relationships between participants answers in multiple questions. To interpret the data from questions four through nine, I will review the descriptive background data gathered about the participants from questions one through three. There were six participants in the study, three of which were associated with BC Stables and Training Center. Since I recruited participants within a one-hundred-mile radius of BC Stables and Training Center, there are a limited amount of EAGALA organizations in the area. Therefore, the data gathered was not generalizable to the local EAGALA organizations due to the limited number of participants and access to local EAGALA organizations. Fortunately, I gathered HEALING HORSESHOES 23 participants that represented all three roles in the current EAGALA interdisciplinary team. The three participants from BC Stables and Training Center all work as equine specialists in the EAGALA model. I purposefully recruited a professional in each area of the EAGALA model to inquire about their perspective to increase generalizability to all EAGALA interdisciplinary team members. However, when recruiting participants, I was unaware of their level of experience under the EAGALA model and the participants reported no experience to up to five years or more. The sample size of participants was small however, I gathered unique clinical data from the six participants. I designed question four (see Appendix A) to determine how familiar my participants were with OT. More than half of the participants reported they were familiar; however, two participants which is one-third of the sample, reported they were not familiar with OT. I question how those two participants could fully answer questions five through nine without any familiarity with OT. After much consideration, I suspect my wording in question four was unclear. According to Merriam-Webster (2021) dictionary, familiar is defined as one who is well acquainted with something. I considered the possibility that a participant felt they were not well enough acquainted with OT because they have not personally or know of someone who has received OT services. Therefore, those participants may have selected no to be familiar with OT because they felt that their OT knowledge was inadequate due to lack of experience. In retrospect, I should have created an open-ended question that allowed the participant to openly express their understanding of OT to reduce the wordings potential misinterpretation. Although one-third of the participants reported not being familiar with OT, over 80% of the participants correctly selected all six OT practice areas listed (see figure 5). One participant did not score 100% because they left out psychosocial (see figure 5). If two participants were not HEALING HORSESHOES 24 familiar with OT, how were they able to correctly answer question five? This was another reason why I believe the word familiar may have been misinterpreted in question four. The questionnaire did not inform the participant of their selections on question five (see Appendix A) were correct; therefore, it should not have impacted on questions six through nine. On question six (see figure 6), all participants scored an eight out of ten or higher on their perceived benefits of adding an OT on the EAGALA team. Considering some participants felt unfamiliar with OT and did not know all of OTs practice areas, is it contradictory they felt the addition of an OT to be more beneficial than not. However, it is important to note clinically, EAGALA professionals from the local organizations felt the addition of an OT to be mostly highly beneficial. Five of the six participants felt there would be an increase in the populations their local EAGALA organizations were serving if an OT were involved. Considering all participants answered question five (see Figure 5) 85% or 100% correctly; therefore, it is unclear why one participant still felt their populations would not increase. Potentially, their EAGALA organization may already provide services to all those populations listed in question six. Therefore, an OTs addition would only overlap with their current populations explaining why they selected no on question seven. However, when participants were asked about hiring or supporting an OTs hire, the participants were split in half. I considered the financial investment an EAGALA organization would have to make to hire an OT. The organizations may not have the financial means or the desire to expand their organization. Some organizations may not want to involve insurance, licensing, and documentation into their organization. As I mentioned before, the organization may already be serving its target population without an OTs help. There are many situations to consider when interpreting the results of question eight. HEALING HORSESHOES 25 If participants and local EAGALA organizations considered an OTs addition, there would be an opportunity to expand their services. An OT practitioner would help the EAGALA organizations to individuals diagnosed with disabilities, specifically, children diagnosed with ASD. However, participants reported mixed comfort levels when asked if they would provide services for children diagnosed with ASD. Throughout the questionnaire, it was clear that most of the participants felt OT was beneficial and the addition of an OT practitioner could expand their services; hence, half of the participants reported potential employment of an OT practitioner. However, only two participants felt highly comfortable, and one participant felt comfortable offering services to children diagnosed with ASD. Three participants scored highly uncomfortable just offering services to children diagnosed with ASD. If organizations are feeling highly uncomfortable, the consideration of employing a professional that is equipped is encouraged. Children diagnosed with ASD already face occupational injustice, limiting their occupational engagement (Grockien et al., 2018; Llambias et al., 2016; Vanessa & Simmonds, 2018). Due to social stigmas, organizations are feeling uncomfortable and deterred from offering services to all children. These EAGALA organizations are physically equipped to provide services to the ASD population but lack the professionals to guide them in utilizing their resources. As mentioned above, researchers confirmed the therapeutic benefits children diagnosed with ASD are experiencing after engaging in equineassisted therapy (Grockien et al., 2018; Llambias et al., 2016; Vanessa & Simmonds, 2018). Advocating for equal opportunities for children diagnosed with ASD in equine-assisted therapy and at EAGALA organizations can provide meaningful opportunities for those children. I conducted a needs assessment at the beginning of my DCE and identified a large gap in the opportunities offered to children diagnosed with ASD in this area. Therefore, my DCE focus HEALING HORSESHOES 26 was to explore the benefits of adding an OT practitioner to the EAGALA interdisciplinary team, specifically at BC Stables and Training Center. Thus, to maximize BC Stables and Training Centers resources, I created a sustainable program called Healing Horseshoes at their organization. I set up connections between BC Stables and Training Center and local OT practitioners that are willing to collaborate with the EAGALA interdisciplinary team and provide sessions for children diagnosed with ASD. A private-pay clinic is in place involving an OT as part of the EAGALA interdisciplinary team. An EAGALA session typically consists of two to three sessions; however, the OT practitioner can evaluate the childs needs and schedule additional sessions to address any parental concerns. For example, if a child has difficulty with activities of daily living the OT practitioner will coordinate with the EAGALA team to set up the environment. The OT may have the child work on sequencing while grooming the horse, and the mental health professional will address behaviors that are interrupting the childs engagement while the equine specialist positions the horse and relays any relevant information concerning the childs interaction with the horse. Limitations and Implications for Future Practice I acknowledge a few limitations that exist in the study. Upon reviewing the relevant literature, I could not locate prior studies exploring OTs role within the EAGALA model. I was also unable to identify previous studies examining the benefits of the EAGALA model used with children diagnosed with ASD. Therefore, further research is recommended to validate the effectiveness of including an OT practitioner on the EAGALA interdisciplinary team. I conducted the study during the COVID-19 global pandemic which limited availability to participants, and I could not implement the program. HEALING HORSESHOES 27 Additionally, within the one-hundred-mile radius of BC Stables and Training Center, there were limited EAGALA organizations to contact to participate in the study. Therefore, I was only able to recruit six participants for the questionnaire, limiting the datas generalizability to the population. I recommend further data collection from a variety of EAGALA organizations to ensure that the findings are more applicable in various settings. Another limitation to the study was not conducting a pre/post-test. The participants perspective on how beneficial adding an OT practitioner in the EAGALA model may be skewed secondary to lack of knowledge of the OT profession. One-third of the participants reported they were not familiar with OT; therefore, I question their ability to fully understand the potential benefit of creating a role for OT within the EAGALA team. In addition, three participants in the study were employed at BC Stables and Training Center. I lived on-site during my DCE therefore, those participants engaged in several personal conversations with me about OT. The three participants had more knowledge of OT prior to completing the questionnaire. Consequently, I recommend future researchers conduct a pre/post-test to measure potential changes in participants perspectives after being educated on both topics. Although limitations in the study were recognized, I discovered implications for future practice. I suggest an increase in advocacy for OT as a professional. During the DCE project, I found several professions with the capability to refer to OT services but did not realize it fell into OTs scope of practice. To increase access to OT services for individuals suffering from occupational injustice, OT practitioners need to educate and advocate for their profession. I suggest an OT screening be distributed to equine associations to help increase referrals. Without referrals, individuals struggling with mental and physical disabilities will not have the opportunity to receive OT services. The evidence suggests the mental and physical benefits of HEALING HORSESHOES 28 equine-assisted therapeutic services. I recommend additional research to explore potential OT collaborations with other equine associations. Additionally, I suggest OT practitioners continue to advocate for their role in EAGALA and other international equine organizations such as the Professional Association of Therapeutic Horsemanship International (PATH) or the International Association of Horse Assisted Education (EAHAE). Conclusion In conclusion, there was a positive clinical relationship between OT and EAGALA found in the data. Participants viewed the addition of an OT practitioner to the EAGALA interdisciplinary model to be beneficial, increase the populations they serve, and some would potentially hire or support the hire of an OT practitioner. However, EAGALA organizations are still feeling uncomfortable serving children diagnosed with ASD. I recommend further exploring of OTs role in the EAGALA model, the EAGALA model offering services for individuals with disabilities, and advocating for OT referrals from equine associations. As always, OT practitioners need to continue to educate others and advocate for referrals so their potential patients will have equal opportunities to engage in their meaningful occupations and stop suffering from occupational injustice. HEALING HORSESHOES 29 References Anderson, S. & Meints, K. (2016). Brief report: The effects of equine-assisted activities on the social functioning in children and adolescents with autism spectrum disorder. Journal of Autism Development Disorder, 46. 3344-3352. doi:10.1007/s10803-016-2869-3 American Occupational Therapy Association (AOTA). (2021). What is occupational therapy? https://www.aota.org/Conference-Events/OTMonth/what-is-OT.aspx American Occupational Therapy Association (AOTA). (2014). Occupational therapy practice framework: Domain and process (3rd ed.). American Journal of Occupational Therapy, 68(Suppl. 1), S1-S48. Baker, S. (2015). Emerging practice areas: Occupational therapy and hippotherapy. A Publication of Occupational Therapy Australia, 12(5). 14-15. Buck, P. W., Bean, N., & Marco, K. (2017). Equine-assisted psychotherapy: An emerging trauma-informed intervention. Advances in Social Work, 18(1). 387-402. doi: 10.18060/21310 Cole, M. B., & Tufano, R. (2008). Applied theories in occupational therapy: A practical approach. Thorofare, NJ: SLACK, Inc. Equine Assisted Growth and Learning Association. (2018). EAGALA: A global standard in equine-assisted psychotherapy and personal development incorporating horses. https://www.eagala.org/index Familiar. 2021. In Merriam-Webster.com. Retrieved March 11, 2021, from https://www.merriam-webster.com/dictionary/familiar HEALING HORSESHOES 30 Gabriels, R. L., Pan, Z., Dechant, B., Agnew, J. A., Brim, N., & Mesibov, G. (2015). Randomized controlled trial of therapeutic horseback riding in children and adolescents with autism spectrum disorder. Journal of the American Academy of Child & Adolescent Psychiatry, 54. 541549. https://doi.org/10.1016/j.jaac.2015.04.007 Grockien, A., Dovidaitien, G., Kerzien, S., & Stankeviius, R. (2018). Influence on functional mobility and motivation of hippotherapy for people with special needs. Veterinarija Ir Zootechnika, 076(98), 2932. http://search.ebscohost.com.ezproxy.uindy.edu/login.aspx? Harvey, C., Jedlicka, H., & Martinez, S. (2020). A program evaluation: Equine-assisted psychotherapy outcomes for children and adolescents. Children and Adolescent Social Work Journal, 37. 665-675. https://doi.org/10.1007/s10560-020-00705-0 Lee, K., Dabelko-Schoeny, Jedlicka, & Burns, T. (2020). Older adults perceived benefits of equine-assisted psychotherapy: Implications for social work. Research on Social Work Practice, 30(4). 399-407. doi:10.1177/1049731519890399 Little, L. M., Sideris, J., Ausderau, K., & Barane, G. T. (2014). Activity participation among children with autism spectrum disorder. American Journal of Occupational Therapy, 68, 177185. http://dx.doi.org/10.5014/ajot.2014.009894 Llambias, C., Magill-Evans, J., Smith, V., & Warren, S. (2016). Equine-assisted occupational therapy: Increasing engagement for children with autism spectrum disorder. American Journal of Occupational Therapy, 70(6), 1-9. http://dx.doi.org/10.5014/ajot.2016.02-701 McNamara, J. (2017). Equine facilitated therapy for children and adolescents: A qualitative pilot study. Journal of Creativity in Mental Health, 12(4), 412-427. https://doi.org/10.1080/15401383.2017.1340215 HEALING HORSESHOES 31 Notgrass, C. G. & Pettinelli, J. D. (2015). Equine assisted psychotherapy: The equine assisted growth and learning associations model overview of equine-based modalities. Journal of Experiential Education, 38(2), 162174. https://doi.org/10.1177/1053825914528472 Trzmiel, T., Purandare, B., Michalak, M., Zasadzka, E., & Pawlaczyk, M. (2019). Equine assisted activities and therapies in children with autism spectrum disorder: A systematic review and a meta-analysis. Complementary Therapies in Medicine, 42. 104-113. https://doi.org/10.1016/j.ctim.2018.11.004 Vanessa X. L. T., & Simmonds, J. G. (2018). Parent perceptions of psychosocial outcomes of equine-assisted interventions for children with autism spectrum disorder. Journal of Autism & Developmental Disorders, 48(3), 459469. https://doi.org/10.1007/s10803017-3399Wilson, K., Buultjens, M., Monfries, M., & Karimi, L. (2017). Equine-assisted psychotherapy for adolescents experiencing depression and/or anxiety: A therapists perspective. Clinical Child Psychology and Psychiatry, 22(1). 16-33. doi:10.1177/1359104515572379 Wood, W., Alm, K., Benjamin, J., Thomas, L., Anderson, D., Pohl, L., & Kane, M. (2020). Optimal terminology for services in the United States that incorporate horses to benefit people: A consensus document. The Journal of Alternative and Complementary Medicine. 1-8. doi: 10.1089/acm.2020.0415 Appendix A HEALING HORSESHOES 32 Google Form Questionnaire  ...

... Establishing a Facility Dog in a School System Shannon Bouchard 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: Jennifer Fogo PhD, OTR A Research Project Entitled Animal-Assisted Therapy in a School System 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: Shannon Bouchard Approved by: Research Advisor (1st Reader) Date 2nd Reader Date Accepted on this date by the Chair of the School of Occupational Therapy: Kate E. DeCleene Huber, OTR, MS, OTD Chair, School of Occupational Therapy Date ESTABLISHING A FACILITY DOG IN A SCHOOL SYSTEM 3 Abstract There are few resources that provide interventions using facilities dogs as an active part of the interventions instead of as a motivator. Research has shown animal-assisted therapy can have generally positive effects for the management of children with developmental, physical, and intellectual deficits, but that the diversity of scales and outcomes measures makes it difficult to establish the effectiveness of previously done research (Charry-Sanchez et al., 2017). The goal of this project is to develop and implement animal-assisted interventions and measure their effectiveness on students participation and motivation. ESTABLISHING A FACILITY DOG IN A SCHOOL SYSTEM 4 Introduction During the summer of 2020, the occupational therapist in a central Indiana school system received a facility dog from Canine Companions for Independence after being on a waitlist for twelve months. Due to the coronavirus pandemic (COVID-19), the occupational therapist has had very few resources or opportunities to utilize the dog in a school setting. Regardless of the COVID-19 pandemic, there are few resources that provide interventions using facilities dogs as an active part of the interventions instead of as a motivator. Facility animals, particularly dogs, have specific training and react to certain commands, but it is up to the animals handler to continue working with and training the dog to use its known commands in a therapeutic setting. While there is a growing demand for and use of service animals, there is also a lack of protocol and evidence-based-practice supporting this trend (Brelsford et al., 2017). As stated by many researchers, for animal-assisted therapy to move forward, it is imperative to develop standardized protocols, interventions, and outcome measures in this field. The goal of this project is to develop and implement animal assisted interventions and measure their effectiveness on students participation and motivation. Animal-Assisted Therapy in Pediatric Settings Research has shown animal-assisted therapy can have generally positive effects for the treatment of children with down syndrome, autism, cerebral palsy (CP), and other diagnoses, but that the diversity of scales and outcomes measures makes it difficult to establish the effectiveness of previously done research (Charry-Sanchez et al., 2017). Occupational therapists support children of all ages by incorporating the occupations that are important to you and your child into the intervention process, whether it is at school, during rehabilitation, or at a medical facility (American Occupational Therapy Association, n.d.). Some diagnoses of patients that ESTABLISHING A FACILITY DOG IN A SCHOOL SYSTEM 5 occupational therapists work with include CP, attention deficit hyperactivity disorder (ADHD), and other intellectual disabilities. Research has been done to find the effects of animal-assisted therapy on each of these diagnoses. Cerebral Palsy Cerebral palsy (CP) is a non-progressive, chronic, neurological condition that causes deficits in motor control and physical activity (Elmaci & Cevici, 2015). The deficits caused by CP can also result in aggression, agitation, social withdrawal, and other psychiatric or behavioral disorders (Elmaci & Cevici, 2015). Research has shown that animal-assisted therapy can have positive effects on socialization, mood, and overall wellbeing for children diagnosed with CP (Elmaci & Cevici, 2015). Additionally, the use of a therapy dog increased compliance with therapy programs and the childs overall attitude during the therapy session (Elmaci & Cevici, 2015). Elmaci & Cevici (2015) also expressed concern that because there was a lack of literature supporting animal-assisted therapy, it was difficult to compare the results and validity of this study. Attention Deficit Hyperactivity Disorder Attention deficit hyperactivity disorder (ADHD) is a common neurological disorder that presents with symptoms, including inattention, hyperactivity, and impulsivity (Busch, Tucha, & Talarovicova, 2016). Standard treatment of ADHD includes medication and behavioral therapy. Recent studies have shown animal-assisted therapy can have a positive impact on the core symptoms of ADHD (Busch et al., 2016; Schuck, et al., 2015). In a study done by Schuck et al. (2015), animal-assisted therapy combined with cognitive behavioral therapy was much more effective than cognitive behavioral therapy alone in reducing ADHD symptoms. Schuck et al. (2015) also states that it is imperative future research focuses on developing standard methods of ESTABLISHING A FACILITY DOG IN A SCHOOL SYSTEM 6 delivering animal-assisted interventions, as well as finding a more accurate, unbiased method to measure the effects of the intervention. Intellectual Disabilities Intellectual disabilities involve problems with general mental abilities, including intellectual functioning (such as learning, problem-solving, judgment) and adaptive functioning (communicating and independent living) (Parekh, 2017). This diagnosis can include autism, developmental disabilities, or other mental disabilities (Maber-Aleksandrowicz, Aventet al., 2016). Maber-Aleksandrowicz et al. (2016) found that animal-assisted therapy can improve selfmotivation, self-efficacy, self-esteem, and decreased depression in those with intellectual disabilities. In order to determine the clinical effectiveness of animal-assisted therapy, as well as establish more evidence-based, animal-assisted interventions, more research must be done (Maber-Aleksandrowicz, 2016). Animal Assisted Therapy in Schools The use of animals in the classroom has grown exponentially in recent years. Animals used include guinea pigs, hamsters, rabbits, dogs, reptiles, and even some farm animals (Brelsford et al., 2017). Teachers have used classroom animals to bestow responsibility on children, as well as expose them to different kinds of animals. In schools, occupational therapy practitioners focus on academics, play and leisure, social participation, self-care skills (ADLs or Activities of Daily Living), and transition/ work skills (American Occupational Therapy Association, 2016). Interventions in school are academically focused and can address deficits such as students motivation, attention, or exposure. As occupational therapy in schools has grown, the use of facility dogs in schools increased as well (Brelsford et al., 2017). This increase in using service dogs in therapy services and rehabilitation services has also begun to expand ESTABLISHING A FACILITY DOG IN A SCHOOL SYSTEM 7 into school and educational settings. Brelsford et al. (2017) found that animal-assisted therapy in a classroom can result in positive outcomes regarding the students' psychological, cognitive, and socio-emotional state. Brelsford states that researchers must develop standardized protocols for animal-assisted interventions and therapies. Theoretical Base I used the person-environment-occupation-performance (PEOP) model to guide my project. This model takes into account a holistic view of both the student and interventions and allows for a specific look into performance skills. Performance skills, such as grip strength and dexterity, are critical in this project, as this is where animal-assisted intervention can be implemented in academically geared interventions. In addition to the PEOP model, I used the developmental frame of reference (FOR). In this FOR, the goal of occupational therapy is to facilitate individuals in mastering developmental skills as they relate to expectations (Creek, 2014). The lifespan frame addresses six adaptive skills (sensory integration, cognitive skills, dyadic interaction skills, group interaction skill, and self-identity skills, and sexual identity skills), all of which overlap with the goals of school-based occupational therapy. Interventions can include activities, relationships, and environments to facilitate developmentally appropriate skills (Creek, 2014). The interventions I created during my project used the facility dog and l focused on the students occupational therapy goals to promote their functioning at the expected level for their age and grade. Methods Participants The Doctoral Capstone Experience (DCE) student implemented this program in a central Indiana school system that contains five city schools, one private school, and a community pre- ESTABLISHING A FACILITY DOG IN A SCHOOL SYSTEM 8 school center. This school system has a median household income of $40,741 (U.S. Census Bureau, 2018). According to the Indiana Department of Education, 65.9% of the students are white, 12.8% are multiracial, 11% are Hispanic, 9.4% are multiracial, .9% are Asian, and .1% are Native American (IDOE, 2018). Occupational Therapy in the School System There is one occupational therapist serving students in this school system. The current occupational therapy caseload is approximately seventy students ranging in age from 3 to 17 and have diagnoses such as developmental delay, intellectual disability, attention deficit hyperactivity disorder, autism, CP, and behavioral disturbance. School based occupational therapy in this school system addresses students legibility, handwriting, attention to task, social skills, clothing fasteners, and behavior management. OT sessions range from 10 to 20 minutes once a week or 30 to 100 minutes per reporting period. Data Analysis The DCE student used this project to create a binder of animal-assisted interventions to use during school-based OT sessions and measure the interventions effectiveness (See Appendix C). Charry et al. (2018) found that it is difficult to establish reliable data regarding animalassisted therapy because a variation of scales and outcomes measures are used to collect data and therefore, making it difficult to compare the outcomes of the intervention. In this study, the DCE student used a goal attainment scale (GAS) to measure the effectiveness of interventions using a facility dog. The GAS is an individualized measure that is standardized, allowing for comparison of scores across multiple interventions for areas including activities of daily living, communication, development, and many more (Turner-Stokes, 2009). In collaboration with the school occupational therapist, the DCE student created a GAS to assess the effectiveness of ESTABLISHING A FACILITY DOG IN A SCHOOL SYSTEM 9 interventions using the facility dog related to students motivation and engagement in the session (See Appendix A). This scale allowed for more cohesive comparisons on the effectiveness of the animal-assisted interventions as they were measured using the same scale and standards. The outcome of each intervention was measured using the GAS. every time the intervention is utilized over 10 weeks to find an average GAS. score and determine effectiveness of intervention. The animal-assisted interventions were not used with every student, as the OT had to choose which students these interventions would be appropriate for and if the dog was able to participate in the current session. Interventions were not standardized and varied from session to session based on therapist feedback and adapting the interventions for student and dog needs. After 11 weeks, I measured 13 animal-assisted interventions using the GAS. The individual average GAS of each intervention, as well as general comments and observations noted during the sessions, were calculated and reported in a Microsoft Excel document. The DCE student added the animal-assisted interventions to an intervention binder, along with comments or observations that were noted, so any OTs using these interventions have an idea of what to expect and are able to plan their sessions accordingly. Policies and Procedures Development Oaklyn, the facility dog the DCE student worked with, was the first facility animal in this school system, therefore there were no policies or procedures associated with her. While having a facility animal is beneficial to students and the environment, issues such as hygiene, allergies, fear, etc. can arise and cause disturbances in the flow of the school day. The DCE student developed policies and procedures related to facility animals to address any concerns or issues that may occur. The DCE student sent out a questionnaire to all principals, special education teachers, school counselors, and rehab team members to collect questions and concerns staff may ESTABLISHING A FACILITY DOG IN A SCHOOL SYSTEM 10 have that can be addressed in the policies and procedures (See Appendix B). Additionally, the DCE student contacted other school districts and outpatient clinics that have facility dogs to review their policies and procedures, as well as reviewed research-based guidelines for facility and services animals in public settings. Results Animal-Assisted Interventions Data was collected over a 10-week period. Interventions were used with both individual students and groups of students and given a GAS score for each session. The number of times each intervention was used varied based on age and diagnosis of the students, time constraints, and availability of resources at each school. Table 1 details each intervention, the number of times the intervention was used, and the average GAS score it received. Table 1 GAS Scores of Animal-Assisted Interventions Name of Intervention # of times used Average GAS Velcro Vest 5 1.2 Tie and Clips 14 1.86 1 1 5 1.4 Magnet 3 0.33 DogMan (Hangman) 8 1.625 Stringing Beads Oaklyn's Choice Board Comments Most students enjoyed being able to pet dog while matching cards. This is harder to complete in a group, better for 1-1 sessions. Facility dog did not cooperate in holding string in mouth; Dog is tired of having tie around neck at the end of the day; students participated to pet Oaklyn. Facility dog had poor engagement, but students enjoyed it when she did participate. Student fear of dogs was hinderance; dog did not like holding magnet in mouth. For some students the downtime it took for facility dog to pick a card was too long; Dog attention is poor by end of day. ESTABLISHING A FACILITY DOG IN A SCHOOL SYSTEM 11 Increased participation in activity from all preschoolers. Enjoyed being able to pick up poms poms off of dogs body and enjoyed her holding basket in her mouth. Facility dog had poor engagement, but students enjoyed it when she did participate. Some students require extra attention due to the varying tasks required; Oaklyn loses interest by the end of the day. Doggie Basket 5 2 Doggie Dice 4 1.75 Barko 5 1 Banana Blast Making Dog Toys 7 1.14 15 1.86 Distraction to preschoolers; good with dog to take turns. Was more difficult to execute in groups versus individual but could be easily graded up or down. Fetch 5 1.2 Many students lacked ability to initiate throwing. Brushing 3 2 Appropriate with pre-school and/or physical disabilities. Policies & Procedures and Educational Presentation The DCE student administered a questionnaire (Appendix B) to all special education teachers, principals, and guidance counselors within the school system. Five people filled out the initial survey. The DCE student used these answers, as well as input from other facility animal programs, to guide the creation of policies and procedures to be used in the school system (Appendix D). This survey also guided the creation of an educational presentation for faculty and staff to address what a facilities animals role is in the school system and introduce new policies and procedures (Appendix E). Sixteen faculty and staff completed a Likert scale survey via google forms to assess the effectiveness of the educational module and was completed by 16 people, as detailed in Table 2. Table 2 Post-Educational Presentation and Policies and Procedures Survey Question Average Score 1. The Facility Animal Policy and Procedure manual addresses all of my concerns about having a facility animal in the schools. 4.9375 ESTABLISHING A FACILITY DOG IN A SCHOOL SYSTEM 12 2. I understand the facility animals role in a school and being used in occupational therapy. 5 3. I understand how to set up a time to use the facility animal for classroom activities or 1-1 time with students. 4.875 DCE Student Satisfaction Survey The supervising OT completed a Likert scale survey to assess her overall satisfaction with the students project and determine if all goals and objectives were met during the DCE. The results are detailed in Table 3. Table 3 Doctoral Capstone Experience Supervisor Satisfaction Survey Questions Score Student created and distributed a needs assessment to staff to guide creation of policies 5 and procedures materials. Student created a policy and procedures manual/educational resource to address staff concerns and questions about the use of a facility animal in the school system. 