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... Running Head: APPROACH TO CHRONIC PAIN Opioid Use Reduction: A Narrative Medicine and Trauma-Informed Approach to Occupational Therapy in Chronic Pain Management Kersten Laughlin May, 2018 A capstone project submitted in partial fulfillment for the requirements of the Doctor of Occupational Therapy degree from the University of Indianapolis, School of Occupational Therapy. Under the direction of the faculty capstone advisor: Brenda Howard, DHSc, OTR APPROACH TO CHRONIC PAIN 2 A Capstone Project Entitled Opioid Use Reduction: A Narrative Medicine and Trauma-Informed Approach to Occupational Therapy in Chronic Pain Management Submitted to the School of Occupational Therapy at University of Indianapolis in partial fulfillment for the requirements of the Doctor of Occupational Therapy degree. By Kersten Laughlin Doctorate of Occupational Therapy Student Approved by: Faculty Capstone Advisor Date Doctoral Capstone Coordinator Date Accepted on this date by the Chair of the School of Occupational Therapy: Chair, School of Occupational Therapy Date APPROACH TO CHRONIC PAIN 3 Abstract Background: The campaign to treat pain as a fifth vital sign exacerbated the use of prescription opioids for chronic pain treatment. Prescription opioids are highly addictive substances that have resulted in the staggering number of overdose-related deaths. In an effort to combat the opioid epidemic, alternative pain management strategies via an interdisciplinary approach must be implemented in clinics throughout the country. Through a narrative medicine and trauma informed approach, practitioners can provide holistic, client-centered treatment for individuals with chronic pain. Objective: A three-part educational series was designed to increase occupational, physical, and speech therapists knowledge of narrative medicine, trauma-informed care, and chronic pain management strategies. A toolkit was developed for both practitioners and chronic pain patients that contained resources for best practices in chronic pain management. These alternative pain management strategies were presented in an effort to reduce the use of prescription opioids. Leaders in the community, such as the Mayor and a State Representative, were made aware of this project through collaboration with this student. Conclusion: The pain management toolkit was utilized by therapists as a resource for patients with chronic pain. Therapists knowledge of narrative medicine and trauma-informed care increased. Through collaboration with the hospital and the community, occupational therapy was received as an integral part of pain management and an alternative treatment to prescription opioids within this community. Keywords: occupational therapy, chronic pain, pain management, narrative medicine, trauma-informed care APPROACH TO CHRONIC PAIN 4 Literature Review Dr. Hershel Jick, Jane Porter, Dr. Russell Portenoy, and Dr. Kathleen Foleys publications unintentionally fueled what today is known as the public health crisis of the opioid epidemic. In 1980, Dr. Hershel Jick and Jane Porter published a paragraph in the New England Journal of Medicine that, out of 12,000 patients who had at least one dose of a narcotic painkiller, only four cases resulted in addiction (Quinones, 2015). Six years later, in 1986, Dr. Russell Portenoy and Dr. Kathleen Foley published their findings on the treatment of chronic pain in 38 patients. Dr. Portenoy and Dr. Foley stated that opioid pain relievers (OPRs) could be prescribed safely on a long-term basis (Kolodny et al., 2015). Since then, OPRs have been marketed as a conventional treatment strategy for the management of chronic pain. Chronic pain is classified as persistent or occurring pain that lasts longer than three months (Rolf-Detlef et al., 2015). It is subjective and influenced by an individuals moods, emotions, and perceptions (Breivik, Collett, Ventafridda, Cohen, & Gallacher, 2006). Opioids are highly addictive substances because they induce euphoria, or positive reinforcement (Kolodny et al., 2015). Prescription OPRs include, but are not limited to, OxyContin, Vicodin, Norco, Percocet, and Demerol. Heroin is in same class as these prescription OPRs. When an individual discontinues the prolonged use of these drugs, it produces dysphoria, or negative reinforcement (Kolodny et al., 2015). The prolonged use results in structural and functional changes in regions of the brain that control impulse, affect, motivation, and reward in an individual (Upadhyay et al., 2010). Pain as a Fifth Vital Sign In 1995, the American Pain Society introduced the campaign Pain is the Fifth Vital Sign. This campaign encouraged health care professionals to treat pain comparable to body APPROACH TO CHRONIC PAIN 5 temperature, pulse rate, respiration rate, and blood pressure. It counselled a more aggressive approach for the use of OPRs in treatment of non-cancer patients suffering from chronic pain (Campbell, 1996). One year later, Purdue Pharma introduced OxyContin to the pharmaceutical market. Even though OxyContin contained a high amount of oxycodone, an extremely addictive substance, Purdue Pharmaceuticals misled the medical community by advertising that due to its time-released formula, OxyContin was not an addictive drug (Quinones, 2015). A few decades later, the rate of prescription OPR use had increased rapidly nationwide. According to Gatchel, McGeary, McGeary, and Lippe (2014), the estimated cost of chronic pain treatment in the United States was $560-635 billion and as of 2011, over 60% of patients with non-cancer pain were prescribed OPRs. As a result of over-prescription of OPRs, there has been an escalation in the amount of opioid-related addiction and deaths nationwide. From 1997 to 2011, there was a 900% increase in individuals seeking treatment for opioid addiction (Kolodny et al., 2015). Between the years 2000 and 2014, death from prescription OPR-related overdoses increased from 1.5 to 5.9 deaths per 100,000 people (Compton, Jones, & Baldwin, 2016). The Relationship between Prescription OPRs and Heroin Heroin is pharmacologically comparable to prescription OPRs. Both heroin and prescription OPRs produce their action through endogenous opioid systems, resulting in a burst of dopamine released that is coupled with the high associated with the use of these drugs (Compton, Jones, & Baldwin, 2016). Doctors are now less willing to prescribe prescription OPRs for pain treatment. The efforts to reduce prescription OPR use and overdose are associated with reports of increased rates of heroin use and overdose-related deaths (Compton, Jones, & Baldwin, 2016). Since 2007, APPROACH TO CHRONIC PAIN 6 there has been a 145% increase in heroin use (Compton, Jones, & Baldwin, 2016). Heroin users are 2.9 times more likely to abuse or have dependence on opioids, and by the year 2013, heroin use was 40 times more likely for an individual with prior prescription opioid abuse or dependence (Compton, Jones, & Baldwin, 2016). The Biopsychosocial Approach In 2016, the Surgeon General called on health care professionals to help address the epidemic of opioid abuse in the United States. Health care professionals should be educated on treating pain safely and effectively, screening patients of opioid use disorder, providing them with evidence-based treatment, and discussing and treating conditions such as chronic illness (American Occupational Therapy Association, 2016). The biopsychosocial model is the overarching model for the treatment of pain. This model promotes pain and disability as a complex and dynamic interaction among physiological, psychosocial, and social factors that perpetuate or worsen one another, resulting in chronic and complex pain syndromes (Gatchel, McGeary, McGeary, & Lippe, 2014, p. 120). The goal is to incorporate physical treatment with cognitive, behavioral, and emotional interventions (Gatchel, McGeary,McGeary, & Lippe, 2014). Using a biopsychosocial approach for the treatment of pain acknowledges that persistent pain is the result of central nervous system dysregulation (Roth, Geisser, & Williams, 2012). There are a variety of psychological and social factors that relate with the biological foundations of symptoms that lead to disability. Psychological factors interact with cortical mechanisms of pain perception and therefore have a direct impact on the way the brain processes pain (Roth, Geisser, & Williams, 2012). Understanding how the disability of pain limits or impacts social factors such as ADLs, relationships, social participation, cultural factors, work history, family APPROACH TO CHRONIC PAIN 7 environment, and environmental stressors complete the understanding of an individual using the biopsychosocial model (Roth, Geisser, & Williams, 2012). Narrative Medicine and Patient Empowerment Pain is a subjective experience; thus, it is important for health professionals to utilize narrative medicine and patient empowerment when treating patients. Established by Dr. Rita Charon, narrative medicine promotes the power of storytelling and invites the health practitioner to be moved by the story of illness (Rosti, 2017). It encourages empathy, reflection, profession, and trust. Using narrative medicine facilitates better communication between the health practitioner and the patient, as the health practitioner is able to understand the issues that impact an individual and how they perceive and deal with those issues (Rosti, 2017). In an individual with pain, a narrative evaluation will assess the impact that the pain has on the patients daily activities and quality of life (Rosti, 2017). Attention and narrative competence are demonstrated during the narrative evaluation. Attention refers to the ability to absorb and demonstrate active listening when a patient is telling their story (Charon, 2005). This leads to the health professional comprehending what is expressed