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... Food Insecurity of Congolese Refugees in Indianapolis By Hannah Joy Edwards Honors Project Thesis Submitted in Partial Fulfillment Of the Requirements for a Baccalaureate Degree With Distinction In the Ron and Laura Strain Honors College of THE UNIVERSITY OF INDIANAPOLIS May 2020 Faculty Advisor: Dr. Kara Cecil, Dr.PH Executive Director of Honors: James B. Williams, Ph.D. Hannah Edwards 2020. Copyright in this work rests solely with the author. Please ensure that any reproduction or re-use is done in accordance with relevant national copyright protection. i Abstract Congolese refugees are the second largest refugee population in the city of Indianapolis, yet there is little to no research to reveal whether or not they are properly equipped to lead holistically healthy lives. In an effort to bridge this critical gap, this research seeks to identify the rate of food insecurity within the Congolese refugee population in Indianapolis. Modeled after the research of Quandt, Arcury, Early, Tapia, & Davis published in Household Food Security Among Migrant and Seasonal Latino Farmworkers in North Carolina in 2004, the survey utilized is the USDA Adult Food Security Module, adapted for the purposes of this study. Through electronic and paper-based surveys translated into four languages and distributed through multiple venues, a total of 27 completed surveys were collected and analyzed. By coding the responses as set forth by the USDA in Guide to Measuring Household Food Security, Revised 2000, it was determined that 48.15% of Congolese refugees surveyed are food insecure while 51.85% are classified as food secure (Bickel, Nord, Price, Hamilton, & Cook, 2000). With a food insecurity rate of 48.15%, this research shows Congolese refugees in Indianapolis to be almost three times more food insecure than the greater Indianapolis population, reported to be 17.4% food insecure in the year 2017 (Gundersen, Dewey, Kato, Crumbaugh & Strayer, 2019). Further research must be done to confirm whether or not this small, non-random sample is indicative of the entire population of Congolese refugees in Indianapolis. Hunger relief leaders should, however, take note of the nearly 50% of Congolese refugees in Indianapolis in need of hunger interventions and use this information to shape their priorities for the benefit of the longterm health of the Congolese refugees living in Indianapolis. Keywords: food insecurity, food security, refugees, Democratic Republic of the Congo, Indianapolis, hunger relief. ii Table of Contents Abstract.i Table of Contents ....ii Acknowledgements....iii List of Figures.iv List of Tables ..v Introduction, Intellectual Context, Framework, and Theory..1 Problem Statement .1 Context....2 Literature Review3 Theory..5 Methods ..6 Results.9 Description of Sample.....9 Interpretation of Data ......9 Discussion..13 Conclusion ....15 Reflection/Future Directions .16 References..18 Appendices.20 iii Acknowledgements My sincerest gratitude goes out to the Ron and Laura Strain Honors College for their assistance in funding the translation needs of this project. I also owe immense credit to the community members who contributed to the success of this project: Pastor Bruce Garrison of The Congo-American Bridge, Pastor Brian Correll and Pastor Fikiri Nukulwe of Life Church 180 (Life4Refugees), Reverend Emmanuel Musinga of Grace Tabernacle Ministries, the staff at Exodus Refugee Immigration, and the staff at Immigrant Welcome Center. Thank you to my project advisor, Dr. Kara Cecil for her consistent encouragement and support, and for challenging me to persist in the face of adversity. Finally, thank you to the brave members of the Congolese refugee community who welcomed me into their sacred spaces during this project. For the glory of God and the good of our neighbor. iv List of Figures 1. A Visual Representation of the Social-Ecological Model...5 2. Number of Congolese Refugees in Each Level of Food Security ....10 3. Congolese Refugees in Indianapolis: Food Secure or Insecure? ..11 v List of Tables 1. Four Level Correlation Table .11 2. Collapsed, Two Level Correlation Table ..13 1 Introduction, Intellectual Context, Framework, and Theory Problem Statement Indianapolis has a new and rapidly growing immigrant population including residents belonging to the Chin, Karen, Kareni, Congolese, Syrian, Iraqi, and Somalian people groups (Exodus Refugee Immigration, n.d.). As stated by the Immigrant Welcome Center in Indianapolis, more than 60 percent of the citys foreign-born arrived in the United States in the last ten years (Indianapolis Immigrant Integration Plan, 2017). As the population has diversified, Indianapolis has implemented many programs and initiatives to take care of and empower impoverished minority residents, but one population in particular seems to have fallen through the cracks. Congolese refugees are the second largest refugee population in Indianapolis, yet very few organizations have been formed to advocate for their community (Exodus Refugee Immigration, n.d). Furthermore, Congolese refugees in particular face a unique set of challenges and come bearing both emotional and physical burdens as they have traveled thousands of miles to flee their war-torn country (Gettleman, 2012). Tuberculosis, parasites, malaria, and posttraumatic stress disorder from sex-based and gender-based violence are common amongst Congolese refugees (Ranard, 2014). These health risks, when combined with Congolese refugees limited knowledge of English and unfamiliarity with American food, put the refugees in a vulnerable position. Food insecurity, as defined by the Journal of Nutrition and utilized by the USDA, is the limited or uncertain availability of nutritionally adequate and safe foods or limited or uncertain ability to acquire acceptable foods in socially acceptable ways (Anderson, 1990). Food insecurity must be considered significant and actionable because, according to the Food Research and Action Center, it is associated with some of the most common and costly health 2 problems and behaviors in the U.S. including diabetes, cancer, stroke, and pregnancy complications (Hartline-Grafton & Dean, 2017). If food insecurity heightens risk for serious medical conditions, all efforts to lower or eradicate food insecurity should be considered worthwhile. Thus, the goal of this project is to survey, assess, and analyze the state of food insecurity within the Congolese refugee community in Indianapolis. By identifying the level of food insecurity in this population, hunger relief oriented nonprofit organizations such as food pantries, food banks, and community organizations can identify whether or not their organization is accountable to the data and if applicable, formulate appropriate next steps towards lowering the rate of food insecurity (if present) or ensuring the rate does not rise in the future. Additionally, this data can be used by the Indy Food Council and Indy Hunger Network to shape their priorities for future years. Both of these organizations work on the city level to streamline hunger relief initiatives towards common goals. This can include making recommendations to funding sources to set priorities for grant funding, and it can also include lobbying state congressmen and congresswomen for new parameters for hunger relief policies and programs such as the Supplemental Nutrition Assistance Program, Special Supplemental Nutrition Program for Women, Infants, and Children, and the Farmers Market Nutrition Program. Context In the fall of 2018, I began a one semester internship in the Family Ministries Department at Shepherd Community Center on the Near Eastside of Indianapolis. The organizations key programs (its onsite school, church, after school programming, mothers mentoring program, and fresh food co-op) are all dominated by Latino clients. In contrast, however, the average Saturday at their food pantry brings less than a handful of Latino men and women compared to twenty or 3 more Caucasian and African American men and women. This disparity sparked my investigation. Discussion with tenured staff members and Spanish-speaking caseworkers revealed a few contributing factors: the food pantry required an ID while many members of the surrounding Latino community were undocumented, the food pantry felt like a handout while the co-op program was more empowering, and finally, the food stocked in the food pantry was not culturally appropriate for Latino clients. Seeing this gap in services for Latino men and women in Indianapolis moved me to find out how the hunger relief community was serving (or failing to serve) other ethnic minorities in Indianapolis. I immediately turned to the ever-growing refugee populations, beginning with the Burmese refugee population. It did not take long, however, to learn that food access for the Burmese was already being addressed through multiple Burmese-run community organizations and a newly founded food pantry stocking Burmese foods (J. Landis, personal communication, October 24, 2019). Thus, I turned to the second largest refugee population in Indianapolis: refugees from the Democratic Republic of the Congo. This population, as it turned out, had few organizations working for their benefit, and initial conversations with community leaders suggested the need was great (B. Garrison, personal communication, March 25, 2019). The combined force of a lack of advocates in the form of non-profit organizations, a stated need from community leaders, and personal interest based on my prior experience at Shepherd Community Center propelled the conception of this specific research. Literature Review Hunger relief is a field of public service that has existed since the New Deal, a series of programs and funding designed to help the nation recover from the Great Depression 4 (Greenberg, Greenberg, & Mazza, 2010). Since then, the nonprofit sector has joined governmental agencies in the fight against hunger. Food pantries, food co-ops, community gardens, soup kitchens, and more models of hunger relief initiatives can be found on nearly every street corner of urban areas (Belding, 2015). There are many research studies investigating food pantries in the United States and their effectiveness in providing healthy foods to low income clients. One such study is Disparities in Access to Fresh Produce in Low-Income Neighborhoods in Los Angeles that found that 13% of food pantry clients in Ponoma did not have walking access to food pantries with fresh produce or limited fresh produce. The conclusion of this study stated that its results were consistent with those of cities like Detroit and Chicago allowing for the assumption that results may be similar in Indianapolis (Algert, Agrawal, & Lewis, 2006). It is difficult, however, to find research at the intersection of food insecurity and clients that are part of ethnic minorities. Where it does exist, it is largely focused on assessing the food insecurity of refugee populations in refugee camps located outside of the United States. This gap is the propelling force behind this research project, but it makes locating comparable or even applicable literature difficult to identify. The research of Quandt, Arcury, Early, Tapia, & Davis (2004), however, is a landmark study in researching ethnic minorities living in a majority white, United States context. These researchers engaged with 102 Latino farmworkers in North Carolina through surveys and indepth interviews. The surveys used in this research are the "U.S. Household Food Security Survey Module published by the United States Department of Agriculture. The results are compelling: 47.1% of households represented in the survey data were classified as food insecure. It should be noted that study limitations are cited as including a non-random sample with a small 5 sample size. As stated in the studys discussion, Such a strategy is necessary in this and other hard to reach populations, but it may produce unintended bias in results (Quandt, Arcury, Early, Tapia, & Davis, 2004). Theory Because this research is a convergence of public health and social work interests, it is useful to apply key theories from each discipline. The Social-Ecological Model, a pivotal theory in the field of public health, views the world through multiple rings of influence, each expanding in scope (Bronfenbrenner, 1977). The exact title of each level has evolved over time, but the meaning remains consistent: it begins with the individual in his or her own ring, which is included in a larger interpersonal ring, which is inside an organizational ring, which is part of a community ring, which is swallowed by a public policy ring. The point of the model is to suggest that individuals are affected by multiple systems, and they contribute to multiple systems as well (Lee, Bendixsen, Liebman, & Gallagher, 2017). Figure 1 A Visual Representation of the Social-Ecological Model Figure 1: Original Diagram based on Lee, Bendixsen, Liebman, & Gallagher, 2017. 6 The Social-Ecological model asserts that people are not people in isolation; they are people in environments. This assertion - that people are influenced by their environments - is the cornerstone of social works Systems Theory. In Systems Theory, each of these rings are systems that form influence one another, whether by completely enveloping one another, overlapping significantly, or touching tangentially. This theory sets a framework for understanding the diverse, yet always interconnected relationships of the various systems that contribute to the flourishing or failure of an individual life (Kirst-Ashman & Hull, 2018). In alignment with the Social-Ecological Model, Systems Theory would agree that humans do not exist in a vacuum. Rather, people are both shaped by and shapers of many complex systems including families, organizations, and cities (Kirst-Ashman & Hull, 2018). Both theories view food insecurity as a multidimensional social issue caused by many factors, not all within the control of the affected individual. Both would allow the researcher to claim that public policies such as food stamps, corporate interests that result in food deserts, and even conflicting cultural values could contribute to one individuals hunger. This consideration the idea that food insecurity can be felt individually but is caused by a combination of many complex systems - is crucial in fully understanding food insecurity in Indianapolis and around the globe. Methods The methodology of this research is adapted from the methods of Quandt, Arcury, Early, Tapia, & Davis (2004) in which the food insecurity of Latino farmworkers was analyzed using the United States Department of Agriculture Adult Food Security Survey Module. Thus, the 7 research utilizes this survey module with modifications for the context of Congolese refugees who live in Indianapolis. Through information gathering meetings with community members, it was clear that the Congolese refugees in Indianapolis speak one or more of any four different languages: French, Swahili, Kinyarwanda, and Lingala (J. Saksena, personal communication, February 12, 2019). According to these sources, very few of the refugees speak or read English (A. Mulumba, personal communication, March 29, 2019). In response to this, Luna Translation Services was consulted to translate the survey into each of those four languages. To reach as many Congolese refugees as possible, the researcher reached out to the three refugee-focused non-profit organizations in Indianapolis, asking for their assistance in distributing the paper surveys. The researcher posed a variety of options for the partnership including the option of survey distribution through agency case workers, through mailings to clients, or by placing surveys in a prominent space at the organization office for an agreed upon duration of time. In the end, Exodus Immigration and Refugee Services and Immigrant Welcome Center were responsive and agreed to place the surveys at the front desk of their organizations for 30 days. The paper surveys were available at the front desks of these organizations for far more than 30 days: from December 9, 2019 to February 21, 2020. Catholic Charities, the third of the trio of refugee focused non-profit organizations in Indianapolis was non-responsive, even after multiple attempted points of contact. At the conclusion of the planned data collection period with Exodus Immigration and Refugee Services and Immigrant Welcome Center, only two surveys were completed. Through additional meetings with community partners, namely Bruce Garrison of the Congolese American Bridge, and after seeing the poor response rate from the 8 first phase of data collection, a new strategy was devised (B. Garrison, Congo American Bridge Board Meeting, November 18, 2019). The next phase of data collection was two-fold: first, the survey was loaded into the University of Indianapolis secure, online survey software, Qualtrics. Second, the survey was taken to a local church for in person data collection. The purpose of the online survey platform was to allow for simple, widespread reach to any Congolese refugee in Indianapolis with access to a computer. At the suggestion of the community leaders present at the Congo-American Bridge Board Meeting, online surveys would be more accessible for a greater number of people. It would also allow for an additional method of data collection at in-person gatherings that could be led by community members without the researcher present. The survey was available in all five relevant languages. It was disseminated to community members with a request for participation, but no online surveys were completed. The second half of the new strategy involved direct communication with Indianapolis area churches that include significant Congolese populations. Pastor Bruce Garrison agreed to set up initial connection emails with a variety of pastors in Indianapolis with Congolese congregations. After numerous emails and phone calls, one church, Grace Tabernacle Ministries, agreed to allow survey data collection after a Sunday service. Following the churchs Sunday service on March 8th, the researcher spoke in front of the congregation, explaining the purpose of the project and asking for their voluntary participation in the surveys. Paper surveys were available in English, French, Swahili, Kinyarwanda, and Lingala, and participants self-selected their preferred language. It was through this outreach that the final 25 surveys were completed. Survey data was analyzed by using the Qualtrics platform to compile and digitize responses. The results were then sorted and evaluated using the guidelines set forth by the USDA 9 in the organizations Food Security Guide (Bickel, Nord, Price, Hamilton, & Cook, 2000). The primary focus was evaluating the food security level of the sample population, with a secondary emphasis on potential correlations tied to language spoken, number of people in the household, and length of time the respondents have resided in the United States. The food security level of each household was calculated by coding results into affirmative and negative responses, as directed by the Food Security Guide (Bickel, Nord, Price, Hamilton, & Cook, 2000). Results Description of the Sample The survey respondents were all given the choice of completing the survey in English or any of the four primary languages spoken by Congolese refugees: French, Swahili, Kinyarwanda, and Lingala. In total, six surveys were completed in English, six in French, two in Swahili, ten in Kinyarwanda, and three in Lingala. An average of 5.34 people lived in each sample household, with datum ranging from one person to nine people. Eight participants reported living in the United States for less than one year, six have lived in the U.S. for three to five years, and three have lived in the United States for six to eight years. Interpretation of Data The USDA Food Security Guide requires that responses to survey questions two through nine be reduced to affirmative or negative responses, using the guidelines listed in Appendix B (Bickel, Nord, Price, Hamilton, & Cook, 2000). Using only the affirmative responses to indicate food insecurity, each participants responses can be evaluated on a four-level scale: food secure, food insecure without hunger, food insecure with moderate hunger, and food insecure with severe hunger. The specific version of the survey module utilized in this research is the most recent form published by the USDA. Because of how recently it was published, a coding scale 10 has not yet been published. The best available equivalent of the scale appropriate for this research is the Households without Children scale values from the 2000 USDA Food Security Guide because this scale has a comparable range (Appendix C) (Bickel, Nord, Price, Hamilton, & Cook). According to this scale, fourteen (or 51.85%) of the survey participants are food secure. Nine (or 33.33%) are in the second status: food insecure without hunger. Three (11.11%) are food insecure with moderate hunger, while a final one participant (or 3.7% of the total sample) is food insecure with severe hunger. When the three food insecure categories are collapsed, a total of 48.15% of Congolese refugees surveyed are food insecure, while 51.85% are food secure. A chart with each participants number of affirmative responses is available in Appendix A, and relevant graphs are included below. Figure 2 Number of Congolese Refugees in Each Level of Food Security 11 Figure 3 Congolese Refugees in Indianapolis: Food Secure or Insecure? As an additional layer of analysis, the data was cross tabulated through the lens of three key demographic points: language of survey completion, number of people in the household, and length of time the respondents have resided in the United States. Each of these sections of data were analyzed for any correlation to level of food security that was 50% or greater. Table 1 Four Level Correlation Table Years in U.S. Language Spoken People in Home Number of Responses One to Three Four to Six Seven to Nine English French Swahili Kinyarwanda Lingala Zero to Two Three to Five Six to Eight Food Secure Food Insecure W/O Hunger 33% 64% 33% 29% Food Insecure with Moderate Hunger 33% 7% 50% 17% 17% 17% 71% 40% 0% 60% 33% 44% 67% 60% 29% 40% 100% 20% 33% 44% 0% 20% 0% 20% 0% 20% 0% 11% 17% 20% 0% 0% 0% 0% 33% 0% 17% 0% Food Insecure with Severe Hunger 0% 0% 12 In the category of homes with four to six people, 64% of respondents were evaluated as food secure., while in homes with seven to nine people, 50% are food secure. This can be compared to homes with one to three individuals where only 33% of participants are food secure, however, it should be noted that only three survey participants live in homes with only one to three individuals. Language is a nuanced metric because Congolese refugees in Indianapolis may speak multiple languages (B. Garrison, personal communication, March 25, 2019). Therefore, the language the participant chose to respond in may not be fully representative of their range of language fluency. Still, it is important that 71% of those who responded in English (of 6 respondents) and 60% of those who responded in Kinyarwanda (of 10 respondents) are food secure, while only 33% of those who responded in Lingala (of 3 respondents), 40% of those who responded in French (of 6 respondents), and 0% of those who responded in Swahili (of 2 respondents) are food secure. Finally, in the category of length of time as a United States resident, two categories have a correlation greater than 50%: those who have lived in the U.S. three to five years (67%) and six to eight years (60%). This suggests that being in United States for more than three years could contribute to an increase in Congolese refugees rate of food security. It cannot be stated that this is a direct cause, but it is a notable correlation to be further investigated. When the three categories of food insecurity are collapsed to analyze the sample as strictly food secure versus food insecure, there are four categories in which the sample surveyed is more food insecure than food secure, as seen in Table 2 below. These four categories are homes with one to three people, French language respondents, Swahili respondents, Lingala respondents, and those who have resided in the United States zero to two years. It is true that 13 correlation does not equal causation, but correlation may be a clue to other aspects of refugee life that should be considered when working towards equitable food access. Table 2 Years in U.S. Language Spoken People in Home Collapsed, Two Level Correlation Table One to Three Four to Six Seven to Nine English French Swahili Kinyarwanda Lingala Zero to Two Three to Five Six to Eight Food Secure 33% 64% 50% 71% 40% 0% 60% 33% 44% 67% 60% Food Insecure 67% 36% 50% 29% 60% 100% 40% 67% 56% 33% 40% Discussion For context, this research must be compared with the average food insecurity rate amongst all United States households. The most recent report, published in September 2019 and using the USDA Food Security Module, reports the 2018 food insecurity rate to be 11.1% (Coleman-Jensen, Rabbitt, Gregory, & Singh, 2019). This datum is explained as a picture of the percentage of homes with any amount of food insecurity. In other words, this statistic captures the same categories of food insecurity as the statistic of 48.15% found in this research. Where the average American population is 11.1% food insecure, the Congolese refugees in Indianapolis are 48.15% food insecure. Though an initial glance at the data collected in this research shows that more Congolese refugees are food secure than are food insecure, when compared with the 14 national average, the 48.15% of Congolese refugees sampled that show signs of food insecurity is clearly a significant proportion. An additional view of food security data published by Feeding America provides the level of food security present in each United States county. This additional layer of detail shows that through the same metrics, the USDA Food Security Module, the rate of food insecurity in Marion County, Indiana was 17.4% in the year 2017 (Gundersen, Dewey, Kato, Crumbaugh & Strayer, 2019). This is an elevated rate when compared to the national average of 11.1% in 2018, but it is still almost three times smaller than the food security rate of Congolese refugees in Indianapolis in 2020 as determined by this research. Regrettably, there were many limitations within the data collection process, which may have resulted in sampling error. The most obvious limitation of this data is the sample size. With only 27 respondents out of thousands of Congolese refugees in Indianapolis, it is difficult to know whether the results collected are a fair representation of the population. Additionally, the sample is a non-random sample with 92.6% of the participants belonging to the same church community. These are, however, fair limitations that are to be expected with difficult to reach populations, according to the work of Quandt, Arcury, Early, Tapia, & Davis (2004). Additionally, one must consider whether or not it is fair to assess the food insecurity of a foreign people group using United States standards such as the USDA Adult Food Security Survey Module. All refugees bring their own experiences and expectations to the table when they immigrate to the United States; it is possible that even in the respondents native language the terminology used in the survey is culturally relevant and thereby interpreted differently by the population surveyed. 15 Time is another limitation of this survey, as the instructions are written to capture only the experience of the refugees last twelve months. With a sample in which 55% of respondents have been in the United States for three or more years, it is understandable that the data may show higher rates of food security than a sample of Congolese refugees in their first year in the United States. Finally, though all efforts were made to make the survey language accessible to the Congolese, the effects of those efforts were cut short due to the poor literacy rate amongst Congolese refugees as reported by community leaders (B. Garrison, Congo American Bridge Board Meeting, November 18, 2019). Even in their native language, many Congolese refugees have poor reading comprehension skills and therefore may have inaccurately filled out the survey. Conclusion Though the research is bound by limitations, the results of this research are vitally important in beginning the journey of understanding a new group of people living, working, playing, and worshipping in Indianapolis. Understanding that nearly 50% of Congolese refugees in Indianapolis are food insecure, especially compared to the 2017 Marion County rate of 17.4% food insecure, is important for government leaders, non-profit organizations, and anyone that crosses paths with these neighbors (Gundersen, Dewey, Kato, Crumbaugh & Strayer, 2019). Participants in fight against hunger have a duty to understand the populations they serve, and this research provides a new level of insight for the Indianapolis hunger relief community to use to shape their mission, vision, and programming. 16 Reflection/Future Directions There is a significant amount of work still to be done in ensuring there is equitable food access for all ethnic groups, not solely in Indianapolis, but in the world. To be done ethically and efficiently, that work must start with research. The progress made through this project leaves stakeholders with a multitude of questions. Would the survey results tell the same story with a larger sample? Why are homes with few individuals more food insecure than homes with up to eight people? What do terms like food security, hunger, and enough to eat, mean to Congolese refugees? Once past the question of whether or not Congolese refugees are food insecure, there is much to discover about how food insecure refugees survive. There is still a great need for data detailing whether Congolese refugees seek assistance from food pantries, food co-ops, community gardens, or other sources of hunger intervention. If they do not utilize community resources, researchers should seek to understand why. Are transportation, timing, or cultural differences contributing elements, or is it because of language, past experiences, or another unknown factor? Throughout the many challenges and redirection imposed by the circumstances of this research, I have learned a better way to approach research with difficult to reach populations. To begin, I would recommend a researcher that is able to speak a language that is not English and is spoken by members of the target population. This would be helpful in reducing translation costs, but more importantly it would help build trust between the researcher and the population at hand. Second, I would recommend partnering with one community organization that is willing to provide the researcher with any and all resources necessary. Part of the downfall of this research was that it relied on many insubstantial community partnerships instead of one robust partner 17 that could have helped carry the project to completion. Finally, I urge future researchers to approach the target population from multiple angles at once. As a trailblazer in this niche research, I began survey collection based on the initial suggestion provided by the community leaders I relied on for access to the population. This was not an inherently wrong choice, but it yielded a much longer data collection process. This research was only successful because of continual commitment to the cause through innumerable instances of redirection from community leaders. The research conducted in this project is only the beginning for the Congolese refugee community in Indianapolis. Once this population is more thoroughly understood, research should be expanded to look at other refugee populations in Indianapolis, the Congolese refugee populations in other U.S. cities, and ultimately, every minority ethnic group in every city in the United States. This is the work that should be done, and this is the work that must be done for the welfare of men, women, and children of every racial and ethnic background in America. Access to equitable health outcomes should not be a privilege, yet when one population is uniquely burdened with food insecurity, it becomes clear that long term wellbeing is not equally attainable. 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Hartline-Grafton, H., & Dean, O. (2017). The impact of poverty, food insecurity, and poor nutrition on health and well-being. Washington, DC: Food Research & Action Center. Indianapolis Immigrant Integration Plan. (2017). In Immigrant Welcome Center. Retrieved from https://www.immigrantwelcomecenter.org/iiip/ Kirst-Ashman, K. K., & Hull, G. H. (2018). Generalist Practice with Organizations and Communities (Seventh ed., pp. 164-167). Boston, MA: Cengage Learning. Lee, B. & Bendixsen, C. & Liebman, A. & Gallagher, S. (2017). Using the Socio-Ecological Model to Frame Agricultural Safety and Health Interventions. Journal of Agromedicine. 22. Ranard, D. A. (2014). Refugees from the Democratic Republic of the Congo. Culture Orientation Research Center. Retrieved March 10, 2019. Survey Tools (2017, October 4). In USDA Economic Research Service. Retrieved March 11, 2019, from https://www.ers.usda.gov/topics/food-nutrition-assistance/food-security-inthe-us/survey-tools/#youth Quandt, S. A., Arcury, T. A., Early, J., Tapia, J., & Davis, J. D. (2004). Household food security among migrant and seasonal Latino farmworkers in North Carolina. Public Health Reports, 119(6), 568-576. 20 Appendices Appendix A: Data Coded by Affirmative and Negative Responses PARTICIPANT CODE GTM-8 GTM-9 GTM-10 GTM-11 GTM-12 GTM-13 EXODUS - 2 GTM-22 EXODUS -1 GTM-5 GTM-14 GTM-15 GTM-16 GTM-17 GTM-18 GTM-19 GTM-20 GTM-21 GTM-23 GTM-24 GTM-25 GTM-1 GTM-2 GTM-3 GTM-4 GTM-6 GTM-7 Q2 Q3 1 1 1 1 0 1 1 1 1 1 0 0 0 1 0 0 1 1 1 1 1 1 1 1 0 1 1 1 1 1 0 0 0 1 0 0 1 1 0 1 0 0 0 0 0 1 0 0 0 0 Q4 Q5 Q6 Q7 Q8 Q9 Q10 FOOD SECURITY SCORE 1 1 0 1 0 0 0 1 0 0 0 0 1 1 1 1 1 0 0 0 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 1 0 1 1 0 1 1 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 1 0 0 1 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 1 1 0 1 1 1 1 0 0 0 0 0 0 1 0 0 0 0 0 1 1 1 1 1 1 1 1 0 1 1 0 0 0 0 0 0 0 1 1 0 1 1 0 1 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 1 0 0 5 4 6 4 0 2 3 4 6 3 0 0 2 3 1 0 8 2 2 9 3 0 5 0 1 0 2 21 Appendix B: Response Coding Guide (Bickel, Nord, Price, Hamilton, & Cook, 2000) 22 23 Appendix C: Score and Status Levels (Bickel, Nord, Price, Hamilton, & Cook, 2000) 24 Appendix D: CITI Training Certificates 25 Appendix E: IRB Exemption Human Research Protections Program (HRPP) 800/232-8634 x5774 1400 East Hanna Ave Sease, Room 201L Indianapolis, IN 46227 1 (317) 781-5774 http://irb.uindy.edu hrpp@uindy.edu October 19, 2019 NOTIFICATION OF EXEMPTION DETERMINATION Study Number: 01138 Study Title: Food Insecurity of Congolese Refugees in Indianapolis Exemption Determination Date: October 17, 2019 Principal Investigator: Kara Cecil, DrPH The above-referenced protocol has been reviewed in accordance with the US Department of Health & Human Services (DHHS), Office for Human Research Protections (OHRP) regulations, specifically 45 CFR 46.104. Based on these criteria, this study is exempt from IRB Review. This exemption is valid unless changes in the project may impact the eligibility for exemption under the federal regulations. If you need to make any changes to the study, please contact the HRPP office hrpp@uindy.edu for guidance on whether additional review is required. Please submit all personnel changes through IRBManager as a Modification of Approved Protocol. Upon completion of your study, please submit a closure report through the IRBManager system. Yvonne Wakeford, Ph.D. Director: Human Research Protections Program (HRRP) HRPP Jan 2019  ...

... The Effect of Observational Perspective on Functional Movement Screen Performance By Allison Ann Edlin Honors Project Thesis Submitted in Partial Fulfillment Of the Requirements for a Baccalaureate Degree With Distinction In the Ron and Laura Strain Honors College of THE UNIVERSITY OF INDIANAPOLIS May 2020 Faculty Advisor: Richard Robinson, Ph.D. Executive Director of Honors: James B. Williams, Ph.D. Allison Edlin 2020. Copyright in this work rests solely with the author. Please ensure that any reproduction or re-use is done in accordance with relevant national copyright protection. i Abstract The aim of this study was to determine if observational perspective (visual-frontal vs. visual-sagittal vs. verbal) had an effect on Functional Movement Screen (FMS) performance. This was an experimental study with a convenience sample of 13 healthy, college-aged participants from the University of Indianapolis. Participants performed the Deep Squat, Hurdle Step, and Inline Lunge assessments of the FMS (commonly referred to as the Big Three) under three randomly presented instructional conditions: video demonstrations by a skilled model from the frontal and sagittal observational perspectives and verbal instruction read by a qualified assessor (the standard FMS protocol). Scoring was recorded in real-time while simultaneous video was captured. The videos were reviewed by an experienced evaluator to ensure scoring accuracy according to the standardized FMS protocol. Recorded scores from each condition were analyzed with the Friedman test to determine if observational perspective had a significant effect on FMS performance. The statistical analyses indicated that observational perspective did not have a significant effect on FMS performance during any of the three movements. ii Table of Contents List of Tables .................................................................................................................. iii List of Figures................................................................................................................. iv Statement of Purpose ..................................................................................................... 1 Introduction .................................................................................................................... 1 Methods ......................................................................................................................... 4 Results .......................................................................................................................... 10 Discussion ..................................................................................................................... 10 Reflection...................................................................................................................... 14 References/Bibliography .............................................................................................. 17 Tables ........................................................................................................................... 21 Figures .......................................................................................................................... 23 Appendix A ................................................................................................................... 26 Appendix B ................................................................................................................... 31 Appendix C .................................................................................................................... 32 Appendix D ................................................................................................................... 33 iii List of Tables Table 1: Participant Demographics ................................................................................ 21 Table 2: Verbal Script ................................................................................................... 21 Table 3: Deep Squat ...................................................................................................... 22 Table 4: Hurdle Step ..................................................................................................... 22 Table 5: Inline Lunge .................................................................................................... 22 Table 6: Friedman Test Deep Squat ............................................................................... 22 Table 7: Friedman Test Hurdle Step .............................................................................. 22 Table 8: Friedman Test Inline Lunge ............................................................................. 22 iv List of Figures Figure 1: Deep Squat Frontal......................................................................................... 23 Figure 2: Deep Squat Sagittal ........................................................................................ 23 Figure 3: Hurdle Step Frontal ........................................................................................ 24 Figure 4: Hurdle Step Sagittal ....................................................................................... 24 Figure 5: Inline Lunge Frontal ....................................................................................... 25 Figure 6: Inline Lunge Sagittal ...................................................................................... 25 1 Statement of Purpose The purpose of this study was to determine if observational perspective (visualfrontal vs. visual-sagittal vs. verbal) had an effect on Functional Movement Screen (FMS) performance. Introduction Literature Review: According to Kleynen et al. (2014), observational learning can be described simply as learning by observing a movement; the observer determines the key spatial and/or temporal features of the task through observation, thereby creating a cognitive representation of the action pattern (p.7). Observational learning is categorized as an implicit form of learning, meaning participants learn from observing a model demonstrating the movement or from other participants also performing the task (Kleynen et al., 2014). In contrast, verbal instruction such as that traditionally given to cue the FMS is categorized as explicit instruction because commands provide detailed technical step-by-step instructions for movement execution including specific body positioning (Meier et al., 2020). Observational learning has been shown to be effective for skill acquisition when movements are demonstrated by a skilled model (Elliott & Khan, 2010; Friedman & Korman, 2019). A meta-analysis of research on observational learning indicated a moderate to strong effect size (0.77) on movement dynamics and a small effect size (0.17) on movement outcome (Ashford, Bennett, & Davids, 2006). Motor resonance involving the mirror neuron system is one explanation for the effectiveness of observational learning (DInnocenzo et al., 2016). When we observe someone performing an action, visual input to our mirror neuron system activates the 2 primary motor cortex (M1) to encode a specific motor program to produce the observed action. Further explanation of the effectiveness of observational learning is provided by the common coding hypothesis (Robrecht et al., 2012) in which perception and action are assumed to be represented by common codes stored and activated in the central nervous system. Because actions are coded in terms of perceptual effects, perception, motor imagery, and action occupy a common representational domain (Robrecht et al., 2012). The mirror neuron system, the impact of motor expertise on action perception, and the influence of motor constraints on action perception have been offered as explanations supporting the common coding hypothesis (Abernethy & Zawi, 2007). Lago-Rodriguez et al. (2014) confirmed that visuo-motor neurons discharge action potentials when executing an action, as well as during the observation of the performance of a similar action. Thus, during an observational learning protocol, learners acquire new motor patterns based on the visual information presented by a model in as little as two demonstrations (Teodoro Bruzi et al., 2019) by transforming the observed visual information into motor commands (visuo-motor transformation). Therefore, the common coding hypothesis might explain how mirror neurons may be responsible for the visuomotor and motor-visual transformation processes that may play a role in the perceptual and motor improvements stimulated by observational motor learning. Alternately, visual perception also has an effect on observational learning. Evidence indicates that the relative motion of the bodys degrees of freedom (e.g., body segments) is perceived through visual observation and enhances initial physical performance (Buchanan et al., 2008; Scully & Newell, 1985; Buchanan & Park, 2017). 3 Only one study did not find that a demonstration led to superior performance during the acquisition and retention tests (Ghorbani & Bund, 2016). Relative motion, relative phase relationships between the degrees of freedom, and possibly relative amplitude information are sources of information that play a role in the development of kinematic processing in the nervous system (Buchanan, Ramos, & Robson, 2015). Variation in demonstration may need to be employed in order to help an observer more readily discriminate perceptually those variables that are important for the generation of that action (Buchanan & Dean, 2010, p.325). While observation has been conclusively shown to aid perception, physical practice may also be necessary for immediate physical performance benefits (Maslovat, Hodges, Krigolson, & Handy, 2010). Observational perspective does appear to have an effect on movement outcomes. A meta-analysis of observational learning (Ste-Marie et al., 2012) concluded that when designing observational interventions, it is important to consider a number of factors that may inhibit their effectiveness. These factors include, but are not limited to, the modality of the demonstration (i.e. video, live or virtual model), the viewing perspective (frontal, sagittal, or both), and the characteristics of the task, observer, and model. Of specific interest to the current study are the findings of Ste-Marie et al. (2012) regarding viewing perspective. They found that an objective or frontal view in which the learner is in front of the model (facing the model while the model faces the learner) might lead to greater learning (Ste-Marie et al., 2012). The Functional Movement Screen (FMS) is a tool developed by Cook et al. (1997) to help clinicians and health care professions screen individuals for risk of injury and/or performance-limiting movement patterns (Cook et al., 2014). It is most commonly 4 used screening test for identification of athletes at risk of injury (McCall et al., 2014). Specifically, the screen is used to identify asymmetries which result in functional movement deficiencies by grading mobility and stability during seven fundamental movement patterns. These movements are designed to uncover weaknesses and imbalances by placing an individual in extreme positions where mobility and motor control are more difficult to maintain. Once deficiencies have been identified through the FMS, a qualified clinician can prescribe corrective exercises in an attempt to prevent musculoskeletal injuries. The FMSs predictive validity has been controversial, however (Philp et al., 2018; Bonazza et al., 2017; Moran et al., 2017). The FMS, since its creation, has used verbal instruction as the standardized method of administering the protocol (Cook et al., 2014). The verbal method of cueing has yet to be validated as the most effective means of instructing participants. This study, then, sought to determine if visual presentations from different perspectives (frontal and sagittal) would produce superior FMS performance compared to verbal instruction. We hypothesized, based on previous research and conclusions made by Ste-Marie et al. (2012) that FMS performance would be superior after visual observation from the frontal perspective. Methods Methodology: An experimental study was executed to determine if observational perspective (visualfrontal vs. visual-sagittal vs. verbal) had an effect on FMS performance. The study took place at the University of Indianapoliss Human Performance Laboratory located in the Health Pavilion. 5 Participants: A convenience sample of thirteen students were recruited by word-of-mouth from the University of Indianapolis. These students had a prior relationship to the student researcher and were asked to participate if willing. Those that gave an initial verbal commitment to participate then completed the informed consent process (Appendix A). Descriptive statistics were calculated for age, weight, height, sex, and limb dominance (Table 1). Participants #3, 4, and 11 had previously performed a Functional Movement Screen. Participant #3 did demonstrate a score of 3 across all 3 conditions and 3 tests. However, there was variation in the scores across conditions for participants #4 and #11. Because of this, none of the participants data was excluded from the study. Ten had never heard of or performed the FMS. Participants were included if they were healthy and between the ages of 18 and 40 years. They were not required to meet fitness guidelines set forth by the American College of Sports Medicine, defined as follows: performed moderate intensity aerobic physical activity for a minimum of 30 minutes 5 days per week or vigorous activity for a minimum of 20 minutes 3 days per week (2018). Although this was not a part of the inclusion criteria, six participants did meet these fitness guidelines. All participants verbally agreed that they participated in some weekly exercise and considered their lifestyle active, even if it was below these ACSM guidelines. Three participants were current NCAA Division II collegiate athletes, while four had previously competed on a NCAA Division II athletic team at UIndy. Participants were eligible if they had no current musculoskeletal pathology that restricted normal movement, such as: recent spine/hip/knee/ankle surgery; ankle/knee sprain; shoulder or upper extremity issues that restricted range of motion. No participants reported 6 musculoskeletal discomfort in any body part on the Nordic Questionnaire (Appendix B) or pain while performing the assessments; therefore, no participants were excluded. Funding from the Honors college was used to purchase gift cards for three random drawings conducted at the conclusion of testing. These drawings were done virtually in an iPhone application called Pickster which uses a random selection algorithm to pick names from a collection. Participants received one entry for participation. Three participants received an extra entry because they referred another participant. Data Collection: Recruited participants completed one testing session that lasted approximately 3045 minutes. An FMS kit was used for all tests. The Honors student conducted all assessments alone and was considered qualified based on training in KINS 470 and previous scoring of assessments conducted under the supervision of Dr. Trent Cayot, PhD who holds a Level 1 FMS Certification. The participants were asked to perform the Big 3 assessments of the FMSthe Deep Squat, the Hurdle Step, and the In-Line Lunge. Before testing, all participants were asked to complete the Nordic Questionnaire to expose musculoskeletal discomforts and gave the administrator permission to palpate via a written and signed consent form. The tests were scored according to the uniform FMS scoring system on a scale of a 0 to a 3; figures 1-6 illustrate the tests being performed at the highest level, a score of a 3 (Cook et al., 2014). The order of the assessments was standardized according to FMS protocol and remained the same for every participant. Each participant completed the group of assessments under the three instructional conditions: (a) visual-frontal; (b) visual-sagittal; and (c) verbal in a randomized sequence to prevent order effects. For one round of 7 assessments, the participants were asked to complete each individual FMS test after viewing a video of a model scoring a 3 (highest possible score) from the frontal plane perspective (Bay Cities Therapy Service, 2017). For another round of tests, participants saw a video of the same model performing the movements and scoring a 3, except video was viewed from the sagittal plane perspective. For these two rounds, each participant was placed in the proper position to perform the movement prior to seeing the model video, but no other verbal cues or critique were provided during the trials. For a third round, participants received only verbal cues. For consistency throughout all screens, a script was used for every assessment for all participants during this round (Table 2). All scoring was determined in real-time by the same investigator who was familiar with the FMS and scoring criteria. Simultaneous video recording (iPhone X & iPad Pro; Apple, Inc, Cupertino, CA) was done in the frontal and sagittal views, and the same qualified individual reviewed movements later to confirm scoring accuracy. Free computer software was used to view these videos (QuickTime; Apple, Inc, Cupertino, CA). Participants were asked to perform the deep squat (Figures 1 and 2); feet were placed in alignment with the axillary crease as determined by a dowel rod. The dowel rod was placed on top of the head, and the hands were moved out or in until the elbows were at a 90 angle. Then, the participant pressed the dowel rod overhead so that the elbows were extended fully. After receiving visual or verbal instruction, the participant performed the movement according to the instruction they previously received. If the participants torso remained vertical and parallel with the tibia, the dowel rod stayed aligned over the feet, the femur reached below horizontal, and the knees did not go inside 8 the feet, he or she received a score of 3. If the participant did not complete the move after three trials, the board was placed under his or her heels. The same movement patterns were performed with identical alignment. If the participant was then able to do the movement according to the standards above with the board under his or her heels, he received a 2. If the participant could still not complete the movement correctly, he received a 1. The presence of pain during the movement would have been scored as a 0 and excluded from the study, but no pain was present for any of the participants during this movement. In another assessment, participants performed the hurdle step (Figures 3 and 4). Before the assessment began, a measurement from the tibial tuberosity to the floor was recorded for each leg. To set up this assessment, the board was placed on its side, and the two smaller rods were placed in the two holes on the side of the board, so that subjects were standing up vertically and perpendicular to the board. The tibial tuberosity length was where the tape was placed parallel with the board across the rods, making a small hurdle. The participant then placed the dowel rod on the back of the shoulders and stood behind the board with feet together and toes touching the board. Next, the subject performed the movement according to the received instructions or visual perspective and the hurdling leg was scored. Three trials were performed on each leg for each. If the participant kept the hips, knees, and feet in the sagittal plane with minimal movement in the torso and the dowel rod, and hurdle remained parallel to the floor, he or she received a 3. If the participant lost alignment in the hip, knee, or foot, the dowel rod and hurdle did not remain parallel, or there was movement in the torso, then they received a score of 9 a 2. If the participant lost balance or could not clear the hurdle step, they received a 1. No one experienced pain during the movement that would have been scored a 0. The final assessment was the inline lunge (Figures 5 and 6). The individuals tibial tuberosity measurement marked the distance to step for the inline lunge. The participant placed the dowel rod along the spine against the head, glutes, and shoulders. The arm opposite of the leg stepped out went up and behind the head to hold the dowel rod in place. The participant stood on the board of the FMS kit with the unmeasured sides foot behind the 0 mark and the heel of the measured leg/foot right in front of that measured and marked length. The individual completed the movement to the best of his or her ability with the knowledge granted them. This was completed three times on each leg. The front leg was scored. The heel of the front foot remained on the board at all times. In order to score a 3, the dowel rod had to stay against the individuals back and head, the front foot had to remain on the board, there had to be minimal to no torso movement, and the knee had to touch the board. If the dowel rod did not stay in contact with the body or remain vertical, if there was movement in the front foot and torso, or if the knee did not touch the board, that person received a 2. If the subject lost balance or fell off the board, if he could not get into the starting position, or if he couldnt complete the movement at all, he received a 1. Any pain reported would have been scored a 0 and excluded from the study. Statistical Analysis: A Friedman Test was conducted (SPSS 24.0, Chicago, IL) to determine if there were significant differences in FMS performance based upon observational perspective (visual-frontal vs. visual-sagittal vs. verbal). 10 Results Tables 3, 4, and 5 present the median and interquartile values for the three FMS assessments across the three experimental conditions. Overall, observational perspective did not have a significant effect on FMS performance during any of the movements. Friedman analysis showed that there was not a significant difference between observational conditions during the deep squat, X2 (2) = 2.947, p = .229. (Table 6). There was also not a significant difference between observational conditions during the hurdle step, X2 (2) = 2.867, p = .239. (Table 7). Finally, there was not a significant difference between observational conditions during the incline lunge, X2 (2) = 0.700, p = .705. (Table 8). Additional Friedman Tests indicated that the hurdle step demonstrated order effects: (a) deep squat, X2(2) = 0.96, p = .6188; (b) hurdle step, X2(2) = 6.58, p = .0373; and (c) inline lunge, X2(2) = 0.35, p = .8395. Discussion This study was the first to analyze if observational perspective (visual-frontal vs. visual-sagittal vs. verbal) had an effect on FMS performance. We collected data in hopes of improving the clinical effectiveness of cueing the FMS. Participants completed three conditions of instruction and performed three movement assessments included in the FMS while they were scored on a scale of 0-3 based on standardized FMS scoring. Scoring was compared and statistically analyzed. Results showed that observational perspective does not have a significant effect on FMS performance. Thus, verbal or visual cues are competent to cue the movements effectively. We expected, based on previous research and in alignment with the formulated hypothesis, that FMS scores 11 would be higher on all three tests after participants viewed the movements in a video of a skilled model in the frontal plane. There are many possible explanations as to why this hypothesis was not supported by the results. For one, the previous research regarding this hypothesis makes its claim with a caveat that we did not previously consider: while the objective/frontal perspective may lead to greater learning, it will require more time to move a learner through the acquisition phase (Ste-Marie et al., 2012, p.17). On the other hand, the subjective view (the learner behind the model) is said to allow a learner to demonstrate skill proficiency sooner (Ste-Marie et al., 2012, p.17). Our hypothesis may have been incorrect because our protocol had a quick turnaround from observation to performance. No practice sessions were allowed prior to scoring. Protocol did not allow the participants enough time or practice to pass through the phases of observational learning. That is, our current study focused on how observation may affect performance, but the effects of observation in a learning situation where there is an opportunity to practice the skill along with observation will likely produce alternative outcomes. Furthermore, it is likely, based on the synthesis of literature, that amount of practice sessions has a greater effect on FMS performance than the type of instruction. Friedman and Korman (2019) confirm that skill learning is a multi-stage process requiring multiple practice sessions (p.1). Furthermore, the hurdle step demonstrated order effects; that is, participants demonstrated significantly better performances on the hurdle step during the third trial regardless of the condition. It appears, then, that the participants were able to improve movement patterns by practicing the movement, not from simply observing it in another condition. This bolsters the hypothesis that physical 12 practice in addition to observation is necessary for immediate physical performance benefits (Maslovat, Hodges, Krigolson, & Handy, 2010). Additionally, the literature describes a variety of factors that may influence the observational learning process: who the model is (model type observed), what is observed (modality, content, focus of attention, instructional features), when observation is provided (before a skill is practiced, interspersed throughout practice trials, or after practice is already complete), how the model is viewed (angle or speed of viewing, frequency of presentation), where the trial is taking place (training, rehabilitation, or competition setting), and for what purpose the participant is viewing the skill (why) (SteMarie et al., 2012). Any one of these variables may have influenced our results. We chose viewing angle as an experimental variable because it has been relatively underresearched in the literature (Ste-Marie et al., 2012). While this study chose to specifically manipulate the how, we recognize that the other factors listed may have influenced the results and are probable limitations of our study. Another possible limitation was that we separated visual and verbal experimental groups. It could be true that both visual video demonstration and verbal cues together produce the greatest degree of observational learning, not one condition over the other. We separated the experimental groups because previous studies have obtained mixed results in regard to using verbal cues in conjunction with video demonstration. In a 1994 study by Meaney, verbal cues aided adults in the acquisition of scarf juggling, but Janelle et al. found that verbal cues in conjunction with video demonstration did not alter the learning of a soccer pass (2003). Janelle et al. also added visual cueing or directional arrows superimposed on the instructional video to point at key features in the soccer pass. 13 The participants who received the visual and verbal cueing techniques showed less movement error and had more correct form than the other groups. Thus, verbal cueing reinforced with visual highlights appears to be an effective technique to enhance the use of observation. Although our study did not use arrows on the demonstration videos, nor did we direct observers to any specific features of the movements, future studies could incorporate this visual cueing as an experimental group and see if it does in fact improve movement outcomes. Finally, results were potentially skewed by the three participants that had previously performed the FMS at an earlier date. These participants were already taught the movements in some capacity, likely by verbal instruction, as is the industry standard. The literature discusses the idea that there are both short-term (i.e., acquisition phase) and long-term (i.e., retention or transfer phase) phases related to skill learning (Ste-Marie et al., 2012). For the participants that had previously learned the FMS, our protocol tested the long-term phases of observational learning. For the majority that had no previous familiarity with the FMS, data more closely reflected observational learning in the acquisition phase. In retrospect, we could have eliminated this variability in the data by excluding those with prior familiarity with FMS procedures. Unfortunately, this study cannot draw conclusions that change the way the FMS is administered in clinical settings. From our results we can conclude, however, that the observational perspective in which people view the movements does not have a significant effect on their performance during the FMS. Perhaps, regardless of what a participant perceives about a movement through observation, how they perform on the FMS is going to be most determined by structural and functional constraints (i.e., 14 strength, flexibility, postural control). It may be worth noting that the majority of participants indicated in a posttest verbal survey that they preferred verbal cues and found them easiest to understand. Still, participants performed at the same level with observation only compared to verbal cues. This finding is consistent with the literature reviewed. People are able to effectively perceive movement-related information through observation. These results of our study further FMS literature and also provide information on observational perspective which to our knowledge has never been studied with a movement screen of this kind. Because there are no previous studies regarding observational perspective when instructing the FMS, there is no normative data by which to compare our results. Published literature by Ste-Marie et al. (2012) presented that the frontal view was the most effective observational perspective for demonstrating movements. These authors concluded that how the movement is viewed (on video, live, animated or presented as a virtual model) has no effect on performance. These hypotheses have yet to be validated by other supporting studies. This study cannot substantiate the hypothesis that the frontal view is the most effective observational perspective for learning movements. Future studies should replicate this research or incorporate an easier movement patterns to see how participants perceive and perform these. Further research could also be done comparing outcomes for different movement viewing strategies (animated video vs. live model vs. virtual model). Reflection While we did not find statistically significant results, we were able to add to the body of research on the topic of observational perspective and learning. We also provided 15 some qualitative recommendations based on our experiences. Coming into this study, I had little knowledge about observational learning; after completing it and doing extensive research on the topic, I now realize the number of gaps in the literature regarding the who, what, when, where, why, and how. In the future, I could study any of these aspects. For example, I could do an experiment in which the speed of video demonstration is manipulated, or frequency of model presentation is the experimental variable. In our current study, both of these were control variables; the videos were played in real time without manipulation and were showed a total of three times each as outlined in the protocol. The large majority of research on observational perspective in a training situation (>80%) have been done in a laboratory setting (Ste-Marie et al., 2012). Similar to the majority, our study was performed in a laboratory and has added to the large body of research performed in this location. Since I am heading into the physical therapy field, I would love to contribute in the future to the less than 5% of research on observational learning that has taken place in a clinical rehabilitation setting (Ste-Marie et al., 2012). Overall, I consider this project a success because I learned a great deal about the topic as well as the research process. The most difficult part of this project was recruiting participants; the most fulfilling part was spreading knowledge and teaching people how to move their bodies well. Professionally, I now consider myself a qualified scorer and administrator of the Functional Movement Screen. I have learned a great deal of information through my research on observational learning that will benefit me down the road should I undertake additional exploration in this domain. I believe that this will benefit me professionally both as a personal trainer and as a physical therapist because 16 this assessment can be used both in the clinic and in the gym to assess movement patterns. 17 References/Bibliography Abernethy, B., & Zawi, K. (2007). Pickup of essential kinematics underpins expert perception of movement patterns. Journal of Motor Behavior, 39(5), 353-367. American College of Sports Medicine. (2018). ACSM's Guidelines for Exercise Testing and Prescription. (D. Riebe, J. K. Ehrman, G. Liguori, & M. Magal, Eds.) (Tenth). Philadelphia: Wolters Kluwer. Ashford, D., Bennett, S., & Davids, K. (2006). Observational modeling effects for movement dynamics and movement outcome measures across differing task constraints: A meta-analysis. Journal of Motor Behavior, 38(3), 185-205. Bay Cities Therapy Service. (2017, February 14). FMS Instructions [Video file]. Retrieved from https://www.youtube.com/watch?v=coN0H2jSZyU&t=256s Bonazza, N., Smuin, D., Onks, C., Silvis, M., & Dhawan, A. (2017). Reliability, validity, and injury predictive value of the functional movement screen: A systematic review and meta-analysis. The American Journal of Sports Medicine, 45(3), 725732. doi:10.1177/0363546516641937 Buchanan, J. J., & Dean, N. J. (2010). Specificity in practice benefits learning in novice models and variability in demonstration benefits observational practice. Psychological Research, 74(3), 313326. https://doi.org/10.1007/s00426-009-0254-y Buchanan, J., & Park, I. (2017). 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Looking to learn: The effects of visual guidance on observational learning of the golf swing. Plos One, 11(5). Elliott, D., & Khan, M. (2010). Vision and goal-directed movement: Neurobehavioral perspectives. Champaign, IL: Human Kinetics. Friedman, J., & Korman, M. (2019). Observation of an expert model induces a skilled movement coordination pattern in a single session of intermittent practice. Scientific Reports, 9(1). doi:10.1038/s41598-019-40924-9 Ghorbani, S., & Bund, A. (2016). Observational learning of a new motor skill: The effect of different model demonstrations. International Journal of Sports Science & Coaching, 11(4), 514-522. doi:10.1177/1747954116655049 Janelle, C.M., Champenoy, J.D., Coombes, S.A., & Mousseau, M.B. (2003). Mechanisms of attentional cueing during observational learning to facilitate motor skill acquisition. Journal of Sports Sciences, 21(10), 825-838. Kleynen, M., Braun, S., Bleijlevens, M., Lexis, M., Rasquin, S., Halfens, J., . . . De Lussanet, M., Editor. (2014). Using a delphi technique to seek consensus regarding definitions, descriptions and classification of terms related to implicit and explicit forms of motor learning. Plos One, 9(6). doi:10.1371/journal.pone.0100227 Lago-Rodrguez, A., Cheeran, B., Koch, G., Hortobgyi, T., & Fernandez-del-Olmo, M. (2014). THE ROLE OF MIRROR NEURONS IN OBSERVATIONAL MOTOR LEARNING: AN INTEGRATIVE REVIEW. European Journal of Human Movement, 32, 82-103. Maslovat, D., Hodges, N., Krigolson, O., & Handy, T. (2010). Observational practice benefits are limited to perceptual improvements in the acquisition of a novel coordination skill. Experimental Brain Research, 204(1), 119-130. doi:10.1007/s00221-010-2302-7 19 McCall, A., Carling, C., Nedelec, M., Davison, M., Le, G., Berthoin, S., & Dupont, G. (2014). Risk factors, testing and preventative strategies for non-contact injuries in professional football: Current perceptions and practices of 44 teams from various premier leagues. British Journal of Sports Medicine, 48(18), 1352-7. doi:10.1136/bjsports-2014-093439 Meaney, K. (1994). Developmental modeling effects on the acquisition, retention, and transfer of a novel motor task. Erratum. Research Quarterly for Exercise & Sport, 65(2), 196. Meier, C., Frank, C., Grben, B., & Schack, T. (2020). Verbal instructions and motor learning: How analogy and explicit instructions influence the development of mental representations and tennis serve performance. Frontiers in Psychology, 11, 2-2. doi:10.3389/fpsyg.2020.00002 Moran, R., Schneiders, A., Mason, J., & Sullivan, S. (2017). Do functional movement screen (fms) composite scores predict subsequent injury? a systematic review with meta-analysis. British Journal of Sports Medicine, 51(23), 1661-1669. doi:10.1136/bjsports-2016-096938 Philp, F., Blana, D., Chadwick, E.K., Stewart, C., Stapleton, C., Major, K., & Pandyan, A.D. (2018). Study of the measurement and predictive validity of the Functional Movement Screen. BMJ Open Sport & Exercise Medicine, 4(1), 1-7. Robinson, R.H. & Gribble, P.A. (2008a). Kinematic predictors of performance on star excursion balance test. Journal of Sport Rehabilitation, 17, 1-12. Robinson, R.H. & Gribble, P.A. (2008b). Support for reduction in the number of trials needed for the star excursion balance test. Archives of Physical Medicine and Rehabilitation., 89, 364-370. Robrecht, P., Natalie, S., & Gnther, K. (2012). People watching: Social, perceptual, and neurophysiological studies of body perception. In Action perception from a common coding perspective. Oxford University Press. doi:10.1093/acprof:oso/9780195393705.003.0007 20 Scully, D.M. & Newell, K.M. (1985) Observational learning and the acquisition of motor skills: toward a visual perception perspective. Journal of Human Movement Studies, 11, 169186 Ste-Marie, D., Rymal, A., Law, B., Jenny, O., McCullagh, P., & Hall, C. (2012). Observation interventions for motor skill learning and performance: An applied model for the use of observation. International Review of Sport and Exercise Psychology, 5(2), 145-176. doi:10.1080/1750984X.2012.665076 Teodoro Bruzi, A., Novellino Benda, R., Ribeiro Palhares, L., Alves Pereira Fialho, J., & Ugrinowitsch, H. (2019). DISCRETE MOTOR SKILL ACQUISITION: EFFECT OF NUMBER OF VISUAL DEMONSTRATIONS. Journal of Physical Education, 31(1). 21 Tables Table 1: Participant Demographics Age (yrs.) Mass (kg.) Height (m) Sex Limb Dominance Mean (SD) 22.2 (4.6) 69.1 (14.0) 1.71 (0.06) 2 males; 11 females 2 left; 11 right Table1:2:Verbal Verbal Script Table Script Assessment Verbal Instructions Deep Squat 1. Stand tall with your feet shoulder-width apart and toes pointed forward. 2. Grasp the dowel in both hands and place it on top of your head so your shoulders and elbows are at 90 degrees. 3. Press the dowel so that it is directly above your head. 4. While maintaining an upright torso and keeping your heels and the dowel in position, descend into a squat as deeply as possible. 5. Hold the bottom position for a count of one, and then return to the starting position. Hurdle Step 1. Stand tall with your feet together and toes touching the test kit. 2. Grasp the dowel in both hands and place it on top of your head so your shoulders and elbows are at 90 degrees. Then while maintaining hand position, lower dowel to the base of the neck and across the shoulders. 3. While keeping an upright torso, raise the right leg and step over the hurdle, making sure to raise the foot towards the shin and maintain foot alignment vertically with the ankle, knee and hip. 4. Touch the floor with your heel and return to the starting position while maintaining the same alignment. In-Line Lunge 1. Step onto the center of the board with the right foot and your toe on the zero mark. 2. The left heel should be placed according to your tibial measurement at "__". 3. Both toes must be pointing forward with the entire foot in contact with the board. 4. Place the dowel along the spine so it touches the back of your head, your upper back and your tailbone. 5. While grasping the dowel, your right hand should be in the curve of your neck, and the left hand should be in the curve of your lower back. 6. Maintaining an upright posture so the dowel stays vertical and you maintain the three points of contact, descend into a lunge position so your right knee touches the center of the board. 7. Then, return to the starting position. 22 Table 3: Deep Squat Descriptive Statistics Percentiles 50th N 25th (Median) 75th Verbal 13 2.0000 2.0000 3.0000 Frontal 13 2.0000 3.0000 3.0000 Sagittal 13 2.0000 2.0000 3.0000 Table 4: Hurdle Step Descriptive Statistics Percentiles 50th N 25th (Median) 75th Verbal 13 1.5000 3.0000 3.0000 Frontal 13 1.0000 2.0000 2.5000 Sagittal 13 2.0000 2.0000 2.5000 Table 5: Inline Lunge Descriptive Statistics Percentiles 50th N 25th (Median) 75th Verbal 13 2.0000 3.0000 3.0000 Frontal 13 2.0000 3.0000 3.0000 Sagittal 13 2.0000 2.0000 3.0000 Table 6: Friedman Test Deep Squat N Chi-Square Df Asymp. Sig. Table 7: Friedman Test Hurdle Step 13 2.947 2 .229 N Chi-Square df Asymp. Sig. Table 8: Friedman Test Inline Lunge 13 2.867 2 .239 N Chi-Square Df Asymp. Sig. 13 .700 2 .705 23 Figures All figures adapted from the official Functional Movement Screen protocol.1 Figure 1: Deep Squat Frontal Figure 2: Deep Squat Sagittal 1 Cook, G., Burton, L., Hoogenboom, B., & Voight, M. (2014). Functional movement screening: The use of fundamental movements as an assessment of function - part 1. International Journal of Sports Physical Therapy, 9(3), 396-409. 24 Figure 3: Hurdle Step Frontal Figure 4: Hurdle Step Sagittal 25 Figure 5: Inline Lunge Frontal Figure 6: Inline Lunge Sagittal 26 Appendix A Informed Consent Document: 27 28 29 30 31 Appendix B Nordic Questionnaire: 32 Appendix C Citi Training (Group 2): Completion Date 14-Jan-2020 Expiration Date 13-Jan-2022 Record ID 33915546 This is to certify that: Allison Edlin Has completed the following CITI Program course: Human Subjects Research (HSR) Group 2: Health Related Research 2 - Refresher Course (Curriculum Group) (Course Learner Group) (Stage) Under requirements set by: University of Indianapolis Verify at www.citiprogram.org/verify/?wafd7eb9b-30b5-4dd3-b9b7-60434352d2e5-33915546 33 Appendix D IRB Approval: 34  ...