5 Student created 15-20 interventions to be used by a school based occupational therapist 4 with a facility dog. Student measured effectiveness of above interventions using the Goal Attainment Scale 5 to create evidence-based resources for facility animals in a school setting. Discussion The DCE students main goal for this project was creating and implementing animalassisted interventions in a school system, as well as measuring the effectiveness of said interventions. Additionally, the DCE student created policies and procedures regarding the facility dog to be used by the school system and shared an educational presentation with staff to introduce these policies. This program was needed as, in general, there are few ready to use ESTABLISHING A FACILITY DOG IN A SCHOOL SYSTEM 13 resources for implementing AAI in school based occupational therapy. AAI is a rather new practice and there are few studies that have measured the effectiveness and discussed the pros and cons of specific interventions, as this program did. Animal-Assisted Interventions In school-based therapy it is common to use similar activities with all students or groups of students and grade them as appropriate for students goals. When this happens, the facility dog is asked to repeat the same activity or command many times during the day. It was noted that whenever the facility animal was asked to repeat similar commands and/or activities the whole day, the dog became bored, disengaged in the activity, and stopped responding to commands. This should be taken into consideration when planning activities for the dog to participate in. To increase the facility dogs cooperation, therapists could plan on using the dog in every other activity, having more than one activity prepared for sessions, or picking specific students that the dog will engage with during the activity. In addition to the dogs behaviors, the therapist also had to take in to account the students behaviors. While most children interacted well with the facility dog, some children were fearful of the dog or were too stimulated by the animal to participate in therapy. There were no specific populations of students or diagnosis that seemed agitated by the dog, but students with lower cognitive functioning were more easily distracted by the dog. On the other hand, many of the students with autism worked exceptionally well with the facility animal and had a noticeable increase in engagement during sessions as compared to last year when the dog was not being used. In school-based therapy, students can be seen individually but more often than not are usually seen in pairs or groups. Using the facility dog in group was difficult initially as more than ESTABLISHING A FACILITY DOG IN A SCHOOL SYSTEM 14 one student was trying to interact with the dog at the same time. It was determined that games in which the dog picked cards or rolled dice were better suited for groups of 2-3 students so as to not overwhelm the dog. During this project, the DCE student researched pther programs involving AAI, and some were implemented in the school setting. There is a plethora of literature showing that children reading out loud to animals can increase literacy skills. Oaklyns Hour was implemented in two building. This was an hour to hour and a half period in which teachers could sign their students up to come to a designated place and read out loud to Oaklyn for ten minutes. Other programs researched included coping skills and emotional regulation groups and physical activity/gross motor groups. These were presented to the school system and the dogs handler for consideration in the next school year. The DCE student was unable to evaluate multiple interventions due to time constraints, lack of appropriate population, and COVID-19 policies. These interventions were included in the intervention binder but do not have an accompanying GAS score (See Appendix C). The DCR student assessed the GAS scores for each intervention session. The supervising OT and DCE student adjusted the interventions as needed from session to session according to the students goals, age, cognitive level, etc., so it should be noted that GAS scores may be higher in later sessions as opposed to early sessions as the interventions evolved and were changed. Overall, some interventions were more successful than other mostly due to how involved the dog needed to be. For example, if the dog was asked repeatedly to get or hold throughout the day, the effectiveness of the intervention decreased because the dog would become noncompliant with later sessions. Interventions that did not require the dog to complete a task, such ESTABLISHING A FACILITY DOG IN A SCHOOL SYSTEM 15 as brushing or the tie and clips, had consistently higher GAS scores as the dog was only asked to maintain a down or sit position. Policies and Procedures The policies and procedures the researcher created for this school system are general guidelines that were based off of other schools protocols and addressed questions raised by faculty and staff. The policies and procedures could be expanded upon to address new problems or concerns that arise or to make the general guidelines more specific to the school system in question. Limitations There are at least three potential limitations in this study. A first includes that interventions were only tested with one facility dog and in one school system. A second limitation includes that both the DCE student and therapist involved in the study were new to working with a facility dog and therefore spent a good amount of time troubleshooting and training the animal. The third and final limitation included COVID-19 protocols were a barrier to the amount of interaction the therapist had with students on her caseload. Despite these limitations, the DCE student was able to increase the use of the facility animal in the therapists sessions and increased both the therapists and DCE students knowledge in regard to using facility animals in practice. Future research Future projects involving interventions with a facility animal could be done with other disciplines, such as speech language pathology, physical therapy, or behaviors management. Additionally, interventions could be measured with more specific goals or be focused on a specific diagnosis ESTABLISHING A FACILITY DOG IN A SCHOOL SYSTEM 16 Conclusions Throughout this project the DCE student was able to increase jer activity analysis skills, interventions planning, and ability to be flexible during intervention sessions. Overall, the program was successful, but many interventions had to be modified based on the dogs behavior or the students skill levels. In the future other therapists will be able to use this information to more accurately plan sessions and activities using a facility dog in the school setting. ESTABLISHING A FACILITY DOG IN A SCHOOL SYSTEM 17 References American Occupational Therapy Association. (n.d.) What is OT Peds? [Fact Sheet]. https://www.aota.org/~/media/Corporate/Files/Practice/Manage/PresentationResources/Brochure/What-is-OT-Peds.pdf American Occupational Therapy Association. (2016). Occupational therapy in school settings [Fact Sheet]. https://www.aota.org/~/media/Corporate/Files/Practice/Children/School-AdministratorBrochure.pdf Brelsford, V., Meints, K., Gee, N., & Pfeffer, K. (2017). Animal-assisted interventions in the classrooma systematic review. International Journal of Environmental Research and Public Health, 14(7), 669. doi: 10.3390/ijerph14070669 Busch, C., Tucha, L., Talarovicova, A., Fuermaier, A. B. M., Lewis-Evans, B., & Tucha, O. (2016). Animal-assisted interventions for children with attention deficit/hyperactivity disorder. Psychological Reports, 118(1), 292331. doi: 10.1177/0033294115626633 Charry-Snchez, J. D., Pradilla, I., & Talero-Gutirrez, C. (2018). Effectiveness of animal-assisted therapy in the pediatric population. Journal of Developmental & Behavioral Pediatrics, 39(7), 580590. doi: 10.1097/dbp.0000000000000594 Creek, J. (2014). Approaches to practice. In W. Bryant, J. Fieldhouse, & K. Bannigan (Eds.), Creek's occupational therapy and mental health (5th ed., pp. 50-69). Edinburgh: Churchill Livingstone. Elmaci, D., & Cevizci, S. (2015). Dog-assisted therapies and activities in rehabilitation of children with cerebral palsy and physical and mental disabilities. International Journal of Environmental Research and Public Health, 12(5), 50465060. doi: 10.3390/ijerph120505046 ESTABLISHING A FACILITY DOG IN A SCHOOL SYSTEM 18 Ernst, L. (2014). Animal-assisted therapy: An exploration of its history, healing benefits, and how skilled nursing facilities can set up programs. Annals of Long-Term Care: Clinical Care and Aging, 22(10). IDOE Inview. (2020). Beech Grove city schools. IDOE. Indiana Department of Education. https://inview.doe.in.gov/corporations/1053800000/population Maber-Aleksandrowicz, S., Avent, C., & Hassiotis, A. (2016). A systematic review of animalassisted therapy on psychosocial outcomes in people with intellectual disability. Research in Developmental Disabilities, 49-50, 322338. doi: 10.1016/j.ridd.2015.12.005 Schuck, S. E. B., Emmerson, N. A., Fine, A. H., & Lakes, K. D. (2013). Canine-assisted therapy for children with adhd. Journal of Attention Disorders, 19(2), 125137. doi: 10.1177/1087054713502080 Turner-Stokes L. (2009). Goal attainment scaling (GAS) in rehabilitation: a practical guide. Clinical rehabilitation, 23(4), 362370. https://doi.org/10.1177/0269215508101742 U.S. Census Bureau. (2018). Quickfacts: Beech Grove, Indiana. U.S. Census Bureau. United States Census Bureau. https://datausa.io/profile/geo/beechgrovein/#:~:text=In%202018%2C%20Beech%20Grove%2C %20IN,%2440%2C741%2C%20a%207.73%25% Vroman, K., & Collins, K. (2015). Animal-assisted therapy: motives and rewards. American Journal of Occupational Therapy, 69(Suppl. 1). doi: 10.5014/ajot.2015.69s1-po1094 ESTABLISHING A FACILITY DOG IN A SCHOOL SYSTEM Appendix A 19 ESTABLISHING A FACILITY DOG IN A SCHOOL SYSTEM Appendix B 20 ESTABLISHING A FACILITY DOG IN A SCHOOL SYSTEM Appendix C 21 ESTABLISHING A FACILITY DOG IN A SCHOOL SYSTEM 22 ESTABLISHING A FACILITY DOG IN A SCHOOL SYSTEM 23 ESTABLISHING A FACILITY DOG IN A SCHOOL SYSTEM 24 ESTABLISHING A FACILITY DOG IN A SCHOOL SYSTEM 25 Appendix D FACILITY ANIMAL 1. Definitions: a. Handler/Facilitator: expertly trained dogs who partner with a facilitator working in a health care, visitation or education setting b. Facility Dog: expertly trained dogs who partner with a facilitator working in a health care, visitation or education setting 2. Facility Dog/Animal Policy The school district supports the use of facility dogs for the benefit of its students subject to the conditions of this policy. Benefits from working or visiting with a facility dog include reduced stress, improved physical and emotional well-being, low blood pressure, decreased anxiety, improved self-esteem and normalization of the environment, increasing the likelihood of successful academic achievement by the student. Examples of activities that students may engage in with a facility dog include petting and/or hugging the dog, speaking to the dog, giving the dog simple commands that the dog is training to respond to, and reading to the dog. Animal Assisted Intervention is a goal-driven intervention, which is directed and/or delivered by a health, human, or education service professional and is meant to improve physical, social, emotional and/or cognitive function of an individual. A facility dog is a dog that has been individually trained, evaluated and registered with his/her handler to provide animal assisted activities, animal assisted facility and animal assisted interactions within a school or other facility. Facility dogs are not the same as emotional support animals, service animals, or therapy animals. ESTABLISHING A FACILITY DOG IN A SCHOOL SYSTEM 26 The handler is an individual school district staff member or volunteer who has been individually trained, evaluated, and registered with the facility dog to provide animal assisted activities, animal assisted facility, and animal assisted interactions within a school or other facility. The facility animal is NOT property of the school, but of the handler and the training organization which the animal came from. The privilege of having a facility dog to any school can be terminated at any time should the handler or dog behave deemed unprofessional or unsafe. 3. Protocols/Standards Vaccinations: Handler will keep animals vaccinations up to date as required by the training organization the dog is sponsored by. Handler will provide vaccinations to the superintendent as required but does not have to carry vaccination records with the dog when working in the school system. Licensing: The handler and facility dog shall wear appropriate identification issued by the school district. Safety: 1. Handler shall ensure that the facility dog does not pose a health and safety risk to any student, employee, or other person at school and that the facility dog is brought to the school district only when properly groomed, bathed, free of illness or injury and of the temperament appropriate for working with children and others in the schools 2. The handler shall be solely responsible for the supervision and humane care of the facility dog, including any feeding, exercising, and cleaning up after the facility dog while the facility dog is in the school building or on school property. The handler shall not leave the facility dog unsupervised or alone on school property at any time unless the dog is enclosed in a kennel or crate. ESTABLISHING A FACILITY DOG IN A SCHOOL SYSTEM Allergies and Aversions: 27 The handler shall remove the facility dog to a separate area, as designated by the school administrator, in such instances where any student or school employee who suffers dog allergies or aversion is present in an office, hallway, or classroom. Additionally, any time the facility dog is coming into a classroom for a scheduled activity, teachers and handlers should be aware of any student allergies beforehand. Scheduling: Faculty and staff are encouraged to reach out to the handler to schedule classroom time or activities with Oaklyn via handlers email, but the facility dogs handler will have final say on the animals schedule and ability to visit classrooms. Cultural/Religious Conflicts: In some religions or cultures, animals are seen as unclean. Teachers/faculty should have permission from students parents before bringing the facility animal into the classroom. The dog's handler will check with their students' family individually before starting intervention with the dog. Control: The handler shall ensure that the therapy dog wears a collar or harness and a leash no longer than four feet and shall maintain control of the therapy dog by holding the leash at all times that the therapy dog is on school district property, including during breaks, unless holding such leash would interfere with the therapy dogs safe, effective performance of its work or tasks. However, the handler shall maintain control of the therapy dog at all times and shall not tether the therapy dog to any individual or object. ESTABLISHING A FACILITY DOG IN A SCHOOL SYSTEM Appendix E 28 ESTABLISHING A FACILITY DOG IN A SCHOOL SYSTEM 29  ...

... SEVEN DIMENSIONS OF WELLNESS FOR IMPROVED QOL 2 Abstract More older adults are desiring to age in place; however, older adults are at higher risk for depression, feelings of loneliness, and a potential decrease in quality of life. Involvement more holistically in life may be beneficial in improving quality of life, depression, and feelings of loneliness. Using an occupation-based model as a guide, the purpose of this project was to design and implement a holistic wellness program based on the Seven Dimensions of Wellness. A needs assessment determined the need for raising awareness of health and wellness and providing education in a more holistic manner. The intent of the program focused on providing education through handouts and activities to increase well-being and awareness of awareness of wellness. A pre-test and post-test questionnaire were conducted via phone call to assess well-being and depression. Participants engaged in seven virtual wellness sessions. Findings revealed that participants who engaged in this wellness program demonstrated improvements in life satisfaction, quality of life and well-being, and depression. Keywords: older adults, holistic wellness, quality of life, Seven Dimensions of Wellness SEVEN DIMENSIONS OF WELLNESS FOR IMPROVED QOL 3 Exploring the Seven Dimensions of Wellness for Improved Quality of Life and Satisfaction Aging in place has always been a desire for many older adults. One program that provides more older adults the ability to age in place is the Program of All-Inclusive Care for the Elderly (PACE). PACE is a non-profit or public organization that's main focus is providing PACE health care services to participants (Centers for Medicare and Medicaid Services, n.d.). One PACE program located in Indianapolis that provides many older adults with care is the Franciscan Senior Health and Wellness PACE Program (Franciscan Health, 2020). This program enables seniors who want to remain aging at home to do so by providing all-inclusive services (Franciscan Health, 2020). Some of the services offered at the Franciscan Senior Health and Wellness PACE Program are primary medical and nursing care, occupational therapy, physical therapy, speech therapy, medications, medically necessary transportation, skilled home care, and other assistive service (Franciscan Health, 2020). The Franciscan Senior Health and Wellness PACE Program, located in Indianapolis, helps to enhance social, emotional, and other obstacles, like depression, that older adults face (Franciscan Health, 2020). The International Council on Active Aging (ICAA) states that wellness is the ability to lead a purpose-filled and engaged life, and by doing this, a person may embody his or her potential to enhance lifes opportunities (n.d.). The Seven Dimensions of Wellness are: emotional, intellectual, physical, professional/vocational, social, spiritual, and environmental (ICAA, n.d.). Major Depressive Disorders are common among older adults and decrease their quality of life (QOL) (Wang et al., 2017). The more engaged older adults are in multiple life domains, like physical, social, and cognitive domains, the higher perceived QOL, higher functional independence, and lower symptoms of depression they had (Hurley & Jones, 2019). Additionally, SEVEN DIMENSIONS OF WELLNESS FOR IMPROVED QOL 4 increased engagement in leisure activities among older adults led to higher life satisfaction (Hurley & Jones, 2019). A program that introduces older adults to the Seven Dimensions of Wellness and educates them on how to address their individual needs related to each dimension of wellness may help improve their QOL. Literature Review Quality of life is especially important for older adults who experience a decline in health, role loss, loneliness, and a social disconnect (Aydiner Boylu & Gunay, 2017). Potential decrease in abilities, which may sometimes occur in older age, may make performing daily activities challenging and thus may lead to decreased QOL (Aydiner Boylu & Gunay, 2017). Critical components of successful aging are maintaining ones physical health, psychosocial capabilities, and independence in daily activities (Hurley & Jones, 2019). For many older adults the quality of the life they are living is more important than longevity (Hurley & Jones, 2019). Gaining an understanding of an aging persons self-perception of QOL may help us enhance the aging experience by providing insight into what is important to them. Emotional wellness is important to address in holistic wellness. Emotional wellness is the ability to cope with maintaining a balance of feelings in life (ICAA, n.d.). Older adults often experience different losses due to their age that may make it challenging for them to adapt and have an ability to cope, which may lead to more of a problem with resilience and successful aging among them (Perez-Blasco et al., 2016). Interventions that encourage openness, acceptance, and bring awareness to a persons sensations, thoughts, bodily states, consciousness, and the environment, like mindfulness or emotion focused coping, are crucial for emotional wellness (Perez-Blasco et al., 2016). SEVEN DIMENSIONS OF WELLNESS FOR IMPROVED QOL 5 Intellectual wellness is important to maintain throughout aging. Decline in cognitive abilities may inhibit an older adults independence (Cheng-Ting, 2019). Leisure or social activities are beneficial ways to implement intellectual wellness. Leisure and social activities that stimulate the midbrain may protect cognitive ability, decrease mortality, and increase quality of life (ChengTing, 2019). Additionally, leisure activities may help stimulate positive emotions and decrease depression (Cheng-Ting, 2019). A lifestyle choice that improves health and functional mobility, the physical dimension of wellness, plays an important role in the lives of older adults (ICAA, n.d.). Physical activity offers many benefits, such as better QOL, increased social participation, decreased depression and anxiety, and fewer chronic diseases that older adults are more at risk for (Castelo Branco de Oliveria et al., 2019; da Fonte et al., 2016). The longer an older adult participated in a communitybased physical activity program, the more positive the trend in the QOL (da Fonte et al., 2016). The professional/vocational dimension of wellness, utilizing a persons skills, and intellectual wellness, keeping the mind creatively engaged and challenged are key components in leisure activities (ICAA, n.d.). Heo et al. (2018) found that when an older adult had a stronger commitment to leisure, then there were lower levels of depression and improved well-being. Furthermore, older adults involved in serious leisure had positive gains like personal enrichment, self-actualization, and self-gratification (Heo et al., 2018). Social wellness, the value of social interactions for maintaining health, is one of the Seven Dimensions of Wellness (ICAA, n.d.). One important component, social wellness, may improve well-being and decrease depression. Socialization through groups has several benefits, like decreasing social isolation and increasing social participation (Novek et al., 2013). Thus, social SEVEN DIMENSIONS OF WELLNESS FOR IMPROVED QOL 6 interactions are valuable for maintaining health and may help reduce depressive symptoms and improve well-being (ICAA, n.d; Wang et al., 2017). The spiritual dimension of wellness is living with meaning and purpose and being guided by ones values and it influences ones well-being (ICAA, n.d.). Spiritual well-being may promote positive outcomes, physical or psychological, for older adults (Palmer et al., 2018). Many older adults who had their spiritual factors met had improved health outcomes (Palmer et al., 2018). Addressing older adults' spiritual factors may help eliminate poor health among this population. The environmental dimension of wellness that encourages active living (ICAA, n.d.). Many older adults have expressed their desire to remain living within their own community with as much independence as possible (JCHS, 2016). However, age and disease related limitations may decrease function, which may limit functional independence and place older adults at risk for falls (Welti et al., 2020). Increased home accessibility may make this possible (JCHS, 2016). Model The Kawa model served to guide the implementation of this program at the Franciscan Senior Health and Wellness PACE program. The Kawa models focus is on enabling and enhancing life flow by enhancing harmony (Iwama et al., 2009). The Seven Dimensions of Wellness enhanced harmony by introducing PACE participants to different wellness activities. The Kawa model focused on the environment, which for many PACE participants was important since they age in place within their community (Iwama et al., 2009). The Kawa model allowed for determination of the participants at PACE life flow and showed the rocks that inhibited their wellness and QOL and helped bring awareness to the participants attributes and values that enhanced their overall QOL (Iwama et al., 2009). The goal with the Kawa model was to achieve a SEVEN DIMENSIONS OF WELLNESS FOR IMPROVED QOL 7 state of well-being with unimpeded life flow (Iwama et al., 2009). This was ultimately the goal of the program. Telehealth Due to the COVID-19 pandemic, telehealth was a safe and effective way to deliver a holistic wellness program. Older adults are at higher risk for complications and mortality from COVID-19, thus telehealth proved as a beneficial alternative service to deliver a program for this population as it limited potential exposure (Beauchat et al., 2020). Additionally, telehealth allowed for increased social connection, which made it the safest option for participation in a wellness program that promoted groups for social connectedness (Beauchat et al., 2020). The Seven Dimensions of Wellness may improve well-being, satisfaction, and QOL in older adults. Different activities that utilized the dimensions of wellness could help reduce depression and enhance coping abilities as a person ages. The older adult population could benefit from a program that improved their QOL, satisfaction, and well-being. The Franciscan Senior Health and Wellness PACE Program would benefit greatly from this implementation at their facility. Needs Assessment The DCE student gathered initial data and information prior to the start of the DCE. A preliminary site visit between the DCE student and the site personnel took place a year prior to the DCE to brainstorm program ideas and gain an understanding of the sites needs. The DCE student and site mentor agreed that a program providing education and resources with a focus on holistic wellness through the Seven Dimensions of Wellness would be beneficial to establish to increase practices of holistic wellness and well-being among PACE participants. SEVEN DIMENSIONS OF WELLNESS FOR IMPROVED QOL 8 After communication with the occupational therapist and other professionals on the PACE team the DCE student created a needs assessment to gather baseline information on the PACE participants knowledge on wellness. Throughout week seven the DCE student administered the needs assessment via phone calls. The needs assessment assessed current knowledge of the Seven Dimensions of Wellness as defined by the International Council on Active Aging (ICCA) (n.d.). Additionally, questions derived from the Centers of Disease Control and Prevention (2018) assessed participants' satisfaction and limitations on ability to participate in activities they enjoy (see Appendix A). Questions related to the participants current satisfaction with their ability to participate in activities was important to understand as Adyiner Boylu and Gunnay, (2017) found that life satisfaction increases when health, income and activity level improve. Current knowledge of wellness guided the wellness program, educational materials, and raised awareness for wellness in more holistic forms. Needs Assessment Findings. Eight participants, six females and two males, above the age of 55, from the Franciscan Senior Health and Wellness PACE Program in Indianapolis, Indiana completed the needs assessment. One of the PACE occupational therapists referred PACE participants to this wellness program based on their availability and fit within the program, thus convenience sampling was the method utilized. When asked what wellness meant to them, many participants were unable to answer. The participants who did provide an answer of what wellness meant to them said it was staying healthy. When asked about the various dimensions of wellness, each participant stated that they had never heard this term before. Many participants were unaware that wellness encompasses many aspects in our day to day lives. Additionally, when asked about their ability to participate in activities they enjoy, several of the participants reported that they felt limited mentally and SEVEN DIMENSIONS OF WELLNESS FOR IMPROVED QOL 9 physically, which left them feeling unsatisfied with their ability to participate in activities they enjoy. Project Implementation Based on the needs assessment completed with the PACE participants and much discussion with the PACE staff, the DCE student created a wellness program for the PACE participants that included different activities and educational materials based on the Seven Dimensions of Wellness. The program lasted over the duration of three weeks in an online environment via Microsoft Teams. There were seven virtual group sessions, held on Mondays and Wednesdays and one session held on a Tuesday during the first week of the program. The sessions lasted between 30 minutes to one hour. Contacting participants with reminders about group sessions occurred via email, text message, or phone call an hour prior to the group start time. Exclusion criteria from this program included not having internet access or an electronic device. A questionnaire administered pre-test and post-test via phone interview to participants, from the Promis Health Measures Positive Affect and Well-being Short Form and Depression Short Form measured outcomes from the wellness program (Appendix B). Each of these outcome measures is patient-reported, which is a good way to capture important information as it related to depression, well-being, and satisfaction (Broderick, DeWitt, Rothrock, Crane, & Forrest, 2013). Patient reported outcomes are also beneficial to identify the patients area of concern and experiences as these areas may be measured more accurately (Broderick et al., 2013). A study by Flynn et al., (2015) found the reliability and validity of the Promis short forms among patients with heart failure before and after a heart transplant. Questions in the pre-test and SEVEN DIMENSIONS OF WELLNESS FOR IMPROVED QOL 10 post-test asked participants about their well-being, life satisfaction, life purpose, and about symptoms of depression. Wellness Sessions The first session in the wellness program included a spiritual wellness-based group that focused on mindfulness meditation as an effective coping strategy to enhance spiritual wellbeing (Appendix C). Mindfulness meditation may lessen stress and improve mental health (Oken et al., 2018). Mindfulness meditation may provide an effective coping strategy to manage stress and other mental barriers and may lead to enhanced occupational performance. The participants received education on how implementing spiritual wellness and mindfulness meditation into their day-to-day lives could help them manage their mental health, or negative thoughts, and help them further engage in activities that were important to them. A study by Oken et al. (2018) found that participants who participated in mindfulness meditation had improved depression and stress levels and improved well-being. Participants then completed mindfulness meditation with the DCE student. The second session in the wellness program included an emotional wellness-based group on gratitude journaling (Appendix D). Participants received education on how gratitude journaling is a useful way to cope with emotions and promote a healthy way to engage in social participation to enhance occupational performance. Gratitude may help with regulating emotions, which may offer positive effects on mental health and may lead to healthy coping strategy (Boggio et al., 2020). Gratitude journaling may increase well-being and enhance optimism, life satisfaction, and decrease negative affect (Schnitker & Richardson, 2019). The DCE student then educated participants on how to complete gratitude journaling and participants completed an activity where they wrote in their own gratitude journal. SEVEN DIMENSIONS OF WELLNESS FOR IMPROVED QOL 11 The third session in the wellness program was a physical wellness group that focused on nutrition, portion sizes and grocery shopping budgeting (Appendix E). Participants received education on how eating a nutritious diet, eating appropriate portion sizes, and buying nutritious foods may provide them with the energy needed to complete the activities that are important and meaningful to them through a PowerPoint presentation. Eating a balanced diet with the right nutrients may help keep a person emotionally balanced, boost immunity, and lead to improved focus and mental alertness, which may contribute to enhanced independence when paired with physical activity (Robinson & Segal, 2020). Overall, eating a well-balanced diet may provide more energy and boost mood and self-esteem (Robinson & Segal, 2020). It is important to prevent malnutrition, which is eating too little food with too little nutrients, and may lead to depression, weakness, a weak immune system, anemia, and digestion, lung, and heart problems (Robinson & Segal, 2020). The PACE dieticians provided helpful feedback to the DCE student on the portion sizes and budgeting session. It is crucial for older adults to have an adequate diet as they continue to age. The fourth wellness session focused on vocational wellness, specifically on the vocation of older adults utilizing the internet and education on how to increase internet safety to enhance occupational engagement in a leisure activity that many older adults enjoy (Appendix F). Due to COVID-19 many older adults turned to using technology, like tablets and computers, to remain connected with their loved ones, and thus time online has become an important occupation; however, older adults could become targeted by scammers. The DCE student provided education to the participants on the most popular scams that targeted older adults as well as how to protect themselves from scams, and how to report a scam. Many financial scams go unreported and are difficult to prosecute because they are considered low-risk crimes; however, they can be SEVEN DIMENSIONS OF WELLNESS FOR IMPROVED QOL 12 detrimental to older adults (National Council on Aging, n.d.). Furthermore, an older adult might find it shameful to report fraud and fear their family members would lose confidence in them (FBI, n.d.) The fifth session in the wellness program focused on intellectual wellness (Appendix G). Participants received education on how engaging the mind may enhance participation in important and meaningful activities. Participants then engaged in a game of jeopardy that promoted intellectual wellness through various trivia categories and one of the trivia categories the DCE student created asked participants to recall what they learned in the program thus far. Decline in cognitive abilities may inhibit an older adults independence (Cheng-Ting, 2019). Leisure or social activities are beneficial ways to implement intellectual wellness. Leisure and social activities that stimulate the midbrain may protect cognitive ability, decrease mortality, and increase quality of life (Cheng-Ting, 2019). Additionally, leisure activities may help stimulate positive emotions and decrease depression (Cheng-Ting, 2019) for enhanced occupational engagement. The sixth wellness session focused on environmental wellness as it relates to ones ability to contribute to the health of the planet and ones own surroundings (Appendix H). The participants received education through a PowerPoint presentation with information on how to incorporate environmental wellness into their day-to-day lives for enhanced safety and increased sustainability within their environment. Home modifications, which are adaptations made to a home to increase usage, safety, and independence by supporting a persons functional performance (Fagan & Sabata, 2016). Some home environmental modifications include making changes or adding railings, grab bars, non-slip surfaces, raised toilet seats, decreasing clutter, and improved lighting (Welti et al., 2020). Participants received education on simple modifications in SEVEN DIMENSIONS OF WELLNESS FOR IMPROVED QOL 13 the home and participated in an activity where they identified potential unsafe barriers in the home and offered suggestions on how to increase safety into the environment. The seventh and final wellness session focused on social wellness through the activity of chair yoga (Appendix I). Participants received education on how social wellness may help them interact with people that are meaningful to them in their day to day lives. Participants learned about the benefits of chair yoga, an engaging leisure activity, could provide for social participation by joining chair yoga groups, offered by PACE. Additionally, participants learned that chair yoga may enhance physical activity and social activity which may increase quality of life and decrease depression and anxiety for enhanced social participation (Castelo Branco de Oliveira et al., 2019). Upon conclusion of each session participants verbalized their understanding of the topic to show understanding. In addition, at the beginning of each session, sessions two through seven, participants verbalized their understanding of the previous wellness topic to check for understanding. Wellness Education The DCE student created infographics for the PACE participants and provided them to the PACE staff for future use. The infographics contained information related to the Seven Dimensions of wellness and included education on the particular dimension of wellness as well as tips and how to implement the dimension of wellness into day-to-day life. The DCE student created eight total infographics to promote health and wellness, as the PACE staff informed the DCE student that the PACE participants would benefit from wellness-based education, for the PACE Program. Spiritual Wellness Infographic. The spiritual wellness infographic created for PACE (Appendix J) focused on activities to implement into day-to-day life to enhance ones spiritual SEVEN DIMENSIONS OF WELLNESS FOR IMPROVED QOL 14 wellness. Spirituality influences a clients motivation to engage in occupations (AOTA, 2020). Spirituality may provide clients life meaning (AOTA, 2020). The mind-body-spirit connection is impactful in engagement and participation in daily life (AOTA, 2020). The purposeful activities included in this infographic included meditation, yoga, and volunteering as these activities may allow for reflection and the ability to act on personal values and beliefs (AOTA, 2020). Emotional Wellness Infographic. The second infographic focused on emotional wellness (Appendix K) and informed participants on how emotional wellness impacted their dayto-day life. This infographic focuses on managing emotions in a healthy way to promote positive engagement by providing them with the needed support to engage in occupations, like social participation, and decrease potential limitations (AOTA, 2020). Furthermore, the emotional wellness infographic contains tips on improving emotional wellness with coping skills and healthy activities, like mindfulness meditation and gratitude journaling, that may enhance emotional wellness and thus promote occupational performance (AOTA, 2020). Physical Wellness Infographics. Two infographics focused on physical wellness. Portion sizes (Appendix L) provided education to participants on the benefits of proper nutrition for participating in activities of daily living, as well as proper portion sizes of various food