by the patient through narrative competence: ability to listen to the narratives of the patient, grasp and honor their meanings, and be moved to act on the patients behalf (Charon, 2001, p. 1897). The health practitioner performs representation privately. It produces reflection through text for the clinician to discover thoughts, feelings, and perceptions, hence promoting narrative knowledge. Narrative knowledge is what one uses to understand the meaning and significance of stories through cognitive, symbolic, and affective means (Charon, 2001, p. 1898). It develops the role of the therapeutic practitioner identifying and interpreting their own emotional responses to patients (Charon, 2001). APPROACH TO CHRONIC PAIN 8 Narrative medicine is parallel to patient empowerment. An individual is empowered when they have the knowledge, skills, attitudes and self-awareness necessary to influence their own behavior to improve the quality of their lives (Anderson & Funnel, 2010). It promotes the ability for patients to have the authority to make decisions for their treatment and care and the right to be primary decision makers (Barrie, 2011). Patient empowerment in pain management treatment is important because it allows for the patient to be aware of their values, needs, goals, and expectations regarding pain (Barrie, 2011). Trauma-Informed Care and Chronic Pain According to the Substance Abuse and Mental Health Services Administration (SAMHSA), individual trauma results from an event, series of events, or set of circumstances that is experienced by an individual as physically or emotionally harmful or life threatening and that has lasting adverse effects on the individuals functioning and mental, physical, social, emotional, or spiritual well-being (SAMHSA, 2014, p. 7). SAMHSA (2014) describes event(s), experience of event(s), and effect as three determinants of trauma. Events can refer to the actual or extreme threat of physical or psychological harm (SAMHSA, 2014). These can occur once or repeatedly over time. The experience of these events determines how the individual will assign meaning to the event (whether or not it is traumatic) and how it disrupts the individual physically or psychologically (SAMHSA, 2014). The assigned meaning can be influenced by an individual's cultural beliefs, availability of social supports, or the developmental stage of an individual (SAMHSA, 2014). Lastly, the adverse effects of trauma may occur immediately or have a delayed onset. Examples of adverse effects include an inability to cope with normal stresses and strains of daily living, inability to trust and benefit from relationships, and affected APPROACH TO CHRONIC PAIN 9 cognitive processes such as memory, attention, thinking, and emotional dysregulation (SAMHSA, 2014). The trauma-informed approach recognizes that all people in an organization must have a basic realization about trauma and how it can impact individuals, be able to recognize the signs of trauma, and then respond appropriately by applying the six key principles identified by SAMHSA. (SAMHSA, 2014) The people in the organization must be able to also recognize the signs of trauma (SAMHSA, 2014). The trauma-informed approach also includes resisting retraumatization of patients and staff. (SAMHSA, 2014). The six key principles of trauma-informed care are safety, trustworthiness and transparency, peer support, collaboration and mutuality, empowerment, voice, and choice, and cultural, historical, and gender issues. Safety should be established so that patients and staff feel physically and psychologically safe (SAMHSA, 2014). Trustworthiness and transparency is aimed to maintain trust with clients and family members (SAMHSA, 2014). Peer support helps to establish safety and hope, trust, the therapeutic relationship, and uses the individuals narrative to promote recovery (SAMHSA, 2014). Collaboration and mutuality place importance on the process of healing in relationships that are meaningful in the sharing of power and decisionmaking (SAMHSA, 2014). Empowerment, voice, and choice reflect the belief that patients are collaborated with in goal setting and decision making to determine their plan of action needed to improve their quality of life (SAMHSA, 2014). Cultural, historical, and gender issues must be treated equally, as an organization must offer treatment to any individual no matter their race, ethnicity, sexual orientation, age, religion, or gender identity (SAMHSA, 2014). Research suggests that individuals who experience trauma are more likely to develop chronic pain (Jones, Power, & Macfarlane, 2009; McBeth et al., 2007; Scarinci, McDonald- APPROACH TO CHRONIC PAIN 10 Haile, Bradley, & Richter, 1994; Young-Casey, Greenberg, Nicassio, Harpin, & Hubbard, 2008). After trauma, the nervous system is stuck in a state of heightened reactivity. Therefore, when a patient with a history of trauma becomes injured or ill, their nervous system is already in a state of persistent reactivity, and they are more likely to develop chronic widespread pain. Around 90% of women with fibromyalgia and 60% of individuals with arthritis (Walker et al, 1997), 76% of patients with low back pain (Schofferman, Anderson, Hines, Smith, & Keane, 1993), 66% of women with chronic headaches (Domino & Haber, 1987), and 56% of women with chronic pelvic pain (Walling et al., 1994) report past histories of trauma. An Interdisciplinary Approach The interdisciplinary approach has demonstrated to be an effective strategy for successful pain management. Interdisciplinary treatment consists of coordination of services in a comprehensive program and frequent communication among health care professionals all providing care (p.120) at the same facility (Gatchel, McGeary,McGeary, & Lippe, 2014). An interdisciplinary team should include at least two physicians, a clinical psychologist, a physical therapist (PT), an occupational therapist (OT), and additional health care providers as needed (Gatchel, McGeary,McGeary, & Lippe, 2014). Patients who have participated in interdisciplinary programs reported improved outcomes across a range of domains such as pain severity and interference with pain function and maintained their gains at one year follow up (Oslund et al., 2009). Interdisciplinary programs base their treatment with a functional restoration approach. A functional restoration addresses the physical, psychological, and vocational challenges during a patients recovery (Gatchel, McGeary,McGeary, & Lippe, 2014). An individuals goals should APPROACH TO CHRONIC PAIN 11 aim to restore physical functional capacity and psychosocial performance (Gatchel, McGeary,McGeary, & Lippe, 2014). Occupational Therapys Role in Pain Management Chronic pain is a complex diagnoses that impacts all areas of functioning. It can lead to a loss of independence, loss of participation in meaningful roles, decreased engagement in everyday activities, difficulties with sleeping, anxiety, depression, social isolation, and overall reduced quality of life (American Occupational Therapy Association, 2002). Occupational therapy can empower individuals to achieve satisfying performance in self-care, productivity, and leisure to support recovery, health, wellbeing, and social participation, and is therefore a necessary component to any rehabilitation program (Hill, 2016). Within the treatment team, the occupational therapist is able to enable individuals to achieve satisfying performance via activity management in meaningful occupations, regardless of pain and fatigue. Activity management includes activity analysis, skill development, activity adaptation, ergonomics, problem-solving, prioritizing, planning, energy conservation, and pacing of activities (Hill, 2016). An occupational therapist works with an individual to develop coping strategies to help them manage their sleep, mood, and stress (Hill, 2016). Examples of coping strategies may include relaxation techniques through mindfulness meditation, yoga, deep breathing, auditory distraction, and visualization techniques. Increased assertiveness and communication skills are also developed through occupational therapy (Hill, 2016). Pain is a diagnosis that impacts those of all ages, at any time during the life span. The broad spectrum of OT as a profession with its diverse skill set, allows for OTs to provide pain management in diverse areas of practice. Whether the setting is pediatrics or hospice care, an occupational therapist will identify specific activities or behaviors that aggravate pain (American APPROACH TO CHRONIC PAIN 12 Occupational Therapy Association, 2002). Once these are identified, the occupational therapist will provide activity modifications by teaching the individual or caregivers methods for decreasing the frequency and duration of pain (American Occupational Therapy Association, 2002). These methods may include the use of adaptive equipment during occupations such as dressing, bathing, and toileting. The implementation of these activity modifications may decrease an individual's depence on or use of prescription OPRs. An occupational therapist also assess the context and environment that surrounds an individual. Assessing these two areas increases functional performance for daily activities at work and home (American Occupational Therapy Association, 2002). Occupational therapists can also offer Lifestyle Redesign, an intervention that is often excluded from traditional interdisciplinary programs. Lifestyle Redesign focuses on promoting patient development of healthy self-care routines and habits to prevent and manage chronic conditions (Uyeshiro Simon & Collins, 2017). Through the use of various modules, patients were able to receive education on implementation of behavior changes into their daily routines. These modules included eating and sleeping routines, physical activity, stress and mood management, energy and fatigue management, activities