... Educating Health Care Professionals on Burmese Endof-Life Care Perspectives By Reilly Dunham Honors Project Thesis Submitted in Partial Fulfillment Of the Requirements for a Baccalaureate Degree With Distinction In the Ron and Laura Strain Honors College of THE UNIVERSITY OF INDIANAPOLIS May 2020 Faculty Advisor: S. Alexander Kemery, Ph.D., RN Executive Director of Honors: James B. Williams, Ph.D. Reilly Dunham 2020. Copyright in this work rests solely with the author. Please ensure that any reproduction or re-use is done in accordance with relevant national copyright protection. i Abstract Background: The purpose of this study was to learn what Burmese immigrants living in the United States want healthcare providers, such as physicians and nurses, to know about their preferences for care given at the end of life. Nearly 12,000 Burmese refugees (McHenry, Umoren, Dixit, Holliday, & Litzelman, 2016, p. 151) reside in the Indianapolis area. Understanding Burmese cultural needs and preferences is important to delivering high-quality health care. Method: Qualitative basic interpretive design utilizing an in-person interview. Sample: 9 local Burmese immigrants. Data Analysis: Hand-coding and looking for commonly occurring ideas or themes in participant responses. Results: Five common themes were noted: the Burmese culture is family-oriented, there is a significant language barrier, there are issues with explanation and education, religion and culture are important, and there is an overall lack of experience in healthcare settings. ii Table of Contents Acknowledgements ....................................................................................................... iii Introduction, Intellectual Context, Framework, and Theory ............................................. 1 Methods .......................................................................................................................... 8 Results ............................................................................................................................ 9 Discussion ..................................................................................................................... 13 Dissemination................................................................................................................ 17 Conclusion .................................................................................................................... 17 Reflection/Future Directions.......................................................................................... 17 iii Acknowledgements I would like to express my gratitude to Dr. S. Alexander Kemery for his guidance and supervision in the process of completing this research project. I would like to thank Professor Caron MacPherson for her help in designing aspects of this research. I would also like to thank Marianna Foulkrod for her assistance in establishing a relationship with the Burmese American Community Institute. Special thanks should be given to the Burmese American Community Institute, and particularly Lian Sang, for assistance in data collection and constructive recommendations through the research process. 1 Educating Health Care Professionals on Burmese End-of-Life Care Perspectives Introduction, Intellectual Context, Framework, and Theory Throughout recent years, the United States has become increasingly culturally diverse. In Indiana, nearly 12,000 Burmese refugees (McHenry, Umoren, Dixit, Holliday, & Litzelman, 2016, p. 151) have recently begun calling Indianapolis home. From the Burmese perspective, there are significant concerns with the American healthcare system and the quality of care many Burmese individuals are receiving (L. Sang, personal communication, February 25, 2019). From a healthcare perspective, lack of familiarity with Burmese culture can lead to less effective communication and outcomes. In order to combat this disparity, it is important that healthcare providers become more culturally competent in regards to Burmese culture. Cultural Competence Cultural competence has been defined in many ways and through various models. One review by Zuwang Shen (2014) combines many of these models and definitions into one big picture. Some definitions of cultural competence include: care that is meaningful and fits with cultural beliefs and lifeway (p. 309), care that is sensitive to issues related to culture, race, gender, and sexual orientation (p. 310), and the nurses effective integration of the patients ethnic cultural background into her nursing processbased patient care (p. 310). Although each of these vary slightly, they all focus on considering the bigger picture of the patient and how to care for them individually. Each of these models can be applied to instruments which can be used when providing care. Cultural competence models have existed for decades, and each take a different 2 perspective on how culturally competent care should be performed. The CampinhaBacote model is one example of a model which can be used as a framework for developing and implementing culturally responsive health care services (CampinhaBacote, 2002, p. 181). Campinha-Bacote describes cultural competence as a process, not an event (2002, p. 181), which implies there is always room for improvement. She lists the aspects of cultural competence as cultural awareness, cultural knowledge, cultural skill, cultural encounters, and cultural desire (Campinha-Bacote, 2002). Cultural awareness involves examining ones own culture and biases (Campinha-Bacote, 2002). This must first be achieved in order to become aware of our own cultural influences. Cultural knowledge is another important concept, and it involves seeking and obtaining a sound educational foundation about diverse cultural and ethnic groups (CampinhaBacote, 2002, p. 182). The ability to collect cultural data and perform cultural assessments is cultural skill (Campinha-Bacote, 2002). Cultural encounter involves directly interacting with clients of diverse cultural backgrounds, which can help to prevent possible stereotyping. Lastly, there must be cultural desire, or the motivation of the health care provider to want to, rather than have to, engage in the process of cultural competence (Campinha-Bacote, 2002, p. 182). This model serves as a theoretical framework for what composes the idea of cultural competence as a whole. Although this is a strong model, Campinha-Bacote recognizes that there is still a lack of application in direct patient care, which is a common finding with such models. Although the importance of cultural considerations in healthcare is widely recognized, there is not one clear, effective methodology which can be applied directly to 3 practice. Shen recognizes that testing needs to be done on these instruments in order to determine their reliability and validity (Shen, 2014). Other limitations of cultural competency models are lack of patient outcome assessments (Shen, 2014). Because of this, healthcare providers may find more value in the development of cultural assessment skills in general, using critical thinking when caring for individuals from a variety of backgrounds (Shen, 2014). Although there are several areas needing further development, it is important to recognize that there are several models related to cultural competency and healthcare providers are attempting to directly apply these to patient care. Burmese Culture As cultural competence models suggest, it is important to be informed about particular cultures in order to be able to understand and care for individuals within that population. More specifically, since Indianapolis has become home to thousands of Burmese refugees over recent years, it is important to consider Burmese culture, immigration, and healthcare perspectives. In a focus group analysis done by researchers at the University of Minnesota, several adult Burmese refugees were recruited in order to gain a qualitative viewpoint. In these groups, two respected members, a physician and a Department of Health employee, (Power & Pratt, 2012, p. 2) of the local Burmese community served as moderators. Many participants had lived in Burmese refugee camps for several years and experienced drastic cultural differences since relocating to the United States (Power & Pratt, 2012). These difficulties involved food, language, work, transport, socializing, money, and health care (Power & Pratt, 2012, p. 4). The transition from Burmese village environments to the United States contributed to differences in 4 diet, work, socialization, and money, as most of these revolved around tending to the crops. Although many different comments were made regarding the life of Burmese refugees in American culture, they all revolved around language barriers, lack of awareness, and ultimately confusion and misunderstandings from both sides. This study is helpful in determining concerns of Burmese refugees in American culture, and the direct responses from Burmese refugees help validate the collected data. Another study by Suneeta Kercood and Trish Morita-Mullaney (2015) sheds light on health perceptions of Burmese refugees using both qualitative and quantitative designs. This study found there are indeed health disparities involved with Burmese refugees, and that there is a lack of knowledge about the Burmese culture among healthcare providers (Kercood & Morita-Mullaney, 2015). In this study, a purposive sample was selected including the criteria of being a person of Burmese descent who came to the United States under refugee status and were taking English classes at an after-school program in the elementary school, and classes within an apartment community guest-house (Kercood & Morita-Mullaney, 2015, p. 6). Data was collected through surveys, individual interviews and focus groups. Results demonstrated that participants who were less educated experienced more challenges in marginalization, and higher levels of education correlated with more adaptation (Kercood & Morita-Mullaney, 2015). Qualitatively, it was found that Burmese refugees expressed concerns with lack of translated forms in healthcare, lack of understanding in spoken interpretation, difficulties adjusting to the American diet, and difficulty exercising due to transportation differences (Kercood & Morita-Mullaney, 2015). As a whole, this study further suggests that 5 Burmese refugees have concerns and difficulties with adjusting to American aspects of healthcare. Although this study had a relatively small sample, it aligns with ideas from other research on similar topics. Similar themes are noted in a study done by McHenry et al. (2016). Surveys, written in both English and Hakha (the most common Chin dialect in Indianapolis), about demographic information and experiences in healthcare settings (McHenry et al., 2016) were distributed to Burmese refugees in the Indianapolis area. Additionally, focus groups were conducted with a medically-trained interpreter who was fluent in English, Burmese, and multiple languages spoken by the Chin (McHenry et al., 2016, p. 152). Similar data was gathered from this study as others previously discussed, as Burmese refugees identified issues associated with healthcare such as time, language barriers, adolescents roles in their community, traditional medicine, and relationships with healthcare providers (McHenry et al., 2016). These language barriers resulted in issues with the timing and type of interpreter available, along with issues with varying Chin dialects. Although possible limitations include miscommunication about the difference between hospital admission and emergency room visits and generalizability, the results of this study further indicate areas for improvement related to Burmese refugees in healthcare. Barriers to Quality End-of-Life Care Knowing there are disparities for Burmese refugees in the American healthcare system, it is assumed that this would apply to end-of-life care as well. Even for the general population, there are several barriers to end-of-life care. According to Omar Daw 6 Hussin, Wong, Chong, and Subramanian (2018), the quality of [end-of-life care] provided to dying patients in hospital settings remains poor and falls below the recommended standards (p. e689). There are many factors contributing to the shortcomings involved with end-of-life care, and many stem from cultural differences. In one Malaysian study, barriers to end-of-life care were examined. Among these barriers included dealing with the cultural differences that family use in grieving (Omar Daw Hussin et al., 2018, p. e694) and unavailability of a support person for family, for example, social worker or religious leader (Omar Daw Hussin et al., 2018, p. e695). Along with many other issues involving staffing and scheduling, these issues seem to be evident in end-of-life care. This study also suggests that facilitators to end-of-life care include talking with the patient about his or her feeling and thoughts about dying and having a social worker or religious leader take primary care of the grieving family (Omar Daw Hussin et al., 2018, p. e969). These are issues which could potentially arise for members of the Burmese community, as there is generally more room for communication error and possible lack of cultural accommodations such as support from religious leaders in hospitals. In a study by Burstin and Johnson (2017), quality measurements for end-of-life care are discussed. This source reflects the need for improvement in the end-of-life setting in general. It is expressed that measures to improve end-of-life care should be person-centered, outcomes-focused, longitudinal, applicable to multiple settings of care, wider in scope, and responsive to current gaps in measurement (Burstin & Johnson, 2017). This is important information to acknowledge when formulating specific 7 improvement measures as this could positively impact all recipients of end-of-life care, including Burmese refugees. According to Burstin and Johnson (2017), being consistent with, respectful of, and responsive to an individuals priorities, needs, and values is critical in order to provide adequate end-of-life care (p. 91). This provides a foundation for how end-of-life care should be performed, which can ultimately be applied to Burmese patients. A study conducted in Australia further contributes to the concept of culture in end-of-life care, surveying 453 older persons in 12 ethno-specific day care centers and five non-ethno-specific day care centers or senior clubs (Ohr, Jeong, & Saul, 2017). This study involved a questionnaire that was distributed to the coordinators of the centers. Participants were asked about their personal preferences for end-of-life care, including what they would want their care to entail in a variety of scenarios. Individuals were organized by ethnic groups, and results showed that there were differences each of the surveyed preferences. This further demonstrates the idea that culture is an important factor to consider in end-of-life care. Although there were limitations in this study such as the possibility of lack of understanding when completing questionnaires and a relatively small sample size, this is supplementary information recognizing the value of cultural considerations in end-of-life care. When considering all of this information, there is plenty of current information about cultural competence, Burmese refugees, and end-of-life care. Although there is plenty of information on each of these specific topics, there is an evident lack in information incorporating these aspects together. The main gap in the literature involves 8 providing end-of-life care to Burmese refugees specifically. Though studies have examined end-of-life preferences in various ethnic groups, the Burmese seem to have been overlooked. Since the Burmese refugee population is growing considerably, especially in the Indianapolis area, this is an area which should be investigated further. Methods This project involved a qualitative basic interpretive design utilizing in-person interviews. Interview questions revolved around Burmese health care preferences, specifically in end-of-life care settings. Inclusion criteria required participants to be Burmese immigrants living in the Indianapolis area, able to read, write, and speak English, and over eighteen years of age. Potential participants were found through recruitment with the help of the Burmese American Community Institute. Volunteer work was conducted in the summer and fall prior to data collection in order to build connection and trust with the community. The sample included nine Burmese refugees in the Indianapolis area. After obtaining informed consent, this process included conducting inperson interviews with members of the local Burmese population. Interviews occurred throughout December 2019 and January 2020, until sufficient and consistent information was obtained. Each interview lasted less than 10 minutes, and interview questions are listed in Appendix A. These interviews took place at Southport High School and at the Burmese American Community Institute. Data analysis consisted of hand-coding for common themes and patterns, in order to understand the most prominent responses from participants. 9 Principles of nursing research were applied throughout the study. These included respect for persons, non-maleficence, and justice. Respect for persons means regarding the feelings, wishes, rights, or traditions of others (Barrow & Khandhar, 2020). This was crucial for this study, since cultural values of Burmese refugees were being addressed. Another important component of nursing research used in this study was nonmaleficence, which means doing no harm. This revolves around avoiding causing any unnecessary physical, emotional, or spiritual pain (Barrow & Khandhar, 2020). Lastly, the component of justice was stressed, which meant treating all participants equally (Barrow & Khandhar, 2020). Each of these principles of ethics were incorporated through gathering informed consent, expressing the idea that there was no penalty for withdrawal from the study, and ensuring consistency in data collection and analysis processes. The University of Indianapolis IRB designated this as exempt research (Appendix B). After data was collected, electronic files were stored in a password-protected device, only accessible to individuals included on the IRB application. De-identified information is being stored indefinitely, and signed informed consents will be maintained for a length of time in accordance with IRB requirements. Informed consents will be stored in a locked cabinet, also accessible to only those included in the IRB application. Ownership of data resides with the Burmese American Community Institute. Results After collecting the data, the responses were hand-coded and analyzed for common themes and patterns. As a result, five common themes were discovered. One was that the Burmese community is family oriented. Another was the language barrier, 10 and similarly, troubles with explanation and education. Another was the importance of religion and culture and those particular values. Lastly, many of the individuals interviewed had a lack of experience in healthcare settings. Family-Oriented Culture When asked what health care providers should know about taking care of Burmese people at the end of life, nearly every participant explained that the Burmese culture is very family-oriented. It was also stressed that in the hospital, if the patient is in critical condition there are always lots of guests. Some participants spoke about personal experience with their family member undergoing the end-of-life process in the hospital setting. The participant stated family members are going to be there the whole night and whole day, thats how it is in Myanmar. They have a certain time the guests can meet with the patient and I think doctors should be more understanding of those conditions. This individual expressed issues her family had with visitation policies in the hospital setting and felt as though staff were not supportive of the family-oriented environment her family was creating. It seems that in whatever setting end-of-life care would occur in, family is very important and having the last moment with family together. Creating that environment is very good, according to one participant. Language Barrier Another major theme was that the language barrier serves as a complex, prominent barrier to all forms of care including in the end-of-life setting. Several participants stated they wished health care providers would explain with an interpreter, and that the nurse/doctor/hospital should always provide a translator so the family and 11 patient can understand what is going to happen. Another participant stressed that nurses may not communicate well with the Burmese patient and family members, so they dont really know what the patient condition is. Participants expressed that without adequate translation, they struggled to understand what was going on in the healthcare setting, and that this would be especially important to know in the end-of-life process. Additionally, some participants expressed that sometimes when we dont speak their language they look down on us. One participant who had spent several days in the hospital stated that a nurse thought she and her sister did not know English, so, She wasnt very nice. After her sister talked to her in English, she was nicer. Not only do Burmese patients find issues with communication due to the language barrier, some also have had experiences being treated poorly as a result. When asked what health care providers should know about providing end-of-life care to Burmese people, this participant stated, Just not being racist. Explanation and Education Another communication-related theme included desire for explanation and education in the end-of-life care setting. Not only do Burmese patients request a translator, they also desire honest and clear communication from health care providers. One individual stated that she likes that health care providers are being honest, and that it was not always the case back in Myanmar. Others expressed room for improvement. One said, I wish that they explained it. Not all family members are educated or know medical terms. Others stated that if they come from small villages, some Burmese people might not have a lot of knowledge about how to take care of themselves medically. Others 12 stressed that even at the end of life, the patient may not understand the problem or issue they are having with their body. One notable response involved a story about one participants family member who died at a local hospital. She stated that throughout the entire end-of-life process and even after, the family members did not know what the real cause of death was. This shows the drastic need for improvement with communication in end-of-life care. Religion and Culture Another major theme revolved around the influence of religion and culture in the end-of-life setting. One participant stated that most of the Burmese people in Indianapolis are Christian, so the pastor from the church is going to come and pray. All participants agreed with this and expressed the desire to incorporate religion and to be able to pray together at the end of life. Religion and culture also seemed to influence decision-making at the end of life. It was stated that even if the Burmese family knows there is a little chance, they would never remove life support. This is because in Burma, that would be considered killing someone. This was not a topic that came up in every interview, but when it did the same response was noted. However, it was very agreed upon that death is big in the Burmese community. One participant stated that if someone dies there will be 2000-3000 people show up at the funeral, even if they have no idea who the person is. This goes to show the sense of community within the Burmese population in our area. 13 Lack of Experience The last prominent theme discovered was that many Burmese individuals have lack of experience in healthcare settings, especially in regards to end-of-life care. Several people stated they did not have much experience with things in the hospital or with healthcare in the United States. When asked about the end-of-life care process, one participant stated they did not know what the process is or how hospice or home care work. Other responses included Ive never been sick and I dont have any family member that has been taken care of in the hospital, and another stated they had no experiences with going to the doctor or hospital in the United States. When discussing this lack of experience with one participant, they stated the elderly ought to know more about their options. Overall, it seemed that most participants were interested in learning more about the process of end-of-life care. Discussion From all of these common themes, there are several conclusions that can be drawn. As health care professionals, there may be steps we can take in optimizing the end-of-life care experience for Burmese patients. Although this information cannot be generalized to the entire Burmese population, there are interventions that can be utilized when appropriate. First, it is important to assess the need for interpretation services and to coordinate this aspect of care as soon as possible. According to one study surveying nurses perceived facilitators of end-of-life care, one major facilitator was talking with the patient about his or her feelings and thoughts about dying (Omar Daw Hussin et al., 14 2018, p. e696). In some cases, this cannot be done without the use of interpretation services. It is shown that communication is an essential indicator for good quality in end-of-life care (Omar Daw Hussin et al., 2018, p. e700). Although there may be difficulties due to the variety of languages in the Burmese community, it is crucial to ensure patients are able to adequately communicate with their health care providers. Secondly, it is important to stress patient and family education. This is important for all patients and throughout all aspects of health care, but especially in end-of-life care. Examples of barriers include family members not understanding aspects of end-of-life care and health care providers talking to families very briefly, so that families often cant understand (Omar Daw Hussin et al., 2018, p. e691). This information coincides with interview responses, showing there is sometimes a lack of understanding in health care settings, specifically in end-of-life care. It is crucial that Burmese patients understand the condition of their health and what to expect. In all settings, as health care professionals we should always strive to respect, dont expect. People cannot be treated as a model, and each patients needs and values should be assessed individually. Another important aspect to consider is cultural humility. Cultural humility consists of the lifelong commitment to self-evaluation and self-critique, the desire to fix power imbalances, and aspiring to develop partnerships with people and groups who advocate for others (Waters & Asbill, 2020). Cultural competence and cultural humility are processes that every health care provider should be making strides towards. 15 Lastly, we should always be providing options. This ties into the idea that not every Burmese patient may understand the end-of-life process or the various important decisions that have to be made. There is a need for end-of-life resources to be printed in Burmese languages, such as Hakha Chin, in order to ensure all patients have adequate access to informative materials. There is also a need for community education before the end of life, including information on advance directives and options for end-of-life care. Burmese patients deserve to understand their options and feel confident in their decisions in the plan of care. Similar results have been noted throughout studies of other ethnic groups residing in the United States (Eckemoff, Sudha, & Wang, 2018; Her-Xiong & Schroepfer, 2018). For example, studies of Hmong end-of-life care perspectives produced similar themes. These include issues with communication, the importance of family involvement in care, the desire for religious and cultural support, and lack of knowledge regarding end-of-life care decisions (Her-Xiong & Schroepfer, 2018). Similar results were also noted throughout studies of Russian immigrants living in the United States. These themes include communication and translation issues, lack of knowledge regarding end-of-life care, and desire for education and explanations from health care providers (Eckemoff et al., 2018). Although Burmese needs did not turn out to be much different than the needs of other groups, the data is still important to consider. Limitations of the project centered mostly around the interview process. Overall, it was expected that much more information would be gathered. The amount of data collected may be due to a variety of factors, including the setting, inclusion criteria, and 16 interview questions. Although the interview settings were convenient for the participants, they also seemed to provide some distraction. At both Southport High School and the Burmese American Community Institute office, participants were stepping away from other activities to participate in interviews. Conducting the interviews in a calmer, more secluded environment may have helped to produce deeper results. In addition, the participants did not seem particularly talkative throughout interviews. Superficial results were obtained, likely due to the minimal amounts of time available to speak with each participant. This may have been due to nerves, unfamiliarity with the topic of discussion, or a variety of other factors. Although working with the community beforehand helped to establish trust, gaining deeper insights may require years of working closely with the community in an ethnographic study. Lastly, one limitation was including only English-speaking participants. Burma is composed of 8 main ethnic groups throughout its 7 states. Among these main ethnic groups are about 135 subgroups and over 100 languages, making the country very diverse (The World Factbook: Burma, 2018). While including only English-speaking participants was the most convenient option for the time frame of this project, additional studies including participants who speak other languages may yield broader results. The results received were somewhat expected, yet somewhat surprising. The idea of the language barrier and communication issues were consistent with previous research completed before the interview process. However, it was surprising to learn that many Burmese refugees living in Indianapolis are unfamiliar with important aspects of health care. As a result of this project, information on end-of-life care was gathered and given to 17 members of the Burmese community at the Burmese American Community Institute. The materials consist of information about advance directives and the differences between hospice and palliative care. Dissemination The results of this study were compiled into a presentation for health care professionals at the University of Indianapolis (Appendix C). Additionally, an educational resource was provided to members of the Burmese community regarding end-of-life care information and resources (Appendix D). Conclusion In conclusion, a lot can be learned from this research. In summary, common themes regarding Burmese end-of-life care perspectives included: the Burmese culture is family-oriented, there is a significant language barrier, there are issues with explanation and education, religion and culture are important, and there is an overall lack of experience in healthcare settings. The hope is that as a result of this research study, health care providers can understand new perspectives of Burmese individuals and can use this knowledge to positively influence their care. Additionally, local Burmese refugees may be able to understand more about the end-of-life process and the various options for care. Reflection/Future Directions Reflecting on this project, several goals were met. One important goal that was met included obtaining important information about the local Burmese community and preferences for end-of-life care. Being able to shed light on the voices of local refugees is 18 one positive outcome of this research. Additionally, health care professionals were educated about these findings, and are now able to apply the information to their practice as nurses. However, the original research design was more ambitious, including a quantitative research design on the impact of presenting the results of the interviews to healthcare providers. Although there was not enough time to complete that portion of the design for this particular study, it is an avenue for future exploration. It would be beneficial to have more information about nursing perspectives and knowledge about culturally competent end-of-life care for the Burmese population. It would also be beneficial to speak to immigrants who do not speak English, and to those who are currently experiencing hospice care themselves or have lost a loved one under hospice care. It may also be useful to research utilization of hospice, in order to know if the proportion of the Burmese Community using hospice is the same as the non-Burmese community in America. Personally, this project was important in terms of widening my point of view and seeing the perspective of others. This was an eye-opening experience that helped me to understand more about different cultural perspectives related to healthcare. Professionally, this project is important due to its implications for other health care providers. Other health care providers can utilize this research in their own professional careers to optimize the quality of end-of-life care given to Burmese patients in the area. 19 References Barrow, J. M., & Khandhar, P. B. (2020, February 19). Research ethics. Retrieved from https://www.ncbi.nlm.nih.gov/books/NBK459281/ Burstin, H., & Johnson, K. (2017). Next-generation quality measurement to support improvement in advanced illness and end-of-life care. Generations, 41(1), 85-93. Campinha-Bacote, J. (2002). The process of cultural competence in the delivery of health care services: A model of care. Journal of Transcultural Nursing, 13(3), 181-184. doi: 10.1177/10459602013003003 Eckemoff, E. H., Sudha, S., & Wang, D. (2018). End of life care for older Russian immigrants: Perspectives of Russian immigrants and hospice staff. Journal of Cross-Cultural Gerontology, 33(3), 229-245. doi: 10.1007/s10823-018-9353-9 Her-Xiong, Y., & Schroepfer, T. (2018). Walking in two worlds: Hmong end of life beliefs & rituals. Journal of Social Work in End-of-Life & Palliative Care, 14(4), 291-314. doi: 10.1080/15524256.2018.1522288 Kercood, S., & Morita-Mullaney, T. (2015). Health perceptions and practices of Burmese refugee families: A participatory study. Journal of Southeast Asian American Education and Advancement, 10(1), 1-30. doi: 10.7771/2153-8999.1124 McHenry, M. S., Umoren, R., Dixit, A., Holliday, R., & Litzelman, D. (2016). Exploring healthcare perspectives of Burmese Chin refugees. Journal of Cultural Diversity, 23(4), 151-157. Ohr, S., Jeong, S., & Saul, P. (2017). Cultural and religious beliefs and values, and their impact on preferences for end-of-life care among four ethnic groups of 20 community-dwelling older persons. Journal of Clinical Nursing, 26(11/12), 16811689. doi: 10.1111/jocn.13572 Omar Daw Hussin, E., Wong., L. P., Chong, M. C., & Subramanian, P. (2018). Nurses perceptions of barriers and facilitators and their associations with the quality of end-of-life care. Journal of Clinical Nursing. 27(3-4), e688-e707. doi: 10.1111/jocn.14130 Power, D. V., & Pratt, R. J. (2012). Karen refugees from Burma: Focus group analysis. International Journal of Migration, Health, and Social Care, 8(4), 156-166. doi: 10.1108/17479891211287058 Shen, Z. (2014). Cultural competence models and cultural competence assessment instruments in Nursing: A literature review. Journal of Transcultural Nursing, 26(3), 308-321. doi: 10.1177/1043659614524790 Waters, A., & Asbill, L. (2020). Reflections on cultural humility. Retrieved from https://www.apa.org/pi/families/resources/newsletter/2013/08/cultural-humility The World Factbook: Burma. (2018, February 1). Retrieved from https://www.cia.gov/library/publications/the-world-factbook/geos/bm.html 21 Appendix A 1. Has anyone in your family died in the United States? If yes, can you tell me about that? a. Additional prompt if needed: Was it unexpected or were they ill for a long time? b. Additional prompt if needed: Was your family member taken care of by healthcare professionals when they died? 2. What would you like your doctors and nurses to know about taking care of you or your family members at the end of life? 3. What can doctors and nurses change to provide you with better end-of-life care? a. Additional prompt if needed: What do you think the most important thing is for doctors and nurses to know about taking care of Burmese people at the end of life? 22 Appendix B Human Research Protections Program (HRPP) 800/232-8634 x5774 1400 East Hanna Ave Sease, Room 201L Indianapolis, IN 46227 1 (317) 781-5774 http://irb.uindy.edu hrpp@uindy.edu October 26, 2019 NOTIFICATION OF EXEMPTION DETERMINATION Study Number: 01142 Study Title: Educating Health Care Professionals on Burmese End-of-Life Care Perspectives Exemption Determination Date: October 24, 2019 Principal Investigator: S. Alexander Kemery, MSN, RN School of Nursing The above-referenced protocol has been reviewed in accordance with the US Department of Health & Human Services (DHHS), Office for Human Research Protections (OHRP) regulations, specifically 45 CFR 46.104. Based on these criteria, this study is exempt from IRB Review. This exemption is valid unless changes in the project may impact the eligibility for exemption under the federal regulations. If you need to make any changes to the study, please contact the HRPP office hrpp@uindy.edu for guidance on whether additional review is required. Please submit all personnel changes through IRBManager as a Modification of Approved Protocol. Upon completion of your study, please submit a closure report through the IRBManager system. Yvonne Wakeford, Ph.D. Director: Human Research Protections Program (HRRP) HRPP Jan 2019 23 Appendix C 24 25 26 27 28 29 30 31 32 33 34 35 Appendix D 36 37 Appendix E  ...

... Histological Analysis of the Integument of the Zigzag Salamander, Plethodon dorsalis By Breanna C. Davis Honors Project Thesis Submitted in Partial Fulfillment Of the Requirements for a Baccalaureate Degree With Distinction In the Ron and Laura Strain Honors College of THE UNIVERSITY OF INDIANAPOLIS May 2020 Faculty Advisor: Kevin M. Gribbins, Ph.D. Executive Director of Honors: James B. Williams, Ph.D. Breanna C. Davis 2020. Copyright in this work rests solely with the author. Please ensure that any reproduction or re-use is done in accordance with relevant national copyright protection. 1 Abstract Studies conducted on the integument of amphibians within Plethodontidae revealed these salamanders have mucous, granular, and modified composite multicellular glands in their skins. Unfortunately, few species have been studied to date. Thus, the purpose of this study was to investigate the histological diversity of the integumentary glands found on the ventral and dorsal surfaces of the Zigzag Salamander, Plethodon dorsalis, and compare these features to those found on the Northern Two-Lined Salamander, Eurycea bislineata, and the Cave Salamander, Eurycea lucifuga. These three species are found in the same family, Plethodontidae, which is comprised of more than 250 species. The data was then used to form a preliminary comparative study that investigated the histological diversity of integumentary glands found on the ventral and dorsal surfaces of terrestrial adult lungless salamanders. Results showed that P. dorsalis had polarization to its two skin surfaces, with mucous glands dominating ventrally and poison glands dominating dorsally. Additionally, P. dorsalis had similar morphology to their glands as that observed in other lungless salamanders with the distinction of the stratum corneum lining the ducts of both poison and mucous glands in a valve like manner. 2 Table of Contents Cover Page Abstract i Table of Contents ii Acknowledgement iii List of Figures iv Statement of Purpose 1 Introduction 2 Method/Procedure 5 Results 9 Analysis/Conclusion 18 Reflection 23 References 26 Appendices 29 Appendix A: Copy of CITI Training 29 Appendix B: Lab Safety Information 33 Appendix C: Scientific Poster 45 Appendix D: Illustration Development 46 3 Acknowledgments Dedicated to my parents, for always supporting and believing in me, my friends, for helping me find the fun in even the most stressful times, and my professors, for encouraging and challenging me. Special thanks to Dr. Kevin Gribbins for his support and mentorship, Professor James Viewegh for his illustration guidance, and Katie Rust and Mikia Davis for their contributions to the data collection. 4 List of Figures Figure 1: Histological sections of the dorsal skin from P. dorsalis taken using a light microscope at varying powers depicts both poison (A,B,D) and mucous (A,C) glands with E and F as idealized illustrations for comparison 9 Figure 2: Sections of ventral skin of P. dorsalis taken with a light microscope at different magnifications shows multiple mucous glands 11 Figure 3: Transmission electron microscope (TEM) micrographs of a P. dorsalis myoepithelial cell (D) and mucous gland, focusing on specific features within the gland (A,B,C) at various magnifications 12 Figure 4: Integument from E. bislineata at varying magnifications via light microscopy, shows both poison and mucous glands on the dorsal surface (A,B) and mucous and mixed glands on the ventral surface (C,D) 14 Figure 5: E. lucifuga integument at different magnifications shows both poison and mucous glands dorsally (A) and mucous glands ventrally (B,C) 16 1 Statement of Purpose Chytrid disease, or chytridiomycosis, has been one of the leading causes of amphibian deaths in recent years, with studies mostly focusing on the decline in frog populations (Weinstein et al. 2009; Retallick et al. 2004). Uniquely, the few studies that focus on the effects of chytridiomycosis in salamander populations have shown that salamander populations with the disease in the wild have not declined (Weinstein et al. 2009). Multiple species of salamanders have yet to be studied and these could provide insights into what distinguishing features may allow salamanders to survive chytridiomycosis while other amphibians die off. Chytridiomycosis is caused by the pathogenic fungus, Batrachochytrium dendrobatidis, which often causes epithelial infections and skin lesions, making integumentary features the most likely source of the survival features salamanders possess to fight this disease (Nichols et al. 2001). Plethodon dorsalis is a terrestrial lungless salamander, whose integument histology has never before been studied. This study provides a preliminary histological investigation into the integumentary features observed in P. dorsalis as well as clear visual drawings of the key distinguishing features of this salamanders skin. It also gives a preliminary comparative analysis of the integumentary features found in the Plethodontidae family based on Plethodon dorsalis, Eurycea bislineata, and Eurycea lucifuga salamanders. It was hypothesized that the dorsal and ventral surfaces of P. dorsalis would differ in features such as gland number, type, and pigment, and that plethodontid salamanders would have similar skin gland morphologies to that of other previously studied lungless salamanders with varying distribution of gland types between species. 2 Introduction Chytridiomycosis Chytridiomycosis is caused by the fungus Batrachochytrium dedrobatidis (Weinstein et al. 2009). Thought to have originated in Africa, this disease has been found in amphibians all over the world and continues to play a significant role in their decline (Weldon et al. 2004). Most studies have focused on the effects of chytridiomycosis on frogs and found that environmental factors may play a part in how the disease affects frog populations (Weinstein et al. 2009; Retallick et al. 2004). Nichols et al. (2001) studied the effect of chytridiomycosis in poison dart frogs, Dendrobates tincttorius and D. auratus, and found that all the frogs exposed to the fungus developed a fatal skin disease and skin lesions. Weinstein et al. (2009) studied the effect of chytridiomycosis in salamanders and found that those collected with chytridiomycosis infection always died in captivity, but populations with the disease studied in the wild did not show signs of decline. A study conducted on the effect of chytridiomycosis in Tiger Salamanders, Ambystoma tigrinum, indicated that several harbored extensive infections in their sloughed skin but were not morbidly affected (Davidson et al. 2003). This led the scientists to conclude that the rapid rate of sloughing in salamanders may be the distinguishing feature that allows them to survive the disease, but further experimentation would need to be conducted to support their hypothesis (Davidson et al. 2003). The specific features that allow salamanders to survive with chytridiomycosis are still under investigation as there are still many species of salamander that have not been studied to date. Even fewer histological studies have been conducted to investigate the skin, or integument, features in these salamanders that might offer more insight into the survival mechanisms they possess. 3 Plethodon dorsalis Plethodon dorsalis, more commonly referred to as the Zigzag salamander, is part of the Plethodontidae family (Dodd et al. 2004). This family comprises over 250 species of lungless salamanders and can be found along the west coast of North America and throughout the eastern United States (Heying et al. 2003). This family is characterized by a loss of several cranial bones, are all lungless, and possesses four legs and four digits on each foot (Heying et al. 2003). The word plethore in Greek means fullness or full of, and odon means teeth so the name Plethodon refers to the many teeth found on both the jaw and the roof of the mouth of this salamander taxon (Dodd et al. 2004). The term dorsal means back in Latin, so dorsalis refers to the pattern found along the back of P. dorsalis. While amphibians have evolved to be able to successfully live in both aquatic and terrestrial ecosystems by undergoing metamorphosis (Bonnett and Chippindale 2006), P. dorsalis is a completely terrestrial salamander. Plethodon dorsalis practices direct development, meaning that all developmental stages occur within the egg and neonates hatch from their terrestrial eggs as miniature adults, thus skipping the larval stage (Heying et al. 2003). As no histological studies have ever been conducted on P. dorsalis, it is unknown what developmental changes occur in the skin glands as it develops within the egg or whether their skin glands differ from other larval or adult salamanders that are not fully terrestrial. Integumentary System The integumentary system is comprised of the skin and its derivatives, such as hair and exocrine glands (Barclay 1999). Studies conducted on the integument of the plethodontid salamander family have shown mucous, granular, and modified composite multicellular glands in their skin (Fontana et al. 2006). Histological studies of the skin, such as those done within the 4 Gastrophryne carolinesis and Proteus anguinus (Siegel et al. 2008; Mali and Bulog 2004), can be utilized to understand the specific structure and location of the multitude of different multicellular glands and cellular structures unique to amphibian skin. Data on the morphology of Caudata skin glands is limited to a handful of studies between aquatic and terrestrial salamanders or their larvae (Bonnet and Chippindale 2006; Fontana et al. 2006; Mali and Bulog 2004; Sever et al. 2016). The authors of one comprehensive study on the skin in the salamander Karsenia koreana found and described mucous, granular, and modified granular glands (Sever et al. 2016). Evidence from several other studies has shown that there are two types of dermal glands found in all adult amphibians: the granular and mucous glands (see Fontana et al. 2006 for review). This study will provide histological and ultrastructural data on the integumentary glands, compare their distribution on the ventral and dorsal surfaces of P. dorsalis, and then compare our data with the other salamanders in the Plethodontidae family to analyze potential similarities and differences of integumentary features among terrestrial adult salamanders. 5 Methodology Role of Advisor As my advisor, Dr. Gribbins, provided guidance and training as the project was completed. We met in person at least once every two weeks to discuss my progress, sometimes more often if questions arose while executing the project. He provided me with lab safety information and helped me refine the procedures necessary for the use of dangerous chemicals during the embedding process. Because of the dangerous nature of these chemicals, as shown in appendix B, I adorned gloves, goggles, and a lab coat for most of the embedding process. A fume hood was also utilized while completing the embedding process for the transmission electron microscope (TEM) samples, which can contain toxic fumes. Once the samples were prepared for analysis, Dr. Gribbins and I photographed the samples using light and electron microscopes. These images were then referenced when drawing the distinguishing features found in the poison and mucous glands of the integument. He also then provided resources for labeling and determining the identity of the structures found in the skin. Lastly, Dr. Gribbins assisted me in preparing to present my results by conducting the final edits and critiques of both my poster and formal manuscript. Timeline My project began in September 2018 as I began learning microscopy and staining techniques by practicing on already embedded samples utilized just for practice. In January of 2019, the dissection and embedding of P. dorsalis for light microscopy was completed. Once this was accomplished, I began sectioning and staining samples to use as preliminary data for the Undergraduate Research Conference (URC) and the Indiana Academy of Science (IAS) conference. Dr. Gribbins then took the samples I sectioned and used the more advanced Leica 6 Ultracut S microtome, that he does not allow undergraduate students to use, to get clear-cut sections of integumental tissues. These sections provided good images that were easily analyzed to identify structures. My proposal was submitted to the honors counsel on March 18, 2019 and accepted with minor revisions. After having my proposal accepted, I presented a poster at the IAS conference on March 30, 2019 and the URC at Butler University on April 12, 2019. Then in August 2019, I began embedding samples for TEM analysis. By early October, I had finished sectioning and Dr. Gribbins had produced images from his TEM. I then added the TEM results to my poster and presented at the National Collegiate Honors Council conference in November 2019. The present manuscript on P. dorsalis was completed in early 2020. Tissue Preparation for Light and Transmission Electron Microscopy P. dorsalis were overdosed using an anesthetic known as MS222. The salamander body cavity was opened and exposed and then the entire salamander was placed in a solution of Trumps fixatives in order to prevent autolysis, bacterial attack, and to aid in tissue fixation. Forty-eight hours after fixation, dorsal and ventral skin pieces were dissected from the body using a dissecting scope. The skin was then cut into multiple squares approximately 3x3 millimeters in size. For light microscopy, gloves, goggles, and a lab coat were adorned while rinsing the samples three times for ten minutes each in cacodylate buffer. Once the rinses were complete, the samples were then stored in 70% ethanol until ready to complete the dehydration and embedding process. To use epon plastic to embed the skin samples, a modified method was used based off of the process described by Seigel et al. (2008). Before starting the dehydration process, a solution of plastic was made by mixing the plastics ERL-4221, DER-736, NSA, and DMAE for about two and a half hours and then covered with parafilm until ready for use. 7 Then the dehydration process was performed on skin samples, using an ascending series of ethanol washes to remove water and fixative from the skin samples. Once the ethanol washes reached 100% the samples were infiltrated with the plastic made earlier in a solution of two-parts ethanol and one-part plastic. The skin samples were then incubated in a 1:1 ethanol/plastic solution, and then finally in 100% plastic overnight. The skin tissues were then incubated in a new batch of 100% plastic for two hours. Lastly the samples were placed in disposable molds and put in a vacuum oven set at 70C. After 24 hours, the skin samples were taken out of the oven and removed from the disposable molds. For transmission electron microscopy, the 3x3 millimeters samples were rinsed in cacodylate buffer three times for five minutes. The samples were then post-fixed in osmium tetroxide for an hour and a half before being rinsed again in cacodylate buffer three times for two minutes. The samples were then stored in 70% ethanol until ready to complete the dehydration and embedding process. From here the steps are the same as those for the dehydration and embedding of the light microscopy samples detailed above. Sectioning and Staining Once the plastic hardened, it provided enough support for the tissue samples to be cut into very thin sections via microtomy. These sections were then placed on microscope slides and stained with LAD dye in order to clearly see the integumentary structures. The slides were then analyzed under light and transmission electron microscopes to identify the structures and architecture of the P. dorsalis skin. Drawing the Structures Once all the sectioning was complete, Dr. Gribbins verified that the poison and mucous glands comprised the most distinguishing features of the integument of P. dorsalis. With this 8 verification, illustrations of both gland types were drawn to clearly depict the unique structure and features of each gland and provide a clear comparison. A sketchpad and graphite pencils were used to sketch out the structures seen in the photographs and under the light microscope. By utilizing multiple section images, an idealistic illustration of each gland was drawn emphasizing all the features unique to each gland. This allowed all the distinguishing features to be observed at once in the drawings, which were not always represented in each of the histological sections at the same time. The graphite illustrations and the photographs of the microscopic images used as references were then shown to Professor Viewegh for critiques and edits. Once the accuracy of the sketches was approved by Professor Viewegh and Dr. Gribbins, the sketches were retraced using micron pens and digitally scanned to incorporate into the final manuscript. Familial Comparison After the preliminary findings were completed for P. dorsalis, a comparison was done including the preliminary histological findings of the integument of E. bislineata and E. lucifuga completed by other students of Dr. Gribbins. The preliminary results of E. bislineata and E. lucifuga are shown in Figures 4 and 5 in the results section. As all three salamanders were of the Plethodontidae family, this comparison was considered a preliminary familial comparison. Specific key features such as gland types present ventrally and dorsally, abundance of chromatophores, and the presence of stratum corneum lining the excretory ducts were analyzed across all three species to find similarities and differences within their integuments. 9 Results Plethodon dorsalis KC v KC KC E Epidermis Stratum Corneum PG F Epidermis Stratum Corneum EEC CH CH MuG EEC Mucus Granules Poison Granules ME Dense Regular CT Figure 1 A-D: Histological sections of the dorsal skin from P. dorsalis taken using a light microscope at varying powers depicts both poison (A,B,D) and mucous (A,C) glands with E and F as idealized illustrations for comparison. Mucous gland, MuG; Poison gland, PG; Chromatophores, CH; Myoepithelial cells, ME; Connective tissue, CT; Epidermal Epithelial Cells, EEC; Keratinocyte, KC. Bars = 50 and 10m. The dorsal integument of P. dorsalis shows both mucous and poison glands present in the dermis (Fig. 1A; MuG, PG). The stratum corneum, which serves as the outermost layer of the epidermis, is present all the way around the body superficially and lines the ducts of both gland types (Fig. 1C,D; MuG, PG). The stratum corneum lining the ducts appears valve-like with the thickness and angle of the lining towards the opening at the apical surface (Fig 1C,D). Keratinocytes, the main cell type of epidermis, are seen clearly in the epidermis of the 10 integument (Fig. 1C,D; KC). The main gland found on the dorsal side is the poison gland and, as shown, are relatively the same size as the mucous glands (Fig. 1A; MuG, PG). Chromatophores are seen throughout the dermis surrounding the glands and produce clusters of small granules (melanin) around the glands that give the skin its pigment (Fig. 1B,C,D; CH, MuG, PG). Myoepithelial cells are observed in and around the mucous and poison glands as they help expel mucous and poison from the glands, through the ducts and onto the skin surface (Fig 1C; ME, MuG). Dense irregular connective tissue makes up the basal layer of the dermis with skeletal muscle found deep to the dermis (Fig 1A). The illustrations of the poison and mucous glands provide an idealized depiction of the structures present in the integument of P. dorsalis (Fig. 1E,F; PG, MuG). The epidermis clearly shows the stratum corneum as the most superficial layer that also lines the inside of the gland ducts forming a valve like structure (Fig. 1E,F). The poison and mucous glands are shown as relatively the same size in the dermis layer with epidermal epithelial cells forming the barrier between the dermis and the interior of the glands (Fig. 1E,F; EEC). Chromatophores are found throughout the dermis surrounding both gland types and myoepithelial cells are most easily observed around the mucous glands (Fig. 1E,F; CH,ME, MuG). Poison granules, differing in size and density, are depicted within the poison gland and mucus granules are depicted within the mucous gland (Fig. 1E,F; PG, MuG). Dense regular connective tissue is shown as the basal layer of the dermis (Fig. 1E,F). The illustrations emphasize the distinguishing features between the poison and mucous glands to make them more easily discernible (Fig. 1E,F). 11 Figure 2 A,B: Sections of ventral skin of the P. dorsalis taken with a light microscope at different magnifications shows multiple mucous glands. Mucous gland, MuG; Chromatophores, CH. Bars = 50 and 10m. The ventral integument of P. dorsalis only has mucous glands present in the dermis (Fig. 2A,B; MuG). Mucous glands are more abundant in the ventral integument in comparison to the dorsal integument (Fig.2A and Fig. 1A; MuG). The mucous glands seen ventrally are developing mucus glands and have not produced or concentrated mucin granules like those shown in Fig.1C (Fig. 2B; MuG). Myoepithelial cells are present in the dermis and around the 12 mucous glands, similar to those found in the dorsal integument seen in Fig. 1C (Fig. 2B; ME, MuG). The stratum corneum is superficially lining the epidermis of the ventral skin as seen in the dorsal skin in Fig. 1A,C,D (Fig. 2 A,B). Chromatophores are grouped around the mucous glands throughout the dermis, similar to those seen around the poison and mucous glands on the dorsal surface (Fig. 1A,B,C,D; CH, PG, MuG and Fig.2A,B; CH, MuG). Mv M Figure 3 A-D: Transmission electron microscope (TEM) micrographs of a P. dorsalis myoepithelial cell (D) and mucous gland, focusing on specific features within the gland (A,B,C) at various magnifications. Mucous gland, MuG; Microvilli, Mv; Rough endoplasmic reticulum, RER; Actin, Ac; Mitochondria, M; Blue arrow = desmosome junction. Bars = 1m. Mucous glands are found on both the dorsal and ventral surfaces of P. dorsalis. Transmission electron microscope images are used to analyze these glands subcellularly. 13 Mucin producing cells within mucous glands have mitochondria and rough endoplasmic reticulum dominating the organelle composition within these cells (Fig.3A; M, MuG, RER). The nuclei of mucous gland cells clearly show light staining euchromatin and large conspicuous nucleoli, which is a clear indication of a cell active in transcription and the cytoplasm is filled with enlarged and active rough endoplasmic reticulum (Fig. 3C; RER). As these nuclei are active, these cells are starting production of a new wave of mucin protein granules (Fig. 3C). Prominent mucin granules can be seen within the mucous gland that would have been developed and secreted to form mucus from actively secreting glands (Fig. 3B; MuG). The surfaces of the mucous cells show microvilli that increase surface area (Fig. 3A; Mv). The nucleus and cytoplasm of a myoepithelial cell can be seen in Fig. 3D. Actin appears to be in great abundance within the cytoplasm of these myoepithelial cells with multiple desmosome junctions (blue arrow) located between them and the mucus producing cells of the gland (Fig. 3D; Ac). 14 Eurycea bislineata S Figure 4 A-D: Integument from the E. bislineata at varying degrees of power via light microscopy, shows both poison and mucous glands on the dorsal surface (A,B) and mucous and mixed glands on the ventral surface (C,D). Poison gland, PG; Stratum corneum, SC; Mucous gland, MuG; Keratinocyte, KC; Mixed gland, MiG; Myoepithelial cell, ME; Serous cell, S; Microvilli, MV; Connective tissue, CT. Bars = 50 and 10m. Part of the Plethodontidae family comparison includes the study of the integument of Eurycea bislineata. Multiple poison glands as well as some mucous glands are seen on the dorsal integument of E. bislineata (Fig. 4A; PG, MuG). Some of the glands shown are empty of poison granules while others are partially or completely full of poison granules (Fig. 4A; PG). The stratum corneum thinly lines the apical surface of the integument with dense regular connective tissue forming the basal layer of the dermis (Fig. 4A; SC). Melanocytes, also known 15 as chromatophores, are scattered throughout the dermis and myoepithelial cells are seen near the mucous and poison glands (Fig. 4B; ME). The ventral integument of E. bislineata shows multiple mucous glands as well as some mixed glands used to perform both serous and mucous secretions (Fig. 4C; MuG, MiG). Poison glands are not found on the ventral surface (Fig.4C). Microvilli are seen on the superficial layer of the epidermis (Fig. 4C; Mv). Dense regular connective tissue is also seen making up the basal dermis layer and keratinocytes are seen throughout the epidermis of the integument (Fig. 4C; KC). One of the key features within the ventral integument of E. bislineata is the mixed glands that are present (Fig. 4D, MiG). Mucous granules can be clearly seen within the mixed gland as well as a few serous cells within the apical region of the gland (Fig. 4D; MiG, S, MG). Melanocytes are seen grouped around the glands and microvilli are found on the superficial layer of the epidermis (Fig. 4D; Mv). 16 Eurycea lucifuga Stratum corneum A B MuG Dermis C SC Dermis PG MuG Epidermis MuG Epidermis Dense Irregular CT Figure 5 A-C: E. lucifuga integument at different magnifications shows both poison and mucous glands dorsally (A) and mucous glands ventrally (B,C). Mucous gland, MuG; Poison gland, PG; Stratum corneum, SC; Connective Tissue, CT. Bars = 50 and 10m. Eurycea lucifuga integument is also studied for the Plethodontidae family comparison. The dorsal surface of E. lucifuga integument has both poison and mucous glands (Fig. 5A; PG, MuG). Most of the mucous glands seen dorsally are empty with only a thin lining of epithelium cells making up the outer edges of the gland to form a barrier between the gland and the rest of the dermis. (Fig. 5A; MuG). Poison granules seen within the poison glands show that the glands were ready for secretion (Fig. 5A; PG). The ventral surface shows an abundance of mucous glands (Fig. 5B,C; MuG). The stratum corneum forms a thin apical layer at the top of the epidermis similar to that seen in both P. dorsalis and E. bislineata (Fig. 2B; Fig. 4A; Fig. 5B). The basal layer of the dermis is dense irregular connective tissue that provides a sturdy connection point for the skeletal muscle seen deep to the integument (Fig.5B). An empty mucous gland and a full mucous gland of E. lucifuga are shown in Fig. 5C. Within the epidermis the mucous gland duct provides an opening from the mucous gland to the apical surface of the epidermis (Fig. 5C; MuG). The stratum corneum is also observed lining the duct similar to that found in P. dorsalis but the 17 lining of P. dorsalis appears significantly thicker and more like a valve (Fig. 1C,D; compare to Fig. 5C). Very few chromatophores, or melanocytes, are seen in Fig. 5C and they appear in less abundance in the epidermis of E. lucifuga compared to that of P. dorsalis and E. bislineata (Fig. 1C; Fig. 2A; Fig. 4A; Fig. 5C). 18 Analysis/Conclusion Plethodon dorsalis The integumentary system includes the skin and any of its derivatives such as nails or glands (Barclay 1999). The few studies conducted on the integument of plethodontid salamanders have shown mucous, granular, and modified composite multicellular glands in their skin (Fontana et al. 2006). Plethodon dorsalis has mucous glands as well as granular glands, more commonly known as poison glands, present in the dermis. The dorsal integument of P. dorsalis has both gland types, while the ventral integument only has mucous glands. This is most likely due to poison glands being used to secrete a deterrent as protection from predators that typically strike from above (Arrivillaga and Brown 2018). The mucous and poison glands found in P. dorsalis are relatively similar in size, but in histological studies of other amphibians, such as G. carolinesis, the poison glands are significantly larger in size in comparison to the mucous glands (Siegel et al. 2006). The overall structure of the P. dorsalis integument is similar to that of other amphibians in that the epidermal and dermal layers have many of the same features, including: stratum corneum, keratinocytes, chromatophores, myoepithelial cells, and dense irregular connective tissue (Garton and Mushinsky 1979). The stratum corneum makes up the most superficial layer of the epidermis providing the first line of defense against pathogens attempting to enter the body. Keratinocytes are found in the epidermis and produce keratin proteins that act as intermediate filaments for anchoring structures and forming junctions. When keratin proteins build up, they make the epidermis hard (Eckert and Rorke 1989). Chromatophores found throughout the dermis provide the integument with the pigment that makes distinct patterns and colors used for breeding and protection. Myoepithelium cells are found around glands and help 19 secrete the granules from these glands (Balachander et al. 2015). Dense irregular connective tissue is found at the basal layer of the dermis and provides the structural support of the integument as well as an anchorage point for the skeletal muscle found deep to the dermis. These commonly found integument structures make up much of the P. dorsalis integument. The most distinguishing feature of the P. dorsalis integument is the stratum corneum lining the ducts of both gland types. Studies of other amphibians did not show the stratum corneum contributing to the lining of any of the gland ducts (Garton and Mushinsky 1979; Siegel et al. 2006). The stratum corneum of P. dorsalis, however, lines the excretory ducts of the poison and mucous glands of the dorsal integument as well as the mucous gland ducts of the ventral integument. This morphological feature is also found in the Plethodontid salamander, Karsenia korenea (Sever et al. 2016). The way the stratum corneum is angled and positioned in the ducts of P. dorsalis suggests that it acts as a plug, or more likely a valve, that may aid in the building of pressure before the gland releases its contents, helping the glands secretion efficiency. The ventral integument of P. dorsalis is found to be structurally the same as the dorsal integument with the most notable difference being the lack of poison glands. In comparison to the dorsal integument, the ventral integument has a larger abundance of mucous glands. Transmission electron microscope analysis of the mucous glands shows the mucoid producing cells that make up the lining of the mucous glands and produce the mucin granules that are secreted. The mucoid producing cells show enlarged nucleoli in the nucleus indicating active transcription as well as an abundance of rough endoplasmic reticulum seen in the cytoplasm, a clear indicator of protein production destined for exocytosis. These subcellular structures are important for the protein production function of these cells. Desmosome junctions are found between the mucus producing cells and myoepithelial cells; these junctions are like spot welds 20 and hold these cell types together. Since myoepithelial cells have high actin content, the contractions of these cells most likely pulls on the desmosome junctions forcing the mucus producing cells together. Thus, the lumen of each gland would be constricted, squeezing the contents of the glands into the duct and out of the body. These structures make up the mucous glands and allow them to produce and secrete the mucin granules (Balachander et al. 2015). In conclusion, based on the histological analysis of the P. dorsalis integument, the dorsal and ventral surfaces have the same structural profile with the significant difference being that the ventral surface lacks poison glands and has a larger abundance of mucous glands. The P. dorsalis integument also has a similar morphology to that of other amphibians with the same structural components found in the epidermis and dermis. The most significant distinction between other amphibian integuments and that of P. dorsalis is the stratum corneum found lining the ducts of both poison and mucous glands potentially acting as a valve. As this is the first study done examining the integument of P. dorsalis, more studies will need to be conducted to build upon these findings as well as verify them. A TEM analysis of the poison glands and a closer examination of the stratum corneum could provide support for its possible valve-like function. Future studies can be conducted on embryonic salamander integument and then compared to the adult salamander integument from this study to gain a better understanding of the morphology that occurs between the embryonic and adult stages of salamanders. Familial Comparison The histological integument studies of the Northern Two-Lined salamander, E. bislineata, Cave salamander, E. lucifuga, and Zigzag salamander, P. dorsalis, conducted by students of Dr. Gribbins, were used to form a preliminary familial comparison of the integument within the Plethodontidae. All three of these salamander species have similar 21 morphological features to those found in the epidermis and dermis of other amphibians, such as poison glands, mucous glands, keratinocytes, stratum corneum, and chromatophores (Garton and Mushinsky 1979). The most distinct differences found between the integument of P. dorsalis and that of E. lucifuga and E. bislineata is the mixed glands found in the dermis of E. lucifuga and E. bislineata but not in P. dorsalis and the valve-like lining of the ducts in P. dorsalis. All three species of lungless salamanders show the stratum corneum lining the ducts of their excretory glands such as the poison, mucous, and mixed glands. This structural characteristic is not found in other amphibians and appears to be unique and possibly synapomorphic to the Plethodontidae family (Garton and Mushinsky 1979; Siegel et al. 2006). Plethodon dorsalis appears to have a thick lining of stratum corneum within the ducts that angles to form what appears to be a valve, while the stratum corneum lining the ducts of E. bislineata and E. lucifuga is rather thin in comparison. The valve-like lining of stratum corneum appears to be unique to P. dorsalis. The three species also all show poison glands only in the dorsal integument most likely used to secrete a deterrent for protection. One characteristic of the P. dorsalis integument is that the poison and mucous glands are similar in size. The poison, mucous, and mixed glands of E. bislineata and E. lucifuga are not all relatively the same size. Instead, the mucous glands are found to be smaller in comparison to the poison and mixed glands in E. bislineata and E. lucifuga. A distinguishing feature of the E. lucifuga integument is the significantly smaller number of chromatophores seen in the dermis compared to the amount found in the dermis of E. bislineata and P. dorsalis both dorsally and ventrally. In conclusion, the integument of Plethodontidae salamanders is found to be morphologically similar to that of other amphibians with the unique characteristic of having 22 the stratum corneum lining the ducts of excretory glands. The distinct characteristics of the P. dorsalis skin is the lack of mixed glands and the valve-like stratum corneum lining the excretory ducts. The most notable characteristic of E. lucifuga is the less abundant grouping of chromatophores in the dorsal and ventral integument. All three species of lungless salamanders have poison glands only in the dorsal integument. Future studies should build upon this study to include a TEM analysis of the poison and mixed glands for more detailed comparisons. This familial comparison can be used in future studies to determine any different integument features found in salamanders that are not found in other amphibians, such as frogs. The data from this study could be used as a control to compare to the integument of Plethodontid salamanders proven to be infected with chytridiomycosis. A study such as this could give insight as to why salamanders have been able to survive chytridiomycosis (Weinstein et al. 2009). 23 Reflection This project has been extremely informative, both academically and professionally. I began this project my sophomore year and worked hard to learn the technical skills needed to complete this project. This included learning to obtain clean sections of integument for staining and the intense protocols needed to embed the integument in plastic. Throughout this project, I also learned to overcome my setbacks and relish my successes. My first setback occurred while learning to use the microtome to cut thin sections of tissue. It took me many hours to learn what adjustments needed to be made to the microtome based on the sections I was producing. Often the angle of the blade or the embedded plastic needed to be adjusted to achieve a clean section that provided intact tissue structures that could be clearly observed. I had not anticipated it to take as long as it did for me to become proficient at using the microtome, but I learned it is a machine best mastered by practice. Another setback I encountered occurred the first time I embedded. The embedding process itself is rather intense as it takes almost two days to complete and requires someone to be available most of the first day to move the tissues between different concentrations of solutions at exact time intervals. When we finally added the tissues to the wells of plastic, I learned how hard it is to get the tissue to orient the way you want in the plastic as the tissue liked to rotate within the liquid plastic. I lost a few samples due to bad orientation or having the label float up and cover the tissue, but I learned from that experience so the second time I embedded I did not lose any samples. Another major problem I had while completing this project was procrastination. As my course load progressively increased, this project became less of a priority as it did not need to be completed for several years. Completing this project seemed like a dauntless task that could wait until my more pressing schoolwork was done, especially when it came to the final 24 manuscript writeup. While taking this approach allowed me to be successful in my classes, it did cause me more stress later as the project deadline loomed ever closer. Looking back, if I had been better about my time management I would not have been as stressed about completing the project. The corona virus pandemic also posed a problem as it prohibited me from performing any further TEM analysis on the integument. Originally, TEM analysis of both the mucous and poison glands of P. dorsalis was going to be included in my final manuscript. The poison gland analysis was going to be completed in early March and added to the already completed manuscript, but due to the restrictions caused by the outbreak it was not possible to complete this analysis in time to add to my manuscript. Further TEM analysis of the P. dorsalis integument will need to be conducted in future studies. Personally, this project taught me stress management. I have never undertaken a project of this magnitude, and to do it while taking some of my most rigorous college classes caused a great deal of stress. As a biology major hoping to be accepted into graduate school to become a veterinarian, I knew that completing this project would teach me how to better manage my time as well as stress. Veterinarians have a relatively high suicide rate due to the stress of their job, so I decided to persevere and complete my project so I could begin learning to manage my stress before entering graduate school. I learned that taking some time for myself every day, even if it was just ten minutes, really reduced my anxiety. Painting was another way I relieved stress while completing this project. Taking art classes to obtain my art minor, I realized that getting lost in the beauty of making an image come to life on paper or canvas was very cathartic for me and rejuvenated me when I felt stressed. 25 Academically, this project forced me to learn embedding and sectioning techniques I never would have learned otherwise. It also introduced me to histology and integumentary features with the aid of my mentor before ever taking classes that taught these subjects. This project also gave me the opportunity to present my research multiple times and even travel across the country for one of these presentations. Finally, the independent research done for this project presented me with unique experiences that aided me in promoting myself to graduate schools. 26 References Arrivillaga, C., Brown, T.W. 2018. Primary Descriptions of Defense Mechanisms Employed by Neotropical Salamanders (Bolitoglossa, Oedipina, Nototriton, and Cryptotriton sp.: Plethodontidae) in Cusuco National Park, Honduras. IRFC Reptiles and Amphibians Journal 25(2): 99-103. Balachander, N., Masthan K.M., Babu, N.A., Anbazhagan, V. 2015. Myoepithelial cells in pathology. Journal of Pharmacy & Bioallied Sciences 7(Suppl 1): S190-193. Barclay, T. 1999-2020. Integumentary System [Internet]. San Mateo (CA): Innerbody. [updated 2020 Feb 24; cited 2019 Jan 12]. Available from: https://research.wou.edu/c.php?g=551314&p=3785531. Bonnett, R.M., Chippindale, P.T. 2006. Streambed microstructure predicts evolution of development and life history mode in the plethodontid salamander Eurycea tynerensis. BMC Biology 4: 6-18. Davidson, E.W., Paris, M., Collins, J.P., Longcore, J.E., Pessier, A.P., Brunner, J. 2003. Pathogenicity and Transmission of Chytridiomycosis in Tiger Salamanders (Ambystoma tigrinum). Copeia 3: 601-607. Dodd, C.K., Southern Zigzag Salamander (Plethodon ventralis). The Amphibians of Great Smoky Mountains National Park. Knoxville (TN): The University of Tennessee Press, 2004. p. 200-202. Eckert, R.L., Rorke, E.A. 1989. Molecular Biology of Keratinocyte Differentiation. Environmental Health Perspective 80: 109-116. Fontana, M.F., Ask, K.A., MacDonald, R.J., Carnes, A.M., Staub, N.L. 2006. Loss of traditional mucous glands and presence of a novel mucus-producing granular gland in the 27 plethodontid salamander Ensatina eschscholtzii. Biological Journal of the Linnean Society 87: 469-477. Garton, J.D., Mushinsky, H.R. 1979. Integumentary toxicity and unpalatability as an antipredator mechanism in the narrow mouthed toad, Gastrophryne carolinesis. Canadian Journal of Zoology 57: 1965-1973. Heying, H. 2003. Plethodontidae Lungless Salamanders [Internet]. Ann Arbor (MI): Animal Diversity Web. [updated 2003; cited 2019 Jan 12]. Available from: https://animaldiversity.org/accounts/Plethodontidae/. Mali, L.B., Bulog, B. 2004. Histology and Ultrastructure of the Gut Epithelium of the Neotenic Cave Salamander, Proteus anguinus. Journal of Morphology 259: 82-89. Nichols, D.K., Lamirande, E.W., Pessier, A.P., Longcore, J.E. 2001. Experimental Transmission of Cutaneous Chytridiomycosis in Dendrobatid Frogs. Journal of Wildlife Diseases 37: 1-11. Retallick, R.W.R., McCallum, H., Speare, R. 2004. Endemic Infection of Amphibian Chytrid in a Frog Community Post-Decline. PLOS 11: 351-355. Sever, D.M., Pinsoneault, A.D., Mackenzie, B.W., Siegel, D.S., Staub, N.S. 2016. A Description of the Skin Glands and Cloacal Morphology of the Plethodontid Salamander Karsenia koreana. Copeia 4: 816-823. Siegel, D.S., Sever, D.M., Schriever, T.A., Chabarria, R.E. 2008. Ultrastructure and Histochemistry of the Adhesive Breeding Glands in Male Gastrophryne carolinensis (Amphibia: Anura: Microhylidae). Copeia 4: 877-881. 28 Weinstein, S.B. 2009. An Aquatic Disease on a Terrestrial Salamander: Individual and Population Level Effects of the Amphibian Chytrid Fungus, Batrachochytrium dentrobatidis, on Batrachoseps attenuatus (Plethodontidae). Copiea 4: 653-660. Weldon, C., du Preez, L.H., Hyatt, A.D., Muller, R., Speare, R. 2004. Origin of the Amphibian Chytrid Fungus. Emerging Infectious Diseases 10: 2100-2105. 29 Appendices Appendix A- CITI Training 30 31 32 33 Appendix B- Chemical Safety Sheets 34 35 36 37 38 39 40 41 42 43 44 45 Appendix C- Scientific Poster 46 Appendix D- Illustration Development Graphite Illustration of Poison and Mucous Gland (above) Traced Micron Pen Illustration of Poison and Mucous Gland (above) 47 Scanned Micron Pen Illustration of Poison and Mucous Gland (above)  ...