groups. It is important to supply ones body with the energy needed to engage in occupations that are important and meaningful (AOTA, 2020). The infographic, Eating on a Healthy Budget (Appendix M), provided participants with education on the importance of nutrition and provided tips on grocery shopping on a budget to overcome potential limitations participants may encounter that decrease occupational performance (AOTA, 2020). SEVEN DIMENSIONS OF WELLNESS FOR IMPROVED QOL 15 Vocational Wellness Infographic. The vocational wellness infographic focused on internet safety (Appendix N) as many older adults may be the targets of financial scams. Due to COVID-19, many older adults are spending time everyday online for leisure and social participation. The internet has become an important activity that occupies time and brings meaning and purpose to their lives (AOTA, 2020). This infographic went into detail providing education on vocational wellness, as well as popular financial scams, tips to keep oneself safe from financial scams when using technology, and how to report a scam to promote safe engagement within this occupation. Intellectual Wellness Infographic. The intellectual wellness infographic (Appendix O) provided participants with education on the benefits of intellectual wellness and various activities, like puzzles, reading, or learning new skills, could stimulate ones mind. Engaging in leisure activities that are meaningful and promote meaning and engagement may enhance occupational engagement by supporting performance skills, like process skills for applying knowledge, organizing timing, and adapting performance (AOTA, 2020). Environmental Wellness Infographic. The environmental wellness infographic (Appendix P) educated participants on simple ways for enhanced safety in their home environment, by suggesting participants remove clutter, throw rugs, and wear appropriate footwear inside and outside their homes. Environmental factors, that are inside or outside the home, influence function, by either promoting function or causing barriers that inhibit function (AOTA, 2020). Interacting in ones environment may enable or restrict participation in meaningful occupations (AOTA, 2020). Additionally, the environmental wellness infographic educated participants on environmentally sustainable changes they could implement in their SEVEN DIMENSIONS OF WELLNESS FOR IMPROVED QOL 16 homes to contribute to the health of the planet to enhance participation in meaningful occupations. Social Wellness Infographic. The social wellness infographic (Appendix Q) provided education to participants regarding social wellness and the benefits social participation offers. Social participation is an important occupation. This infographic also lists activities to engage in for enhanced social wellness and thus promote engagement in social participation in their day-today lives as COVID-19 has created barriers that can limit occupational engagement (AOTA, 2020). Results There were eight participants recruited for this program, but only five participants attended group sessions. Attendance in group sessions each week varied. Table 1 displays the number of participants that attended each session. One participant began attending group sessions during session two and another participant began attending sessions during group four. Participants who participated in the program reported enjoying the program and the various activities implemented throughout the program. Participants requested implementation of these activities when they may return to the PACE site in person. Table 1. Session Attendance Session Topic Number of Participants who Attended 1. Mindfulness Meditation and Spiritual Wellness 2 participants attended 2. Gratitude Journaling and Emotional Wellness 1 participant attended 3. Portion Sizing, Grocery Budgeting, and Physical Wellness 3 participants attended SEVEN DIMENSIONS OF WELLNESS FOR IMPROVED QOL 4. Vocational Wellness and Financial Fraud Awareness 5 participants attended 5. Intellectual Wellness and Jeopardy 2 participants attended 6. Environmental Wellness and Safety and Sustainability in the Home 4 participants attended 7. Chair Yoga and Social Wellness 3 participants attended 17 Findings from the pre-test and post-test showed a small improvement or no decrease in most participants' sense of wellbeing, life satisfaction, and level of depression upon completion of the program based on participants self-reported ratings. Participants also verbalized increased understanding of the Seven Dimensions of Wellness and a desire to implement the different activities into their day to day lives. One participant stated that I wished PACE would implement more activities and programs, like this wellness program, into the PACE Program. Findings from the post-test revealed that four out of five participants scored themselves higher on the item of Lately I had a sense of well-being upon completion of the program which suggested improvement in their well-being. Additionally, two out of five participants had an increase in feeling hopeful following completion of the program as they rated themselves higher on the item Lately I felt hopeful, and two out of five participants reported higher ratings on the item of I had a sense of balance in my life, which also suggested improvement in well-being and satisfaction. Along with well-being, depression was also measured on the pre-test and post-test. Participants reported a decrease in depression as they scored lower on items In the past seven days I felt depressed, In the past seven days I felt hopeless, and In the past seven days I felt I had no reason for living, which suggested a decrease in levels of depression following completion of the wellness program. Overall, participants who attended the majority of the group SEVEN DIMENSIONS OF WELLNESS FOR IMPROVED QOL 18 sessions throughout the program had a bigger improvement in their sense of well-being, life satisfaction, and decreased depression than participants who attended half or less than half of the group sessions. Discussion Based on participation in this program, participants reported improvements in life satisfaction, quality of life, and depression through engagement in various leisure activities. Throughout this program participants engaged in educational leisure activities for enhanced performance in their day-to-day lives. Sala et al. (2019) found that leisure activities are positively associated with cognitive function, physical function, and mental health in late adulthood. Participants reported including more wellness-based activities in their day helped them to cope with their limitations and brought them more enjoyment. Additionally, leisure activities can help stimulate positive emotions and decrease depression (Cheng-Ting, 2019). When older adults engage in more activities, then they have increased satisfaction in life (Aydiner Boylu and Gunay, 2017), which the findings from this program suggest as participants reported positive outcomes of feeling less depressed, and increased satisfaction by rating higher on items on the post-test. Given feedback from the participants, they enjoyed the leisure activities within this program and wanted incorporation of more wellness-based leisure activities at PACE in the future. Recommendations for future programming include incorporating social participation as it may lead to positive outcomes. Furthermore, the DCE student recommends continuation of a holistic wellness-based program for the Franciscan Senior Health and Wellness PACE Program to bring a positive relationship between occupation and health for PACE participants (AOTA, 2020). Actively engaging in occupations promotes, facilitates, maintains, and supports health SEVEN DIMENSIONS OF WELLNESS FOR IMPROVED QOL 19 and participation (AOTA, 2020, p. 5). Wellness-based leisure activities that enhance occupational engagement by supporting performance skills and patterns may help PACE participants continue to live safely and independently within the community (AOTA, 2020). One modification for this program is increasing social participation through more teamwork-based activities so participants can reap more of the benefits social participation offers. Therefore, the DCE student recommended that older adults receive education on the benefits of engaging in holistic wellness leisure-based activities in their day-to-day lives as it may lead to positive outcomes. The Seven Dimensions of Wellness are important to the occupational therapy profession because it helps promote engagement in occupations by providing motivation or support (AOTA, 2020). The Seven Dimensions of Wellness may help with interaction of the mind, body, and spirit, which is important for engagement and participation in daily life (AOTA, 2020). Each of the sessions helped provide participants with different skills and support that may have enhanced occupational performance and achieved well-being. For example, participants learned healthy ways to cope with various stressors or limitations in their lives to promote occupational engagement through different activities that could provide occupational support like mindfulness meditation, gratitude journaling, and chair yoga. One limitation of this program included motivating participants to participate in the program. Due to COVID-19 the Franciscan Senior Health and Wellness PACE Program did not allow for the DCE student to be in direct contact with PACE participants. Another limitation to this program was managing technology to attend the virtual group sessions. Managing technology seemed to be a common issue among participants' ability to attend the group sessions that could have led to decreased participation, as well as prior commitments such as SEVEN DIMENSIONS OF WELLNESS FOR IMPROVED QOL 20 appointments with other members of the PACE interdisciplinary team or other responsibilities. Additionally, the DCE student conducted the pre-test and post-test via phone call due to not having the ability to be in contact with participants. Phone interviews are another limitation to the program as they may have led to participant bias or response bias since participants could not fill the questions out privately and the DCE student asked them the questions. Implications This wellness program based on the Seven Dimensions of Wellness left a positive impact on the Franciscan Senior Health and Wellness PACE program and the PACE participants. Engagement in occupations is part of our health and day to day lives (Scaffa et al., 2010). The participants at the PACE program as well as the site itself had educational materials provided to them along with activities that helped to eliminate participants occupational risk factors, like loneliness or occupational alienation (Scaffa et al., 2010). Furthermore, PACE participants participated in wellness activities that had positive influences on their well-being that encouraged socialization, purpose, and belonging (Scaffa et al., 2010). Occupational therapists have the ability to eliminate disparities this population faces by providing health promotion opportunities and interventions to improve overall health, wellness, and promote occupational engagement (Scaffa et al., 2010). Conclusion Based on participation and feedback from PACE participants the program findings revealed that the PACE participants would continue to benefit from further engagement in a wellness program, based on the Seven Dimensions of Wellness, that may improve their QOL, satisfaction, and well-being, which was the overall purpose of this program. A wellness program that utilized different wellness-based activities helped reduce depression, increase quality of life SEVEN DIMENSIONS OF WELLNESS FOR IMPROVED QOL 21 and enhance coping abilities as a person ages. The findings from this program demonstrated improvements or no decline in participants' sense of wellbeing, life satisfaction, and level of depression as reported by participants. Finally, PACE participants verbalized greater awareness of the Seven Dimensions of Wellness and an increased desire to implement the different wellness activities from this program into their day to day lives. SEVEN DIMENSIONS OF WELLNESS FOR IMPROVED QOL 22 References: American Journal of Occupational Therapy. (2020). Occupational therapy practice framework: Domain and process (4th ed.) American Journal of Occupational Therapy, 74(Suppl. 2: 7412410010. Aydiner Boylu, A., & Gunay, G. (2017). 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Archives of Gerontology & Geriatrics, 76, 1-5. doi.org/10.1016/j.archger.2018.01.007 Perez-Blasco, J., Sales, A., Melendez, J. C., & Mayordomo, T. (2016). The effects of mindfulness and self-compassion on improving the capacity to adapt to stress situations in elderly people living in the community. Clinical Gerontologist, 39(2), 90-103. doi.org/10.1080/07317115.2015.1120253 Robinson, L. & Segal, J. (2020). Eating well as you age. Help Guide. https://www.helpguide.org/articles/healthy-eating/eating-well-as-youage.htm#:~:text=Good%20nutrition%20can%20boost%20immunity,enhanced%20indepe ndence%20as%20you%20age. Sala, G., Jopp, D., Gobet, F., Ogawa, M., Ishioka, Y., Masui, Y., Inagaki, H., Nakagawa, T., Yasumoto, S., Ishizaki, T., Arai, Y., Ikebe, K., Kamide, K., & Gondo, Y. (2019). The impact of leisure activities on older adults cognitive function, physical function, and mental health. PLoS ONE, 14(11), 113. doi.org/10.1371/journal.pone.0225006 Scaffa, M. E., Reitz, S. M., & Pizzi, M. A. (2010). Occupational therapy in the promotion of health and wellness. Philadelphia, PA: FA Davis Company. Schnitker, S. A., & Richardson, K. L. (2019). Framing gratitude journaling as prayer amplifies its hedonic and eudaimonic well-being, but not health, benefits. Journal of Positive Psychology, 14(4), 427439. https://doi.org/10.1080/17439760.2018.1460690 SEVEN DIMENSIONS OF WELLNESS FOR IMPROVED QOL 26 Wang, C., Hua, Y., Fu, H., Cheng, L., Qian, W., Liu, J., . . . Dai, J. (2017). Effects of a mutual recovery intervention on mental health in depressed elderly community-dwelling adults: A pilot study. Bmc Public Health, 17(1), 1-10. doi:10.1186/s12889-016-3930-z Welti, L. M., Beavers, K. M., Mampieri, A., Rapp, S. R., Ip, E., Shumaker, S. A., & Beavers, D. P. (2020). Patterns of Home Environmental Modification Use and Functional Health: The Womens Health Initiative. Journals of Gerontology Series A: Biological Sciences & Medical Sciences, 75(11), 21192124. doi.org/10.1093/gerona/glz290 SEVEN DIMENSIONS OF WELLNESS FOR IMPROVED QOL 27 Appendix A Needs Assessment: Wellness and Satisfaction and Participation in Activities 1. What does wellness mean to you? 2. Have you ever heard that there are different dimensions of wellness? 3. How satisfied do you feel in your ability to participate in activities you enjoy? 4. Have you felt limited by your health, mentally or physically, to participate in activities that kept you from doing your usual activities? References: Centers of Disease Control and Prevention. (October 31, 2018). Healthy days measure. https://www.cdc.gov/hrqol/hrqol14_measure.htm SEVEN DIMENSIONS OF WELLNESS FOR IMPROVED QOL Appendix B Pre-test and Post-test 28 SEVEN DIMENSIONS OF WELLNESS FOR IMPROVED QOL 29 SEVEN DIMENSIONS OF WELLNESS FOR IMPROVED QOL 30 Appendix C Session 1 Protocol Title: The Value of Mindfulness & Achieving Spiritual Wellness Introduction: Thank you all for taking the time to participate in these wellness groups! These groups will continue throughout the next 3 weeks and there will be 7 groups in total. Each session, we will be focusing on one dimension for the Seven Dimensions of wellness, and we will complete an activity that relates to it. Before I get started in explaining wellness, I would like everyone to say their name and one activity you enjoy doing in your free time. To get started today, I would like to discuss wellness. What comes to your mind when I say the word wellness? Maybe exercise, health, sleep? Each of those are good thoughts! To give a background about the Seven Dimensions of Wellness which are physical wellness, emotional wellness, environmental wellness, social wellness, spiritual wellness, intellectual wellness, and vocational wellness. Some of these dimensions I just listed might not have been areas of wellness you had thought about before. The many dimensions of wellness help to form our ability to understand, accept, and act on our capacity to lead a purpose-filled and engaged life (ICAA, 2020). In todays group, we will be focusing on spiritual wellness. Does someone want to take a guess at what they think spiritual wellness is? Spiritual wellness is establishing peace and harmony and being connected with something greater than yourself and having a set of values, principles, morals, and beliefs that provide a sense of purpose and meaning to your life (ICAA, 2020). Having a sense of purpose in meaning in our lives is important for us to engage in the activities that are most important to us. SEVEN DIMENSIONS OF WELLNESS FOR IMPROVED QOL 31 Today we will be working on our spiritual wellness through mindfulness meditation. Mindfulness meditation is a great way to free our minds and enhance our connection with ourselves. It allows for time for self-reflection and can promote relaxation. It can help us take some time so that we can refocus ourselves so we can continue to engage in what is important to us. Mindfulness meditation can provide us with a mind-body connection, and it can reduce stress (Monika & Sharmila, 2020; Oken et al., 2018). Can anyone think of any mindfulness activities someone could do? (meditation, yoga, journaling). Has anyone tried meditation before? Meditation can be helpful to focus your attention and engage your senses by having you focus on sights, sounds, and smells and can help you to stay in the present. Instructions on how to do mindfulness meditation: To complete mindfulness meditation, it is important to go to a quiet place and get comfortable. When doing mindfulness meditation, it can be helpful to set aside a time to do it. You can meditate for as long as you would like. There is no time requirement. Lastly, when meditating it is important to just clear your mind and focus on your breathing and try to remain calm. Activity: Now we are going to try a guided mindfulness meditation video. This video is about 10 minutes. Make sure you are sitting in a comfortable position and I am going to mute everyone so that it is quiet, and we will have no distractions. Is everyone ready? I am going to play the video now. https://www.youtube.com/watch?v=6p_yaNFSYao SEVEN DIMENSIONS OF WELLNESS FOR IMPROVED QOL 32 Sharing/Reflection: Would anyone like to share how the meditation made them feel? Did it feel easy to focus on being in the moment? If not, why? Did any of your senses (sight, touch, smell, taste) seem heightened during the activity? If so what one, and what do you think caused that? What did you learn from todays activity? How do you think implementing mindfulness meditation into your day-to-day life could help you engage in activities that are important to you? Summary: Does anyone have any questions? Could someone give a recap on what spiritual wellness is? Spiritual wellness is establishing peace and harmony and being connected with something greater than yourself (ICAA, 2020). Thank you all so much for participating in todays group! I appreciate each of you for being willing to share. I look forward to meeting with you all again tomorrow at 2pm for our next session. References: Bullock, G., Cullen, M., Kuyken, W., Hunter, J., Sofer, O. J., & Newman, K. M. (2020, February 11). What is mindfulness? Mindful. https://www.mindful.org/what-is-mindfulness/ International Council on Active Aging. (n.d.) Active aging and wellness. Retrieved from https://www.icaa.cc/activeagingandwellness/wellness.htm Monika, & Sharmila, K. (2020). Role of Happiness in Health of Elderly. Indian Journal of Gerontology, 34(4), 544552. SEVEN DIMENSIONS OF WELLNESS FOR IMPROVED QOL 33 Oken, B. S., Goodrich, E., Klee, D., Memmott, T., & Proulx, J. (2018). Predictors of Improvements in Mental Health From Mindfulness Meditation in Stressed Older Adults. Alternative Therapies in Health & Medicine, 24(1), 4855. The Honest Guys. (2015, March 24). Mindfulness Meditation-Guided 10 minutes. [Video]. YouTube. https://www.youtube.com/watch?v=6p_yaNFSYao SEVEN DIMENSIONS OF WELLNESS FOR IMPROVED QOL 34 Appendix D Title: Gratitude Journaling & Emotional Wellness Warm up: Hello everyone! How are you all doing today? I would like to have everyone go around and say your name and say one thing youre grateful for. Would anyone like to start? Introduction: Would someone be able to give a recap on what the Seven Dimensions of Wellness are that we discussed last session? They help to form our ability to understand, accept, and act on our capacity to lead a purpose-filled and engaged life. The Seven Dimensions are physical, emotional, environmental, social, spiritual, intellectual, and vocational. Who can explain what spiritual wellness is? It is establishing peace and harmony between our mind and body. Todays session, we will be focusing on emotional wellness. Emotional wellness is how we view the world and our ability to be aware of and direct our feelings to help create a balance in life. With emotional wellness, coping skills are essential so we can engage in what is important to us. Emotional wellness plays a big part in our day to day lives as it may influence how we interact with people and activities that are meaningful to us. For todays activity we will be learning how to create a gratitude journal. Activity: Has anyone done any gratitude journaling before? A gratitude journal is a great way to improve happiness and cope with our emotions. Gratitude journal can help boost our mental health. Gratitude journaling could be a helpful tool to help us manage our emotions better so we can engage with people who are meaningful to us or activities that are important for us to do. SEVEN DIMENSIONS OF WELLNESS FOR IMPROVED QOL 35 When gratitude journaling, you can write down small things you are grateful for, or big things. When doing gratitude journaling it is important to be specific, get personal, be grateful for the negative outcomes you avoided. Now, I would like for each of you to take about 10 mins and write down 5-10 things you are grateful for. There is no right or wrong way to complete this activity. Just try your best! I will let you know when the 10 minutes are up. Sharing: I would like to go around the group and have each person share one thing they are grateful for. How did the gratitude journaling make you feel? How do you think gratitude journaling could help you engage with others more successfully? How do you think gratitude journaling would be helpful to do when you are having negative thoughts or a bad day? What did you learn from completing gratitude journaling? How do you think completing gratitude journaling 1-2 times a week would be a feasible goal to obtain? Summary: Does anyone have any questions? Could someone summarize what emotional wellness is? Emotional wellness is how we view the world and our ability to be aware of and direct our feelings to help create a balance in life. With emotional wellness, coping skills are essential so we can engage appropriately with those around us. Thank you all so much for participating in SEVEN DIMENSIONS OF WELLNESS FOR IMPROVED QOL 36 todays group! I appreciate each of you being open and willing to share. I look forward to meeting with you all next tomorrow at 10:30 for our last group this week. References: International Council on Active Aging. (n.d.) Active aging and wellness. Retrieved from https://www.icaa.cc/activeagingandwellness/wellness.htm King, N. (Host). (2018-present). If you feel thankful, write it down. Its good for your health. [Audio Podcast]. NPR. https://www.npr.org/transcripts/678232331 SEVEN DIMENSIONS OF WELLNESS FOR IMPROVED QOL 37 Appendix E Title: Benefits of a Healthy Lifestyle through Nutrition & Physical Wellness Warm Up: Introductions: each person states their name and one food that they enjoy eating or making. Introduction: Recap on 7 dimensions for people who were not in past groups: The Seven Dimensions of Wellness helps to form our ability to understand, accept, and act on our capacity to lead a purpose-filled and engaged life. The Seven Dimensions are physical, emotional, environmental, social, spiritual, intellectual, and vocational. Yesterday, we discussed emotional wellness. Emotional wellness is how we view the world and our ability to be aware of and direct our feelings to help create a balance in life. Emotional wellness is a part of our day-to-day lives as it helps us engage with those around us. Today we will be talking about physical wellness! What are some ways we can be physically well? (exercise, eating healthy, getting enough sleep). Physical wellness is lifestyle choice that can maintain or improve health and functional ability (ICAA, 2020). This can include engaging in physical activity, choosing healthy foods with adequate nutrition, getting adequate sleep, managing stress, limiting alcohol intake, not smoking, making appointments for check-ups, and following medical recommendations (ICAA, 2020). For todays activity we are going to discuss healthy foods we can eat and how to make a budget for buying healthy foods. Eating healthy and nutritious food is important to provide us with energy needed to engage in activities that are important and meaningful to us every day. It is important to treat our bodies right with proper nutrition. SEVEN DIMENSIONS OF WELLNESS FOR IMPROVED QOL 38 Activity: PowerPoint that outlines the 5 main food groups and gives examples of how much proportion of foods to eat with examples of food choices. Budgeting is included in PowerPoint. Time for questions at the end. Have participants complete myplate.gov Sharing: What did you learn today? Did you learn anything you did not know before this activity? How easy do you think it will be to complete a budget and follow it? Summary: Who can summarize what we learned today before we end todays group? Physical wellness is lifestyle choices that can maintain or improve health and functional ability (ICAA, 2020). This can include engaging in physical activity, choosing healthy foods with adequate nutrition, getting adequate sleep, managing stress, limiting alcohol intake, not smoking, making appointments for check-ups, and following medical recommendations (ICAA, 2020). It is important to fuel our bodies with adequate nutrition so we can have the energy we need to engage in activities that are important to us. Thank you all so much for participating in todays group! I appreciate each of you being open and willing to share. I look forward to meeting with you all on Monday at 2:30pm for our next group. References: International Council on Active Aging. (n.d.) Active aging and wellness. Retrieved from https://www.icaa.cc/activeagingandwellness/wellness.htm SEVEN DIMENSIONS OF WELLNESS FOR IMPROVED QOL 39 National Institute on Aging. (2019, April 29). Serving and portion sizes: How much should I eat? https://www.nia.nih.gov/health/serving-and-portion-sizes-how-much-should-i-eat U.S. Department of Agriculture. (n.d.). Whats on your plate? https://www.myplate.gov/ SEVEN DIMENSIONS OF WELLNESS FOR IMPROVED QOL 40 Appendix F Title: Vocational wellness & how to be avoid scams Warm Up: Hi everyone! I am glad to see you all here today! I would love for everyone to go around and just say their name and name a type of fraudulent activity you are aware of because fraud is what we are going to be talking about today! Introduction: Before we get started into todays topic could someone remind the group of what physical wellness is. Who can remind the group what physical wellness is? Physical wellness is lifestyle choices that can maintain or improve health and functional ability (ICAA, 2020). This can include engaging in physical activity, choosing healthy foods with adequate nutrition, getting adequate sleep, managing stress, limiting alcohol intake, not smoking, making appointments for check-ups, and following medical recommendations (ICAA, 2020). Thank you! Todays group will be focusing on vocational wellness. Vocational wellness involves preparing and making use of your gifts, skills, and talents in order to gain purpose, happiness and enrichment in your life. You all contribute to society as experienced professionals, caregiver, mentors, teachers, and volunteers. Your main vocation now is retirement. And your Leisure-time vocations in the arts and through hobbies maintain your occupational skills. What are some leisure vocations you enjoy? Todays group focuses on your vocation and how you are a group that is at risk for financial fraud and some ways to be safe on the internet. Activity: SEVEN DIMENSIONS OF WELLNESS FOR IMPROVED QOL 41 In todays activity I am going to be discussing several different financial scams out there that are targeting older adults. I also have a couple videos I will play, with a former FBI agent who fell for a scam, and a police officer who discusses financial scams. I will also tell you how you can report the scam to your local FBI agent if this ever happens to you because each year millions of older Americans fall for financial fraud, racking up more than $3 billion in losses! The scammers will use various methods to try and deceive you and will try and gain your trust. These scammers might try talking to you through the computer, mail, by phone, TV, radio, or in person. Here are some of the scams you can be on the lookout for. Romance Scam: Perpetrators pose as interested romantic partners through dating websites to capitalize on their elderly victims desire to find companions. Perpetrators may contact you through Facebook, phone calls, texts, or emails. They might ask you for money for a procedure, travel expenses, or fees or debts they have. Tech Support Scam: Perpetrators pose as technology support representatives and offer to fix non-existent computer issuesgaining remote access to victims devices and, thus, their sensitive information. Perpetrators might target you through phone calls or pop-up windows on your computer stating that your computer has threats or by telling you that your computer has problems, like a virus, that it does not have. Grandparent Scam: Perpetrators pose as a relativeusually a child or grandchild claiming to be in immediate dire financial need. This is where a perpetrator will call pretending to be a loved one. They will likely sound frantic and create a fake situation where they are in trouble and will try to urge you to send them money. SEVEN DIMENSIONS OF WELLNESS FOR IMPROVED QOL 42 Government Impersonation Scam: Perpetrators pose as government employees and threaten to arrest or prosecute victims unless they agree to provide funds or other payments. These perpetrators will likely contact you by phone or email and will try to get you to send money to a phony website. Sweepstakes/Charity/Lottery Scam: Perpetrators claim to work for legitimate charitable organizations to gain victims trust. Or they claim their targets have won a foreign lottery or sweepstake, which they can collect for a fee. Perpetrators might try to solicit you through phone calls or online. Home Repair Scam: Perpetrators appear in person and charge homeowners in advance for home improvement services that they never provide. TV/Radio Scam: Perpetrators target potential victims using illegitimate advertisements about legitimate services, such as reverse mortgages or credit repair. Family/Caregiver Scam: Perpetrators are relatives or acquaintances of the elderly victims and take advantage of them or otherwise get their money. Perpetrators steal money or valuables or run up bills on your credit cards. Videos: Now we are going to watch a short 3-minute video of a former FBI director who got caught up in a scam. https://youtu.be/yqsgKsO6H_c Any thoughts on what you heard in this video? Next, we will watch a police officer from Florida discuss how to stay safe from scams and his experiences of working with older adults who were victims to scams. https://www.youtube.com/watch?v=tl4DE6JmneM SEVEN DIMENSIONS OF WELLNESS FOR IMPROVED QOL 43 So how can I protect myself from being scammed? Recognize scam attempts and end all communication with the perpetrator. Search online for the contact information (name, email, phone number, addresses) and the proposed offer. Other people have likely posted information online about individuals and businesses trying to run scams. Resist the pressure to act quickly. Perpetrators create a sense of urgency to produce fear and lure victims into immediate action. Call the police immediately if you feel there is a danger to yourself or a loved one. Be cautious of unsolicited phone calls, mailings, and door-to-door services offers. Never give or send any personally identifiable information, money, jewelry, gift cards, or checksor wire information or fundsto unknown or unverified persons or businesses. Ensure all computer anti-virus and security software and malware protections are up to date. Use reputable anti-virus software and firewalls. If you receive a pop-up or locked screen on your device, immediately disconnect from the internet and shut down the affected device. Pop-ups are regularly used by perpetrators to spread malicious software. To avoid accidental clicks on or within a pop-up, enable pop-up blockers. Do not open any emails or click on attachments you do not recognize and avoid suspicious websites. If a perpetrator gains access to a device or an account, take precautions to protect your identity; immediately contact your financial institutions to place protections on your accounts; and monitor your accounts and personal information for suspicious activity. HOW TO FILE A COMPLAINT If you feel if you have fallen victim to a scam, then contact your local FBI agent! Our FBI agent in Indianapolis is Paul Keenan It is important to give the agent as much detail as possible in the complaint. It is best to include: 1. 2. 3. 4. 5. 6. Dates the perpetrator had contact with you, and the methods of communication. Names of the perpetrator and company. Phone numbers, email addresses, and mailing addresses used by the subject. Websites used by the subject company. Method of payment. Account names and numbers and the financial institutions to which you sent funds, including wire transfers and prepaid card payments. SEVEN DIMENSIONS OF WELLNESS FOR IMPROVED QOL 44 7. Descriptions of interactions with the perpetrator and the instructions you were given. Lastly, contact PACE and let them know this has happened to you. PACE is on your side and will help you take the actions necessary to report the fraud. Sharing: What questions do you have? What is something you learned today that you hope to implement to protect yourself in the future? Summary: I know todays session contained a lot of information. Could someone restate what vocational wellness is? Vocational wellness is utilizing a persons skills while providing personal satisfaction is valuable for society as well as the individual. Vocations are whatever are meaningful to you. Participating in the paid and unpaid workforce means maintaining or improving skills and helping others. Thank you all for participating today! I hope you all have a great rest of the day! References: Council on Aging of West Florida. (2016, July 27). Scams Targeting Seniors. [Video]. YouTube. https://www.youtube.com/watch?v=tl4DE6JmneM FBI. (n.d.). Elder Fraud. https://www.fbi.gov/scams-and-safety/common-scams-andcrimes/elderfraud#:~:text=Each%20year%2C%20millions%20of%20elderly,scams%2C%20to%20na me%20a%20few.