of daily living (ADLs), instrumental activities of daily living (IADLs), home management, body mechanics and posture, transportation, socialization, paid or unpaid work, establishing a baseline, pain flare-up planning, assertive communication, and pain communication (Uyeshiro Simon & Collins, 2017). Uyeshiro Simon and Collins (2017) suggest that with LifeStyle Redesign, overall quality of life for those living with chronic pain improves. The purpose of this doctoral capstone experience (DCE) was to promote occupational therapys role in providing non-pharmaceutical pain management strategies and to educate health APPROACH TO CHRONIC PAIN 13 practitioners on implementing narrative medicine and trauma-informed care into their treatment approach. Through the use of a holistic treatment process and non-pharmaceutical pain management strategies, occupational therapists play an important role in providing safe and alternative treatment for chronic pain. Screening and Evaluation A needs assessment was conducted within the first four weeks of the doctoral capstone experience. The purpose of the needs assessment was to perform systematic collection, assembly, analysis, and dissemination of information related to the evaluation and treatment of individuals with chronic pain (Scaffa & Reitz, 2014). The findings of the needs assessment set the priorities regarding needs, how to address those needs, and assisted with proposing a plan to implement the best solution for developing and delivering this project (Scaffa & Reitz, 2014). Community Profile The opioid crisis is unique because it affects individuals of all ages, races, socioeconomic statuses, and education levels. This diversity becomes evident when looking at the impact of prescription opioid use and overdoses of a county in the Midwest. At the beginning of 2016, two local hospitals treated 130 patients for drug overdoses in the first 113 days of the year (Bangert, 2017). In 2013, it was reported that there were 71 opioid prescriptions per 100 residents (Lafayette sues opioid, 2017). From 2004 to 2013, there were 149 accidental drug overdose deaths (Bangert, 2017). Non-fatal emergency department visits due to opioid overdoses increased 75% from 2011-2015 (Bangert, 2017). As of 2016, 25-34 year olds made up the largest number of drug overdose deaths in the county, with 9.91 deaths per 100,000 people. Of all the overdose deaths in 2016, 9.04 per 100,000 people were due to opioids and 5.31 per 100,000 APPROACH TO CHRONIC PAIN 14 people were due to heroin, with 81% male and 19% female (Indiana State Department of Health, 2016). In an effort to reduce the amount of prescription opioid use, alternative therapies should be offered to chronic pain patients. The hospital network where the doctoral capstone is taking place advertises alternative treatments for pain management. According to their Pain Management website, they provide interventions such as disc decompression or fusion, dry needling, epidural steroid injections, facet joint injections, infusion pumps, intercostal nerve blocks, joint/bursa injections, occipital nerve blocks, peripheral nerve injections, spinal cord stimulators, trigger point injections, and Xolair injections. There was not any information about therapys role in providing pain management. While those alternatives provide pain relief, it is not the most comprehensive, holistic, evidence-based approach to treating individuals with chronic pain. Data Collection A survey (Figure 1A) was emailed to all physical therapists, occupational therapists, athletic trainers, speech-language pathologists, and massage therapists within the hospital network. The purpose of the survey was to gain an understanding of health practitioners knowledge of narrative medicine, pain management evaluations and interventions, and screens for opioid abuse prior to the implementation of the doctoral capstone experience. Two lead physical therapists were also contacted via email and interviewed about their intervention approaches for the following pain diagnoses: chronic pain, fibromyalgia, back pain, and migraines. For chronic pain, the intervention approaches they identified were dry needling, exercise, electrical stimulation through use of a home TENS unit, and possible Hivamat (a deep oscillation device). These interventions are all dependent upon the location of the pain. For APPROACH TO CHRONIC PAIN 15 fibromyalgia, they identified deep breathing, diaphragmatic release, craniosacral therapy, cupping, myofascial stretching, neuro-reeducation of muscles, exercise, recommendations for swimming, electrical stimulation, and possible dry needling. For back pain they identified dry needling, exercise, manual therapy techniques such as mobilizations and soft tissue mobilization, electrical stimulation, positional release, cupping, direct muscle release, neuro-reed, craniosacral therapy, imagery, tai chi, and Hivamat. For migraines they identified craniosacral therapy, manual therapy with mobilizations, cupping, yoga style body positioning stretching, low light/quiet rooms, manual traction, trigger point release, and dry needling. The information collected from the therapist surveys was used to guide the best possible strategy for implementing non-pharmaceutical, interdisciplinary pain management evaluation and treatment. Data Analysis and Interpretation Eight surveys were returned prior to the implementation of the doctoral capstone experience. Results from the pre-survey indicated that discomfort with the topic of narrative medicine was high. There was a lack of an evidence-based protocol for chronic pain patients and knowledge surrounding a way to screen patients at risk for substance abuse. The majority of therapists were not familiar with supports in the community for chronic pain patients. The majority of therapists did not feel that they had the right tools to offer the most effective pain management strategies. Refer to Figure 2A for survey results. These findings indicated the need for education on narrative medicine, evidence-based chronic pain management strategies, and increased support for chronic pain patients within the community. In addition to the likert scale, an occupational therapist and physical therapist different from the two lead therapists were contacted via email, and identified current protocols for pain APPROACH TO CHRONIC PAIN 16 management as using the Hivamat, manual techniques, and kinesiotaping. The physical therapist stated their approach was very manual-based, while the occupational therapist stated her interventions included a lot of education on adapting and increasing awareness of positioning; however, there is no specific protocol for this. The physical therapist identified community resources such as Alcoholics Anonymous, contacts with Narcotics Anonymous, and referrals to psychotherapists and psychiatrists. Patient compliance was identified as a barrier to success of a patients treatment. The was a lack of education on psychosocial interventions, and knowing when and how to refer the chronic pain therapy patient to other services such as Behavioral Health and the Healthy Living Center. Problems Related to Occupational Performance According to a group of occupational therapists, limitations of occupational performance in chronic pain patients includes pain behavior that prevents engagement in activities, a lack of knowledge about pain mechanisms and strategies to deal with pain, occupational imbalance in work, leisure, and home, emotional stress and depression due to pain, and physical or environmental strain resulting in limitations in occupational performance (Skjutar, Schult, Christensson, & Mullersdorf, 2009). The implications from this provided the guidelines for designing intervention approaches by OT practitioners. An individual who has a treatment plan that is client-centered and focuses on addressing limitations in occupational performance will have better functional performance outcomes and increased quality of life (Skjutar, Schult, Christensson, & Mullersdorf, 2009). Implementation Phase Diverse responses across professions from the surveys indicated the hospital network did not have an interdisciplinary approach to pain management. There was a lack of education and APPROACH TO CHRONIC PAIN 17 knowledge of treatment providers on an evidence-based approach to pain evaluation and treatment. The responses supported the need for education on narrative medicine, evidence-based pain management evaluation and treatments, how to refer to other services within the organization, and the education of a screening tool to identify at risk patients for opioid abuse. The needs assessment results guided the strategies that would be utilized during the DCE to promote education, staff development, and service provision. The DCE consisted of a series of three educational sessions delivered to staff and management. Trauma-informed care was added after the needs assessment was completed, and the screen for the at risk substance abuse was removed from this project. The first presentation was narrative medicine, the second was trauma informed care, and the third was chronic pain and the pain management toolkit. These topics were chosen after collaboration with the supervisors to educate the staff not only on treating just the physical aspects of chronic pain, but to learn how to evaluate, treat, and respond to the psychosocial aspects as well. Leadership and Advocacy Leadership was a skill necessary to be successful in implementing the strategies for staff development and service provision throughout the DCE. At the beginning of the DCE, the occupational therapy student and supervisors collaborated on objectives and goals to be achieved at the end of the experience. These objectives and goals provided the student with the direction and focus of the experience. It is important to note that throughout the 16 week