... Academic Major Changers: An Analysis of Trends Among Students Changing Majors at the University of Indianapolis By Emily Crafton Honors Project Thesis Submitted in Partial Fulfillment Of the Requirements for a Baccalaureate Degree With Distinction In the Ron and Laura Strain Honors College of THE UNIVERSITY OF INDIANAPOLIS April 2020 Faculty Advisor: Jerry P. Flatto, ScD Executive Director of Honors: James B. Williams, Ph.D. Emily Crafton 2020. Copyright in this work rests solely with the author. Please ensure that any reproduction or re-use is done in accordance with relevant national copyright protection. i Abstract This project consists of an analysis of trends among students who change majors at the University of Indianapolis. Literature on the subject is reviewed in order to provide context concerning changing majors. This research revealed that a significant proportion of students change their majors. Consequently, it is a worthy topic for research, particularly with the knowledge that having a better grasp of the populations involved can lead to greater understanding of observed correlations. Although the university collected student data prior to this project, information regarding changes of major was unavailable. This project determined what constituted a change of major, executed technical procedures including pre-processing the data using Tableau Prep and model building in Tableau, and analyzed the results of the data. UIndy students add and drop majors more frequently than they transition directly between majors. The percentage of students who change majors is higher among those with the admit types of Distinct and Advised. The average GPAs for those students who did and did not change their majors are not vastly different, showing minimal correlation between GPA and change of major. Those who did change majors attempted more credit hours on average. This information can guide decision making and future research. ii Table of Contents Abstract ............................................................................................................................................ i Table of Contents ............................................................................................................................ ii Acknowledgments.......................................................................................................................... iii List of Tables ................................................................................................................................. iv List of Figures ................................................................................................................................. v Statement of Purpose ...................................................................................................................... 1 Introduction: .................................................................................................................................... 1 Overview: .................................................................................................................................... 1 Literature Review: ....................................................................................................................... 2 Key Terms: .................................................................................................................................. 8 Method/ Procedure: ....................................................................................................................... 10 Data Cleaning ............................................................................................................................ 10 Data Analysis Process ............................................................................................................... 24 Product Produced .......................................................................................................................... 26 Results ........................................................................................................................................... 27 Change of Majors/Minors/Concentrations ................................................................................ 28 Admit Type ............................................................................................................................... 50 GPA ........................................................................................................................................... 58 Credit Hours .............................................................................................................................. 65 Analysis/ Conclusion .................................................................................................................... 71 Reflection ...................................................................................................................................... 75 References ..................................................................................................................................... 77 Appendices .................................................................................................................................... 79 iii Acknowledgments The development of this manuscript would not have been possible without the help of the University of Indianapolis and its faculty. Thank you to Jerry Flatto, Greg Smith, James Wilson, and Jim Williams for their extensive efforts in supporting this research process. iv List of Tables Table 1: Census Table...13 Table 2: Major Table.20 Table 3: Graduate Table23 Table 4: Percent of Admit Type of Major 1 Changers..52 Table 5: Percent of Admit Type of Major 2 Changers..53 Table 6: Percent of Admit Type of Minor 1 Changers..54 Table 7: Percent of Admit Type of Minor 2 Changers..55 Table 8: Percent of Admit Type of Concentration 1 Changers.56 Table 9: Percent of Admit Type of Concentration 2 Changers.57 Table 10: Major Grouped Descriptions.79 v List of Figures Figure 1: The Majors that students changed "from" (i.e., their previous Major 1) and the number of unique students that changed from that previous Major 1........................................................ 29 Figure 2. The Majors that students changed "from" (i.e., their previous Major 2) and the number of unique students that changed from that previous Major 2........................................................ 31 Figure 3. The Minors that students changed "from" (i.e., their previous Minor 1) and the number of unique students that changed from that previous Minor 1. ...................................................... 32 Figure 4. The Minors that students changed "from" (i.e., their previous Minor 2) and the number of unique students that changed from that previous Minor 2. ...................................................... 33 Figure 5. The Concentrations that students changed "from" (i.e., their previous Concentration 1) and the number of unique students that changed from that previous Concentration 1. ................ 34 Figure 6. The Concentrations that students changed "from" (i.e., their previous Concentration 2) and the number of unique students that changed from that previous Concentration 2. ................ 35 Figure 7. The number of unique students for Major 1 that students changed "from" (i.e., their previous Major) and the Major 1 they moved "to." ...................................................................... 37 Figure 8. The number of unique students for Major 2 that students changed "from" (i.e., their previous Major) and the Major 2 they moved "to." ...................................................................... 38 Figure 9. The number of unique students for Minor 1 that students changed "from" (i.e., their previous Minor) and the Minor 1 they moved "to." ...................................................................... 39 Figure 10. The number of unique students for Minor 2 that students changed "from" (i.e., their previous Minor) and the Minor 2 they moved "to." ...................................................................... 40 Figure 11. The number of unique students for Concentration 1 that students changed "from" (i.e., their previous Concentration) and the Concentration 1 they moved "to." .................................... 41 Figure 12. The number of unique students for Concentration 2 that students changed "from" (i.e., their previous Concentration) and the Concentration 2 they moved "to." .................................... 42 Figure 13. The Major 1 that students moved "to" (i.e., their current Major 1) and the number of unique students that moved "to" the current Major 1. .................................................................. 44 Figure 14. The Major 2 that students moved "to" (i.e., their current Major 2) and the number of unique students that moved "to" the current Major 2. .................................................................. 45 Figure 15. The Minor 1 that students moved "to" (i.e., their current Minor1) and the number of unique students that moved "to" the current Minor 1. .................................................................. 46 Figure 16. The Minor 2 that students moved "to" (i.e., their current Minor 2) and the number of unique students that moved "to" the current Minor 2. .................................................................. 47 Figure 17. The Concentration 1 that students moved "to" (i.e., their current Concentration 1) and the number of unique students that moved "to" the current Concentration 1. .............................. 48 Figure 18. The Concentration 2 that students moved "to" (i.e., their current Concentration 2) and the number of unique students that moved "to" the current Concentration 2. .............................. 49 vi Figure 19. The unique number of students for each admit type, split into FALSE (those who did not change their Major 1) and TRUE (those who did change their Major 1). .............................. 52 Figure 20. The unique number of students for each admit type, split into FALSE (those who did not change their Major 2) and TRUE (those who did change their Major 2). .............................. 53 Figure 21. The unique number of students for each admit type, split into FALSE (those who did not change their Minor 1) and TRUE (those who did change their Minor 1). ............................. 54 Figure 22. The unique number of students for each admit type, split into FALSE (those who did not change their Minor 2) and TRUE (those who did change their Minor 2). ............................. 55 Figure 23. The unique number of students for each admit type, split into FALSE (those who did not change their Concentration 1) and TRUE (those who did change their Concentration 1). .... 56 Figure 24. The unique number of students for each admit type, split into FALSE (those who did not change their Concentration 2) and TRUE (those who did change their Concentration 2). .... 57 Figure 25. Average GPAs, split into FALSE (those who did not change their Major 1) and TRUE (those who did change their Major 1). .......................................................................................... 59 Figure 26. Average GPAs, split into FALSE (those who did not change their Major 2) and TRUE (those who did change their Major 2). .......................................................................................... 60 Figure 27. Average GPAs, split into FALSE (those who did not change their Minor 1) and TRUE (those who did change their Minor 1). .......................................................................................... 61 Figure 28. Average GPAs, split into FALSE (those who did not change their Minor 2) and TRUE (those who did change their Minor 2). .......................................................................................... 62 Figure 29. Average GPAs, split into FALSE (those who did not change their Concentration 1) and TRUE (those who did change their Concentration 1). ........................................................... 63 Figure 30. Average GPAs, split into FALSE (those who did not change their Concentration 2) and TRUE (those who did change their Concentration 2). ........................................................... 64 Figure 31. The Average Hours Earned and the Average Hours Attempted, split into FALSE (those who did not change their Major 1) and TRUE (those who did change their Major 1). ..... 65 Figure 32. The Average Hours Earned and the Average Hours Attempted, split into FALSE (those who did not change their Major 2) and TRUE (those who did change their Major 2). ..... 66 Figure 33. The Average Hours Earned and the Average Hours Attempted, split into FALSE (those who did not change their Minor 1) and TRUE (those who did change their Minor 1). ..... 67 Figure 34. The Average Hours Earned and the Average Hours Attempted, split into FALSE (those who did not change their Minor 2) and TRUE (those who did change their Minor 2). ..... 68 Figure 35. The Average Hours Earned and the Average Hours Attempted, split into FALSE (those who did not change their Concentration 1) and TRUE (those who did change their Concentration 1)............................................................................................................................ 69 Figure 36. The Average Hours Earned and the Average Hours Attempted, split into FALSE (those who did not change their Concentration 2) and TRUE (those who did change their Concentration 2)............................................................................................................................ 70 vii Figure 37. The difference between the Actual and Expected Graduation Term for each student. The number of unique students who hold each value is listed. .................................................... 74 1 Statement of Purpose There were a variety of questions related to changing of academic major that could not be answered by simply accessing the existing collection of University of Indianapolis student data. Such key questions considered were as follows: What are the trends connected with students who change majors at the University of Indianapolis? How is change of major correlated with GPA and admit type? Time to graduation was also explored, but was not able to be included in the final analysis, which will be further explained. It is important to note that this project did not seek to find methods for how to reduce the number of students who change their majors or suggest the majors students should pursue. Instead, its purpose was to determine the statistics related to the rate and frequency of changes in major as well as the specific majors which were most often moved into and out of. The final product of this study includes visual representations in the form of graphs and tables, which demonstrate the trends linked to major changers at the University of Indianapolis. Introduction: Overview: This project entailed an investigative scientific analysis of current and former University of Indianapolis students in order to discover what trends could be seen among those students who change their majors over the course of their education. Detailed factors related to changing of major are not included in the current data collection of University of Indianapolis student information. This project used data analysis to fill in these gaps that presently exist in the university reports. It is imperative that the results of this project be utilized wisely. They should not be used to predetermine majors that certain groups of students should select since it is impossible to fully 2 understand the complete picture of students motivations simply based on the raw data. Maintaining relationships with advisors and faculty through personal conversations is essential to the major-changing and identification process. Rather, this project sought to identify trends regarding the number of students who change their academic majors among the various majors within the university, and it provided information gleaned from the results of the data analysis concerning the admit types of students, GPA, and credit hours commonly associated with change of academic major. Literature Review: Declaring an academic major can be a difficult choice for college students. Even students who initially feel confident in choosing a major may ultimately change their course of study before graduation. When deciding a future career path, the selection of a suitable academic major is a critical matter that students often reconsider and alter over time. Understanding trends among students who change their majors may assist academic advisors and students in their decision making. In order to further explore the subject of changing an academic major, it is essential to consider a multitude of areas within this process. The prevalence of changing majors among students, the perception and reasoning behind major changes, the impacts of major changes, and the identification of student populations for whom academic advisors can assist in this decision are all vital considerations to understand background information for this study. Prevalence It is not a rare occurrence for students to change their majors over the course of their undergraduate education. According to research performed by a variety of sources, a majority of students do not graduate with a degree in the first major that they choose. Some inconsistencies exist among the exact proportions of students who are said to have changed their majors, but this 3 is to be expected, as this number fluctuates from year to year and across universities. Additionally, researchers may interpret what constitutes a change of major differently, depending on the situation, so this issue is addressed later in greater detail. Jeffrey Sklar, author of the journal article Event History Analysis for Investigating the Likelihood and Timing of Changing Majors, explains that more than half of students change their majors, placing the proportion somewhere between 50% and 85% (Sklar, 2018). Information gathered from the U.S. National Center for Educational Statistics by authors Wine, Janson, and Wheeless (as cited in Sklar, 2018) states that approximately 46% of all rst time full-time students entering 4-year institutions in 2003 switched majors at least once within the following 6 years (p. 47). Sklars study employs an event history analysis in which variables are measured repeatedly over time in order to find occurrences of changes in the data. A similar method was used for this project, as the data reflects each semester that students attend UIndy. In keeping with the range of students who change majors as described by Sklar, another study by authors Karen Cunningham and Anthony Smothers reports that in the year 2012, somewhere between 50% and 70% of the 20.4 million undergraduate students in the United States switched majors during their collegiate careers (Cunningham & Smother, 2014). Even further support comes from Marade and Brinthaupts article in which another study is credited for finding that more than half of undergraduate students change majors a minimum of one time before completing their degrees (Brooks, 2012 as cited in Marade & Brinthaupt, 2018). In addition, the U.S. Department of Education reported that at the national level, the percentage of students who change majors at least once was approximately 30% in the year 2014 (Leu, 2017). Although the national percentage of major changers may be lower, this is still a notable statistic. The prevalence of those who change majors in universities across the world indicates 4 that the same is likely true for the University of Indianapolis, and as such, this was a subject worthy of investigation. It would not be anticipated that most students entering college already have a clear vision of their future career path, so many may desire to change their focus of study at some point in time. It was beneficial to gain this background and context for this subject. Perception and Reasoning Despite the fact that changing majors is common, not everyone views this trend with the same concerns. It is important to consider the predisposition that people, including both students and faculty, already hold with regard to changing majors, instead of assuming that they will or will not be receptive to the implications of the analysis or a recommendation for future research. One study by authors Marade and Brinthaupt shows that there are both positive and negative connotations held by students and faculty regarding reasons for changing ones major. In this study, researchers first compared presently enrolled students major-changing rate and frequency to that of the faculty when they were students, finding that current students had a higher number of major changes in both rate and frequency (Marade & Brinthaupt, 2018). Of the 98 students surveyed, 79% had changed majors compared to 52% of the 67 faculty members surveyed (Marade & Brinthaupt, 2018). This seems to indicate a greater acceptance and willingness to switch majors from the perspective of the students; however, students expressed more negativity concerning changing majors than the faculty did. More students claim that future regrets may arise as a result of changing majors (Marade & Brinthaupt, 2018). Some of these regrets are further discussed in a later section of this manuscript entitled, Impact of Changing Majors. Author Spights study focuses on the group of students who are expected to change their majors: undecided students. The only alternative to this involves these students leaving their current institutions. Spight explains that many administrators, faculty, staff, and parents 5 believed quitting or postponing college to be a greater possibility for undecided students than for those who had already declared a major (Spight, 2018). Spight makes an important note in his explanation of these issues, describing that across universities, terms such as undecided and persistence have varied, inconsistent definitions (Spight, 2018). This project operated in a similar manner, in that an important section involved determining the definition of change of major, which is further discussed in the Key Terms section of this manuscript. Spight indicates that a main goal for students is graduating with a degree, and many people presume that prioritizing the selection of a major early in ones college experience is necessary to achieve this goal. However, the results of his study show that this is not actually always the case, and he argues other issues that could be impacting completion should take precedence in terms of change-making efforts. The researchers also take the position that major exploration should be advised, primarily to encourage students to be more well-versed in their experiences (Spight, 2018). Gaining the perspective that the declaration of a major may not be the most pressing matter toward timely graduation and accepting the idea that exploration may be beneficial are points that were taken into consideration as I conducted my study to discover and investigate the implications of switching majors at the University of Indianapolis. Impact of Changing Majors All students academic journeys are different, and as such, there are a variety of negative and positive impacts that could occur as a result of changing majors. Understanding the full gamut of consequences allowed for a broader analysis of the current University of Indianapolis trends. Students who decide to change their majors may encounter difficulties. According to Marade and Brinthaupt, a frustrating issue that students may face after changing their majors is 6 realizing later that the new choice of major is not a preferred one. These authors cite another study performed in 2005 by Roese and Summerville specifically related to regret, in which incorrect educational commitments ranked as the highest reported life regret (Marade & Brinthaupt, 2018). Another downside to changing majors for many students involves the potential or perceived waste of time and money. This varies from student to student, as it is reliant upon when and what alterations to the academic major are made, but Marade and Brinthaupt report that two additional years and up to a 50% increase in cost of education could occur as a result of changing majors (Marade & Brinthaupt, 2018). This may in turn delay a students entry into the workforce, potentially losing those years to begin earning a full-time salary as well. Spight reiterates the notion that timely graduation may be adversely affected by major changes. Even though this may not always be the case, he describes how stakeholders place pressure on universities to encourage early career path decisions in order to maintain a quick and clear route to degree completion (Spight, 2018). According to Spight (2018), some of these stakeholders include students, families, colleges and universities, and surrounding communities (p. 1). Universities in particular face pressure to achieve high student graduation rates in order to maintain funding, while students, families, and their communities face the need to produce college graduates in order to avoid additional student debt and create students who are prepared for the workforce (Spight, 2018). In spite of the possible negative outcomes involved with changing majors, students who switch majors may experience certain benefits as well. Marade outlines a variety of positive examples, including having the opportunity to explore multiple subject areas during a critical time of self-discovery. Also, because previous majors may be attributable to the influence of parents or possibly due to an ill-informed or impulsive decision, a new more carefully chosen 7 major in a different area may be more fitting for the individual to achieve academic success. Changing to a major in which a student can be more successful, in terms of grades and knowledge of the subject area, may also be a long-term advantage (Marade & Brinthaupt, 2018). Identification of Student Groups and Majors for Advising Support The University of Indianapolis currently provides a variety of resources for undecided students and students seeking to change majors, particularly through the Professional Edge Center and the Center for Advising and Student Achievement. However, having a greater understanding of the particular types of students and academic majors that are most frequently affected by major-changing decisions would allow for a more tailored experience that could set students on the most efficient path. Some of the specific subgroups of those who change majors include students in STEM majors, students in gender-atypical majors, and first-generation students, which are topics examined in detail by several journal articles (King, 2015; RiegleCrumb, King, & Moore, 2016; Glaessgen, MacGregor, Cornelius-White, Hornberger, & Baumann, 2018). Having greater context as to external factors that influence changes of majors may allow some patterns to become more clear or explainable. Kings article focuses on students who are physical science & engineering majors, whether students remain in this major, and what impact certain factors have on their decision to drop or complete the major. The study highlights several aspects in an effort to determine not only how often, but also why these students decide to alter their majors. Some potential influential elements studied in this research include high school preparation and grades, competitive advantage across majors in terms of the ease of earning higher grades, and future job opportunities. Kings study provides information concerning some data to which this project did not have access, such as high school grades (King, 2015). To combat this issue, student 8 information such as admit type and GPA were included and analyzed in this study, which provided valuable background information about the students who change majors. Authors Reigle-Crumb, King, and Moores article observes the patterns of those students who major in gender-atypical fields. The study found that males who enrolled in femaledominated fields are more likely to change their areas of study than men who major in other subjects. However, females tend to have the same odds of switching majors no matter the field (Riegle-Crumb, King, & Moore, 2016). The social research as to why this is the case as well as implications for future students are both discussed (Riegle-Crumb et al., 2016). The authors of the article First-Generation Students With Undecided Majors: A Qualitative Study of University Reacculturation outline the barriers faced by first-generation college students. As a result of these challenges, first-generation students are not as likely to remain enrolled after their first year as continuing-generation college students. Through performing a case study of 35 students, their research aimed to promote awareness of what the difficulties faced by first-generation students entail. The findings indicate that it is important for these students to have a well-thought-out, preplanned course of action in order to identify the options available as a means of accomplishing their ambitions (Glaessgen, MacGregor, Cornelius-White, Hornberger, & Baumann, 2018). While a study of first-generation students was not explicitly conducted for this project, it is important to work with the knowledge that many groups of students face barriers that may directly or indirectly lead to a change of major or discontinuation of enrollment. Key Terms: One key term in this project is change of major. It is possible that students may change their majors privately before officially declaring this to the Office of the Registrar. This study 9 only tracks those who made documented changes to their majors. A bigger issue was defining what constituted a change of major. Alterations to ones major may include any of the following: changing between colleges within the university; changing majors between very similar majors; changing from exploratory or undecided students to declared majors; changing and/or dropping of double majors, minors, or concentrations; or changing by addition of a second major, minor, or concentration. Some of these modifications may be due to a students choices, but other times, they are out of a students control, as in situations where the university changes the name of a major or the majors that are offered. All of these scenarios have been tracked in the data analysis performed as a part of this project. Exploratory, undecided, and interdisciplinary are terms that have been used previously to denote students who have not yet declared a major, but may be taking general education courses in addition to courses specific to a variety of majors. For this project, these students are only referred to as exploratory students with a label designation of EXPL. The admit type is another main term utilized within this project. The Office of Admissions uses this term to represent the demonstrated aptitude and college readiness of students, which may also suggest the likelihood of degree completion. Admit type is a variable comprised of the following major categories along with their descriptions: Distinct- high level of demonstrated aptitude and college readiness Regular- moderate level of demonstrated aptitude and college readiness Advised- low-moderate level of demonstrated aptitude and college readiness Contingent- low level of demonstrated aptitude and college readiness These levels are determined by high school academic performance, based on criteria including class rank, GPA, and scores from college entrance exams, such as the SAT and ACT. 10 There are explicit values that distinguish which scores fall under each ranking, although these are confidential to the Office of Admissions. The process of assigning an admit type to a student is not always straightforward and can involve a collaborative effort between the faculty admissions committee members. Method/ Procedure: Data Cleaning Information currently collected by the University of Indianapolis detailing academic and demographic statistics of University of Indianapolis students was obtained from the Undergraduate Director of the School of Business via the Office of the Registrar. It was analyzed in order to explore change-of-major trends. To maintain confidentiality, the data was completely deidentified prior to my analysis, and all identifying information such as student name, ID, and address was removed by faculty prior to my receiving the data tables. When analyzing the data, a randomly generated identification number was used to differentiate students. Upon obtaining the final results, there was no effort to reidentify the data or reconnect it to any identifying information including student ID or name. Rather than reporting on individual student trends, data was aggregated for this final report. The data provided for this analysis came from three separate tables, referred to as the Census table, the Major table, and the Graduate table. In order to properly analyze this data, it first had to be cleaned and joined together to form a single output. Census Table Census data from 2007 to 2019 was used for this project since 2007 was the first year that the university transitioned to the current system for storing data: SCT Banner. This dataset 11 contains various demographic characteristics for each student at the university; most notably, it denotes the majors, minors, and concentrations each student has held. Each row in this database represents the characteristics of one student for a single semester. Because this dataset encapsulates so many students over a long time period, it began at a size of approximately 130,000 rows and nearly 60 columns, containing information about more than 29,000 unique students. It was a substantial task to clean this data and create a table that contained only the records that pertain to this study. Upon cleaning the data, the dataset was a more manageable size of approximately 66,000 rows and approximately 30 columns, containing information about approximately 15,000 unique students and encompassing only the relevant and accurate information. In order to clean this data, the Excel file was imported into Tableau Prep, which is a data cleaning software. The first task required to clean this table included removing unnecessary columns. Columns were removed for a few different reasons. One reason that a column may have been removed was because it contained duplicate information already listed in another column. Because this data is used for a variety of reporting purposes, the data has been duplicated and presented in different formats that essentially show the same information to fit the needs of the various people who access it. Another reason to remove a column of data was to eliminate variables that were irrelevant to the scope of this project. An additional step performed was renaming the column titles, in order to clearly state the contents of each field. In some situations, it was also necessary to split a single column into multiple columns to allow for analysis on two separate data points. For example, the Term is formatted at YYYYSS, with the Y representing year and S representing semester. In order to perform analysis on only the year or only the semester, this field was split into the two separate columns of Term Year and Term Semester. Filtering columns was also necessary. For example, this project focused on 12 Undergraduate students, so Graduate students were filtered out of the dataset. Changing the data type was also necessary for some fields. It was important to correctly identify which variables were String, Number, and Date variables in order to be able to correctly perform calculations. Not all fields that contain numbers were actually numeric data, such as Term. Grouping of values within a field also occurred as a part of this cleaning process. For example, Psychological Sciences was grouped with Applied Behavioral Sciences. While these appear to be two separate colleges, in reality it is one unit that changed names over time. To address this issue, these values were grouped into a single college title. Each of these tasks are represented as individual clean steps in Tableau Prep, and all of the changes made are recorded in Table 1. 13 Table 1: Census Table Column Name Removed? TERM Renamed To Term PIDM Filters/ Actions Data Role Split into two additional columns: Term Semester= RIGHT([TERM],2) and Term Year= LEFT([TERM],4) Dimension Data Type String DEGC PROGRAM GRAD_TERM Term represents both the year and semester number. It was split into two columns in order to allow for analysis on semester and year separately. String In order to ensure confidentiality, this identifying number is not the University Student ID. Instead, it is a randomly generated number created internally within the database. The level of education that the student is pursuing, filtered to only include Undergraduates. Dimension String The type of academic degree the student is pursuing. Dimension String The date that a student is expected to graduate, based on the term enrolled. It was split into two columns in order to allow for analysis on semester and year separately. Student ID Filter to include only Undergraduate Level LEVL COLLEGE Definition Removed Degree Removed Grad Expected Term Split into two additional columns: Grad Expected Term Semester= RIGHT([GRAD_TE RM],2) and Grad Expected Term Year= LEFT([GRAD_TER M],4) 14 MAJOR_1 Dimension String Dimension String Dimension String Dimension String Dimension String Dimension String Dimension String Measure Number Hours Earned Measure Number Transfer Hours Measure Number Major 1 MAJOR_2 Major 2 MINOR_1 Minor 1 MINOR_2 Minor 2 CONC_1 CONC_2 KEY_ADVISOR IACRAO_CLASS CUM_OVER_HRS_ ATTEMPT CUM_INST_HRS_ ATTEMPT CUM_OVER_HRS_ EARNED CUM_INST_HRS_ EARNED CUM_TRANS_HR S_EARNED Conc 1 Conc 2 The primary major. Every student has a value for Major 1. The students second major. Students are not required to have a Major 2. The students minor. Students are not required to have a Minor 1. The students second minor. Students are not required to have a Minor 2. The students concentration. Students are not required to have a Concentration 1. The students second concentration. Students are not required to have a Concentration 2. Removed Class Hours Attempted Removed Removed Designates student class level: freshman, sophomore, junior, or senior. This is based off of the number of credit hours, not the number of years that a student has attended the university. 15 CUM_OVER_GPA _HOURS CUM_INST_GPA_ HOURS CUM_OVER_QPOI NTS CUM_INST_QPOI NTS CUM_OVER_GPA CUM_INST_GPA DIVISION SUBDIVISION COLLEGE_TITLE CT_ORDER CT_STATUS CREDIT_HRS BILL_HRS CRSE_CNT Measure Number Measure Number Overall GPA Dimension String The title of the college, or the unit, within the University of Indianapolis. Credit Hours Measure Number Total Credit Hours Course Count Measure Number Number of Courses GPA Hours Removed Removed Removed GPA Overall Removed Removed Filter to include Day Undergraduate only Removed College Title Grouped and replaced Psychological Sciences with Applied Behavioral Science. Grouped and replaced Physical Therapy with Health Services. Removed Removed Removed 16 FTPT COHORT UG_ADMISSION CONTINUE CTLG_TERM ADMIT_UG ADMIT_GRAD ADMIT_DOC ADMIT_FIRST STU_ATTRIB DECISION_CODE Full Time vs. Part Time ENROLLED_DATE String Full Time Student (12 credit hours) vs. Part-time student (fewer than 12 credit hours) Dimension String The admit type is a key variable in understanding the students background. This may also indicate whether or not a student is more likely to persist within his or her major. In order of highest to lowest, the following are current options for admit type: distinct, regular, advised, and contingent. The admit type of the student is classified based on demonstrated aptitude and college readiness, which could indicate the likelihood of degree completion. This is also related to the determination by admissions of credit hour enrollment capabilities. Dimension Date The date enrolled at the University Removed Removed Removed Removed Removed Removed Removed Removed Removed Removed Filter to include only Distinct, Regular, Advised, and Contingent DECISION STUDENT_TYPE ADMIT Dimension Admit Type Removed Removed Enrolled Date 17 In addition to all changes noted in Table 1, it was determined that the GPA values of 0.0 also needed to be cleaned. Upon initial inspection, the average GPA value seemed much lower than expected. This was due to the fact that many 0.0 GPA values were included within the dataset. Many of these values belonged to students who had a GPA of 0.0 simply because they did not yet have any GPA hours, rather than having truly earned a GPA of 0.0. Many students who had only been enrolled for one semester fell under this category, since they had not yet earned a GPA. In order to clean these rows to mitigate this issue, the values of 0.0 GPA were replaced with a value of NULL for those students who did not have any GPA hours. The formula which performed this change for GPA Overall was as follows: IF [GPA Hours] != 0 THEN [GPA Overall] ELSE NULL END. Following this, a step was added to remove all students who had only attended the university for one semester. The number of rows, which also denotes the number of semesters, was aggregated at the Student ID level. Any Student ID with only one row was excluded from the analysis since students cannot change majors, minors, or concentrations within a single semester. Major Table In addition to student data, it was necessary to obtain and analyze data related to the specific majors, minors, and concentrations. This refers to which majors are offered by the university as well as data clarifying which majors have changed names over time. For example, Information Systems and Business Analytics majors have been labeled with various major codes in the past including CIS, MIS, IS, and ISA. All of these codes needed to be grouped into one consistent code in order to accurately determine if a student actually changed majors, or if the title of their major was altered. Had this step been ignored, many more students would have 18 appeared to have changed majors in the final analysis, when in reality they stayed in the same major and only the name of the major had changed. Another example that illustrates this issue occurs for Nursing majors. There were 29 different Nursing codes that were ultimately grouped into two major codes for Associate and Bachelors of Nursing. Because Nursing codes vary slightly in order to track students from an accreditation perspective, there are many different codes that all represent a Bachelors of Nursing. Grouping these codes was not eliminating Nursing majors, it simply prevented the software from incorrectly identifying changes of major that were in reality slight changes in the code used to designate the same major. In order to accomplish this task of properly identifying majors across time, majors were grouped based on their shared names. A key factor used to create these groupings was the Classification of Instructional Programs Code, also known as CIPC. This numeric code is listed in the existing major table for each major, and the descriptive titles associated with this code are regularly updated and provided on the National Center for Education Statistics website (My CIP Code Summary Report, 2020). The list of updated CIPC titles for 2020 was utilized to create a table listing all of the numeric codes and their corresponding titles. In Excel, a vlookup function was employed in order to match the numeric CIPC in the existing table with the most recent title from the NCES website. This was done to apply a single, consistent name, deemed the Grouped Description, to all of the majors that changed names over time. Upon identifying the Grouped Description utilizing the CIPC, the Grouped Major Codes were manually added into the table. These codes are all three- or four-digit alphanumeric codes based on the Grouped Description title. This product is included in the Appendix. After determining the Grouped Major Codes, the updated Excel sheet was imported into Tableau Prep for further data cleaning. This included removing unnecessary columns. The 19 columns that were removed, Major Code and Major Description, were ultimately replaced by the more accurate Grouped Major Codes and descriptions, so leaving these columns in the analysis would have been redundant and inaccurate. Columns were also renamed in order to provide a more clear description of the data represented. This data is recorded in Table 2. 20 Table 2: Major Table Column Name CIPC Major Code Major Description Removed? Renamed Filters/Actions Data Role Data to Type Dimension String Major Code Grouped College The Classification of Instructional Programs Code Removed Removed Major Code (grouped) Grouped Description Definition Major Desc (grouped) College (Major) Dimension String The three- to four-digit alphanumeric code denoting the major, minor, or concentration name after being grouped based on CIPC. Dimension String The major description after being grouped based on CIPC. Dimension String The college in which the student belongs, based on his or her Major 1. 21 In order to create a cohesive output of data, it was necessary to join the Major table data with the Census table data. Because the data was contained in two separate tables, it would not have been possible to analyze all of the data at once. Joining the tables served to combine the multiple columns from these two tables into one single table. In this case, the original major codes from the Major table had to be joined with the major codes in the Census table in order to apply the newly grouped major code to each line of data in the Census table. Without this join, it would not have be possible to identify the true major code of each student, since the Census table did not include the grouped Major Code column and the Major table did not contain individual student records. The matching columns between these two datasets, which served as the join key, were the original Major Code in the Major table as well as Major 1, Major 2, Minor 1, Minor 2, Concentration 1, and Concentration 2 in the Census table, resulting in a total of six joins. These fields were joined on a left join, meaning all of the data from the Census table was matched to the data in the Major table. Any records that appeared in the Major table, but did not appear in the Census table, were excluded. After each join, the original Major/Minor/Concentration columns as well as the Major Code column were removed in order to leave only the newly created Grouped Major column to work off of in the final analysis. All of the grouped columns were then renamed as follows: Major 1, Major 1 Description, Major 2, Major 2 Description, Minor 1, Minor 1 Description, Minor 2, Minor 2 Description, Concentration 1, Concentration 1 Description, Concentration 2, and Concentration 2 Description. The next step in cleaning the combined Census and Major data involved replacing null values in the Major 2, Minor 1, Minor 2, Concentration 1, and Concentration 2 columns. Students are required to have a Major 1, but none of the other categories are mandatory. In order 22 to more clearly identify which students have elected to not fulfill these particular categories, the default null value was replaced with N/A. This was achieved by creating five calculated fields for each of these five values. The formula for these calculated fields reads: IFNULL([Major 2], "N/A"). For each calculation, the Major field is replaced with the appropriate corresponding field. Graduate Table Another factor contained in this study is the comparison of the expected graduation date and the actual graduation date of the major-changing students. In order to access this information, another dataset known as the Graduate table was utilized. The steps required in the cleaning of this table are listed in Table 3. 23 Table 3: Graduate Table Column Name Removed? Renamed To Filters/ Actions Data Role Dimension Data Type String Student ID PIDM Removed Filtered to keep only Undergrads Number LEVL GRAD_TERM Grad Actual Term Split into two additional columns: Grad Actual Semester= RIGHT([Grad Actual Term],2) and Grad Actual Year= LEFT([Grad Actual Term],4) Measure Number Definition In order to ensure confidentiality, this identifying number is not the University Student ID. Instead, it is a randomly generated number created internally within the database. The level of education that the student is pursuing, filtered to only include Undergraduates. The students actual graduation date. It was split into two columns in order to allow for analysis on semester and year separately. 24 Finally, the Graduate table data was joined with the previously joined Census and Major tables. This was performed to combine all of the data into one final table. The common field between these two tables was the Student ID, which was used as the join key in order to correctly apply the data from each tables columns to the appropriate row. A left join was utilized to capture all of the students included in the Census data. This means that any records that appeared in the Graduate table, but did not appear in the Census table, would have been excluded. The records excluded from the Graduate table would have consisted of the graduate students and any other students who were not ultimately included in the Census table for the purpose of this study. It is also important to note that not all rows in the final joined table included an actual graduation date, since not all of the students in the Census data had graduated. This concludes the data cleaning portion of the project which utilized Tableau Prep. The following analysis of the data was performed by importing the Tableau Prep output into Tableau. Tableau is a data visualization software that can be used to analyze data. Data Analysis Process Analysis of the data first involved identifying how many students changed majors over the course of their education for each of the categories of major, minor, and concentration as well as to what their majors were changed. To accomplish this, the process involved identifying the major of a student in one term and then identifying the major held by the same student for the previous term. If the name of the major was the same for both that term and the previous term, this indicated that the student did not change majors in that term. If the names of the majors for each term were different, this meant that the student did change majors for that term. In order to identify this for every single student without manually checking every row of data and then 25 comparing these to their previous terms, a variety of calculations were created utilizing Tableau. The technical steps performed in Tableau are provided. The entire process involved identifying string changes, which are changes in text. This step required a logical comparison of two strings of major code to see if the name in the major column was the same or different for a single student over the course of multiple semesters. In order to complete this task, a variety of calculations were performed. First, six calculations were executed to create new dimensions for Major 1 through Concentration 2: lookup(min([Major 1 (G)]), -1). For each calculation, the Major field was replaced with the appropriate corresponding field. Essentially, this calculation was used to identify a students previous major so as to compare majors across semesters. The lookup function was performed relative to the current row, which is a single term. The -1 in the calculation signifies that the calculation should return the value of the previous row, or in this case, the previous term. In order to prevent the calculation from returning values of other students in the dataset, it was set to compute restarting for every Student ID. Once each students previous major and actual major were identified for every term, these two values could be compared to see if they stayed the same or changed. Six more calculations were created for Major 1 through Concentration 2: min([Major 1 (G)]) <> lookup(min([Major 1 (G)]), -1). For each calculation, the Major field was replaced with the appropriate corresponding field. This calculation compares the students previous major (found in the second half of the equation) to the current major (the first half of the calculation). The calculation is labeled Major 1 Changed (T/F). If the majors identified do not equal each other, then the value is True. This means that the student did change majors since the previous term because the alphanumeric strings of Major 1 and Major 1 Previous do not match. If the majors 26 identified do equal each other, then the value is False. This means that the student did not change majors since the previous term because the alphanumeric strings of Major 1 and Major 1 Previous do match. Upon formulating these calculations, six tables were created utilizing the variables of Student ID, Term, Major/Minor/Concentration Previous, Major/Minor/Concentration, Major/Minor/Concentration Changed(T/F), Admit Type, GPA Hours, Hours Attempted, Hours Earned, Class, Grad Actual, and Grad Expected. The six individual tables covering Major 1, Major 2, Minor 1, Minor 2, Concentration 1, and Concentration 2 were all saved as CSV files and imported into individual Tableau files, in order to allow for filtering on the calculated variables without disrupting related calculations. To further analyze the time to graduation as impacted by the change of majors, a calculation was created to subtract the Grad Expected value from the Grad Actual value. A value of 0 meant that the Grad Expected Term was the same as the Grad Actual Term, indicating that the student did graduate on time. Any value that was not 0 meant that the Grad Expected Term was not the same as the Grad Actual Term, indicating that the student did not graduate on time. However, due to inaccurate source data, this calculation was ultimately not able to be used, which will be further discussed in the Analysis/ Conclusion section. Product Produced The overall product of this project included a Tableau Prep file which wholly cleaned and manipulated the three provided data files and prepared it for further analysis. The Tableau Prep software allowed for the cleaning of the data to be performed in individual steps, which are represented as nodes. Each step in the process refined the three provided data files through steps such as removing unneeded columns, renaming columns, changing the designated data type, and 27 joining the tables together. The output of Tableau Prep was a single table of data that could then be imported into Tableau. Within Tableau, the analysis of the data was performed and the individual visualizations were created. The first Tableau file produced a clear picture of the changes in Major, Minor, and Concentration for every student and every term that was presented in the cleaned data. This was achieved by applying the various calculations to the entire set of data. The subsequently created Tableau files supplied individual visualizations for Major 1, Major 2, Minor 1, Minor 2, Concentration 1, and Concentration 2 changers, comparing these groups at a high level to the other variables in order to identify trends and correlations among them. The final product will enable the university to more readily acquire and learn relevant data about students major-changing choices, so that staff can make more informed decisions in selecting and implementing appropriate student resources and support. The procedures and processes by which these outputs were created can also be replicated for future data and research. This is valuable because prior to this project there was no way to access succinct, comprehensible information regarding changes of major in previous University of Indianapolis reports. With the establishment of these techniques and steps, the university has the capability to more easily identify and analyze the major-changing trends of students in the future. This is vital so that services may be adapted to the evolving actions and needs of students. Results From the data generated, the results of this project include an examination of the following aspects: change of majors/minors/concentrations, admit type, GPA, and credit hours. With a focus on key observations regarding these aspects, implications of the UIndy trends are also considered and provided. As outlined in the Literature Review, major changing is not an uncommon phenomenon, with many students changing their majors, minors, and concentrations 28 each year. Within the provided dataset of University of Indianapolis students, there were nearly 7,000 occurrences of a change of Major 1 alone, which displays the potential to delve deeper into the trends of changing majors. Change of Majors/Minors/Concentrations First, the most popular majors to change out of were observed. It was somewhat surprising to find that the most common Major 1 to change from was Exploratory, with 839 unique students having done so (Figure 1). This does make sense logically since students do not ultimately graduate as Exploratory, having had to choose a different major prior to graduation. However, I had hypothesized based on the negative connotations held by many students surrounding major changes, as described in the literature review, that students would be more likely to initially pick a major in a specific discipline even if they were unsure about it. Then, I reasoned that they would eventually decide to change from their first selections, instead of from the more ambiguous Exploratory designation. However, this is an encouraging statistic since some researchers from the literature review believe that major exploration is advisable. 29 Figure 1: The Majors that students changed "from" (i.e., their previous Major 1) and the number of unique students that changed from that previous Major 1. 30 In every other category of Major 2, Minor 1, Minor 2, Concentration 1, and Concentration 2, the most popular action was adding a major, minor, or concentration after having previously held none (N/A). This suggests that there is not one particular area of study that students are more likely to change from, but instead they are willing to add additional courses of study to the majors that were previously held. This may mean that resources should be focused toward helping more of these students manage the challenge of additional course work, rather than easing a transition between two different courses of study. It is important to note that the faculty and students associated with majors higher up on this list of majors that students change from should not necessarily be discouraged that individuals are leaving the major. A high placement on the list is certainly not indicative of a greater percentage of students leaving the major as compared to other majors because it is possible that a greater number of students declared this major in the first place. Additionally, other students could be simultaneously electing to move into the major, effectively equaling out the loss of students changing out of the major. No matter the perceived positive or negative actions, it is important to recognize whether this is a current phenomenon so that university staff may better understand how to guide students through such a transition. The most popular majors to change from for Major 2 through Concentration 2 are listed in Figures 2 through 6. 31 Figure 2. The Majors that students changed "from" (i.e., their previous Major 2) and the number of unique students that changed from that previous Major 2. 32 Figure 3. The Minors that students changed "from" (i.e., their previous Minor 1) and the number of unique students that changed from that previous Minor 1. 33 Figure 4. The Minors that students changed "from" (i.e., their previous Minor 2) and the number of unique students that changed from that previous Minor 2. 34 Figure 5. The Concentrations that students changed "from" (i.e., their previous Concentration 1) and the number of unique students that changed from that previous Concentration 1. 35 Figure 6. The Concentrations that students changed "from" (i.e., their previous Concentration 2) and the number of unique students that changed from that previous Concentration 2. 36 In order to more closely analyze the majors, minors, and concentrations that are changed from, the majors that these students ultimately moved into were also tracked. In looking only at the subset of the most popular majors, minors, and concentrations to change from (EXPL and N/A), the most popular Major 1, Major 2, Minor 1, and Minor 2 to move to were all PSYC: psychology. The Concentrations varied with CRIM, criminal justice/ police science, being the top Concentration 1 and PMED, pre-med, being the top Concentration 2. Psychology is clearly one of the more predominant areas of study at the University of Indianapolis. However, it is beneficial to realize that many of these students are beginning the major after already spending at least one semester at the university. This could be helpful as advisors and professors guide these PSYC students, particularly by recognizing that many of these students already have some experience with university practices and functions. However, many are also adding on a second major or minor after previously holding none, so some of these students may be adjusting to a heavier course load or managing study in two academic fields simultaneously. Figures 7 through 12 detail the most common majors that students change out of as well as the most common majors that those students move into. 37 Figure 7. The number of unique students for Major 1 that students changed "from" (i.e., their previous Major) and the Major 1 they moved "to." 38 Figure 8. The number of unique students for Major 2 that students changed "from" (i.e., their previous Major) and the Major 2 they moved "to." 39 Figure 9. The number of unique students for Minor 1 that students changed "from" (i.e., their previous Minor) and the Minor 1 they moved "to." 40 Figure 10. The number of unique students for Minor 2 that students changed "from" (i.e., their previous Minor) and the Minor 2 they moved "to." 41 Figure 11. The number of unique students for Concentration 1 that students changed "from" (i.e., their previous Concentration) and the Concentration 1 they moved "to." 42 Figure 12. The number of unique students for Concentration 2 that students changed "from" (i.e., their previous Concentration) and the Concentration 2 they moved "to." 43 Another point of observation was which majors are the most likely to be moved into overall, no matter the students previous majors. Again, the most popular to move into for Major 1 was PSYC: psychology. The reappearance of PSYC on this list confirms that there is simply a larger population of students involved in PSYC, rather than it being a major that people are especially likely to avoid or add as compared to others. However, this does mean that it is important for staff and advisors to be especially prepared for both situations. First, they may need to assist students with finding alternative majors if they decide to change from PSYC, and second, they may need to help prepare many new PSYC students who are switching over from a previous field of study. In every other category, the most frequent action was dropping a major, minor, or concentration and not replacing it. This reveals that there is not one particular area of study that students are more likely to move into. In addition, this may indicate that students decide to drop areas of study before figuring out new ones to adopt, which also suggests that a new interest in an alternative major, minor, and concentration did not instigate the decision to drop previous ones. Based on this scenario, it may be worthwhile to pursue this for future research, primarily to determine if and when these students replace their dropped majors, minors, or concentrations. Depending on the findings of such an investigation, this could prove to be an area that demands more attention and guidance. All of the details for the popular Major 1 through Concentration 2s to move into are shown in Figures 13 through 18. 44 Figure 13. The Major 1 that students moved "to" (i.e., their current Major 1) and the number of unique students that moved "to" the current Major 1. 45 Figure 14. The Major 2 that students moved "to" (i.e., their current Major 2) and the number of unique students that moved "to" the current Major 2. 46 Figure 15. The Minor 1 that students moved "to" (i.e., their current Minor1) and the number of unique students that moved "to" the current Minor 1. 47 Figure 16. The Minor 2 that students moved "to" (i.e., their current Minor 2) and the number of unique students that moved "to" the current Minor 2. 48 Figure 17. The Concentration 1 that students moved "to" (i.e., their current Concentration 1) and the number of unique students that moved "to" the current Concentration 1. 49 Figure 18. The Concentration 2 that students moved "to" (i.e., their current Concentration 2) and the number of unique students that moved "to" the current Concentration 2. 50 Admit Type Another key consideration in examining the results of the data was the admit type of the students who did or did not change majors. To review, admit type is the classification provided by the Office of Admissions to denote the demonstrated aptitude and college readiness of students. The level of demonstrated college aptitude and readiness is ranked from high to low in the order of Distinct, Regular, Advised, and Contingent. Of all the admit types, the one with the greatest percentage to exhibit changes of major, minor, or concentration was the Distinct group of students. These are the students who were admitted based on the highest level of demonstrated aptitude and college readiness. The percentages of Distinct students who did change majors was 14.08% for Major 2, 27.85% for Minor 1, 6.18% for Minor 2, 17.01% for Concentration 1, and 3.31% for Concentration 2. These percentages were higher than in any other admit type. This only varied in the Major 1 category, in which a higher percentage of Advised students changed majors, at 34.382%. These are the students who were classified with a low-moderate level of demonstrated aptitude and college readiness. This implies that particularly those students who are admitted as Distinct may need extra resources to assist them with transitioning between various second majors, minors, and concentrations in order to supplement their Major 1. Despite the fact that these students demonstrate a high level of college readiness, it should not be assumed that all of these students have made concrete decisions regarding their choices of major. As described in the literature review, background information about students can be used to classify groups of students and identify causes of major-changing behavior. In this situation, it is important to remember that the high correlation between having a Distinct admit type and changing majors does not necessarily mean that this factor is the underlying cause of the change of major. However, understanding this 51 background information and classification does reveal the past trends in major changing for these classifications of students, which may influence the approach and perspective that one could take in future research. For example, it may be worth investigating the possible influence that a dualcredit curriculum has on early major selection and eventual changes of college major for Distinct students who may have participated in advanced-placement programs during high school. All of the specific numbers, as well as the percentage of each category, are listed in Figures 19 through 24. These figures are supplemented by crosstabulations in Tables 4 through 9. These crosstabs allow for the identification of correlations between the two variables of admit type and whether or not students changed majors. 52 Figure 19. The unique number of students for each admit type, split into FALSE (those who did not change their Major 1) and TRUE (those who did change their Major 1). Table 4: Percent of Admit Type of Major 1 Changers Advised Did not change Major Did change Major Percent of Students who changed Major Contingent Distinct Regular 1773 352 2948 9516 929 181 946 3334 34.382% 33.959% 24.294% 25.946% 53 Figure 20. The unique number of students for each admit type, split into FALSE (those who did not change their Major 2) and TRUE (those who did change their Major 2). Table 5: Percent of Admit Type of Major 2 Changers Advised Contingent Distinct Regular Did not change Major Did change Major Percent of Students who changed Major 1943 388 3009 9908 207 28 493 1050 9.627% 6.730% 14.07% 9.582% 54 Figure 21. The unique number of students for each admit type, split into FALSE (those who did not change their Minor 1) and TRUE (those who did change their Minor 1). Table 6: Percent of Admit Type of Minor 1 Changers Advised Did not change Minor Did change Minor Percent of Students who changed Minor Contingent Distinct Regular 1926 383 2968 9806 532 81 1146 2774 21.643% 17.456% 27.856% 22.0508% 55 Figure 22. The unique number of students for each admit type, split into FALSE (those who did not change their Minor 2) and TRUE (those who did change their Minor 2). Table 7: Percent of Admit Type of Minor 2 Changers Advised Contingent Distinct Regular Did not change Minor Did change Minor Percent of Students who changed Minor 1964 392 3020 9999 52 7 199 360 2.579% 1.754% 6.182% 3.475% 56 Figure 23. The unique number of students for each admit type, split into FALSE (those who did not change their Concentration 1) and TRUE (those who did change their Concentration 1). Table 8: Percent of Admit Type of Concentration 1 Changers Advised Did not change Concentration Did change Concentration Percent of Students who changed Concentration Contingent Distinct Regular 1899 385 2996 9846 373 60 614 1542 16.417% 13.483% 17.008% 13.540% 57 Figure 24. The unique number of students for each admit type, split into FALSE (those who did not change their Concentration 2) and TRUE (those who did change their Concentration 2). Table 9: Percent of Admit Type of Concentration 2 Changers Advised Contingent Distinct Regular Did not change Concentration Did change Concentration Percent of Students who changed Concentration 1965 393 3037 10015 20 5 104 136 1.007% 1.256% 3.311% 1.339% 58 GPA GPA was another key aspect in analyzing the results of this project. The average of all GPAs for those students who did not change their Major 1 through Concentrations 2 is 2.7313, while the average of all GPAs for those students who did change their Major 1 through Concentration 2 is 2.6858. Because all of these GPAs are averaged and there is no way of identifying the final GPA upon graduation, the .0455 difference between these averages may not be significant enough to indicate that there is a major correlation between a students decision to change majors and his or her overall GPA. However, it would be advisable to more closely monitor any possible correlation as future data may more accurately reflect the reality of undergraduate students. It could turn out that at some point a significant difference does come to fruition, and then those who change majors may actually necessitate additional assistance to achieve and maintain a higher GPA. If so, it may be valuable to learn if a students academic difficulties with the first major were the main cause of a lower GPA and the decision to change majors. This is not to suggest that specific majors would need to lessen the rigor of their programs to retain students, but to propose that faculty be aware that these students may require extra support once they change majors to be successful in reaching graduation. The average GPA values for each category of Major 1 through Concentration 2 are shown in Figures 25 through 30. 59 Figure 25. Average GPAs, split into FALSE (those who did not change their Major 1) and TRUE (those who did change their Major 1). 60 Figure 26. Average GPAs, split into FALSE (those who did not change their Major 2) and TRUE (those who did change their Major 2). 61 Figure 27. Average GPAs, split into FALSE (those who did not change their Minor 1) and TRUE (those who did change their Minor 1). 