&text=With%20the%20elderly%20population%20growing,to%20be%2 0a%20growing%20problem. SEVEN DIMENSIONS OF WELLNESS FOR IMPROVED QOL 45 FBI. (2019, March 7). Former FBI Director William Webster Helps Foil Scam. [Video]. YouTube. https://youtu.be/yqsgKsO6H_c International Council on Active Aging. (n.d.) Active aging and wellness. Retrieved from https://www.icaa.cc/activeagingandwellness/wellness.htm SEVEN DIMENSIONS OF WELLNESS FOR IMPROVED QOL 46 Appendix G Title: Intellectual Wellness and the Power of Games Introduction: Just a reminder before we get started today on the Seven Dimensions of Wellness, which are what each of these groups are based on. They help to form our ability to understand, accept, and act on our capacity to lead a purpose-filled and engaged life. The Seven Dimensions are physical, emotional, environmental, social, spiritual, intellectual, and vocational. Last group, we learned about vocational wellness. Could anyone provide a refresher on what vocational wellness is? Vocational wellness is utilizing a persons skills while providing personal satisfaction is valuable for society as well as the individual. Does anyone have any additional questions about that dimension of wellness? Today we will be focusing on intellectual wellness! Intellectual wellness is engaging in creative pursuits and intellectually stimulating activities is a proven approach to keeping minds alert and interested (ICAA, n.d.). It is important to engage in activities that help stimulate our mind to keep our minds healthy so we can continue to engage independently in the activities we enjoy. There are many ways to stay intellectually active, including journaling, painting or joining a theater company, and challenging oneself with games and puzzles (ICAA, n.d.). What are some ways you like to keep your mind engaged? Activity: Today we are going to play a game of jeopardy to get our minds engaged! Jeopardy PowerPoint activity. Sharing: SEVEN DIMENSIONS OF WELLNESS FOR IMPROVED QOL 47 Questions? Summary: So today we learned about intellectual wellness, which is engaging in creative pursuits and intellectually stimulating activities is a proven approach to keeping minds alert and interested (ICAA, n.d.). Thank you all again for participating in todays group session! I hope you had fun playing jeopardy and learned a little bit. I will see you all on Monday at 2:30pm for our next wellness group session. References: International Council on Active Aging. (n.d.) Active aging and wellness. Retrieved from https://www.icaa.cc/activeagingandwellness/wellness.htm SEVEN DIMENSIONS OF WELLNESS FOR IMPROVED QOL 48 Appendix H Title: Environmental wellness & How to make my environment safe Introduction: To begin today, I just want to remind the group about the Seven Dimensions of wellness, which help form our ability to understand, accept, and act on our capacity to lead a purpose-filled and engaged life. The Seven Dimensions of Wellness which are physical wellness, emotional wellness, environmental wellness, social wellness, spiritual wellness, intellectual wellness, and vocational wellness. Last session, we focused on intellectual wellness. Who can define intellectual wellness? Intellectual wellness is engaging in creative pursuits and intellectually stimulating activities is a proven approach to keeping minds alert and interested (ICAA, n.d.). For todays activity we are going to be learning about environmental wellness and how we can be safe in our own environments. Environmental wellness is choosing to be green and re-use and recycle goods (ICAA, n.d.). Environmental wellness is important to incorporate in our day-to-day lives, especially as we think about our home environment. It is important to make modifications, like securing or removing rugs, improving lighting, or adding grab bars to name a few, to our home for increased safety and sustainability. Activity: Powerpoint for todays activity with photos to identify unsafe things in a room. Education on what is unsafe, why it is unsafe, and how to improve the picture. Discussion on how to make the home more environmentally sustainable with simple changes. SEVEN DIMENSIONS OF WELLNESS FOR IMPROVED QOL 49 Sharing: What are some changes you could make to your home to increase your safety? What are some environmental changes you can make to go green? Did you learn anything today that you did not know before? Summary: Who can remind us what environmental wellness is? Environmental wellness is choosing to be green and re-use and recycle goods (ICAA, n.d.). We can all try to incorporate this dimension of wellness into our day to day lives as best as we can. Thank you all for participating! I will see you on Wednesday for our last wellness group session where we will be doing chair yoga! References: Government of Canada. (2013, December 13). Stay safe. https://www.canada.ca/en/publichealth/services/health-promotion/aging-seniors/publications/publications-generalpublic/stay-safe-poster.html International Council on Active Aging. (n.d.) Active aging and wellness. Retrieved from https://www.icaa.cc/activeagingandwellness/wellness.htm Sustainability Victoria. (n.d.). Top 10 tips for living sustainably. https://www.sustainability.vic.gov.au/You-and-your-home/Live-sustainably/Top-10-tipsfor-living-sustainably SEVEN DIMENSIONS OF WELLNESS FOR IMPROVED QOL 50 Appendix I Title: Social Wellness and Chair Yoga Introduction: For todays group session, we will be focusing on social wellness. Before we start in with social wellness, does anyone remember what environmental wellness from our last group is? Environmental wellness is choosing to be green and re-use and recycle goods (ICAA, n.d.). Social wellness is our ability to interact successfully with others within our community and live up to the demand of our personal roles (University of California Merced, n.d.). We can work on social wellness by participating in different groups and spending time with friends or family. You all have been incorporating social wellness into each of these group sessions we have been having by communicating with one another and being present for each group. You can continue to engage socially each week in the other leisure focused groups that are offered by PACE. Social wellness is an important part of our day-to-day activities! For todays group activity we will all be doing chair yoga together! Chair yoga is a great leisure activity that incorporates social wellness by engaging with each other and can enhance our physical and social activity. Activity: Lets learn a little bit about what chair yoga can do for us. Yoga offers a lot of great benefits! Yoga can help to reduce our stress, tension, improve our flexibility, reduce our pain, boost our mood, improve sleep, and decrease anxiety and depression. To do chair yoga, it is important to be in a stable chair at a flat and level surface. And make sure you have plenty of space to move your arms and legs. When doing chair yoga, just complete the exercises to the best of your ability. If at any time you feel pain, just stop and rest. I will give everyone a minute SEVEN DIMENSIONS OF WELLNESS FOR IMPROVED QOL 51 to get situated because I am going to lead us through some chair yoga today and I need to set up my space so you can all see me! Chair yoga poses and session: Begin with taking deep breaths. Breathing in and out through your nose. Be mindful of your posture. Keep continuing with slow steady breath. We will begin with some neck circles. Make sure to relax your jaw so there is no tension. Then when have head back over to the right shoulder leave it there and extend your left arm out to deepen the stretch. If you want, then you can bring your right hand and help pull your right ear toward your right shoulder. Hold for 30 seconds. Then lift the head back up and switch sides. So, we will bring our left ear toward our left shoulder and extend our right arm. Hold for 30 seconds. Then come back to center. Next move we will be doing is cat and cow pose. You can hold on to the front of your knees. As you inhale left your chest up to the sky and squeeze your shoulder blades behind you and on the exhale round forward and contract in. We will do this 5 times. Now lets come back to center. Now for our next move, you want to reach your right arm across your chair, like this. And reach your left arm, as best as you can, up to the sky and move into a side bend. Just go as far as you can. Make sure you are holding onto your chair, so you dont fall over. Then bring your left hand to the back of the chair to twist your body open. If you can, try to look over your left shoulder. Then exhale to release and now we will switch sides. Now bring your left hand over the chair, reach your right arm up into the air as best as you can and bend toward your left side. Then we will breathe into our twists and bring our right arm to the back of the chair and hold on. Again, try to look back over your right shoulder. Then release and face forward. SEVEN DIMENSIONS OF WELLNESS FOR IMPROVED QOL 52 Now we will do some half sun salutations. As you inhale, circle the palms wide and bring them together at the top and exhale and fold down and bring your belly down to rest on your thighs. Inhale and halfway lift and then rest back on your thighs. Now. We will repeat our sun salutation and when we exhale bring your hands to your heart. One more time. And exhale and fold all the way down. Next, we are going to do chair pigeon. So, for this, if you can we will bring our leg and do our best to cross over our knee, and then we will lead forward and hold. Lastly, we will work on some leg strengthening. So, if you can, we will just extend our right leg out and hold it for as long as you can. Then we will repeat and do the other leg. Next, we are going to scoot forward in our chair and keep our heels planted on the floor and just squat right over the chair. Let your arms help you as much as needed. We will come forward in one more forward fold. So, bend at the hips and let your belly rest on your thighs. This is a good pose to release the neck, the spine. Make sure you keep breathing. Now carefully curl your body up so its back into a seated position. Now sit back in your chair and get comfortable as we wind down to end todays chair yoga session. Relax your arms on the top of your legs. And just focus on your breathing. Notice how you feel now verse when we started. Take 5 deep breaths here. And bring your palms together in front of the heart. Namaste. Thank you so much for participating in this yoga activity! Sharing: How comfortable did you feel doing the chair yoga? Did you have a favorite chair yoga move? Would you use chair yoga to help manage stress in the future? SEVEN DIMENSIONS OF WELLNESS FOR IMPROVED QOL 53 What have you learned from our different sessions together? Is there anything you would like to share or have any feedback for me? Summary: Thank you all for taking the time to participate in my groups! I hope you feel like you have learned a lot about wellness and enjoyed the groups! I will be calling you all tomorrow to ask the final questions I need for my project. I hope you all have a great rest of the day and thanks again for taking the time to participate in these groups with me! References: International Council on Active Aging. (n.d.) Active aging and wellness. https://www.icaa.cc/activeagingandwellness/wellness.htm Yoga with Kassandra. (2019, July 11). Gentle Chair Yoga for Beginners and Seniors. [Video]. YouTube. https://www.youtube.com/watch?v=1DYH5ud3zHo Senior Lifestyle. (n.d.). Infographic: Top 10 chair yoga positions for seniors. https://www.seniorlifestyle.com/resources/blog/infographic-top-10-chair-yoga-positionsfor-seniors/ University of California Merced. (n.d.). Seven dimensions of wellness. https://health.ucmerced.edu/resources/seven-dimensions-wellness SEVEN DIMENSIONS OF WELLNESS FOR IMPROVED QOL Appendix J 54 SEVEN DIMENSIONS OF WELLNESS FOR IMPROVED QOL Appendix K 55 SEVEN DIMENSIONS OF WELLNESS FOR IMPROVED QOL Appendix L 56 SEVEN DIMENSIONS OF WELLNESS FOR IMPROVED QOL Appendix M 57 SEVEN DIMENSIONS OF WELLNESS FOR IMPROVED QOL Appendix N 58 SEVEN DIMENSIONS OF WELLNESS FOR IMPROVED QOL Appendix O 59 SEVEN DIMENSIONS OF WELLNESS FOR IMPROVED QOL Appendix P 60 SEVEN DIMENSIONS OF WELLNESS FOR IMPROVED QOL Appendix Q 61  ...

... A Comprehensive Evaluation of the COTAD Chapters Program M. Emma Baldwin, OTS, PCBIS July 6, 2021 A research project submitted in partial fulfillment for the requirements of the Doctor of Occupational Therapy degree from the University of Indianapolis, School of Occupational Therapy. Under the direction of the DCE advisor: Dr. Brenda Howard, DHSc, OTR A Research Project Titled A Comprehensive Evaluation of the COTAD Chapters Program 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 M. Emma Baldwin, OTS, PCBIS Approved by: Dr. Brenda Howard, DHSc, OTR DCE Advisor & 1st Reader Dr. Ryan Lavalley, PhD, OTR/L 2nd Reader Accepted by the Chair of the School of Occupational Therapy: Kate E. DeCleene Huber, OTR, MS, OTD Chair, School of Occupational Therapy Running Head: COMPREHENSIVE EVALUATION OF THE COTAD CHAPTERS PROGRAM A Comprehensive Evaluation of the COTAD Chapters Program M. Emma Baldwin, OTS, PCBIS University of Indianapolis 1 COMPREHENSIVE EVALUATION OF THE COTAD CHAPTERS PROGRAM 2 Abstract Background: This program evaluation seeks to evaluate the effectiveness and sustainability of the Coalition of Occupational Therapy Advocates for Diversity (COTAD) Chapters program, both processes and outcomes of programming. Health disparities, racism, oppression, and injustice in the healthcare field, contextualized with a lack of diversity and diversity awareness of the occupational therapy (OT) profession, prompt the necessity for the COTAD Chapters program. The COTAD Chapters program is a volunteer-run program that empowers and supports OT students into advocacy for increasing diversity in the OT profession and eliminating discrimination and health disparities. Methodology: Through a mixed-methods program evaluation for formative and summative purposes, program evaluators interpreted surveys, interviews, preexisting Chapter data, document review, direct observation, and social media analysis. Results: The results indicate that stakeholders believe the COTAD Chapters program is fulfilling its intended purposes and that Chapters are enacting changes within OT on multiple scales. However, the COTAD Chapters program processes are not yet optimized to accommodate and support students in their efforts as effectively as the administrators would like. Implications: The COTAD Chapters program would benefit from a new structure that accommodates more volunteers, offers more to COTAD Chapters, and continues to promote the impacts and outcomes toward which the COTAD Chapters are already working. Conclusion: The COTAD Chapters program transforms OT education, practice, and research by energizing student advocacy for increased diversity within the OT profession and creating a national network of future generations of action-oriented and empowered OT practitioners. COMPREHENSIVE EVALUATION OF THE COTAD CHAPTERS PROGRAM 3 Table of Contents Introduction......................................................................................................................................5 Program Description............................................................................................................5 Program Motivations and Assumptions...............................................................................8 Method...........................................................................................................................................11 Ethics..................................................................................................................................11 Study Approach / Design...................................................................................................11 Data Sources......................................................................................................................13 Results............................................................................................................................................19 What Are the COTAD Chapters Processes and Activities? .............................................19 What Are the COTAD Chapters Intended Outcomes?......................................................25 What Are the COTAD Chapters Actual Outcomes? ........................................................30 Discussion......................................................................................................................................61 COTAD Chapters Processes..............................................................................................61 COTAD Chapters Goals and Outcomes............................................................................62 Value of an Occupational Perspective...............................................................................66 Recommendations for Program.........................................................................................66 Limitations.71 Recommendations for Further Research...........................................................................72 Conclusion.....................................................................................................................................73 References......................................................................................................................................75 Appendix A. Full Logic Model......................................................................................................80 Appendix B. Data Map..................................................................................................................81 COMPREHENSIVE EVALUATION OF THE COTAD CHAPTERS PROGRAM 4 Appendix C. Survey Questions and Indicators..............................................................................83 Appendix D. Survey Questions in Chair Transition Form............................................................93 Appendix E. Semi-Structured Interview Questions.......................................................................94 COMPREHENSIVE EVALUATION OF THE COTAD CHAPTERS PROGRAM 5 A Comprehensive Evaluation of the COTAD Chapters Program Founded in 2014, the Coalition of Occupational Therapy Advocates for Diversity (COTAD) is a nonprofit organization within occupational therapy (OT), poised to address systemic racism and oppression, occupational injustice, healthcare equity, and educational decolonization (Coalition of Occupational Therapy Advocates for Diversity [COTAD], n.d.-a). The COTAD Chapters program was formed in 2017 to support students in addressing the aforementioned initiatives, locally and nationally (COTAD, n.d.-b). To date, no evaluations of program processes or outcomes have been completed. Thus, the purpose of this Doctoral Capstone Experience is to evaluate the effectiveness and sustainability of the COTAD Chapters program processes and programming, and to examine the intended and actual outcomes of the program, through completing a mixed-methods program evaluation. Program Description In 2013, a small group of leaders in the American Occupational Therapy Association (AOTA) Emerging Leaders Program formed the COTAD. By 2017, the founders expanded these efforts into the student realm, to increase diversity in the OT profession (A. Anvarizadeh, personal communication, April 9, 2021). A lack of diversity in healthcare workforces can contribute to healthcare inequity (Noone et al., 2016; Phillips & Malone, 2014). Thus, COTAD launched the COTAD Chapters program in OT and OTA programs across the country, first at West Coast University (WCU), to foster safe spaces to grow anti-oppressive practitioners (A. Anvarizadeh, personal communication, April 9, 2021). The program description will describe the COTAD Chapters program activities and processes from 2017-2020, prior to the evaluation and data collection process. Processes changed or implemented in 2021, as a result of the program evaluation process, are outlined in the discussion. COMPREHENSIVE EVALUATION OF THE COTAD CHAPTERS PROGRAM 6 The COTAD Chapters program leverages volunteers across the country to network with and support students within OT and OTA programs, to work towards increasing the diversity within the OT profession and eliminating discrimination and health disparities (Coalition of Occupational Therapy Advocates for Diversity (COTAD, n.d.-b.; Cohen et al., 2002). With the Chapters programs structure, processes, resources, and COTAD National leader guidance, students reach out to establish Chapters'' to begin or continue work towards diversity, equity, inclusion, justice (DEIJ), anti-racism, and anti-oppression, within their OT and OTA programs. Dr. Anvarizadeh is the current Chair of the COTAD Chapter program with two volunteers assisting her. At minimum, each Chapter has a student Chapter Chair and a facility liaison to support the student-led initiatives, events, and work. Chapter processes require Chairs to attend quarterly All-Chapter Calls, document at least four yearly goals aligned with COTADs mission, and plan and coordinate Chapter events or initiatives. The COTAD Chapters program serves to create new leaders and facilitates long-term and action-oriented commitments within the educational system, to promote and sustain the work outlined in COTADs mission and vision. As the COTAD Chapters program grows, COTAD wants to evaluate its processes and outcomes to prepare the program for growth, and to ensure the program is meeting its goals. A scheme of the COTAD Chapters program is in Figure 1. Figure 1 represents what was known about the COTAD Chapters program prior to initiating this program evaluation project. The following section will describe the visual further. A more detailed program logic model is in Appendix A. The indicators in the logic models guided data collection and evaluation, as seen in Appendix B. COMPREHENSIVE EVALUATION OF THE COTAD CHAPTERS PROGRAM Figure 1 Simplified Logic Model of the COTAD Chapters Program Evaluation Note. This figure demonstrates the simplified logic model created by the program evaluation team, which can be viewed in more detail at: https://miro.com/app/board/o9J_l7lmKRU=/?moveToWidget=3074457361033864959&cot=14 7 COMPREHENSIVE EVALUATION OF THE COTAD CHAPTERS PROGRAM 8 Program Motivations and Assumptions The Need The following literature review describes the motivations and assumptions that drive the COTAD Chapters program in their efforts against discrimination, inequity, inequality, injustice, oppression, and racism within the OT educational context. Diversity is lacking within the OT profession as compared to the general population (Brown et al., 2011; U.S. Census Bureau, 2019). Increasing the diversity of the OT workforce could improve access to health care for underserved populations, advance cultural humility, strengthen research about marginalized populations and healthcare disparities, and ensure a healthcare system suited for a diverse society (Cohen et al., 2002; Ford et al., 2021). Occupational therapists work with an increasingly diverse population whose occupations are rooted in culture and identity (AOTA, 2020-c.; Hildebrand et al., 2013), which ethically requires OT professionals to learn and implement cultural humility and cultural effectiveness in providing effective, socially-just, and equitable care to all clients (Agner, 2020; AOTA, 2015; Brown et al., 2011; Howard et al., 2018; Landy et al., 2016; Wilson et al., 2015). As the profession attempts to grow toward a more diverse workforce, practitioners and students have the onus to bridge the gap between themselves and their more diverse clientele, through learning cultural humility and cultural effectiveness (Howard et al., 2018; Wilson et al., 2015). Bolding et al. (2020) reported to provide effective occupational therapy, students and practitioners must be able to recognize differences in underrepresented populations health beliefs and behaviors, and address clients needs in ways that are respectful of the clients beliefs, priorities, and preferences. Cultural humility has the potential to reduce health disparities by increasing the effectiveness of health professionals working with diverse clients (Acker, 2017; Agner, 2020). A COMPREHENSIVE EVALUATION OF THE COTAD CHAPTERS PROGRAM 9 systematic review determined that health patient care outcomes can relate to practitioner levels of implicit biases and identified that most health providers and students have implicit biases (Hall et al., 2015). Therefore, targeting reducing implicit bias at an educational level may improve patient outcomes (Acker, 2017; Hall et al., 2015). AOTA recently stated that increased awareness about oneself, personal biases, and others can promote more equitable care for all people, and the organization articulated the need for OT educators to demonstrate and teach such skills to students (AOTA, 2020-a.; AOTA, 2020-c.). In working to prepare OT and OTA students to work with a diverse population, educators can help the profession begin to address the health disparities that affect minoritized and underrepresented clients within healthcare (AOTA, 2020-c.; Wilson et al., 2015). Student Perceptions Murden (2008) reported that students felt a need for more focus on cultural differences and their influences on occupational therapy delivery to feel competent in their fieldwork experiences. Other studies have indicated that students felt they lacked basic knowledge, clinical skills, and attitudinal awareness in preparation for clinical practice with LGBTQIA+ clients (Acker, 2017; Bolding et al., 2020). OT students also perceived the need for increased factual education about culture to promote adequate patient care, rapport building, family participation, and person-centered goal creation (Cheung et al., 2002; Murden, 2008). Studies indicated that students and the field of OT would benefit from educators reexamining classroom climates, implicit biases, course content, and programmatic policies and construction (Bolding et al., 2020; Dennis et al., 2020), and Trentham et al. (2020) demonstrated that students have the desire to learn. COMPREHENSIVE EVALUATION OF THE COTAD CHAPTERS PROGRAM 10 Student Safety. Evaluators identified that the need for improved OT educational experiences also arose from a lack of comfort and safety that students with underrepresented identities perceived within their educational programs. Moreover, they identified a cultural disconnect within their curricula and between their majority White faculty and peers (Lucas, 2018). Dennis et al. (2020) found that students from non-majority backgrounds had significantly less trust in institution policies and practices, and less faith that their program supported positive work with people of diverse cultures, than their less diverse classmates. Overt discrimination and racism affected the educational experiences of students from underrepresented groups (Ackerman-Barger et al., 2020; Ford et al., 2021; Lucas, 2018; San & Breen-Franklin, 2019). Studies indicated that fear and microaggressions negatively affected and limited students, which impacted their learning, academic performance, and wellness (Ackerman-Barger et al., 2020; San & Breen-Franklin, 2019). Students in a study by Ackerman-Barger et al. (2020) specified that the provision of informal and formal safe spaces might allow for improved student experiences. To foster positive conversations about DEIJ and engage students in multicultural education to in turn improve patient care, students must feel safe and supported in their environment first (Kumagai & Lypson, 2009; Trentham et al., 2020). Mentorship. Ford et al. (2021) reported diverse students, specifically students of color, had a need for mentorship for connections and relationship building. Trentham et al. (2020) determined that mentor-led small groups enabled students to feel less fear and engage in peer dialogue about diversity and inclusion. Studies indicated that peer mentorship programs mentoring diverse students through the pipeline better allowed students to thrive in school (Edgoose et al., 2019; Noone et al., 2016). Norcross et al. (2020) determined e-mentoring across time zones could provide beneficial support as well. Mentorship for students with COMPREHENSIVE EVALUATION OF THE COTAD CHAPTERS PROGRAM 11 underrepresented identities was best when individuals could relate to their mentors, and mentors provided technical and emotional support (Edgoose et al., 2019; Ford et al., 2021). Why Action is Needed Students identified needs related to DEIJ, anti-racism, and anti-oppression within their OT programs, pipelines into OT schools, and the OT profession. AOTAs Commitment to Diversity, Equity, and Inclusion states that AOTA supports all efforts towards DEIJ within OT practice, education, research, policy development, and advocacy (AOTA, 2020-c.). However, Taff & Blash (2017) identified that initiatives and statements are only the start of efforts towards DEIJ, anti-oppression, and anti-racism within OT. Educational programs are not solely able to equip students to address these challenges (Taff & Blash, 2017). Honest reflection and conversation within individual, institutional, and professional contexts are insufficient if not followed by understanding, commitment, and action (Taff & Blash, 2017, p. 81). Johnson & Lavalley (2020) stated that OT must address the influence of racism on occupation to prevent producing new forms of racism and reproducing old forms of racism. As the COTAD Chapters program seeks to take overt action against all forms of discrimination, inequity, inequality, injustice, oppression, and racism in the educational context, a program evaluation is warranted to determine the effectiveness of its actions. Method Ethics The UIndy Human Research Protections Program approved this study as non-human subjects research. Study Approach / Design COMPREHENSIVE EVALUATION OF THE COTAD CHAPTERS PROGRAM 12 A team of OT professionals guided a program evaluation of the COTAD Chapters program in 2021. The team primarily included Emma Baldwin, OTS, PCBIS and Dr. Ryan Lavalley, PhD, OTR/L. Dr. Brenda Howard, DHSc, OTR., COTAD and the University of Indianapolis Occupational Therapy Doctorate (UIndy OTD) program also provided input about evaluation priorities, processes, and methods. The team completed a program evaluation using a mixed-methods approach to evaluate processes, activities, outcomes, and impacts of the COTAD Chapters program from 2017 until 2020. The team collected additional data following changes made in 2021. The evaluation team conducted this program evaluation for both formative and summative purposes according to Saunders et al. (2005). The formative evaluation provided feedback about the COTAD Chapters programs theoretical framework, design, activities, and operation, whereas the summative evaluation identified COTAD Chapters program outcomes and impacts (Scaffa & Reitz, 2014). To conduct a formative and summative program evaluation, the evaluation team completed a logic model, combining the theory and outcome approaches (W.K. Kellogg Foundation, 2004, Chapter 1). The evaluation team used six methods of quantitative and qualitative data collection, as described in Table 1. Appendix B provides additional details about the evaluation sources and types of analysis conducted. Due to the intended student-oriented impacts of the COTAD Chapters program and the student-oriented nature of the Chapters, the evaluation team particularly attended to student responses in the program evaluation results and discussion; however, the team still incorporated and analyzed faculty feedback. COMPREHENSIVE EVALUATION OF THE COTAD CHAPTERS PROGRAM 13 Table 1. Data Collection Methods Data source Surveys What the team evaluated Experiences and outcomes of involvement with the COTAD Chapters program, from the following stakeholders: COTAD Chapter student leaders and volunteers, COTAD Chapter faculty liaisons, & COTAD National leadership Responses from students about their needs following COTAD national events (from their Ignite series) Responses about students experiences from newly implemented (2021) Chapter Chair transition surveys Interviews Process changes and improvements over time, experience and outcomes of being a COTAD Chapters program volunteer leader Preexisting Chapter Data Analysis Activities, events, goals, and outcomes Student leadership experiences Chapter locations and universities Document Review o Meeting Minutes o Google Drive Documents o COTAD Courier o COTAD Media o COTAD Website COTAD Chapter meetings, activities held, national reach Direct Observation COTAD Chapters program processes, organizational experiences, and outcomes Reach of COTAD Chapters programs Social media reach and use Social Media Data Analysis Data Sources Surveys To capture program outcomes and determine program effectiveness, the evaluation team conducted online surveys about the experiences of student COTAD Chapter leaders, faculty liaisons, and COTAD National leaders (see Appendix C). The program evaluation survey included multiple-choice questions with Likert scale-like questions. To ensure validity, the COMPREHENSIVE EVALUATION OF THE COTAD CHAPTERS PROGRAM 14 evaluation team sought feedback from involved parties to refine question content and phrasing. Between May 14th and June 3rd of 2021, the evaluation team sent out the survey and two additional email reminders to stakeholders whose emails were in the COTAD database. They disseminated 465 surveys: 247 to current and past COTAD Chapter chairs, 87 to Chapter student volunteers and members, 109 to past and present faculty liaisons, and 22 to COTAD National leaders. The program evaluators also interpreted student responses from previously conducted needs assessment surveys, transition surveys, national event surveys. New Chapters disseminated needs assessment surveys to 1,545 students prior to founding their COTAD Chapters, which provided the evaluation team with valuable information about initial student needs. The evaluation team also analyzed written answers from 111 student surveys submitted after students attended the 2020-2021 COTAD Ignite Series national events, to see additional needs students identified. The program evaluation team also interpreted survey responses from the newly implemented transition surveys about student leader experiences (see discussion and Appendix D for survey questions). Program Evaluation Survey Participants. The evaluation team received 126 total program evaluation survey responses from COTAD Chapter stakeholders: 66 from students, 49 from faculty, and 11 from COTAD National leaders. Three COTAD National leaders completed interviews. Faculty and students represented 64 of the 93 existent chapters. The demographics of the survey participants are reported in Figures 2-9. As some respondents selected more than one demographic to describe their identities, those with multiple identities are categorized separately and the identities are accounted for in Figures 4-7 and Figure 9. COMPREHENSIVE EVALUATION OF THE COTAD CHAPTERS PROGRAM Figure 2 Figure 3 Survey Respondent Gender Identity (n=126) Survey Respondent Length of Involvement 15 with COTAD Chapters (n=114) Note. This included students, faculty liaisons, and COTAD National leadership. Note. This included students and faculty liaisons. Figure 4 Student Survey Respondent Racial and/or Ethnic Identity (n=66) COMPREHENSIVE EVALUATION OF THE COTAD CHAPTERS PROGRAM Figure 5 Faculty Survey Respondent Racial and/or Ethnic Identity (n=49) Figure 6 COTAD Leadership Survey Respondent Racial and/or Ethnic Identity (n=11) 16 COMPREHENSIVE EVALUATION OF THE COTAD CHAPTERS PROGRAM Figure 7 Student Survey Respondent Sexual Orientation (n=66) Figure 8 Faculty Survey Respondent Sexual Orientation (n=49) Figure 9 COTAD Leadership Survey Respondent Sexual Orientation (n=11) 17 COMPREHENSIVE EVALUATION OF THE COTAD CHAPTERS PROGRAM 18 Interviews The first author conducted semi-structured interviews (see Appendix E) with the COTAD Chapters Coordinator and her Support Staff volunteers to understand the previous COTAD Chapters program processes, goals, and activities, and how changes resulting from the program evaluation process have impacted the programs development. The program evaluation team sought feedback from an external individual about the semi-structured interview questions, to ensure validity of questions. The first author and interviewer video- and audio-recorded the interviews for re-interpretation as necessary and took notes during the interviews. Preexisting Data Analysis Following intervention by the program evaluation team (see discussion), administrators collected and stored all data for interpretation on a cloud-based platform called Airtable. These data included individual universities COTAD Chapter information and history, commitment forms, needs assessment results, goals and goal updates, transition surveys, event details, dues payment histories, and other stored documents. The evaluation team used these data to analyze factors of the COTAD Chapters programs functionality, progress, and outcomes. For more information about the data analysis process and indicators, see Appendix C. Document Review Prior to data collection and analysis refinement, Chapters saved documents within Google Drive shared folders. For data collection, investigators reviewed documents about events held, Chapter bylaws, transition testimonials, meeting minutes, and other Chapters advocacy efforts within Google Drive. Additionally, investigators reviewed the COTAD website and COTAD Chapter Media (youtube.com) videos to provide background information about the COTAD Chapters program. COMPREHENSIVE EVALUATION OF THE COTAD CHAPTERS PROGRAM 19 Direct Observation The evaluation team participated in improvements to the COTAD Chapters program processes throughout the evaluation time, and thus used their experiences, observations, and forms created to note changes to the COTAD Chapters program processes. Social Media Data The evaluation team used public information as of May 24th, 2021, regarding the number of followers each of the COTAD Chapter Instagram social media accounts had, to share metrics and information about the reach of COTAD Chapters. Data Analysis Quantitative data analysis from surveys consisted of descriptive data, including frequencies, counts, and percentages. (Saunders et al., 2005; W.K. Kellogg Foundation, 2004). Investigators used keywords, field notes, quotations, and memoing to synthesize themes and conclusions about qualitative data through multiple close readings (Saunders et al., 2005; W.K. Kellogg Foundation, 2004). Results The purpose of this Doctoral Capstone Experience was to evaluate the effectiveness and sustainability of the COTAD Chapters program processes and programming, and to examine the program's intended and actual outcomes. The program evaluation team achieved this purpose using a mixed-methods approach (Table 1). Results indicated that the COTAD Chapters program processes and outcomes are promoting students to work towards DEIJ, anti-racist, and antioppressive changes in the educational sector of OT. What Are the COTAD Chapters Processes and Activities? COMPREHENSIVE EVALUATION OF THE COTAD CHAPTERS PROGRAM 20 The COTAD Chapters administrative processes and Chapter activities are in the following paragraphs. The program evaluation team collected data from interviews with COTAD Chapter leadership, surveys, meeting minutes, social media data, and Google Shared Drive interpretation. These data will help the evaluation team understand the sustainability and effectiveness of the COTAD Chapters program. Program Assets & Resources The COTAD Chapters program assets and resources include the people in leadership and the technological platforms used to manage the Chapters work. The COTAD Chapters program Founder and Coordinator, Dr. Arameh Anvarizadeh, OTD, OTR/L, FAOTA, is an occupational therapist, Director of Admissions, and Associate Professor of clinical occupational therapy at the University of Southern California (USC). She was also a Founder and current Chair of COTAD National. The COTAD Chapters program is entirely volunteer led, primarily by the COTAD Chapters Coordinator and Support Staff. The COTAD Chapters Coordinator is responsible for all program management duties, and as the COTAD Chapters program grew, she also attempted to facilitate more attainable Chapter goal creation, by providing Chairs with more structure, guidance, and deadlines. The Support Staff includes Dr. Jabari Hoyte, OTD, OTR/L (COTAD Chapter Dues Manager) and Whitney Harris, MS, OTR/L (COTAD Chapter Groupchat Liaison). Dr. Hoyte is a previous COTAD Chapter Chair and a practicing occupational therapist, who is acting as the Chapter Dues Manager. Ms. Harris began within the program as the first COTAD Chapter Chair at WCU, and now is also a practicing occupational therapist. Since her time as a student, in addition to being the Chapter Groupchat Liaison, Ms. Harris stayed involved in COTAD National through multiple other roles. A COTAD Chapter Document team of three COMPREHENSIVE EVALUATION OF THE COTAD CHAPTERS PROGRAM 21 volunteers helped create official documents when needed. The program evaluation team suggested and outlined refined roles in the discussion. Throughout the existence of the COTAD Chapters program, administration used Zoom Pro to communicate and host events, and GroupMe to provide the COTAD Chapter Chairs with a group chat. Google Drive was the programs primary data management system, with PDFs, Word documents, and scanned documents stored in a shared drive for each established Chapter. As the program grew, Chapter administration completed fillable PDFs and generalized and streamlined documents and processes. With continual programmatic changes, organization and consistency was challenging to maintain. COTAD Administrators managed the COTAD Chapters program Google Drive, but assigned the current Chapter Chairs responsibility for organizing and maintaining their individual Chapters shared folder. In 2021, the evaluation team introduced the use of Airtable as a dynamic relational database, primarily to streamline data collection processes and analysis within the program evaluation. See the results and discussion for further detail about this process shift. Program Functions and Processes COTAD Chapter program processes were constantly changing and refined throughout the growth of the program. Table 2 outlines the Chapter processes that the Chapters program were using at the end of 2020. Most of the communication, form collection, and organizational data was kept individually by the COTAD Chapter Coordinator. COMPREHENSIVE EVALUATION OF THE COTAD CHAPTERS PROGRAM 22 Table 2 2017-2020 COTAD Chapter Processes Using Google Drive Creating a Chapter Transitioning and Maintaining a Chapter Required steps: 1. Students disseminate a needs assessment Google Form; COTAD receives all the data 2. COTAD Chapter administrator receives needs assessment feedback and disseminates the results to pending Chapters 3. Pending Chapters use needs assessment results to complete the commitment form 4. Pending Chapters create goals for Chapter on the commitment form 5. Pending Chapters provide the official names of Chapter Chair(s) and Faculty Liaison(s) 6. Pending Chapters pay dues ($100/year) 7. New Chapters complete 1:1 initiation call, discuss their goals and outcome measures 8. New Chapters receive all resources, communication systems, and data management system access Required steps for transitioning: 1. Chair(s) identify new future Chair(s) 2. Chair(s) complete(s) transition form (email to Chapter Coordinator and store in shared folder) 3. Chair(s) set up 1:1 transition meeting with Chapter Coordinator Other required tasks (no set timeline, constantly changed and refined): Fill out logo use and request forms when terms of use are updated (email to Chapter Coordinator and store in shared folder) Outcome and impact tracking: Prior to August 2020: fill out annual initiative form to track goal progress (email to Chapter Coordinator and store in shared folder) After August 2020: prior to quarterly All-Chapter call, fill out goal update form (email to Chapter Coordinator and store in shared folder) Note. During these processes, COTAD Chapters must communicate with COTAD Chapters Coordinator for completion of each numbered step. During the early years of the COTAD Chapters program, COTAD Chapter Chairs often created their Chapter as a committee within their Student OT Associations (SOTA). Students reported formation within SOTA initially reduced the financial burden of COTAD Chapter efforts and provided a standard election procedure. The structure of Chapters was open to interpretation, to suit the needs of the Chapter. As time went on, integrating COTAD Chapters into SOTA became a less popular option due to administrative challenges, lack of flexibility, and COMPREHENSIVE EVALUATION OF THE COTAD CHAPTERS PROGRAM 23 limited room for growth. Once formed, students acted as Chapter Chairs to implement DEIJ efforts as a COTAD Chapter within their OT program, with access to guidance from COTAD Chapter leadership. Chapter Chairs attended mandatory quarterly All-Chapter calls to discuss COTAD National updates and COTAD Chapter updates. Until August of 2020, Chapters completed and submitted a yearly commitment form, explaining progress toward their goals and committing to another year of work. Starting in August of 2020, Chapters filled out a goal update form prior to each quarterly All-Chapter Call, to update progress about each goal and summarize the quarter. Both forms were in PDF or Word document format, submitted to the COTAD Chapter Coordinator through email, and then stored in the appropriate shared drives. Once a year, COTAD awarded a Chapter the COTAD Chapter of the Year award and shared their accomplishments with the COTAD community. Due to interest from COTAD National in improving the efficiency and sustainability of the COTAD Chapters program as soon as possible, this program evaluation describes recommendations that the Chapter administrators ultimately implemented following, and sometimes during, the program evaluation process to improve infrastructure, organize, and streamline processes. Themes from Interviews General Challenges: Chapter Formation, Carryover, and Organization. In the program evaluation interviews (see Appendix E for questions), COTAD Chapter administrators reported multiple challenges with the sustainability and effectiveness of the 2017-2020 Chapter processes. The Chapter Coordinator shared that the COTAD Chapter creation process was complicated for students trying to initiate the process and could take months. The interviews identified that potential Chapters sometimes fell through when students did not have the ability to follow through with all steps. The Google Drive was difficult for administrators to keep COMPREHENSIVE EVALUATION OF THE COTAD CHAPTERS PROGRAM 24 organized, and not all Chapters would upload all required documents. They reported the quick turnover of student leaders often caused poor Chapter Chair transition support, and delayed follow-through with dues payment. The COTAD Chapter Groupchat Liaison reported that the group chats would benefit from more interactive engagement, to promote communication between peers. Time Challenges. Two of three Chapter administrators shared the hours required of administrative duties (Dues Manager: 5 hours per week, Coordinator: 40 hours per week) were too much for them to maintain. The COTAD Chapter Coordinator reported receiving an average of 10-15 emails a day, from new and existing Chapters about process steps, inquiries, and meeting requests. Dr. Anvarizadeh also reported the 1:1 transitions and initiation calls required the biggest time commitment and became repetitive. Themes from Surveys National Leadership is Involved. In the program evaluation survey (see Appendix C for questions), COTAD National leaders reported involvement with the COTAD Chapters program on a smaller scale. 82% of leaders reported that they helped local university Chapters, interacted on social media with Chapters, or spoke as a guest at COTAD Chapter events. Due to COTAD administrative procedures, National leaders also helped problem solve and provide ideas about the COTAD Chapter and processes at COTAD Board meetings. The quarterly All-Chapter Call consistently had three to four COTAD National leaders, which meeting minutes also confirmed. Chapters as a Pipeline for Leaders. COTAD National Leaders survey responses (see Appendix C for questions) also showed that two COTAD Chapter Chairs continued to stay involved with COTAD following their original Chapter leadership role. Seven previous COTAD Chapter Chairs became paying members of the COTAD National Membership and two became COMPREHENSIVE EVALUATION OF THE COTAD CHAPTERS PROGRAM 25 COTAD National leaders. Surveys also indicated COTAD National provided leadership opportunities for three previous Chapter Chairs within breakout sessions at the 2020-2021 COTAD National Ignite Series events. Four COTAD National leaders recently published an article with two previous COTAD Chapter Chairs, three COTAD National leaders offered support and mentorship to two previous COTAD Chapter Chairs during their Doctoral Capstone Experiences (DCE), and one reported they assisted a student to use COTADs network to further their research. The AOTA Annual Conference and Expo was a major networking opportunity between COTAD National leaders and COTAD Chapter students. Collaborations on short courses, interactions at exhibit hall booths, and participation in volunteer and community events brought both types of leaders together in collaborative efforts towards DEIJ initiatives. What Are the COTAD Chapters Intended Outcomes? The primary intended outcomes of the COTAD Chapters program were to increase diversity and decrease discrimination in the OT profession (see Figure 1). Program evaluators used the COTAD website (COTAD, n.d.-b), the lived experience of Dr. Lavalley as a COTAD Board Member, Chapter documentation, and conversations with the COTAD Chapters team to inform all intended impacts of the COTAD Chapters program (see Appendix A). Program evaluators also explored intended outcomes apparent within the needs assessments, Ignite surveys, program evaluation surveys, and goal documentation. Themes from Needs Assessments: Culture, Diversity, and Open Discussions in an Educational Setting Prior to becoming an official Chapter, 1,545 students at all 93 COTAD Chapter-affiliated universities completed a needs assessment survey about their OT and OTA programs needs related to diversity, equity, inclusion, justice (DEIJ), anti-oppression, and anti-racism. Students COMPREHENSIVE EVALUATION OF THE COTAD CHAPTERS PROGRAM 26 reported what aspects of DEIJ need to be addressed within their OT programs, provided choices between: culture and occupations, microaggressions, occupational justice, privilege, and unconscious bias. Figure 10 displays the frequency of responses, with culture and occupations occurring the most. Additionally, the most common write-in answers were diversity which appeared 14 times, and racism which appeared 13 times. The needs assessment top answers about beneficial activities for respective programs appear in Figure 11. Of particular note is that students expressed the need for open discussions more in 2021, following the start of the pandemic and the murder of George Floyd (The New York Times, 2020). Interpretation and analysis of this observation is outside the scope of this paper but could be explored in further research studies. Figure 10 DEIJ Aspects Programs Should Address from Chapter Needs Assessment Respondents (n=1,545) COMPREHENSIVE EVALUATION OF THE COTAD CHAPTERS PROGRAM 27 Figure 11 Beneficial Program Activities from Chapter Needs Assessment Respondents (n=1,545) Themes from Ignite Surveys: DEIJ Activities and Support in an Educational Setting COTAD National leadership collected feedback from students who attended COTAD Ignite national events, which continued to assess student needs and informed the intended outcomes of the Chapters program. The themes from the 111 students who responded indicate that in addition to their program supports, students wished for further DEIJ education, events, safe spaces, advocacy, action, and support. Students stated they wanted to be heard, seen, and to feel more included and comfortable within their OT communities. Theme from Leadership Surveys: A More Diverse Workforce for Occupational Therapy Regarding intended impact, COTAD Leadership survey responses (see Appendix C for questions) indicated a consensus that they hoped the COTAD Chapters program would impact the entire field of OT, by producing what one survey respondent called a more diverse workforce with a more equitable distribution of services and power. Leaders shared that if the COTAD Chapters program can increase the number of practitioners who understand diverse COMPREHENSIVE EVALUATION OF THE COTAD CHAPTERS PROGRAM 28 individuals lived experiences, or the number who could work to understand and appreciate them, the field of OT will be better prepared to address the needs of all clients. Themes from Goal Documentation: Activating Chapters and Advocating in Spaces The results of the COTAD Chapters needs assessments (n=1,545) informed the Chapters intended goals. Chapters documented 504 total goals: 382 in progress, 81 closed and updated with new goals, 37 completed, and four needing assistance. The most frequent words used within the Chapters goals are displayed in Figure 12. Thematic analysis uncovered that goals addressed topics of: getting involved in diverse communities, establishing and developing their Chapters, hosting events of all types, and holding open dialogues in safe spaces. Chapters also identified goals towards creating active allies. Figure 12 Word Frequency Within Reported Chapter Goals COMPREHENSIVE EVALUATION OF THE COTAD CHAPTERS PROGRAM 29 Themes from Student Surveys: Assistance in Navigation and Safety in an Educational Setting The survey administered to students for this program evaluation (n=66) did not explicitly ask students what their hopeful impact of the COTAD Chapters program was (see Appendix C for questions). However, themes that emerged from these surveys showed that Chapters would benefit from additional resources and programming opportunities from COTAD National leaders, funding assistance, help with collaborations between Chapters, and clearer program structures. Chapters also requested guidance about events, research, ethics of advocacy, and forming a new chapter. Data showed Chapters thought they would benefit from help navigating power dynamics and feeling safe in their respective educational settings, as they attempted to enact DEIJ, anti-racist and anti-oppression efforts within their program. Valued Work of COTAD Chapters: Impacting Diversity for Individuals, Communities, or Populations Program evaluators were able to identify the valued work of COTAD Chapters using the COTAD Chapter of the Year Award. After Chapter members nominated their Chapters for this award, three to four COTAD National leaders used a rubric of criteria to judge the application and evaluate which Chapter had the most meaningful impacts on individuals, communities, and populations that year. COTAD National leaders identified that these impacts were valuable as they aligned with the COTAD National mission and vision. In 2021, the National Board for Certification in Occupational Therapy (NBCOT) committed to sponsoring the COTAD/NBCOT Chapter of the Year award to promote diversity in the OT profession. They provided winners with study materials and waived one exam fee. Exemplary projects from the previous Chapter of the Year winners included advocating for curricular changes in their programs, collaborating on holistic admissions initiatives, creating COMPREHENSIVE EVALUATION OF THE COTAD CHAPTERS PROGRAM 30 mentorship programs for students who are Black, Indigenous, or People of Color (BIPOC), and hosting career days or school visits for high school students who may have historically been excluded from exposure to occupational therapy as a profession. Other programming included hosting mental health check-ins'' for underrepresented students, fundraising for diverse students to attend national advocacy and networking events, and holding interactive workshops promoting learning various languages. What Are the COTAD Chapters Actual Outcomes? Preexisting Chapters data and the program evaluation surveys provided the evaluation team with the most comprehensive and measurable perceived outcomes of the COTAD Chapters program. Below are the actual outcomes explored in this study from the COTAD Chapters Program. The program evaluation team collected data from preexisting Chapters data, goal and transition documentation, and surveys with students, faculty, and COTAD Leadership. Themes from Preexisting Chapters Data Growth and Regions of the Programs. To understand the measurable outcomes of the COTAD Chapters program, the evaluation team sought to understand the growth of the program first. From 2017 to 2021, the number of COTAD Chapters grew from one to 93. COTAD Chapters growth is shown in Figure 13. To date there have been 123 Faculty Liaisons, and 440 students involved the program: 344 Chairs or Vice-Chairs, and 96 Chapter Members. Student Chapters were located in 34 of the 50 U.S. states (see Figure 14). Comprehensively, fewer Chapters existed in the West and Southwest United States than the rest of the country. COMPREHENSIVE EVALUATION OF THE COTAD CHAPTERS PROGRAM Figure 13 Growth of COTAD Chapters 31 COMPREHENSIVE EVALUATION OF THE COTAD CHAPTERS PROGRAM Figure 14 COTAD Chapter Location Map 32 COMPREHENSIVE EVALUATION OF THE COTAD CHAPTERS PROGRAM 33 Chapters are Promoting Appropriate Content and Working for Sustainability. The program evaluators used Chapter goal documentation to examine the content Chapters promoted and the sustainability of individual Chapters. At the time of writing, Chairs marked 382 documented goals as in progress, and 37 as completed. Themes emerged that Chapters were meeting these goals by facilitating events, holding open discussions, and hosting guest speakers. Qualitative thematic analysis identified that Chapters events and conversations focused on efforts about DEIJ, anti-racism, and anti-oppression within the OT profession. These events highlighted experiences of oppressed groups such as non-White, queer, or disabled persons. Program evaluators identified themes that Chapters met sustainability goals by creating Chapter bylaws and sustainable Chapter processes, and completed community engagement goals through outreach programs and volunteer efforts. Documentation noted that goals became closed when they were too vague or unattainable, or when the worldwide COVID-19 pandemic and sudden conversion from in-person graduate programs to virtual or hybrid formats prevented progress towards goals in 2020 and 2021. For example, goals that would require in-person events like potlucks and retreats had to be restructured to allow for virtual, distanced programming. Themes emerged that Chairs marked goals as needs assistance when they required help finding and sharing resources, communicating and working with administration for curricular and environmental changes, and combating barriers in terms of community outreach and Chapter engagement. Chapters Formal Events and Other Activities: Promoting Learning, Discussion, and Outreach Program evaluators used documents from Google Drives and newly implemented Chapter event documentation data (see discussion) to understand Chapters efforts and outcomes. Chapters documented 101 events, 13 retroactively from May 2020-December 2020, and 88 COMPREHENSIVE EVALUATION OF THE COTAD CHAPTERS PROGRAM 34 beginning in January of 2021. Documentation indicated that 2,956 total individuals nationwide attended Chapter events, with an average of 29 attendees per event. Chapter Chairs reported events or achievements during their time as Chair in the 33 submitted transition surveys. Documented events were 63.4% formal events, and 36.6% other activities, and more details on the type of events from transition surveys and event documentation are in Table 3. Results indicated that formal events revolved around celebrating and learning about diversity, reaching outward, helping OT students, and building community. Other activities typically involved fostering discussions and providing volunteer opportunities. Based on themes that emerged from student data, panels and virtual events occurred more commonly in 2020 and 2021, which coincided with the COVID-19 pandemic. COMPREHENSIVE EVALUATION OF THE COTAD CHAPTERS PROGRAM Table 3. Types of Events Formal Events Celebrating Diversity and Learning about DEIJ, AntiOppression and Anti-Racism Cultural holiday celebrations Podcast, journal, and book clubs Events about systemic racism DEIJ training sessions Bias workshops Cultural and identity-based Activities of Daily Living (ADL) learning sessions Disability topic events Panels and guest speakers highlighting various underrepresented groups Occupational Justice (OJ) info sessions Support for OT Students Mock interview workshops Local mentoring and mentorship events and opportunities Inter-Chapter collaborations Reaching Out Community outreach events OT info sessions at high schools Community volunteering Social media campaigns Interprofessional collaborations Advocacy efforts to state and national organizations Other Fostering Activities Discussions Providing Volunteer and Fundraiser Opportunities Streaming parties Open dialogues Moments of Solidarity Safe space provisions Listening sessions for support Resource sharing Bias incident addressing Brainstorming and advocating for curricular changes Blood drives Clothing drives Fundraisers and walks for causes Fundraisers for local businesses Content and Focus of Quarterly All-Chapter Calls 35 COMPREHENSIVE EVALUATION OF THE COTAD CHAPTERS PROGRAM 36 The quarterly All-Chapter Call minutes indicate that each meeting consisted of COTAD National updates, COTAD Chapters program updates and support, and then individual COTAD Chapter updates from students. Attendance at mandatory All-Chapter Calls almost doubled in August of 2020 and continued to increase since that time (see Figure 15). The most common topics COTAD Chapters activities addressed, according to the first three All-Chapter Call minutes (August 2019-May 2020), are displayed in Figure 16. Figure 15 Quarterly All-Chapter Call Student Attendance COMPREHENSIVE EVALUATION OF THE COTAD CHAPTERS PROGRAM 37 Figure 16 Common Quarterly Call Topics Note. The larger the word, the more frequently the topics were addressed in the All-Chapter Calls. Beginning in August of 2020, individual Chapter updates took place in breakout rooms in the following Chapter calls; thus, the minutes only recorded summaries of what groups discussed. The 2019 minutes showed that Chapters hosted cultural potlucks, held DEIJ trainings and retreats, attended Disability Pride Parades, educated attendees about pronoun usage and biased language, and hosted speakers. In May of 2020, the Chapters shared they were working COMPREHENSIVE EVALUATION OF THE COTAD CHAPTERS PROGRAM 38 on readjusting plans to allow for virtual events. The August 2020 minutes indicate that Chapters struggled with a lack of faculty buy-in following the murder of George Floyd on May 25, 2020, which sparked protests nationally (The New York Times, 2020). Additionally, Chapters held watch parties for COTAD National events (such as the Ignite Series), advocated for Blackowned businesses, shared resource lists for further learning, discussed best strategies for increased engagement, and attempted virtual distance events due to the pandemic. According to the December 2020 minutes, Chapters discussed Chapter collaborations, virtual events, advice for facing adversity, and ideas for writing advocacy letters to faculty. The April 2021 AllChapter Call minutes noted that many National and programmatic updates did not allow time for breakout room updates and discussion. Social Media Increasing Reach COTAD Chapters reported using social media for outreach, community building, and communication. The most common form of social media Chapters used was Instagram (IG), with 54 Chapters (58.1%) confirming they managed an IG accounts on which they used the COTAD Chapters logo to advertise for one or more COTAD Chapter event. The survey also indicated that Chapters used Facebook and LinkedIn, yet these numbers were not reported or accessible to the evaluation team. There were 7,329 users following COTAD Chapters IG accounts, with an average of 138 followers per account. One COTAD National leader reported that they believed Chapter events reached more attendees outside of their schools Chapter when Chapters conducted virtual events and advertised on social media. The program evaluation surveys also indicated that Chapter Chairs witnessed current OT practitioners attending their virtual COTAD Chapter events, accessed through advertisements on social media. The program evaluation team COMPREHENSIVE EVALUATION OF THE COTAD CHAPTERS PROGRAM 39 was not able to obtain data about the exact reach of virtual events or the number of current practitioners who attended. Chapter Sustainability and Resource Storage Chapters stored materials and accomplishments in their Google Shared Drive to preserve resources and maintain institutional history and data for future Chapter Chairs. Nearly 20% of Chapters documented standards, bylaws, and constitutions they created to provide future COTAD Chapter Chairs with structure and consistent expectations. Four Chapters created newsletters, and one provided their annual performance report summarizing all their COTAD Chapter actions and outcomes from the year. Three Chapters reported they presented their advocacy work and examples of Chapter efforts at local and state OT conferences. Themes from Student Surveys Increased Program Awareness and Receptiveness, Ambiguous Responsiveness. Items on the program evaluation student survey asked for measurable and perceived outcomes following COTAD Chapters efforts (see Appendix C for questions). Responses showed that 74.2% of students believed their programs experienced changes in awareness and receptiveness towards DEIJ initiatives during their time with their COTAD Chapter, resulting from COTAD Chapter initiatives (see Figure 17). Data displayed in Figure 18 show the students observations of institutional changes resulting from COTAD Chapters work. Student data indicate a wide variety of OT department responsiveness towards COTAD Chapters initiatives (see Figure 19). COMPREHENSIVE EVALUATION OF THE COTAD CHAPTERS PROGRAM Figure 17 Program Awareness and Receptiveness Towards DEIJ Initiatives: According to Student Responses (n=66) Figure 18 Student Reported Programmatic Change, in Order of Frequency (n=66) 40 COMPREHENSIVE EVALUATION OF THE COTAD CHAPTERS PROGRAM 41 Figure 19 Program Responsiveness to COTAD Chapter Initiatives: According to Student Responses (n=66) Perceived Influence on Program Admissions. Although 69.7% of students reported they did not notice any changes to their programs admissions processes to increase diversity, the remainder of students reported observing changes while involved in their COTAD Chapter (see Figure 20). Figure 20 Program Admissions Changes to Promote Diversity: According to Student Responses (n=66) COMPREHENSIVE EVALUATION OF THE COTAD CHAPTERS PROGRAM 42 There were 10.6% of students who claimed their COTAD Chapter's efforts changed their programs admissions processes. The students who identified changes to admissions specified the changes included diversifying advertisements, advertising COTAD Chapters, increasing student access for prospective student questions, asking students for input and ideas for more inclusive admissions, holding virtual COTAD Chapter info sessions, and increasing admissions outreach to pre-OT and local high school students. Student Safety. The COTAD Chapters program hoped to increase students feelings of safety, which program evaluators addressed by asking students to rate their feelings of safety within their program before and after they became involved with their COTAD Chapter. Many students reported feeling very and mostly safe, 65% before and 82% after becoming involved in the COTAD Chapters program (see Figure 21). Data indicate that 26 students felt an increase in safety following involvement in their COTAD Chapter, 38 felt no change, and two felt a decrease in safety (see Figure 22). Figure 21 Student Safety Ratings Before & After Becoming Involved in COTAD Chapter (n=66) COMPREHENSIVE EVALUATION OF THE COTAD CHAPTERS PROGRAM 43 Figure 22 Individual Students Safety Rating Changes (n=66) Increase in Perceived Safety. When asked to describe their COTAD Chapters impact on their perceived safety within their program, students who felt an increase of safety described that they felt like they were no longer alone, and they had found a safe space to be themselves. One said, I feel safer knowing I am supported and more similar to my peers than originally expected. Of the 26 students who reported feeling increased safety after their COTAD Chapter, 24 reported at least one racial, ethnic, or sexual orientation underrepresented identity. Students reported the COTAD Chapters provided increased support by helping them find students with similar values and lived experiences. One stated, I feel safe knowing there is support within the program for students who are a part of an underrepresented community. They reported COTAD Chapters provided students with a community of natural support, both locally and nationally, and especially within the COTAD Chapter group chats. Qualitative reports showed students felt safer because of the support shown by their program, and due to relationships formed with faculty COMPREHENSIVE EVALUATION OF THE COTAD CHAPTERS PROGRAM 44 through COTAD Chapter work. Qualitative comments also included reports that students felt empowered and more comfortable in advocating, speaking out, and standing up against injustice and discrimination, both as students from underrepresented groups and as allies. One student said that their COTAD Chapter was the only thing they liked about their OT program. No Change in Perceived Safety. Out of the 38 students who reported no change in perceived safety, 20 reported at least one underrepresented identity, and 18 reported they were cisgender, heterosexual, and White. Qualitative comments indicated that the students with majority identities who felt no change in perceived safety reported high levels of safety to start with, and explained they felt safe advocating and comfortable being themselves. One reported that they felt more aware of other classmates discomforts, and they felt comfortable advocating with and for them. One student shared I feel that my friends feel safer, yet they did not feel an increase in perceived safety themselves. Two students reported their Chapters were too new to notice a difference in safety, and another mentioned that the virtual format of COTAD Chapters during the pandemic made it hard to feel safe or assess safety levels. Another student shared they did not feel a change in safety because they [hadnt] seen any tangible change within the program [but] faculty have shown that they are somewhat responsive to the students' suggestions. Themes indicated that students noted slow growth of support within their program, and thus some had not yet witnessed movement towards positive change. Decrease in Perceived Safety. All six students who reported feeling unsafe also reported at least one underrepresented identity. They reported that they felt at risk for retribution by faculty for speaking [up], and that they didnt feel safe, free, accepted, or comfortable. One student identified that it was specifically their classmates actions and words that made them feel unsafe in the classroom. The two students who reported decreased feelings of safety explained COMPREHENSIVE EVALUATION OF THE COTAD CHAPTERS PROGRAM 45 that once they got involved with the COTAD Chapters program, they became more aware of pushback towards DEIJ initiatives. One reported the allyship of their faculty and program was performative, as they visibly showed support of their Chapter yet they did not follow through with small acts of assistance. The other stated they noticed their program was smaller and less open-minded than they expected, and that they did not expect to receive so much negative feedback on COTAD Chapter initiatives. Challenges Related to Student Roles and Slow Progress. Despite all the successes and activities Chapters facilitated, student surveys identified that students faced challenges with promoting their respective COTAD Chapters initiatives. Chapter Chairs reported numerous challenges related to COVID-19 and 2020, including zoom-fatigue, emotional exhaustion, time limitations, virtual event planning, virtual miscommunications, and providing safe and vulnerable spaces virtually. Students also reported challenges with political barriers and defensiveness within conversations. Other prominent challenges included a lack of classmate and faculty involvement or buy-in, faculty liaison disengagement, and a lack of funding and school support. Multiple schools reported barriers due to program and faculty push-back, censoring, and institutional bullying. Program flexibility about the Chapters structure, limited startup resources, and continual changes of the COTAD Chapters program were also themes that challenged some Chapters. Students experienced performative allyship from faculty and programs, and one Chair stated that their program claimed the Chapters achievements as their own, without providing support. Chairs also recognized that lack of respect for student leaders limited Chapter progress towards goals. Chairs noted slow progress toward change, and one Chair stated, progress and change [are] slow within academia, so it was challenging to advocate for change within the program and see it implemented, within the time we are students. COMPREHENSIVE EVALUATION OF THE COTAD CHAPTERS PROGRAM 46 Themes