period, objectives were modified to better implement the end goals. This required flexibility and adaptation to the projects to better accomplish the modifications. The literature review conducted on narrative medicine, trauma-informed care, and chronic pain was a self-led process. The student presented the research and updates on the APPROACH TO CHRONIC PAIN 18 project to supervisors in weekly meetings. The meetings required this student to prepare the tasks for the coming week. This collaboration guided the doctoral capstone timeline and allowed for the occupational therapy student to independently work on the implementation strategies. The presentations delivered to the staff were created and delivered by the occupational therapy student. The goal of the presentations by the occupational therapy student was to promote an open environment for interdisciplinary communication through education opportunities. Advocacy to leaders in the community was also a component of this DCE. This student met with the Mayor of Lafayette, Tony Roswarski, and Representative Sheila Klinker who serves in the House of Representatives from the Lafayette area. Both meetings involved education on what occupational therapy is, where OTs work, an explanation of the DCE, and how OT is an evidence-based treatment for chronic pain management. The goal of these meetings was to increase knowledge of the occupational therapy profession within leaders of the community. These leaders are now allies of the profession and understand the benefit of including OT services as an alternative to prescription opioids. Staff Development Staff development was implemented via direct and consultative service provision approaches. A direct service approach consists of small groups having contact with the OT (Dunn, 1988). The direct service approach was used through interactions with therapists of different professions (physical, occupational, and speech therapy) in small groups during presentations. Each presentation was 50 minutes to an hour long. Staff were encouraged to participate throughout the presentations by asking questions and providing suggestions about their ideas on implementing narrative medicine and trauma informed care into chronic pain treatment. APPROACH TO CHRONIC PAIN 19 A consultative approach provided expertise that was used to facilitate the appropriate environment towards the needs of the therapists and patients to implement the narrative medicine and trauma informed approach to chronic pain (Dunn, 1988). Colleague consultation addressed the needs of other professionals (physical, occupational, and speech therapy) to improve their skills and knowledge in chronic pain evaluation and treatment, narrative medicine, and trauma informed care. The consultative approach was also used while working with Behavioral Health and the Healthy Living center to form a referral relationship for each service provided. Session 1: Narrative Medicine. The first presentation topic was narrative medicine. Staff received education on the definition of narrative medicine, narrative evaluation, attention, representation, patient empowerment, and emotional intelligence. After the explanation of narrative medicine, staff members participated in a close reading. Close readings are a thoughtful, critical analysis of a text that focuses on significant details or patterns in order to develop a deep, precise understanding of the texts form, craft, and meanings (Wasmuth, 2017). They encourage the health professional to listen to their own observations, observe their initial responses and see how their experiences affect our relationships (Wasmuth, 2017). Therapists read the poem Ode to the Chronically Ill Body by Camisha Jones, then free-wrote to the response Chronic pain impacts someone by for five minutes. Once five minutes passed, therapists were invited to participate in an open discussion (length varied) sharing their reaction and analysis of the poem. One of the most important aspects of narrative medicine that the supervisors wanted to portray to the staff was acting on the patient's behalf. The Stages of Change from the Transtheoretical Model of Change was presented. A therapist must be able to identify their own willingness to change their attitude and approaches to chronic pain patients before they can APPROACH TO CHRONIC PAIN 20 identify their patients readiness to change. The five stages consist of precontemplation, contemplation, preparation, action, and maintenance and relapse prevention (Zimmerman, Olsen, & Bosworth, 2000). For example, a therapist who is in the precontemplation stage is not seriously thinking about changing their treatment approach to utilizing narrative medicine and trauma-informed care in an individual with chronic pain. If the therapist is unable to change, then the likelihood of the patient remaining compliant throughout treatment may decrease. If the therapist is in the preparation stage, they have made an attempt to incorporate narrative medicine into their chronic pain treatment approach. Thus, they can assist their patients in a more effective manner in implementing change and modifications in their patients lives. Once a therapist can identify their own willingness to change, they can collaborate with their patients on their own willingness to change. A patient who is in the contemplation stage has considered changed their behavior and lifestyle to better compensate chronic pain. The therapist will work with the patient to move throughout the stages of change. Through incorporating narrative medicine, patient satisfaction should increase. Patients who feel their health professionals demonstrate empathy are more likely to remain complaint during their treatment, have greater outcomes, and an overall increase in quality of life (Merritt Hawkins, 2018). A total of 12 narrative medicine presentations were delivered. Session 2: Trauma-Informed Care. The second topic was trauma-informed care. The OT student collaborated with an experienced OT, with a heavy background in mental health services, to develop this presentation. This presentation emphasized the importance of changing the question from What is wrong with him/her or Why are they behaving that way to What has happened to him/her? If healthcare professionals do not look at someones narrative and do not have an understanding of the role of trauma and how it may impact their current state, we APPROACH TO CHRONIC PAIN 21 will not be effective in our treatment. The SAMHSA definition of trauma was presented to the therapists as an event, series of events, or set of circumstance that is experienced by an individual as physically or emotionally harmful or life threatening and that has lasting adverse effects on the individuals functioning and mental, physical, social, emotional, or spiritual wellbeing (Substance Abuse and Mental Health Services Administration, 2014, p. 7). Examples of trauma include combat, domestic violence, sexual assault, natural disasters, terrorism, historical trauma, amputation, automobile accident, and a new diagnoses. Understanding trauma and trauma-informed care will provide effective services needed to understand life situations that may contribute to the persons current problems, problems faced by patients may be related to traumatic life experiences, and people who have experienced trauma are more sensitive to situations that remind them of the people, places, or things involved in their traumatic event. Appendix A outlines the impact trauma has on the individuals biological and psychosocial systems. This was included in the powerpoint. Therapists participated in a second close reading. A clip from the movie Cake was shown. In this clip, Claire, played by Jennifer Aniston interacts with Nina, played by Anna Kendrick. Claire was in a car accident that resulted in the death of her son and the development of chronic pain accompanied by an addiction to pain medicine. Nina had previously passed away from suicide. Nina is sitting on the train tracks and Claire walks over to her and lies down on the tracks. She discusses what her last thoughts would be, and then gets up when she hears Silvana, her assistant, calling out her name. Silvana is very frustrated with Claire and expresses that openly. The prompts for therapists were: How can you identify trauma in a patient?, Think of a difficult patient that you have had. If your patient was in Claires shoes, would you have APPROACH TO CHRONIC PAIN 22 done anything differently?, and How will trauma (known or unknown) impact treatment or plan of care? Therapists were invited to share their responses in an open discussion. After the close reading, the other OT presented the rest of the powerpoint. He went over the signs and symptoms of someone with trauma, as well as what to look for in the clinic. These included a patient who fails to progress, consistently arrives late, no shows or cancels frequently, is not compliant or does not follow their home exercise program, has a flat affect, is vague in symptom reporting, their pain response is not consistent with their diagnoses, and they have lack of investment or decreased motivation in treatment. He then presented the Dos and Donts what to do when a patient has trauma or reveals trauma in their past. Table 1 outlines these. This session ended with four different scenarios, developed by the student and the OT practitioner. This prompted clinical reasoning from the therapists to analyze a situation and how they would respond in said situation. A total of nine trauma-informed care presentations were delivered. Session 3: Chronic Pain. The final part of the educational series was a presentation over chronic pain. Misconceptions and corrections of chronic pain were discussed with therapists. Common misconceptions include that the health professional is the best judge of existence of a patients pain, the health professional must believe what the