62 Figure 28. Average GPAs, split into FALSE (those who did not change their Minor 2) and TRUE (those who did change their Minor 2). 63 Figure 29. Average GPAs, split into FALSE (those who did not change their Concentration 1) and TRUE (those who did change their Concentration 1). 64 Figure 30. Average GPAs, split into FALSE (those who did not change their Concentration 2) and TRUE (those who did change their Concentration 2). 65 Credit Hours Credit hours was the final area of focus for the results of this project. The number of credit hours in which a student is enrolled and the time it takes to reach a degree are typically highly correlated. Thus, it is likely that those with more credit hours took longer to graduate. For both Major 1 and Major 2, the students who changed majors had a greater number of both attempted and earned credit hours, as compared to the students who did not change majors. An implication of this finding may be a higher cost of education for students who changed majors since they completed more credit hours on average by their senior year. Trends involving credit hours for majors are illustrated in Figures 31 and 32. Figure 31. The Average Hours Earned and the Average Hours Attempted, split into FALSE (those who did not change their Major 1) and TRUE (those who did change their Major 1). 66 Figure 32. The Average Hours Earned and the Average Hours Attempted, split into FALSE (those who did not change their Major 2) and TRUE (those who did change their Major 2). 67 For Minor 1, Minor 2, and Concentration 1, students who changed their majors exhibited a higher average of attempted credit hours than those who did not change their Minor 1, Minor 2, and Concentration 2. However, the students who did not change had a higher number of earned credit hours in each of these categories. This could indicate that the students who did not change majors are getting more for their money, since they do end up earning those credits. Data regarding credit hours for minors and concentrations are shown in Figures 33, 34, and 35. Figure 33. The Average Hours Earned and the Average Hours Attempted, split into FALSE (those who did not change their Minor 1) and TRUE (those who did change their Minor 1). 68 Figure 34. The Average Hours Earned and the Average Hours Attempted, split into FALSE (those who did not change their Minor 2) and TRUE (those who did change their Minor 2). 69 Figure 35. The Average Hours Earned and the Average Hours Attempted, split into FALSE (those who did not change their Concentration 1) and TRUE (those who did change their Concentration 1). 70 Interestingly, those students who did not change their Concentration 2 both attempted and earned more credit hours on average than those who did change their Concentration 2. It is possible that outliers in the group of students who did not change majors created this larger number. The number of students who did change Concentration 2 is relatively small, so this could explain the difference from the previous visualizations regarding Credit Hours. Information for Concentration 2 is illustrated in Figure 36. Figure 36. The Average Hours Earned and the Average Hours Attempted, split into FALSE (those who did not change their Concentration 2) and TRUE (those who did change their Concentration 2). 71 Analysis/ Conclusion This project fully addresses the areas of exploration outlined in the proposal. It includes information about the most popular majors to change from and move to, the background of those students (admit type), the examination of how GPA may be correlated with changing academic major, and time to degree, which is represented by credit hours. It also attempted to calculate and display the actual and expected graduation comparison. In accordance with the precedence set by the research provided in the literature review, the background of those students was observed, via admit type, in order to better categorize the major-changing outcomes. As a whole, major-changing students at the University of Indianapolis tend to add and drop majors more frequently than they transition directly between majors. In addition to N/A (no major/minor/concentration) being popular to both change from and move into, EXPL (exploratory majors) was also popular to move from. The percentage of those who change majors is higher among those with the admit types of Distinct and Advised. The percentages of Distinct students who did change majors was 14.08% for Major 2, 27.85% for Minor 1, 6.18% for Minor 2, 17.01% for Concentration 1, and 3.31% for Concentration 2. A higher percentage of Advised students changed their Major 1, at 34.382%. The average of all GPAs for those students who did not change their Major 1 Concentrations 2 is 2.7313, while the average of all GPAs for those students who did change their Major 1 Concentration 2 is 2.6858. These are not vastly different statistics, showing little correlation between GPA and change of major. Those who did change majors attempted more credit hours on average, which could indicate a longer time to degree and more money spent on earning college credits. In order to expand upon the results gleaned from this research, additional questions can be asked of this data for further exploration. One area of research that could prove to be valuable 72 in the future is researching whether students are more prone to change their majors within a college at the University of Indianapolis or whether it is more likely for students to change across different colleges at the university. This could reveal the level of academic preparedness for students changing majors as well as implications for time to graduation. It is likely that those moving within the same college would not require as many additional credit hours, since credits from the previous major may apply to their new majors. Another area of study for future research could involve tracking the major-changing experiences of athletes versus non-athletes. It would be interesting to know if athletes have any influences that may guide them into exploring more majors, or conversely, staying with the same major. The differences that exist between athletes and non-athletes could provide more background regarding the likelihood of major-changing habits in the future. Additionally, the current research and methodology could be taken to an even more granular level in order to see if there are significant differences in student trends or outcomes between those who change majors early in their college careers versus those who change majors as upperclassmen. This comparison may show the implications, be they positive or negative, of waiting to change majors after already completing many credit hours. Such research could guide advising practices with setting policy guidelines for declaring and/or changing majors as well as providing resources and support. Finally, comparing the exact time to graduation between students who change majors and those who do not change majors could stand to be more closely observed. This effort was made as a part of this project, but in the end was unable to be used. The methodology for performing such an analysis was created, but it was ultimately invalid due to inaccurate data. Initially, it was believed that Expected Graduation Date data was always updated to reflect the term in which a 73 student should graduate based on the credit hours required to graduate in four years. However, the Expected Graduation date field is actually an estimate, set to five years after the admit term. It is not updated or adjusted based on the number of credit hours in which the student enrolls. The ineffective analysis shown in Figure 37 displays the amount of time difference between the Expected and Actual Graduation. 74 Figure 37. The difference between the Actual and Expected Graduation Term for each student. The number of unique students who hold each value is listed. Based on the current data, it appears that most students either graduate on time (0) or a term early (-100). However, because Expected Graduation date is not reliably generated, this analysis should not be taken as fact. Although this data could not be accurately analyzed within 75 this project, it was not a wasted effort. The method by which future data could be analyzed has been outlined and modeled, so future semesters of accurate data collected through a program such as DegreeWorks can be properly observed. In the event that this study was to be continued, it is important to remember the parameters upon which the descriptive analysis was performed. This data includes only undergraduate students, so expanding future studies to include graduate students may reveal different results. Reflection Overall, this project was both personally and professionally important to me. I started at the University of Indianapolis as an exploratory student who had not yet decided on a major, so I understand the challenges of finding ones career path, the value of receiving support to determine a major, and the benefits of having decided which major and career to pursue. This project allowed me to practice both business understanding and technical understanding, which are key skills for my major: Information Systems and Business Analytics. The business understanding that was required for this project involved understanding how the university stores student data and what that data really means. It was crucial to understand how the major names changed over time and identify which majors needed to be grouped together. Additionally, understanding the meaning behind each of the columns was necessary. This was especially evident in the case of the expected graduation date, since it did not represent the data that was initially believed to exist. The technical understanding that occurred throughout this project concerned the main areas of cleaning data and building visualizations. Utilizing the Tableau software proved to be useful in that it allowed for greater understanding of the provided data. The experience gained 76 from employing business and technical understanding as well as related techniques will enable me to perform similar analysis in future projects. 77 References Cunningham, K. & Smothers, A (2014). The Effect of Career Cruising on the Selfefficacy of Students Deciding on Majors. NACADA Journal, 34(2), 16-25. Retrieved from https://doi.org/10.12930/NACADA-13-033\ Glaessgen T., MacGregor C., Cornelius-White J., Hornberger R., and Baumann D. (2018) FirstGeneration Students With Undecided Majors: A Qualitative Study of University Reacculturation. NACADA Journal, 38(1), 22-35. Retrieved from https://doi.org/10.12930/NACADA-16-030 King, B. (2015). Changing College Majors: Does It Happen More in STEM and Do Grades Matter? Journal of College Science Teaching, 44(3), 44-51. Retrieved from https://ezproxy.uindy.edu/login?url=http://search.ebscohost.com/login.aspx?direct=true& db=eric&AN=EJ1050940&site=ehost-live Leu, K. (2017). Beginning College Students Who Change Their Majors Within 3 Years of Enrollment. National Center for Education Statistics, Retrieved from https://nces.ed.gov/pubsearch/pubsinfo.asp?pubid=2018434 My CIP Code Summary Report. (2020). Retrieved February 11, 2020, from https://nces.ed.gov/ipeds/cipcode/wizard/report.aspx Marade, A. A., & Brinthaupt, T. M. (2018). Good and Bad Reasons for Changing a College Major: A Comparison of Student and Faculty Views. Education, 138(4), 323336. Retrieved from https://ezproxy.uindy.edu/login?url=http://search.ebscohost.com/login.aspx?direct=true& db=eric&AN=EJ1180201&site=ehost-live 78 Riegle-Crumb, C., King, B., & Moore, C. (2016). Do They Stay or Do They Go? The Switching Decision of Individuals Who Enter Gender Atypical College Majors. Sex Roles: A Journal of Research,74, 436-449. doi:10.1007/s11199-016-0583-4 Sklar, J. (2018) Event History Analysis for Investigating the Likelihood and Timing of Changing Majors. NACADA Journal, 38(1) 47-60. doi:10.12930/NACADA-17-039 Spight, D. B. (2018). Early Declaration of a College Major and Its Relationship to College Student Persistence. ProQuest LLC. Retrieved from https://ezproxy.uindy.edu/login?url=http://search.ebscohost.com/login.aspx?direct=true& db=eric&AN=ED585673&site=ehost-live 79 Appendices Table 10: Major Grouped Descriptions CIPC Major Code 30103 EGEO 30104 ENSC 50103 ASTD Major Description Earth-Space Sci/Env Geol Conc Environmental Science Asian Studies Major Code Grouped College 90101 COMM Communication (COMM) COMM 90101 VISJ 90401 JOUR Visual Journalism Journalism COMM JOUR Digital Media Studies Data Science Computer Science (CSCI) Elementary Education Elementary Education (EDUC) Elementary Education (EDUC) Middle Level Teaching Visual Arts Teach (Jr/Sr HS) Visual Arts Teaching (K12) DIGI DATA CSCI EDUC Environmental Studies. Environmental Science. Asian Studies Speech Communication and Rhetoric. Speech Communication and Rhetoric. Journalism Digital Communication and Media/Multimedia. Data Science Computer Science. Elementary Education and Teaching. EDUC Elementary Education and Teaching. School of Education EDUC EDUC ART2 ART2 Elementary Education and Teaching. Elementary Education and Teaching. Art Teacher Education. Art Teacher Education. Business and Innovation/Entrepreneurship Teacher Education. 90702 110301 110701 131202 DIGI DATA CSCI ELE2 131202 ELM2 131202 131202 131302 131302 ELME MLT2 ART2 ART5 131303 BUE2 Business Educ & Admin (BUE2) EGEO ENSC ASTD Grouped Description BUE2 College of Arts & Sciences College of Arts & Sciences College of Arts & Sciences College of Arts & Sciences College of Arts & Sciences College of Arts & Sciences College of Arts & Sciences College of Arts & Sciences College of Arts & Sciences School of Education School of Education School of Education College of Arts & Sciences College of Arts & Sciences School of Business 80 131303 BUS2 Business Education (BUS2) BUE2 131305 ENG2 131311 MAT2 131312 MUS5 131314 PED5 English Teaching Mathematics Teaching Music Teaching (K-12) Health & Physical Education Health & Phys Ed P-12 (PED5) 131314 PEES Phys Ed (Exercise Science) HPED 131314 PESA HPED 131316 CHX2 Phys Ed (Sports Adm) Chemistry Teaching (CHX2) 131316 LSC2 Life Science Teaching LSC2 131316 PHX2 PHX2 131318 GG2 131325 FRE2 Physics Teaching (PHX2) Earth Space Science Tch (SCE2) Government/Geography Teaching French Teaching 131330 SPA2 Spanish Teaching SPA2 131399 TCER Teacher Certification/NonDeg TCER 131314 HPED 131316 SCE2 ENG2 MAT2 MUS5 HPED HPED CHX2 SCE2 GG2 FRE2 Business and Innovation/Entrepreneurship Teacher Education. English/Language Arts Teacher Education. Mathematics Teacher Education. Music Teacher Education. Physical Education Teaching and Coaching. Physical Education Teaching and Coaching. Physical Education Teaching and Coaching. Physical Education Teaching and Coaching. Science Teacher Education/General Science Teacher Education. Science Teacher Education/General Science Teacher Education. Science Teacher Education/General Science Teacher Education. Science Teacher Education/General Science Teacher Education. Social Studies Teacher Education. French Language Teacher Education. Spanish Language Teacher Education. Teacher Education and Professional Development, Specific Subject Areas, Other. School of Business College of Arts & Sciences College of Arts & Sciences College of Arts & Sciences College of Health Sciences College of Health Sciences College of Health Sciences College of Health Sciences College of Arts & Sciences School of Education College of Arts & Sciences College of Arts & Sciences College of Arts & Sciences College of Arts & Sciences College of Arts & Sciences School of Education 81 131399 THE2 Theatre/Secondary Education 131401 TELL Teach. Eng. Lang. 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... An Exploration of Latin American Mythology within Magical Realism and the Genres Effects on Gender Expression and Post-Colonial Experiences By Tyrah Chery Honors Project In the Ron and Laura Strain Honors College of THE UNIVERSITY OF INDIANAPOLIS April 20th, 2020 Faculty Advisor: Dr. Sean Robisch, Ph.D. in English & Prof. Daniel Vice, M.F.A. Creative Writing (Fiction) Executive Director of Honors: Dr. James B. Williams, Ph.D. Citation Style: MLA Style Citation Chery 1 Table of Contents An American Way of Death Manuscript 2 Analysis of Texts .. 65 Chery 2 An American Way of Death By Tyrah Chery Chery 3 One Early one morning, deep in March, young Tommy LaVaughn went for a swim. When his mother awoke, her old house broke its silence and whispered news of her sons adventure. The streets slept so soundly that many didnt hear her cries as she walked through the streets, making her way to the station under the waning moonlight. The nights in Hubris were generally lackluster with little disturbance but a misplaced chime of the grandfather clock that lived abandoned against the red bricks on the corner stores eastern face. It took fifteen weak knocks against the oak double doors of the police station before anyone knew of the crying womans presence. Door to door, the police chief and his officers went searching. They made their way along the waking sidewalks, collecting citizens, some joining the search out of worry for Tommy, some just to know his fate. It wasnt until the dawn breeze began to mumble that the police chief and a volunteer, Lila Dennis, found Tommy stuck between two boulders. He lay in a state past sleep, wrapped in stone. As the police chief stepped aside to radio his men that the search was over, the volunteer stared on in pity. She wondered what brought the poor boy here and for an instant wished she could feel the sadness and dread Mrs. LaVaughn felt for her lost boy. Moments later, from deep in the brush, they heard a whimper. Tucked in the orange butterfly weed, the police chief found a baby wrapped in sheer cloth. His first thought was of the small town, devoid of any orphanages and legalities for such an occurrence, as Hubris knew only those born within its borders. Then he thought of three children he had at home and how four would be too much. The volunteer, however, thought of her lonely room, and her restless home with her mother, and her sisters and how well the baby would fit. The town, named Hubris, Chery 4 thought of drought and things to come. The melancholy taste of that March would stay on the tongues of the lilies and tulips until the summer sun brought them new worries. For a time, Hubris slept under the heat of the Illinois summer sun. Some years had passed since the river kissed it awake. So much time that it didnt flinch when Juden Casey arrived in a taxicab at Orvilles corner store. Instead, it slept on. Juden, however, didnt know sleep. For days, he lay awake in his apartment staring at the popcorn ceilings for so long they began to shift into shapes of his childhood. Those were worse than the nightmares that came to him when he closed his eyes. But still, sleep evaded him. Now he sat in the old oak rocking chair on Orvilles front porch, waiting amidst the lingering smoke and anxiety. Each time the rickety door swung open he heard the hums of the old ice cream machine, the pop of the fluorescent lights, and the whispers from inside. Two pounds of lima beans and a pound of rice. The door creaked shut. Whos on the porch, Orville? a muffled voice said. The door wheezed as its hinges twisted open. I wonder what the churchll do now. Juden rocked a little farther back. He couldnt bring himself to travel to the south side of town. He couldnt even bring himself to pick up the phone and call his mother, just to ask how she was. She wouldnt want that anyway, he thought. In the distance against the dried crabgrass, Father Ire moved along the trail like the plague. Juden felt his spine stiffen. He didn't remember many people in Hubris, but he Chery 5 remembered Father Ire. Years ago when sleep had been a friend and visited him often, those short moments were filled with memories of choir practice under Father Ires watchful glass eye. And wherever Ire went, beside him stood his shadow. Judens mother had done her best to explain to him that the holiest of men walked with the Holy Spirit. But Juden knew there was nothing holy about Ires spirit. Youve gone to see it, correct? Father Ire said. No, Juden said. The shadow scoffed as it shifted against the wooden posts along the porch. Theres nothing left. Ive seen many things in my life, boy. But Ive never seen anything disappear so quickly. Ires voice caught itself on the last word. Im sorry, Juden said. I dont need your horse shit condolences, Father Ire said. The voices inside sounded no louder than hums. Everyone knows you havent called your ma, I cant. Juden looked away. Your ma never did anything to you. Im glad you get to decide that. Even though the sun glared down onto the porch, the shadow grew darker. Its edges began to blur and stretch. With every movement it made, Juden began to feel more like a little boy. I need you to figure out what happened here. That useless police chief can barely find time to wipe the dirt off his face, let alone actually find who did this, Father Ire said. You shouldve called the county police. I cant do anything for you. Chery 6 I did. You think they care about us? Youre younger than the drought, boy. Weve made do on our own without the city. Why would they care now? I cant help. Maybe if you did that investigative journalism thing? And brought it back to those folks you work for. Maybe then somethingll happen. Juden rocked the chair back again. Go see your ma, Ire said. Juden flinched. Against the wind, the shadow whispered something to Ire. Juden couldnt make out the words, but he felt a wave of sickness overcome him. Father Ire turned on his heel and as he and his shadow shifted across the pavement, he fumbled through his pocket and pulled out a pack of cigarettes. Juden pulled himself off the porch and under the glare of the sun, he saw images of the children he once knew playing through the overgrown dandelions and bulbous buttercups in the empty lot across the street. He wrung his hands against his stomach, hoping the sickening feeling would find its way to his fingertips and drip onto the warm concrete. But he knew he wouldnt be that lucky. The burst of yellow reminded him of the stuffed canary above the mantle in his mothers house and the unnervingly bright walls of the old kitchen. Thinking about the details of his old home made his palms sweat and his chest tighten. Father Ires words filled him with a thunderous spite that threatened to crawl past his lips, flop down, and tan itself on the tarmac. Why would he listen to that old man? Why had he listened to that old man and come here in the first place? He knew why. Hope had dug its way under his skin. A hope that things had changed Chery 7 now that he was dead. Maybe it had. Or maybe it hadnt. Juden stood a long time in the empty lot, sweat dripping down his brow and into his eyes. It wasnt until the wind began to change and the dirt shifted beneath his feet that, in an instant of dread, Juden turned towards home. Even after years away from the twisting dirt roads around the town square, Judens feet knew the steps to take up the old trail. His mothers house lay on the outskirts of town, tucked deep inside the canopy of American elm. As the trees sang against the breeze, Juden remembered the afternoons he spent in his makeshift garden of scrap tulip and morning glory seeds Madame Pierre had given him. That summer, one of the hottest Hubris had seen in a long while, she had stopped by to invite his mother to the annual Cathedral Craft Night. Apparently, some ladies down at Orvilles had told her about his mothers affinity for taxidermy. Juden didnt remember exactly what she saw, but he remembered the look on Madame Pierres face when she handed him the seeds. Hed never seen pity before, but somehow, he knew that was what she felt. His mother never went out that night. Instead, she spent hours in the tub as Juden listened to her muffled cries through the door. The old cottage sat on the bank of the river like a beached trout. Weathered, gasping for air, the silvery blue panels had lost their sheen. He remembered the stories his mother told him of her childhood in this house. For years, he would stay up until the witching hour to hear if he could whisper messages to the family members that had died. They didnt whisper back unless he had misinterpreted the squeaks in floorboards as only that. Now, seeing the crooked home a breath away from toppling over, he wondered if any of them were even left. The trees sang loudly, drowning out Judens memories. Were they trying to calm him? Did they know how cold his blood ran now, his hand inches away from the bell? Juden wished Chery 8 the trees of Hubris spoke of other things and not melodies about their leaves. Feeling the time pass by made him queasy, and he didnt think the ballad of pine needles would comfort him. His finger on the doorbell, a chime shook apart the trees song, scattering their words across the grass. Eight years had passed since he saw his mother. When he imagined this encounter, late at night when the only sound in the air was the ticking of his watch, he thought of his mother as he remembered her. Pale-faced, splotchy cheeks and as anxious as a wild animal with a broken leg. Then again, something had always been broken about his mother then. His father made sure of it. But the woman who opened the door wasnt the woman he remembered. She stood solidly in the doorway. Even with her thin frame, she looked like a barricade. Her nose was broken. Bulging and swollen, it looked like a beak. For an awful moment, Juden fought the urge to laugh. Juden, she said flatly. He couldnt read her. Hello, he said. Why are you here? Even with her aura of confidence, Juden could feel her anxiety. I thought it was time for me to visit. She didnt move. Just above her shoulder, Juden could see the glimmer of the kitchen walls. Can I come in? No. What? Chery 9 He didnt want to come here, but now that he was, he knew he had to make her speak to him. Why? he said. Youre not welcome here. Did you forget? Yes, apparently. Juden. What? Dont do this. Let me inside. I wont be long. She looked at him for a while. Her hair was graying from the roots, a field of snow sprinkled against the gray sky. Juden never thought about what his mother would look like when she got old. He never thought hed be around long enough to see it. But here she was. Angry and gray and paper bag wrinkled. You need to go. Really? You made yourself unwelcome here, dont blame me, she said. Dont put that on me. You decided to leave. You dont just get to show up here and magically everything would be fine. Its not fine. Just please. He had walked all the way here under the hum of the leaves and the bluebirds. He had thought of all the reasons why he would let his feet take him down the worn path. None of them made sense, but why would they have? Juden hadnt known how much of a boy he would feel Chery 10 like when he stood in front of his mother, her shaky frame strong in the doorway. Then something snapped inside of him, letting go of the tear it was holding in place along his lashes. A single tear, nothing more, nothing less. His mother watched it trail its way down his cheek and across the bones of his shoulders. The heat of her eyes made him feel sick again, his belly filling with bile and grief. Dont be long, she said. She shifted out of the doorway. Thank you. His mother found an escape in dead things. It had started out with books from the library, ones shed stay up under the porch light on summer days to read. Then, in the one act of kindness Juden had ever seen from his father, the renovation of the shed in the overgrown backyard as her workshop. For a while, she chose squirrels and mice up until the day she found a Northern Cardinal dead on the doorstep. Dead birds werent an uncommon occurrence around the old home. But his mother knew birds and knew those bright golden feathers shouldnt have been around those woods. Juden didnt know his mother could feel love. Hed never seen it before. Yet, the day she brought the small animal back to life, he saw what little love his mother was capable of. Hed stay awake at night hearing his mothers tears through the walls and feel his fathers soft anger radiate through his thin mattress and think about the life the cardinal once had. Sometimes, when the wind blew just right through his windowpane, it would carry him through the sleeping forest. Hed fly over Hubris and feel the town kiss his cheeks, and when the wind carried him high enough that he felt like he could almost touch the stars, hed see the glimmer of his wings under Chery 11 the moonlight. The next morning, hed wake up in his bed, the soft brush of feathers across his forearms fading with the small comfort those nights brought. Years later, Juden stood in front of the tacky stuffed cardinal in a house more foreign than he could ever imagine, with a woman he barely recognized. If I remember correctly, you said you were never coming back, his mother said. That was my plan. Then why are you here? You didnt come back for anything else, so whats so important for you to be here now. Father Ire called me. His mother stood up straighter at the priests name. He had always hated that about her. She had done everything in her power to impress him. The worst times were when she pretended to care about Juden. When she had first started pretending, Juden had actually believed her. She would hold his hand on the walk down to the cathedral or even carry him when his fathers yells shook the house so violently the night before, Juden couldnt keep track of the sheep that found pasture at his bedside. Shed whisper bible verses under her breath as a child would. She is clothed with strength and dignity; she can laugh at the days to come. Proverbs 31:25. She opens her mouth with wisdom, and the teaching of kindness is on her tongue. Proverbs 31:26. You should be known for the beauty that comes from within, the unfading beauty of a gentle and quiet spirit, which is so precious to God. 1 Peter 3:4. Judens Sunday school teacher would talk about the power of Biblical affirmations. That if you said something enough, and pray hard enough, you could speak it into existence. He had Chery 12 always been too scared to try it himself, too fearful that one of his bad thoughts would ooze in through the cracks and into his words. But no matter how many times his mother said those things, they refused to plant themselves inside her to blossom into truth. That wasnt their purpose for her. She said the verses every Sunday so that they could cloak her in a disguise. Juden hadnt noticed the first few times, as the summers in Hubris had been filled with other oddities. His eyes trailed the worms dried out on the pavement, frozen in their last moment of panic forever. Or at least until his polished church shoes kicked them into the grass. The distant humdrum of the highway miles and miles away making the smallest pebbles dance the polka from the sidewalk into the street. He hadnt noticed the thin veil that fell over her. Pure, faint gold that wrapped around her fingers and up to his until they faded at his wrists. He hadnt noticed how it braided itself through her hair and left a trail like stardust behind them. Why would he call you? she said. He thought I could help with the cathedral. Thought? Thought. Im leaving, theres nothing happening here, he said. Then why come to this house? To insult me? Tell me how good you have it? What? Im not fighting with you. Juden put his head in his hands, frustrated. I dont know why I came back. Juden reached up to touch the fraying top feathers of the yellow bird. He never had the courage to as a kid. But he wasnt a kid anymore. Everyone was at the funeral, she said. Chery 13 Juden looked around the drab living room until his eyes settled on her. As he watched his mother, Juden could see something behind her eyes change. The angry waters had suddenly gone still. He remembered that look. The blue of her eyes stopped raging, but they were anything but calm. The same look she gave his father every time he told her to stop fighting him. The look of the water becoming complacent to the sway of the wind. He knew he was speaking to her now, somehow. Your father left you some things, she said. Mom, he said. All he did was talk about you in the end. He even wrote you a letter. She stopped testing the waters between them and began to push. Mom, I didnt come-.. He had me write it, but still. He said how sorry he was for all this misunderstanding. Misunderstanding? Thats what you think this was. Juden was getting angrier, but she wasnt listening. All he talked about was how much he missed you. Juden watched her, his eyes slowly taking in the inches that made up her silhouette. Just take it. Dont read it if you dont want to, Ill never know. Judens palms itched inside his pockets as he thought over the request. He could feel the seconds move past them, between them, until they seemed to pause and watch the silent tug-ofwar within him. He reached out towards her. Give it to me. Thank you. I want to see my room. Chery 14 She looked away. We moved him down there when he couldnt keep making the trip upstairs. I havent gotten the chance to move his things out. He hated that room. Not after you left it. It was the only thing we had of you. Why did you two care? After I left, why? You were sixteen, Juden. You could barely get up for school on time, let alone live on your own. Why wouldnt we care? He told me to go and you did nothing. You wanted to leave! We thought you would have your tantrum and come back in your own time. He treated you like a punching bag. Your father never laid a hand on you. Thats not what I said. Your father and I had our differences, Juden, but they werent for you to worry about. You made it when youd sit up at night and cry in the hall. It became my business when no one in this godforsaken town cared enough to help you. They all knew, and they did nothing. Small towns always have the biggest secrets, huh? It was between your father and I; it was never something for them to worry about. So, you just let it keep happening? Let the punches keep coming? But he never laid a hand on you. Juden pressed his palms to his temples. Chery 15 Do you know what its like to grow up with a mom whos never there? To see her, hear her, but never once know what its like to hear her say I love you? he said. Juden. Or what its like to know that every day when you came home thered be crying and screaming and blood? He never put a hand on you. That isnt the point! Judens voice slammed against the ceiling. In the following quiet, he could feel the soft vibrations drizzle down from above, stinging his skin with its venom. A monster had woken up inside him somewhere and he didnt know if he could silence it again. That was never the point, Juden said, his voice shuddering. His mother stared through him, missing his eyes, staring at something beyond. She stood up a little straighter, moved cautiously towards the door and turned the handle. I think you should be on your way. Its getting too late for quarrelling. Chery 16 Two It had quieted outside. He roamed these forests in the days when the river flowed through Hubris. When the water ran through the towns veins, pulsating and pleasant, the town had been alive. In those days, the river had run strong and crisp, smelling sweet of the mammee apples and banana flowers that had fallen along the bank. Sometimes he would pick the honeyed fruit from the tree limbs and bring them home. In the summer, Juden would sit on the front step and tear at the amber flesh. The warm ground and sugary sap brought solace to Juden. His father away at work, too busy on Petersons farm mating cows and shoveling manure to worry about the saccharine smell the apples left behind on Judens overalls. His mother away at the cathedral too occupied with hymns and summer sermons to hear the sound his gluey fingers made as they slipped against the old crystal doorknob. When the planet of seed began to rise up from beneath the apricot fruit, Juden would sweep his feet along the waters edge and place the pit back into the earth. The mammee trees didnt grow now and the river had gone. But the fireflies still danced. His anger had seeped out of him by then and all he felt now was the chill of the dry air against his forearms. Through the canopy of trees, Juden could see brighter, yellower lights in the distance. He thought of what Father Ire said as he walked. Juden hadnt expected to return from the deli next door, the one with the old gray cat with geranium eyes that lived outside on the steps, to find a message on his answering machine asking for his help. Let alone a message from Ire. He had stayed up that night, raking through his memories of Hubris, attempting and failing to convince his curiosity to behave itself. He had packed a small bag, ordered a taxi and made his way down the clamoring highway and the backwoods of Illinois farm country to the small town. Chery 17 He wanted nothing more than to leave and return to the life he had become accustomed to. But as Juden approached the lights, his curiosity stirred itself awake. The cathedral had never lived up to its name. No one knew what its real name was anymore. Ask anyone in town and theyd tell you something different. If you asked anyone who was around before the drought, before the highway, they would call it Freedmans Methodist. To others who knew the days of Lake Dantor, it was Old St. Marys. A few who have been in the town for so long their feet had become rooted to its soil, their boundary of freedom ending with the town line, those made of as much Hubris as the homes and the trees and the sweet wilted air, would even call it Seventh Day Revelation Church on 9th Street. Somewhere down the line, the crisis of identity the church suffered became too much for the people of the town, who knew only lives of routine and consistency. To pinpoint the churchs nomenclature, they began to call it simply the cathedral. No matter who had come to make a religious home out of the weary walls, that was its name. And in the glimmer of the rising moonlight, Juden sat in awe of it. The cathedral sat on the earth like a cracked egg, a yolk of golden light spilling from the charred gray shell. The candles had been lit, their flames licking against the night air, breathing it in. It was a beacon against the growing indigo sky. Juden felt a wave of embarrassment wash over him as he stared. It felt wrong, the exposed religious ephemera as if he should look away and cover his eyes. But all at once, it was magnificent. The prophets preached in the fresh air. So why shouldnt we. Father Ire appeared on the edge of the burnt wood floor, just before the dark hardwood became greenery. Where his shadow manifested against the reflection of the candles was nothing more than a pit. Chery 18 Youre still having services? Juden said. Of course, we fucking are. Gods word has made it through the falls of civilizations. Some fire and a few mosquitos aint gonna stop me, boy. The persistence is admirable. Did you see your ma? A plume of smoke surrounded his shadow, wispy and sheer, almost like it had lit its own cigarette. Yeah. And? Dont be short with me. Honestly, its none of your business, old man. Is that how you speak to your elders. Apparently today it is. And my offer? Juden watched as the moon grew larger in the sky, silently competing with the dancing lights. Juden felt as if he was watching God and Mother Nature have an argument. Each glimmering against the night, beckoning him to watch them, to ignore the other. It was a fight he could watch forever. What happened the last time? Juden asked. Father Ire shoved his hands into his pant pocket and pulled out a folded piece of paper. Happened a while ago. Back when I first came to the cathedral. An old janitor lit the cathedral up after knocking over a candle. So, they say. Father Ire unfolded the paper and handed it to Juden. Chery 19 The church decided to sue, and he couldnt pay. They sent him to jail for a coupla months. The paper was faded, the black ink lightened to a deep cerulean. Through the thinned parchment, the candlelight danced as if trapped between the words. On its face was a picture of a man sitting in Hubris version of a courtroom. When cases of criminal activity were ever scandalous enough to warrant a trial, the sheriff would order the evacuation of the librarians from Humphrey Memorial Library. Nothing of that importance had ever happened when Juden had lived in the town, but he knew the protocol and the expansive columns of aged books in the background reassured him. Who was he? Juden said. The page felt as though it would break apart at the slightest gust of wind. He worked up in the post office most days. He was quiet, but I guess you cant expect much talking from a deaf man. He still lives here? I dont think Ive ever seen him, Juden said. Died in jail. Aneurysm bless his soul. But his crazy old woman still lives here. You know her. That old crone Erzu up on the hill. The wind ruffled Judens hair playfully, stirring up memories. I never knew she was married. That miss she begs everyone so hard to use is useless. I wouldnt be surprised if that hag was older than the river. Shit, I know she is. Juden chaffed at Ires words, slowly growing more uncomfortable with his and his shadows presence. He thought that he should leave and felt his feet begin until he had to stop them. He didnt have anywhere to go. The summer sun had dipped past the horizon and the cool Chery 20 air had begun to sing a midsummer lullaby to the closing flower buds. As if he could read Judens mind, Father Ires shadow inched over his boots and started to tug at his shoelaces, asking him to follow. Ill show you to the room on the other side of the chapel for visiting ministries. Luckily thats still intact. Juden let the silence grow between them. That is, assuming youre gonna keep looking into this. That night, in the cold concrete room in a bed too lavish for the prison it occupied, Juden found new horrors that lived in the night. As every night before, sleep had taken a different path. But his mind opened itself to a new wandering stranger and that night Juden welcomed in waking nightmares. Ms. Erzu was the town medicine woman. Her concoctions never being strong enough to rid one of any ailments, but strong enough to keep any blessing from coming loose. Her garden was one the town told stories about. Tales of milk thistle, damiana, passionflower, and blue skullcaps littered the path up the hill, whispering their uses to any who happened past. When sleep kissed his lashes and dreams, rare, star-filled dreams, caressed his skin and slipped past his fluttering eyelids, he dreamt of this garden. Her small house had been talking to Juden for a few minutes. Shifting, settling, ticking, turning, recounting days when the white kitchen walls had been covered with photos and paintings. Splashes of color that had made the deep winter shade, once described to be a variation of snow plum seem inviting. But thats not how Juden would describe it now. Chery 21 Judens fingers thrummed across the tabletop as the grandfather clock in the hall sang tap-tap-tap in response. Behind him, a whales mouth of a doorway opened into the living room. The reflection of ink blue walls danced across the silver canvas of the old rumbling refrigerator. A scent of vanilla and honeysuckle oozed from the cracked window into the sink and up towards the slanted ceiling. Juden didnt mind any of these things. The silence, the sweet air, the bleached lavender walls all hummed stories of times past. Juden liked stories. But these werent the stories he wanted to hear. Ms. Erzu had sat him in front of the linoleum kitchen table in a pine chair. Somewhere in his mind, he knew that the curiosity sparked from the day before would not be easy to kill. There had been something in Ires story that inspired an interest to nest in the crease of Judens brow. Eske ou grangou? I make lunch right now, Ms. Erzu said. She shuffled out from the stomach of the whale, her house shoes smacking and sliding across the worn wood floors. Her hands held tightly to a basket of produce. Eggplants, carrots, and heads of cabbage poured over the sides and visibly weighed the small woman down. Before Juden felt guilty enough to offer his help, she made her way to the window and placed the basket in the sink. I guess I could eat. She sucked air through her teeth. I guess? she said, Kisa w vle di I guess? I dont know what you mean. Are you hungry or no? Im hungry, but youve done enough already. Seeing me is enough. Chery 22 Hush. I supposed to leave you outside? We know your manman and you dont see, kijan ou di, see eye to eye, Is this common knowledge then? That Juden and his mother dont get along? Non, it is common knowledge that your manman is a scattered woman. You have gone long, ti fi. No one expects you to sleep with a hurricane in the next room. Ive actually been staying at the cathedral. Her frame stilled, the tension rising up her spine and bursting above her head. After a while, she relaxed again. En bien. Juden felt the table begin to shiver under the rhythmic fervor of the pads of his fingers. Ms. Erzu placed a tanned leather hand against the cold tabletop and with the other set a tall mug of coffee down with a clink. What do you do with your time, nowadays? Cant be as many people left in town to have you that busy. Cook, clean, read the bible, listen to radio. She had a colorful spread in front of her, vegetables with the dull yellow light of the overhead lamp glinting off taut skins. She reached around the cutting boards to pull a longsharpened knife from the stand underneath the cabinets. I remember when you worked at the dentist. Ha! She slammed the knife down against the wooden slab. Know something funny? I have wanted to be dentist since when I live en Ayiti. Here, I got to be assistant to dentist. What happened? Whyd you stop? Chery 23 Dan se zo. Judens face warped with confusion and Ms. Erzu answered with the thunderous scream of the knife against a hard surface. How are your daughters? Marie, useless girl. She walk all the way to the store with no money. Ki f sa? She must go back. The eggplants had been sliced vertically and Ms. Erzu patted them dry between waterlogged paper towels. Lila works. The library always needing her. That hasnt changed much. Mm, you live here, you work. Ou, you Marie. This made her chuckle, a deep gruff thing wrapped up in sunshine colored ribbon. Florence? Juden said after a moment. Bl anfm pa vle di lasante. Shed moved onto the cabbage, stripping off the earth kissed outer leaves. She say she fine in that city. That all she say. But I know she eat bad food. She sucked on her teeth again. Judens hand thumbed the handle of his mug. He didnt know what to ask next. Ms. Erzu was a woman he remembered well. Just like Ire, her silhouette had etched itself in the layers of his brain. She was a bubbling pot. Somedays Ms. Erzu would appear in town with a grin plastered across her chin. Somedays she blew through like a lost dust storm. But youd never know what kind of day it was until you started asking her questions. Chery 24 When he was 12, Judens mother got sick. His father reluctantly took her to the hospital in the city and not trusting him alone, left him in the hands of the wise Ms. Erzu. They got along well at first. Her proverbs and parables were lost on him, but they all sounded like the punchline of a joke. Her voice filled rooms, seeping through the floorboards and the mouse holes and out to the yard to shake the trees and make the birds chatter in excitement. He had loved it. Then, after a lunch of rice and chicken spiced with peppers and cabbage, Juden had roamed the halls of the old house. He ran his hands over the painted panels, tapping in rhythm with the grandfather clock. When he reached the cactus room, he paused a moment in the doorway. Of the rooms that made their home in the cottage, this one had been the most alive. Cacti blossomed from clay pots and twist themselves up and up, pushing against the bay windows. They wanted to be outside. Their pins scrapped against the glass every few hours as they followed the sun. He found his way to the center of the quilted rug and sat amongst the thorns. He sat for hours until Ms. Erzu came to collect him. Your manman and papi come soon. And I made bonbon. In the kitchen, fingers holding onto chocolate chip cookies for dear life, Juden had been content. In front of the running tap, Ms. Erzu hummed church hymns under her breath. His mother sang these songs, too. But here Juden felt a warmth ease up his arms when he listened. He had been happy. Ms. Erzu? Juden said. Oui, mon cherie? I wish my mom was like you. She turned off the faucet and pivoted to look at his crumb covered face. Chery 25 Petit, lane pase toujou pi bon." He put the remnants of his cookies back onto his plate. I-I dont know what that means. Kijan ou di, the grass is greener past the other fence. On the other side. Ce sa, greener is the grass on the other side. Other manmans seem sweeter to you than your own. Mais, non. Just as bitter. Then I wish I didnt have a papi, too. Juden had found solace in the cacti before. They held pain between their skin and their soft insides and choose to leave him be. Now, Ms. Erzu prickled over and Juden felt too close to her thorns. Ungrateful. What? Juden felt his stomach twist. Ou ye ungrateful. I didnt mean to be. But you are. Her face contorted into someone Juden couldnt recognize. You have a papi. You speak no ill of that. I didnt think. Im sorry, Ms. Erzu. No, you are not. You say how you feel. You speak freely. Go. Juden watched her for a moment. Go? Go. Leave. Ale. Chery 26 You said my parents were coming. Oui, and you will go sit outside. Not here. Ungrateful garcon do not get bonbon. She ripped the plate off of the table, letting it fall to the floor. The crashing sound brought the tears Juden had been holding back to his eyes. Im sorry. Ale! The walls trembled with Ms. Erzus anger. Juden felt his heart clench under the pressure of her glare. She looked like his father. And when she raised his hand to point again to the doorway, Juden caught his shoulders raising in an instinctual flinch. For a moment, Ms. Erzus eyes softened, seeming to remember he was a child. But just as quickly, Juden could see the realization infuriate her all over again. Timoun dezobeyi! She clutched his wrist with a vice grip, pulled him up off the pine chair, and dragged him to the back door. I say ale and you sit and cry. I say go and you forget Anglais. Disobedient, ungrateful. Never again I watch ou fou timoun. He spent an hour outside. The sun had set, and his father was late and Juden had run out of tears to cry when the fireflies came out to play. Behind him, the floorboards shifted. Juden turned to find himself staring straight into the face of black birch. Her skin was as dark as the river at midnight, reflecting the kitchen light like a pool of inked glass. Along the curve of her cheeks were two thin scars, still glistening under the light as if they were made yesterday. The brown of her eyes reminded Juden of a freshly filled puddle of summer mud mixed with the gasoline that dripped off the sides of rusted tractors. They Chery 27 were the kind of eyes that made him feel like if he stared long enough, something no one had ever experienced before would rise from inside them and say a quaint Hello. Bon matin, Manman, she said. Her voice was apple crisp. Bonjour, ma chere, Ms. Erzu said. May I ask where Marie has run off to? Emilia said shed be running some errands with her today. You know ta soeur. Nothing above but some bats and a pail of water. She went shopping then. She was answered by the quick chop of the knife. And who is this? Juden watched as she turned her attention to him. Panic shot through his feet and up to his knees. Something was emerging from the pools, but Juden was too afraid to keep staring. You remember Sophias boy, non? Sophias boy? Oui. The gears were moving behind her eyes as they raised a platform through the puddles, her realization awakening. Ah. Sophias boy. I thought you had left. I did, Juden said. Apparently you didnt go far enough. Father Ire called me back. Chery 28 She sucked in the air sharply through her teeth, mimicking the agitation Ms. Erzu had shown. Why is Father Ire calling strangers now? Im not a stranger. You. She pointed a willowy finger towards him. Her petal lips were pursed and twisted. are a stranger here. So please, tell me why Father Ire is calling strangers. Look at her. No manners just rudeness through and through. Lila, behave, Ms. Erzu interrupted. Lila crossed her arms across her white linen shirt, the sapphire bangles on her arms tinkling against one another in the move. The more he watched her, the whales mouth open and bright behind her, the more he saw the tree rings in her center. The glow underneath her surface told him that she was younger than his mother, but she was aged, her bark creased and pinched by weathering. Why are you here, Sophias boy? Juden. Why are you here? The cathedral burned down. We know. Unlike you, we live in this town. His palms were sweating. Father Ire wanted me to look into it. He doesnt think the sheriff is doing enough. Sharp air through teeth. Sheriff never does anything except drink beer and smell like sour piss, Ms. Erzu said. Manman, Lila snapped. Chery 29 Se vre. He should leave it alone. You should leave it alone. That place is old and vile, no reason to beat the dead horse. Judens interest blossomed. Vile? Lila never liked that church. We say when she was young, she was touched. Hated that church. Hated that priest. Maybe shes a changeling, Ms. Erzu said. Manman, stop. She turned to Juden. That place has bad juju. And Father Ire isnt a man to confess to. Who does a priest confess to when he himself has sinned, huh? Judens mind began to pace. Would you care to explain? he said. No. Id like to see where my daughters gone off to. What do you mean by vile? Manman, when did they say theyd be back? Have you spoken to Father Ire recently? No. Why would I? Manman, did you at least tell her to make sure to prune the trail? The weeds are sprouting inside the path. What do you mean by vile? Strangers ask too many questions I have no reason to answer. Did Father Ire do something to you? The knife hit the cutting board again and snapped. A large, heavy half fell onto the floor, showering the white tile with a rainbow of produce and as it hit the ground, shattering the linoleum into pieces. Chery 30 Three Manman! the whales mouth screeched. It was a daisy. Her round golden face wide with fear and shock, her arms raised above her head, dark hair wrapped around in a makeshift crown. Emilia, where have you been? Lila said. She rushed over to the girl who couldnt have been older than nineteen. Marie and I went to the store. Leave me be. Manman could be hurt. Emilia said, shrugging off her mothers worried and searching hands. Im fine, ma chere. Ms. Erzu said. She rubbed her hands in the dishrag draped across her waist. Emilias face was bright, golden like chickweed with midnight petals curling over its center. She was blemished, her skin haphazardly splattered with moles and her lips a startling contrast of silt brown and rose petal pink. Yet, whatever intention was had when sculpting the valleys of her face was translated clearly. He was mesmerized. Let me help you clean. Please, she said. Emilia reached for an extra rag strewn across the counter. Lila watched Juden attentively, eyeing him as he sat in awe of the girl. You can leave, she said. What? Juden said. Were finished answering your questions. You can leave, stranger. But Im not finished. It doesnt matter. Chery 31 Be quiet. Ms. Erzus voice cut the tension between them, reverting the two to no more than bickering children. He will not leave. He sleep at the cathedral, I know, in that room they say is fit for guests. Is fit for nothing more than rats and the dead. You stay here. We have bed in the shed. She didnt look up from her cleaning while doling out her commands. Mais, Manman Mais non. This is my house, you do not make commands, Lila. Juden could smell the ozone rising in the air. Emilia, ma chere, show Juden the shed, tanpri, Ms. Erzu said. No. The urgency in Lilas voice shook the house violently, lifting the discarded vegetables into the air in an attitude. Emilia, f vite. Emilia slowly raised herself to her feet and with one stem outstretched, beckoned for Juden to follow. In silence, she led him through the whale and past the wooden doors onto the lawn. Under the late morning sun, the lush garden was showered with beads of gold. Emilia walked through the scattered gravel and brushed her fingers against the herbs and flowers that grabbed at her skirt. With each touch, they sighed and leaned themselves back against the wind in relief. Juden thoughtlessly followed her lead, grazing his fingers against the tea chrysanthemums, feeling them shyly kiss the pads. My mother was right, you know? You are a stranger. To me at least, Emilia said. Chery 32 Juden glanced up from the thicket to find two pits staring back at him. Im Juden. Emilia. I heard. Why are you here? Manman and my mother argue often, but not like this. And most certainly not over a man. I just came to ask some questions. They must be some very important questions for them to be bickering so angrily. Juden didnt respond. He didnt know how. Shes too young to know much, he thought. Younger than him, much younger than the drought, and the cathedral and the answers to the questions that still ran wild through his head. They were about the cathedral, he said. She stopped for a moment. In front of them, an expanse of greenery stretched towards the teal horizon. When he had last cast his eyes on it, the garden hadnt reached more than 100 yards past the house. Now he saw that in the time he had gone, it had grown to encompass an entire acre. Wild, lively plants danced amongst each other, close enough to exchange the sweet morning dew into the waiting palms of the next. Why are you asking about it? Father Ire asked me to. At the mention of his name, Juden could see the electricity run through her hair and into the air. The wind happily carried the currents up into the sky and to the clouds above. Chery 33 Your family doesnt seem to like him very much. Id assume you arent excluded from those emotions. He Her voice trailed off, falling onto the gaggle of lavender below. He, she began again, is an unsettling man, dont you think. He is. His shadow says the most horrible things, you know. Judens steps faltered. In all his years, he had never known what Ires shadow said. As far as Juden was concerned, the only person who knew had been Ire himself. As his days in Hubris grew longer, Juden was realizing he didnt know much of anything, let alone enough to be concerned. What do you mean? I can never remember exactly what it says, but I remember the feel. Like cold aloe sliding down your tongue and sticking to the inside of your throat. Ive heard its different for boys. No less unnerving, but different. Ive never heard it. Lucky you. In the distance, the shed began to appear. It was a small, marvelous thing. Though he could barely make out the door, he could see the vines that had made their homes against the faded orange shackles and the rainbow of florets along with the emerald arabesques. Marie wont be too happy about you staying there. Where? Chery 34 In the shed. Its where she likes to spend her nights. Manman and mother fight often and she doesnt have much stomach for it after Florence left. As if Emilias words had been a call to battle, the rickety door opened, sending the melodic shriek of its hinges cascading across the prairie. Out of it stepped a ghost. Where Lila had been the color of deep, sable winter and Emilia, the incarnation of the lingering morsels of a midsummer twilight, Marie was a bushel of peonies gracing the warmed spring snow. Her hair was stark against the hue of the woodshed, a stripped-bare ochre. Rosy cheeks painted themselves across a tan canvas, washed out over time by the sun. Her eyes the color of pastel blue lavendin. They were staring at Juden in surprise. Emilia pulled the woman in close to kiss her cheeks in greetings. Maries eyes never left Judens. Who is this, Emilia? Her voice was no louder than a hum, her words spoken so quickly Juden could have lost them forever to the wind. Juden Casey, he said. Hes here looking into the fire, Emilia said. Marie wrung her hand on her pale blue skirt and placed it in the air to take Judens. For a moment, he thought she was asking to shake it, but her fingers wrapped around the back of his hand and thrust his palm towards the sun. She took her time looking over it, freshwater puddles dripping their attention onto callused skin. After a time, she let go. Manman and Lila are fighting? Marie said. When arent they, Emilia said. Are you simply escaping, or do you have more to share? Marie said. Chery 35 Manman wants Juden to stay in the shed while hes doing his work. A sigh left Maries lips, gentle and thoughtful, brushing his cheeks. Give me some time to clean. Ive been studying a strain of pansies to plant before the weather turns and it seems Ive made quite the mess. Marie looked again at the two before turning towards the shed and disappearing past the doorway. Come. The gardenias would enjoy our company. When the moon glided against the cerulean curtain of the sky, Juden found himself in the same place he found himself every night. Awake on the small cot of the shed staring at the wood-paneled ceiling wondering what path sleep had taken that night. It took any path that led away from him. Tonight, however, something else came to him. The small frosted window of the woodshed left little barrier between Juden and the crisp evening air, and every so often when the night breeze blew just right, a pair of fireflies would find their way through the cracks and dance their nightly waltz before his eyes. They danced as if every movement was necessary for their survival. And in muted awe, in the faint darkness, Juden watched. What was it to be a firefly dancing in the summer air away from this, the perils of human nature? What was it to be free? But were they truly? Could he say that? They did this dance every night, no matter whether they wanted to or not. This was their only calling. Each and every summer's night, and when the wind blew to different plains far away from here, from Hubris, they would dance themselves to their graves. Is that free? Juden thought. Chery 36 He was still, watching their wings beat in time to music the night played only for them. They pulled each other across the room, their backside lighting the cobwebs and giving a glow to the petals of the pansies. Is this truly freedom? Juden thought. Is anyone truly free? Against his thoughts, he heard a soft knocking on the door. At first, he thought it a waking dream, the ghost of the summer's eve brushing palms against the soft wood. But again, it came. Slowly, Juden raised himself from the cot, breaking the performance of the fireflies and out the corner of his eye, he saw them rush through the frosted window and into the night to waltz their way to death. On the other side of the door was Emilia. Under the moonlight, her skin glowed. Otherworldly. I want to answer your questions, she said. Her hands held onto a small book, her head bowing to the dirt. Do you think thats a good idea? Juden said. He was happy that she had felt him worthy to give an answer to, yet he didnt know if it was right. These werent her stories to tell, her secrets to keep or give away. Juden quarreled with himself. A quarrel hed never known before. But his curiosity was ravenous. He followed her into the night. Past the pastures, under the inky tresses of the sky, dimly lit by the waning moon, he followed her. When they reached the edge of the official town line, he stopped. His head filled with more questions than he could keep pace with. Why here? Why the forest? he thought. Why not tell me before, at the shed? Or somewhere further in the field. Or on the walk. Chery 37 Maybe the smiling flowers had ears and they whispered their tales back to Ms. Erzu. He laughed at the thought. Only half a laugh, nowhere full enough to convince himself of its folly. He followed on. They made their way along the path of tree trunks and gatherings of fairy lights, the fireflies dancing amongst each other. Dancing, spinning, twirling, leaving traces of themselves behind. Juden wished he could take a moment and be entranced. When he was a boy, he had found these gatherings to be pure beauty. They seemed so content moving in circles around one another. Flying upwards towards the sky, just close enough to taste drooping starlight. Then dipping down to the ground, close enough to feel the soft silt brush against their wings. Now there were better things to pay attention to, especially now, that he realized that in the distance, through faint shivers of leaf against leaf, he heard water. Where are you taking me? he said. He was scared. He didnt know why. Im taking you somewhere special. My aunt, Marie and I, have a garden out here. Away from Manman and mother and their arguments. Her voice was soft. So soft that Juden felt it caress his skin. He felt sad. He knew the rumble of arguments through thin paper walls and bedding. He knew the feeling of moments before a storm when the trees filled with anticipation. He saw the somber blue ooze from her skin and into the air around her, clinging to her and it made him melancholic. After a time, they reached a pasture open and drenched in moonlight. Just ahead of them, Juden saw a stream. Fresh, clear stream water flowed and Juden stood aghast. Father Ire had been wrong. Judens early boyhood, though tainted with memories of screams and streaks of crimson, was also filled with this water. Fleeting memories of fruit, trees, Chery 38 and mud between his toes. Memories of days that made up for the nights spent cowering beneath his sheets. He just preferred to keep these instances of natures affection to himself. They were his to keep and carry in ways that he knew no one else could. Only he knew that they could only be handled with great care, that at any moment, they could crumble before your eyes and be replaced with something angrier, much angrier. When he was born, the drought had already begun, sipping up the rivers and the lakes and the small pools that littered the forests brush. But the arteries still flowed, even though the heart of Hubris had gone cold with rock and sand. You just had to know how to find them. Juden had been the only one to find success. The old men in town, the ones who missed the days of waking up to the Sunday sun and packing their bags to go fish in the spring waters. The men who talked of listening to nothing but the nature around them speak to themselves in languages they would never be able to decipher. These men spoke of the streams hidden away somewhere no one could find them. No one but Juden. They had made a ritual of the search, Juden remembered. Every Sunday morning, waking up with the roosters call, packing their bags as if nothing had changed. They journeyed off into the forest in search. Theyd go two, sometimes three hours, just until the breakfast bell rang at whatever house they called home. Theyd return empty-handed, packed away their things, and sit telling stories to the children of Hubris. Stories of lakes and creeks and streams. Stories of the sound of trickling water, against dirt, against the rock. When they told these stories, Juden would think of the taste. The cleanest thang youve ever drank. theyd say. Clean water. Real water, theyd sigh. Theyd lean back in their chairs and close their eyes and as Juden watched, he remembered his little hidden sanctuaries. He remembered what the water tasted like after a lunch Chery 39 of oranges and peach. He remembered the feeling of the small green lizards, the ones that spent their days tanning in the patches of light that slipped past the canopy of leaves, slurping the liquid from his welcoming palms. He remembered where they could do nothing but imagine. Back then, the reality of these things disappearing seemed impossible. But they were possible, and he had lost those moments. He had lost grip of many moments, but very few had truly made him sad. Come, Emilia said. She took his hand. He didnt know what he thought she would feel like, but what he had imagined was nothing like what he actually felt. Her hands had looked soft before, untouched, young. But they werent. They were calloused, gardeners hands. Hands that knew the feeling of dirt, and rot, and death. Hands that were nimble. Hands that knew the difference between weed and flower, that knew just where to trim the rosebud and bush. Hands that were molded from the earth. These hands, her hands, were older than him, wiser than him, knew more about the world than he could ever imagine. And he felt ashamed that he had ever thought otherwise. He was the child, the inexperienced, the ignorant. However, now was his time to learn. Chery 40 Four They sat in the center of the meadow surrounded by blushing hibiscuses. Emilias skirt was covered in mud, fallen petals clinging to the material like paint on a muddied canvas. I hope I didnt wake you, Emilia said. You didnt. I dont sleep most nights. Juden said. He could feel the gentle rumbling of the water vibrating off the wet ground and through his leather soles. Theres nothing like the feeling of missing your dreams, Emilia said I still dream. Just not the way most do, I suppose. Theyre all memories floating just out of reach. Do you miss sleep? I think Id be crazy not to. But its been so long that I dont know if shed even remember who I was. Do you remember much of your time in Hubris? she said. She twisted her hands back and forth across the spine of the journal she held in her lap. The cover was a faded taupe, the edges lined with pale lilac, the pages were tied closed with a thin ribbon of gold. It looked old and though worn, appeared as pristine as a reliquary. Under the full moon, the gold glittered to life, dancing against the wind. Bits and pieces. Manman said theres things about Hubris shed understand if you forgot. Its always nice to be reminded about how hard it is for secrets to hide here. Id almost call it honesty if anyone were willing to point them out. Im sorry. I shouldnt have said anything. Chery 41 No. Its alright. Juden felt his chest twist a little. He wasnt afraid to tell the truth. He was more afraid of it grabbing hold of him and pulling him down into its depths. Somewhere deep, dark, where every one of his fears grew to the size of his father. My father wasnt the best man; which I suppose youve gathered. He didnt care for me, so I didnt get his anger much. My mom, though, was never a very lucky woman. A soft bubbling broke the silence as a trout kissed the surface of the water, reaching towards an illuminated couple dancing too close. Some nights it was alright. Her crying wasnt so loud, and he only broke a bottle or two. And then Id hear them creak into bed and watch the moon on my windowsill. Those were the nights when I slept. Other nights, her screams curdled milk. You wouldnt even hear my father. He was already a shade, stalking her down the hallways. Those nights, Id lie awake until the sun came up. Id listen to the spiders have conversations. Some nights Id even try to mimic the grasshoppers crying. Thats when the insomnia started. He shifted across the grass. The nights just got worse and worse. I guess sleep wasnt a fan of the commotion. Its been so long; I dont remember what she feels like. His nerves began to quake under the weight of his words. She was quiet for a long while, brushing her finger pads across the faces of the blades of grass. Thank you. For telling me. Please dont thank me. Juden watched the stream flow. He wanted to plunge his hands into its icy tresses and cool the bonfire in his belly. But he couldnt. There were things he needed to know. Chery 42 My mother is protective of me, Emilia said. That was pretty obvious. Shes always been that way. Manman said shes always had a tornado in her head, picking up her worries and running wild with them. But she said that when my mother found me it became steady. I guess shed found something to keep her worries tethered to. Manman called me good luck. Last summer, I made a mistake. I trusted a man I knew I