from Faculty Surveys Increased Awareness & Receptiveness. Faculty liaisons answered the same questions as students regarding changes in awareness and receptiveness towards DEIJ initiatives (see Appendix C for questions). Data indicate that 59.2% of faculty noticed changes in awareness and receptiveness resulting from COTAD Chapter efforts, and 67.3% noted they saw changes due to outside factors (see Figure 23). Faculty reported institutional or programmatic changes resulting from COTAD Chapter work; these changes are displayed in Figure 24. One faculty member reported they thought current OT students benefitted from the COTAD Chapters program the most. Figure 23 Program Awareness and Receptiveness Towards DEIJ Initiatives: According to Faculty Responses (n=49) COMPREHENSIVE EVALUATION OF THE COTAD CHAPTERS PROGRAM 47 Figure 24 Faculty Reported Programmatic Change, in Order of Frequency (n=49) Many Changes to Admissions. Data showed 71.4% of faculty reported changes to admissions to promote more diversity within their respective OT and OTA programs, with 20% of those attributing at least some changes due to COTAD Chapter efforts (see Figure 25). Figure 25 Program Admissions Changes to Promote Diversity: According to Faculty Responses (n=49) COMPREHENSIVE EVALUATION OF THE COTAD CHAPTERS PROGRAM 48 Reported admissions changes included: changes to admissions language, interview questions, and test score requirements, virtual interview options and financial considerations for students who need it, diversity statements on admissions pages, COTAD Chapter information sessions at interview days and orientations, and more scholarships for diverse students. There were 39 faculty whose program had undergone an admissions process while acting as Chapter liaison, and 30.8% of them reported observable changes in the diversity of admitted students (see Figure 26). Faculty who reported observable changes in admitted-student diversity identified which types of diverse identities increased; 91.7% of them reported noting increases in students of Color (see Figure 27). Figure 26 Admitted-Student Diversity Changes: According to Faculty Responses (n=39) Note. Only faculty who said their program underwent an admissions process during their time as a Faculty Liaison responded to this question. COMPREHENSIVE EVALUATION OF THE COTAD CHAPTERS PROGRAM 49 Figure 27 Increase in Admitted-Student Diversity of Who? According to Faculty Responses (n=12) Note. Only faculty who stated that admitted-student diversity appeared to have increased since their Chapters existence answered this question. Many Curricular Changes. Figure 28 shows faculty responses when asked about curricular changes related to DEIJ and the driving forces behind them. Data indicated 13 distinct types of curricular changes identified by faculty (see Figure 29). Themes from faculty surveys indicated that some faculty and programs began to request course content feedback and suggestions from students. Two faculty admitted that changes were implemented slower than they wished, sometimes one faculty at a time. One faculty reported that the university listens more when changes are student driven. COMPREHENSIVE EVALUATION OF THE COTAD CHAPTERS PROGRAM 50 Figure 28 DEIJ-Related Curricular Changes: According to Faculty Responses (n=49) Figure 29 Faculty Reported DEIJ-Related Curricular Change, in Order of Frequency (n=49) Other Changes. Faculty and students reported other concrete changes in response to the 2020 racism-based violence (The New York Times, 2020), but reportedly not all changes resulted from a COTAD Chapters effort. This program evaluation will only report on the COTAD Chapter or student-initiated change. Qualitative data shows faculty reported intentional changes including founding student led COTAD Chapters at their university, increasing support of COTAD Chapter initiatives, and encouraging participation in COTAD National events. COMPREHENSIVE EVALUATION OF THE COTAD CHAPTERS PROGRAM 51 However, one faculty liaison stated in my opinion, my program thinks being able to say we have a COTAD Chapter is sufficient. I was the only faculty member who knew [of] or was involved in COTAD prior to 2020. Themes from Student Transition Surveys COTAD Chapter Chairs documented 189 Chapter Chair transitions since the beginning of the COTAD Chapters program and completed 33 transition surveys once the new data management system was implemented in 2021 (see discussion). In the open-ended question transition surveys (see Appendix D), outgoing Chairs reflected on the benefits of leading and participating in their COTAD Chapter. Chapters Provided Resources for Learning. Chapter Chairs reported that COTAD Chapters provided resources and afforded them a greater understanding about DEIJ, anti-racism, and anti-oppression, than their OT and OTA programs could provide. One outgoing Chapter Chair shared, it has been an incredible, eye-opening, and meaningful journey that has impacted me. What a valuable learning experience it was! It was truly motivating to be a part of this community and it was an honor to have this role. Through Chapter work, outgoing Chapter Chairs also reported they became more aware of the needs of their local communities. Chapters Supported Growth of Leadership Skills. Qualitative data from the transition surveys indicated that the student work through the COTAD Chapters program improved student leadership skills and confidence, ignited their passions, and provided them with inspiration. Data indicate students felt responsibility and accountability for the profession and grew out of their comfort levels. Students documented increased comfort with public speaking, making and giving presentations, and educating others. One student stated, this journey taught me how to speak up so that you are heard, showed me the leadership skills I have, and challenged me beyond my COMPREHENSIVE EVALUATION OF THE COTAD CHAPTERS PROGRAM 52 comfort level. Never did I think I would be the face of the force, but it proved brown women can have leadership [roles] and that we can be professional." One Chapter Chair identified that the facilitation of leadership roles allowed them to step out of a passive role in addressing social justice issues and racism. Instead, they said they actively engaged in these topics, which provided them with relief and empowered them to address the problems and challenges they faced. Qualitative data analysis also indicated that students also felt perseverance through difficulties in their time with their Chapter was rewarding. Themes from COTAD National Leadership Surveys In the program evaluation survey, COTAD National Leaders shared their views on how the COTAD Chapters program benefited students, the OT profession, and beyond (see Appendix C for questions). Chapter Benefits to Students. Learning and Leadership. In the program evaluation surveys, COTAD National leadership shared students gained a greater understanding of DEIJ topics through participation in a COTAD Chapter and said this learning allowed students to be more prepared for working with diverse clients. Both National leadership and Chapter Chairs reported students learned organizational and long-term planning, problem solving, and navigating of hierarchical educational structures through participation in this program. A common theme throughout COTAD National leadership survey responses was that the program taught advocacy and empowered students to remain vigilant to continue to do DEIJ work. COTAD National leadership qualitative data analysis specified that Chapters allow students to have a unified voice to advocate to their university on behalf of themselves, their clients, or others. COMPREHENSIVE EVALUATION OF THE COTAD CHAPTERS PROGRAM 53 Community. According to qualitative data analysis, the feeling of community provided by the COTAD Chapters program allowed students to advocate for each other, stand in solidarity together, and feel like they were not alone. National leadership shared that the community also allowed national networking and connections between diverse students, further facilitating problem solving and student efforts to act towards COTADs mission. The connections to COTAD National leadership provided resources and inspiration to students, and both National leadership and students noted the benefits of mentorship from both previous COTAD Chapter Chairs and national leaders. Safe Spaces. National leadership data analysis identified that the Chapters program supported students in ways that universities could not. Qualitative data analysis identified that both students and leadership agreed that COTAD Chapters afforded students with a new and safe space to facilitate and participate in meaningful group conversations within their programs and created a welcoming space for people of all diverse backgrounds. Students called these safe and brave spaces, and said they allowed the sharing of different perspectives and lived experiences. Chapter Benefits to the OT Profession: Future Leaders, and Transformative and Inclusive Practice. The program evaluation with COTAD National leadership indicated that the leadership strongly believed the COTAD Chapters program benefited the profession of OT. Leaders reported that they believed the Chapters program would help create future leaders to work towards justice in their practice, by creating a compassionate student body to enter the OT workforce. Data showed leaders thought the program played a pertinent role in increasing the OT professions awareness of the need for increased diversity, cultural humility, and cultural responsiveness, facilitating a more transformative and inclusive practice. A COTAD National leader stated they hoped the Chapters program would help [address] systemic oppression and COMPREHENSIVE EVALUATION OF THE COTAD CHAPTERS PROGRAM 54 inequality at the root of the oppression, by challenging educational institutions to actively enact anti-oppression strategies and inclusive practices. By having more conversations about this work, a COTAD National leader claimed that they hoped it would foster a culture of accountability and inclusivity in the foundation of the OT profession the educational system. Other Chapter Benefits: Addressing Health Disparities and Building Momentum. National leadership surveys indicated that they believed that the aforementioned changes would in turn improve OT patient care and the outcomes of diverse clients, by also decreasing health inequities. COTAD National leadership claimed that patients and clients would benefit from a more diverse and diverse-aware field of practitioners serving them. They shared that increased visibility of diverse professionals of all backgrounds could impact the OT profession and the community beyond it, and observed that Chapter media content creates a wave of opportunities to learn and find resources for the OT community. Respondents reported that the more people who gain awareness and engage in this work, the more informed our communities will be. By sending the message that COTAD and the COTAD Chapters program is doing the work, the leaders hoped these messages will impact other professions and show that these efforts matter. Themes from Both Faculty and Student Surveys High Satisfaction and Leadership Accessibility. Overall, 86.4% of students and 87.8% of faculty were mostly to very satisfied, with the remainder reporting somewhat and slight satisfaction (see Figure 30). COMPREHENSIVE EVALUATION OF THE COTAD CHAPTERS PROGRAM 55 Figure 30 COTAD Chapter Stakeholders Reported Satisfaction with the COTAD Chapters Program According to program evaluation survey responses, 86.8% of students respondents found COTAD Chapter leadership mostly to very accessible when they needed assistance with their COTAD Chapter (see Figure 31). Chapter Chairs provided the topics they sought assistance from leadership for, and 64.1% of Chapter Chair respondents reported they needed assistance to transition roles within a Chapter (see Figure 32). Figure 31 Student Chapter Chair Reported Accessibility of COTAD Leadership When Needed (n=53) COMPREHENSIVE EVALUATION OF THE COTAD CHAPTERS PROGRAM 56 Figure 32 Student Chapter Chair Reported Topics Requiring Assistance From Leadership (n=53) Ideas for Improvement: Support, Networking, and Resources. Additionally, students and faculty provided comments about the COTAD Chapters and improvements they wished the COTAD Chapters could make. Data indicated that categories of improvement students wished COTAD could help Chapters with were how to drive more change, advocate within specific roles, support Faculty Liaisons best, improve COTAD Chapter processes, and receive more specific resources (see Table 4). Table 5 shows additional innovative event and resource ideas that Chapter Chairs suggested. Table 4 Survey Respondent Ideas for COTAD Chapters Program Improvement Categories of Improvement Specific Recommendations or Requests How to drive more change Students requested help advocating to faculty (for curricular and policy changes) Students requested help advocating to faculty for more holistic and inclusive admissions Students requested help promoting faculty buy-in to COTAD Chapter initiatives COMPREHENSIVE EVALUATION OF THE COTAD CHAPTERS PROGRAM Categories of Improvement 57 Specific Recommendations or Requests Students and faculty requested help increasing attendance at COTAD Chapter events Students requested financial support to allow them to afford guest speaker fees, room rental fees, and promotional items Students requested help and guidance on how to gather and disseminate research on COTAD Chapter efforts How to advocate appropriately, respectfully, and effectively within certain roles Students requested help navigating power dynamics with faculty Students requested specific training for allies doing advocacy work How to best support Faculty Liaisons Students requested help providing more resources to faculty Faculty felt overwhelmed with resources provided and multiple resource channels (COTAD Ed, COTAD Chapter efforts, and COTAD National programs) Faculty requested a faculty liaison community How to improve COTAD Chapter processes Students requested assistance coordinating collaborations with other Chapters Students requested more help setting up their Chapter Students requested help separating their COTAD Chapter from their SOTA organization Students requested a more standard set of guidelines or expectations for set-up Students requested more ease of communication and resource access for all members of their COTAD Chapter, rather than simply the COTAD Chapter Chairs Students requested clear updates and explanations of structural changes on the COTAD Chapters program level How to receive more specific resources Students and faculty requested additional event and activity ideas Students and faculty requested starter kits, Chapter instructions, transition guidance Students and faculty requested templates and outlines for Chapter documents and processes Students requested training on advocacy to help them stay up to date on current events and proper language and terminology Students requested additional guest speaker resources and connections COMPREHENSIVE EVALUATION OF THE COTAD CHAPTERS PROGRAM 58 Table 5 Survey Respondent Innovative Ideas for COTAD Chapter Program Implementation Innovative Idea Themes Specific Innovative Ideas Additional Events Chapter networking ideas DEIJ student conference about national student efforts Fieldwork preparation events Promote COTAD Chapters at state conferences Additional Resources COTAD Chapter newsletter COTAD merchandise NBCOT study tips Employment connections Policy updates Thankfulness. Although students reported it was challenging to balance schoolwork and COTAD Chapter advocacy, many reported they want to continue to volunteer for COTAD at a national level. Overall, the students were grateful and thankful for the support COTAD Chapters provided and for the opportunities for their voices to be heard. One student stated, every OT program should have a COTAD Chapter. The education and experiences are invaluable, and some students might not otherwise get this exposure before becoming OT practitioners. Institutional Impacts: Movement Toward the Cause Data collected across the entire program evaluation indicated themes of institutional impacts. Student surveys, social media data, and program evaluation surveys were crucial in understanding the institutional impacts. National leadership believed the COTAD Chapters program increased awareness of DEIJ, anti-oppression, and anti-racism within OT and OTA programs at universities, and created a more culturally humble and fluid environment. Surveys indicated Chapters provided students opportunities to engage in these topics, and topics not in COMPREHENSIVE EVALUATION OF THE COTAD CHAPTERS PROGRAM 59 the structured curriculums. COTAD National leadership shared that due to COTAD Chapters, universities gained the ability to identify student leaders in this type of work, for feedback or perspective on DEIJ-specific programmatic issues, strategic plans, or goals that could help increase funding. Additionally, qualitative data analysis indicated that COTAD National leaders thought the efforts of COTAD Chapters encouraged universities to embrace holistic admissions and hiring, and the existence of COTAD Chapters increased the programs appeal to diverse students. Across the data, student advocacy impacted OT programs. As goals of COTAD Chapters program included influencing DEIJ, anti-oppressive, and anti-racist change and policies institutionally, (see Appendix A), surveys requested information from both faculty and students about programmatic statements and advocacy letters written. Data show that nearly half of OT and OTA programs represented by COTAD Chapters faculty and students put out a statement about racism and race-based violence (see Figure 33). Figure 33 Programmatic Actions Since March of 2020: About Racism and Race-Based Violence COMPREHENSIVE EVALUATION OF THE COTAD CHAPTERS PROGRAM 60 Approximately 19.7% of student respondents reported and shared letters they wrote to their faculty or programs, advocating for marginalized communities and student needs following hate crimes, civil disruptions, and important social changes. Two students stated they did not advocate to their program about making a statement due to fear of retaliation from administration and faculty. Another example of COTAD Chapter impacts on their institution is demonstrated in Figure 34. Not only does this image show impacts on the institution, but it also shows the power of social media in sharing and spreading efforts and movement towards DEIJ causes. Figure 34 Example of a COTAD Chapter Institutional Impact Note. This image depicts a screenshot of the COTAD National Board group chat, sharing a sign they saw a COTAD Chapter share on social media. The sign was shown on a bathroom door, stating the University does not discriminate based on gender identity or expression. You are allowed to use the restroom with which you identify. The sign identifies the location of single-stall restrooms on their campus. Leadership reported that this sign was posted after a COTAD Chapter requested a speaker from the Board and that the speaker encouraged them to make institutional changes. COMPREHENSIVE EVALUATION OF THE COTAD CHAPTERS PROGRAM 61 Discussion The program evaluation team sought to determine the effectiveness of the COTAD Chapters program processes and programming, and to examine the programs intended and actual outcomes. This purpose was met through mixed methods, collecting data from semistructured interviews, document review, surveys, direct observation, preexisting data, and social media. Results demonstrated that the COTAD Chapters program processes are constantly changing to meet the growth of the program and would benefit from a refined structure. Further, results demonstrated that the outcomes of the COTAD Chapters program support COTADs mission by working toward increasing diversity within the OT profession through the support and empowerment of OT students. The COTAD Chapters program is succeeding, but can improve in working towards its intended outcomes by promoting national growth and use of social media to spread advocacy efforts, addressing and supporting student safety, and providing more resources and assistance for students learning to navigate and engage in advocacy work. COTAD Chapters Processes Challenges with COTAD Chapters Program Processes The program evaluation results show that the COTAD Chapters program administrative processes evolved to adapt as the program grew. However, the administrators' time commitments and workloads were not divided sustainably and previous COTAD Chapter Chairs had limited opportunities to grow into leadership roles that would continue to support the program. Thus, the ever-changing processes were complicated and confusing to students and faculty involved in the program, which sometimes caused Chapters to request increased support. The increased support was often especially related to Chapters administration and structure, transitioning Chapter Chair leadership, and forming new Chapters. COTAD Chapter administration had limited capacity to COMPREHENSIVE EVALUATION OF THE COTAD CHAPTERS PROGRAM 62 address these needs on a programmatic/systemic level, which increased time managing and supporting individual Chapters. Additionally, Google Drive was not sufficiently effective at organizing all the data and resources throughout the programs continual changes, and GroupMe did not have enough capabilities to effectively benefit the Chapters as the primary communication platform. Implications for Processes and Administration The findings related to COTAD Chapter processes demonstrate a need for a bigger team and a newly defined administrative structure, to decrease administrative burden and improve student experiences. The COTAD Chapters program would benefit from creating a new structure that outlines a transparent pipeline to allow students to continue to volunteer with the Chapters program following their role as a Chapter Chair. Provision of recommendations or additional resources to answer questions about forming a new COTAD Chapters and transitioning Chapter Chairs would also decrease administrative burden by helping students. Additionally, this program evaluation prompted reconsideration and suggested exploration of new COTAD Chapters Program organization and communication platforms. COTAD Chapters Goals and Outcomes COTAD Chapters Goals are Successful The COTAD Chapters program is addressing and achieving outcomes that are the vision of the COTAD National organization. The COTAD Chapters program intended to activate Chapters within the OT educational system to help promote open discussions, educate about culture and diversity, hold DEIJ activities, improve student support, and safely navigate advocacy. Nationally, the Chapters program intended to create a more diverse workforce within OT and positively impact diversity and reduce healthcare disparities within the contexts of COMPREHENSIVE EVALUATION OF THE COTAD CHAPTERS PROGRAM 63 individuals, communities, and populations. Respondent demographics demonstrated that the identities of students affiliated with Chapters and COTAD National leaders were more diverse than Chapter faculty liaisons. This program evaluation also informed evaluators that COTAD Chapters appear to have more active Chapters in the Midwest and the East than in the West and the Southwest. COTAD Chapters social media presence increased the reach of COTAD Chapters, and the advertising of virtual events spread their efforts wider than ever before. Student Experiences Differed As COTAD Chapter efforts are intended to be student led, the evaluation team purposefully attended to the experiences and responses of students. Widely, results showed that students felt the COTAD Chapters program and the existence of their own respective Chapters improved their student experiences, promoted their growth, and allowed them to engage in local and nationwide advocacy. However, it appeared that advocacy efforts for underrepresented groups sometimes omitted disability as an underrepresented group. Students had differing experiences related to feelings of safety, depending on individual experiences with Chapter advocacy within their program. Results also indicated that living with underrepresented identities within OT programs may influence feelings of students' perceptions of safety. Program Satisfaction Most students appeared highly satisfied with the COTAD Chapters program, but it is important to note that a few students reported lesser satisfaction. The evaluation team observed that often reports of lesser satisfaction resulted from barriers and challenges students faced within OT programs that prevented their Chapters from making progress towards change, rather than from the Chapters program itself. Faculty had higher satisfaction in the COTAD Chapters program, and reported more change to receptiveness and awareness, curriculums, and COMPREHENSIVE EVALUATION OF THE COTAD CHAPTERS PROGRAM 64 admissions. It is possible that programmatic admissions processes procedures may have caused faculty to be more aware of changes than students. Impact on OT Programs COTAD Chapters impacted their OT programs in terms of DEIJ, anti-racism, and antioppression, by improving receptiveness and awareness, curriculum and policy, and sometimes admissions. Although Chapters impacted their OT programs, results showed that students encountered varying degrees of responsiveness from OT program administration. Some program administration and faculty met student advocacy with performative allyship, and some promised change that they did not deliver. Many changes that OT programs implemented to date were small and immediate fixes, rather than systemic and programmatic changes. Both faculty and students had different impressions of progress and demonstrated that it was challenging to determine whether changes made within programs were truly motivated by the Chapters efforts or other factors. Students also appeared to be more likely to attribute changes to their Chapters efforts than faculty. Impact Beyond OT Programs In line with the programs intended impacts, the COTAD Chapters program has demonstrated positive impacts on communities, the OT profession, and beyond. Results demonstrated that the COTAD Chapters program has created student leaders who would continue this work within the OT profession after graduating, which has been apparent in students' comments. suggestions, and willingness to stay involved and improve the program. Implications for Outcomes COMPREHENSIVE EVALUATION OF THE COTAD CHAPTERS PROGRAM 65 Opportunities for Improving General Outcomes. The results of the COTAD Chapters program evaluation in terms of outcomes has important implications for the future of the program and further research. It is important for the Chapters program to investigate the regional distribution of Chapters and to find ways to promote a presence in OT programs across the nation. As Edgoose et al. (2019) found, mentorship and support from individuals who can relate to students with marginalized identities is beneficial, which demonstrates the need to also promote increased diversity in faculty and COTAD Chapter faculty liaisons. Advocates also need to make an effort to ensure disability is included in their advocacy efforts. Social media and virtual events have the potential to spread the work and impact of the COTAD Chapters exponentially, including to current practitioners and those in the OT professional world. Chapters may be impacting current OT practitioner skills and awareness, in addition to students. Opportunities for Improving Student Safety. The COTAD Chapters program must be intentional in supporting students with marginalized identities, especially those who engage in this work. It is important to note that when people engage in advocacy, they will often find discomfort in situations, and conversations that create tension, rather than safe spaces. Asking students to exist in COTAD Chapters and create advocacy efforts within their programs mean that the COTAD Chapters program is asking students to step into the tension of this work. Therefore, these students may need support at the national level, and assistance to find and navigate safety within spaces with responsive faculty and mentors. Students also may feel safer and more satisfied with their Chapters efforts if programmatic changes related to DEIJ are more transparent. Students challenges with roles, power dynamics, slow changes, and performative allyship demonstrate that there are opportunities for the COTAD Chapters program to provide more training and support for students engaging in these efforts. COMPREHENSIVE EVALUATION OF THE COTAD CHAPTERS PROGRAM 66 Value of an Occupational Perspective Approaching the program evaluation through an occupational lens provided valuable insight. The program evaluation team essentially completed an occupational (activity) analysis of the COTAD Chapters program (AOTA, 2020-b.). Once discerning the specific occupations and contexts that needed to be addressed, they determined the demands of the occupations and activities, and used specific quality measurements to assess performance patterns and skills (AOTA, 2020-b.). Similar to the therapy process, once the occupational analysis was completed, the evaluation team synthesized the data and developed an intervention plan (AOTA, 2020-b.). The recommendations for the program act as the intervention plan, as they encourage occupational balance for volunteer administrators, promote principles of universal design for accessibility, and emphasize sustainability, efficiency, and continuous data collection (AOTA, 2020-b.). Recommendations for Program Implemented Within the Program Evaluation Process Changes to Data and Procedural Organization. Due to the data collected during this program evaluation, the COTAD Chapters program implemented various changes during the program evaluation process to improve efficiency and sustainability. Following observation and interviews with the COTAD Chapter Coordinator and Support Staff about old chapter processes and roles, the evaluation team disseminated the new roles and processes, and oriented the team to Airtable, a new cloud collaboration system to support data analysis and organization. In April of 2021, to preserve the continuity of the COTAD Chapters program processes, the COTAD Chapters coordinator requested the team replace all PDF forms with fillable forms on Airtable to collect future information and preserve processes for further data evaluation. The team COMPREHENSIVE EVALUATION OF THE COTAD CHAPTERS PROGRAM 67 collaborated with the COTAD Chapter Coordinator to ensure that the forms created preserved the integrity of the program, and intentionally collected meaningful data. New and improved processes included an initiation form, needs assessment form, goal and goal update form, commitment form, transition form, event submission form, and automated dues renewal emails. The evaluation team beta tested forms and new processes, and then disseminated them to students in May of 2021. The links were embedded on the COTAD website (COTAD, n.d.-b) for full student access in June of 2021. The Airtable implementations greatly decreased the workload and logistical efforts of the Chapter Coordinator. However, the COTAD Chapter Coordinator reported even with these changes, her workload was only lessened to ~35 hours per week. Table 6 outlines the refined processes for creating and maintaining a COTAD Chapter. Table 6 2021 Refined COTAD Chapter Processes Using Airtable Creating a Chapter Required steps: 1. Students complete initiation form 2. Students complete needs assessment results form 3. Students complete new goal form 4. Students complete commitment form 1. Pay dues ($100/year) 2. Identify Chapter Chair(s) and Faculty Liaison(s) 5. Schedule a meeting for 1:1 meeting Maintaining and Transitioning a Chapter Required steps for transitioning: 1. Chair(s) identify new future Chair(s) or faculty transitioning 2. Chairs complete chair/faculty transition form in Airtable 3. Chapter admins reach out to schedule 1:1 transition meeting Other required tasks (no set timeline, complete Airtable form) Fill out logo permission form Fill out goal update form prior to each AllChapter Call and new goal form if necessary Fill out event submission form prior to events Note. Now, Chapters only engage with Chapter Coordinator or assigned Chapter leadership after final numbered step, rather than throughout the processes. COMPREHENSIVE EVALUATION OF THE COTAD CHAPTERS PROGRAM 68 Changes to Other Program Processes. Office Hours Implementation. In 2021, five previous COTAD Chapter Chairs began the COTAD Chapter Monthly Office Hours for current Chapter Chairs, to improve engagement, communication, and increase volunteer opportunities for previous Chapter Chairs. COTAD Chapter Office Hours occurred every other month, in the months other events were not offered. At Office Hours, Chapter Chairs asked any questions they may have about processes and procedures, received supported from their COTAD community, and discussed any issues they encountered as COTAD Chapter Chairs. To date, 11 students attended the four one-hour office hours that previous Chapter Chairs offered. According to the office hour minutes, students expressed gratitude for access to advice, mentorship, and support from the COTAD Chapter Support Team at these meetings. Most questions revolved around clarifying transitioning and new Chapter processes, collaborating with other Chapters, increasing Chapter engagement, managing time better during grad school, and staying involved with COTAD after passing on the Chapter Chair role. Communication Platform Changes. Additionally, in early 2021, the primary communication platform changed from GroupMe to Slack, an instant communication platform with channels, to allow for more functionality for communication, following suggestions from students. 