client says about pain, and that there is no reason for someone to be in pain if no physical cause is found (McCaffery & Pasero, 1999). Best practice of chronic pain includes the patients self-report as the most reliable measure of the existence of pain, the standard of pain rating should be the patients report and the clinician should accept and respect the self-reported rating, and that pain is a complex diagnoses and not all causes of pain can be physically determined (McCaffery & Pasero, 1999). APPROACH TO CHRONIC PAIN 23 The current state of chronic pain treatment and desired state of chronic pain treatment were evaluated with the therapists in attendance. The current state consists of a referral to physical therapy, general evaluation with a pain scale rating of 1-10, manual therapies, suboccipital release, progressive muscle relaxation, gentle exercises, and occasionally craniosacral therapy. The desired state was outlined as including a narrative evaluation, potential referrals to OT, massage therapy, Behavioral Health, and the Healthy Living Center when appropriate. Pain should be evaluated with a functional pain scale and assessed both before and after the treatment session. The shift to the functional pain scale, rather than numerical, allows for a more comprehensive evaluation process through understanding the implications pain has on an individuals daily occupations. This student created a functional pain assessment adapted from the ratings of the Functional Pain Scale and Balance your Life pie. Refer to Appendix B. In order to establish a true interdisciplinary approach, the scope of practice of PT, OT, and speech-language pathology were reviewed. This promoted staff education on the roles each profession has with chronic pain patients. The goal was to specifically help physical therapy know when to refer to OT or massage therapy. For the purpose of this DCE, the role of OT was heavily presented on. For chronic pain, an occupational therapist can identify activities that aggravate pain, perform an activity analysis, and modify specific activities, teach methods to decrease duration of painful episodes, promote function in daily activities, act as part of the interdisciplinary team, and educate and demonstrate adaptive equipment to assist with tasks such as reaching, dressing, bathing, and household chores (American Occupational Therapy Association, 2002). Occupations were then reviewed. This promoted physical therapists knowledge of basic and instrumental activities of daily living that chronic pain patients may be experiencing difficulty in performing; and therefore, to refer these patients to OT. These APPROACH TO CHRONIC PAIN 24 included bathing and showering, toileting, dressing, functional mobility, personal hygiene and grooming, sexual activity, pet care, driving and community mobility, health management and maintenance, financial management, home establishment and management, meal preparation and cleanup, safety, shopping, rest and sleep, job performance, leisure, and social participation (American Occupational Therapy Association, 2014). While the outpatient staff incorporated a variety of physical evidence-based treatments, not all avenues of chronic pain treatment were being utilized, specifically psychosocial interventions. The benefits of mindfulness through yoga and meditation, lifestyle redesign, sleep interventions, craniosacral therapy, massage therapy, relaxation and visualization with guided imagery, theories of gratitude, mirror therapy, cognitive-behavioral therapy, therapeutic listening, and coping skills were introduced. These interventions were outlined in the pain management toolkit available to therapists. A third close reading was conducted. The subject of the close reading was the spoken word poetry I am NOT black, you are NOT white. by Prince Ea. This poem outlines the effects labels have on different populations and society. Therapists watched the poem and responded to the prompt: How do labels influence you treat your patients? What labels are associated with chronic pain patients? How can we change them?. Once the five minutes of free writing was complete, therapists were invited to participate in an open discussion. The presentation also reviewed the referral processes and guidelines for both the Behavioral Health Department and the Healthy Living Center. Educating therapists on how to refer to other specialities increases the ability to treat the chronic pain patient in a client-centered, holistic way. A total of four presentations were delivered. APPROACH TO CHRONIC PAIN 25 Pain Management Toolkit. The pain management toolkit was available to all therapists and other health professionals, such as nurses, no matter the setting they are worked in. Staff would find this toolkit via a network folder on the shared drive. Contained in the toolkit are folders that included evidence supporting various interventions for chronic pain, scripts for guiding patients in meditation, yoga, relaxation, and guided imagery, an energy conservation handout, a yoga home exercise plan, handouts for patients of what they can do at home and what they may receive at the outpatient therapy clinic in terms of pain management, a worksheet for patients to document their pain symptoms as a resource to take to the doctor, a sleep hygiene tip sheet, and a change plan worksheet to outline the changes they want to make and barriers that may prevent this change. The toolkit resources will be finalized via the hospital organization. Discontinuation and Outcome Phase The discontinuation phase began during the 14th week of the doctoral capstone experience. A survey was distributed to the therapy staff via email and at the last educational session to determine the effects of the educational series. This survey was modified from the original survey to better correspond with the capstone experience. Refer to Figure 1B for the survey. Twenty-four surveys were received back; however, four were excluded because they were not complete. Post-survey results indicated that there was an overall increase in knowledge of narrative medicine, evidence-based pain management strategies, sufficient knowledge in trauma-informed care, increased knowledge in community resources, and an increase in having the right tools for pain management (See Figure 2B). Suggestions for how to better implement narrative medicine and trauma-informed care included an interdisciplinary approach (such as including nursing), specific protocols with practicing therapeutic support and listening, simulations for clinicians as APPROACH TO CHRONIC PAIN 26 training tools, and continued discussion of evidence-based practice. It should be noted that due to inconsistent sample size, the pre-education and post-education surveys were not completely related. Eight therapists returned the pre-education survey, while twenty-four returned the posteducation survey. Quality improvement involves systematic and continuous actions that lead to measurable improvement in health care services and the health status of targeted patient groups (U.S. Department of Health and Human Services: Health Resources and Services Administration, 2011, p. 3). For the purposes of this capstone experience, the health care services included entire therapy staff and the targeted patient group was individuals with chronic pain. The educational series was designed to improve the quality of treatment provided by therapists through incorporating narrative medicine and trauma-informed care to individuals with chronic pain. Each educational presentation involved open discussions, whether through a close reading or statements made during the presentations. Through these discussions, the managers and this student were able to gain knowledge about what the therapists needed to feel successful in implementing these strategies. Staff suggested things such as more time for documentation and consistency of care. All of these have been taken into consideration by the management team as to how they can be implemented to daily care. Sustainability of this education will be conducted by a subcommittee of two OTs, two PTs, and one speech-language pathologist. The topics of narrative medicine and traumainformed care will be incorporated into therapists annual competency reviews. The education will be provided from the powerpoints used in the DCE. Overall Learning APPROACH TO CHRONIC PAIN 27 The experiences gained from the DCE are invaluable to the occupational therapy profession as an entry-level practitioner. This student had the opportunity to work with various health professionals and leaders in the community and increased knowledge on the importance of advocacy, collaboration, and open communication through various interactions. The purpose of this doctoral capstone experience was to promote OT as an alternative treatment to prescription OPRs for patients with chronic pain. Because chronic pain patients have an increased likelihood of past traumatic events, trauma-informed care, along with narrative medicine, provides a way to promote patient empowerment in treatment. As the pre-study suggested, therapist knowledge in narrative medicine and evidence-based chronic pain management strategies were limited. Through the implementation of this capstone experience, knowledge in narrative medicine and trauma-informed care increased overall within the therapy department. The collaboration between Behavioral Health and the Healthy Living Center was an integral part of the capstone experience. Collaboration occured in person through meetings as well as electronically. Early on in this experience, it was learned that there was a lack of understanding between Therapy Services, Behavioral Health, and the Healthy Living center as to how each service could benefit from one another. Meeting with each department, this student was able to educate on how a dynamic diagnoses like chronic