shouldnt have. A man my mother warned me about. But I didnt care. Do you ever wonder what its like to be a bird flying through these trees? Free to do whatever you wish. Your mother just knowing when to let you fall and run and fly on your own. Never having to plead to the wind. Juden thought of the fireflies. I suppose you wouldnt have to. You flew away a long time ago, she said. Hubris sighed sleepily as the nights breeze held onto the pair lovingly. Juden felt the hair raise along his exposed arms and reach towards infinity. May I ask who it was? Stern eyes stared back at him. Theres only a few ways to hear what that shadow has to say. Some more unsavory than others, she said. I found out I was pregnant a few months later. I didnt tell anyone. For a little while, it was nice to have a secret. It was a painful one, but to have something that was mine and only mine was nice. Especially something my mother had never experienced. But it didnt last long. I lost it. Chery 43 The moon had shifted in the sky, pushing the Milky Way off-center and signaling to the Earth the suns close appearance. The pain was excruciating. There was blood everywhere. My mother has always had an ear for my pain, always appearing when I scraped my knee or fell too hard. But I dont think anything could have prepared her for what she saw that night on the bathroom floor. She was understanding in the beginning. I think she was trying to comfort me in her own way. When I healed, though, she turned into something else. Someone else. Ever since then, shes kept me as close to her as possible. I only find respite when Im with Marie and in the night when shes asleep. So, I bargained away my dreams to have these small freedoms. Juden watched her face. I want you to figure it out. I have a feeling Ires scorned more people than theyd like to admit. She handed him the journal. Its Manmans. She keeps it hidden in the attic, but she takes it out on grandpapas birthday every year. She thinks no one knows about it, but I saw her bringing it down last year when Marie sent me back for a grocery basket. Juden moved the journal between his hands. It was heavier than it looked, reminding his palm of a sack of river stones. Just dont read them here. With me. I dont want to know whats inside it just yet. she said. I wont. Manman and mother think theyre protecting me by lying. Thats one thing theyve learned to agree on. But all it does is make me want to leave. Runaway from here. Chery 44 I know the feeling. Why did you leave? The flowers had begun to mimic the stream, giggling along with its gargling. The conversation of giddy children. This town is a great place for secrets, you know. They can walk the streets with a plaque and a bright neon sign, and everyone would still pretend it doesnt exist. That it never existed. No one thought my mother needed help, or they didnt care to help. So, they left it be. Im sorry. I learned that most people are like that. Hubris just perfected it in ways others havent. I lived here all my childhood and never knew the cathedral had burned down all those years. Yet, it seems to be common knowledge here. Grandpapa Frank was well-liked when he lived here. No one believed he had done it you know. What? They said Manman had done it. Thats why they call her medicine woman. They would have called her a witch, but they knew better of it. Ire said it was an accident. That doesnt stop rumors. People may ignore the secrets head-on, but that doesnt mean they dont speculate its character. Over the horizon, the Earth gave birth to the dawn. We should head back. Emilia lifted herself off of the grass and reached again for Judens hands. Actually, wait here a minute. Chery 45 She disappeared into the trees. Juden watched the place she had been until she appeared with a bushel of plants on her hands. Passionflower and skullcap should help you sleep. Crush them and mix with a glass of water. Thank you. They parted ways once they reached the garden path. His fingers traced the edges of the glass cup, staring into the swirling contents. The friendly tug of anxiety woke the butterflies in his stomach, their legs scraping against lining. He downed the liquid in a swift gulp and fell back into his pillow. He didnt know how long he stared at the ceiling, disappointment readying itself. He slowly closed his eyes and took in deep breaths. When he opened them, he saw in front of him the cathedral. It was whole, a gloomy structure of gray against a colorless sky. It felt like midday, but as he looked around, he could see the streetlamps on Main Street glow faintly in the distance. It was night and as his senses began to focus, he heard whispers. He followed them. Please, ma chere. Dont do this. Think of the girls, the first voice said. It was gruff, scratching at his ears like mortar against pestle. I do think of them. This is why I am here. Ms. Erzu. Juden didnt feel his feet move, but he made his way around the stone corner. Ms. Erzu stood in front of a tall man. He looked like Marie, pale and long as an orchid. Ms. Erzu was younger than he had ever seen her, and she was angry. Then dont do this. You will not stop me, Frank. Chery 46 There are other ways to punish him. Ways that wont put us at risk. He was staring down at her, blue eyes searching her face, watching her lips. He was waiting to read what came out of them. As what? What ways? Who will punish the beloved priest, eh? The sheriff who know he is married and still comes to pray? The people who pay his bread and his home? Who, Frank? Frank was silent, his eyes moving to the ground. Do it. But you cant take the blame. It has to be me. They wouldnt survive without you. Frank didnt raise his head to see her response. Before Juden could catch her words, the wind picked him up and all he could see was black. He woke with a start. The sun peaked through the cracks in the wooden wall and shone on his face. He rose from the cot, opened the window, and began to thumb through the pages of the journal. It was filled with letters. Written and posted letters, tapped to the insides of the pages. Some pages were filled with paragraphs, others held the envelopes the paragraphs had traveled in. All of them coated in sadness. Frank, I do not know what to do anymore. The girls ask where youve gone but I do not think I am ready to tell them the truth. What do I do? I spend every day blaming myself for this. I havent slept in weeks. The night is filled with ghosts I do not know how to face on my own. I miss you. He came again last night. That priest. Spewing viciousness, Chery 47 saying he knew you did it on purpose. I told the girls to stay away from him. Especially Lila. Stubborn girl doesnt understand the reality of life. All she does is argue and fill with anger. She is nothing like you. Florence has taken time for bed. She does not speak to me anymore. I do not know what to do with her, Frank. What would you say? All Marie does is cry. That one is too much like you. Too sensitive. She say it was her fault you left. I have stopped saying it is not. Always she cries. I have stopped listening. Am I wrong for it? No matter what I say, she cries. All she do is cry. What am I to do, Frank? Please come home. Erzu Ma Chre Erzu, My sweet, have patience. These few months will pass quickly if you hold strong. Stay sweet to Marie, reassure her that she had nothing to do with this, no matter how many times she asks. Lila is too much like you. Approach her with the caution you expect of others. I know the two of you dont see eye to eye, but please, take it a step at a time. Chery 48 Florence has always been this way. You know this. She is a bird built to migrate. She will find her way home in time. I miss you with all my heart, my love. But I know, as should you, that what we did was for the best. I am a peacemaker at home, but what good am I if the waters have calmed with your absence. You are their mother. I wouldnt know what to do with myself. Anyways, I dont think you would have done well in the monotony of imprisonment. You are a tornado, my dear. Confinement was not intended for you. Yours, Frank Juden turned through the letters gingerly, hoping the ink didnt gather the courage to lift off the page and disappear. He felt a wave of guilt wash over him. This was a correspondence not meant for him. The words between the two were filled with such affection, Juden thought it unreal. But it lay in front of him, cupped between his open palms. Frank, I cannot tell them you are gone. That would mean I must admit my mistake. Our mistake. We should not have lied, Frank. I should have taken the responsibility. I burned it. Chery 49 Not you. You took the accusations anyways. And now we are both alone. This could have been avoided if we had done Lila right. What have I done in this world to have a daughter such as this? What did we do, Frank? And that Priest. Ire. He deserves worse than what we have. Worse than what we are living. They have given him the money to rebuild. The town says the fire was only enough to do surface damage. I should have stayed longer. I should have burned every stone to ash. I should have done more. I should have killed him. But instead, he has killed you. Erzu He had been wandering for hours, searching inside for a resolve he didnt think he had. When his eyes focused and the fog had cleared over his mind a little, he saw the door to his mothers home and his finger against the bell. She held the door firmly, keeping him out. I just need to talk about all this. Please. She hesitated for what felt to Juden like a lifetime. She moved out of the way. Juden sat on the chaise and began to collect his thoughts. What was he to say now? Now when he was in the place he had always imagined, telling his mother how he felt. He couldnt find anything inside him to say. Your father always said he loved you, Juden. He was just never the type to say it aloud. Chery 50 This he knew the answer to. You believe that? It was never a question of what she believed. Why wouldnt I? Hes your father, Juden, no matter how much you want to act like he isnt. Youre unbelievable. Honestly, I cant understand why you still make excuses for him. He never showed one ounce of love for me. Excuses? He loved you, Juden. When did he love me? Between the times he was yelling at you. Or maybe when Id have to roll him off his stomach when he was drunk on the floor after beating you senseless? Everyone in this fucking town knew he was a piece of scum. Everyone saw the blood, the bruises, the black eyes. and they did nothing. Except let the bastard keep doing it. She went quiet for a moment. Something inside of him twisted. He wished he had kept his mouth closed because now his anger was bubbling up against the folds of his throat and burning the inside of his cheeks, trying to claw its way past his front teeth. No, you came back to insult your father. Dont speak ill of the dead, Juden. He went through enough. I taught you better than that. Judens vision filled with a field of poppies. You taught me nothing good, he said, You taught me to be weak, to tell lies, to eat up all the shit that waste of air fed me. The quiet was deafening. How dare you? her voice was bare. You taught me how to salvage corpses to make up for your goddamn mistakes. Chery 51 The poppies ripped out of their roots. Juden, please go. No. Youre going to hear this. You ruined me. Both of you. I didnt leave because of a misunderstanding. I left because if I stayed, I wouldve had to watch him parade you around like the puppet you are. And watch everyone in this godforsaken town pretend nothing was happening. You taught me nothing good. Because theres never been anything good inside of you. Tears streamed down her cheeks as the poppies lifted into the air and painted the sky a deep crimson. In that clarity, Juden saw the dull old bird on the mantel. He took note that the journey that had once taken fifteen and a half steps now only took three. He took note of how light the bird was against his palm. He also took note, against the high, shrill scream behind him, of the sickening feeling of wires against feather and the crunching sound of dried skin scraping metal. His shoes were wet. Juden watched as his mother knelt in front of the fireplace, tears running down her cheeks, hands cupping the twice-slain bird. They ran past her eyelids, down her cheeks, and onto the floor in a puddle. They began to soak the mahogany legs of his grandmothers chaise, once out of place in the raggedy home, now drowning in silence. They made their way up the canvas of his shoes. He was little more than a spectator to his mothers anguish. Juden missed the imagined comfort of his bed. He missed the cold sweats and the night terrors and the knowledge that when the gallop of his heart became too much, that he only had to open his eyes to break the spell of his nightmares. But this was real. Leave, his mother said. Her voice was little more than a hiss against the crackle of the fireplace. Chery 52 I didnt mean to, he said. Yes, you did. Youve always been such an awful boy. Mom. Leave. The bird was drowning, waterlogged and silent against her wrinkled palms. He felt his feet move before his mind did. As his fingers twisted the doorknob awake, he heard his mother apologize. But not to him. He knew that, as a wave of deep ache washed over his head and down past his shoulders, that she would never apologize to him. Chery 53 Five Once again, Juden found himself in the faded kitchen, staring at the reflections on the linoleum table. This time, all four women sat before him, watching his muscles twitch under the cotton of his shirt. What is it you have to say, mon fils? Juden placed the journal on the table. The melodic ting-tang of water onto the steel sink was the only sound in the room. Emilia, Ms. Erzu said. Im sorry, Emilia said. She doesnt even know whats in here. Should I tell her, or would you like to? Juden said. It is not yours to tell, ungrateful. Juden could feel the sweat pool in his palms and the butterflies drag their wings against his stomach. What is that? Lila said. Theyre letters. Between your father and your mother, Juden said. Fem. Ms. Erzu said. Her voice was solid, slamming against his chest. He saw stars. Marie had sat quietly opposite of Juden, her eyes fixed on her lap. Now, frozen pools looked accusingly at her mother. You never let us look at them. You said he only talked about work and it was nothing for us to worry ourselves over, Marie said. Give it to me, Lila said. Chery 54 She reached across the table and took the journal in hand. Before Ms. Erzu could object, she flipped through the pages. Therere so many, she said. Let me see, Marie said. Ms. Erzus eyes never left Judens. Theyre all from the Riverside Jailhouse, Lila said. Manman. What are these? Marie said. She was met with silence. Manman, what are these? Marie repeated herself. They are from your father, Ms. Erzu said. Why from the jailhouse? Why are they all from the jailhouse? Lila said. Because that was where he was, ti fi. You lied then. All those years, you just lied to us? Lila said. Emilia still sat in her seat. Her eyes darted back and forth between the three women and Juden could see her trying to make sense of the commotion. Why? Juden said. Ms. Erzu turned her head towards him and peered past his skin. Frank say we should keep to ourselves the truth. He say he did not want you to worry. He say he come back, Ms. Erzu said. So, you told us he went away to work? Lila said. Juden could feel her anger coming off the tiled floor. But you knew the truth, Emilia, Juden said, You knew Frank had gone to jail all those years ago and they didnt? Chery 55 Emilia shifted in her seat. You knew? How did you know? Lila said. Emilia looked down at her hands for a long while before lifting her head. Ire told me. I thought it was one of the things you wanted to protect me from, so I kept it to myself. I didnt know. I thought you wouldve known. Everyone in town knew. It was not for them to tell. It was for me and I did not, Ms. Erzu said. Why? Why lie about this? Lila said. Tears flooded her eyes. Her face matched Maries, red and swollen. Because you would have to know why he go. And we never want to tell you. He was meant to return, ma chere. It was meant to mean nothing, Ms. Erzu said. What the fuck do you mean? Lila said. Ms. Erzu flinched at the remark. I burned cathedral. Many, many years ago. To protect you, Lila. You were little girl, so sweet, no anger yet. And he use your sweetness against you. It was all I know to save you. What are you talking about? Why cant you just be clear? Lila said. You girls never know why I hate that priest. You ate what I serve you. But he hurt you, Lila. He did. Frank took blame for the fire and went to county jail. Three months. His sentence was three months. But he die. He die there, alone. Please stop, Marie said. Her face was streaked with tears, her skin so white each of her veins had begun to glow under the lights. Shut up, Marie. Youve never had the guts to speak up before, dont start now. Lila, this is too much! Arrte! Ms. Erzu said. Chery 56 You have always protected her! And now you blame me for father leaving. For him dying? Why do you hate me? Why have you always hated me? I love you, Lila. We save you. You killed who I could have been. You killed our father. You left us without him and nothing but a bitter woman unhappy with the choices shes made. Silence. The walls of the small house shuddered under the weight of it. Ms. Erzu stood up straighter, her hand still resting against the chair, her head lifted high. You may be true, but your father left to protect you, ma chre. He prey on you, that priest, when you were a girl. Always had his eyes on you. One day, he went too far. Your father say go to the police, but I know he was wrong. They would have done nothing. So, I burn it down. The cathedral. I watch the smoke rise up and hope he burn with it. I did that for you. And your father pay the price. Lila stood mouth gasping for air, for words to express the storm forming behind her eyes. When they say the cathedral had burned again, I know it was you. For Emilia. Frank always say you like me. But I never know you take my mistakes. Lilas face went stark. What? Emilia said. I Lila said. Please, Lila. Do not continue my mistakes, Ms. Erzu said. I think its too late for that, Manman. At this, Ms. Erzu sat back in her seat. She took in a deep, shaky breath and closed her eyes. She held on to the air in her lungs as if she were drowning, her face turning a faint blue. Chery 57 Then, in a simple sigh, released the weight of her secrets into the air. She never opened her eyes again. It was Marie who screamed first. A shrill cry that electrocuted Judens nerves and sent pain to the back of his eyelids. Her banshee wails spoke to the old wallpaper, commanding it to curl out of place and down the length of the kitchen. Lila stood in silence until Emilia made her way over to her grandmother and took her hand into her own. Manman? she whispered. Ms. Erzu was still. Manman? she said again. I think it is time for you to leave, Lila said. She looked at Juden. Juden didnt return her gaze. He walked the town border, retracing his steps until a moat had formed. The butterflies had torn through him, ripping at his insides and leaving nothing behind but open wounds and an empty pit. He had lost track of the path his feet followed; his eyes too glossed with tears. He felt his way through the dark and sat on a brick step after a time. He was home again. The door creaked open and the warm light reflecting off of the bright yellow kitchen walls danced along the grass. Juden? his mother asked from behind. He sobbed. Juden, what is it? Whats wrong? I thought I was doing a good thing. What? I told the truth. I thought I was doing something good for Hubris, for once. Chery 58 She sat beside him and from the corner of his eye he could see the yellow satin robe she had wrapped tightly around her waist. Hubris isnt a place for the truth, sometimes. Why did you let him do it? She was quiet. The crickets leapt into the space, filling the silence with chirps about the moon and the dewdrops on the blades of grass. Juden wished they would stop. Your father was a good man when we met. A kind, good man. He would do anything to help anyone. Thats why I fell in love with him. Right before you were born, when you werent much bigger than a dream inside me, he got in a horrible accident working on the farm. No one really ever told me exactly what happened. Peopleve always said I was too fragile for certain realities. So, he went away for a while, to get better, and I found out I was pregnant with you. Then he came back. Juden wrung his fingers together, straining out the anxiety. I wanted so badly for him to be better that I believed he was. But he was different, Juden. I knew he was bad when he came back, but I couldnt leave. There was you. So, I stayed. It only started with the screaming, then he started drinking. Thats when he started to hit me. I shouldve left then but I didnt know how. Ive only known Hubris. This is my home; this is my house. And you were only a baby, I wouldnt know what to do with you on my own. So, I stayed. After a while, I started believing I was doing the right thing. That I was doing it to protect you. Thats the thing about Hubris. Its not that it refuses the truth. Hubris is a place that doesnt believe in ruining the show. If you believe in something so violently, why would it bother telling you otherwise. Chery 59 Juden felt the cooling air pull at the hairs on his arms. His vision had filled with a mist. But I think I think I became bitter towards you. I love you, Juden. Ive never said it, but I do. I spent so many years thinking I was showing you how much I loved you by staying here with your father, but I wasnt. And your father did love you. He said it often after you left. He never expected you to leave, because I never did. I guess I did teach you something good. I taught you not to be like me. What changed? Why are you telling me this now? After a while of crying over that dead bird I realized it was hollow. It was full of nothing. I realized I was alone. And I dont know if its selfish, but I dont want to be alone with my mistakes anymore. Clumsily, he followed the path Emilia had taken the night before. He didnt stop for the fireflies or the evening toads signing to the moon. He didnt stop for the crickets, the owls, or dance the stars had begun with the trees. He didnt stop when he made it to the pasture. Only the sight of Emilia, alone and weeping into the grass, halted his steps. Why would you come here? she said. I wanted to apologize, Juden said. For destroying everything? I dont think sorry will suffice. If I had known, I would have never helped you. I thought I was doing something good. Chery 60 You know, I thought you were too. Until I realized something. A good person would have left it alone. They would have thought of what this would do to us. But you werent doing this for me. For us. You did this for yourself. To prove something. I had nothing to prove. You did. You had to prove that we were wrong for keeping our secrets. That Hubris was wrong for keeping your secrets. And that may have been true, but who are you to choose for the rest of us. Juden felt exposed under the moonlight, naked as Emilias eyes glared into him. I thought I was doing something good. Maries dead. She left in tears after you did. My mother told me to wait for her. To let her be. So, I did. And now shes dead she said. What? Juden said. I found her, a little bit farther up the river. There were so many rocks in her pockets. She pointed towards the tree line. In one day, you managed to kill my grandmother and my aunt and leave me nothing but a woman so angry at the world she didnt shed a single tear when she saw Manman. Not when we moved her. Not even when we had to clean and dress her. Not once. The evening birds chirped as they hopped from branch to branch, singing love songs to each other. It made Juden even more sick. Can you leave? I need to say goodbye. Alone. This was our place. Her place. I can wait for you. I can wait and bring you home. Youve done enough. Please, just go. Juden looked at her one last time before turning away. Chery 61 The air had become charged with violent electricity. Juden felt it grab hold of his hair and pull them up in attention. The static sent memories surging through his muscles. With each jolt, his legs followed the trail of moments through the woods. Juden didnt know what he was feeling. His head raged with a sea of conflicting emotions, battling each other with such ferocity they seemed almost calm, unmoved. But he knew that the currents were pushing against each other as if their existences depended on it. Then he saw it. The cathedral and its illuminated doorway in the middle of the deep cerulean sky. For once, Juden wasnt afraid. His stomach was still, the butterflies have flown away to a warmer climate. Juden was too cold inside for them now. The trees had joined together in a powerful chorus against the unwelcoming wind. Juden couldnt hear the words, but they were stirring something up inside of him. He was becoming restless. Hey, boy. Father Ire said. Juden stood still. He appeared beside Juden, his shadow shrouding the candlelight in a dark aura. Did you find anything useful? A storm was brewing under Judens skin. Those women have always been off. No wonder they couldnt hold themselves together. Wish it wouldve happened earlier honestly. You have no tact, Juden said. I never said I did. You knew who did this. Aint no evidence in an assumption. Chery 62 Juden could feel his excitement. He could feel the bile fill in his stomach. Whatd you find? I dont have time for this. Nothing. What? The ground shook with his anger. The candlelight faltered for a moment. I didnt find anything, Juden said. Youre a fucking liar. So are you. Unlike you, however, I only have to face myself. Lets say I did find something. Something that would explain two dead women and a burned church. Would you want me to write about it? Fucking course I would. Really? Even if this story included a villain in disguise? A wolf in priests clothing who preys on young girls and hides away in a cave made of stone and satin, thinking no one will ever find him and his pile of corpses? If I found that story, youd want me to write about it. Ire was quiet. The candles had been completely blown out and in the subsequent darkness, Ires shadow had become a giant. The stone walls were engulfed by a pit of obsidian nothingness. The urge to walk towards it pulled at Judens shoelaces and the buttons of his shirt. He felt the temptation palpably, grabbing at his curls and pinching at his skin. Only cowards throw accusations. Ire said. Im okay with being a coward. The question is, are you? Juden turned to look at Ires face. He was stricken white, his eyes cast with a color so deep, Juden didnt think a word had been invented for it yet. For an instant, Juden felt his blood warm enough for his fear to creep up behind his eyes. But only for an instant. Chery 63 Is God? Juden said. In front of him was only darkness. Any recollection of the cathedral had vanished under the blanket Ires shadow had draped over the fixture. Its anger vibrated through Juden and shook the trees as their voices reached a crescendo. Juden took one final look at the cathedral, what little was left of it, and closed his eyes tightly. He let his breath settle in his lungs. When his eyes opened and the air flew past his lips, he saw the paneled ceiling of the shed. Then, he closed his eyes again and fell. He fell into the dark and all he felt was comfort. He lay still, floating in a pit of nothingness. Far away, he heard a door. He wanted to open his eyes and see. But as his mind reached up to peek through the shade of his eyelids, he felt a hand wrap itself around his wrist. Sleep had found him. He woke to the pitter-patter of rain on rooftops. With his eyes still shut, he thought he was dreaming. But the slumber he had was too murky for dreams to float in. He opened his eyes and for the first time in his life, he saw the rain come down on Hubris. Juden stood under the falling curtain. The droplets rolled down his skin, reminding his skin what it felt like to feel tears trail along with them. He felt overwhelmed. Barefoot, he walked the trail. He persisted, though blinded by the rain. He lost his footing and fell against the mud, his knees scraping against dried stems. The flowers were dead. Withered and dry, they bent against the weight of the rain. He ran his hands along the ground. pellets of water ricocheted off the dirt, returning themselves upwards only to return and continue the game. The wind quieted for a moment and behind him, Juden heard weeping. Lila sat in the mud at the top of the hill. She was disheveled, hair falling along her shoulders. She was drowning in tears. Chery 64 Lila, you should get inside, Juden said. Shes gone. Emilia? When? Shes left me. Shell come back. Shes gone. Lila. She left me. Juden sat beside her in the mud. Please, Lila. Shes gone. Between them, water carried the bodies of the fireflies downhill. Chery 65 An Analysis of the Symbols and Motifs within An American Way of Death and its Relationship to Magical Realist Works of Latin America and the United States In August of 2018, I took my first steps into the world of novel writing. Through the Ron and Laura Strain Honors College, I was allowed the opportunity to combine my creative writing background with my interest in historical artistic movements to create an analysis of Haitian cultural mores. Though I had initially intended to write a 150-200-page manuscript, I decided against this. This choice was made because as I wrote and developed my novel, I realized there was much more that I wanted to develop than I had time for. So, under the advice of my original advisor, I focused on establishing the plot of my novel and analysis. I also believe it is important to note that there were several resources in the form of books that I used when creating this piece. With the magnitude of this project, I chose to only focus on two of the texts I used as reference when delving into my analysis. When deciding which of these texts to use when writing my comparison, I decided I wanted to specifically use women of color. In the fall of 2019, I was able to create my Capstone Project with the help of Dr. Leah Milne. Through my work with Dr. Milne, we spoke about specifically use Toni Morrisons Beloved instead of Song of Solomon as the latter novel is one of Morrisons few novels written from the point of view of a male character. Contrastingly, Beloved focuses on a cast of women and their relationships with their pasts, which I believed to be more appropriate to the project at hand. Finally, the three novels I have chosen to write about are significant in that they personify the exact kind of magical realism I am attempting to replicate. Magical Realism, as you will learn later in this analysis, is a genre with many variations on how it can be done properly. When writing a genre piece, not having set rules and expectations on how they are created can be difficult. This fact is Chery 66 why I believe something such as this has never been done at our university. But when approached with an understanding of that reality, I believe more students can and will succeed in something of this nature in the future. In writing An American Way of Death, many portions were deeply influenced by magical realist writers of the 20th century, including Gabriel Garcia Marquez, Morrison, and Alejo Carpentier as well as magical realist artists like Cuban painter Toms Sanchez. In this analysis, I will explain the history of magical realism, common themes associated with magical realist texts and conclude with a comparison of my writing and those of notable authors of the movement. By focusing on the texts of Laura Esquivel, Morrison, and Coates, I will be able to analyze my work, what aspects I have chosen to include that are representative of the magical realist genre, and how these aspects exemplify the sociological and cultural statements I wish to express. In her chapter of A Companion to Magical Realism entitled Swords and Silver Rings: Magical Objects in the Work of Jorge Luis Borges and Gabriel Garca Mrquez, Lois Parkinson Zamora says that the term magical realism was popularized in 1925 by German art critic Franz Roh. Roh had intended the term to describe the Expressionist art movement and separate it from its realist predecessors. The term magical realism had three major surges of popularity in the 20th century with the first being in Europe with writers like Franz Kafka. But magical realism as we have defined it today wasnt popular until the late 1920s and into the 1940s when it was adopted by communities in Latin America and the Caribbean (Zamora). Alejo Carpentier and Venezuelan artist Arturo Uslar-Pietri are attributed to be the first Latin American writers to use the term of magical realism, or as it was translated realismo mgico, in 1927. In his 1943 essay entitled On the Marvelous Real in America, Carpentier notably attempts to set Latin American magical realism apart from the European Surrealist movements. He points out that there is a Chery 67 difference in how the two attempts to distort reality, stating that magical realism was built off of the understanding shared throughout Latin American cultures that the border between reality and the fantastic is easily permeated. Zamora describes magical realism as such and states that: texts accurately referred to as magical-realist do indeed raise questions about the visualizing capacity of language in ways that realistic texts do not. While all works of fiction require that we visualize objects, realism requires of objects that they represent only themselves. They may, of course, have symbolic or psychological or metaphysical content, but their signifying function is nonetheless different from the objects in magical realist texts, which must represent not only themselves but also the potential for some kind of alternative reality, some kind of magic (Zamora 30). Experts who have written on the genre of magical realism often disagree on what aspects characterize a text as magical realist. However, Wendy Faris, professor of English at the University of Texas at Arlington, has identified some widely accepted characteristics that she believes are often found in magical realist narratives. In her writing, Scheherazades Children: Magical Realism and Postmodern Fiction, Faris begins by reiterating the definition given to us by Zamora, stating that [m]agical realism combines realism and the fantastic in such a way that magical elements grow organically out of the reality portrayed (Faris). She then defines 5 primary characteristics of the genre: 1. The text contains an irreducible element of magic, something we cannot explain according to the laws of the universe as we know them. In terms of the text, magical things really do happen (Faris 167). 2. Descriptions detail a strong presence of the phenomenal worldthis is the realism in magic realism, distinguishing it from much fantasy and allegoryRealistic descriptions Chery 68 create a fictional world that resembles the one we live in, in many instances by excessive use of detail (Faris 169). 3. The reader may hesitate (at one point or another) between two contradictory understandings of eventsand hence experiences some unsettling doubts, often hallucination or miracle? (Faris 171). 4. We experience the closeness or near-merging of two realms, two worlds (Faris 172) 5. These fictions question received ideas about time, space, and identity (Faris 173). Faris explanation gives readers a deeper understanding of what would categorize a work of the magical realist genre based on the popular habits of the movement. Some of these characteristics are mentioned in Zamoras work, yet Faris emphasizes the duality created by blurring the line between reality and the mystical. Details and imagery are deeply important to magical realist narratives as they make it harder for the reader to separate reality from phenomena, as excessive uses of detail are characteristic of realist works of the early-mid twentieth century. There is an aspect of magical realist narratives that scholars like Zamora, Faris, Helen Price, and the contributors of A Companion to Magical Realism agree on and that is the relationship magical realism has with postcolonial storytelling. In a paper entitled The Question of the Other: Cultural Critiques of Magical Realism, Faris writes that though not all magical realist novels address the issues of decolonization and history, the genre effectively lends itself to portraying narratives that would have otherwise been hidden and silenced by the literary movements of old, many of which were created with a white, Eurocentric experience in mind. Isabel Allende, a Chilean writer whose work have oftentimes contained variations of magical realism, once said in an interview entitled The Shaman and the Infidel for New Perspectives Quarterly that: Chery 69 [M]agic realism is a literary device or a way of seeing in which there is space for the invisible forces that move the world: dreams, legends, myths, emotion, passion, history. All these forces find a place in the absurd, unexplainable aspects of magic realism... It is the capacity to see and to write about all the dimensions of reality (Allende). Homi Bhabha, a scholar, theorist, and Professor of English and American Literature and Language at Harvard wrote in 1990 Nations and Narrations, a piece that delves deep into the cultural habits of communities experiencing dishevel. In this text, Bhabha explains what sort of importance magical realism as a literary genre may have had in Latin American communities. In Bhabhas work, he attempts to spread light on why Zamora and McKinney both chose to emphasize the importance of the Latin American sect of the genre. In Nations and Narrations, Bhabha writes that 'Magical realism' after the Latin American Boom, becomes the literary language of the emergent post-colonial world (Bhabha). Bhabha explains that countries with extensive histories of turbulence and extreme political situations have a higher likelihood of creating and expressing these histories through unique narratives. Though the terminology of magical realism was not created within Latin America, it attached itself to the literary and artistic community because of the vast history of political and governmental upheaval that the countries within this portion of the global south experienced. Carpentier specifically credits Haiti with inspiring the movement. According to Carpentier: [a]fter having felt the undeniable spell of the lands of Haiti, after having found magical warnings along the red roads of the Central Maseta, after having heard the drums of Petro and the Rada, I was moved to set this recently experienced marvelous reality beside the tiresome pretension of creating the marvelous that has characterized certain European literature over the past thirty years (Carpentier). Chery 70 Carpentier encountered the marvelous real around every corner. Carpentier also expands on Allende's description of magical realism as a device, stating that the movement and its use can be likened to bureaucratic systems, stating [t]he result of willing the marvelous or any other trance is that the dream technicians [writers] become bureaucrats. By invoking traditional formulas, certain paintings are made into a monotonous junkyard of sugar-coated watches (Carpentier). Writers of magical realist texts are technicians, creators of dream narratives deeply connected with the cultural traditions of those connected to them. Magical realism is both a narrative of the oppressed and a narrative inherently connected to my ancestry and culture. By understanding these different aspects of what can make up a magical realist narrative, where it comes from, and why it holds specific importance to Latin America and Haiti, we can move on to comparing An American Way of Death to the works of other known magical realist writers. When writing the novel manuscript, I was influenced by the artworks of Toms Sanchez, a Cuban painter known for his dream-like landscapes. Much of his work depicts natural spaces that are untouched by human interactions. Though he is described heavily as a realist as his works depict the reality of nature, they remain in a dimension where they are unnatural and, in many ways, magical. Sanchezs love for the untouched, fairytale understanding of the world and spaces led me to grasp for that sort of representation in my writing. Magical imagery is an important facet of the magical realist genre and is often used to accurately classify what works fall under this umbrella. Through my research in building my novel and reading works as a reference, Ive learned that many characteristics can be categorized as distinct to the magical realist genre, as the genre encapsulates a myriad of styles, writers, and cultures. Chery 71 Of these many writers, few have perfected the use of magical realism in their work as Laura Esquivel. Esquivels pivotal work, Like Water for Chocolate, follows the story of Tita De La Garza and her mother, Mama Elena. Throughout their tale, detailed to the reader through monthly entries and family recipes, the reader becomes privy to a story of two contradicting forces battling against each other. In her chapter of A Companion to Magical Realism, Helen Price notes that Esquivels work maintains its magical realist status not by subversion of colonial expectations of the women in the text, but through the mundane nature of the magic they create and interact with. Price writes [b]oth book and film do emulate the magical-realist style, in that fantastic occurrences are recounted, in a matter-of-fact tone, as if they were commonplace events. In other words, within the ontological parameters of the text, magical things [really] do happen (Price). From the beginning, the novels narrator establishes the conflict. Tita is forced to abstain from romance to satisfy the long-held family tradition of the youngest daughter remaining unmarried and childless to care for her mother once she becomes old. Mama Elena responds to Titas query of Pedro, her love interest, coming to visit Mama Elena with If he intends to ask for your hand, tell him not to bother. Hell be wasting his time and mine too. You know perfectly well that being the youngest daughter means you have to take care of me until the day I die (Esquivel). Tita is forced to acknowledge the reality of her future and the forbidden nature of love for her. She attempts to fight back against her mother but fails. Esquivels narrator establishes to the reader that Titas conflict is the repression of her emotions at the hands of her mother. To counter this repression, Esquivel allows Tita to express her emotions through the foods she makes and the way she interacts with the ingredients, as Price notes for the recipe for quails on a bed of rose petals [t]he text makes clear that it is the desire and excitement provoked Chery 72 in Tita by the roses that produce this effect, rather as if Tita were subconsciously projecting her passion into the food (Price). Tita has been forced into a family with cultural expectations that force her to obey her mothers wishes and refrain from negative emotional responses to perceived injustices. Esquivel initiates the rebellion from these cultural norms from the introduction of Titas character. Esquivel writes that Tita was literally washed into this world on a great tide of tears that spilled over the edge of the table and flooded across the floor (Esquivel). The flood of tears soon evaporates and becomes salt to be used by Nacha, the familys cook, in seasoning food. The magic of emotions and cooking become inherent symbols of Tita, almost impossible to separate from her character and the arc she is forced to follow throughout the novel. These traits contrast with the will of Mama Elena as she tells Tita You dont have an opinion, and thats all I want to hear about it, (Esquivel). Titas existence in the world of the novel has already established her as this daughter, this breaker of tradition as she is described through her magic. She becomes the patron saint of emotion, opinion, and individual expression. Her domesticity and femininity are not used here to reinforce gender norms, but instead to subvert the narrative of what it means to be independent. The actions associated with what it meant to be a woman during the time of the story are amplified and expounded on to become the ways an oppressed woman can express the love she is forced to smother. When comparing my work to Esquivel, there are similarities between using magical realism to express and oppose sociological preconceptions. In An American Way of Death, the emphasis on the divine feminine is reminiscent of the expression of femininity and expectations of women in Esquivels text. Price brings up Esquivels following of traditional heteronormative binaries and notably has an issue with this as it seemingly goes against the post-colonial narrative of magical realism. Yet, I believe, Esquivels concept of domesticity is used in Like Chery 73 Water for Chocolate to express Titas emotions, which is subversive in the cultural habitat the text takes place, though expressed through a socially acceptable medium. Adhering to the traditional binary does not force a text out of creating post-colonial commentary, especially when it is attached to a story of people not given the privilege of these descriptions in Eurocentric, westernized literature. With this belief, I have written the feminine within my work not only through the prevalence of female characters but also through the imagery of the flora, fauna, and stereotypically coded language. Nature, generally written to be feminine in its characteristics, maintains this femininity within the novel. However, it is used as a powerful descriptor of the emotions and psyche of my characters, especially that of my male lead. When Juden is forced to recount the experiences of his childhood and the emotional abuse he experienced from both of his parents, his first response is to this anger is to reminisce on the plants of his childhood and the comfort they evoked within him. [h]e saw images of the children he once knew playing through the overgrown dandelions and bulbous buttercups in the empty lot across the street (Chery). He had roamed these forests when the river flowed through Hubris. When the water ran through its veins, pulsating and pleasant, the town had been alive. In those days, the river had run strong and crisp, smelling sweetly of the mammee apples and banana flowers that had fallen along the bank. Sometimes he would pick the honeyed fruit from the tree limbs and bring them home (Chery). Juden has witnessed his fathers abuse towards his mother and many of the memories he associates with Hubris that are separate from those acts of violence are associated with nature. What Juden lacked in real parental, specifically maternal, compassion, he gained through the nurturing relationship he held with the environments around him. Juden ultimately becomes a Chery 74 child of nature. This maintains the aura of telling a feminine/ womens story in the presence of a male protagonist, as he has been taught how to emote by an omniscient and motherly nature. The natural world of Hubris is also used within the text to smear the line between the naturally occurring plant life of Illinois and Haiti, the homeland of both magical realism and Ms. Erzu. In the quote, mammee apples and banana flowers are found within the forests of Hubris. These types of vegetation are only found on Hispaniola, the island that is home to Haiti and the Dominican Republic. In their 2012 paper entitled Magic(al) Realism as Postcolonial Device in Toni Morrisons Beloved, Mehdi Razmi and Leyli Jamali writes that Morrison used this interest in culture when writing Beloved, utilizing magical realism in her attempt to write outside of the Euro-centric literature model. They state that: Black lore, the myths and rituals of black culture are the most prominent elements in Beloved. Morrison feels a strong connection to ancestors because they were the culture holders. She applies magical realism in order to be able to use black folklore instead of authorized beliefs of Western world. Her magical character Beloved might have been formed after a mixture of abiku, bakalu and orisha, Oshun of West African Yoruba mythology. The mysticism of Haitian folklore bleeds through every crevice of the novel. The storys plot has been modeled after the vodou loa, Erzulie Dantor. Within Haitian mystical beliefs, Erzulie Dantor is a deity of revenge, motherhood and the protector of children. When she leaved a ceremony, she leaves in tears. The driving conflict within the novel all follows these characteristics. To protect her children, Ms. Erzu makes the decision to burn down the cathedral and the livelihood of Father Ire. Lila, though ignorant to her mothers past choices, follows in her Chery 75 footsteps years later. The cultural importance of religion and mysticism is passed down through Haitian families over generations, with all Haitians knowing the importance of vodou in gaining our independence. Familial histories are ingrained, and trauma is believed to be passed down through ancestry. These Haitian cultural truths litter An American Way of Death. Esquivels work is also heavily dependent on the understanding culture, notably Mexican culture, and the expectations attached to these sorts of existences. The use of recipes to exude emotion is also connected to the cultural understanding of Like Water For Chocolate as many of the recipes are unique to the surroundings of Tita and her family on the ranch. This cultural connection between the tradition Tita is forced to adhere to, the relationship she has with her mother, and the acceptance of these norms is important to know why Tita chooses to maintain the conflict of the story and keep her emotions hidden in the sense of refusing to openly state them. Magical realism here is used by Esquivel to make the beliefs held by society of women and how women express themselves into a powerful reality that places Tita above these perceptions. She is overly emotional and driven by these emotions, but she is also powerful enough to create empathic links with those around her. Her emotions are not her own, they are connected to the world she lives in. She was born to oppose her reality just as magical realism was created to oppose the mundane. Much of what people consider as magical realism in literature is associated with Latin America, yet post-colonialism is not solely a movement found in the global south. Toni Morrisons work embodies many of the commonly accepted characteristics of magical realism, specifically with her novel Beloved. Beloved tells the story of Sethe and her relationship with the traumatic experiences she was forced to endure during her time as a slave on a Kentuckian plantation known as Sweet Home. To escape with her three children and a fourth growing inside Chery 76 her, Sethe decides it is better to kill her children than to see them enslaved under a man like schoolteacher ever again. With these events in mind, the overarching plot of the novel deals with the repercussions of these decisions, the specter, and ultimate human possession of the reality of the violence committed by Sethe. From the beginning, Morrison forces her readers to acknowledge the violence of Sethes reality, and in turn the realities of sixty million and more, as stated in the acknowledgments of the novel (Morrison). This phrase sixty million and more refers to the undocumented number of African diasporas forced to endure the horrors of slavery in the Americas. This acknowledgment is to be noted as Sethes experience, though seemingly unique with its supernatural elements and ghost story likeness, is not as unique as we would like to think. To understand Beloved, a story of a ghost and its wrath, one must understand the true story it is based on. According to an archived article from the Cincinnati Museum Center, Margaret Garner was a slave born on a plantation in Boone County, Kentucky (Cincinnati). After escaping with her husband and several other slaves, they were apprehended and instead of return to slavery, Margaret Garner decided that she would rather take the lives of her children. Garner only succeeded in killing her two-year-old daughter, wounding herself and her other children. All features of this narrative relate to Faris and the characteristics of magical realist texts. A repetitive feature noted by all sources mentioned previously is the prevalence of myth in the genre. In The Question of the Other, Faris states that: Because magical realism often gives voice in the thematic domain to indigenous or ancient myths, legends, and cultural practices, and in the domain of narrative technique to the literary traditions that express them with the use of non-realistic events and images, it can be seen as a kind of narrative primitivism (Faris 103). Chery 77 Within Beloved, Morrison uses this sense of myth to express the realities of slavery and the African American experience. Myths are the stories that communities and kinfolk pass between themselves. Oftentimes African Americans arent described to be the colonized as they still maintain themselves on taken Indigenous land. However, just as those we would generally consider as a colonized community, they are deeply affected by the supremacist views of Western imperialism and colonial rule. The history of ancestral erasure, erasure of African-ness, and assimilation to the realities of white supremacist views and beliefs towards ones skin color mean that the myths of this community hold onto the events of slavery as their legends and ancient practices. Razmi and write that The source of this transgressive and subversive aspect of magical realist narrative in Beloved lies in the fact that, once the reader finds that the category of the real is not definite then all assumptions of truth becomes vague. Because the setting of Beloved is realistic, when the category of the real is questioned within the fiction, the world outside the fiction is made less certain as well (Razmi). Morrisons use of the story of Margaret Garner establishes this belief. Margaret Garners story is a reality, documented in papers during the 1800s. But the unimaginable choice placed on Garners shoulders from the truth of slavery in America is unimaginable to the reader of Morrisons novel. It is here in this dissonance between the reader and the text that Morrison bridges the gap with magical realist elements. Where Beloved blatantly addresses the mythology surrounding the history of slavery, An American Way of Death attempts to talk about the issue of generational trauma in subdued conversation. All characters and their stories are connected to the main conflict of the story. The trauma created by traditions passed down through generations in multi-faceted ways, a monster with many hands. Returning to the death of Ms. Erzu, she dies with a sigh. The repercussions of Chery 78 her life and the nature of her death reverberates through the very beings of each of my characters as they must come to terms with these secrets coming to light. Both An American Way of Death and Beloved utilizes the genre of magical realism as a device that reflects, mirrors, the essence of the conflict they hold at their center. Morrison introduces the reader to the violence and magical realist elements of her novel from the first line. Morrison writes 124 was spiteful. Full of a babys venom on page 1. The house is personified from the start, forcing the reader out of a realistic understanding of what the purpose of the structure is. It is described as vengeful and most notably, a space only occupied with those who are in some way understanding of the violence that they are forced to experience. The character of Beloved, conversely, is violence. Though it is believed by Sethe and Denver that Beloved is the embodiment of the infant daughter killed, Beloved becomes representative of much more. With her inability to formulate expansive thoughts and her childlike cadence, Beloveds statements on her otherness can be read and understood in a multitude of ways. After Beloveds introduction, Denver asks her about the other side. Morrison writes: Beloved closed her eyes. In the dark my name is Beloved. Denver scooted a little closer. What's it like over there, where you were before? Can you tell me? Dark, said Beloved. I'm small in that place. I'm like this here. She raised her head off the bed, lay down on her side and curled up. Denver covered her lips with her fingers. Were you cold? Beloved curled tighter and shook her head. Hot. Nothing to breathe down there and no room to move in. You see anybody? Chery 79 Heaps. A lot of people is down there. Some is dead. [] Tell me, how did you get here? I wait; then I got on the bridge. I stay there in the dark, in the daytime, in the dark, in the daytime. It was a long time. All this time you were on a bridge? No. After. When I got out (Morrison). Beloved is not simply referring to death, the other-worldly space that she was forced to inhabit all those years as a ghost. She is also referring to the Middle Passage of the slaves brought over in the Trans-Atlantic slave trade. Her inability to detail the specifics of her experience allows her and Morrison to connect the death and trauma that she experienced to be inseparable from the past and history of slavery within America. In her Masters thesis Functions of Magic Realism in Toni Morrison's Beloved, Justina Kembryt writes The novel could be considered as a dedication for the history of America due to the truthfulness of the facts Toni Morrison describes by using magical elements (Kembryt 38). Beloveds death was a product of her mothers situation, trapped and cornered, with much understanding of the violence attached to the existence of slaves in the Americas. And due to this, Beloved is not solely a product of her killing, but the killings and degradation of sixty million and more (Kembryt). Beloved states that she is small in that place, alluding not only to the fact that she was a child when she died but also the fact that slaves were forced into the ships and made small. In documentation given by historical societies that keep and maintain the records of the slave ships, many images created and produced to express the best way to transport multitudes of slaves at once depict men, women, and children packed into the vessels like sardines. They are made small and compact in the name of higher probabilities of profit. This is expanded when Beloved also states here that Chery 80 she saw heaps of people. This subversion of the expectations of what is experienced when one dies and correlating it to the experience of slaves in the Middle Passage leads to the understanding of generational trauma and how racism and white supremacy affect communities of color or more specifically in this instance, the black community. Even after death, the past attaches itself to the present. Morrison reiterates this in the novels ending, where when Denver returns to the home with an army of women intending to exorcise the specter of Beloved, she appears nude and pregnant on the porch. Many scholars speculate exactly what this is intended to mean, however by understanding the lineage of racial trauma it can be assumed that Beloved is pregnant with grief. Beloved, both the embodied experience of Sethe and the experiences of the sixty million and more is depicted pregnant and nude, bare in the face of the community with the trauma that has been passed down through her family, only to be broken by Denver and her insistence of casting her out. Similarly, In An American Way of Death, Emilia ultimately leaves Hubris and in turn breaks the cycle started by her grandmother and continued by her mother. Potentially the most pivotal example of violence and the magical realist narrative in Beloved is that of Sethes murder of her daughter. Though it is deeply implied and told to the reader at the beginning of the novel, when Sethe finally explains to Paul D. exactly what happened that night so many years ago, Morrison chooses to mask it in heavy detail and imagery. Possibly the most violent act in the entire novel and Morrison, rather than bask in the grotesque nature of the decision, takes us into the mind of Sethe and describes to us in detail, the feeling of the action. Morrison writes: Sethe knew that the circle she was making around the room, him, the subject, would remain one. That she could never close in, pin it down for anybody who had to ask. If they didnt get it right off she could never explain. Because the truth is simple, not a Chery 81 long-drawn-out record of flowered shifts, tree cages, selfishness, ankle ropes, and wells. Simple: she was squatting in the garden and when she saw them coming and recognized schoolteachers hat, she heard wings. Little hummingbirds stuck their needle beaks right through her headcloth into her hair and beat their wings. And if she thought anything, it was No. No. Nono. Nonono. Simple. She just flew. Collected every bit of life she had made, all the parts of her that were precious and fine and beautiful, and carried, pushed, dragged them through the veil, out, away over there where no one could hurt them. Over there. Outside this place, where they could be safe (Morrison). In Faris characteristics of magical realism, she details approximately 8 secondary characteristics to magical realist narratives and texts. Though she acknowledges that these characteristics are not required of these types of narratives, she says that they are commonly found within them. Of these 8 secondary characteristics, Faris states that [t]he reader may experience a particular kind of verbal magica closing of the gap between words and the world. This is the belief that metaphors are made real. In this excerpt of Beloved, Sethes avoidance of the reality of her decision is made real through the metaphor and motif of hummingbirds. With great attention to detail, Morrison uses magical realist motifs to allow her reader into the psyche of Sethe and breaks away from the reality of the horror she has experienced throughout her short life. Sethe is in a world of her own in this piece of writing. Her thoughts become hummingbirds as she thinks back to that day. What Paul D. learns of the experience is bare bones, the tragedy, the death, and of course, the violence. The reader, however, learns the emotions Sethe experiences at this moment. She dissociates in a way tangible to the reader. As they witness the scene and Sethe recounts the setting as she was squatting in the garden and when she saw them coming and recognized schoolteachers hat, she heard wings. The gravity of the situation, the gravity of the Chery 82 death of a child at the hands of their mother becomes nothing more than the word simple. Magical realism, according to Faris, is heavily dependent on the juxtaposition between reality and fantasy disappearing. Faris states that [t]he reader may hesitate (at one point or another) between two contradictory understandings of eventsand hence experiences some unsettling doubts, often hallucination or miracle?. Comparatively, with An American Way of Death, fireflies and birds are used to break through the boundary between real and imaginary. The use of these natural images, the world as we understand it, is a common way for magical realist authors to signal to the reader the destruction of these lines. Morrisons depiction of the events, especially in comparison to what they are, conflict with each other. It is a serene depiction of hummingbirds caressing Sethes hair wrap, beating their wings against her head and the fabric and creating a comforting image of flora and fauna interacting with humanity. But the reader must remember that Sethe is slitting the throat of her infant daughter, all while these images are being fed back to them. Juden experiences this when he argues with his mother after returning home. In An American Way of Death, Juden recalls: Judens vision filled with a field of poppies (Chery). The poppies ripped out of their roots (Chery). Tears streamed down her cheeks as the poppies lifted into the air and painted the sky a deep crimson (Chery). While many characters would understand their anger in more violent, negative ways, Juden turns to flowers. His anger is deconstructed and expressed through an experience separate from one of violence and rage, yet the image still holds the severity of his emotions. This mirrors how Juden is understanding his anger. Similarly, instead of downplaying the severity of Sethes situation, Morrisons use of magical detail against the backdrop of the unthinkable actions intensifies how Chery 83 inconceivable Sethes choice was, and in turn, allows those separated from the events that led her here to have some form of understanding as to why she did what she did. The final novel I will write about is The Water Dancer by Ta-Nehisi Coates, published in 2019. When researching this project, much of what I chose to focus on were works that have established themselves in the magical realist genre. Yet, this leaves us to wonder what path the genre took in the years since the publication of these novels. In The Water Dancer, Coates borrows from Morrisons Beloved and writes another narrative on the importance of memory and ancestry within black communities. The novel depicts the story of a mixed slave in Virginia named Hiram, nicknamed Hi, and his journey to freedom and spiritual awakening. Hi is born to an enslaved woman and the plantation master. He possesses a photogenic memory that allows him to remember everything he has experienced, yet even with this ability, he is unable to recall anything about his mother who was sold to another plantation when he was nine. This novel, drenched in religious and historical imagery, is a perfect example of Faris expectations of magical realist narratives. After a tragedy catapults Hi into his awakening, he becomes an agent of the Underground Railroad. He gains a new ability called conducting which allows him to help other enslaved people to freedom. Though the addition of a superpower can oftentimes take away from the reality of a novel, Coates uses this superpower as both a true aspect of his story and a metaphor of our historical reality. Coates writes But we must tell our stories, and not be ensnared by them (Coates). Throughout American history, African-American people in America have been subject to manipulation and erasure of their history. The ancestral psychological trauma of racism is a topic too often written about in post-colonial literary works as so little information has been gathered about it as an epidemic. The power Hi possesses acts as Chery 84 both a gift and a curse as he must use it to change the lives of many, but must also deal with the weight of the horrific truths of Black history. Though my novel comparisons did not include Coates work, it remains a powerful example of why I chose the themes I use for my novel. Generational and ancestral trauma is a conversation being had by all formerly colonized people on the Earth. Expressing the effects oppression has had on our interpersonal relationships is a part of decolonizing the mind. This concept of decolonizing the way people of color interpret the world they live in is what magical realism is attempting to achieve. Through the analysis and research done with this project, I have gained the confidence to grow my work into the full 200-page manuscript. The information I found all point to the importance of post-colonial literary movements being analyzed in their entirety. Much of English coursework revolves around a white, Euro-centric understanding of the world. By taking the time to understand this literary movement, I have learned the importance of breaking away from this norm and completely restructuring the way that literature is taught. Without this project, I would not have known about this genre, and that is a fact that both saddens and angers me as a person of color. Magical realism is a genre that is consistently under debate from scholars and literary critics. It is a genre that is dominated by people of color, not created by them nor was it created for them. But it is a genre that lends itself well to the cultural practices of the oppressed. Mysticism is oftentimes lost in Western literature as much of societal functions are built on logic, reasoning, and understanding of why humans react to their environments in the ways they do. Magical realism rejects this belief and because of this, it is allowed to flourish in communities Chery 85 built off of superstitions, religious traditions, and cultural mores with a foundation in the unknown. By using magical realism within their works, Laura Esquivel and Toni Morrison are able to amplify the realities of coded female life experiences and the gruesome history of slavery in America, respectively, to a level that allows these works to be easily understood by those who know little of the emotions and histories attached. The relationship the characters in these novels have with their setting is deeply reminiscent of Faris beliefs of what characterizes magical realism. Magical things do happen on Mama Elenas ranch, at the house known as 124, and their inhabitants understand this. Throughout Like Water For Chocolate and Beloved, Esquivel and Morrison express traumas and expectations through these elements. Titas emotions are powerful enough to move and imprint themselves on the lives of others. Her emotions are enough to change the course of her destiny. In Esquivels work, magical realism makes the realities of womanhood and love more powerful than sheer violence. The introduction of Beloved as a character is the introduction of the past and its relationship with the present, personifying the terror created by racism and white supremacy. Beloved gives birth to the grief that Sethe and those of Sweet Home have worked so hard to run from. And when she disappears, the memories of these experiences disappear with her. Morrison's coupling of trauma and magical realism is not a coupling of doom. This is not the story of tragic lovers whose inherent forces work against each other to contradict. Morrisons coupling is instead a story of hope. Magical realist narratives are stories of the evolution of past pains, past beliefs, and healing from the situations they create. To begin this process, one must acknowledge this pain. And sometimes, to truly acknowledge a concept so inconceivable, one must expand past their known realities. This is what An American Way of Death does. Chery 86 Works Cited Allende, Isabel. The Shaman and the Infidel (interview). New Perspectives Quarterly 8.1, 1991. 54-58. Bhabha, Homi. Introduction, Nation and Narration (London: Routledge, 2008) Carpentier, Alejo. On the Marvelous Real in America (1949). Magical Realism, 1995, pp. 75 88., doi:10.1215/9780822397212-004. Cincinnati Museum Center. Margaret Garner: African American Resources: Cincinnati History Library and Archives. Margaret Garner | African American Resources | Cincinnati History Library and Archives, 2004, library.cincymuseum.org/aag/bio/garner.html. Coates, Ta-Nehisi. The Water Dancer. Penguin, 2020. Esquivel, Laura. Like Water for Chocolate. National Library for the Blind, 2001. Faris, Wendy. Scheherazades Children: Magical Realism and Postmodern Fiction. Magical Realism: Theory, History, Community. Ed. L. Parkinson and W. Faris. Durham: Duke UP,1995. 163-190. Print. Faris, Wendy B. The Question of the Other: Cultural Critiques of Magical Realism. Janus Head 5, 2002. 101-118. Print Kembryt, Justina. Functions of Magic Realism in Toni Morrison's Beloved . Lithuanian University of Educational Sciences, Lithuanian University of Educational Sciences, 2018, pp. 170. Morrison, Toni. Beloved. Vintage, 2016. Razmi, Mehri & Jamali, Leyli. Magic(al) Realism as Postcolonial Device in Toni Morrison's Beloved. International Journal of Humanities and Social Science. 2012. Chery 87 Price, Helen. Unsavoury Representations in Laura Esquivels Like Water for Chocolate. Companion to Magical Realism, by Stephen M. Hart, Boydell & Brewer, 2005, pp. 181 190. Zamora, Lois Parkinson. Magical Realism: Theory, History, Community. Duke Univ. Press, 2005.  ...