1:1 Call Time Reduction. Also in 2021, to lessen the time required for 1:1 transition and initiation Zoom Chapter Chair calls, the Chapter Coordinator requested the evaluation team create two Intro to the COTAD Chapters program videos to reduce required communication about COTAD Chapters program history and program logistics. Following a discussion with the COTAD Chapter Coordinator, the COTAD quarterly All-Chapter Call was changed to a COMPREHENSIVE EVALUATION OF THE COTAD CHAPTERS PROGRAM 69 trimester All-Chapter Call to promote sustainability, reduce time commitment, eliminate holiday scheduling issues, and allow other programming for COTAD Chapter Chairs. Due to the increasing number of Chapters, administration increased the length of the calls to an hour and a half, and Chapters gave updates n breakout rooms rather than one-by-one to all attendees. Outcomes of the Chapter Process Changes. Based on COTAD Chapter administration interviews and continuous data collection throughout the program evaluation process, the changes were well received. All three individuals reported that the changes began to address the primary problems identified, and that they were necessary to optimize processes and promote program sustainability. However, program evaluators have suggested further changes to further reduce the time commitment and logistical workload of the COTAD Chapter Coordinator and improve support for Chapter Chairs. Yet To Be Implemented Recommendations for Organizational Structural Changes. Despite the changes already implemented, the program evaluators have further suggestions to improve COTAD Chapter processes and outcomes. First, program evaluators suggest that the COTAD Chapters program adapt a new leadership structure shown in Figure 35. This programmatic structure outlines roles and delegates tasks to multiple volunteers under a chain of command. The evaluation team recommends COTAD National creates positions for a COTAD Chapter team to divide up the workload, including primary Chapter committee positions for: Dues and Airtable management Chapter Chair transitioning support New Chapter management Student ambassador support and organization COMPREHENSIVE EVALUATION OF THE COTAD CHAPTERS PROGRAM 70 Figure 35 Recommended COTAD Chapters Structure Note. This figure demonstrates the simplified COTAD Chapters program recommended structure, created by the program evaluation team, viewable at: https://miro.com/app/board/o9J_l7lmKRU=/?moveToWidget=3074457361033864958&cot=14 This recommended structure uses Airtable for all management and forms, designates that there is one individual person in charge of dues management and uses Airtable for ongoing organization, data collection, and Chapter management. It also divides new Chapter and existing Chapter support for decreased workload, and creates a definitive pipeline for leaders to COMPREHENSIVE EVALUATION OF THE COTAD CHAPTERS PROGRAM 71 volunteer, grow, and learn. It also allows for previous Chapter Chairs to stay involved through volunteering with the COTAD Chapters committee. If the Chapter coordination roles continue to require substantial amounts of volunteer time, the Chapter Coordinator shared that the program may need a full-time paid employee to run the program. Other Recommendations for COTAD Chapters Program Administration. Engaging Chapter Chairs in the new communication platform (Slack), using training and prompts, to promote more beneficial communication with the Chapters community on the new platform Creating a structure for faculty liaison renewal each year as they transition Chapter Chairs, to promote student safety and comfort in engaging in this work with responsive mentorship and support Providing more resources for student involvement and advocacy about holistic admissions within their programs, to increase transparency and drive change to recruit a more diverse workforce Taking notes within future trimester All-Chapter Call breakout rooms, to maintain continuous data about COTAD Chapter happenings, ideas, and concerns Recruiting Chapters regionally and attending to why regions may or may not be starting COTAD Chapters, to promote nationwide growth of the program The program evaluation team suggested changes to the COTAD Chapter leadership, and the implementation of change is being strategized after the conclusion of this program evaluation. Limitations This program evaluation is not without limitation. The scope of the program evaluation was so large that program evaluators had to determine what data collection and interpretation COMPREHENSIVE EVALUATION OF THE COTAD CHAPTERS PROGRAM 72 was within and what was not within the bounds of this evaluation. Additionally, the changes implemented during the program evaluation process made data and data analysis less straightforward. Preexisting Chapter data was incomplete prior to the process refinement, which caused data collection to be incomplete. The mixed-methods approach attempted to mitigate possible weaknesses and gaps in data. Previously, the COTAD Chapters program did not collect the actual impacts of Chapter efforts, so the program evaluation team was required to collect accounts of what individuals perceived in surveys. The individuals surveyed were volunteer leaders affiliated with the COTAD Chapters program, and thus may represent a biased group. Their personal accounts were not standardized and may have differed due to varying experiences and points of view. Moreover, investigators assumptions regarding positive outcomes of the COTAD Chapters program may have influenced results. Respondents may have interpreted questions on the program evaluation survey differently, including the Likert-style items that did not include numbers, which may have affected results. Some faculty and students noted that their answers may lack validity, as they reported their Chapters effects from afar in the wake of distance-learning and virtual events. Additionally, the first writer disseminated the survey initially from a non-school affiliated email, which caused some survey requests to go to spam. The program evaluation team caught the mistake and sent all follow up emails from a school affiliated email. In data collection, the reach of social media and events may not have been measured accurately by the number of followers or attendees, as evaluators had no way to determine whether individuals followed multiple accounts or attended multiple events. Recommendations for Further Research COMPREHENSIVE EVALUATION OF THE COTAD CHAPTERS PROGRAM 73 The evaluation team recommends that the COTAD Chapters program solicit feedback from all affiliated students and event attendees, rather than only the leaders, to interpret feedback from a less biased sample. This program evaluation suggests a need for further exploration of the relationships between faculty and students in engaging in advocacy work, and their effects on students perceived safety in OT schools. It may be enlightening to interpret the survey responses of those with marginalized identities individually and interview those willing, to examine the relationship between identity and experiences within the COTAD Chapters program and OT programs. Further research can explore comparisons between data collected in this program evaluation, such as student perceived safety vs. race, gender, or sexual orientation, or number of years involved vs. perceptions of change. In the future, the COTAD Chapters program could investigate the uneven regional distribution of Chapters. They could also further evaluate the impact of George Floyds death on Chapter efforts, goals, and outcomes (New York Times, 2020). Conclusion Overall, the COTAD Chapters program has been effective in both processes and programming, and it would benefit from improvements to processes and support it provides. The efforts and impacts of COTAD Chapters align with the mission of COTAD National. Chapter stakeholders have observed change enacted by the COTAD Chapters program and demonstrate great commitment toward continuing efforts to create change and a better future for the entire OT profession. The wide community of support provides a great foundation for nationwide advocacy to activate DEIJ, anti-racist, and anti-oppressive efforts within all sectors of OT. The COTAD Chapters program formidably transforms OT education, practice, and research by COMPREHENSIVE EVALUATION OF THE COTAD CHAPTERS PROGRAM energizing student advocacy for increased diversity within the OT profession and creating a national network of future generations of action-oriented and empowered OT practitioners. 74 COMPREHENSIVE EVALUATION OF THE COTAD CHAPTERS PROGRAM 75 References Acker, G. M. (2017). Transphobia among students majoring in the helping professions. 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Occupational therapy in community-based practice settings (3rd ed.). F.A. Davis Company. Taff, S.D. & Blash, D. (2017). Diversity and inclusion in occupational therapy: Where we are, where we must go. Occupational Therapy In Health Care, 31(1), 72-83. https://doi.org/10.1080/07380577.2016.1270479 COMPREHENSIVE EVALUATION OF THE COTAD CHAPTERS PROGRAM 79 The New York Times. (2020, September 8). How George Floyd Died, and What Happened Next. The New York Times. https://www.nytimes.com/article/george-floyd.html Trentham, B. L., Langlois, S., Sangrar, R., Stier, J., Cockburn, L., Cameron, D., Renwick, R., & DSouza, C. (2020). Student engagement in peer dialogue about diversity and inclusion. Journal of Occupational Therapy Education, 4(3), 1-19. https://doi.org/10.26681/jote.2020.040304 U.S. Census Bureau. (2019). Quick facts: United States. https://www.census.gov/quickfacts/fact/table/US/PST045219 Wilson, S., Anvarizadeh, A., Drazen, C. H., Holland, D., Kwebetchou, N., Reyes Smith, C., & Skownronski, J. (2015). Diversity in the workforce: Perspectives from emerging leaders. OT Practice, 20(21), 19-21. W.K. Kellogg Foundation (2004). Logic model development guide. W.K. Kellogg Foundation. https://www.betterevaluation.org/sites/default/files/LogicModelGuidepdf1.pdf COMPREHENSIVE EVALUATION OF THE COTAD CHAPTERS PROGRAM Appendix A Full Logic Model Note. This full logic model is viewable at: https://miro.com/app/board/o9J_l7lmKRU=/?moveToWidget=3074457361033864942&cot=14 80 COMPREHENSIVE EVALUATION OF THE COTAD CHAPTERS PROGRAM Appendix B Data Map 81 COMPREHENSIVE EVALUATION OF THE COTAD CHAPTERS PROGRAM 82 Note. The full data map is viewable at: https://miro.com/app/board/o9J_l7lmKRU=/?moveToWidget=3074457361033864746&cot=14 COMPREHENSIVE EVALUATION OF THE COTAD CHAPTERS PROGRAM 83 Appendix C Survey Questions and Indicators Item on Survey Potential Answers Intended Recipients Indicator What is/was your affiliation with the COTAD Chapters program? Faculty Liaison Student Chapter Chair Other Student Affiliation COTAD National Leadership All Demographic information, all indicators How long have you been involved with your COTAD Chapter? Less than 1 year 1 year 2 years 3+ years Faculty liaisons, student chapter chairs, other student affiliations Demographic information, all indicators related to COTAD Chapters What is your current gender identity? Please select all that apply. Cisgender man Cisgender woman Transgender man Transgender woman Genderqueer / genderfluid Decline to answer Additional gender category / other All Create a diverse network, for diverse students to diverse OTs / Access to COTAD Leadership If you answered other, what current gender identity do you wish to report? Write-in answer Those who answer other above Create a diverse network, for diverse students to diverse OTs / Access to COTAD Leadership Do you think of yourself as...? (select all that apply) All Create a diverse network, for diverse students to diverse OTs / Access to COTAD Leadership Lesbian, gay, or homosexual Straight or heterosexual Bisexual / pansexual Queer Dont know Prefer not to say Other COMPREHENSIVE EVALUATION OF THE COTAD CHAPTERS PROGRAM Item on Survey Potential Answers Intended Recipients 84 Indicator If you answered other on the previous question, what do you wish to report? Write in answer Those who answer other above Create a diverse network, for diverse students to diverse OTs / Access to COTAD Leadership How do you describe your racial and/or ethnic identity? Please select all that apply. White or European American Black or African American Latin@ or Latine Asian or Asian American Native American, Native Alaskan, Native Hawaiian Prefer not to say Other All Create a diverse network, for diverse students to diverse OTs / Access to COTAD Leadership If you answered other, what racial or ethnic identity do you wish to report? Write in answer Those who answer other above Create a diverse network, for diverse students to diverse OTs / Access to COTAD Leadership What is your school/institution affiliation? Select from all COTAD affiliated institutions Faculty liaisons, student chapter chairs, other student affiliations Demographic information, all indicators related to COTAD Chapters Has your institution gone through (at least) one admissions cycle, while you were a faculty liaison for a COTAD Chapter? Yes No Faculty liaisons Improve inclusive admissions processes to improve access to OT COMPREHENSIVE EVALUATION OF THE COTAD CHAPTERS PROGRAM 85 Item on Survey Potential Answers Intended Recipients Indicator Which statement comes closest to your institution's experience? (please select all that apply) A. Your OT program has undergone changes in awareness and receptiveness towards diversity, equity, inclusion, and justice initiatives because of your COTAD Chapter. B. Your OT program has undergone changes in awareness and receptiveness towards diversity, equity, inclusion, and justice initiatives because of outside factors. C. Your OT program has not undergone changes in awareness and receptiveness towards diversity, equity, inclusion, and justice initiatives. Faculty liaisons, student chapter chairs, other student affiliations Schools implement new DEIJ efforts and education at COTAD Chapter universities / Improve awareness, person by person, that DEI and DEI awareness must improve within OT Please describe the changes you have witnessed because of your program's COTAD Chapter. Write in answer Those who answer A above Schools implement new DEIJ efforts and education at COTAD Chapter universities / Improve awareness, person by person Which statement comes closest to your views about your OT curriculum? (please select all that apply) A. Your COTAD Chapter's efforts have caused positive curricular changes related to diversity, equity, inclusion, and justice. B. Other factors have caused positive curricular changes related to diversity, equity, inclusion, and justice. C. There have been no curriculum changes related to diversity, equity, inclusion, and justice. Faculty liaisons Schools implement new DEIJ efforts and education at COTAD Chapter universities COMPREHENSIVE EVALUATION OF THE COTAD CHAPTERS PROGRAM Item on Survey Potential Answers Intended Recipients 86 Indicator Please describe the curricular changes (related to diversity, equity, inclusion, and justice) you have witnessed because of your program's COTAD Chapter. Write in answer Those who answer A above Schools implement new DEIJ efforts and education at COTAD Chapter universities Which statement most closely describes your impression of changes to your program's admissions processes? A. The admissions process for your program has changed to promote more diversity within your program because of your COTAD Chapter's efforts. B. The admissions process for your program has changed to promote more diversity within your program because of other factors. The admissions process for your program has not changed to promote more diversity within your program. Faculty liaisons, student chapter chairs, other student affiliations Improve inclusive admissions processes to improve access to OT Please describe how your admissions process has changed because of your program's COTAD Chapter. Write in answer Those who answer A above Improve inclusive admissions processes to improve access to OT Which statement comes closest to your view? A. You have seen more diversity in your admitted students since your COTAD Chapter's existence. B. You have not seen more diversity in your admitted students since your COTAD Chapter's existence. You don't know. Faculty liaisons, student chapter chairs, other student affiliations Improve inclusive admissions processes to improve access to OT / Increase diversity within the profession COMPREHENSIVE EVALUATION OF THE COTAD CHAPTERS PROGRAM Item on Survey Potential Answers Intended Recipients 87 Indicator We have increased our diversity of admitted students in the following populations: (please select all that apply) Students of color Queer students Disabled Students Other minoritized religious, cultural, or ethnic backgrounds Those who answer A above Improve inclusive admissions processes to improve access to OT / Increase diversity within the profession How would you describe your program and OT department's responsiveness towards COTAD Chapter initiatives? Very responsive Mostly responsive Somewhat responsive Slightly responsive Not responsive Student chapter chairs, other student affiliations Schools implement new DEIJ efforts and education at COTAD Chapter universities Before becoming involved in your program's COTAD Chapter, how safe did you feel within your program? Note defining safety as: how comfortable, included, and free from harm or risk you feel within your program. Very safe Mostly safe Somewhat safe Slightly safe Not safe Student chapter chairs, other student affiliations Increase safety of OT students in their programs, at their universities, and beyond COMPREHENSIVE EVALUATION OF THE COTAD CHAPTERS PROGRAM Item on Survey Potential Answers Very safe Mostly safe Somewhat safe Slightly safe Not safe 88 Intended Recipients Indicator Student chapter chairs, other student affiliations Increase safety of OT students in their programs, at their universities, and beyond After becoming involved in your program's COTAD Chapter, how safe do you feel within your program? Note defining safety as: how comfortable, included, and free from harm or risk you feel within your program. How has COTAD support and having a COTAD Chapter affected your feelings of safety and comfort within your program/university? Note defining safety as: how comfortable, included, and free from harm or risk you feel within your program. Write in answer Student chapter chairs, other student affiliations Increase safety of OT students in their programs, at their universities, and beyond Which most closely aligns with your program's actions since March of 2020? A. Your program put out a statement about racism and race-based violence. B. Your program did not put out a statement about racism and racebased violence, but referred you to a statement made by the larger institution. C. Your program did not make or refer to a statement at all. Faculty liaisons, student chapter chairs, other student affiliations Schools implement new DEIJ efforts and education at COTAD Chapter universities COMPREHENSIVE EVALUATION OF THE COTAD CHAPTERS PROGRAM Item on Survey Potential Answers Intended Recipients 89 Indicator If your program put out a statement (mentioned above), please attach an image or PDF of your program's statement. Place for file attachment here Those who answer A above Schools implement new DEIJ efforts and education at COTAD Chapter universities Which most closely describes your COTAD Chapter's actions regarding your program putting out a statement after March of 2020 regarding racism and race-based violence? A. COTAD Chapter members urged faculty to address these topics prior to a statement coming out. B. COTAD Chapter members urged faculty to address these topics and no statement was put out. C. Your COTAD Chapter did not explicitly urge faculty to address these topics prior to the statement your program put out. D. Your COTAD Chapter did not explicitly urge faculty to address these topics and no statement was put out by your program. Student chapter chairs, other student affiliations Students learn advocacy and leadership skills Those who answer A or B above Students learn advocacy and leadership skills If COTAD Chapter Place for file attachment here members wrote a letter to faculty/our program (mentioned above), please attach an image or PDF of your letter. COMPREHENSIVE EVALUATION OF THE COTAD CHAPTERS PROGRAM Item on Survey Potential Answers Intended Recipients 90 Indicator What other statements or concrete actions did your program take in regards to other forms of DEI outside of antiracism (e.g. queer, disability inclusion) in response to your COTAD Chapter's advocacy? Write in answer Faculty liaisons, student chapter chairs, other student affiliations Schools implement new DEIJ efforts and education at COTAD Chapter universities Throughout your time as a COTAD Chapter leader, how accessible would you say COTAD National leadership was? Student chapter chairs Access to COTAD Leadership / Mentorship availability / Create a diverse network, for diverse students to diverse OTs When you needed assistance from COTAD National leadership, what was it typically in reference to? (Please select all that apply) Leadership skills / management / conflict resolution COTAD Chapter events Airtable / forms / dues Transitioning in or out of a COTAD Chapter leadership role COTAD Chapter structure Other (please specify) Student chapter chairs Access to COTAD Leadership / Mentorship availability If you answered "other" above, what did you typically need assistance with? Write in answer Those who answer other above Access to COTAD Leadership / Mentorship availability Very accessible Mostly accessible Somewhat accessible Slightly accessible Not accessible COMPREHENSIVE EVALUATION OF THE COTAD CHAPTERS PROGRAM Item on Survey Potential Answers Very satisfied Mostly satisfied Somewhat satisfied Slightly satisfied Not satisfied Intended Recipients 91 Indicator How satisfied are you with the COTAD Chapters program overall? Faculty Student liaisons, Chapters student chapter chairs, other student affiliations What else would you like COTAD to provide for you or your Chapter at the National level? Write in answer Student chapter chairs, other student affiliations Student Chapters / Mentorship availability Please add any additional comments or feedback about the COTAD Chapters program. Write in answer Faculty liaisons, student chapter chairs, other student affiliations Student Chapters / Mentorship availability How have you interacted with the COTAD Chapters program in any capacity in the past? Write in answer COTAD National leadership Create a diverse network, for diverse students to diverse OTs / Mentorship availability / Volunteer opportunities / Access to COTAD Leadership What benefits do you believe the COTAD Chapters program offers to the OT profession? Write in answer COTAD National leadership Welcoming answers to support all Outcomes indicators COMPREHENSIVE EVALUATION OF THE COTAD CHAPTERS PROGRAM Item on Survey Potential Answers Intended Recipients 92 Indicator What benefits do you believe the COTAD Chapters program offers to students? Write in answer COTAD National leadership Welcoming answers to support all Outcomes: Summative indicators What benefits do you believe the COTAD Chapters program offers to universities? Write in answer COTAD National leadership Welcoming answers to support all Outcomes: Summative indicators What benefits do you believe the COTAD Chapters program offers to any additional people or groups? Write in answer COTAD National leadership Welcoming answers to support all Outcomes: Summative indicators How have you, as a Write in answer COTAD National leader, interacted with members of COTAD Chapters or the COTAD Chapters program at past AOTA Conferences? COTAD National leadership Volunteer opportunities COMPREHENSIVE EVALUATION OF THE COTAD CHAPTERS PROGRAM Appendix D Survey Questions in Chair Transition Form 1. What benefits did you personally gain from your general participation in your COTAD Chapter? 2. What benefits did you personally gain from leading your COTAD Chapter? 3. What positive achievements did your COTAD Chapter accomplish during your time as Chair? 4. What challenges or barriers did you face in your COTAD Chapter work? 5. Other general feedback or reflections: 93 COMPREHENSIVE EVALUATION OF THE COTAD CHAPTERS PROGRAM 94 Appendix E Semi-Structured Interview Questions Questions for All: What is your role with the COTAD Chapters program? Who are the other people you work closely with for the COTAD Chapters program and what are their roles? Before 2021, how many hours a week (or month) would you estimate that you spent working with the COTAD Chapters program in an administrative capacity? Now that the recent (2021) changes have been somewhat implemented, how many hours a week would you estimate that you spend working with the COTAD Chapters program in an administrative capacity? What does your new role look like (especially welcoming and orienting new chapters)? How have the changes we have made within 2021 impacted your workload? How was the COTAD Chapter improvement process for you, and how does it feel now? What do you think still needs to be improved within the COTAD Chapters program? Questions for Chapter Coordinator (and others if their role overlaps with these questions): Before 2021, how long were your 1:1 meetings with chapter leaders and faculty liaisons? Since the recent changes, how long are your 1:1 meetings with chapter leaders and faculty liaisons? Now, after we have made some changes, what do the processes of welcoming and forming new chapters look like? Now, after we have made some changes, what do the processes of transitioning chapter leadership look like? COMPREHENSIVE EVALUATION OF THE COTAD CHAPTERS PROGRAM 95 How do you determine the winner of the COTAD Chapter of the Year award? What are the criteria? What do you envision for the COTAD Chapters Program in the next 5 years?  ...

... GROUP REMINISCENCE THERAPY PROGRAM 1 Addressing Social Participation and Quality of Life in Older Adults: Implementation of a Group Reminiscence Therapy Program Jennifer L. Ashton School of Occupational Therapy, University of Indianapolis GROUP REMINISCENCE THERAPY PROGRAM 2 Abstract The study aimed to develop, implement, and evaluate a group reminiscence therapy program to promote meaningful social participation in a long-term care facility. A doctoral capstone experience student conducted a weekly 45-60 minute group reminiscence therapy program across six sessions. A total of 29 participants attended some or all of the sessions. Pre-test/posttest outcome measures were the Older Peoples Quality of Life - Brief version and the ThreeItem Loneliness Scale. The student noted observations from the sessions and administered a feedback survey at the last session. The program did not significantly impact the participants quality of life or loneliness level. However, participants provided positive feedback on the feedback survey, reporting satisfaction with the activity. The study implies the future continuation of the program may be successful for an enjoyable and meaningful activity but may need to be offered more frequently with smaller groups and assessed with other outcome measures to evaluate for impact on quality of life or loneliness effectively. Thus, occupational therapists can incorporate concepts of reminiscence therapy into practice to promote meaningful social participation with the therapist and promote improved quality of life. GROUP REMINISCENCE THERAPY PROGRAM 3 Addressing Social Participation and Quality of Life in Older Adults: Implementation of a Group Reminiscence Therapy Program The definition of social participation is activities that involve social interaction with others, including family, friends, peers, and community members, and that support social interdependence (American Occupational Therapy Association (AOTA), 2020). Social participation is vital for overall quality of life, as it increases health and wellness and provides structure and meaningfulness in daily life (Fox et al., 2017; Nordin et al., 2017; Roberts & Adams, 2018). There has been extensive research on the topic in the older adult population, including a quantitative study, with researchers reporting increased participation in formal social activities was associated with a slower rate of decline of overall quality of life (Roberts & Adams, 2018). In addition to improved quality of life, residents in nursing homes with higher levels of social engagement, compared to those with lower social engagement, tended to live longer, with an 18% lower 5-year mortality risk and a 3-year higher median survival (PastorBarriuso et al., 2020). Several researchers, including Li et al. (2017) and Holtfreter et al. (2017), found lower levels of social participation associated with higher levels of depressive symptoms in older adults. However, Holtfreter et al. (2017) noted that high-quality familial ties lessened the association between depression and inactivity. Other researchers focused on a narrow population of older adults, including Kang (2012) who focused on older adults with dementia. Kang (2012) found that older adults with dementia tended to display a negative correlation of participation in meaningful social activities and performance of ADLs, impaired cognition, depression, and vision. According to the Centers for Disease Control and Prevention (2021), in 2016, 47.8% of residents in nursing homes within the United States had a diagnosis of Alzheimers disease or GROUP REMINISCENCE THERAPY PROGRAM 4 other dementias. The large prevalence of a dementia diagnosis among residents of care facilities emphasizes the need for addressing social participation in this population. The purpose of this paper is to discuss the Doctoral Capstone Experience (DCE) that an occupational therapy doctoral capstone student completed at a senior living facility. The site serves older adults by providing multiple levels of care, including assisted living, long-term care, rehabilitation, and memory care. The program development completed for the DCE aimed to promote social participation to improve quality of life for the residents. Literature Review Introduction The literature review serves to provide an understanding of the barriers and facilitators that older adults experience relating to social participation; identify a need to improve social participation levels in senior living facilities; and outline methods for promoting social participation in the older adult population living in care facilities. The literature review includes 15 research articles sourced from online databases, including both quantitative and qualitative studies. The literature suggests that older adults often experienced decreased social participation due to a variety of barriers. The literature also indicated there are many facilitators to social engagement and several methods to promote social participation, including reminiscence therapy. Additionally, researchers suggest that lower levels of social participation are associated with decreased health and wellness and decreased performance in activities of daily living (ADLs). The reviewed literature aids in identifying the gap between social participation desire and actual social participation. The identified gap applies to the DCE project, aiming to improve high-quality and meaningful social participation levels of older adults with and without dementia at the facility. GROUP REMINISCENCE THERAPY PROGRAM 5 Barriers to Social Participation Numerous factors can act as barriers to the social participation of older adults. Researchers of a quantitative study about leisure engagement listed common barriers to be physical environment, social environment, medical conditions, mobility difficulties, and activity limitations (Nilsoon et al., 2015). The most influencing factor to social participation was activity limitations, examples of which were fear of falling, use of mobility devices, and partial dependence to complete bathing or cleaning (Nillsoon et al., 2015). Other researchers focused on the physical environment within residential care facilities, and indicated that the social participation decreases when there are barriers of the physical environment (Nordin et al., 2017). Examples of physical barriers identified include closed doors without automatic opening, heavy doors, and smaller rooms (Nordin et al., 2017). Goll et al. (2015) found illness and disability to be a barrier to social engagement. Other researchers have found specific conditions, such as visual impairments and glaucoma, to influence formal and informal social participation, with participation levels being lower than older adults without visual impairments (Jin et al., 2019; Rudman et al., 2016). According to Rudman et al. (2016), common reasons for the decrease in social engagement of older adults with visual impairments were increased mobility difficulties and increased fall risk due to the physical environment. Other researchers focused on the impact of incontinence on social participation and depressive symptoms, finding incontinence to be significantly associated with lower levels of social participation (Lai et al., 2017). Kang (2012) and Theurer et al. (2015) both focused on the condition of dementia, reporting that there tend to be lower levels of social participation, possibly due to communication difficulties associated with symptoms of dementia. Researchers conducted a qualitative study regarding activity disengagement with participants aged 60 and older, finding the most common activities maintained to be considered GROUP REMINISCENCE THERAPY PROGRAM 6 instrumental or low-demand (Fox et al., 2017). The activities listed as the most maintained were often performed alone, such as shopping for groceries, watching television, paying bills, and taking out the trash (Fox et al., 2017). The study indicated that social activities are given up or performed less (Fox et al., 2017). Within the same study, the most common barrier to engaging in social activities was having no one to do them with (Fox et al., 2017). The researchers reported that older adults often continue participation in easier or unavoidable tasks and decrease engagement in social activities due to social limitations (Fox et al., 2017). Goll et al. (2015) found that barriers to social engagement include loss of friends, family, and community, which correlates with the findings from Fox et al. (2017), as individuals may have lost their friends or family that they previously engaged with socially. Other barriers of social participation were related to psychological aspects of the individual, such as fear of social rejection or exploitation and fear of losing aspects of identity, including independence, youth, and preferred social identity (Goll et al., 2015). Similarly, Rudman et al. (2016) found that older adults with age-related vision loss experience an additional fear of social embarrassment or misunderstanding. Facilitators to Social Participation Although there are many barriers to the social participation of older adults, researchers have also identified facilitators through qualitative and quantitative research. Researchers found that the most common facilitator to social participation was to do an activity with someone (Fox et al., 2017). Similarly, individuals living with someone else experienced higher levels of leisure engagement (Nilsoon et al., 2015). Another common facilitator to social participation was having more opportunities for general leisure activities (Fox et al., 2017). Other researchers found that individuals with a higher income experienced higher levels of leisure engagement (Nilsoon et al., GROUP REMINISCENCE THERAPY PROGRAM 7 2015). A possible connection between the two studies is that when an older adult has a higher income, they can access more opportunities due to less financial strain. Researchers also found that the physical environment was a facilitator for social engagement. On the contrary to the limiting aspects of the physical environment described as barriers previously, Nordin et al. (2017) found that an open floor plan and larger rooms increased the opportunity for independent mobility. With a physical environment that is easier to navigate independently, it can ease socializing with others in the room, the building, or the community (Nordin et al., 2017; Rudman et al., 2016). The Desire for Social Activities Researchers indicated that there were activities that many older adults desire to do again or more often. Many of these desired activities involve social engagement, such as attending concerts, attending a party or picnic, visiting with friends, and visiting with friends or family who are ill (Fox et al., 2017). Likewise, Nordin et al. (2017) identified that many residents of residential care facilities wished to independently participate in social activities such as gardening or eating with others. Tak et al. (2015) emphasized the desire to participate in meaningful social activities rather than activities intended to stay busy. However, although there is an established desire for social activities, Nordin et al. (2017) reported residents often encountered barriers that decrease the ability to participate in the activities at the independence level they desire. Promoting Social Participation Many approaches can impact the social participation levels of older adults living in care facilities. One approach is identifying and addressing the barriers listed above to create facilitating factors. For example, making environmental modifications to increase physical ability to participate. Staff can also create activity modifications to account for medical GROUP REMINISCENCE THERAPY PROGRAM 8 conditions that may be limiting participation, such as visual impairments or physical deficits (Jin et al., 2019; Rudman et al., 2016; Tak et al., 2015). Another method to increase social participation is to implement meaningful social activities. Researchers reported that residents of care facilities preferred to take part in activities that they considered meaningful rather than something to keep busy (Tak et al., 2015). Theurer et al. (2015) emphasized a need for social revolution in residential care, describing a need for a switch from providing superficial recreational activities to providing meaningful activities that allow for emotional and social connection. Staffing can obtain the residents input for activities they would find meaningful and have interest in attending (Theurer et al., 2015). Reminiscence therapy is the process of using multi-sensory stimuli to recall meaningful or positive personal experiences from the past, completed as a group or individually (MelndezMoral et al., 2013). As a group, it provides opportunities for meaningful social interaction and relationship building. Reminiscence therapy as an intervention or activity for older adults in care facilities provides the benefit of social participation. This activity is often meaningful to participants as they can discuss their personal past. Many other benefits include the following: increased self-esteem, increased life satisfaction, increased quality of life, and decreased depressive symptoms (Chang & Chien, 2018; Kim et al., 2016; Melndez-Moral et al., 2013; Siverova & Buzgova, 