pain could benefit from the services provided within each area. In order to establish a relationship between services, a document was created that states conditions and diagnoses, therapy interventions, and the referral process for therapy services. This document will be used by Behavioral Health and the Healthy Living Center to assist in referring their patients to therapy services. This student also educated the therapy staff through a presentation and creation of a referral tree of the referral process and APPROACH TO CHRONIC PAIN 28 the services and groups provided by Behavioral Health and Healthy Living that therapy patients could benefit from. Collaboration was also essential in developing the pain management toolkit. Multiple meetings with physical therapists and occupational therapists were held to gain a greater understanding of the current process of pain management in therapy services. The goal was to create an interdisciplinary tool that provided all therapists, no matter their specific skill set, with the information needed to deliver effective, evidence-based interventions to patients with chronic pain. Advocacy was an important and unique opportunity during this capstone. This student had the opportunity to meet with the Mayor and State House Representative. The meetings with the Mayors were attended by the student and supervisors. During these meetings, alternative therapy services provided by Franciscan Health and how they can help to combat the opioid crisis in Lafayette and West Lafayette were discussed. Representative Klinker and Mayor Roswarski were very interested in understanding occupational therapy in a new light by understanding OTs role in chronic pain management and mental health. They were willing to support the profession in any future needs. This student learned that there is no reason to not reach out to leaders in the community about the benefits that occupational therapy services can provide. The best way to advocate for the profession is to educate those who have influence over policy. Not only was this student involved in discussing this capstone with community leaders, but also had the opportunity to attend internal meetings within the hospital network aimed to reduce the use of prescription opioids. These meetings were attended by physicians, nurse practitioners, case managers, pharmacists, and were lead by a business team leader. An A3 form APPROACH TO CHRONIC PAIN 29 was completed in the first meeting to create a plan on how to analyze current use of prescription opioids and the overall goals of this initiative. This specific form is used to understand the background of the improvement goal (reduction in use of prescription opioids), the current conditions (how are opioids currently being used in the hospital system), specific goals (trying to accomplish alternatives to prescribing opioids), an analysis of the current and desired state, barriers that may limit success of the goals, plan for improvement (incorporating alternative therapies - such as OT), and follow-up (LeanProject, n.d.). While attending these meetings, this student learned how change occurs within a large hospital organization. In order for change to be successful, the current state must be analyzed (in this case the process of prescribing opioids) and then the future state is created. This student was able to advocate for therapys role in this process by educating the committee about alternative approaches to pain management. In order to advance any health profession, research must be conducted. The hospital network was provided with an opportunity for research on TENS units. The opportunity came about through contacting a professor at Purdue University who was able to refer this student to a biomechanical engineer professor. Through phone call meetings, we were able to identify clinical problems with TENS units. Purdue University will create a team of engineers that will develop a research protocol for the use of TENS units with specific diagnoses with this hospital network providing the data. The DCE was more than this student ever could have imagined. This student was able to develop a project with the support of the supervisors and faculty mentors that will have a lasting impact on the OT career. Not only did this student have an impact within the hospital and therapy clinic through education on narrative medicine and trauma-informed care, but this APPROACH TO CHRONIC PAIN 30 student was able to work with leaders in the community about the integrating occupational therapy as a viable treatment option for pain management. There is a substantial need in todays society for alternative treatment options for individuals with chronic pain. Providing these alternative treatment options aims to reduce the dependence on opioids for pain relief. This capstone was successful in increasing overall knowledge of narrative medicine and trauma-informed care of staff within a therapy department. Knowledge of chronic pain management increased; however, it is still important for evidencebased treatment approaches to be utilized in the future. In order to use a true interdisciplinary approach, occupational therapy must be included in pain management programs and clinics. Promoting occupational therapys role in chronic pain management, with a narrative medicine and trauma-informed approach, may help alleviate the need for opioid use with chronic pain patients. APPROACH TO CHRONIC PAIN 31 References American Occupational Therapy Association. (2014). Occupational therapy practice framework: Domain and process (3nd ed). American Journal of Occupational Therapy, 68(Suppl. 1), -S48. http://dx.doi.org/10.5014/ajot.2014.682006 American Occupational Therapy Association. (2015). The role of occupational therapy in palliative and hospice care. Retrieved from https://www.aota.org/~/media/Corporate/Files/AboutOT/Professionals/WhatIsOT/PA/Fac ts/FactSheet_PalliativeCare.pdf American Occupational Therapy Association. (2016). Surgeon general calls on health care professionals to combat opioid abuse. Retrieved from https://www.aota.org/PublicationsNews/AOTANews/2016/combat-opioid-use-epidemic-surgeon-general.aspx American Occupational Therapy Association. (2002). Chronic pain. Retrieved from https://www.aota.org/About-Occupational-Therapy/Patients-Clients/Health-andWellness/Pain.aspx Anderson, R. M., & Funnel, M M. (2010). Patient empowerment: myths and misconceptions. Patient Education and Counseling, 79(3), 277-282. B. Taylor, personal communication, March 20, 2018 Bangert, D. (2017, December 22). City sues drug makers for opioid crisis ravaging Lafayette; county considers following. Journal and Courier. Retrieved from http://www.jconline.com/story/news/2017/12/22/city-sues-drug-makers-opioid-crisisravaging-lafayette/977075001/ Barrie, J. (2011). Patient empowerment and choice in chronic pain management. Nursing Standard, 25(31), 38-41. APPROACH TO CHRONIC PAIN 32 Breivik, H., Collett, B., Ventafridda, V., Cohen, R., & Gallacher, D. (2006). Survey of chronic pain in Europe: Prevalence, impact on daily life, and treatment. European Journal of Pain, 10(4), 287-333. Campbell, J. (1996). APS presidential address. 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Retrieved from https://event.on24.com/eventRegistration/console/EventConsoleApollo.jsp?&eventid=14 87728&sessionid=1&username=&partnerref=&format=fhaudio&mobile=false&flashsup portedmobiledevice=false&helpcenter=false&key=89BF794F37726508B0671C4362E3 A2C5&text_language_id=en&playerwidth=1000&playerheight=650&overwritelobby=y &eventuserid=197921555&contenttype=A&mediametricsessionid=161236014&mediam etricid=2135572&usercd=197921555&mode=launch APPROACH TO CHRONIC PAIN 33 Domino, J. V., & Haber, J. D. (1987). Prior physical and sexual abuse in women with chronic headache: Clinical correlates. The Journal of Head and Face Pain, 27, 310-314. Dunn, W. (1988). Models of occupational therapy service provision in the school system. The American Journal of Occupational Therapy, 42(11), 78-723. Gatchel, R. J., McGeary, D. D., McGeary, C. A., & Lippe, B. (2014). Interdisciplinary chronic pain management: Past, present, and future. American Psychological Association, 69(2), 119-130. doi: 10.1037/a0035514 Hill, W. (2016). The role of occupational therapy in pain management. Anesthesia and Intensive Care Medicine, 17(9), 451-453. Indiana State Department of Health. (2016). 2016 fatal opioid overdose demographics. Retrieved from http://in.gov/isdh/files/Tippecanoe_2016_MortInfo.pdf Johnson, E. M., Lanier, W. A., Merrill, R. M., Crook, J. Porucznik, C. A., Rolfs, R. T., & Sauer, B. (2013). Unintentional prescription opioid-related overdose deaths: Description of decedents by next of kin or best contact, Utah, 2008-2009. Journal of General Internal Medicine, 28(4), 522-529. doi: 10.1007/s11606-012-2225-z Jones, G. T., Power, C., & Macfarlane, G. J. (2009). Adverse events in childhood and chronic widespread pain in adult life: Results from the 1958 British Birth Cohort Study. Pain, 143, 92-96. Kolodny, A., Courtwright, D. T., Hwang, C. S., Kreiner, P., Eadie, J. L., Clark, T. W., & Alexander, G. C. (2015). The prescription opioid and heroin crisis: A public health approach to an epidemic of addiction. Annual Review of Public Health, 36, 559-574. APPROACH TO CHRONIC PAIN 34 Lafayette sues opioid companies for addiction crisis. (2017, December 22). Retrieved from http://www.wlfi.com/content/news/Lafayette-sues-opioid-companies-for-addiction-crisis465926103.html LeanProject. (n.d.). A3 reporting and problem solving. Retrieved from http://www.leanproject.com/what-we-do/key-components/lean-tools-techniques/a3-moredescription/ McBeth, J., Silman, A. J., Gupta, A., Chiu, Y. H., Morriss, R., Dickens, C., King, Y., & Macfarlane, G. J. (2007). Moderation of psychosocial risk factors through dysfunction of the hypothalamic-pituitary-adrenal stress axis in the onset of chronic