... Pre-Health Care Professionals Stigmatizing Attitudes and Beliefs, Perceptions of Blame and Responsibility, and Motivation to Treat Overweight and Obese Patients By Kristopher Thomas Butler Honors Project Thesis Submitted in Partial Fulfillment Of the Requirements for a Baccalaureate Degree With Distinction In the Ron and Laura Strain Honors College of THE UNIVERSITY OF INDIANAPOLIS May 2020 Faculty Advisor: Erin Fekete, Ph.D. Executive Director of Honors: James B. Williams, Ph.D. Kristopher Butler 2020. Copyright in this work rests solely with the author. Please ensure that any reproduction or re-use is done in accordance with relevant national copyright protection. WEIGHT STIGMA TOWARDS OVERWEIGHT AND OBESE PATIENTS i Abstract As rates of overweight and obesity increase in the United States, health care providers will interact with more patients with these conditions. Health care providers frequently make negative attributions about patients with overweight and obesity, and they may blame patients for their condition. This has negative implications for patients, including health care avoidance and weight gain. Limited research examines negative attitudes and beliefs among pre-health professional students, and even less research examines how stigmatizing attitudes vary based on patient BMI. This study hypothesized that pre-health care professional students weight stigmatizing attitudes and beliefs, perceptions of blame and responsibility, and motivation to treat would be greater as patient weight increased. Pre-health care professional students (n = 127) read a vignette depicting a patient who was overweight, obese, or severely obese and then completed questionnaires. Results suggested that pre-health professional students in the severely obese condition reported significantly higher negative weight-based attitudes and beliefs compared to participants in the overweight and obese conditions. No differences were observed in participants attributions of blame, responsibility, or in motivation to treat. Health care professionals may start to develop stigmatizing attitudes and beliefs about weight during education, so intervention should occur before individuals transition to practice. WEIGHT STIGMA TOWARDS OVERWEIGHT AND OBESE PATIENTS ii Table of Contents List of Tables iii Introduction, Intellectual Context, Framework, and Theory 1 Method 8 Results 17 Discussion 19 Conclusion 24 Reflection and Future Directions 25 References 28 Appendices 33 WEIGHT STIGMA TOWARDS OVERWEIGHT AND OBESE PATIENTS iii List of Tables Table 1: Main Effects of Vignette Condition on Negative Weight-based Attitudes and Beliefs 17 Table 2: Post-hoc Analyses of the Effects of Vignette Condition on Negative Weightbased Attitudes and Beliefs Controlling for Participant BMI 18 WEIGHT STIGMA TOWARDS OVERWEIGHT AND OBESE PATIENTS 1 Introduction, Intellectual Context, Framework, and Theory Obesity as a Public Health Issue The prevalence of obesity in the United States has increased over the past few decades (National Institute of Diabetes and Digestive and Kidney Diseases, 2017). The Centers for Disease Control and Prevention (2017a) indicated that from 2015 to 2016, 71.6% of adults 20 years of age or older in the United States were overweight (Body Mass Index; BMI: 25 29) and obese (BMI: 30-39), and in particular, 39.8% of adults were obese. Further, the National Health and Nutrition Examination Survey (NHANES), a nationally representative survey from the National Center for Health Statistics, found that in 2013 and 2014 7.7% of American adults were classified as severely obese (BMI: 40+; National Institute of Diabetes and Digestive and Kidney Diseases, 2017). Obesity can exacerbate or contribute to numerous health conditions, including hypertension, heart disease, high low-density lipoprotein (LDL) cholesterol, stroke, type II diabetes, osteoarthritis, and sleep apnea which can prompt more frequent medical care visits (Centers for Disease Control and Prevention, 2015). More frequent medical care visits and the development of medical conditions can increase health care costs for individuals with obesity. The estimated cost for obesity-related health care costs in the United States was $147 billion (Centers for Disease Control and Prevention, 2017b). Weight Stigma Facing Overweight and Obese Individuals In addition to the potential threats to physical health and the financial burdens of obesity, individuals with obesity face prejudice and discrimination from other members WEIGHT STIGMA TOWARDS OVERWEIGHT AND OBESE PATIENTS 2 of society, including the health care providers managing their care (Malterud & Ulriksen, 2011; Phelan et al., 2015; Rand et al., 2017). Prejudice is negative attitudes towards individuals based on their membership to a certain group, and discrimination is treating individuals differently based on their membership to a certain group (Puhl et al., 2008). Together, these prejudiced attitudes and discriminatory behaviors contribute to weight stigma, which is an individuals negatively held beliefs and attitudes about individuals with overweight and obesity (Puhl et al., 2008). In particular, weight stigmatizing attitudes and beliefs held by health care providers can be a challenge facing individuals with overweight and obesity. Health care providers may possess negative stereotypes and perceptions of blame and responsibility about the weight of individuals with overweight or obesity. For example, a stereotype among health care providers is the perception of a lower likelihood of patients with obesity following medical recommendations (Phelan et al., 2015). Prior research has also indicated that health care professionals tend to perceive that individuals with obesity are lazy, have a lack of discipline, have weaker willpower (Phelan et al., 2015), and do not take responsibility for their weight (Malterud & Ulriksen, 2011). Finally, research has noted health care providers feelings of disappointment and frustration towards patients, which suggests that health care providers may convey a sense of perceived blame and responsibility towards individuals who are overweight and obese (Malterud & Ulriksen, 2011; Phelan et al., 2015). These feelings of perceived blame and responsibility may lead to a decreased motivation to treat individuals with overweight and obesity. For example, health care WEIGHT STIGMA TOWARDS OVERWEIGHT AND OBESE PATIENTS 3 providers may utilize less time to educate patients with obesity about their health, and in one study, health care providers were more likely to rate encounters with patients with obesity as a waste of time and spend less time with those patients compared to patients within the normal weight range (Phelan et al., 2015). Research has also indicated that individuals with obesity have reported feelings of condemnation from health care providers (Rand et al., 2017). If health care providers enter a patient care scenario with weight stigmatizing attitudes and beliefs, such as negative stereotypes, perceptions of blame and responsibility, and have less motivation to treat the patient, there are a multitude of negative health implications. A critical review of fifteen different research studies concluded that weight stigmatizing attitudes among health care providers were less likely to impact patient care of patients with obesity than what had been historically reported (Budd et al., 2011); however, the weight stigmatizing attitudes and beliefs of health care providers can still affect patient care for patients with overweight and obesity. Further, research studying patient care interactions in an intensive care unit with patients with severe obesity observed that social awkwardness was an issue in the interactions between health care providers and patients with severe obesity due to the awareness of weight stigmatizing attitudes (Hales et al., 2016). These studies, however, did not address how patient care interactions between health care providers and patients differed for patients with severe obesity compared to the interactions for patients with obesity and patients with overweight. WEIGHT STIGMA TOWARDS OVERWEIGHT AND OBESE PATIENTS 4 Research has indicated that individuals with obesity might avoid treatment to avert embarrassment (Phelan et al., 2015). Furthermore, a synthesis of information from thirty studies between 1990 and 2010 found that obesity had affected patient care interactions, such as treatment avoidance by patients (Mold & Forbes, 2013). Another study reported that 19% of participants would avoid health care appointments in the future and 21% of participants would look for a new physician if the individuals felt as though they had experienced weight stigma from their physician (Puhl et al., 2013). Additionally, one study found that there was an association between weight labeling, such as too fat, of ten-year-old girls and an obese BMI about ten years later (Hunger & Tomiyama, 2014). Not only is treatment avoidance an impediment to addressing other medical conditions or pursuing preventative care, but it could also lead to weight gain. Weight Stigma From Pre-Health Professional Students While the issue of weight stigmatizing attitudes and behaviors held by health care professionals presents a challenge to patient care for patients with overweight and obesity, the prevalence of weight stigmatizing attitudes and behaviors of pre-health professional students, such as medical students and nursing students, is also important to address. Pre-health professionals likely begin to develop negative attitudes towards patients with overweight and obesity during training. For instance, one study observed that exercise science students displayed conscious bias towards individuals who were overweight and obese (Langdon et al., 2016). Another study reported that 74% of first year medical students demonstrated unconscious weight bias and 67% of first year medical students demonstrated conscious weight bias (Phelan et al., 2014). In addition, a WEIGHT STIGMA TOWARDS OVERWEIGHT AND OBESE PATIENTS 5 study analyzing patient care recommendations for a virtual patient by medical students found that despite the weight stigmatizing attitudes and beliefs of the medical students, bias was not evident in the care recommendations that the students made for the virtual patient with obesity compared to the non-obese virtual patient (Persky & Eccleston, 2011). However, the medical students viewed the face of the patient less for the virtual patient with obesity compared to the non-obese virtual patient (Persky & Eccleston, 2011). The findings of this study were important because they illustrated that while patient care recommendations may not differ, the communication aspect as well as other aspects of the patient care experience could threaten the effectiveness of the patient care experience. One limitation to these studies, however, is that they did not analyze how the bias differed for individuals with severe obesity compared to individuals with overweight and obesity. Weight stigmatizing attitudes and behaviors likely manifest themselves in prehealth professional students due to factors such as a lack of obesity education, media and advertising messages about societal expectations for body image, and a lack of experience communicating with patients with overweight and obesity in a patient care setting. A study in which interviews were conducted with nursing students found that the students felt as though they did not have the confidence and skills to communicate with patients about weight management, and they also perceived that obesity education was not thorough (Keyworth et al., 2013). Addressing the weight stigmatizing attitudes and beliefs in the early stages of pre-health care professional students education, professional development, and career allows for early educational intervention to help combat the WEIGHT STIGMA TOWARDS OVERWEIGHT AND OBESE PATIENTS 6 weight stigma. For example, nursing students attitudes about individuals with obesity became more positive after participating in an activity that involved wearing bariatric empathy suits (Hunter et al., 2018). Another study found that there was no association between the patient care advice and the nursing students attitudes about obesity or the patient care advice and the cause of obesity, which was either behavioral, social, or medical (Nicholls et al., 2016). The non-biased advice from the nursing students reflected the utilization of their training recommendations (Nicholls et al., 2016). Thus, learning situations for pre-health professional students regarding weight stigma could help reduce the weight stigma involved in patient care. Weight Stigma and Body Mass Index The current literature has focused heavily on the negative effects of weight stigma from health care providers and pre-health care professional students on individuals with overweight and obesity. However, a lack of research has examined how weight stigma experiences from health care providers and pre-health care professional students differ across weight categories, including overweight, obese, and severely obese. Research has found that the likelihood of experiencing weight stigma increased with BMI (Puhl et al., 2008). Thus, further research is necessary to address the variation in weight stigma experiences at differing levels of obesity. To date, the majority of research tends to combine overweight and obesity into one category, and even less research acknowledges the differences between obesity and severe obesity. However, the percentage of the population that has grade 3 obesity, also classified as severe obesity, increased by almost 5% in the span of about 30 years from WEIGHT STIGMA TOWARDS OVERWEIGHT AND OBESE PATIENTS 7 2.9% between 1988 and 1994 to 7.7% between 2013 and 2016 (National Center for Health Statistics, 2019). Since over half of the individuals in the United States are considered to be overweight, overweight may be considered the new norm, and weight stigma may not be prevalent until BMI increases to the level of obesity or severe obesity (Centers for Disease Control and Prevention, 2017a). The Present Study The purpose of this study was to examine how the weight stigmatizing attitudes and beliefs held by pre-health care professional students, particularly nursing students, pre-physical therapy students, pre-occupational therapy students, and pre-medicine students, differ based on a patients weight category (overweight, obese, or severely obese). This study will contribute to the existing literature on weight stigma in pre-health care professional students and health care professionals by separating weight categories into overweight, obese, and severe obesity. It was hypothesized that pre-health professional students stigmatizing attitudes and beliefs towards the patient, perceptions of blame and responsibility, and motivation to treat the patient would differ based on a patients weight level. More specifically, it was expected that compared to a patient who was described as being overweight, pre-health professional students would have more negative attitudes, attribute more responsibility and blame, and have less motivation to treat a patient who was described as being severely obese. In addition, it was expected that compared to a patient who was described as being overweight, pre-health professional students would have more negative attitudes, attribute more responsibility and blame, and have less motivation to treat a patient who was described as being obese. WEIGHT STIGMA TOWARDS OVERWEIGHT AND OBESE PATIENTS 8 It was also expected that compared to a patient who was described as being obese, prehealth professional students would have more negative attitudes, attribute more responsibility and blame, and have less motivation to treat a patient who was described as being severely obese. Method Participants Undergraduate students from the University of Indianapolis were recruited to participate in this study. To be eligible for the study, students had to be 18 years of age or older and be classified as a pre-health professional student. The pre-health professional student classification included nursing students, pre-physical therapy students, preoccupational therapy students, and students with a pre-medicine concentration. Before reading the informed consent document, the participants answered a question regarding their desire to participate or not to participate. If the individuals were 18 years of age or older, pre-health professional students, and expressed desire to participate, the individuals were eligible to proceed with participation in the study. Although recruiting a sample that was representative of the population of pre-health professional students at the University of Indianapolis in terms of gender, grade level, race, and ethnicity was the objective, it was expected that the data would be skewed towards Caucasian female students. A sample size of at least 180 participants was needed to provide the power to detect a significant effect, assuming that there was a medium effect size. Because data from some participants needed to be excluded, such as in the case of an incomplete survey (i.e., more WEIGHT STIGMA TOWARDS OVERWEIGHT AND OBESE PATIENTS 9 than 25% missing data) or failing to answer the comprehension check correctly, data collection from 200 participants was the objective. Data were collected from a total of 151 participants, but participants with excessive missing data or incorrectly answered attention checks were removed, which resulted in a final sample size of 127 participants. Despite the intended sample size of 200 participants, data were collected from 151 participants due to lower participation in research studies through the University of Indianapolis SONA system in the fall semester of the 2019-2020 academic school year. Random assignment placed 42 participants in the overweight vignette condition, 42 participants in the obese vignette condition, and 43 participants in the severely vignette condition. A post-hoc power analysis indicated that based on the current sample size, the power of the study to detect a medium effect size was .70. In terms of participant gender, 84.25% were female, 14.96% were male, and 0.79% were non-binary. The mean age of participants was 19.54 years (SD = 1.24 years). The racial background of the participants was 92.1% White, 4.7% Black or African American, 1.6% Asian, and 1.6% Biracial or Multiracial. The ethnic background of the participants was 92.9% not Hispanic or Latino and 7.1% Hispanic or Latino. About one-third of the participants were freshmen (33.1%), one-third were sophomores (31.5%), and the remainder were juniors (25.2%), and seniors (10.2%). The different pre-health care professions of the participants included 32.3% nursing students, 26.8% pre-medicine students, 23.6% pre-occupational therapy students, and 15.7% pre- WEIGHT STIGMA TOWARDS OVERWEIGHT AND OBESE PATIENTS 10 physical therapy students. The final 1.6% selected other but opted not to list which prehealth profession they were studying. In terms of self-rated health, 44.9% of the participants selected very good, 33.1% selected good, 18.1% selected excellent, 3.1% selected fair, and 0.8% selected poor. The mean body mass index (BMI) of participants was 25.15 (SD = 5.18, range = 17.58 - 47.46). Over half of the participants were classified as being normal weight (61.4%), 20.5% were overweight, 15.7% were obese, 1.6% were severely obese, and 0.8% were underweight. Handling, Storage, and Ownership of Data This study was conducted in accordance with the ethical standards set forth by the University of Indianapolis Human Research Protection Program. Specifically, potential participants were informed of their rights before participating in research, participants rights were respected throughout the research process, participants were given the right to discontinue participation in the study at any time, participants personally identifiable information was protected, and risks or discomforts that could be experienced by participation in the study were fully considered. Numerous steps were taken to maintain the confidentiality of participants. Data were collected online and stored on password protected computers. Participant names were not recorded with their responses. The participants were offered the opportunity to be entered into a drawing for one of fifteen $10 gift cards upon the completion of the survey, and SONA participants also received .25 credits for their participation. To be entered into the drawing and receive credit, the participants were directed to click on a link that took them to a second, voluntary survey WEIGHT STIGMA TOWARDS OVERWEIGHT AND OBESE PATIENTS 11 where they had the opportunity to enter their names into a drawing for the gift cards. The names entered in the second survey were not linked to the participants responses in the first survey to maintain the confidentiality of the participants responses. In addition, only the principal investigators had access to the data collected during the project. The principal investigators, Erin Fekete, Ph.D. and Kristopher Butler, are the owners of the data collected in this project. Data from this project may be disseminated at local and regional conferences and in peer-reviewed journals. Study Design This study used a between-subjects experimental design, and participants were randomly assigned to one of three fictional patient vignette conditions (overweight, obese, or severely obese). The study utilized vignettes and an online questionnaire to collect data. The independent variable was the weight of the patient in the vignette, and the dependent variable was the attitudes and beliefs held by the pre-health professional students. Data Collection Procedure Participants were recruited through the Department of Psychological Sciences online participant pool (i.e., SONA), through emailing the professors of various prehealth professional departments and asking them to distribute the study to their students, and through advertising in the weekly campus-wide announcements email. The individuals who wished to participate completed a screener questionnaire to assess eligibility for the study. After completing the screener, the eligible participants were presented with an informed consent document outlining the details of the study, the rights WEIGHT STIGMA TOWARDS OVERWEIGHT AND OBESE PATIENTS 12 of participants, and the voluntary nature of participation in the research. When the participants finished reading the informed consent, they were randomly assigned to one of three conditions: a vignette with a fictional patient with overweight, a vignette with a fictional patient with obesity, or a vignette with a fictional patient with severe obesity. After reading the vignette, participants answered a series of measures assessing their attitudes and beliefs, perceptions of blame and responsibility, and motivation to treat the patient they read about in the vignette. Upon the completion of the measures, the participants were thanked for their participation, provided with the link to the second survey, and given the contact information for the principal investigators in case they had additional questions, comments, or concerns. Measures All of the vignettes and measures for the current study can be found in the attached Appendices. Vignettes. All of the vignette conditions presented a fictional patient suffering from chronic hypertension (high blood pressure), arthritic knee pain, elevated blood sugar levels, and elevated cholesterol levels because they are medical conditions that may be associated with obesity (Centers for Disease Control and Prevention, 2015). The vignette conditions only differed in the weight classification of the patient (overweight, obese, or severely obese). The weight classification was conveyed with the vignette individuals height, weight, and BMI (body mass index) number from the BMI table on the National Heart, Lung, and Blood Institutes website (National Heart, Lung, and Blood Institute, WEIGHT STIGMA TOWARDS OVERWEIGHT AND OBESE PATIENTS 13 n.d.). The fictional vignette patient was given a name (i.e., Jennifer) to simulate a more authentic patient care scenario. A female patient was chosen because prior research has indicated that women have a higher likelihood of experiencing weight stigma than men (Puhl et al., 2008). Negative weight related beliefs and attitudes. The 14-item short form of the Fat Phobia Scale was utilized to assess stigmatizing attitudes and beliefs about weight towards Jennifer (Bacon et al., 2001). For the purposes of this study, the directions of the Fat Phobia Scale were modified to focus on Jennifer, the character from the vignette instead of obese individuals in general. Specifically, the original instructions stated, Listed below are 14 pairs of adjectives sometimes used to describe obese or fat people. For each adjective pair, please place an X on the line closest to the adjective you feel best describes your feelings and beliefs. The modified instructions stated, Listed below are 14 pairs of adjectives sometimes used to describe obese or fat people. For each adjective pair, please select the number closest to the adjective you feel best describes your feelings and beliefs about Jennifer. Permission to make these changes was granted by the author of the measure, Dr. B. E. Robinson (B. E. Robinson, personal communication, April 11, 2019). Items on the scale used a bipolar adjective scale from 1 to 5 to assess participants negative weight based attitudes and beliefs (Bacon et al., 2001). For example, participants selected a value between 1 and 5 for the terms lazy and industrious. The negative items of the scale (items 1, 2, 8, 9, 11, 13, and 14) were reverse scored, the sum of the items scores was determined, and the sum of the scores was divided by 14 (the number of WEIGHT STIGMA TOWARDS OVERWEIGHT AND OBESE PATIENTS 14 items). Higher scores on the scale indicated higher levels of negative weight related beliefs and attitudes. Previous research has indicated that the short form of the Fat Phobia scale has high reliability (Cronbachs = 0.87 - .91), and also had strong correlations with the 50-item version of the Fat Phobia scale (r = 0.82 - .90; Bacon et al., 2001). This scale has been used in multiple peer reviewed studies to assess the negative attitudes and beliefs of individuals regarding overweight and obese individuals (Puhl et al., 2011; Schvey et al., 2011). Overall, the mean score for the scale was 3.59 (SD = 0.54; range = 1.50 - 4.79; Cronbachs = 0.89). Blame and responsibility. Eight items assessed participants feelings of blame and responsibility towards Jennifer. These items were taken from a measure created by Mantler et al. (2003). Both scales consisted of 4 items measured on a Likert scale from 1 to 7. For example, the blame scale had the following item: It is her own fault that Jennifer is ill. One of the items from the responsibility was Jennifer is accountable for her illness. For both the blame and responsibility scales, negative items were reverse scored and the sum of the item scores was calculated. A comprehension check was included within the blame scale, but it was not factored into the scoring of this scale. Higher scores on the blame scale indicated higher levels of blame placed on the vignette patient for her weight, and higher scores on the responsibility scale indicated higher levels of perceived responsibility of the vignette patient for her weight. Both the responsibility and blame scales have been shown to be reliable measures (Cronbachs = 0.91 for responsibility and Cronbachs = 0.82 for blame; Mantler et al., 2003). These scales have been used in other peer reviewed research to measure attributions of blame WEIGHT STIGMA TOWARDS OVERWEIGHT AND OBESE PATIENTS 15 and responsibility (Seacat et al., 2009). Overall, the mean score for the blame scale was 15.09 (SD = 4.00; range = 4.00 - 26.00; Cronbachs = 0.73) and the mean score for the responsibility scale was 19.67 (SD = 3.65; range = 10.00 - 28.00; Cronbachs = 0.70). Motivation to treat. Because no existing scales exist, a 4-item scale was developed for this study to assess participants motivation to treat the patient in the vignette. These items were created based on the work of Phelan et al. (2015). Phelan et al. (2015) explained that healthcare providers held the belief that obese patients are less likely to be adherent to treatment, the healthcare providers have less respect for obese patients, and healthcare providers spend less time on health education with obese patients. A Likert scale from 1 (completely disagree) to 5 (completely agree) assessed the participants agreement with the following statements: As a healthcare professional I do not think this patient would adhere to the advice that I give, I would have less respect for this patient compared to other patients, I would spend less time treating this patient, and Treating this patient would be a waste of my time. The sum of the scores of the four items were calculated, and higher scores on the scale indicated lower motivation to treat the vignette patient. Overall, the mean score for the scale was 5.65 (SD = 1.26; range = 4.00 - 10.00; Cronbachs = 0.20). Comprehension and attention checks. A comprehension check item was included after the participants read the vignette in order to assess the participants comprehension of the information presented in the vignette. Specifically, participants were asked whether or not Jennifer had blood work completed. The participants could WEIGHT STIGMA TOWARDS OVERWEIGHT AND OBESE PATIENTS 16 not return to the vignette, and participants who responded with answers other than yes were excluded from the analyses. Additionally, in the middle of the 4-item blame scale, an attention check item was included to assess whether participants were carefully reading the instructions and questions. The item was presented with a Likert scale from 1 to 7 like the blame scale items, but it instructed the participants to answer with the number 5. If participants answered with a response other than 5, they were excluded from the analyses. Data Analysis Descriptive statistics were analyzed to determine the normality of the data. To examine the study hypotheses, the data were analyzed using a one-way Analysis of Variance (ANOVA). An ANOVA provides information about whether or not the means of more than two groups differ significantly from one another (i.e., omnibus test) and then allows for post-hoc tests between individual groups to be conducted. An additional one-way Analysis of Covariance (ANCOVA) was conducted with the BMI of the participants as a covariate in order to determine whether the results differed when this third variable was taken into consideration. Prior research has indicated that communication behaviors of health care providers can differ in patient care scenarios based on the BMI of the health care provider (Bleich et al., 2012). WEIGHT STIGMA TOWARDS OVERWEIGHT AND OBESE PATIENTS 17 Results Main effects of vignette condition on negative weight-based attitudes and beliefs. As shown in Table 1, a one-way ANOVA indicated that the main effect of the vignette condition on negative weight-based attitudes and beliefs was statistically significant, F(2, 124) = 7.60, p = 0.001. As predicted, post-hoc analyses revealed that participants in the severely obese condition (M = 3.83, SD = 0.50) reported significantly greater negative weight-based attitudes and beliefs than participants in the obese (M = 3.50, SD = 0.46) or overweight (M = 3.43, SD = 0.58) conditions. However, there was no significant difference between the participants in the overweight and obese conditions. Inconsistent with hypotheses, the main effects of condition on blame, F(2, 124) = 2.15, p = 0.121, responsibility, F(2, 124) = 0.99, p = 0.374, and motivation to treat, F(2, 124) = 0.58, p = 0.560, were not statistically significant. Table 1 Main effects of vignette condition on negative weight-based attitudes and beliefs Variable Negative weight related beliefs and attitudes Blame Responsibility Motivation to treat *p < .05 Overweight Obese Severely Obese M (SE) M (SE) M (SE) 3.43 (0.08) 14.43 (0.61) 19.69 (0.56) 5.57 (0.20) 3.50 (0.08) 14.71 (0.61) 19.10 (0.56) 5.55 (0.20) 3.83 (0.08) 16.09 (0.61) 20.21 (0.56) 5.81 (0.19) F p 7.60 0.001* 2.15 0.121 0.99 0.374 0.58 0.560 Partial Eta Squared 0.11 0.03 0.02 0.01 WEIGHT STIGMA TOWARDS OVERWEIGHT AND OBESE PATIENTS 18 Post-hoc analyses of the effects of vignette condition on negative weightbased attitudes and beliefs. An additional series of one-way ANCOVA analyses were conducted, controlling for participant BMI. As shown in Table 2, the pattern of results remained the same even after controlling for participant BMI. Specifically, the main effect of vignette condition on negative weight-based beliefs and attitudes was significant, F(2, 123) = 7.44, p = 0.001. Consistent with the predictions, the post-hoc analyses indicated that the participants in the severely obese condition (M = 3.83, SD = 0.50) reported significantly greater negative weight-based attitudes and beliefs than participants in the obese (M = 3.51, SD = 0.46) or overweight (M = 3.42, SD = 0.58) conditions. No statistically significant difference was observed between the participants in the overweight and obese conditions. The main effects of condition on blame, F(2, 123) = 2.11, p = 0.126, responsibility, F(2, 123) = 0.74, p = 0.481, and motivation to treat, F(2, 123) = 0.60, p = 0.552, were not statistically significant, which was not consistent with the hypotheses. Table 2 Post-hoc analyses of the effects of vignette condition on negative weight-based attitudes and beliefs controlling for participant BMI Variable Negative weight related beliefs and attitudes Blame Responsibility Motivation to treat *p < .05 Overweight Obese Severely Obese M (SE) M (SE) M (SE) 3.42 (0.08) 14.42 (0.62) 19.63 (0.56) 5.58 (0.20) 3.51 (0.08) 14.73 (0.62) 19.20 (0.57) 5.54 (0.20) 3.83 (0.08) 16.09 (0.61) 20.16 (0.56) 5.82 (0.19) F p 7.44 0.001* 2.11 0.126 0.74 0.481 0.60 0.552 Partial Eta Squared 0.11 0.03 0.01 0.01 WEIGHT STIGMA TOWARDS OVERWEIGHT AND OBESE PATIENTS 19 Discussion The present study examined how the stigmatizing attitudes and beliefs of prehealth care professional students towards patients varied based on whether or not a patient presented as being overweight, obese, or severely obese. The results suggested that pre-health care professionals who read a vignette about a fictional patient with severe obesity demonstrated significantly higher negative weight-based attitudes and beliefs about the patient compared to the pre-health care professionals who read vignettes about fictional patients with overweight or obesity. This finding remained significant even after controlling for the BMI of the pre-health care professionals. Participants in the three conditions did not differ in their attributions of blame or responsibility, or in their motivation to treat the patient. The finding that pre-health professional students had significantly higher negative weight-based attitudes towards a patient with severe obesity compared to patients with overweight obesity is consistent with prior research. Past research has indicated that individuals with obesity face prejudice and discrimination from other people, including health care providers (Malterud & Ulriksen, 2011; Phelan et al., 2015; Rand et al., 2017). Further, as BMI increases, the likelihood of experiencing weight stigma increases (Puhl et al., 2008). These results suggest that even health care professionals, who presumably understand the multiple factors that contribute to obesity, are not immune to bias towards individuals with overweight and obesity. WEIGHT STIGMA TOWARDS OVERWEIGHT AND OBESE PATIENTS 20 These results suggest that the stigmatizing attitudes of health care providers may be present during their educational training. This is noteworthy because this is a formative period in which negative attitudes and beliefs about weight might develop or intensify. Indeed, other research confirms that pre-health care professionals demonstrate weight bias (Langdon et al., 2016; Phelan et al., 2014). These feelings of weight bias may lead to differential treatment in terms of communication with patients, such as conveying empathy, even when medical treatment does not vary from patient to patient. This study contributed to the limited but growing collection of literature because it found that weight stigmatizing attitudes and beliefs may be strongest towards individuals with severe obesity, which is concerning due to the considerable health risks facing individuals with severe obesity and the likely need for the most intervention from health care professionals. Although the negative weight-based attitudes of the pre-health care professionals might not have manifested in terms of blame, responsibility, or motivation to treat in this study, it is possible that they could lead to problems such as patients avoiding treatment (Mold & Forbes, 2013; Puhl et al., 2013). Among the three vignette conditions, there were no statistically significant differences in the perceptions of blame and responsibility from the pre-health care professionals. These findings were surprising because previous research has indicated that perceptions of blame and responsibility are frequently found among health care providers (Malterud & Ulriksen, 2011; Phelan et al., 2015). It is possible that participants in the current study made high attributions of blame and responsibility across all participant conditions, and not just for participants with severe obesity. The lack of a WEIGHT STIGMA TOWARDS OVERWEIGHT AND OBESE PATIENTS 21 significant difference between the overweight, obese, and severely obese conditions in terms of blame and responsibility in the current study could suggest that while negative attitudes increase with weight levels, there are similar perceptions of blame and responsibility for a patients weight regardless of the severity of the weight level. It is possible that if the blame and responsibility scores for the overweight, obese, and severely obese conditions were compared to a control condition depicting a patient with a healthy weight, the scores for all three non-control conditions might have been significantly higher than the control condition. Additionally, no differences were found in participants motivation to treat the fictional patient based on the participants weight. One reason for this may be that the motivation to treat scale that was developed for this study was not reliable. Although the measure was guided by previous research on the different factors related to health care professionals motivation to treat patients (Phelan et al., 2015), it is possible that the items in the scale did not effectively measure motivation to treat patients with overweight and obesity. Another potential reason for the lack of reliability could have been the limited number of items in the scale. The reliability of the scale did not improve by removing any items, but an analysis of the scales items separately could have potentially yielded different results. However, it is also possible that these findings indicate that even though participants had more negative attitudes towards a patient with severe obesity, their motivation to treat that patient was not lower. In fact, these findings were consistent with some of the prior research indicating that negative weight-based attitudes and beliefs did WEIGHT STIGMA TOWARDS OVERWEIGHT AND OBESE PATIENTS 22 not have a profound impact on patient care situations when obesity was involved (Budd et al., 2011; Nicholls et al., 2016; Persky & Eccleston, 2011). These findings are important because they indicate that the approach to patient care did not differ depending on a patients weight, which should be the objective. On the other hand, reducing prehealth care professionals negative attitudes towards patients should also be emphasized in order to prevent a potentially detrimental impact on patient care communication and mutual trust between health care professionals and patients. Limitations and Strengths This study has several limitations which should be noted. First, this study utilized self-report measures in an online setting, which means that the data could be influenced by factors such as social desirability. For example, some participants may have answered the item As a health care professional, I would have less respect for this patient compared to other patients with more disagreement than they actually believed because they felt like as a health care professional they should respond in a favorable manner. Additionally, the final sample size was 127 participants, which was significantly less than the intended amount of 180 participants. As such, the study was slightly underpowered to detect significant differences. If the intended sample size was obtained and power was established to detect significant effects at a medium effect size, some of the results, such as the group differences in blame, might have been significant. The distribution of the sample with regard to race and gender were limitations because the study primarily involved Caucasian participants and female participants, which likely did not represent WEIGHT STIGMA TOWARDS OVERWEIGHT AND OBESE PATIENTS 23 the general population of pre-health care professional students at the University of Indianapolis. Despite its limitations, there are several strengths of the current study. First, this study is among a small but growing body of literature to examine the negative attitudes and beliefs towards individuals with severe obesity in relation to overweight and obesity. Additionally, this study separated the categories of overweight and obesity, which differs from past research that did not differentiate the categories. This study also analyzed multiple avenues in which stigmatizing attitudes and beliefs held by pre-health care professionals towards patients could be expressed (negative weight-based attitudes and beliefs, perceptions of blame, perceptions of responsibility, and motivation to treat). The distribution of participation from the four different pre-health professions would be a strength of this study because each of the four pre-health professions constituted at least 15.7% of the sample of participants. Implications and Applications Negative weight-based attitudes and beliefs may start to develop or be exacerbated during the education of pre-health care professionals. These findings are relevant because health care professionals should approach patient care scenarios in a consistent manner regardless of a patients weight classification, and the consistent approach to patient care should be encouraged during the education and transition to practice for the pre-health care professionals. Additionally, these results suggest that negative weight-based attitudes are present during students training, which means the curriculum and education should address the issue of weight bias and how it may impact WEIGHT STIGMA TOWARDS OVERWEIGHT AND OBESE PATIENTS 24 treatment. For example, discussions regarding weight stigmatizing attitudes and beliefs, and their relationship to health care fields, could be emphasized in social psychology, ethics, and sociology courses to establish a greater awareness of the potential implications in practice. Moreover, educational interventions focused on weight bias and bias reduction may help to reduce negative weight-based attitudes and beliefs towards patients of various weight classifications. Conclusion As the prevalence of overweight and obesity increases in the United States, health care providers will increasingly interact with overweight and obese patients. Weight stigmatizing attitudes and beliefs held by health care providers and pre-health care professional students can present challenges to health care experiences of patients. The results of this study illustrated that pre-health care professionals exhibited significantly greater negative weight-based attitudes and beliefs towards a fictional patient with severe obesity compared to the fictional patients with overweight and obesity, even after controlling for the participants BMI. However, no statistically significant difference was observed in perceptions of blame, perceptions of responsibility, or motivation to treat among the pre-health care professionals of three vignette conditions. These results suggest that while the pre-health care professionals hold differing levels of negative weight-based attitudes and beliefs towards patients depending on the weight levels of the patients, these attitudes and beliefs were not significantly influencing the responses in patient care scenarios when patient weight varied. These results are important because a WEIGHT STIGMA TOWARDS OVERWEIGHT AND OBESE PATIENTS 25 standard approach to patient care should be the objective for health care providers regardless of a patients weight level. Reflection and Future Directions Over the last two years that I have planned and conducted this study with Dr. Erin Fekete, the majority of the project goals have been accomplished, including developing a research question, conducting a literature review, designing a study, writing a research proposal and obtaining approval, obtaining approval from the Institutional Review Board to conduct the study, collecting data, and analyzing data. This project helped me gain a better understanding of the research process and the topic of weight stigma in health care professions. Developing and conducting this study included numerous challenges and shortcomings. For instance, formulating a research question, determining the variables of interest and how to measure them, creating the online survey, and collecting the data all presented challenging moments. However, these challenges were valuable because they allowed me to see all of the considerations that the research process entails and how decisions made at one point in the research process have implications for later steps. In particular, seeing how earlier decisions in the research process impacted later decisions was an invaluable experience. The two most significant shortcomings of this project were the smaller sample size than expected and the lack of reliability of the motivation to treat scale that was developed for this study. Experiencing these problems provided the valuable lessons of how to handle research-related issues and how to consider possible solutions in future situations. If this study was going to be conducted over again, I would WEIGHT STIGMA TOWARDS OVERWEIGHT AND OBESE PATIENTS 26 have pursued the variety of recruiting strategies for data collection, including displaying the study on the SONA system, asking professors to share information about the study with their classes, and sharing information through the campus-wide weekly email, from the outset of the project in order to address the smaller sample size issue. Additionally, I would have considered adding more items to the motivation to treat scale, which might have made the measure more reliable. Engaging in this research project also provided excellent opportunities for personal and professional growth. This project facilitated my ability to ask my own questions, explore information, and process new information, which was helpful for my personal growth. While I had gained research experience through the undergraduate Research Fellowship at the University of Indianapolis and working in Dr. Erin Feketes research laboratory, this project allowed me to engage in the research process from start to finish, which facilitated the development and refinement of my academic skills. Additionally, the information that I have learned from studying weight stigmatizing attitudes and beliefs among pre-health care professionals will be helpful to consider as I pursue a career as a physician. After conducting this research study, there are multiple opportunities for exploration in future research. For example, future research could add control groups, including a vignette condition with a patient with normal weight or the inclusion of nonhealth professional students. While the current study analyzed how the overweight, obese, and severely obese vignette conditions compared to one another, adding a control group would allow for the examination of how much the stigmatizing weight-based WEIGHT STIGMA TOWARDS OVERWEIGHT AND OBESE PATIENTS 27 attitudes facing the vignette patients with overweight, obesity, or severe obesity differ from other patients in society, such as a vignette patient with normal weight. Future research could also include practicing health care professionals, which would allow for the comparison of the attitudes and beliefs between health care providers with experience and the pre-health care professional students in training. Additional research could also include vignette conditions with a male patient, which would provide an opportunity to compare the weight-based attitudes and beliefs of pre-health care professionals towards male and female patients. 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Journal of School Health, 81(11), 696-703. doi:10.1111/j.1746-1561.2011.00646.x WEIGHT STIGMA TOWARDS OVERWEIGHT AND OBESE PATIENTS 32 Puhl, R., Peterson, J. L., & Luedicke, J. (2013). Motivating or stigmatizing? Public perceptions of weight-related language used by health providers. International Journal of Obesity, 37, 612-619. doi:10.1038/ijo.2012.110 Rand, K., Vallis, M., Aston, M., Price, S., Piccinini-Vallis, H., Rehman, L., & Kirk, S. F. (2017). It is not the diet; it is the mental part we need help with. A multilevel analysis of psychological, emotional, and social well-being in obesity. International Journal of Qualitative Studies on Health and Well-Being, 12, 1-14. doi:10.1080/17482631.2017.1306421 Schvey, N. A., Puhl, R. M., & Brownell, K. D. (2011). The Impact of Weight Stigma on Caloric Consumption. Obesity, 19(10), 1957-1962. doi:10.1038/oby.2011.204 Seacat, J. D., Litt, M. D., & Daniels, A. S. (2009). Dental Students Treating Patients Living with HIV/AIDS: The Influence of Attitudes and HIV Knowledge. Journal of Dental Education, 73(4), 437-444. Retrieved April 14, 2019. WEIGHT STIGMA TOWARDS OVERWEIGHT AND OBESE PATIENTS 33 Appendix A Vignettes Vignette Condition #1 (Overweight): Jennifer is a 36-year-old teacher. She recently visited her doctor for a routine checkup. At the visit, her height was 65 inches (5 feet, 5 inches), her weight was 162 pounds, and her BMI was 27, which is considered overweight. During her visit to the doctor, she reported having trouble walking due to arthritis in her knees. She also mentioned that she sometimes gets out of breath quickly when walking. Jennifer received the results of her blood work from the doctor, and she had elevated blood sugar levels and elevated cholesterol levels. Jennifers doctor also recommended that Jennifer should start taking medication for hypertension (high blood pressure). The doctor recommended that Jennifer should return in three months for a follow up visit. Vignette Condition #2 (Obese): Jennifer is a 36-year-old teacher. She recently visited her doctor for a routine checkup. At the visit, her height was 65 inches (5 feet, 5 inches), her weight was 204 pounds, and her BMI was 34, which is considered obese. During her visit to the doctor, she reported having trouble walking due to arthritis in her knees. She also mentioned that she sometimes gets out of breath quickly when walking. Jennifer received the results of her blood work from the doctor, and she had elevated blood sugar levels and elevated cholesterol levels. Jennifers doctor also recommended that Jennifer should start taking medication for hypertension (high blood pressure). The doctor recommended that Jennifer should return in three months for a follow up visit. WEIGHT STIGMA TOWARDS OVERWEIGHT AND OBESE PATIENTS 34 Vignette Condition #3 (Severely Obese): Jennifer is a 36-year-old teacher. She recently visited her doctor for a routine checkup. At the visit, her height was 65 inches (5 feet, 5 inches), her weight was 264 pounds, and her BMI was 44, which is considered severely obese. During her visit to the doctor, she reported having trouble walking due to arthritis in her knees. She also mentioned that she sometimes gets out of breath quickly when walking. Jennifer received the results of her blood work from the doctor, and she had elevated blood sugar levels and elevated cholesterol levels. Jennifers doctor also recommended that Jennifer should start taking medication for hypertension (high blood pressure). The doctor recommended that Jennifer should return in three months for a follow up visit. WEIGHT STIGMA TOWARDS OVERWEIGHT AND OBESE PATIENTS Appendix B Modified version of the short form of the fat phobia scale from Bacon et al. (2001) Listed below are 14 pairs of adjectives sometimes used to describe obese or fat people. For each adjective pair, please select the number closest to the adjective you feel best describes your feelings and beliefs about Jennifer. 1.) lazy 5 4 3 2 1 industrious 2.) no will power 5 4 3 2 1 has will power 3.) attractive 1 2 3 4 5 unattractive 4.) good self-control 1 2 3 4 5 poor self-control 5.) fast 1 2 3 4 5 slow 6.) having endurance 1 2 3 4 5 having no endurance 7.) active 1 2 3 4 5 inactive 8.) weak 5 4 3 2 1 strong 9.) self-indulgent 5 4 3 2 1 self-sacrificing 10.) dislikes food 1 2 3 4 5 likes food 11.) shapeless 5 4 3 2 1 shapely 12.) undereats 1 2 3 4 5 overeats 13.) insecure 5 4 3 2 1 secure 35 WEIGHT STIGMA TOWARDS OVERWEIGHT AND OBESE PATIENTS 14.) low self-esteem 5 4 3 2 1 high self-esteem 36 WEIGHT STIGMA TOWARDS OVERWEIGHT AND OBESE PATIENTS Appendix C Responsibility scale adapted from Mantler et al. (2003) On a scale from 1 (completely disagree) to 7 (completely agree), rate your agreement with the following statements: 1.) Jennifer is responsible for her illness. 1 2 3 4 5 6 7 2.) Jennifer is accountable for her illness. 1 2 3 4 5 6 7 3.) Jennifers illness is not a result of her own negligence. 1 2 3 4 5 6 7 4.) Jennifer should not be held personally liable for her illness. 1 2 3 4 5 6 7 37 WEIGHT STIGMA TOWARDS OVERWEIGHT AND OBESE PATIENTS Appendix D Blame scale adapted from Mantler et al. (2003) On a scale from 1 (completely disagree) to 7 (completely agree), rate your agreement with the following statements: 1.) Jennifer is to blame for her illness. 1 2 3 4 5 6 7 2.) It is her own fault that Jennifer is ill. 1 2 3 4 5 6 7 3.) Jennifer does not deserve what happened to her. 1 2 3 4 5 6 7 4.) Jennifer should not feel guilt for being ill. 1 2 3 4 5 6 7 38 WEIGHT STIGMA TOWARDS OVERWEIGHT AND OBESE PATIENTS 39 Appendix E Motivation to treat scale based on Phelan et al. (2015) Please rate the following statements on a scale from 1 (completely disagree) to 5 (completely agree): 1.) As a health care professional, I do not think this patient would adhere to advise that I give. 1 2 3 4 5 2.) As a health care professional, I would have less respect for this patient compared to other patients. 1 2 3 4 5 3.) As a health care professional, I would spend less time treating this patient. 1 2 3 4 5 4.) As a health care professional, treating this patient would be a waste of my time. 1 2 3 4 5 WEIGHT STIGMA TOWARDS OVERWEIGHT AND OBESE PATIENTS Appendix F CITI Program: Responsible Conduct of Research 40 WEIGHT STIGMA TOWARDS OVERWEIGHT AND OBESE PATIENTS Appendix G CITI Program: HIPAA Privacy and Security 41 WEIGHT STIGMA TOWARDS OVERWEIGHT AND OBESE PATIENTS Appendix H CITI Program: Human Subjects Research 42  ...