2018). Reminiscence therapy is often used with individuals diagnosed with mild or moderate dementia since it decreases demands on cognitive impairments and focuses on preserved cognitive functions, including long-term memory (Kim et al., 2016). Conclusion Reviewing recent research highlights a perspective that emphasizes the need for increased social participation in older adults that is also meaningful. There is a disconnect between the desire that older adults experience to participate in meaningful social activities and GROUP REMINISCENCE THERAPY PROGRAM 9 the actual time spent doing social activities. Health and wellness should be a priority for older adults, especially when they go through changes in the physical or social environment. Continued social participation is one way to maintain or improve quality of life. It should be a focus for occupational therapists because it is a part of the Occupational Therapy Practice Framework (AOTA, 2020). Through the findings of numerous research studies, it was evident that a program to increase meaningful social participation levels of older adults in a care facility would be beneficial, especially for individuals diagnosed with dementia. The program involved aspects of reminiscence therapy to promote social participation, mental health, and well-being. Throughout the creation of the program, the student considered barriers and facilitators of social participation to ensure an optimal environment for the residents participating. Overall, improving the social participation levels of older adults in a care facility was likely to consequently enhance the participants quality of life. Needs Assessment The doctoral capstone student completed a needs assessment prior to being at the site through interviews and research and then during the initial two weeks at the site through interviews, research, and observation. The on-site needs assessment consisted of observing various activities offered at the facility in assisted living, long-term care, and memory care, to assess current social participation levels. In addition, the student completed observation of a monthly Town Hall meeting for assisted living residents and at a monthly resident council meeting for long-term care residents to listen to the residents' concerns about the facility. Semistructured interviews were conducted with staff members, including the activity director, therapy supervisor, and therapy speech-language pathologist (SLP) staff (see Appendix A for semistructured interview questions). Unstructured interviews were completed with activity assistants. GROUP REMINISCENCE THERAPY PROGRAM 10 The needs assessment revealed that the site offers various activities and accounts for resident input through the monthly resident meetings. The offered activities, however, are limited due to Covid-19 safety precautions. At the time of completing the DCE project, the restrictions were lessening than they had been prior, which allowed for more participation in socially distanced activities. Another finding is that the activity department also has a protocol to encourage social participation for all residents on the units. In addition, they complete one-onone socializing with individuals who do not want to attend the offered group activities. A concern noted is that many of the activities do not encourage direct conversation between residents. Often, the activities provide a space for residents to be around other residents, but they do not take part in conversation. Additionally, findings revealed that education of methods to promote social participation is lacking, especially information about promoting social participation specifically with individuals diagnosed with varying levels of dementia. While the site uses the global deterioration scale (GDS) with the SLP therapy patients, the other staffing departments are not all aware of what this scale means and how to apply it to encouraging meaningful social participation. The overall findings of the needs assessment, in combination with the literature review, resulted in the program development, implementation, and evaluation of a reminiscence therapy group for the residents in the long-term care units of the site. In addition, the student created educational materials and distributed the materials to inform staffing of evidence-based methods to promote social participation and how to address social participation based on GDS score. Resources about facilitating a reminiscence therapy program, and reminiscence kits containing themed objects and pictures, were also provided to the activity department to promote sustainability of the program. GROUP REMINISCENCE THERAPY PROGRAM 11 Theoretical Framework The occupation-based model (OBM) that will guide the doctoral capstone experience (DCE) is the Model of Human Occupation (MOHO). The primary focus of the MOHO is on the impact that the mind and body can create on occupational performance and volition (Cole & Tufano, 2008). Additionally, there is a focus on how the environment influences volition, behavior, and occupational performance (Cole & Tufano, 2008). Researchers applied the MOHO in a study focused on community participation, which supports the use of the MOHO applied to the population of older adults, particularly for social activities (Papageorgiou et al., 2016). The MOHO applied to the population of older adults living in a care facility is a relevant guiding model because it focuses on how the environment impacts motivation to participate in occupations and the quality of participation. Furthermore, the MOHO brings attention to the performance skills impacting the other aspects of the human. In the population of older adults living in a care facility, these performance skills are often decreased. Moreover, the frame of reference (FOR) of Lifespan Development will guide the DCE project. The Lifespan Development FOR is relevant to guide the project because of the projects focus on helping clients with transitional tasks, which in this setting can occur when moving into the facility, or from adapting to physical or cognitive changes from a medical condition (Cole & Tufano, 2008). The Lifespan Development FOR impacts the concepts of the MOHO through the consideration of a clients age and how it aligns with their performance skills and habituation. Lastly, the Activity Theory will also guide the DCE project. The Activity Theory supports that maintaining participation in physical and mental activities is correlated with higher life satisfaction as people age (Havighurst, 1961; Li et al., 2017). As the DCE project focuses on promoting meaningful social participation, and consequently, quality of life, the activity theory is a perfect guiding theory. The Activity Theory correlates with the concepts from Lifespan GROUP REMINISCENCE THERAPY PROGRAM 12 Development through encouraging continued participation that is age-appropriate throughout the aging process. The concepts from the MOHO relate to the Activity Theory through focusing on the impact that the environment has on occupational participation, which should be addressed and maximized when viewing from the perspective of the Activity Theory. Materials and Methods This section outlines the implementation of a group reminiscence therapy program to promote meaningful social participation and improve quality of life of the older adults involved. Details are included of the participants, outcome measures, and procedures. Participant Recruiting Twenty nine older adults participated between two LTC units at the senior living facility. The student recruited participants through voluntary response sampling. Any individuals living on the units were able to attend the program. The program was advertised in the monthly activities calendar that the residents received at the start of each month. In addition, a flyer was posted each week on the units as a reminder of when the program was and the details of that weeks theme. Materials The materials that follow were used as outcome measures to evaluate the programs impact on the participants. The student based the selection of outcome measure materials on the evidence-based research of what psychosocial aspects were impacted by participating in a group reminiscence therapy program. Older Peoples Quality of Life - Brief version (OPQOL-Brief) The OPQOL-Brief was a self-report, pre-test and post-test outcome measure to assess changes in quality of life (QoL). The student administered the assessment at the first and last session. The OPQOL-Brief consists of 13 scored items and an additional single item on global GROUP REMINISCENCE THERAPY PROGRAM 13 QoL, outlined in Appendix B (Bowling et al., 2013). The items were scored on a Likert scale, as follows: Strongly agree, Agree, Neither, Disagree, Strongly disagree. The single item on global QoL is the only exception, scored on a Likert scale, as follows: Very good, Good, Alright, Bad, Very bad. The tool has been shown to have high reliability and high convergent and discriminant validity when used with older adults (Bowling et al., 2013). Three-Item Loneliness Scale The Three-Item Loneliness Scale was a self-report, pre-test and post-test outcome measure to assess for changes in level of loneliness. The student administered the assessment at the first and last session. The Three-Item Loneliness Scale consists of 3 items outlined in Appendix C (Hughes et al., 2004). The items were scored on a Likert scale, as follows: Hardly Ever (1), Some of the Time (2), Often (3). The tool has demonstrated good reliability and good concurrent and discriminant validity (Hughes et al., 2004). Feedback Survey The student administered a survey at the last session to receive feedback on the program (see Appendix D for survey questions). The survey consists of five total questions, with a mix of open-ended and closed-ended questions. The questions focus on the personal perspective of the participants regarding their satisfaction, what they enjoyed about the program, and what they would like to see changed in the program. Procedure Residents in the two LTC units completed a survey for the student to gain more information about the possible participants. The survey provided information for planning the themes and items needed for the individual program sessions (see Appendix E for questions). GROUP REMINISCENCE THERAPY PROGRAM 14 Seventeen individuals responded to the survey. The student used responses from the questions to assist in planning for sensory stimuli brought to the sessions. The student then created an activity protocol template to follow throughout the sessions (see Appendix F for activity protocol template). Each session consisted of the same format, including an introduction, educational concepts, activity with discussion, and a summary. The format slightly differed for the first and last session, incorporating time to complete the outcome measures of the OPQOL-Brief and the Three-Item Loneliness Scale. At the last session, the student administered the feedback survey. Participants received assistance, if needed, to complete the outcome measures. The student provided assistance to those who had difficulty reading or writing due to visual, motor, or cognitive deficits. The activity facilitator also used observation of participation at each session as a means of results. The activity of each session used the same outline, revolving around the chosen theme, and incorporated the five senses of touch, sight, smell, taste, and sound. The sensory stimuli used at each session were individualized based on the theme of the session. The DCE student acted as the activity facilitator for a total of six 45-60 minute sessions. The themes included childhood; favorite holidays; life at home and work; vacations; dating, weddings, and marriage; and family, parenting, and pets. The student used open-ended questions throughout the sessions to prompt further discussion of memories. At each session, the student encouraged participants to attend the next session. Results Participants A total of 29 residents participated, consisting of four males and 25 females. See table 1 for details on the number of sessions attended by participants. GROUP REMINISCENCE THERAPY PROGRAM 15 Table 1 Number of Sessions Attended by Participants Number of Sessions Attended Number of Participants 1 9 2 4 3 3 4 1 5 8 6 4 Older Peoples Quality of Life - Brief version (OPQOL-Brief) Seventeen participants completed the pre-test, and ten of those participants completed the post-test. Only participants who completed both were included in the results to assess for score changes. The OPQOL-Brief scores showed an initial average of 23.9. After participating in the program, the average scores were 25.4. The OPQOL-Brief global QOL item showed an initial pre-test average of 1.7 and a post-test average of 2.2. Figure 1 displays the changes between the pre-test and post-test scores. Three-Item Loneliness Scale Seventeen participants completed the pre-test, and ten of those participants completed the post-test. Only participants who completed both were included in the results to assess for score changes. The Three-Item Loneliness Scale scores showed an initial average of 4.9. After participating in the program, the average scores were 5.3. Figure 1 displays the changes between the pre-test and post-test scores. Figure 1 Pre-Test and Post-Test Average Results GROUP REMINISCENCE THERAPY PROGRAM 16 Feedback Survey Ten participants completed the feedback survey. Regarding satisfaction with experiences in the program, five participants were extremely satisfied, four were satisfied, and one was neutral. Nine out of ten participants reported interest in participating in future sessions, and one participant said they might attend a future session. Participants suggested the following new themes: life before 60, schooling, and friendships. The participants reported enjoyment of looking at pictures, sharing their stories, listening to others, learning what they had in common with other participants, recalling about family, comparing their life with new generations, and general reminiscing. One participant suggested changes to the program implementation to include more encouragement for participating. The other participants reported feeling the sessions were adequate as they were. One participant commented about general activities at the facility, stating that they should be more applicable to the residents. Observations GROUP REMINISCENCE THERAPY PROGRAM 17 The activity facilitator noted during sessions that smaller groups of eight or less participants demonstrated higher participation success than larger groups of nine or more participants. The participants heard each other better to engage in conversations. Participants also displayed higher participation and engaged in more conversations when they were able to sit closer to each other. An additional observation is that many of the participants enjoyed the activity; however, some did not enjoy it as much and did not attend many of the sessions due to this. Discussion and Implications The results indicate that the program did not significantly impact participants quality of life or loneliness. This differs from Siverova and Buzgova (2018) finding that reminiscence therapy increases quality of life with a weekly group reminiscence therapy program. Future program evaluation may include a quality of life scale that scores in domains like The World Health Organization Quality of Life-BREF (WHOQOL-BREF) or The World Health Organization Quality of Life-Old (WHOQOL-OLD). In addition, future program evaluation could include measuring depressive symptoms, as several previous studies found reminiscence therapy to decrease depressive symptoms (Holtfreter et al., 2017; Li et al., 2017). Although there were no significant changes on the pre-test/post-test outcome measures, the participants provided positive feedback on their satisfaction with the program, indicating that the continued offering of a reminiscence activity may be enjoyable and meaningful. The satisfaction with offered activities is an important consideration for success, supporting Theurer et al. (2015) who described a need to switch from providing superficial recreational activities to providing meaningful activities that allow for emotional and social connection. GROUP REMINISCENCE THERAPY PROGRAM 18 The observation of increased success in smaller groups indicates that future use of reminiscence therapy activities should be completed in smaller groups of eight or less or have more group facilitators to split the participants into smaller groups. This aligns with Kim et al.s (2016) findings that group reminiscence therapy yields more positive results with no more than five individuals to one facilitator. Additionally, according to Kim et al. (2016), a higher frequency of more than one time per week may yield stronger results. Therefore, future programming may consider offering more often than weekly in order to aim for a larger positive impact on the participants. Another suggestion for future programming from Kim et al. (2016) is to individualize the sensory stimuli with the participants personal photos or objects. Implications include that many residents of the site would enjoy a continued program of reminiscence therapy. Suggestions for change throughout the discussion should be implemented to enhance the programs benefits, and the program should continue to be evaluated for impact on the participants. The reminiscence kits and materials provided to the site aim to help in the sustainability of the program. Occupational therapists may implement the concepts of reminiscence therapy into their treatment with older adults to promote meaningful social participation with the therapist and promote quality of life. Occupational therapists can also promote meaningful social participation through other methods, including advocating for the desired meaningful activities of residents, which aligns with the concepts of Theurer et al. (2015). Limitations COVID-19 pandemic precautions limited the study due to initial social distancing and mask requirements. This decreased the ability of the residents to hear each other as well and engage in conversation. Another limiting factor was the inconsistency in participant attendance. GROUP REMINISCENCE THERAPY PROGRAM 19 Although there were some participants that attended consistently, some did not attend as much so those individuals may have experienced less of the potential program benefits. Lastly, inability to impact all areas of quality of life led to many aspects of the outcome measure not changing significantly. Due to this, it may be beneficial for future program evaluation to choose a quality of life outcome measure that is broken into domains. GROUP REMINISCENCE THERAPY PROGRAM 20 References American Occupational Therapy Association. (2020). Occupational therapy practice framework: Domain and process (4th ed.). American Journal of Occupational Therapy, 74(Suppl. 2), 7412410010p1-7412410010p87. Bowling, A., Hankins, M., Windle, G., Bilotta, C., & Grant, R. (2013). A short measure of quality of life in older age: The performance of the Brief Older Peoples Quality of Life questionnaire (OPQOL-Brief). Archives of Gerontology and Geriatrics, 56(1), 181187. https://doi.org/10.1016/j.archger.2012.08.012 Centers for Disease Control and Prevention. (2021). Alzheimer Disease. Retrieved from https://www.cdc.gov/nchs/fastats/alzheimers.htm Chang, H., & Chien, H.-W. (2018). Effectiveness of group reminiscence therapy for people living with dementia in a day care centers in Taiwan. Dementia, 17(7), 924-935. doi:10.1177/1471301217725185 Cole, M. & Tufano, R. (2008). Applied theories in occupational therapy: A practical approach. Thorofare, NJ: SLACK Incorporated. Fox, K., Morrow-Howell, N., Herbers, S., Battista, P., & Baum, C. M. (2017). Activity disengagement: Understanding challenges and opportunities for reengagement. Occupational Therapy International, 2017, 1-7. doi:10.1155/2017/1983414 Goll, J. C., Charlesworth, G., Scior, K., & Stott, J. (2015). Barriers to social participation among lonely older adults: The influence of social fears and identity. PLoS ONE, 10(2), e0116664. doi:10.1371/journal.pone.0116664 Havighurst, R. J. (1961). Successful aging. The Gerontologist, 1, 813. https://doi.org/10.1093/geront/1.1.8 GROUP REMINISCENCE THERAPY PROGRAM 21 Holtfreter, K., Reisig, M. D., & Turanovic, J. J. (2017). Depression and infrequent participation in social activities among older adults: the moderating role of high-quality familial ties. Aging & Mental Health, 21(4), 379-388. doi:10.1080/13607863.2015.1099036 Hughes, M. E., Waite, L. J., Hawkley, L. C., & Cacioppo, J. T. (2004). A short scale for measuring loneliness in large surveys: Results from two population-based studies. Research on aging, 26(6), 655672. https://doi.org/10.1177/0164027504268574 Jin, S., Trope, G. E., Buys, Y. M., Badley, E. M., Thavorn, K., Yan, P., Jin, Y.-P. (2019). Reduced social participation among seniors with self-reported visual impairment and glaucoma. PLoS ONE 14(7): e0218540. doi:10.1371/journal.pone.0218540 Kang, H. (2012). Correlates of social engagement in nursing home residents with dementia. Asian Nursing Research, 6(2012), 75-81. doi:10.1016/j.anr.2012.05.006 Kim, E. S., Cleary, S. J., Hopper, T., Bayles, K. A., Mahendra, N., Azuma, T., & Rackley, A. (2006). Evidence-based practice recommendations for working with individuals with dementia: Group reminiscence therapy. Journal of Medical Speech-Language Pathology, 14(3), xxiii-xxxiv. Lai, D. W. L., Bai, X., & Guo, A. (2017). Mediating effect of social participation on the relationship between incontinence and depressive symptoms in older Chinese women. Health & Social Work, 42(2), e94-e101. doi:10.1093/hsw/hlx018 Li, C., Jiang, S., Li, N., & Zhang, Q. (2017). Influence of social participation on life satisfaction and depression among Chinese elderly: Social support as a mediator. Journal of Community Psychology, 46(2), 345-355. doi:10.1002/jcop.21944 GROUP REMINISCENCE THERAPY PROGRAM 22 Melndez-Moral, J., Charco-Ruiz, L., Mayordomo-Rodriguez, T., & Sales-Galn, A. (2013). Effects of a reminiscence program among institutionalized elderly adults. Psicothema, 25(3), 319323. doi:10.7334/psicothema2012253 Nilsoon, I., Nyqvist, F., Gustafson, Y., & Nygard, M. (2015). Leisure engagement: Medical conditions, mobility difficulties, and activity limitations A later life perspective. Journal of Aging Research, 2015, 1-8. doi:10.1155/2015/610154 Nordin, S., McKee, K., Wallinder, M., Koch, L. V., Wijk, H., & Elf, M. (2017). The physical environment, activity and interaction in residential care facilities for older people: a comparative case study. Scandinavian Journal of Caring Sciences, 31, 727-738. doi:10.1111/scs.12391 Papageorgiou, N., Marquis, R., & Dare, J. (2016). Identifying the enablers and barriers to community participation amongst older adults. British Journal of Occupational Therapy, 79(12), 742-751. doi:10.1177/0308022616656195 Pastor-Barriuso, R., Padron-Monedero, A., Parra-Ramirez, L. M., Garcia Lopez, F. J., & Damian, J. (2020). Social engagement within the facility increased life expectancy in nursing home residents: a follow-up study. BMC Geriatrics, 20(480), 1-9. doi:10.1186/s12877-020-01876-2 Roberts, A. R., & Adams, K. B. (2018). Quality of life trajectories of older adults living in senior housing. Research on Aging, 40(6), 511534. doi:10.1177/0164027517713313 Rudman, D. L., Gold, D., McGrath, C., Zuvela, B., Spafford, M. M., & Renwick, R. (2016). Why would I want to go out?: Age-related vision loss and social participation. Canadian Journal on Aging, 35(4). 465-478. doi:10.1017/S0714980816000490 GROUP REMINISCENCE THERAPY PROGRAM 23 Siverova, J., & Buzgova, R. (2018). The effect of reminiscence therapy on quality of life, attitudes to ageing, and depressive symptoms in institutionalized elderly adults with cognitive impairment: A quasi-experimental study. International Journal of Mental Health Nursing, 27, 1430-1439. doi:10.1111/inm.12442 Tak, S. H., Kedia, S., Tongumpun, T. M., & Hong, S. H. (2015). Activity engagement: Perspectives from nursing home residents with dementia. Educ Gerongol, 41(3), 182192. doi:10.1080/03601277.2014.937217 Theurer, K., Mortenson, W. B., Stone, R., Suto, M., Timonen, V., & Rozanova, J. (2015). The need for a social revolution in residential care. Journal of Aging Studies, 35(2015), 201210. doi:10.1016/j.jaging.2015.08.011 GROUP REMINISCENCE THERAPY PROGRAM 24 Appendix A Semi-Structured Interview Questions Semi-Structured Interview Questions with Therapy Supervisor (Prior to Being On-Site) 1. What levels of care does the facility provide? What does this look like? 2. What are the current goals that your therapy department is trying to achieve? Are there plans in place to achieve these goals? 3. What are some areas of your therapy department or the general facility that you think could be improved that could become a focus for my DCE project? Do you have any ideas for further development? 4. Do you find that the activities offered at the facility are client-centered? 5. Do the residents engage in much social participation? a. In what ways do they do this? b. In what ways does the facility encourage social participation? c. For those in assisted living, do they often leave the facility? If so, do they have any difficulties with community mobility? Semi-Structured Interview Questions with Therapy Supervisor (After Starting On-Site) 1. Is occupational therapy (speech or physical therapy) involved in any social activities / groups with residents? If so, what type of involvement? If not, do you think it would be beneficial for the department to have more involvement? 2. Does the facility utilize ACL or similar assessment tools with any residents? 3. What is your perception of the current quality of life of residents? Semi-Structured Interview Questions with Activity Director 1. What activities are currently available for residents? Is there a schedule I can have a copy of? 2. How do you decide what activities to offer? Is resident satisfaction with offered activities considered and do you account for what activities they may be interested in having started up? 3. What are current visitor restrictions with family/friends? 4. Is there anything set up for residents to socialize with family other than visitation? Video calls, phone calls, etc.? If so, what assistance is provided to patients who have difficulty with using technology? 5. Do you keep track of participation levels in the offered activities? If so, how? 6. Do you keep track of participation levels of individual residents to know if they are being socially isolated and need increased encouragement? If so, how? 7. What are restrictions/rules with Covid around current activities? 8. What are limitations non-Covid related that tend to decreased social engagement? 9. What actions do you take right now to try to improve social engagement? a. How do you encourage social engagement? 10. What resources are available that I may be able to use as I either work on current programs or develop a new program? GROUP REMINISCENCE THERAPY PROGRAM 25 11. How are activities funded? 12. What is your perception of the quality of life of residents? 13. Do you have any advice for me as I look into developing current activities or creating new activities to promote social engagement? 14. What do you think could be improved with your activities programs? 15. With new residents, is there a method that you use to track how they are doing with adjusting to the facility? 16. How do you determine what activities new residents may be interested in? Semi-Structured Interview Questions with Therapy Staff (SLP) 1. ACL levels / GDS levels: how are they used to benefit client care after your evaluation of their level? Are other staffing departments (nursing, activities, etc.) aware of what it means to be at a certain ACL or GDS level, and how to facilitate the best quality participation in activities or social engagement? 2. Is there education provided to other non-therapy staffing on cognitive levels and how to adapt activities based on this? If so, what does this entail? Do you think there is room for improvement in this? 3. What is the typical level of cognitive function on the different units at this facility? 4. Do you think the idea of reminiscence / recollection-based therapy as a small group would be beneficial? Do you think long-term care and/or memory care would benefit from this? 5. Do you have any advice on implementing a reminiscence therapy group? GROUP REMINISCENCE THERAPY PROGRAM Appendix B Older Peoples Quality of Life - Brief version (OPQOL-Brief) 26 GROUP REMINISCENCE THERAPY PROGRAM 27 GROUP REMINISCENCE THERAPY PROGRAM 28 Appendix C Three-Item Loneliness Scale Question First, how often do you feel that you lack companionship: Hardly ever, some of the time, or often? How often do you feel left out: Hardly ever, some of the time, or often? How often do you feel isolated from others? (Is it hardly ever, some of the time, or often?) NOTE: For both scales, the score is the sum of all items Source: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2394670/ Hardly Some of Ever the Time 1 2 Ofte n 3 1 2 3 1 2 3 GROUP REMINISCENCE THERAPY PROGRAM 29 Appendix D Feedback Survey Mingling and Memories Feedback Thank you for your participation in the Mingling and Memories (reminiscing) program. Please answer the following questions the best that you can to provide important feedback about your experience. As a reminder, themes were as follows: Childhood, Holidays, Work, Vacations, Dating & Weddings/Marriage, and Family & Parenting. 1. How satisfied were you with the program? Please circle one. Extremely Satisfied Satisfied Neutral Unsatisfied Extremely Unsatisfied 2. What did you like about the sessions? 3. What changes do you suggest for future sessions? 4. Would you attend more sessions of this activity if it was offered again? Please circle one. Yes Maybe No a. If yes, what types of memories would you like to reminisce on? 5. Provide any other comments here. GROUP REMINISCENCE THERAPY PROGRAM Appendix E Resident Survey Questions 1. What were your favorite childhood games and/or pastimes? 2. What was your favorite toy as a child? 3. What was your favorite snack growing up? 4. What was your favorite thing to do with your parents? 5. What is your favorite vacation spot you have been to? 6. What is your favorite movie or show from when you were younger? 7. Who is your favorite musician/band from when you were younger? 8. What are some hobbies you did when you were younger? 9. What did you do for a living? 10. What is your favorite recipe to cook or bake? 11. What was your favorite thing to do with your children when they were young? 30 GROUP REMINISCENCE THERAPY PROGRAM 31 Appendix F Activity Protocol Template 1. Group title: Mingling and Memories (Reminiscence Therapy) 2. Session title: __________ Session theme: __________ 3. Format a. Warm-up and introductions: 5 minutes b. Educational Concepts: 5 minutes c. Activity: 25 minutes d. Sharing/Discussion: 20 minutes e. Summary: 5 minutes 4. Supplies: Must be about the theme chosen, preferably supplies are from the time period of the participants childhood and adulthood. The goal is to include as many senses as you are able to throughout the session to promote reminiscing (touch, sight, hearing, smell, taste). a. Touch: Objects to pass around b. Visual: Pictures to look at (printed or on digital slide show if large screen available for viewing) or short video to watch c. Smell: Scents to smell d. Taste: Snacks/Drinks e. Sound: Music or sound effects 5. Description a. Warm-up and introductions i. Optional: Play 1-2 songs as participants come in and get settled ii. Introduce self, name/title of group, participant introductions 1. Hello, my name is ____. Thank you for joining today for Mingling and Memories. Todays session is called ____, which will focus on the theme of ____. We are going to start by everyone introducing themselves, and then I will explain more about the purpose and plan for todays session. 2. Participants will now take turns to introduce themselves. b. Educational Concepts i. Thank you for introducing yourselves, I am excited to get us started on the session and reminisce with you all for the next hour. The purpose of this group is to provide an opportunity for positive social interaction, as well as a chance to learn more about each other and build friendships. It also provides an opportunity for you to feel happy emotions as you share your memories from the past. By taking part in reminiscing on the past and talking about your happy memories, researchers have found this to help with holding onto these memories that are dearest to you. It is also beneficial for increasing your happiness, self-esteem, and life satisfaction. To help you in remembering times from your past, I have chosen a theme for todays session, and have brought a variety of items with me, which are focused around this theme. The items I brought will help you use your different senses of touch, sight, hearing, smell, and taste, in order to remember the past. The reason for doing this is because research shows that by using the different senses, it helps you GROUP REMINISCENCE THERAPY PROGRAM 32 to remember things that you may have not thought about in a long time. Your brain stores a lot more memories than you may think, and you may be surprised with what you are reminded of today. c. Activity i. We are now going to start with our activity of sharing memories. You are all welcome to share any memory that you feel comfortable sharing. I want this to be an open space to learn more about each other and enjoy remembering times from your past. You are welcome to comment on each others stories if it reminds you of something from your own life, or you just want to say something positive or ask a question. We will start with ____ (choose activities below based on sensory experiences provided this session. Use prompts under the sharing/discussion section as needed.). ii. Objects - Participants will choose an object from the table or walk around with a basket/bag of objects for them to choose from. Participants will share why they chose that object and what it makes them think about. Give each resident a chance to do this. Participants can comment on each others stories and objects as they take turns sharing. iii. Pictures - Participants will look at provided pictures about the session theme, and take turns sharing what the pictures make them think about. Give each resident a chance to do this. Participants can comment on each others stories and objects as they take turns sharing. iv. Scents - Pass around scented objects (ex - unlit candle, spices), and ask participants what the smell reminds them of. Participants can comment on each others stories as they take turns sharing. 1. Another option is to have an essential oil diffuser turned on throughout the session with oil choice based on theme. You can also use the smells of snacks brought to the session. Ask participants what the smell reminds them of. Participants can comment on each others stories as they take turns sharing. v. Snacks/Drinks - Have participants choose a snack/drink (if multiple options provided) and share why they chose the one they did, and what it reminds them of. Participants can comment on each others stories as they take turns sharing their stories. vi. Music/Sounds - Play chosen music or sounds and ask participants to share what it reminds them of. Participants can comment on each others stories as they take turns sharing. 1. You may ask participants to choose songs from a certain time in their life (based on the theme of the session), and then play these songs through your phone, playing over a speaker, or through a CD if one is available. d. Sharing/Discussion i. Throughout activities above, use the following prompt ideas, as needed, to facilitate sharing and discussion. Ask any other open-ended questions that are relevant to the discussion happening. 1. What does this picture/object/smell/food/sound remind you of? 2. What is your favorite memory of ___ (ex - childhood, parenting, holidays, etc.)? GROUP REMINISCENCE THERAPY PROGRAM 33 3. Think back to what it was like when you were ___ (ex - growing up, getting married, having children, on vacation). Describe the sights, sounds, and smells of the time you are remembering. e. Summary i. Thank you for being here and participating in sharing your stories and listening to each other. I hope you all enjoyed yourselves as you reminisced about your past and learned more about each other. We will have another session next week on ___ (day) at ___ (time) that I hope you will come to, with the theme of ___.  ...