widespread musculoskeletal pain: Findings of a population-based prospective cohort study. Arthritis & Rheumatism, 56, 360-371. McCaffery, M. & Pasero, C. (1999). Pain: Clinical manual (2nd ed.). St Louis, MO: Mosby. Merritt Hawkins. (2018). Physician recruiting and emotional intelligence: Going beyond IQ and Type A personalities. Retrieved from https://www.ihaconnect.org/_layouts/15/WopiFrame.aspx?sourcedoc={F60F40E8-A8844A2A-96C0864B177583E7}&file=MHA%20Whitepaper_Emotional%20Intelligence.pdf&action=de fault&DefaultItemOpen=1 Odell, S. & Logan, D. E. (2013). Pediatric pain management: The multidisciplinary approach. Journal of Pain Research, 6, 785-790. doi: 10.2147/JPR.S37434 Oslund, S., Robinson,R. C., Clark, T. C., Garofalo, J. P., Behnk, P. Walker, B., . . . Noe, C. E. (2009). Long-term effectiveness of a comprehensive pain management program: APPROACH TO CHRONIC PAIN 35 Strengthening the case for interdisciplinary care. Proceedings (Baylor University Medical Center), 22(3), 211-214. Quinones, S. (2015). Dreamland: The true tale of Americas opioid epidemic. New York, NY: Bloomsbury Press. Rolf-Detlef, T., Winfried, R., Barke, A., Aziz, Q., Bennett, M., Benoliel, R.,Wang, S. J., (2015). A classification of chronic pain for ICD-11. International Association for the Study of Pain, 156(6), 1003-1007. doi: 10.1097/j.pain0000000000000160 Rosti, G. (2017). Role of narrative-based medicine in proper patient assessment. Support Care Cancer, 25(1), S3-S6. doi: 10.1007/s00520-017-3637-4 Roth, R. S., Geisser, M. E., & Williams, D. A. (2012). Interventional pain medicine: Retreat from the biopsychosocial model of pain. Translational Behavioral Medicine, 2(1), 106116. doi: 10.1007/s13142-0110-0090-7 Scaffa, M. E., & Reitz, S. M. (2014). Occupational therapy in community-based practice settings. Philadelphia, PA: F. A. Davis Company Scarinci, I. C., McDonald-Haile, J., Bradley, L. A., & Richter, J. E. (1994). Altered pain perception and psychosocial features among women with gastrointestinal disorders and history of abuse: A preliminary study. The American Journal of Medicine, 97, 108-118. Schofferman, J., Anderson, D., Hines, R., Smith, G., & Keane, G. (1993). Childhood psychological trauma and chronic refractory low-back pain. The Clinical Journal of Pain, 9, 260-265. Skjutar, A., Schult, M-L., Christensson, K., & Mullersdorf, M. (2009). Indicators of need for occupational therapy in patients with chronic pain: Occupational therapists focus groups. Occupational Therapy International, 17(2), 93-103 doi: 10.1002/oti.282 APPROACH TO CHRONIC PAIN 36 Substance Abuse and Mental Health Services Administration. (2014). SAMHSAs concept of trauma and guidance for a trauma-informed approach. Retrieved from https://store.samhsa.gov/shin/content/SMA14-4884/SMA14-4884.pdf U.S. Department of Health and Human Services: Health Resources and Services Administration. (2011). Quality improvement. Retrieved from https://www.hrsa.gov/sites/default/files/quality/toolbox/508pdfs/qualityimprovement.pdf Upadhyay, J., Maleki, N., Potter, J., Elman, I., Rudrauf, D., & Knudsen, J.,Borsook, D. (2010). Alterations in brain structure and functional connectivity in prescription opioid patients. Brain: a journal of neurology, 133(7), 2098-2114. doi: 10.1093/brain/awq138 Uyeshiro Simon, A. & Collins, C. E. R. (2017). Lifestyle Redesign for chronic pain management: A retrospective clinical efficacy study. American Journal of Occupational Therapy, 71, 7104190040. https://doi.org/10.5014/ajot.2017.025502 Walker, E. A., Keegan, D., Gardner, G., Sullivan, M., Bernstein, D., & Katon, W. J. (1997). Psychosocial factors in fibromyalgia compared with rheumatoid arthritis: II Sexual, physical, and emotional abuse and neglect. Psychosomatic Medicine, 59, 572-577. Walling, M. K., Reiter, R. C., OHara, M. W., Milburn, A. K., Lilly, G., & Vincent, S. D. (1994). Abuse history and chronic pain in women: I. Prevalences of sexual abuse and physical abuse. Obstetrics & Gynecology, 84, 193-199. Wasmuth, S. (2017). Narrative Medicine [PowerPoint slides]. Young-Casey, C., Greenberg, M. A., Nicassio, P. M., Harpin, R. E., & Hubbard, D. (2008). Transition from acute to chronic pain and disability: A model including cognitive, affective, and trauma factors. Pain, 134, 69-79. APPROACH TO CHRONIC PAIN Zimmerman, G. L., Olsen, C. G., & Bosworth, M. F. (2000). A stages of change approach to helping patients change behavior. American Family Physician, 61(5), 1409-1416. 37 APPROACH TO CHRONIC PAIN 38 Tables Table 1 Dos and Donts of Responding Dos Invite conversation Donts Touch without spoken permission. Allow expression of emotions Talk about your own trauma or anyone elses. Allow silence Make promises you cannot keep. Listen, Listen, Listen! Get too close maintain emotional, personal boundaries. Invite conversation Ask too many questions. Allow expression of emotions Ask What can I do for you now? Ask What has helped you to feel better in the past? Offer options to feeling better and healing that you have available (refer to therapist, get ice water, take outside for fresh air). Provide choices. Inform them of the treatment. What will happen next. Ask if it is okay to touch them. Provide privacy Be able to say I dont know When asked Why? No guessing as to motives. Note: This table was presented to therapists during the Trauma-Informed Care presentation. An OT who works on the psychiatric unit developed this list. (B. Taylor, personal communication, March 20, 2018). APPROACH TO CHRONIC PAIN 39 Figures My name is Kersten Laughlin and I am an Occupational Therapy student from the University of Indianapolis. I am completing my Doctoral Capstone Experience here at Franciscan Health, and I am focusing on promoting non-pharmaceutical pain management strategies via PT, OT, ST, AT, and Massage Therapy, while educating health practitioners on narrative medicine. I am interested in understanding the health practitioners perspective about the current approach to pain management. Please respond to each statement correspondingly. 1 Strongly Disagree 2 3 4 Disagree Neutral Agree 5 Strongly Agree 1. I am familiar with narrative medicine and know how it can be applied to individuals with chronic pain. 1 2 3 4 5 2. I have an evidence-based, current protocol for an individual with chronic pain. 1 2 3 4 5 Explain: 3. I am familiar with using a screening tool to detect an individual who may be at risk for opioid abuse. 1 2 3 4 5 Screening Tool Used (if applicable): 4. I am aware of resources in the community, such as support groups, for this population. 1 2 3 4 5 Examples of Resources: 5. I feel I have the right tools to offer the most effective pain management strategies. 1 2 3 4 4 Explain: Figure 1A: Pre-survey that was sent out to therapy staff via email prior to education series. APPROACH TO CHRONIC PAIN 40 It has been a pleasure working with all of you for my Doctoral Capstone Experience. Your feedback on this survey is greatly appreciated. Please respond to each statement correspondingly. 1 2 3 4 5 Strongly Disagree Disagree Neutral Agree Strongly Agree 1. I am familiar with narrative medicine and know how it can be applied to individuals with chronic pain. 1 2 3 4 5 Explain: 2. I have an evidence-based, current protocol for an individual with chronic pain. 1 2 3 4 Explain: 5 3. I am familiar with the trauma-informed care approach and know what signs and symptoms to be aware of that may represent trauma. 1 2 3 4 5 Explain: 4. I am aware of resources in the community, such as support groups, for this population. 1 2 3 4 5 Examples of Resources: 5. I feel I have the right tools to offer the most effective pain management strategies. 1 2 3 4 Explain: 5 6. What are your suggestions on how to best implement narrative medicine and trauma-informed care? Figure 1B: Post-survey that provided to therapy staff after implementation of educational series. APPROACH TO CHRONIC PAIN Figure 2A: Results from surveys administered to therapy staff prior to education series. 41 APPROACH TO CHRONIC PAIN Figure 2B: Results from post-survey that was sent to therapy staff after attending educational sessions. 42 APPROACH TO CHRONIC PAIN 43 Appendix A APPROACH TO CHRONIC PAIN 44 Appendix B Visualize Your Pain Using the following colors, color code your pain at the corresponding time of day. Try to identify activities that make your pain worse or better. Completing this will give you a visual representation of how pain is impacting your daily activities. Black: Intolerable and intense. You are unable to do anything or verbally communicate because of the pain. Red: Intolerable. You are not able to perform activities such as using the telephone, watching TV, or read. Orange: Intense, strong, piercing pain; however, you are able to use the telephone, watch TV, or read. Yellow: Tolerable. The pain does prevent some activities but you have learned to adapt to it during activities. Green: Tolerable and does not prevent any activities. Blue: No pain experienced.  ...