... Gendered Attitudes: Evaluating the Impact of Leadership Programming on Students Political Interest and Engagement By Callie Bucher Honors Project Thesis Submitted in Partial Fulfillment Of the Requirements for a Baccalaureate Degree With Distinction In the Ron and Laura Strain Honors College of THE UNIVERSITY OF INDIANAPOLIS May 2020 Faculty Advisor: Dr. Laura Wilson, Ph.D. Executive Director of Honors: James B. Williams, Ph.D. Callie Bucher 2020. Copyright in this work rests solely with the author. Please ensure that any reproduction or re-use is done in accordance with relevant national copyright protection. i Abstract The purpose of this study is to compare the attitudes and opinions of those that attend leadership programming in regard to political interest and engagement. By analyzing anonymous surveys taken before and after a leadership training module, the variation between responses was measured to form conclusions on the effectiveness regarding leadership training. In this study, programming regarding female elected officials and engagement in political elections was presented to undergraduate students who were then taught and encouraged to practice different skills in order to facilitate more successful student government campaigns. Participants responses suggest that the leadership programming does have an effect on their political interest and engagement as they tended to be more likely to participate in elections and to vote for female elected officials after they attended the Elect Her programming. The conclusions reached throughout the study impact the literature on political engagement and the effectiveness of leadership training courses on political interest. ii Table of Contents Acknowledgements iii Introduction 1 Literature Review 2 Methods 6 Discussion 9 Conclusion 14 Reflection 15 References 17 Appendices CITI Training Certificate 18 IRB Authorization 19 Survey Data Report 20 iii Acknowledgements This project was made possible through the cooperation and support of many different individuals and organizations. The Strain Honors College supported this research through their generous grant to fund the essential training program, Elect Her. Without this grant, the research would have lacked programming and would not have been possible. I would also like to thank Sara Blanco and Hanna Calvert at the organization Running Start. Their involvement made the Elect Her event successful and provided an opportunity for students to learn about women in political office and how they can become engaged. It is also essential to recognize Indianapolis Student President Danielle Merlo, Representative Cherrish Pryor, and Councilor Kristin Jones as they donated their time to speak at the Elect Her event as women in different political offices, providing an invaluable resource for the program. 1 Introduction This research project is based on a study conducted in which student attitudes are evaluated before and after an event aimed towards educating women on running in student elections, and therefore promoting female involvement in higher level elections. The overall research question is: How does leadership programming affect students political interest and engagement? There is a distinct gap in the literature in regard to student attitudes and how to engage them in political endeavors, making this a worthwhile study. The research question was chosen as Indiana has had a lack of female representation in government. By creating content at the University of Indianapolis that addresses this issue it is possible to educate and potentially empower more young women to run for student government positions and/or other positions. Running Start and the American Association of University Women found that women that participate and run in student elections are more likely to run in the future. In order to have a leadership program in which to evaluate attitudes, it was necessary to bring the Elect Her program to campus. Elect Her focuses on training women in college on how to run for office thereby providing a controlled opportunity in which student attitudes can be studied. By evaluating attitudes before and after we are able to measure the effectiveness of this type of program, thus contributing to literature regarding women in politics and expanding possible solutions to address the gap of female elected officials. 2 Literature Review Female candidates running for election face many obstacles in their campaigns. Some of these obstacles are typical for any candidate, yet in other instances female candidates seem to have disproportionate difficulties in their respective races. Burrell (2014) investigates the number of women running for political office while evaluating the election environment and the ambition these candidates have to run for office. Her chapter in Gender in Campaigns for the U.S. House of Representatives offers a comparative analysis between the campaign experiences of male and female candidates as well as the differences between women running for the Democrat and Republican parties (Burrell 2014). Using nine election cycles, the prospects for womens elections are evaluated by incumbents, incumbent primary challengers, opposition party challengers, open seat candidates, special election candidates, and other situations. This provides insight into the current state of women running for election with the updated information in this chapter contributing to a more complete view. This insight affects my project as it will consider these aspects, especially the election environment and the motivations for women to run for positions in college government. Along with the idea of the motivation for running for positions, Kanthak and Woons (2015) contributions to the topic are essential in the study on election incentives for women. Their study differs from others in the canon in that it is more focused on the actual candidates and what the incentives are rather than on public reaction and support. Kanthak and Woon (2015) devised an experiment to manipulate the electoral environment and thereby control the incentives that the potential candidates could gain. 3 The results concluded that when the candidate will be chosen from the volunteer pool randomly that men and women are equally likely to volunteer. However, women are less likely to become candidates when an election chooses the representative (Kanthak & Woon 2015). The difference was not attributed to differences in abilities, risk aversion, or beliefs of the candidates but from the structure of the strategic component of campaigns. Women are more likely to run when they perceive elections to be costless and completely truthful according to this study, which is simply not found in real elections. Womens likelihood to participate in elections pertains to the research in determining the factors causing election aversion in potential female candidates for college elections. By determining the barriers causing election aversion, it is more possible to educate and neutralize them. Another concern is that these factors may differ across the United States. Due to the extreme variation in the rates of women being elected across the different states, Oxley and Fox analyzed elections to determine the factors that made women more likely to run for office. Some of the influences that affected the election of women were the supply of candidates, demands of gatekeepers (media and others that hold candidates accountable), and the specific characteristics of a states political system (Oxley & Fox 2004). The authors argue that this study is relevant because addressing the cause of the variations is the first step to solving the gender inequalities in elections and to having more equal representation. While similar to Kanthak and Woons research, Oxley and Fox consider the variable of geographic location. The differences between how the states consider female candidates can influence our research as states with more successful 4 female candidates can be analyzed. Data from states with higher occurrences of female candidates can inform and be used as a teaching measure in order to effectively educate female college students on running for election in their schools. While the motivations for seeking election are important, it is also important to understand the key issues causing womens underrepresentation. Lawless and Pearson take on conventional wisdom in order to fill a perceived gap in knowledge about the lack of women in congress and found issues with the neutrality of primary elections (2008). Although it is generally accepted that women win at the same rate as men in general elections, primary election tend to be more competitive for women in both political parties. Considering that the victory rate for general elections for female candidates is about the same as male candidates they evaluated the gender dynamics for primary elections. This is relevant in that it focuses on womens underrepresentation which is one of the main issues that the study will be looking at in regard to the attitudes toward women running for election in the college atmosphere. Educating and understanding the attitudes that create the right mindset for women to run is essential, however, it is also necessary to fully realize the support that women generally receive from the public. Dolans chapter in Voting the Gender Gap (2008) evaluates the support that women have when running in an election, another component to the overarching issue of attitudes towards women running for elected position. According to Dolans research, gender gap in the support for female candidates is not as large as conventional wisdom suggests (2008). Despite the anecdotal evidence, both male and female voters seem to support female candidates at roughly the same rates. 5 Dolan gives examples of other factors that affect the support for female candidates before their gender, such as party identification and the incumbency advantage among others. This allows an alternate perspective and suggests that addressing the disparity of female candidates could be tackled by encouraging more women to run through the major parties. By having female candidates with more varied stances, the chances of success in their campaigns would increase. How women are viewed by the public during campaigns also affects their likelihood to run. Zurbriggen and Sherman (2010) studied the public view of candidates through editorial cartoons and how the candidates were depicted, specifically focusing on the 2008 election (2010). This study provides insight into how Hillary Clinton, as a female candidate, was depicted. However, this study also faces narrowness as it is impossible to make many concrete generalizations based on gender. Considering Hillary Clinton was the only female whose candidacy was analyzed, it is impossible to conclude whether other potential candidates would face the same criticisms. This is relevant to our research in that it informs a better understanding in how the public reacts to female candidacy. Boris and Currans further explore this idea while focusing on the 2012 presidential election (2013). They present a different take on the issue as they look at it from a gender studies standpoint. An analysis of how womens input on different issues affects public opinion ties together how women are perceived by the public. These factors influence the support that female candidates receive for their campaigns and their willingness to become a candidate. By applying these concepts to our survey gauging attitudes towards women running in student government a more well-rounded set of 6 questions can be offered. By having the questions touch on different aspects of female candidacy it will mark which areas need improvement in the college atmosphere. This projects campus component included the Elect Her training program being advertised across campus with students from our institution and others being invited to attend. The research component is the evaluation of the attitudes towards women running for office and women in government by synthesizing the data gathered from before and after the program. By having both qualitative and quantitative data there will be multiple conclusions to draw from the research, and a better understanding of attitudes towards women in politics will be gained. Methods In order to analyze the attitudes towards women in elected positions and the effectiveness of the training, it was incredibly important to create, disseminate, and analyze a survey geared towards college students and their beliefs regarding women in student government. A large part of this endeavor was bringing the Elect Her conference to the University of Indianapolis as a training seminar. Its purpose is to educate young women who could become candidates and eventually elected officials in student government, and young men who wish to know more about the issues facing women running for elected positions. In order to comply with the Internal Review Board (IRB) an application was submitted and the IRBs official authorization to complete the research is included in the appendix. This project includes both qualitative and quantitative data, as the survey was used to gather a variety of information. The results of the surveys have been evaluated to 7 view the differences between the data from the pre- and post-surveys. While interviews would have provided more qualitative data, the surveys were intended to reach a larger audience than what could have been accomplished through other means. By having a larger sample size, it was thought that they would potentially be more representative of the student population. The surveys were able to gather about twenty-five responses, and the interviews would have led to fewer responses. Although it would have been preferable to run the data through regression analysis software, there simply was not enough data collected. In order to create the sample of students the attendees of the Elect Her conference that are enrolled in the Women in Politics class were asked to participate in a survey regarding attitudes towards female candidates and women running for elected positions. Attendance at the Elect Her conference was mandatory for those enrolled in the Women in Politics class, and flyers as well as other advertisements were distributed across campus in order to encourage participation by other students. Women4Change, an organization that has a student chapter here at the University of Indianapolis, also distributed flyers via their newsletter at IUPUI. Attendance at the event was encouraged by offering lecture/performance credit at the event, as the University approved the lecture/performance credit application. By partnering with community organizations such as Girls, Inc. and University of Indianapoliss registered student organization Women4Change this event was marketed to reach a further audience. The Elect Her conference occurred on University of Indianapolis campus in UIndy Hall B & C. It included three female speakers that have or currently are holders of public office. Indianapolis Student Government President Danielle Merlo, Indiana House 8 Representative Cherrish Pryor, and City-County Councilor Kristin Jones spoke at the conference about their experiences as females in politics and answered questions from the participants about the topic as well. The speakers were chosen in order to represent a variety of viewpoints with office held, demographics, political alignment, and schedule availability being considered. As an essential part of the research, the surveys were carefully handled. The presurveys were distributed to the Women in Politics class before the conference, and the purpose of the study was explained as well as the agenda for the conference itself. The post-surveys were collected after the event in the same manner. Both surveys included the exact same questions and were formatted identically in order to control bias in the questioning. By collecting the surveys before the event officially began through Qualtrics, it was possible to control the environment and not let the information be biased by the event after it had taken place. A link to the Qualtrics survey was given to all attendees in order to ensure that they had access to the survey. In order to protect confidentiality, the survey did not ask for any identifying information and there is not a record of the individuals taking the survey. The anonymity allowed for safe transportation of the data and protected the identities of the students surveyed. The survey was completely voluntary, and students were made aware that there were no repercussions for choosing not to participate in the survey. Surveys were chosen as the most effective way to gather data for this research, however there are still inadequacies inherent in using surveys that must be addressed. Without incentives respondents may not feel encouraged to provide accurate and honest 9 answers, and there is also the possibility that they are not comfortable in providing answers that may be viewed as unfavorable. Time constraints or an unwillingness to devote time to the survey can lead to incomplete responses, as was evidenced in one of the post-survey responses. One student did not complete the post-survey, thereby creating an incomplete data set. In order to encourage complete and accurate surveys, participants that were in the Women in Politics class were given devoted class time in order to fill out the pre- and post-surveys. Another difficulty in choosing surveys is the possibility that respondents may interpret the answer options differently. One persons somewhat agree could be anothers agree, leading to variations in the responses. The decision to use the 5-point Likert scale in the survey allowed for balanced responses and is standard within these types of surveys. The goal for the research was to analyze at least 25 surveys gathered from the events. Although this is not a large sample size, it was a realistic goal for the number of students that we expected to participate in the conference. While the demographic data was not as widespread as would be optimal, the demographic questions in the survey allow us to be transparent about the results and this potential failing of the experiment. After the data was collected it was then reviewed and synthesized in a survey data report, offering the information in a succinct and clear format. Graphs were added in some of the analysis in order to give a clear view of the data. Discussion The data collection and analysis suggest that the student programming was able to affect student political engagement and interest, while the magnitude of its effect is 10 uncertain. In some instances, the data suggests that the programming had a positive effect on the students in that they were more likely to vote in a local election. In the presurvey about voting in local elections 16% stated that they were somewhat unlikely while the post-survey only had 4.17% answer that they were somewhat unlikely. This decrease in the unlikely category suggests increased awareness of local politics and elections and the potential growth of community engagement. Other instances suggested that the programming had a negative impact as students reported that they were less likely to run for student government office after the program than before. A potential explanation for this considers the content of the programming. The training was aimed at giving students the tools to run for government should they choose to, and also made the realities of running for student office transparent. While it was structured to encourage students campaigns, it is possible that the realities of a political campaign changed some students perspective. It was interesting to note that while this question trended negatively, the broader question of whether students are likely to become a candidate in the future trended more positively, although the shift was not drastic. There are many potential explanations for this, a prominent one being that students feel that they will have more time and/or resources to run for office in the future than they do currently. The data collected was particularly compelling when examining the differences between pre- and post- survey. In the following table, the survey questions and their preand post- values are given for reference. The demographics and the open-ended questions have not been included to maximize clarity. For further information on the 11 complete survey questions and data please refer to the Data Survey Report found in the appendix. Survey Questions 7. Consider running for student government? 8.Vote for a female in student gov.? 9. Vote for a female in federal gov.? 10. Vote in a Presidential election? 11. Vote in a midterm election? 12. Vote in a local election? 13. Vote for female candidate? 14. Become a candidate in the future? 15. Name female officials in your state? Pre- or Extremely PostUnlikely Survey Somewhat Unlikely Neither likely nor Unlikely Somewhat likely Extremely Likely Pre 20% 20% 24% 28% 8% Post 29.17% 20.83% 12.50% 20.83% 16.67% Pre 4% 4% 12% 20% 60% Post - - 16.67% 20.83% 62.5% Pre 4% 4% 12% 20% 60% Post - 4.17% 12.5% 25% 58.33% Pre - 8% - 8% 84% Post - 4.17% - 12.5% 83.33% Pre 4% 4% 4% 24% 64% Post - 4.17% 8.33% 33.33% 54.17% Pre - 16% 4% 32% 48% Post - 4.17% 20.83% 29.17% 45.83% Pre - - 4% 28% 68% Post - 4.17% 4.17% 8.33 83.33% Pre 16% 8% 32% 24% 20% Post 12.5% 16.67% 25% 33.33% 12.5% Pre 8% 8% 12% 36% 36% Post 20.83% 12.5% 12.5% 20.83% 33.33% 12 17. Name female officials in federal gov.? 19. Barriers for women? 21. Female candidates judged differently? Pre 8% 12% 20% 12% 48% Post 8.33% - 16.67% 20.83% 54.17% Pre - 4% - 20% 76% Post - 4.17% 4.17% 8.33% 83.33% Pre - 4% 8% 12% 76% Post - - 8.33% 16.67% 75% When examining the data regarding the likelihood of the participant voting for a female candidate in student government the data trended upward. There were no responses in the extremely unlikely and the somewhat unlikely categories in the postsurvey, while the pre-survey had one response in each of those categories. This data suggested a shift as neither likely nor unlikely, somewhat likely, and extremely likely all had a higher percentage of responses in the post-survey. When evaluating it on a scale of one to five, the average of the responses shifted from 4.28 to 4.46 with 60% and 62.5% of the participants responding with extremely likely respectively. Interestingly, this different when the participants were asked about voting for a female in federal government, as the somewhat unlikely responses remained constant. When the participants were asked if they would participate in the Presidential elections the data suggested that the Elect Her programming did not have an effect as there was little to no change in the responses. The same question in reference to midterm elections skewed towards being more likely to vote in the midterm elections after the programming was completed. Considering the national average for voting in the 13 Presidential election in 2016 was only 61.4% of the eligible voting population, the data suggests that the students are more politically engaged in Presidential elections than the average eligible voter (Thom File 2017). Another aspect in this realm of questioning that showed a dramatic shift was that of whether participants were likely to engage in local elections. This dramatic shift was likely encouraged by the speakers at the program, as they were all elected officials from different levels of local government. Each was able to give testimony in how their position in local office affects the daily life of their constituents, thus promoting the power of local government officials. Councilor Kristin Jones testimony was especially poignant as she explained some of the ways in which her position has directly affected the people in her district. I had low expectations for those surveyed being able to name a female elected official in their state as many students do not seem to be very politically engaged, however the data did not support this hypothesis. As a self-selected group, the participants were more knowledgeable about specific women in national politics and their participation in the Women in Politics class created an outside influence that affected this part of the survey. Due to this bias it would not be effective to consider these specific open-ended responses from the participants, as there was no way to isolate the Elect Her programs impact versus that of the Women in Politics class. However, as expected students were able to name more female federal government officials than those in the state government. 14 After the programming, participants felt that it was more likely that women face barriers in running for public office that are different than those that men face. The open responses suggested that the participants had some knowledge on the subject, likely from the Women in Politics class, although it also suggested that the participants actively listened and engaged in the material presented at the Elect Her programming. Conclusion The implementation of the training module, Elect Her, was used to evaluate the participants in regard to their feeling knowledgeable about running campaigns and their abilities to succeed as a candidate. With these responses it was possible to determine that the student programming does have an effect on student engagement and interest in politics, although this study was not able to determine the extent of the impact. Based on these findings, it is possible to conclude that student programming is important to the development of the student and that it can affect the students beliefs and political engagement. As for the programming, it can be deemed effective as to having an impact in general. This contributes to the literature as university students have been a neglected population within the research on voting groups. The information from this study provides a look at how students feel regarding women in politics and their viewpoints on participating in the political structure of the United States election system. This study exercised the training program as a way to promote engagement in a group that is generally thought to be less engaged than other eligible voting groups. The Elect Her program provided an essential service at the University of Indianapolis by educating 15 students about women in the political sphere as well as helping students to implement strategies that will benefit them in the future. One skill taught at the program was elevator speeches, which while definitely important in a political campaign can also be beneficial in students other various careers. With the Elect Her program and the surveys disseminated it was possible to see political interest and engagement when examining women in politics and the participants engagement in different elections. The impact of the programming, while inconclusive in regard to magnitude, was able to demonstrate that the programming was effective in altering participants perspectives. Reflection This research was productive and able to fulfill the project goals originally set forth. The Elect Her program was successfully brought to the University of Indianapolis, and we were able to attain diverse female politicians to speak at the program. One way to improve the group of speakers would have been if a female Republican official would have been able to attend the conference. Unfortunately, although many were contacted and invited, prior engagements and scheduling conflicts did not allow for this. An aspect of the research that could be improved upon in future studies is the sample group. While it would have been optimal to have surveyed more students, time restraints and the need for consistency created difficulties in obtaining the surveys from program attendees that were not from our university. It also would have been more representative if the demographic of gender was more evenly distributed in regard to the composition of the campus. This composition was likely skewed due to the subject 16 matter of women in the political sphere, although there were some male participants in the study. In the future, this type of study could be optimized by having a much larger population surveyed. Another interesting variable would be to change the content of the political programming so that while bipartisan, it is focused on an issue that appeals more broadly to both male and female students. If interviews were added to the study, it would be possible to collect data with a deeper look at the sample group including in depth questions and less structured responses. However, with interviews there would not be as many respondents and the sample group would be less representative than in this project. Personally, this project was important to me in that it developed many researching skills that I will be able to take with me as I further my education. I have also learned a great deal about data collection and how I can improve my research in future studies. Professionally, the planning of the Elect Her program and coordination of the meal afterwards was a vital lesson in event planning. Coordinating with the public officials was essential, and the creation of the agenda while maintaining the content of the programming was a valuable experience. Overall, leadership programming and its effect on students political interest and engagement is a subject that can sustain more research with broader populations. However, despite any inherent shortcomings, this study was able to create valuable literature on the topic. 17 Works Cited Boris, E., & Currans, E. (2013). Feminist Currents. Frontiers: A Journal of Women Studies, 34(2), 255260. https://doi.org/10.5250/fronjwomestud.34.2.0255 Burrell, B. (2014). Womens Campaigns for the U.S. House of Representatives beyond the Year of the Woman. In Gender in Campaigns for the U.S. House of Representatives (pp. 29-50). Ann Arbor: University of Michigan Press. Retrieved from http://www.jstor.org/stable/10.3998/mpub.213944.5 Dolan, K. (2008). Women Voters, Women Candidates: Is There a Gender Gap in Support for Women Candidates? In WHITAKER L. (Ed.), Voting the Gender Gap (pp. 91-107). Urbana; Chicago: University of Illinois Press. Retrieved from http://www.jstor.org/stable/10.5406/j.ctt1x74fg.10 Kanthak, K., & Woon, J. (2015). Women Don't Run? Election Aversion and Candidate Entry. American Journal of Political Science, 59(3), 595-612. Retrieved from http://www.jstor.org/stable/24583085 Lawless, J., & Pearson, K. (2008). The Primary Reason for Women's Underrepresentation? Reevaluating the Conventional Wisdom. The Journal of Politics, 70(1), 67-82. doi:10.1017/s002238160708005x Oxley, Z., & Fox, R. (2004). Women in Executive Office: Variation across American States. Political Research Quarterly, 57(1), 113-120. doi:10.2307/3219838 File, T. (2017, May 10). Voting in America: A Look at the 2016 Presidential Election. Retrieved from https://www.census.gov/ 18 Welch, S., & Studlar, D. (1996). The Opportunity Structure for Women's Candidacies and Electability in Britain and the United States. Political Research Quarterly, 49(4), 861-874. doi:10.2307/449141 Zurbriggen, E. L., & Sherman, A. M. (2010). Race and Gender in the 2008 U.S. Presidential Election: A Content Analysis of Editorial Cartoons. Analyses of Social Issues & Public Policy, 10(1), 223247. https://doi.org/10.1111/j.15302415.2010.01211.x Appendices CITI Training Certificate 19 20 Survey Data Report Leadership Programming and Political Engagement Survey Comparison *Note: One student did not complete the post survey, leading to fewer responses and possible discrepancies in the data. Q1 - Do you consider yourself: Pre-Survey # Answer % Count 1 Democrat 56.00% 14 2 Republican 32.00% 8 3 Other 0.00% 0 4 Don't Identify with a Party 12.00% 3 Total 100% 25 # Answer % Count 1 Democrat 60.00% 15 2 Republican 32.00% 8 3 Other 0.00% 0 4 Don't Identify with a Party 8.00% 2 Total 100% 25 Post Survey 21 Q2 - Where do you tend to fall ideologically? Pre-Survey # Answer % Count 1 Far Left 8.00% 2 2 Left 40.00% 10 3 Slightly Left 4.00% 1 4 Center 16.00% 4 5 Slightly Right 16.00% 4 6 Right 16.00% 4 7 Far Right 0.00% 0 8 Not Sure 0.00% 0 Total 100% 25 22 Post Survey # Answer % Count 1 Far Left 0.00% 0 2 Left 48.00% 12 3 Slightly Left 4.00% 1 4 Center 12.00% 3 5 Slightly Right 4.00% 1 6 Right 24.00% 6 7 Far Right 4.00% 1 8 Not Sure 4.00% 1 Total 100% 25 23 Q3 - How do you identify? Pre-Survey # Answer % Count 1 Male 12.00% 3 2 Female 88.00% 22 3 Transgender (MtF) 0.00% 0 4 Transgender (FtM) 0.00% 0 5 Non-binary 0.00% 0 6 Prefer not to answer 0.00% 0 7 Other 0.00% 0 Total 100% 25 # Answer % Count 1 Male 8.00% 2 2 Female 92.00% 23 3 Transgender (MtF) 0.00% 0 4 Transgender (FtM) 0.00% 0 5 Non-binary 0.00% 0 6 Prefer not to answer 0.00% 0 7 Other 0.00% 0 Total 100% 25 Post Survey 24 Q4 - What ethnicity do you identify with? Please select all that apply. Pre-Survey # Answer % Count 1 White 71.43% 20 2 Black or African American 21.43% 6 3 Hispanic or Latino 3.57% 1 4 Asian/Pacific Islander 0.00% 0 5 Native American or American Indian 3.57% 1 6 Other 0.00% 0 Total 100% 28 # Answer % Count 1 White 67.86% 19 2 Black or African American 25.00% 7 3 Hispanic or Latino 3.57% 1 4 Asian/Pacific Islander 0.00% 0 5 Native American or American Indian 3.57% 1 6 Other 0.00% 0 Total 100% 28 Post Survey 25 Q5 - Are you currently an undergraduate student? If so what year? Pre-Survey # Answer % Count 1 Freshman (1st year) 0.00% 0 2 Sophomore (2nd year) 16.00% 4 3 Junior (3rd year) 48.00% 12 4 Senior (4th year) 36.00% 9 5 I am a graduate student 0.00% 0 6 I am not a student 0.00% 0 Total 100% 25 # Answer % Count 1 Freshman (1st year) 0.00% 0 2 Sophomore (2nd year) 16.00% 4 3 Junior (3rd year) 48.00% 12 4 Senior (4th year) 36.00% 9 5 I am a graduate student 0.00% 0 6 I am not a student 0.00% 0 Total 100% 25 Post Survey 26 Q6 - What is your major(s)? Pre-Survey Political Science and International Relations Political Science/ International Relations Criminal justice International Relations & Political Science History (psci & legal studies minors) Political Science/International Relation w/ a minor in legal studies Political Science and Philosophy International Relations and Franco-Germanic Studies Political Science & Communication Political Science and Spanish Communication . minor in political science Political Science. Environmental science History Psychology Political Science History political science, pre law, communications Human Biology International Relations and Criminal Justice Political Science International Relations & Political Science Political Science Political Science Political Science 27 Post Survey Criminal justice Political Science Political Science/IR Political Science International Relations and Franco-Germanic Studies Psychology criminal justice communication Political Science Political Science PoliSci Political Science and Philosophy Political science History History w/ Psci minor History Environmental Science Political Science and Spanish Political Science PSCI and IREL Human Biology International Relations & Political Science Political Science International Relations and Criminal Justice Political Science/ International Relations 28 Q7 - On scale from 1 - 5, with 1 being 'highly unlikely' and 5 being extremely likely please answer the following question: Would you consider running for an elected position in student government? Pre-Survey # 1 Std Variance Count Deviation Field Minimum Maximum Mean On scale from 1 - 5, with 1 being 'highly unlikely' and 5 being extremely likely please answer the following question: Would you consider running for an elected position in student government? 1.00 5.00 2.84 1.25 1.57 # Answer % Count 1 1. Extremely unlikely 20.00% 5 2 2. Somewhat unlikely 20.00% 5 3 3. Neither likely nor unlikely 24.00% 6 4 4. Somewhat likely 28.00% 7 5 5. Extremely likely 8.00% 2 Total 100% 25 25 29 Post Survey # 1 Field Minimum Maximum Mean On scale from 1 - 5, with 1 being 'highly unlikely' and 5 being extremely likely please answer the following question: Would you consider running for an elected position in student government? 1.00 5.00 2.75 Std Variance Count Deviation 1.48 2.19 24 # Answer % Count 1 1. Extremely unlikely 29.17% 7 2 2. Somewhat unlikely 20.83% 5 3 3. Neither likely nor unlikely 12.50% 3 4 4. Somewhat likely 20.83% 5 5 5. Extremely likely 16.67% 4 Total 100% 24 30 Q8 - On scale from 1 - 5, with 1 being 'highly unlikely' and 5 being extremely likely please answer the following question: How likely are you to vote for a female candidate in student government? Pre-Survey # Field Minimum Maximum Mean On scale from 1 - 5, with 1 being 'highly unlikely' and 5 being & extremely likely please answer 1 the following question: How likely are you to vote for a female candidate in student government? 1.00 5.00 Std Variance Count Deviation 4.28 1.08 1.16 # Answer % Count 1 1. Extremely unlikely 4.00% 1 2 2. Somewhat unlikely 4.00% 1 3 3. Neither likely nor unlikely 12.00% 3 4 4. Somewhat likely 20.00% 5 5 5. Extremely likely 60.00% 15 Total 100% 25 25 31 Post Survey # 1 Field Minimum Maximum Mean On scale from 1 - 5, with 1 being 'highly unlikely' and 5 being extremely likely please answer the following question: How likely are you to vote for a female candidate in student government? 3.00 5.00 4.46 Std Variance Count Deviation 0.76 0.58 24 # Answer % Count 1 1. Extremely unlikely 0.00% 0 2 2. Somewhat unlikely 0.00% 0 3 3. Neither likely nor unlikely 16.67% 4 4 4. Somewhat likely 20.83% 5 5 5. Extremely likely 62.50% 15 Total 100% 24 32 Q9 - On scale from 1 - 5, with 1 being 'highly unlikely' and 5 being "extremely likely" please answer the following question: How likely are you to vote for a female candidate in the federal government? Pre-Survey # 1 Field Minimum Maximum Mean On scale from 1 - 5, with 1 being 'highly unlikely' and 5 being extremely likely please answer the following question: How likely are you to vote for a female candidate in the federal government? 1.00 5.00 Std Variance Count Deviation 4.28 1.08 1.16 # Answer % Count 1 2 1. Extremely unlikely 2. Somewhat unlikely 4.00% 4.00% 1 1 3 4 5 3. Neither likely nor unlikely 4. Somewhat likely 5. Extremely likely 12.00% 20.00% 60.00% 3 5 15 Total 100% 25 25 33 Post Survey # 1 Field Minimum Maximum Mean On scale from 1 - 5, with 1 being 'highly unlikely' and 5 being extremely likely please answer the following question: How likely are you to vote for a female candidate in the federal government? 2.00 5.00 4.38 Std Variance Count Deviation 0.86 0.73 24 # Answer % Count 1 1. Extremely unlikely 0.00% 0 2 2. Somewhat unlikely 4.17% 1 3 3. Neither likely nor unlikely 12.50% 3 4 4. Somewhat likely 25.00% 6 5 5. Extremely likely 58.33% 14 Total 100% 24 34 Q10 - On scale from 1 - 5, with 1 being 'highly unlikely' and 5 being "extremely likely" please answer the following question: How likely are you to vote in a Presidential election? Pre-Survey # Answer % Count 1 1. Extremely unlikely 0.00% 0 2 2. Somewhat unlikely 8.00% 2 3 3. Neither likely nor unlikely 0.00% 0 4 4. Somewhat likely 8.00% 2 5 5. Extremely likely 84.00% 21 Total 100% 25 35 Post Survey # Answer % Count 1 1. Extremely unlikely 0.00% 0 2 2. Somewhat unlikely 4.17% 1 3 3. Neither likely nor unlikely 0.00% 0 4 4. Somewhat likely 12.50% 3 5 5. Extremely likely 83.33% 20 Total 100% 24 36 Q11 - On scale from 1 - 5, with 1 being 'highly unlikely' and 5 being "extremely likely" please answer the following question: How likely are you to vote in a midterm election? Pre-Survey # Answer % Count 1 1. Extremely unlikely 4.00% 1 2 2. Somewhat unlikely 4.00% 1 3 3. Neither likely nor unlikely 4.00% 1 4 4. Somewhat likely 24.00% 6 5 5. Extremely likely 64.00% 16 Total 100% 25 37 Post Survey # Answer % Count 1 1. Extremely unlikely 0.00% 0 2 2. Somewhat unlikely 4.17% 1 3 3. Neither likely nor unlikely 8.33% 2 4 4. Somewhat likely 33.33% 8 5 5. Extremely likely 54.17% 13 Total 100% 24 38 Q12 - On scale from 1 - 5, with 1 being 'highly unlikely' and 5 being "extremely likely" please answer the following question: How likely are you to vote in a local election? Pre-Survey # Answer % Count 1 1. Extremely unlikely 0.00% 0 2 2. Somewhat unlikely 16.00% 4 3 3. Neither likely nor unlikely 4.00% 1 4 4. Somewhat likely 32.00% 8 5 5. Extremely likely 48.00% 12 Total 100% 25 39 Post Survey # Answer % Count 1 1. Extremely unlikely 0.00% 0 2 2. Somewhat unlikely 4.17% 1 3 3. Neither likely nor unlikely 20.83% 5 4 4. Somewhat likely 29.17% 7 5 5. Extremely likely 45.83% 11 Total 100% 24 40 Q13 - On scale from 1 - 5, with 1 being 'highly unlikely' and 5 being extremely likely please answer the following question: How likely are you to vote for a female candidate, with all other features considered equal? Pre-Survey # 1 Field Minimum Maximum Mean On scale from 1 - 5, with 1 being 'highly unlikely' and 5 being extremely likely please answer the following question: How likely are you to vote for a female candidate, with all other features considered equal? 3.00 5.00 4.64 Std Variance Count Deviation 0.56 0.31 # Answer % Count 1 1. Extremely unlikely 0.00% 0 2 2. Somewhat unlikely 0.00% 0 3 3. Neither likely nor unlikely 4.00% 1 4 4. Somewhat likely 28.00% 7 5 5. Extremely likely 68.00% 17 Total 100% 25 25 41 Post Survey # 1 Field Minimum Maximum Mean On scale from 1 - 5, with 1 being 'highly unlikely' and 5 being extremely likely please answer the following question: How likely are you to vote for a female candidate, with all other features considered equal? 2.00 5.00 4.71 Std Variance Count Deviation 0.73 0.54 24 # Answer % Count 1 1. Extremely unlikely 0.00% 0 2 2. Somewhat unlikely 4.17% 1 3 3. Neither likely nor unlikely 4.17% 1 4 4. Somewhat likely 8.33% 2 5 5. Extremely likely 83.33% 20 Total 100% 24 42 Q14 - On scale from 1 - 5, with 1 being 'highly unlikely' and 5 being extremely likely please answer the following question: How likely are you to become a candidate in the future? Pre-Survey # Field Minimum Maximum Mean On scale from 1 - 5, with 1 being 'highly unlikely' and 5 being extremely likely please 1 answer the following question: How likely are you to become a candidate in the future? 1.00 5.00 3.24 Std Variance Count Deviation 1.30 1.70 25 # Answer % Count 1 1. Extremely unlikely 16.00% 4 2 2. Somewhat unlikely 8.00% 2 3 3. Neither likely nor unlikely 32.00% 8 4 4. Somewhat likely 24.00% 6 5 5. Extremely likely 20.00% 5 Total 100% 25 43 Post Survey # 1 Field Minimum Maximum Mean On scale from 1 - 5, with 1 being 'highly unlikely' and 5 being extremely likely please answer the following question: How likely are you to become a candidate in the future? 1.00 5.00 3.17 Std Variance Count Deviation 1.21 1.47 24 # Answer % Count 1 1. Extremely unlikely 12.50% 3 2 2. Somewhat unlikely 16.67% 4 3 3. Neither likely nor unlikely 25.00% 6 4 4. Somewhat likely 33.33% 8 5 5. Extremely likely 12.50% 3 Total 100% 24 44 Q15 - On scale from 1 - 5, with 1 being 'highly unlikely' and 5 being "extremely likely" please answer the following question: Can you name any elected female officials in your state that hold office? Pre-Survey # Answer % Count 1 1. Extremely unlikely 8.00% 2 2 2. Somewhat unlikely 8.00% 2 3 3. Neither likely nor unlikely 12.00% 3 4 4. Somewhat likely 36.00% 9 5 5. Extremely likely 36.00% 9 Total 100% 25 45 Post Survey # Answer % Count 1 1. Extremely unlikely 20.83% 5 2 2. Somewhat unlikely 12.50% 3 3 3. Neither likely nor unlikely 12.50% 3 4 4. Somewhat likely 20.83% 5 5 5. Extremely likely 33.33% 8 Total 100% 24 46 Q16 - Please name any women that you know that hold office in state government. Pre-Survey Councillor MAGGIE A Lewis Susan W. Brooks Alabama- Kay Ivey, Martha Roby, Teri Sewell, Lori Lightfoot Christina castro, Lori Lightfoot Lt. Gov. Suzanne Crouch, Chief Justice Loretta Rush, Jennifer McCormmick Chief Justice Loretta Rush, Susan Crouch Nancy Pelosi, AOC, Elizabeth Warren, Lakeisha Jackson Connie Lawson, Suzanne Crouch, Kelly Mitchell, Susan Brooks Susan Brooks Suzanne Crouch Karen Tallian Lt. Gov None in state government Suzanne Crouch Kelly, Carrie Crista Carlino, Susan Crouch 47 Post Survey Susan Brookes, Jackie Walorski, Sen. Victoria Sparks, Rep. Cindy Kirchhofer, Lt. Gov. Suzanne Crouch, Rep. Cherrish Pryor, Rep. Kristin Jones, U.S. Rep. Susan Brooks, Chief Justice Loretta Rush, Auditor Tera Klutz, Secretary of State Connie Lawson, Senator Erin Houchin, Senator Jean Leising, Rep. Wendy McNamara Kelly Mitchell lakeisha jackson Cindy Kirchoffer Kristen Jones, Crista Carlino, Jessica McCormick, Susane Crouch Macer, terry, Lt. Gov. Crouch, Susan Collins, Crouch, Brooks, Lawson tammy duckworth, lori lightfoot Karen Tallian Jeniffer McCormick, Cherish Pryor Connie Lawson, Kelly Mitchell Jennifer McCormick, Suzanne Crouch 48 Q17 - On scale from 1 - 5, with 1 being 'highly unlikely' and 5 being extremely likely please answer the following question: Can you name any female elected officials in the federal government? Pre-Survey # Answer % Count 1 1. Extremely unlikely 8.00% 2 2 2. Somewhat unlikely 12.00% 3 3 3. Neither likely nor unlikely 20.00% 5 4 4. Somewhat likely 12.00% 3 5 5. Extremely likely 48.00% 12 Total 100% 25 49 Post Survey # Answer % Count 1 1. Extremely unlikely 8.33% 2 2 2. Somewhat unlikely 0.00% 0 3 3. Neither likely nor unlikely 16.67% 4 4 4. Somewhat likely 20.83% 5 5 5. Extremely likely 54.17% 13 Total 100% 24 50 Q18 - Please name any and all women that you know of that hold office in the federal government. Pre-Survey Please name any and all women that you know of that hold office in the federal government. n/a Nancy Pelosi, AOC, Ilhan Omar, Rashida Talib, Kelly Loeffler nancy pales Nancy Pelosi, Susan Collins AOC, Nancy Pelosi Alexandria Ocasio-Cortez, Nancy Pelosi, Maxine Waters, Ayanna Presley, Rashida Tlaib, Lisa Murkowski, Susan Collins Nancy Pelosi, Sonia Sotomayor,RBG, Nancy Pelosi AOC, Nancy Pelosi Nancy Pelosi, AOC, Ilhan Omar, Susan Collins, Elizabeth Warren, Amy Klobuchar nancy Pelosi Jackie Walorski Nancy Pelosi Nancy Pelosi, RBG Rashida Tlaib Susan Brooks AOC, Warren, Harris Nancy Pelosi, RBG, Hillary Clinton, AOC 51 Post Survey Please name any and all women that you know of that hold office in the federal government. AOC, Harris, Warren, Kamala Harris Maxine waters Etc Sen. Kamala Harris, Sen. Elizabeth Warren, Rep. Alexandria Ocasio Cortez, Rep. Tulsi Gabbard, Sen. Martha McSally, Rep. Ilhan Omar, Rep. Rashida Tlaib, Warren, Talib, Omar, AOC, Pelosi Tera Klutz nancy pelosi Martha McSally RBG, Elena Kegan, AOC, Ilhan Omar AOC, pelosi, Nancy Pelosi, Pelosi Elizabeth Warren, Amy Klobuchar, Kamala Harris, AOC, Susan Collins, Ilhan Omar nancy pelosi, tammy ducksworth, ayanna pressley, Nancy Pelosi. Elizabeth Warren, Alexandria-Oscario Cortez, Nancy Pelosi Betsy Dvos, Nancy Pelosi, Sonia Sotomayor, RBG Marsha Blackburn, Nancy Pelosi, AOC, Elizabeth Warren RBG, dianne feinstein, joyce beatty Jackie Walorski, Nancy Pelosi, AOC Ilhan Omar 52 Q19 - Are there barriers that women face today in running for public office that are different than those that men face? Pre-Survey # Answer % Count 1 Definitely yes 76.00% 19 2 Probably yes 20.00% 5 3 Might or might not 0.00% 0 4 Probably not 4.00% 1 5 Definitely not 0.00% 0 Total 100% 25 53 Post Survey # Answer % Count 1 Definitely yes 83.33% 20 2 Probably yes 8.33% 2 3 Might or might not 4.17% 1 4 Probably not 4.17% 1 5 Definitely not 0.00% 0 Total 100% 24 54 Q20 - What barriers do women face today in running for public office? Pre-Survey What barriers do women face today in running for public office? Access to equal opportunities, and patriarchy They are sometimes perceived differently than men. incumbency disadvantages and being looked down upon They get looked at as a lower standard than men. Extra media criticism, incubant preferences, discrimination Social barriers including electability worries, harsher criticism from the press and opponents Gender Biases, Race Biases bias and stereotypes Domestic life, perception issues Societal expectations to do other professions They have less money than men on average, people think theyre too emotional image issues, confidence, resources to run for a position They are not as well received by the public. Old social barriers none Sexism, different forms of criticism (I.e. physical appearance-based) Not being taken seriously in politics, sexism There are still a lot of objectification Sexism They either dont run or theyre not the incumbent Bias, Marginalization, their gender 55 Post Survey What barriers do women face today in running for public office? Color,gender bias Feeling qualified for the position, fundraising, people's opinions of female candidates Discrimination, heightened media scrutiny The barries women face today in running for public office would be simply their gender because if a woman ran for president, they wouldn't be taken seriously since their a woman, and often times plagued with intimidation tactics from males. sexism, family life Party line barriers "too emotional", appearance Incumbents, discrimination, There is a gender gap difference. Women tend to be looked at different and lesser than men. They are less likely to be asked to run, they are less likely to consider running incumbency disadvantage Social, monetary, biases Lack of support and votes from men, different priorities inequality Duties at home, the public watchdog on items outside of policy discrimination, etc Lack of confidence, judged for being too emotional, what they wear Not taken seriously 56 Q21 - Do you believe female candidates are judged differently than male candidates today? Pre-Survey # Answer % Count 1 Definitely yes 76.00% 19 2 Probably yes 12.00% 3 3 Might or might not 8.00% 2 4 Probably not 4.00% 1 5 Definitely not 0.00% 0 Total 100% 25 57 Post Survey # Answer % Count 1 Definitely yes 75.00% 18 2 Probably yes 16.67% 4 3 Might or might not 8.33% 2 4 Probably not 0.00% 0 5 Definitely not 0.00% 0 Total 100% 24 58 Q22 - How do you believe women candidates are judged differently than male candidates today? Pre-Survey How do you believe women candidates are judged differently than male candidates today? They get ridicule if they and dont do certain things in a manner expected of women. Because women are not taking more seriously than male candidates when trying to run for office and its women have a hard time running for office they are viewed as an inferior gender They are looked to be lower then men. Since men typically hold office, its different for women to be involved Females may be judged more by their appearance, their past Criticized more heavily for looks and statements Women candidates are not allowed to be "too feminine" or "too masculine" in society especially politics. We live in a world where these stereotypes define a women especially in politics women making power moves are looked at as bitchy, men are looked at as powerful By how they look, what they wear, how they sound Women candidates are often judged on what they wear and how emotional they are They are seen as too emotional, not as level headed as men they are viewed based off of their emotions and ability to take criticism rather than getting the job done Women are considered to be more emotional. Women are judged on what they are wearing while this is not an issue with male candidates. Scrutinized for more reasons, and for reasons irrelevant to the position that they are running for Women are judged more by their looks and mannerisms than men. Previously mentioned They are seen to be more emotional 59 Post Survey How do you believe women candidates are judged differently than male candidates today? Women are expected to "have it all," balance a high powered career and motherhood, all while being a wonderful friend, daughter, sister, and more. Judged on traditional gender role matter such as clothing, appearance, family I believe woman candidates are judged differently than male candidates today because women work just as hard as men and being able to run for office is a huge deal for men because women are just as smart as a man but are judged based on their gender. weaker, less qualified They are often looked to be less qualified. They are judged more on appearance than what their policies are social standards are harsher on women Have to walk different lines and standards that men dont have too Women candidates are often judged for the things they wear and their temperament, while men are more so judged on ability to do the job. inequality because of sexism Outfits, if they are fit for office, their personal life discrimination They are seen as being too emotional. Their attire is judged. Women are judged on their looks more than male candidates  ...

... i Effects of Workload, Work Hours, and Policy Attitudes on Critical Care Nurse Fatigue: A Quantitative Study By Taylor Nicole AmRhein Honors Project Thesis Submitted in Partial Fulfillment Of the Requirements for a Baccalaureate Degree With Distinction In the Ron and Laura Strain Honors College of THE UNIVERSITY OF INDIANAPOLIS May 2020 Faculty Advisor: Sarah Holmes MSN, BSN Executive Director of Honors: James B. Williams, Ph.D. Taylor AmRhein 2020. Copyright in this work rests solely with the author. Please ensure that any reproduction or re-use is done in accordance with relevant national copyright protection i Abstract Chronic nursing fatigue is an issue that continues to put patients at risk. Heavier workloads and longer work hours increase nursing fatigue. Critical care (CC) nurses may be more at risk to develop chronic fatigue, which may negatively affect patient outcomes. The purpose of this quantitative study was to 1) discover the prevalence of chronic fatigue within CC nurses in Indiana; 2) explore the relationship between chronic nursing fatigue, workload, and work hours; and 3) explore attitudes toward regulatory work hour policies and if they correlate with chronic fatigue levels. Likert-style surveys were used to explore CC nurse chronic fatigue levels as well as their workloads, work hours, and work hour regulatory policy attitudes. No correlations or significant differences were found between chronic fatigue total scores, workload totals scores, work hours, or policy attitudes. Most surveyed reported moderate to high levels of chronic fatigue (62.5%) and moderate workloads (63.6%). Nurses who were older and those who had practiced longer had higher mean chronic fatigue scores. Almost all surveyed worked 12hour shifts and at least 72-hours every two weeks. The majority of participants were unsure if work hour restriction policies should be adopted. The results of this study indicate a need for interventions that help alleviate and/or prevent chronic fatigue in CC nurses working in Indiana. Interventions should address chronic fatigue statements that received the highest mean ratings as well as consider nurse age and years of practice. More research must be done to explore nursing work restriction policies and the knowledge and attitudes that CC nurses have about them in order to understand policy feasibility and benefits. ii Table of Contents Abstract i Acknowledgements iii List of Tables iv List of Figures v Introduction 1 Methods 9 Results 15 Discussion 17 Conclusion 21 Reflection and Future Directions 22 References 24 Tables and Figures 28 Appendices 34 iii Acknowledgements This honors college project could not have been completed without the partnership formed with the American Association of Critical Care Nurses (AACN). A special thanks are extended to Belinda Wallbank MSN, RN-BC, CNRN, the president-elect of the Central Indiana Chapter of the AACN. On a national level, I would like to thank the AACN Clinical Practice Specialist, Marian Altman PhD, RN CNS-BC, CCRN-K. Overall, the collaboration with the AACN as a whole was invaluable and integral to the success of this critical care nursing research. I would also like to thank my nursing faculty advisor, Sarah Holmes MSN, BSN for her diligence, kindness, and dedication to ensuring this project was completed. I would also like to express gratitude to the faculty of the University of Indianapolis School of Nursing. Without their enthusiasm and willingness to support student research, the completion of this project would not have been possible. iv List of Tables Table 1: Differences between Chronic Fatigue Total Scores and 72-Hour Work Groups 30 Table 2: Chronic Fatigue Frequencies and Mean Data by Question 30 Table 3: Differences between Chronic Fatigue Scores and 12-Hour Work Groups 31 Table 4: Correlation Coefficient (r) Calculated between Chronic Fatigue Total Scores and Independent Variables 31 v List of Figures Figure 1: Karaseks Demand-Control-Support Model32 32 Figure 2: OFER Scale by Dr. Peter Winwood PhD 32 Figure 3: Custom Nursing Workload, Work Hours, and Policy Survey 33 Figure 4: Participant age frequency 34 Figure 5: Frequency of 12-hour shifts 34 Figure 6: Chronic fatigue score frequencies 35 Figure 7: Nurse age distribution from the NCSBN National Workforce Study 35 7 Effects of Workload, Work Hours, and Policy Attitudes on Critical Care Nurse Fatigue: A Quantitative Study Introduction Eighty-two percent of emergency, intensive care, and other specialized nurses have moderate to high levels of burnout, which may be a serious consequence of chronic fatigue (Hooper, Craig, Janvrin, Wetsel, & Reimels, 2010). Much literature identifies direct correlations between work hours and adverse patient outcomes such as medication errors (Bae & Fabry, 2014). In fact, the Centers for Medicare and Medicaid Services and The Institute of Medicine report that 1.5 million people are harmed by medication errors in the United States annually (Kinnin, 2006). Nursing chronic fatigue also contributes to personal health issues, increased turnover rates, and low productivity, all of which are costly to nursing professionals and health institutions (Driscoll et al. 2018). Critical care (CC) nurses may be more at risk to develop chronic fatigue due to higher patient acuity and work demands. While research is present related to nursing fatigue, there are important gaps present within the literature as fatigue continues to be a wide-spread problem with costly consequences. Most of the existing research related to fatigue and nursing analyzes the consequences of nurse fatigue while fewer discuss factors that cause fatigue. Other research explores specific types of fatigue including compassion and alarm fatigue as well as studying other nurse specialties such as progressive care, emergency, and medical-surgical nursing. Of note, much of the research revolving around CC nurse fatigue specifically has occurred outside of the United States. Those studies that have examined factors related to nurse fatigue have found that personal characteristics such as sleep patterns, caffeine intake, and age as well as career factors such as 8 workload and work hours, may affect the degree of fatigue experienced by nurses (Knupp et al., 2018). Additionally, some studies have examined ways to solve fatigue issues that plague nurses; self-care suggestions and policy-making are among the most cited recommendations. While policy recommendations have been made to help decrease nurse fatigue, the state of Indiana has not adopted any mandatory workplace regulations for nurses. Thus, Indiana nurses may be more at risk for developing fatigue which may adversely affect both nurse and patient safety and lead to poor health outcomes. Further research is needed to fill these knowledge gaps. The purpose of this honors project and research study was to explore the level of chronic fatigue occurring in CC nurses in Indiana. Specifically, this study aimed to: 1) discover the prevalence of chronic fatigue within the CC nurse population in Indiana; 2) explore the relationship between chronic nursing fatigue, workload, and work hours; and 3) explore attitudes toward regulatory work hour policies and if they correlate with chronic fatigue levels. Literature Review Nursing fatigue is a widespread and significant issue affecting nurses in a variety of practice settings. Recurring themes echoed throughout the literature include the impact that fatigue has on patient safety and nurse well-being as well as factors that influence nursing fatigue. Negative patient outcomes and nurse safety issues have been related to fatigue within the literature. For example, a systematic review that assessed nurse and patient outcomes in relation to fatigue found that nurse fatigue negatively affected patient care outcomes and increased the incidence of nurse needlesticks, musculoskeletal disorder/injuries, alcohol consumption, health complaints, absenteeism, intent to stay/intent to leave, or motor vehicle crashes (Bae & 9 Fabry, 2014, p. 142). Additionally, the literature suggests that causes of fatigue in CC nurses are multifactorial and are related to work hours, workload, and work environmental culture. Work hours are one factor that has been shown in the literature to increase nursing fatigue. Generally, most nurses work 12-hour shifts (Josten, Ng-A-Tham, & Thierry, 2003). Unfortunately, a study was done by Knupp, Patterson, Ford, Zurmehly, and Patrick (2018) revealed higher levels of fatigue with more hours worked, and literature from the Ohio Nurses Association (2018) suggested that nurses who work long hours or overtime note more fatigue, sleep deficiencies, and decreased level of consciousness. Ann Pages book, Keeping Patients Safe: Transforming the Work Environment of Nurses (Quality Chasm), discusses the factors precipitating patient harm. She quotes that nurse condition deteriorates with fatigue and yields outcomes such as, slowed reaction time, lapses of attention to critical details, errors of omission, compromised problem solving, reduced motivation, and decreased vigor for successful completion of required tasks (p. 216). Nurses under the influence of fatigue lose the mental sharpness necessary to perform their job, and they achieve less throughout the day. Specifically, Caruso (2014) found that working 12-hour shifts in comparison to working eight-hour shifts increased the risk of nurse and patient harm by 28%. Bae and Fabry (2014) support these findings as many of the studies cited within their systematic review identified a strong correlation between work hours and patient outcomes. The six studies analyzed found that when nurse shift-length met and exceeded twelve hours, adverse patient outcomes (hypoglycemic events, errors or near errors, and pneumonia death), perceived adverse events, and patient dissatisfaction increased (Bae & Fabry, 2014, p. 149). 10 Workload, which includes the amount, level, and intensity of work, has also been connected to nursing fatigue levels. Increases in nurse workload have been occurring since the 1980s and contribute to nursing fatigue (Josten, Ng-A-Tham, & Thierry, 2003). Specific to the ICU, nurses operate under different conditions compared to other areas. Within CC nursing, there may be constant changes in patient condition and treatment. Patients are often unstable and there may be some unpredictability within the critical care patient population, so CC nurses must be diligent and monitor patients closely. Additionally, patients may be unable to speak due to sedation and respiratory support measures, increasing further nurse workload. Many times CC nurses are also involved in helping patients and families to make end-of-life decisions (Chuang, Tseng, Lin, Lin, & Chen, 2016). Thus, increased workload stems from increased patient acuity and from the advanced skills needed to care for these patients and their families (Smith-Miller et al., 2014). High acuity patients who require ongoing care from nurses with specialized skill-sets are challenging and may increase the likelihood of nurses developing fatigue due to this heavier mental , emotional, and physical stressors. Such stressors may interfere with the nurses ability to carry out competent and compassionate care, which then may negatively affect patient safety and satisfaction. Furthermore, nursing shortages have been a recurring theme in healthcare since the 1970s as the number of patients has increased (Josten, Ng-A-Tham, & Thierry, 2003). Because of these shortages, not only has the nurses workday gradually increased over time but also workload. Nursing shortages have led to inadequate staffing and nurse-to-patient ratios (Driscoll et al., 2018). When one nurse cares for many patients, that nurses workload increases because he or she is attempting to deliver quality healthcare to many patients efficiently and effectively. 11 Trying to work efficiently when the nurse is pulled in too many directions with little staff support is not just physically draining but also mentally and emotionally taxing. Within the literature, Driscoll et al. (2018) cite that shortages of staff and increased nurse-to-patient ratios have led to higher patient mortality and patient care dissatisfaction. However, as nurse staffing increased, patient outcomes improved. Driscoll et al. (2018) recommended more research, but by increasing staffing, patients were 14% less likely to perish and were less likely to experience adverse events. While work hours and workload seem to contribute to nursing fatigue, literature also suggests that fatigue may be connected to the organizational climate the nurse is working in and may include policies enforced and/or adopted by the organization and the state in which the organization is located. Organizational climate includes the work environment and associated factors of social support from superiors and peers, role clarity, physical factors, and job pressures. Organizational climate and nurse well-being were analyzed by Dehring, von Treuer, and Redley (2018). They found that a negative work environment and related factors contributed to a decline in nurses emotional health and an increase in fatigue. If a nurse perceived little support from management and peers, had a low level of autonomy and had high levels of pressure in the workplace, mental workload rose which, in turn, increased feelings of fatigue. When a nurse felt little support from management or coworkers on the CCU, physical and mental demands increased and produced overwhelming feelings of fatigue (Dehring et al., 2018). Dehring et al. (2018) also found that job satisfaction was dependent on shift hours. In turn, the shift hours that are usual to an organization depend much on the culture of an organization as well as the policies informing its decisions. 12 While policy formulation has been on the radar of the American Academy of Nursing since 2017, consistent policy creation is still lacking across the United States. The American Academy of Nursing has three strategic goals, one of which includes, to position the academy and nursing profession to lead change and drive policy and practice to improve health and health care (2017-2020 Strategic Plan, n.d.). This statement seems to suggest that nurses drive policy to improve both patient and nurse health. Yet, currently, only 18 of 50 states in the United States prohibit mandatory overtime via policy (Ohio Nurses Association, 2018). Some studies have equated the lack of nurse-restoration reinforced by policy to near-crisis conditions (Nejati, Shelpley, & Rodiek, 2016). Lack of policy to protect nurses from incurring fatigue and eventual burnout is causing the field of nursing to suffer as a whole, especially as it reduces the interest of current nurses maintaining their practice and discourages others from going into nursing in the first place (Nejati, Shelpley, & Rodiek, 2016). In order to prevent a complete crisis within the field of nursing, proper intervention and protective policies have been suggested within the literature to reduce nursing fatigue and its impact on providers and patient well-being. Indeed, the literature suggests that work regulations limiting work-time can be effective measures in helping reduce fatigue. The policy seeks to achieve tailored, organizational goals. Overall, most organizational goals include providing high-quality care and serving as a partner to patients on their healthcare journey. Quality care in the healthcare industry includes delivering care that is compassionate, competent, and patient-centered. Nurses plagued by fatigue are unable to provide what their organizations promise. Some states have employed two methods to help reduce overwork and fatigue. The first of these methods encourage nurses to reject 13 mandatory overtime while the second method restricts consecutive shifts within a threshold of hours (Bae & Yoon, 2014). As this literature review demonstrates, fatigue is perpetuated by conditions involving work hours, workload, work environment, and policy regulations. Fatigue associated with these circumstances comes at a cost to patients, nurses, healthcare institutions, and taxpayers nationwide. It appears that while under the influence of fatigue, CC nurses may lose their keen sense of judgment and increase their likelihood to be negligent. Definitions To better understand the honors project and the context in which this honors project viewed concepts, fatigue, workload, work hours, and CC nurses must be defined. Fatigue, as defined by Smith-Miller, Shaw-Kokot, Curro, and Jones (2014), is a work-related condition that ranges from acute to chronic in nature and can produce an overwhelming sense of tiredness, decreased energy, and exhaustion resulting in impaired physical functioning, cognitive functioning, or both (p. 488). Thus, there are levels of fatigue, which include acute and chronic. Winwood, Winefield, Dawson, and Lushington (2005) summarize acute fatigue that is not recuperated between working shifts gives rise to chronic fatigue. Chronic fatigue is known to be more of an enduring trait (Winwood et al., 2005, p. 594). While acute fatigue may be treated with a period of rest, chronic fatigue persists even with rest. Burnout is a serious consequence of chronic fatigue and is defined as a sense of disconnectedness, depersonalization, and emotional depletion (Smith-Miller et al., 2014, p. 487). This honors project focused specifically on chronic fatigue in CC nurses. Workload, in this case, is understood as the mental and physical demands of work that are influenced by factors such as increased patient acuity and inadequate nurse-to-patient ratios. 14 Formally, workload is defined as, the amount of work or of working time expected or assigned (Merriam Webster, 2019). Typically, these demands in nursing place psychological and physiological strain on CC nurses that are unsustainable. Work hours are the amount of time an individual exerts himself or herself at the workplace. Both workload and work hours may be influenced by the nurse and patient turnover and nursing shortages. A CC nurse is a registered nurse who works in a CCU or ICU where most patients have life-threatening injuries or acute illnesses that require specialized skills and care. Many of these nurses have advanced CC certifications such as the Advanced Cardiac Life Support (ACLS) Certification (Critical Care, n.d.). Theory A theory provides a basis for current beliefs and practices. The same principles apply to research regarding nursing fatigue within CC nursing. Kate van Heugtens (2011) book, Social Work under Pressure: How to Overcome Stress, Fatigue, and Burnout in the Workplace, addresses that universal psychological and physiological dysfunction that exists in occupations that involve helping or human service careers, which in this case would be nursing. The Demand-Control-Support Model (1979) by Karasek and Theorell (Figure 1) explains why occupational stress and fatigue occurs and how the relationship of continuous stress and fatigue occur across most occupations. They synthesized that stress increases when workload, control, and necessary skill set also increase. This theory is very relevant to the demands and overall stress within the realm of CC nursing care and was used to frame this study. 15 Methods This study used a cross-sectional descriptive design with correlational aspects. Two electronic Likert-type surveys were distributed and available over a one-month period. This design enabled researchers to gather basic data related to demographics, the current state of Indiana CC nurse chronic fatigue, and factors related to chronic fatigue (i.e., workload, work hours, and policy attitudes). Groups could then be compared. Additionally, correlational aspects of the design were used to determine if the independent variables of workload, work hours, policy attitudes, years of practice, and age were associated statistically with the independent variable of total chronic fatigue scores. Sample and Setting Participants were from a convenience sample easily reached through social media and through an affiliation with the American Association of Critical Care Nurse (AACN). Research participants had to meet the inclusion criteria in order to contribute to the study. A participant had to: 1) possess a registered nurse license; 2) be working in Indiana; 3) be currently practicing as a CC nurse in an intensive care/critical care unit; 4) have access to the internet via computer, laptop, or cell phone; and 5) be able to read and understand English. Vulnerable populations were not sampled in this study. Researchers gathered demographic data of participants including gender, age range, and years of the practice range. Instruments The Custom Nursing Workload, Work Hours, and Policy Survey assessed the state of nurse workload, work hours, and attitudes related to the presence of restrictive work hour policies. The other survey that was used measured the level of chronic fatigue reported by 16 participants. Chronic fatigue was measured using a subscale of the Occupational Fatigue Exhaustion Recovery (OFER) scale (Figure 2), and workload, work hours, and policy attitudes were evaluated through the aforementioned customized Likert survey developed by researchers of this study. Both questionnaires were compared after participant completion in order to gain insight into the prevalence and extent of chronic fatigue in CC nurses practicing in Indiana as well as the involvement of age, years of practice, workload, work hours, and policy attitudes on chronic fatigue levels. Occupational Fatigue Exhaustion/Recovery Scale. The OFER scale was used to determine the chronic fatigue scores of participants. For this studys purpose, researchers used the OFER subscale that specifically measured chronic fatigue. The OFER scale was deemed reliable and internally consistent with an average Cronbachs alpha of .83 between the three subscales evaluating acute fatigue, chronic fatigue, and inter shift recovery. The closer the Cronbachs alpha value is to one, the more consistent and reliable the scale is (Winwood et al., 2005). A year later, creator, Peter Winwood re-tested his slightly amended OFER scale. This time, he revealed that the scale had been used in various populations, was gender-bias free, had a Cronbachs alpha value of 0.8, and had both face and discriminant validity (Winwood, Lushington, & Winefield, 2006). Custom Nursing Workload, Work Hours, and Policy Survey. The Custom Nursing Workload, Work Hours, and Policy Survey was eight questions in length and measured responses on a Likert-scale. Professionals in nursing education, as well as those involved with nursing professionals performing research themselves, were consulted for generating appropriate format and questions for the customized survey (Figure 3). Thus, the 17 authors survey is a non-validated tool developed from an analysis of research and professional guidance. Data Collection, Ethical Considerations, and Data Ownership IRB approval was sought and obtained from the University of Indianapolis. After receiving notification of this studys exempt status, the collection of data commenced. Procedures for collecting data included using Qualtrics online software to create the survey and to track and store participant data anonymously. Confirmation of consent and inclusion criteria questions were listed first, followed by demographic questions. Then the main survey questions were asked with the OFER subscale questions coming first followed by questions related to workload, work hours, and policy attitudes. Data collection occurred over a one-month period. Data collection began after the AACN posted the survey and a research description on its chapter website and social media pages. When the one-month window expired, the survey was closed via Qualtrics and removed from the AACN website and social media pages. Of note, electronic data gathered online through Qualtrics was password-protected, and the researchers were primary controllers of the data. Additionally, no personal identifiers were collected by researchers. Qualitrics software does not allow participants to take the survey more than once, prevents public access to the survey, and secures participant files so those with permission can view responses (Privacy statement, 2018). Data was stored on a password protected researcher computer, as well. Per request, researchers will share any significant results with the author and copyright owner of the OFER scale. The researchers are also the owners of the data acquired through this study. The author and copyright owner of a scale used in this study asked that any significant results be shared with 18 him. Researchers using Qualtrics are controllers of the data. Qualtrics software was a medium used to collect and store data. Data Analysis Once data collection ceased, data was exported from Qualitrics to Microsoft Excel where it was organized by category and incomplete surveys were voided. Researchers then created a codebook to label variables and to assist with data consistency and ease of future data interpretation. During this time, the scale of measurement for each variable was also determined. Cut-offs for data in the category of workload total scores were made apriori before true data analysis. For ease of interpretation, workload scores were divided into three subgroups of low workload (scores of 0-5), moderate workload (scores 6-10), and high workload (scores of 11-15). Chronic fatigue scores were calculated by dividing initial scores by 30 and then multiplying by 100. After the initial calculation, scores were divided into quartiles of low, low/moderate, high/moderate, and high per OFER scale author recommendations (Winwood, 2005). Once the process of data labeling and organization was complete, the Microsoft Excel spreadsheets were then exported to the Statistical Package for Social Sciences (SPSS), a program created by the International Business Machines Company (IBM). SPSS was used to organize data further as well as run descriptive and statistical tests. To satisfy the honors project aims, researchers processed descriptive data initially. Then correlational tests were performed along with tests to determine group differences. Descriptive data uncovered frequencies and measures of central tendency, which included means, medians, and standard deviations. Descriptive data were used to better capture the spread of data related to CC nurse age, years of practice, and chronic fatigue total scores. 19 After descriptive statistical tests were completed, researchers performed tests of normality for multiple variables. The variables of age, years of practice, total chronic fatigue scores, workload total, and work hour data consisting of those participating in 12-hour workdays and/or working more than 72 hours in two weeks were evaluated for normality using the Shapiro Wilk statistical test. Normality tests establish the distribution of data and, along with the scale of measurement, helped to determine whether to use parametric or nonparametric tests later. Correlation, or the strength of associations between variables, was determined using the nonparametric Spearmans Rank-Order Correlation (rho) statistical test (McDonald, 2014). Correlations between the dependent variable, total chronic fatigue scores, and independent variables such as age, years of practice, workload total scores, work hour data (i.e., working 12hour shifts or less and working 72-hours in a two-week period or more), and attitude toward restrictive work hour policies were performed. Researchers also evaluated differences between independent variable groups and total chronic fatigue scores. When normal distribution assumptions were not met, researchers used the nonparametric Kruskal-Wallis statistical test (McDonald, 2014). The Kruskal-Wallis statistical test calculated if there were differences in total chronic fatigue scores between groups related to policy attitude, total workload scores, and 12-hour shifts. When the distribution was normal, as, in the case of the 72-hour work hour data, the One-Way ANOVA statistical test was used to determine if there was a significant difference between total chronic fatigue scores and those that worked more than 72-hours in two weeks and those that worked less than 72-hours in two weeks (Table 1). While post-hoc testing was planned to be run in order to determine exactly where 20 difference existed between groups and total chronic fatigue scores, these tests were not necessary to complete due to initial test results. Results This honors project aimed to 1) discover the prevalence of nurse chronic fatigue within the CC nurse population in Indiana; 2) explore the relationships between chronic nursing fatigue, workload, and work hours; and 3) explore attitudes toward regulatory work policies and if they correlate with chronic fatigue levels. A total of 88 CC nurses met inclusion criteria, completed the entire survey, and were included in this honors project study. Forty-five participants were aged 20-30 years, 20 participants were aged 31-40 years, and 23 participants were aged 41-60+ years (Figure 4). Of the 88 CC nurses surveyed, 48 (55.2%) reported having 0-5 years of nursing practice experience, 13 (14.8%) reported having 6-10 years, 15 (17.2%) reported having 11-20 years, and 11 (12.6%) reported having 21-30+ years of CC nursing experience. Females dominated the large majority of subjects (n= 77). While there was no significant difference between total fatigue scores and age groups and total fatigue scores and years practiced, the 41-60+ age group had the highest mean chronic fatigue total score (66.22 [19.6]), which was 10.7 points higher than the mean chronic fatigue total score of the youngest age group surveyed (20-30-years-olds). Additionally, those who had practiced the longest (21-30+ years) had higher mean chronic fatigue total scores (61.27 [22.9]) than those who had practiced 0-5 years, 6-10 years, and 11-20 years, respectively. In order to gain a better understanding of the prevalence of chronic fatigue in CC nurses in the state of Indiana, frequencies of total chronic fatigue scores were calculated (Figure 6). 21 Seven (8%) CC nurses surveyed reported low levels of chronic fatigue, 26 (29.5%) reported low/moderate chronic fatigue, 30 (34.1%) reported moderate/high scores, and 25 (28.4%) of those studied reported high chronic fatigue levels. Overall, 62.5% of nurses noted that they experienced moderate/high to high levels of chronic fatigue. Specifically, of the five questions of the OFER chronic fatigue subscale, the question that had the highest mean score was, I wonder how much longer I can keep going at my work, with a mean of 3.81 (1.74) (Table 2). The association and relationships between CC nursing chronic fatigue total scores and workload total scores and work hours were also explored. Total workload scores ranged from 013 on a 15-point scale. The mean workload score was 7.62, indicating a moderate level of workload. Specifically, 11.4% of the sample had a low workload, 83% had a moderate workload, and 5.7% had a high workload. There was no strong correlation between chronic fatigue total scores and total workload scores (r=0.087) (Table 4), and there was no significant difference between workload groups and chronic fatigue total scores (p= 0.405). Most CC nurses in the study reported working 12-hour shifts (93.2%) (Figure 5) while 63.6% indicated working overtime (over 72-hours in two weeks time) in the weeks proximate to survey participation. Weak correlations were yielded between total chronic fatigue scores and queries about 12-hour workdays (r = -0.027) and working an excess of 72-hours in two weeks (r = 0.150) (Table 4). Testing between CC nurse chronic fatigue total scores and those that worked 12-hour shifts versus less than 12-hour shifts resulted in no statistically significant differences between groups (p = 0.753). Lastly, there was no significant difference in chronic fatigue total scores between groups who indicated working more than 72-hours in two weeks and those working less than 72hours in two weeks (p = 0.122). 22 CC nurse attitudes toward regulatory work hour policies and if their answers correlated with chronic fatigue total scores were the last pieces of data analyzed. Policy responses consisted of yes, no, and unsure when asked to evaluate if work hours should be restricted at their facility/hospital. A total of 43.2% of nurses were unsure, 34.1% did not think that work hours should be restricted, and 22.7% thought that their place of work should restrict work hours. Of all correlations run in this study, chronic fatigue scores and policy attitudes has the strongest correlation (Table 4), albeit still weak (r = 0.195). Discussion While many findings of this honors project were not significant, findings do suggest that the majority of CC nurses in Indiana have moderate levels of chronic fatigue and that older aged nurses as well as nurses who have been practicing longer have higher levels of chronic fatigue overall. Additionally, most CC nurses surveyed reported moderate workload levels, working excessive hours, and being unsure about their attitude toward the need for regulatory work hour policies. While it is not surprising that females dominated the studys sample, the fact that few men took the survey does limit the generalizability of results. However, this data is comparable to the 14.2:1 ratio of female to male nurses in Indiana (The Kaiser Family Foundation and Beckers Hospital Review (Rappleye, 2015)). The National Workforce Study for Nursing analyzed nursing data related to age distribution across the profession of nursing. While the results of the 2020 study have not resulted, research data from 2013, 2015, and 2017 is available (Figure 7). While the National Workforce Study showed a majority of the workforce comprised of older nurses, aged 55 years and older, the amount of younger nurses aged 18 to 34-years-old 23 has increased from 2013 to 2017 (National Council of State Boards of Nursing, n.d.). The growth of younger registered nurses, as a whole, correlates with this studys participants being largely nurses ages 20-30-years-old. Interestingly, most of the sample had only practiced CC nursing for 0-5 years. While the studys demographic findings and chronic fatigue total scores support the idea that chronic fatigue is likely to increase as both age and experience increase, it is concerning that, cumulatively, all the CC nurses surveyed, even younger and less experienced nurses, reported moderate fatigue levels. It appears that chronic fatigue, which is an evolution of acute fatigue, is a condition that develops early in CC nursing careers. While workload total scores and chronic fatigue total scores did not strongly correlate and there was no significant difference found between groups, results still showed a moderate level of workload reported among CC nurse participants. There were some interesting findings related to specific questions on the OFER chronic fatigue subscale that seem to have workload implications. The three chronic fatigue questions and corresponding means of the most agreedupon questions across participants were those pertaining to the statements: I often wonder how long I can keep going at my work (3.81); Too much is expected of me at my work (3.74); and I often feel at the end of my rope with my work (3.70). The means and agreeance across these survey items reflect that nurses are becoming exhausted with their work and struggle to meet overwhelming expectations. The high occurrence of agreement with these points is key markers in the development of chronic fatigue. Winwood et al. (2005) state that chronic fatigue is, accompanied by negative emotions. It thus has many characteristics in common with clinical depression. Such fatigue is not relieved by simple rest or task moderation (p. 2). It was also noted by Winwood et al. (2005) that solutions to overcome chronic fatigue are largely unknown. 24 Perhaps the issue of chronic fatigue is a more complex issue. Strong agreeance with these three questions is worrisome and seems to suggest that solutions will need to cater not only to age and years of experience but also to address more mind and spirit as well as body needs. Solutions should also focus on factors that are modifiable within the work environment, such as workload. The lack of significant differences between chronic fatigue total scores and those working 12-hour shifts and those who do not was expected because most CC nurses in the sample worked 12-hour shifts (n= 82) (Table 3). This data aligns with both Bae and Yoons (2014) study on the negative outcomes nurses, healthcare systems, and patients experienced when nurses work extended hours. Because nurses often work 12-hour days, they have less time for recovery and are more at risk for fatigue, poor sleep quality, impaired vigilance, and lack of alertness (Bae & Yoon, 2014). Future studies should take this information into consideration and be purposeful about sampling groups that specifically work 12-hours and those who do not. Similarly, a large portion of participants worked more than 72-hours in a two-week period prior to taking the survey (n=56). A weak correlation between chronic fatigue scores and working 12-hour days was noted (r= 0.33); however, this correlation between variables was stronger than the correlation between the variable about work more than 72-hours in the two-week period before survey participation and chronic fatigue (r= 0.160). Since a majority of nurses work 36-hour workweeks, working over 72-hours would be overtime. Bae and Yoon (2014) also say that working overtime is also positively associated with adverse patient outcomes such as catheterassociated urinary tract infections, decubitus ulcers, and medical errors, as well as, patient mortality and dissatisfaction (p. 1639). Future studies should take overtime into consideration 25 and explore whether the number of overtime hours worked holds any significance in relation to chronic fatigue levels. Most surprisingly, a majority of participants were unsure about whether they thought there was a need to have work-hour regulatory policies in their workplace. This specific finding created more questions for researchers such as: Do CC nurses know what policies are actually in place at their institution or at the state level? Little to no policy regulations related to workload and work hours have been noted throughout the research. However, Occupational Safety and Health Association (OSHA) recommends that employers alter environments, educate employees, and train employees on signs of fatigue in the workplace (United States Department of Labor, n.d.). Despite these recommendations, fatigue still persists in nursing. While studies related to policy regulations reducing work hours and fatigue are limited, policies and concrete restrictions could be a viable solution to monitor the number of hours worked consecutively as well as overtime, thereby reducing fatigue levels and eventual burnout. Indeed, unlike the acuity of patients who CC nurses care for, the organizations cultural environment and the adoption of certain policies may be controlled. More research still needs to be done on this topic, and more specific questions regarding the policy should be explored to better understand CC nurse knowledge and attitudes toward policy employment as well as the feasibility of certain restrictions. Data from this study suggests a knowledge deficit within the CC nursing population in Indiana related to work hour regulations. Participants may not be aware that other states have policies restricting work hours/mandatory overtime. 26 Conclusion Chronic nursing fatigue is a hazard to patients and nurses alike and may have deadly outcomes. As the general population ages along with the baby boomer generation, societys reliance on the healthcare system and those who provide healthcare are increasing; the demand may lead to nurses working longer and harder. Through this honors project study, researchers were able to delve into the issue of chronic fatigue within the CC nursing population in the state of Indiana. There is an alarmingly large occurrence of upward trending chronic fatigue among registered nurses surveyed. Researchers were able to note the prevalence of chronic nurse fatigue, analyze workload and work hours in relation to chronic fatigue total scores, and investigate some registered nurse regulatory policy attitudes. Exploring these topics highlighted CC nursing chronic fatigue and specifically provided more information related to the number of CC nurses who have developed a moderate level of chronic fatigue early in their careers as well as reinforced the idea that age and years of practice may be a factor in chronic fatigue development. Additionally, this study provided more information related to work hours and to workload questions that received the highest agreeance. It also uncovered the need for CC nurses to be better educated about policies that could potentially increase the health and well-being of nurses and patients alike. With additional research in the future, hopefully, more tailored interventions that reflect the multifaceted demands of nursing may be created and tested. These interventions would ideally allow nursing fatigue, in general, to be alleviated, working conditions to be improved, and both patient and nurse outcomes to be enhanced. 27 The research completed for this honors project has helped to fill knowledge gaps and has provided a further exploration of the presence and degree of the relationship between workload, work hours, and fatigue specifically in the Indiana CC nursing population. This research took a novel approach as it asked CC nurses about their attitude toward work-hour policy presence and sought to compare this with chronic fatigue levels. Additionally, a broader definition of fatigue was used rather than the narrower concepts of alarm fatigue and compassion fatigue. Ultimately, the research performed for this honors project in conjunction with other research studies may help healthcare leaders in the future to develop purposeful, customized strategies to decrease and to manage fatigue presence in CC nurses, especially in Indiana. Reflection and Future Directions Researchers did meet the projects goals outlined in the proposal submitted to the review committee; however, weaknesses were presently related to survey development and the sample captured. The shortcomings of this research and lack of significant findings could be avoided in future research with larger, broader sample size and that used other sampling techniques besides convenience. This research also only studied critical care nurses in the state of Indiana; therefore, results may not be generalizable to the population. More significant results may have been achieved using the validated OFER scale in its entirety and not just its subscale measuring chronic fatigue. Furthermore, the custom survey created by researchers to examine workload, work hours, and policy attitudes was not validated, and cut-off points for score ranges were more arbitrary in nature. Finally, the exclusion of outliers in data could promote stronger results using additional statistical tests. 28 Personally, this research really tested researcher perseverance, time management, and adaptation. With a future in the field of nursing, these characteristics are essential to developing. This research opportunity made possible through the Honors College allowed the improvement of my critical thinking skills that emerged from performing the research process, and specifically the data analysis and interpretation of research findings sections. After graduation, the primary student researcher plans to work in an Indiana hospital ICU and is excited to apply what has been learned to support a healthier self, healthier nurses, and ultimately a healthier patient population. 29 References 2017-2020 Strategic Plan. (n.d.). American Academy of Nursing. Retrieved from https://www.aannet.org/about/strategic-plan-2017-20 Antnez, J., Ariza-Montes, A., Fernndez-Navarro, F., & Molina-Snchez, H. (2018). Effect of a job demand-control-social support model on accounting professionals health perception. International Journal of Environmental Research and Public Health, 15(11), 2437. doi:10.3390/ijerph15112437 Bae, S. & Fabry, D. (2013). Assessing the relationship between nurse work hours/overtime and nurse and patient outcomes: Systematic literature review. Nursing Outlook, 62(2), 138156. doi: 0.1016/j.outlook.2013.10.009 Bae, S. & Yoon, J. (2014). Impact of states nurse work hour regulations on overtime practices and work hours among registered nurses. Health Services Research, 49(5), 1638-1658. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4213053/ Chuang, C.H., Tseng, P., Chen, Y. (2016). Burnout in the intensive care unit professionals. Medicine- Wolters Kluwer Health, 95(50), 1-22. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5268051/pdf/md-95-e5629.pdf Critical Care. (n.d.). Retrieved from https://medlineplus.gov/criticalcare.html Dehring, T., von Treuer, K., & Redley, B. (2018). The impact of shift work and organisational climate on nurse health: a cross-sectional study. BMC Health Services Research, 18(1), N.PAG. https://doi.org/10.1186/s12913-018-3402-5 Del Pozo-Antnez, J., Ariza-Montes, A., Fernndez-Navarro, F., & Molina-Snchez, H. (2018). Effect of a job demand-control-social support model on accounting professionals health 30 perception. International Journal of Environmental Research and Public Health, 15(11), 2437. doi:10.3390/ijerph15112437 Driscoll, A., Grant, M.J., Carroll, D., Dalton, S., Deaton, C., Jones, I., Astin, F. (2018). The effect of nurse-to-patient ratios on nurse-sensitive patient outcomes in acute specialist units: a systematic review and meta-analysis. European Journal of Cardiovascular Nursing. 17(1) 622. https://doi.org/10.1177/1474515117721561 Fatigue. (2019). In Merriam-Webster.com. Retrieved from https://www.merriamwebster.com/dictionary/fatigue Hooper, C., Craig, J., Janvrin, D.R., Wetsel, M.A., & Reimels, E. (2010). Compassion satisfaction, burnout, and compassion fatigue among emergency nurses compared with nurses in other selected inpatient specialties. Journal of Emergency Nursing. 36(5), 4207. doi:10.1016/j.jen.2009.11.027 Josten E., Ng-A-Tham, J., & Thierry, H. (2003). The effects of extended workdays on fatigue, health performance and satisfaction in nursing. Journal of Advanced Nursing, 44(6), 64352. https://doi.org/10.1046/j.0309-2402.2003.02854.x Kinnan, J.P. (2006). Sentinel events. The Hospitalist. https://www.thehospitalist.org/hospitalist/article/123211/sentinel-events Knupp, A. M., Patterson, E. S., Ford, J. L., Zurmehly, J. & Patrick, T. (2018). Associations Among Nurse Fatigue, Individual Nurse Factors, and Aspects of the Nursing Practice Environment. JONA: The Journal of Nursing Administration, 48(12), 642648. doi:10.1097/NNA.0000000000000693 31 McDonald, J.H. (2014). Handbook of Biological Statistics [eBook edition]. Sparky House Publishing, Baltimore, Maryland. http://www.biostathandbook.com/index.html National Council of State Boards of Nursing. (n.d.). National nursing workforce study. Retrieved from https://www.ncsbn.org/workforce.htm Nejati, A., Shepley, M., & Rodiek, S. (2016). A review of design and policy interventions to promote nurses restorative breaks in health care workplaces. American Association of Occupational Health Nurses, 64(2), 70-7. doi: 10.1177/2165079915612097 Ohio Nurses Association. (2018). House bill 456/prohibit mandatory overtime passes house. Retrieved from http://ohnurses.org/house-bill-456-prohibit-mandatory-overtime-passeshouse/ Privacy statement. (2018). Retrieved from https://www.qualtrics.com/privacy-statement/ Rappleye, E. (2015). Gender ratio of nurses across 50 states. Beckers Hospital Review. https://www.beckershospitalreview.com/human-resources/gender-ratio-of-nurses-across50-states.html Sholtz, S., Nel, E., Poggenpoel, M., & Myburgh, C. (2016). The culture of nurses in a critical care unit. Global Qualitative Nursing Research, 3. 3-11. doi:10.1177/2333393615625996 Smith-Miller, C.A., Shaw-Kokot, J., Jones, C.B., & Curro, B. (2014). An integrative review: Fatigue among nurses in acute care settings. The Journal of Nursing Administration, 44, 487-494. doi:10.1097/NNA.0000000000000104 van Heugten, K. (2011). Social Work under Pressure: How to Overcome Stress, Fatigue and Burnout in the Workplace, 25(2), 145-146. doi:10.1080/09503153.2013.780751 32 Winwwod, P.C. (2005). Manual for the occupational fatigue, exhaustion recovery scale (OFER). Unpublished manuscript. Winwood, P. C., Winefield, A. H., Dawson, D., & Lushington, K. (2005). Development and validation of a scale to measure work-related fatigue and recovery: The Occupational Fatigue Exhaustion/Recovery Scale (OFER). Journal of Occupational and Environmental Medicine, 47(6), 594606. Retrieved from https://ezproxy.uindy.edu/login?url=http://search.ebscohost.com/login.aspx?direct=true& db=mnh&AN=15951720&site=ehost-live Workload. (2019). In Merriam Webster.com. Retrieved from https://www.merriamwebster.com/dictionary/workload 33 Tables and Figures Table 1 Differences between Chronic Fatigue Total Scores and 72-Hour Work Groups Sum of Squares df Mean Square F Sig. Between Groups 2455.542 3 818.514 1.986 .122 Within Groups 34527.174 84 412.228 Total 37082.716 87 Table 2 Chronic Fatigue Frequencies and Mean Data by Question OFER (Chronic) Question 1 OFER (Chronic) Question 2 OFER (Chronic) Question 3 OFER (Chronic) Question 4 OFER (Chronic) Question 5 Frequency 88 88 88 88 88 Mean 3.70 3.20 3.81 3.25 3.74 SD 1.440 1.710 1.741 1.656 1.657 34 Table 3 Differences between Chronic Fatigue Total Scores and 12-Hour Work Groups N Mean Rank Disagree/Strongly Disagree 6 55.25 Agree/ Strongly Agree 82 42.09 Total 88 Kruskal Wallis H df Asymp. Sig 0.567 2 0.753 Table 4 Correlation Coefficient (r) Calculated between Chronic Fatigue Total Scores and Independent Variables Chronic Fatigue Total Score (n=88) Age (n=88) Years of Practice (n=88) Workload Total (n=88) 12-hours (n=88) 72-hours (n=88) Policy (n=88) 0.193 0.078 0.087 -0.027 0.150 0.195 35 Figure 1. Karaseks Demand-Control Support Model Del Pozo-Antnez, Ariza-Montes, Fernndez-Navarro, and Molina-Snchez (2018) Figure 2. OFER scale by Dr. Peter Winwood Winwood et al. (2005) 36 Workload Strongly Disagree Disagree Agree Strongly Agree Strongly Disagree Disagree Agree Strongly Agree No Unsure Yes (1) The patients I care for require three or more pieces of equipment to manage. (i.e., lines, ventilation/ oxygenation devices, dialysis machines, etc.) (2) I typically care for more than two patients at a time per shift. (3) My superiors (charge nurse/manager/CNO) provide needed support, education, and guidance to enable sufficient patient care. (4) When multiple team members are involved in patient care, coordinating care and decision-making is more challenging than it should be. (5) The unit is usually staffed sufficiently when I work. Work Hours (6) I have worked more than 72 hours in the last 2 weeks. (7) I mostly work 12-hour shifts. Policy (8) Work hours should be restricted at my facility/hospital. Figure 3. Custom Nursing Workload, Work Hours, and Policy Survey 37 Figure 4. Participant age frequencies Figure 5. Frequency of 12-hour shifts 38 Figure 6. Chronic fatigue score frequencies Figure 7. Nurse age distribution from the NCSBN National Workforce Study National Council of State Boards of Nursing. (n.d.) 39 Appendices Appendix A Appendix B 40 Appendix C  ...

... High School Creative Nonfiction Writing Workshop By Shauna Sartoris Honors Project Thesis Submitted in Partial Fulfillment Of the Requirements for a Baccalaureate Degree With Distinction In the Ron and Laura Strain Honors College of THE UNIVERSITY OF INDIANAPOLIS December 2019 Faculty Advisor: Professor Barney Haney, MFA Executive Director of Honors: James B. Williams, Ph.D. Shauna Sartoris 2019. Copyright in this work rests solely with the author. Please ensure that any reproduction or re-use is done in accordance with relevant national copyright protection. i Project Abstract The purpose of my honors project was to engage adolescents with the under-taught genre of creative nonfiction while also teaching them the value of representing minority voices (or counternarratives) in the world today. I accomplished this by hosting a creative nonfiction writing workshop series for adolescent students in Indianapolis. My curriculum challenged them to write and revise their own personal stories using familiar narrative techniques, as well as new ones, to structure their creative work. These young writers were asked to consider their own experiences and how to share them through the written word, and were encouraged to do so in the voice, language, dialect, and tone that felt most comfortable to them. In the process, we explored how counternarratives can shape a readers perspective on real-life issues. In these conversations, I aimed to boost the students confidence in both the value of their own stories and in their storytelling capabilities. The students engaged with the material presented and ultimately expressed a desire to independently continue learning about the genre presented. ii Table of Contents Acknowledgements .......................................................................................................iii List of Figures ............................................................................................................... iv Project Development and Background Research ...................................................... 1-7 Introduction ................................................................................................................. 1 Literature Review ........................................................................................................ 2 Project Narrative and Products Produced ................................................................ 8-9 Product Narrative Summary......................................................................................... 8 Products Produced Summary ....................................................................................... 8 Project Analysis and Reflection ............................................................................. 10-15 Conclusion .............................................................................................................. 16-17 Works Cited ............................................................................................................ 18-19 Appendices ...............................................................................................................20-48 Appendix A: Annotated Bibliography ........................................................................ 20 Appendix B: Observation Letter by Professor Barney Haney ..................................... 30 Appendix C: Checklist of Tasks for Preparation ....................................................... 35 Appendix D: Post-Workshop Journal Entry (Workshop 1) ........................................ 36 Appendix E: Post-Workshop Journal Entry (Workshop 2) ........................................ 38 Appendix F: Post-Workshop Journal Entry (Revisiting Entries 1 and 2) .................... 40 Appendix G: Participant Surveys (Workshop 1)......................................................... 41 Appendix H: Participant Surveys (Workshop 2)......................................................... 45 Appendix I: Observer Surveys ................................................................................... 47 iii Acknowledgements Special thanks to the Warren Branch of the Indianapolis Public Library for providing me with an event space to host these workshops. Thanks to Susan Davis, program director at the Indianapolis Public Library, for helping to schedule this event, and to Shannon ODonnell and Bambi Pea for their organizational assistance on the day of the events. Additional thanks to Professor Barney Haney for his continued support throughout the development, implementation, and analysis of this workshop. iv List of Figures Figure 1: This advertisement flyer for both workshops was distributed to the Indianapolis Public Library, the Indiana Writers Center, and several high schools around Indianapolis. The design of the flyer was intended to be both informative and engaging, with bright colors and a tagline that emphasized the participants stories being told. Figure 2: This figure is taken from Student As workshop two participant survey. It demonstrates her increased level of interest in the genre of creative nonfiction. Her primary genre, she indicated during our workshops, was fiction. Figure 3: This PowerPoint slide accompanied a discussion about how to structure a creative nonfiction essay. Student B expressed heightened interest in the subject after this discussion. Figure 4: This figure is taken from Student Bs workshop one participant survey. Student B appeared nervous to engage in group conversation during the workshop and hesitated to share his work or speak up about the writing exercises. Despite this, he expressed in his participant survey that he felt that his voice had been heard, and noted that everyone was listening to him for the first time. 1 Project Development and Background Research Introduction The youth of America today face political, racial, and economic crises that are not easily solved. These issues represent a complex web of social dynamics that adolescents are tasked with understanding and addressing. Storytelling can help. The value of storytelling is in its power to shape perspectives, lead raw fights for justice, pave the way for cultural understandings, and pursue unity in an atmosphere of distrust. Our greatest American influencersMartin Luther King Jr., Thomas Paine, Abraham Lincoln, James Baldwin, Marsha P. Johnson, Maya Angelou, Harvey Milk, W.E.B. Du Bois, Oprah Winfrey, and many othersunderstood the importance of intentional storytelling, using speech and the written word to produce long-lasting positive change in society. The purpose of my service project was to engage high-school adolescents with the under-represented genre of creative nonfiction, and in so doing, encourage them to understand the value of storytelling. I accomplished this goal by hosting a two-day creative nonfiction writing workshop series at the Warren Branch of the Indianapolis Public Library. My curriculum challenged participants to write and revise their own personal stories using familiar narrative techniques, as well as new ones, to structure their creative work. These young writers were asked to consider their own experiences and how to share them through the written word, and were encouraged to do so in the voice, language, dialect, and tone that felt most comfortable to them. Additionally, my workshop addressed the ways that dominant ideologies have historically repressed counternarratives, a term that refers to the misrepresented or 2 marginalized experiences of a minority group who lack the autonomy or power to tell their own stories. Participants were given the chance to explore their own counternarratives by considering, and writing about, their identifiers, such as their race, ethnicity, and gender. This exploration was encouraged with diverse video and essay examples, and by actively engaging in conversations about how these identifiers shaped the lives of the participants. By highlighting the importance of counternarratives, and by encouraging the young writers in attendance to engage with them, I aimed to empower their exploration of storytelling itself, including its historic and modern importance. At the same time, the participants gained practice in literacy outside of the classroom in a way that taught them the value of the written word. This service project did not assess any one method of teaching or learning. It did, however, benefit both teacher and student, and the reflections and surveys produced throughout these workshops have allowed me to analyze my curriculum and teaching for successes and failures. In doing so, I have sought answers to two important questions: Why this outcome? and What comes next? Literature Review In order to lead a successful workshop, I first had to have an understanding of my participants needs, the subject matter I was teaching, and the barriers that existed in my field. My research spanned each of these topics and was the framework from which I developed the curriculum and the learning atmosphere for my creative nonfiction workshop. 3 A service project such as mine often begins with a need, and by extension, a target population. My target population was high-school students living in the Indianapolis area and attending either private or public schools. Demographic research by STATS Indiana, the main source for demographic data in the state, provides valuable information for understanding the racial demograaphics of Marion County, where my workshops was held. According to this source, the percentage of white residents in this area is higher than that of any other race, representing approximately sixty-four percent of the community, with the black population representing twenty-eight percent of the community. The Hispanic population represents ten percent of the community (Marion County, Indiana). Although this data did not account for additional identification factorssuch as gender, sexuality, physical ability, or religious affiliationsI was still able to prepare for a range of possible participants based on the information I gained in my demographic research. To add to my demographic research, I read several sources on how to effectively teach adolescents. My primary source on this topic was Nancie Atwells book In the Middle. Though the first edition was published in 1987 (and the second edition, which I worked from, was published only slightly later, in 1998), this guide to teaching adolescents is still well-regarded by educators and is widely taught in the field of adolescent education (Nancie Atwell). At the forefront of Atwells teaching method is her emphasis on partnering with students individually and encouraging them to engage with classroom material by relating it to their own experiences (12-15). She also speaks to the value of participating in writing activities alongside her students as a form of motivation and collaboration (3-23). The effectiveness of these methods has been echoed by other voices as well, including renowned journalist and professor Donald M. Murray, whose approach 4 to teaching emphasizes listening above talking. In his essay The Listening Eye: Reflections on the Writing Conference, Murray asserts that he rarely teaches in the traditional sense of the word, but rather engages his students in questions about their work so as to make them more aware of their own process and needs (100-101). Where Murrays essay falls short is in relating his methods to younger age groups, such as the adolescents I engaged with. The book Rethinking the Adolescent in Adolescent Literacy by Sarigianides, Petrone, and Lewis, fills in these gaps. The first chapter in this source challenges the way that adolescent students have traditionally been taught by suggesting that teachers have largely been ignorant of adolescents needs as well as their potential (23). The authors of this text reinforce Murray and Atwells methods by claiming the importance of dialogue in an adolescent classroom. They argue against seeing adolescents as misguided, disinterested, and rebellious; instead, they suggest that educators ought to treat them as independent thinkers, passionate spokespeople, and capable learners (6-7). Each of these sources gave me a more focused understanding of what my target population would need, as well as how I could meet those needs by engaging with their learning while also allowing them to make their own independent choices in the process of writing and revising. This mindset made me more familiar and comfortable with being adaptable in teaching, which proved valuable in my workshop. My exploration of the genre of creative nonfiction also played a key role in how I taught this genre to my participants. Because of this, I find it worthwhile to discuss a few of the instructional sources that I referenced when building my curriculum. My primary authority on creative nonfiction was Lee Gutkind, who was labled the Godfather behind creative nonfiction in a 1997 Vanity Fair article by James Wolcott. Gutkinds book You 5 Cant Make this Stuff Up is an instructional guide that outlines the genre and provides suggestions for how to write and revise a creative nonfiction essay. Gutkind covers a range of topics, including the ethical considerations of the genre (14-43), the how tos of writing an engaging story (55-68), and the benefits of writing habitually (44-54). Gutkind also devotes a large portion of his book to the revision process, with topics like knowing what to cut (135-182), smoothing out inconsistencies (124-134), and making your story airtight and readable (183-217). Other sources serve similar functions, such as Tim Bascoms Picturing the Personal Essay: A Visual Guide, which draws attention to the form of the essay. But Gutkinds book offers the most thorough and expansive consideration of the genre. It has served as a guide to my own study of creative nonfiction and also served as scaffolding for my workshop curriculum. The majority of my research was focused on being aware of potential social barriers in the field of writing, namely the whitewashing of education that discourages both improper grammar, bilingual texts, and the writing of counternarratives. In the last decade or two, many scholars have written essays and books challenging the assumption that standard American English is a necessary and attainable standard for all young writers. These authors, such as Sarah W. Beck, H. Bernard Hall, Allison Skerrett, and Randy Bomer, claim that what academia considers conventional grammar is, in reality, far from the conventions of many multicultural or multilingual students. Beck highlights the way that this disconnect has historically silenced counternarratives by stifling multicultural or multilingual students sense of competency regarding writing (264). Hall demonstrates this idea through the genre of hip-hop and its lack of acceptance in the classroom, claiming that this rejection is a microcosm of the nations challenges to manifest its rhetoric of 6 multiculturalism, diversity, and inclusion (348). Similarly, Allison and Bomer write about the importance of encouraging students bilingual experiences in the classroom (334). These authors reaffirm a rising concern of multilingual repression in schools. To counter this repression, I encouraged my participants to write using language that is familiar to them, and I used a bilingual essay as well as a slang essay example in workshop two to emphasize this point. The choice to use these examples represented an attempt to counter the cultures narrative of conventional rhetoric in essay writing. As Beck claims, issues of rejecting literacy are often linked to a similar rejection of counternarrativesthat is, stories written by a minority and reflecting that minoritys experiences (264). A Social Justice Approach as a Base for Teaching Writing by Chapman, Hobbel, and Alvarado advocates for teachers practicing a form of social justice education within their classrooms (539-541). This approach, according to the authors, would affirm the students multicultural identities, improve their response to academic criticism, challenge stereotypes and discrimination, and otherwise foster a more positive learning environment (539). Although the phrase social justice education is unique to this article, the concept can be found in other sources as well, including Kinloch, Burkhard, and Penns article When School is Not Enough: Understanding the Lives and Literacies of Black Youth. Each of these sources addresses the history of literacy in America and how it has beenand continues to beshaped by expectations that disadvantage minorities. The knowledge of these issues culminated as a checkpoint for my own biases when I entered my workshop, and drove my decisions about the workshop curriculum, the type of feedback I provided, and how I addressed the language that came up in the writing process. 7 My research on how to teach adolescent creative writers, how to engage with the creative nonfiction genre, and how to challenge generations of whitewashing in the field, was thorough. As a result of these studies I became far more informed about the issues at hand and far more prepared to lead my own creative nonfiction workshop that addressed them. (See Appendix A for a full annotated bibliography of these sources.) 8 Project Narrative and Products Produced Project Narrative Summary I conducted two workshops at the Warren Branch of the Indianapolis Public Library. The first took place on Saturday, September 7, and the second took place one week later, on Saturday, September 14. Both workshops lasted from 1pm to 4pm. I had two total participants. The first (Student A) was a young Argentinian-American girl who attended both workshops and was eager to engage both weeks. The second (Student B) was a young African-American boy who arrived partway through the first workshop and did not return for the second. Despite liking to write poetry, he was uneasy in the workshop. Products Produced Summary Over the course of these workshops, I gathered surveys from participants and observers, wrote a narrative account of each workshop, and completed a preparation checklist for each event. Additionally, my project advisor wrote an observation letter detailing both workshops. Each of these products is summarized below and appears, in full, in the Appendices. Observation Letter by Professor Barney Haney: My project advisor, Professor Barney Haney, attended both workshops. His observation letter presents an account of each workshop, including the activities that I led, an analysis of how the students engaged with the material, and a summary of the workshops successes and opportunities for improvement. (See Appendix B for Observation Letter by Professor Barney Haney.) 9 Checklists of Tasks for Preparation (Workshops 1 and 2): Prior to each workshop, I evaluated my preparedness by completing a checklist of tasks. These checklists are presented as evidence of my preparedness. (See Appendix C for Checklist of Tasks for Preparation.) Post-Workshop Journal Entries (Workshops 1 and 2): Following each workshop, I completed a journal entry analyzing the events of the day. This allowed me to reflect on what worked well, what fell flat, how participants did or did not engage, how I felt as the organizer, and how I could improve. I also wrote a final analysis revisiting both journal entries. (See Appendices D-F for all Post-Workshop Journal Entries.) Participant Surveys (Workshops 1 and 2): Following each workshop, I distributed a survey to each participant. These surveys were designed to give me feedback on how well I marketed, organized, and led these workshops. The workshop one survey also asked participants to make suggestions for what they still wanted to learn, which helped me prepare for workshop two and adjust my curriculum to meet my participants needs. (See Appendices G-H for all Participant Surveys.) Observer Survey: In addition to surveying my participants, I also surveyed two additional observers, both of whom are librarians at the Warren Library where the workshop was held. (See Appendix I for all Observer Surveys.) 10 Project Analysis and Reflection I had only two participants over the course of the two days as opposed to the 10-15 participants that I had planned for, but by adopting a more individualized approach, I was still able to successfully engage this smaller group in both the genre of creative nonfiction and the topic of counternarratives. Figure 1. This advertisement flyer for both workshops was distributed to the Indianapolis Public Library, the Indiana Writers Center, and several high schools around Indianapolis. The design of the flyer was intended to be both informative and engaging, with bright colors and a tagline that emphasized the participants stories being told. My low attendance levels could be attributed to several factors, including the marketing for the event, the time and date I selected, and the location of the workshops. I chose the Warren Branch of the Indianapolis Public Library because I was told that they 11 have high event-participation from high school students, but when I arrived at the library which is near a local schoolI learned that the students who are known to participate at that location are only on-site during after-school hours. Thus, scheduling for a Saturday at this particular location drastically lowered the participation that I had counted on. Had I known this in advance, I would have planned to host on a different day or at a different location. My marketing strategy, which was to send out an event flyer (see Figure 1 above) to the Indianapolis Public Library, the Indiana Writers Center, and some surrounding schools, also fell flat. Both students who attended the workshop indicated on their participant surveys that they heard about the event through The Public Library, meaning that my attempt to draw participants from outside the library was not successful. But despite low attendance, the students who showed up were eager to learn and to engage with the genre of creative nonfiction. They both demonstrated an interest in the genre, despite not being familiar with it prior to these workshops. Student A, who attended both workshops, indicted on her survey for workshop two that her interest in the genre of creative nonfiction had doubled over the course of our two weeks (see Figure 2 below). Figure 2: This figure is taken from Student As workshop two participant survey. It demonstrates her increased level of interest in the genre of creative nonfiction. Her primary genre, she indicated during our workshops, was fiction. Student B, who was only available for one of the two workshops, had a background in poetry that I encouraged him to translate into prose. He was hesitant to write or to share his 12 work with the group, but his participation visibly increased when I presented Tim Bascoms visual diagrams from Picturing the Personal Essay (see Figure 3 below). Figure 3: This PowerPoint slide accompanied a discussion about how to structure a creative nonfiction essay. Student B expressed heightened interest in the subject after this discussion. He was excited to talk about these visual examples of how to represent rising and falling action, and to connect these diagrams to voice as well. Thus, although each student engaged in different aspects of the lessons, they both demonstrated an interest in the learning process. In addition to their engagement with the material, Student A demonstrated acute interest in the importance of the genre of creative nonfiction. I began workshop one by introducing the genre of creative nonfiction with a few examples that I hoped would be familiar to the students, such as The Diary of a Young Girl by Anne Frank and I Am Malala by Malala Yousafzai. Student A quickly identified the historic importance of these stories and proceeded to give other creative examples, such as the movie Hidden Figures. She talked about how these stories had impacted her own perceptions, and how they had the power to do so worldwide. She continued to reference Hidden Figures and other examples 13 throughout the workshop. On her survey for workshop two, the participant indicated that she would have liked to participate in even more discussions about creative nonfiction in the world, suggesting that she was interested, not just in the genre, but in the relevance of counternarratives in the world. I was eager to encourage her, not just because of her interest in the genre, but because of the experiences that she shared with me during our time together. In workshop one I learned that her parents had emigrated from Argentina, and that her family frequently visited their native country to visit the family members who still lived there. She spoke about the impact of moving from one place to another, and seemed interested in exploring the depths of that experience. After a writing activity where we wrote about our childhood kitchens, she began to compare her old kitchen in Florida to her new kitchen in Indiana, then to the kitchen of her grandparents in Argentina. Wanting to encourage this exploration, I told her how interested I would be to read a story comparing these kitchens, and made sure to bring it up again when I saw her the following week as well. Between workshops I revised my curriculum to include an essay called Letters to Frida. This story is about a young Mexican-American girl whose parents immigrated to America. It is told in a series of letters to the famous Mexican painter and icon Frida Kahlo, and it contains both English and Spanish phrases. When we read this essay together, the student was visibly excited to tell me more about Frida Kahlo and to translate all of the Spanish phrases. She continuously drew her answers back to these Spanish phrases, even when they didnt directly connect to the question I was asking, demonstrating a clear excitement at having a platform to talk about her Spanish heritage. Although she was engaged in the other readings as well, it was 14 clear that seeing a familiar but underrepresented language and culture really made her even more excited to participate. Although my intent in this workshop was not to analyze any one teaching style, I found myself using Nancie Atwells teaching methods throughout the workshops. I used her method of partnering with students in their individual learning journeys with Student A once I discovered that she was a motivated learner who enjoyed being given hard questions and being encouraged to explore the answers more deeply. I also used Atwells method of participating in writing activities alongside the students once I realized that there would only be a few participants. I opted to respond to every prompt alongside my participants so that I could increase the material we had for dialoguing, and so that I could more deeply connect to the students through a shared experience. This became particularly important when I needed to make a quick connection with Student B upon his late arrival. These strategies opened the door for more conversations about the uniqueness of each individuals story and each authors voice, and it also provided an opportunity to create a more collaborative working environment. I demonstrated feedback to my participants and then encouraged them to give me feedback on my material as well, thus teaching them about the importance of collaboration while also breaking down the stigma against receiving feedback that can result from bad classroom experiences. Creating this relaxed, collaborative environment was paramount to such an intimate workshop with only a few participants, and it allowed me to better engage with their learning experience and make them feel comfortable doing the same. Both students indicated on their survey responses that they felt they had been heard during the workshop; Student B added in the comments that everyone was listening to me for the first time (see Figure 4 below). 15 Figure 4: This figure is taken from Student Bs workshop one participant survey. Student B appeared nervous to engage in group conversation during the workshop and hesitated to share his work or speak up about the writing exercises. Despite this, he expressed in his participant survey that he felt that his voice had been heard, and noted that everyone was listening to him for the first time. This feedback told me two things: that I had succeeded in creating an atmosphere of trust in my workshop, and that Student B had never before had a platform to share his counternarrative. 16 Conclusion The genre of creative nonfiction requires individuals to first consider their own experiences, and then how to share them through the written word. This isand should bea lifelong process of growth. In the course of a humble six hours, spread over two days of workshops, I aimed to equip the young thinkers who attended with the skills (and an eagerness) to step into the role of storytellers, encouraging them to see the genre of creative nonfiction as not only an accessible outlet for their stories, but as a platform for lifelong growth and positive social change. I believe that I accomplished this goal. At the conclusion of my second workshop, Student A approached me and asked if I would be leading any more writing classes. When I told her that my teaching project was over, she expressed disappointment. Despite her intense level of engagement for six hours of workshops, she was not satiated. Through her, I saw a need in the community. After she left, I asked the librarian if I could come back again, this time during after-school hours when students would be sitting around the library. The librarian was enthusiastic about this opportunity, and told me that the library usually saw 40-60 adolescent students during after-school hours because they had nowhere else to go or nobody to go home to. These numbers increase in the winter. We have since been in contact about hosting another workshop in January, this one aimed at a wider audience. It will be a condensed version of the workshops I led in September, running only 30-60 minutes rather than a full three hours, so as to keep the students attention. I plan to use similar writing prompts, and to facilitate even more discussion about sharing counternarratives. I look forward to hearing the stories that emerge from these young writers, and will continue to use what I learned through my prior 17 workshop experience to shape the way I engage with these students as I teach them to share their stories. 18 Works Cited Wolcott, James. Me, Myself, and I. Vanity Fair, Oct. 1997 Atwell, Nancie. In the Middle, 2nd ed., Boynton/Cook Publishers, 1998. Bascom, Tim. Picturing the Personal Essay: A Visual Guide. Creative Nonfiction, 2013, www.creativenonfiction.org/online-reading/picturing-personal-essayvisual-guide. Beck, Sarah W. Individual Goals and Academic Literacy: Integrating Authenticity and Explicitness. English Education, vol. 41, no. 3, Apr. 2009, pp. 259280. Chapman, Thandeka K., et al. A Social Justice Approach as a Base for Teaching Writing. Journal of Adolescent & Adult Literacy, vol. 54, no. 7, Apr. 2011, pp. 539541. Gutkind, Lee. You Can't Make This Stuff up: the Complete Guide to Writing Creative Nonfiction--from Memoir to Literary Journalism and Everything in Between. Langara College, 2012. Hall, H. Berhard. Deeper than Rap: Expanding Conceptions of Hip-Hop Culture and Pedagogy in the English Language Arts Classroom. Research in the Teaching of English, vol. 51, no. 3, Feb. 2017, pp. 341350. Kinloch, Valerie, et al. When School Is Not Enough: Understanding the Lives and Literacies of Black Youth. Research in the Teaching of English, vol. 52, Aug. 2017, pp. 3454. Marion County, Indiana. InDepth Profile: STATS Indiana, STATS Indiana, 2019, www.stats.indiana.edu/profiles/profiles.asp?scope_choice=a&county_changer=18 097. 19 Murray, Donald M. The Listening Eye: Reflections on the Writing Conference . The Writing Teacher's Sourcebook, by Edward P. J. Corbett et al., Oxford University Press, 2000, pp. 96101. Nancie Atwell. Heinemann, Houghton Mifflin Harcourt, https://www.heinemann.com/authors/109.aspx. Parker, Priya. The Art of Gathering: How We Meet and Why It Matters. Riverhead Books, 2018. Rankine, Claudia. In Our Way: Racism in Creative Writing. AWP: Writer's Chronicle Features Archive, Association of Writers & Writing Programs, 2016, www.awpwriter.org/magazine_media/writers_chronicle_view/4120/in_our_way_r acism_in_creative_writing. Sarigianides, Sophia T, et al. Rethinking the "Adolescent" in Adolescent Literacy. National Council of Teachers of English , 2017 Skerrett, Allison, and Randy Bomer. Recruiting Languages and Lifeworlds for BorderCrossing Compositions. Research in the Teaching of English, vol. 47, no. 3, Feb. 2013, pp. 313337. 20 Appendix A Annotated Bibliography Atwell, Nancie. In the Middle, 2nd ed., Boynton/Cook Publishers, 1998. This source is primarily an educators guide to teaching reading and writing in a classroom, but it contains several chapters on how to conduct workshops. Atwell emphasizes the importance of allowing the student to guide their own writing, but also encourages educators to become partners in their students writing experiences by asking them about their writing, making suggestions for improvements, and allowing students to critique her own writing. When going into my own writing workshop, I implemented some of Atwells strategies for the classroom in order to engage with my writers while also giving them freedom within their work. Bascom, Tim. Picturing the Personal Essay: A Visual Guide. Creative Nonfiction, 2013,www.creativenonfiction.org/online-reading/picturing-personal-essay-visualguide. This source, published in the reputable online magazine Creative Nonfiction, addresses what a creative nonfiction essay might look like when diagramed. He offers, not just an analysis of several essays and their form, but a visual image outlining the progression of the story. 21 The source, as the title suggests, is an excellent visual guide to structuring essays. In conducting my workshop, I used his images as an example of how to structure an essay. Beck, Sarah W. Individual Goals and Academic Literacy: Integrating Authenticity and Explicitness. English Education, vol. 41, no. 3, Apr. 2009, pp. 259280. This article discussed various classroom teaching strategies for how to encourage students to write from their own cultural and linguistic backgrounds. It also discusses the barriers that exist to this type of teaching, namely the decades-long tradition of silencing counternarratives. The article listed several examples of how to encourage students, and I was able to implement these strategies when I led my own writing workshop. Chapman, Thandeka K., et al. A Social Justice Approach as a Base for Teaching Writing. Journal of Adolescent & Adult Literacy, vol. 54, no. 7, Apr. 2011, pp. 539541. This short article suggests that there are countless ways in which social justice can be used in a classroom to engage students with the practicalities of literacy. This is particularly relevant in the field of creative nonfiction, where writers are able to tell their own stories of injustice. 22 Since creative nonfiction naturally overlaps with themes of social justice, this source was useful when I was considering my workshop. I kept the principles of social justice in the back of my mind during my workshops so that I could to encourage students to tell their own stories of injustice. Gutkind, Lee. You Can't Make This Stuff up: the Complete Guide to Writing Creative Nonfiction--from Memoir to Literary Journalism and Everything in Between. Langara College, 2012. Lee Gutkind is the most well-known writer of, and advocator for, the genre of creative nonfiction. His book You Cant Make this Stuff Up is an instructional guide that outlines the genre and provides suggestions for how to write and revise a creative nonfiction essay. Gutkind covers a range of topics, including the ethical considerations of the genre, the how tos of writing an engaging story, and the benefits of writing habitually. Gutkind also devotes a large portion of his book to the revision process, with topics like knowing what to cut, smoothing out inconsistencies, and making your story airtight and readable. Gutkinds book offers the most thorough and expansive consideration of the genre. It has served as a guide to my own study of creative nonfiction and also served as scaffolding for several sections of my workshop curriculum. 23 Hall, H. Berhard. Deeper than Rap: Expanding Conceptions of Hip-Hop Culture and Pedagogy in the English Language Arts Classroom. Research in the Teaching of English, vol. 51, no. 3, Feb. 2017, pp. 341350. This article takes a deeper look at Hip-hop culture and the potential impact it could have on an English classroom. The author takes the approach that Hip-hop represents storytelling in a valuable way, and that students could benefit from being encouraged to use the storytelling strategies of hip-hop when they are writing their own creative pieces. The author also addresses why hip-hop has been shunned from the classroom in the past, calling it a microcosm of the nations challenges to manifest its rhetoric of multiculturalism, diversity, and inclusion. In other words, the rejection of hip-hop is a manifestation of the whitewashing of language. I found this article incredibly useful because it impacted the environment I chose to foster in the writing workshop I hosted. This article taught me that there are things I can do, as the instructor of a class, to ensure that students feel comfortable writing in whatever multicultural style they are most called to. Kinloch, Valerie, et al. When School Is Not Enough: Understanding the Lives and Literacies of Black Youth. Research in the Teaching of English, vol. 52, Aug. 2017, pp. 3454. 24 This source looks at how formal education strategies have disadvantaged black youth who succeed outside of the classroom when they are encouraged to pursue their own understanding of literacy. It details the story of several black students who used their literacy capabilities to have a positive impact on their community. One focus of the article is the importance of representing counternarratives. This is incredibly relevant in the field of creative nonfiction, which gives students a direct opportunity to share their counternarrative. In my writing workshop I left room for students to explore these counternarratives without the restrictions of a formal education environment. Marion County, Indiana. InDepth Profile: STATS Indiana, STATS Indiana, 2019, www.stats.indiana.edu/profiles/profiles.asp?scope_choice=a&county_changer=18 097. This source comes from STATS Indiana, which is the primary source for demographic data in the state. It provides valuable information for understanding the racial standing of residence of Marion County, where my workshop was held. For instance, it outlines the percentages of each race in Marion County according to their population sizes. The percentage of white residents is higher than that of any other race, representing approximately sixty-four percent of the community, with the black population representing twenty-eight percent of the community. The Hispanic population represents ten percent of the community. 25 Knowing this data allowed me to prepare for a range of possible participants. The data, unfortunately, did not account for additional identification factorssuch as gender, sexuality, physical ability, or religious affiliationsthat were represented in my workshops. Murray, Donald M. The Listening Eye: Reflections on the Writing Conference. The Writing Teacher's Sourcebook, by Edward P. J. Corbett et al., Oxford University Press, 2000, pp. 96101. This book is a collection of articles written by prominent educators about various strategies for teaching students. The book covers several topics, including the management of classrooms, composing and revising strategies, and how to teach basic writing. Of the many articles within this book, the one that most caught my attention was Donald M. Murrays The Listening Eye: Reflections on the Writing Conference. In this article, Murray summarizes decades of writing conferences by outlining the strategies he uses. His approach is to engage the student with their own writing process, asking them questions that get them thinking about ways that they can improve. He rarely teaches in the traditional sense of the word, but rather facilitates a conversation with writers about their work so as to make them more aware of what they want to do next. Thus, in writing conferences, he values listening above talking. 26 This was helpful advice as I prepared to workshop with students that Id never met, especially because the advice to listen rather than talk gave me more opportunities to get to know the young writers I met. Parker, Priya. The Art of Gathering: How We Meet and Why It Matters. Riverhead Books, 2018. The book is intended for anyone intending to host an event. It talks through some of the considerations of hosting that often get overlooked or poorly represented. For instance, the author emphasizes that a host ought to have a clear conceptual purpose for the gathering that extends beyond the basic events of the meeting. The author also instructs readers on how to take charge of an event while still being generous to, and engaged with, your guests. Although this source is not strictly directed towards my field of study or the methodology behind my event, it allowed me to clearly articulate my own purpose and goals for gathering. Rankine, Claudia. In Our Way: Racism in Creative Writing. AWP: Writer's Chronicle Features Archive, Association of Writers & Writing Programs , 2016, www.awpwriter.org/magazine_media/writers_chronicle_view/4120/in_our_way_r acism_in_creative_writing. 27 This essay by Claudia Rankine, adapted from a speech given at a 2016 conference for the Association of Writers & Writing Programs, primarily challenges white writers and educators to consider the impact that institutional whiteness has had on them. Rankine takes a direct approach in addressing the reader, urging them to take a second look at the ways that they interact with minorities and the material that they produce. She also emphasizes the importance of being intentional about considering and producing change. Each of Rankines calls to action are predicated on the idea that services in academia and in publishing continue to favor whiteness. Acknowledging this is important because it allows us to take an honest look at our own experiences and conversations. I needed to reconcile this concept in order to effectively lead a multiracial workshop without discouraging or alienating the minority students who attended. Sarigianides, Sophia T, et al. Rethinking the "Adolescent" in Adolescent Literacy. National Council of Teachers of English , 2017 This source, of which I have only read the Introduction and the first chapter on The Underlying Myth of Adolescence in Adolescent Literacy, reconsiders the way that adolescent students have been taught in the past and suggests that teachers have largely been ignorant of their true potential as well as their true needs. 28 Chapter one of this book was useful for considering how I would engage with those who attended my workshop, as I was aiming to reach out to adolescents. It gave me a framework for thinking intentionally about the activities I would conduct with them and the ways that I interacted with their writing. Skerrett, Allison, and Randy Bomer. Recruiting Languages and Lifeworlds for BorderCrossing Compositions. Research in the Teaching of English, vol. 47, no. 3, Feb. 2013, pp. 313337. This article details a study of two transnational youth and how their writing was shaped by their cultural experiences and their history of border-crossing. The article pointed out the minute ways in which the students literacies were impacted by their experiences while also pointing out that these small details were also indicative of greater cultural impact. This article, which was able to hyper-focus on students choices in the writing process and how they might be indicative of the students experiences, broadened my perspective on how to interpret subtle choices in writing. This sort of hyper focus allowed me to better speak to one of my workshop students about their writing. This article also further supported the idea that it is important to allow students to write their own counternarrative. 29 30 Appendix B Observation Letter by Professor Barney Haney 31 32 33 34 35 Appendix C Checklist of Tasks for Preparation 36 Appendix D Post-Workshop Journal Entry (Workshop 1) My first workshop succeeded in engaging students with the genre of creative nonfiction, even though not everything went according to my original plan. The First Hitch in the Plan: At the start of this workshop, there was only one participant (Student A). She had called ahead to the library that morning to make sure the event was still happening, and then she showed up and engaged immediately. Despite her level of engagement, I was uncomfortable having only one participant in the room because I had planned for a group learning environment and I wasnt sure how to adapt to teach just one person. I also didnt want her to feel like she was alone or outnumbered (given the fact that myself and two other adults were also in the room). Luckily she didnt seem too intimidated by the age of the crowd. I was also able to connect with her by chatting about some shared interests (A Series of Unfortunate Events and Stranger Things, both of which also helped me gauge her creative interests in the process.) This opened up the door for more natural conversations and collaboration. The Second Hitch in the Plan: Eventually a second participant (Student B) showed up, but this happened much later in the day (around two hours into our allotted three hour workshop). At that point I became tense, because I was worried that Id have to revise my lesson plans to accommodate the late-comer. I wasnt sure how to keep the workshop moving forward for Student A while also making sure that Student B felt included and ontrack. Im not sure whether the tension I experienced was felt by the others in the room, but Im worried that it had a negative impact on my teaching from there out. Student B was engaged with the content, but he seemed nervous to share his work or talk about it. I dont feel like I did a good job of engaging with him (partially because he shared at first but didnt want to share at the end). Professor Barney Haney was able to get him talking and writing at the end, but I definitely felt like I should have connected to him better. I think I was uncomfortable with him from the start because he arrived later, which threw me off and made me second guess my lesson plans. I also felt like I couldnt really hear what he was saying a lot of times, because he spoke softly and sat at the far end of the table from where I was positioned. I think if I could have heard him, or even looked at his paper (which he indicated a lot without actually reading it) then I might have been able to connect to him better. When he arrived I decided to switch up my lesson plan and jump into more writing activities instead of reading an example. I did this because I wanted the newcomer to be 37 able to ease into the workshop, and I thought that writing activities would do that better than reading and teaching. I think this was a good move, but at the time I felt like I was abandoning something really important. I think in retrospect, it would have been better to circle back around to that written example after doing those writing activities, rather than ending on a big free-write time like I did. Engagement with Writing Prompts: Both of my participants responded incredibly well to the writing activities that I facilitated and seemed eager to write, regardless of the prompt or the challenge presented to them. The second memory prompt (which was to write about your childhood kitchen) ignited a particularly fruitful conversation about storytelling and writing. There were times when Student A seemed more eager than Student B. She was eager to learn and write and was open to sharing her work from the start. She even offered feedback on myself and Professor Barney Haneys work when we read out loud. Student B was less interested in sharing his work, but liked talking about the process of organizing an essay. Because of this balance, I never felt like I fully lost participation in the room, though I could tell that the two participants had different interests in the subject matter. Engagement with Discussion of Counternarratives: The topic of counternarratives and the importance of storytelling was emphasized a lot at the beginning of the workshop, and Student A was eager to discuss this topic. She was interested in the idea that stories could be powerful, and the longer I talked about examples, the more examples she came up with on her own. It was exciting to see her begin to list off multiple examples, unprompted, of creative nonfiction in movies and such, and to talk about their sociological importance. Although nonfiction was not her genre of choice, she seemed to have a strong background in storytelling and she was interested in talking about the importance of stories. We didnt have a lot of hard conversations about race, economic status, etc. in the last hour of the workshop, so Im not sure how Student B would have done with those conversations. For Next Week: I have a lot of changes that Id like to make to my itinerary for workshop two. Originally I planned to lead a revision workshop where we practice looking at a particular piece, critiquing it, and revising it. Now I think that Ill focus, instead, on how to structure a story in general. I might return to Tim Bascons Picturing the Personal Essay to structure workshop two. Appendix E Post-Workshop Journal Entry (Workshop 2) 38 I felt much more comfortable this week, partially because I knew the participant (Student A) and partially because I had a better idea of what to expect from the event. I tailored my lesson plans to Student A, including the stories we read and the topics we focused on, so I felt like I was able to connect to her really well and strengthen her interest in creative nonfiction substantially. Reading Samples: On her workshop one survey, Student A had marked that she wanted to see more written examples, so I made a point to include these in my lesson plans. We read three examples and she was very engaged with them. I think the moment when Student A was most excited and engaged was when we read a story that included both Spanish and English. The first several questions that I asked about the piece were unrelated to the use of Spanish in the essay, but Student A quickly wanted to talk about that. She continuously drew her answers back to these Spanish phrases, sometimes without really connecting to the question I was asking. She just seemed really eager to explain to us what those Spanish phrases meant, as though she was excited to have a platform to talk about her Spanish heritage. She was already engaged but it was clear that seeing a familiar but underrepresented language/culture really made her even more excited. One of the three reading samples didnt go over quite as well. The story (Swerve) was about a character who was in a verbally abusive relationship with someone who was a drug dealer and drank a lot. Though there wasnt any huge tension when we talked about this piece, Student A seemed a bit uncomfortable with the idea that the narrator was around drugs and alcohol. She also didnt seem to understand that the two were in a relationship, probably because it is implied but never actually written out. This was definitely the hardest piece to read and comprehend, so I think it was a good challenge for her, but she didnt seem to have the background to grasp onto the content as well. I wonder whether this is just because she hasnt experienced any really bad relationshipsshe talked a lot about her parents and extended relatives as if they get along really well. It could be that she was just sheltered from some of the bad things that appeared in this story, so she wasnt able to look past them. Writing Prompts: Just like in workshop one, Student A was incredibly eager to learn and share her work. She was also excited to hear what other people had written. After wed talked about her piece for a while, shed ask Professor Barney Haney and me to share what wed done too. She was also quick to point out Professor Barney Haneys voice in his writing. I, in turn, tried to point out her voice (like how she uses contradicting imagery to enhance the readers experience) to encourage her to continue developing her own voice. 39 I was most proud of how I encouraged her to write a story that shed talked about during the first weeks kitchen activity. She had talked about a story where she goes back and forth between her kitchen in America and her kitchen in Argentina, talking about the differences and the cultural relevance of both. I thought that would be a really cool story, so when I saw her on the 14th I immediately told her that I hadnt been able to stop thinking about how cool her kitchen story would be. By the end of the workshop she decided to write that story. I think seeing a way to structure it really helped her out (she chose to do a braided essay, like the ones wed talked about). Successes in workshop two: If you consider success according to number of participants, then week 2 was a downgrade from week 1. I did set a goal of reaching 5-10 participants, and that goal was not met. However, I feel like Student As participation, and my ability to adapt my lesson plans to focus on giving her the encouragement and essay-scaffolding that she needed, made for an improved workshop. I feel like I was more tuned in to what she needed, including breaks! I tried to split up my lecturing better so that I had more activities sprinkled in, and I think that worked really well. It kept her attention better. Even though Student A was really interested in counternarratives during week 1, I think the bilingual reading example in week 2 helped solidify that her story (her cultural background, her family, her experiences) mattered. It was at the end of week 2, not week 1, that she finally wrote her kitchen story. 40 Appendix F Post-Workshop Journal Entry (Revisiting Entries 1 and 2) After reviewing both journal entries, I would like to revisit three topics. 1. In my workshop one entry, I noted that in retrospect, it would have been better to circle back around to that written example after doing those writing activities, rather than ending on a big free-write time like I did. The reason I said this was because at that time I still thought that my second week would be structured more like a revision workshop where wed review a students piece and talk about how to revise it. I ended up changing my plan to include a lot more examples of how essays can be structured, which opened up the door to look at some reading examples. We ended up reading three examples of nonfiction essays, and it fit well with the curriculum for the day. So even though I initially worried that I should have forced us to read an example rather than write, I now think that I made a good move in adapting to fit Student Bs needs in workshop one, and that I adapted well in workshop two to fill this gap. 2. In addition to having a new perspective on workshop one after completing workshop two, I can see how my journal entries reflect the confidence I gained during the process of leading these workshops. I was much more sure of myself during workshop two because I was able to evaluate workshop one in writing, through my journal entry, and verbally, through a conversation with Professor Haneyand then alter accordingly. 3. Despite not having a lot of attendance at my workshops, I am pleased with the way that I was able to interact with Student A and facilitate a learning experience for her. More importantly, Im glad that I was able to facilitate a conversation about counternarratives that she latched onto so strongly. I hope she will continue to write and explore her own identity through the soft- and hard-skills developed in these workshops. 41 Appendix G Participant Surveys (Workshop 1) Student A 42 43 Student B 44 45 Appendix H Participant Surveys (Workshop 2) Student A 46 47 Appendix I Observer Surveys Observer A 48 Observer B  ...