... Occupational Therapy Students Role in Advancing Clinical Skills in a Hand Therapy Clinic: Analysis of Gun Shot Wound to the Hand Shelby Allen, OTS May, 2018 A capstone project submitted in partial fulfillment for the requirements of the Doctor of Occupational Therapy degree from the University of Indianapolis, School of Occupational Therapy. Under the direction of the faculty capstone advisor: Jim McPherson, PhD, OTR Running Head: OTS IN HAND THERAPY CLINIC 1 A Capstone Project Entitled Occupational Therapy Students Role in Advancing Clinical Skills in a Hand Therapy Clinic: Analysis of Gun Shot Wound to the Hand Submitted to the School of Occupational Therapy at University of Indianapolis in partial fulfillment for the requirements of the Doctor of Occupational Therapy degree. By Shelby Allen OTS Approved by: Faculty Capstone Advisor Date Doctoral Capstone Coordinator Date Accepted on this date by the Chair of the School of Occupational Therapy: Chair, School of Occupational Therapy Date OTS IN HAND THERAPY CLINIC 2 Abstract Over 67,000 individuals are injured from firearms each year. Occupational therapists are able to treat individuals with upper extremity injuries. Occupational therapy students are trained in school on the basic upper extremity injuries and are able to implement what they have learned through fieldwork rotations. Following a review of literature it has been found that there is an unclear distinction of the expectations of a doctoral capstone student at a hand therapy clinic. The purpose of this project was to bring awareness and education to occupational therapy students and new graduates on the difference between a level II fieldwork rotation and doctoral capstone expectations at a hand therapy clinic. A client analysis guide was also provided as a tool for individuals on the implementation of an advanced hand injury. Assessment tools, such as the QuickDASH can assist therapists in collaborating with patients to establish meaningful goals. The principles of managing pain, preventing infection, and increasing motion were involved during the treatment of a traumatic hand injury patient with the ultimate goal to maximize hand function. After utilizing current literature and providing treatment modalities, the client was able to maximize his daily function. OTS IN HAND THERAPY CLINIC 3 Introduction Approximately 32,000 people die from firearms each year and 67,000 individuals are injured (Fowler, Dahlber, Haileyesus, & Annest, 2015). Between 2010 and 2012, males accounted for 90% of nonfatal firearm injuries treated in emergency departments. The upper extremity accounts for 34% of the nonfatal accidental firearm injuries requiring medical attention (Fowler et al., 2015). Occupational therapists have a unique role in upper extremity rehabilitation by enabling clients to participate in meaningful daily life activities (American Occupational Therapy Association, 2014; Amini, D., 2016). Entry-level masters degree occupational therapy students are expected to treat upper extremity injuries at a general level (Commission on Education, 2015). However, entry-level clinical doctoral degree occupational therapy students have the opportunity to treat more advanced injuries (Commission on Education, 2015). This doctoral level student received a general introduction to an outpatient hand therapy clinic for a level II fieldwork rotation. The student also chose to complete the doctoral capstone experience at the same hand therapy clinic to obtain advanced skills in this area. The purpose of this paper is to bring awareness and education to occupational therapy students and new graduates on the difference between a level II and doctoral capstone student expectations at a hand therapy clinic. Background The paper analysis is intended for occupational therapy students and new graduates. It is designed to educate individuals on the distinction between level II and doctoral capstone student expectations at a hand therapy clinic. This paper analysis can be used as an additional tool to enhance learning and implementation of interventions on advanced injuries at a hand therapy OTS IN HAND THERAPY CLINIC 4 clinic including multiple trauma injuries. It is understood that occupational therapy level II fieldworks typically focus on general clinical skills in the specialized setting. With the additional case analysis, students and new graduates will now have an extra tool to enhance their knowledge when working with advanced injuries including gun shot wounds. Literature Review Gunshot hand injuries are very complex in nature due to the multiple structures of the hand and its functional importance (Kerkar, 2016). Primary care physicians play an important role with traumatic hand injuries (Cheung, Hathell, & Thoma, 2013). Their role is crucial for acute injury prevention for improper management and long-term consequences. With the proper examination, primary care physicians can ensure a timely recovery and initiate surgery or therapy for upper extremity injuries (Cheung, Hatchell, & Thoma, 2013). Communication between multidisplinary teams consisting of hand therapists, hand surgeons, and mental health providers is crucial when stating information to the client and family for long-term functional outcomes (Jacobs, 2016). Individuals who have traumatic hand injuries often have significant challenges they face (Hannah, 2011). Along with physical trauma, individuals with traumatic hand injuries often experience psychological or emotional trauma. Occupational therapists and hand therapists are certified in treating upper extremity injuries and play a role in assisting physical and psychosocial issues by providing education (AOTA, 2014; Amini, 2016; Hannah, 2011). Approximately 85% of all hand therapists have an occupational therapy degree. Upper extremity rehabilitation injuries include fractures, tendon and nerve injuries/repairs, arthritis, shoulder replacements, upper extremity pain, and multiple trauma injuries. Occupational therapists OTS IN HAND THERAPY CLINIC 5 assessments and interventions are holistic and client-centered driven to ensure maximal function in meaningful activities. The holistic approach goes beyond treating upper extremity injuries and includes the whole person, their roles, and their environment (AOTA, 2014; Amini, 2016). By providing education, valuable feedback, and active participation, occupational therapists are able to use a holistic approach in treating individuals with complex hand injuries (Amini, 2016; Hannah, 2011) As part of the educational component that occupational therapists receive in graduate school, fieldwork rotations are arranged for hands on experience as part of preparation for post job placements (ACOTE, 2013). Fieldwork rotations are arranged in levels for advancing clinical reasoning and hands on experience. Level I fieldwork is arranged to have the student be introduced to the fieldwork experience with directed observation. Level II fieldwork promotes clinical reasoning and hands on experience for the student with a goal of developing entry-level, general clinical skills. Many schools are transitioning to entry-level clinical doctoral degree programs from master degree programs and are mandated to move to entry-level doctoral degree programs by 2027 (ACOTE, 2013; AOTA, 2018). Entry-level doctoral degree programs offer an additional semester for advancement of clinical skills, research skills, advocacy, administration, and/or theory development during a 16-week doctoral capstone (ACOTE, 2017; AOTA, 2018). The focus of this doctoral capstone project includes advancing clinical skills beyond the generalist level of hand therapy with a correlated program development project and case analysis. General clinical skills were received at an outpatient hand therapy clinic for a level II fieldwork rotation. At the same outpatient hand therapy clinic, advanced skills are obtained through the doctoral capstone experience. Advanced clinical skills include evaluating and treating more complex injuries that are not typically treated by a level II fieldwork student. These complex OTS IN HAND THERAPY CLINIC 6 injuries can include shoulder injuries, complex fractures, amputations, tendon repairs, gunshot wounds, and multiple traumas. Theory When deciding how this project would be used, theory assisted in guiding this process. The theory that I have chosen to guide this capstone project is the biomechanical/rehabilitative frame of reference. This frame of reference relates to this capstone placement as it focuses on physical deficits (Cole & Tufano, 2008). A main component of this theory is the restorative and rehabilitative approach that is used to guide intervention planning (Cole & Tufano, 2008). This frame focuses on maintaining active range of motion (AROM) and passive range of motion (PROM), reducing edema, promoting wound healing, reducing pain, and providing therapeutic techniques. Possible interventions include positioning, splinting, range of motion, strengthening, and physical agent modalities. These are all typical interventions that are used at this outpatient hand therapy clinic (Cole & Tufano, 2008). Case Analysis A 34-year-old male sustained a self-inflicted gunshot wound to his left hand. The gunshot wound resulted in severe injuries to his left carpus, left middle and ring finger metacarpal fractures, extensor tendon lacerations, and common digital nerve lacerations. At his first surgery, the client underwent an open-reduction internal fixation to the carpus with a dorsal spanning plate, left long and ring finger fractures, carpal tunnel release, ring finger extensor tenodesis to long finger extensor tendon, and second common digital nerve repair with allograft. During the second surgery, the client underwent left wrist midcarpal fusion, removal of deep implant and antibiotic beads, and an iliac crest bone graft to left wrist fusion. With limited OTS IN HAND THERAPY CLINIC 7 motion in the wrist and fingers, the client underwent his third surgery after four months with an extensor tenolysis, metacarpal caps, and hardware removal. Recently the client has been back to therapy for his post fourth surgery with revision of tenolysis, metacarpal caps, and tendon transfer to index finger and long finger intrinsics. Screening/Evaluation This project was created to provide education on the expectations of a doctoral capstone student in an outpatient hand therapy clinic and a case analysis of a traumatic hand injury with assessment and intervention recommendations. The project took place at an outpatient hand therapy clinic in Lafayette. The facility has two sites, where the supervisor and student transferred back and forth to treat clients. The population for at this site consisted of five occupational therapists, with a majority of the therapists as Certified Hand Therapists, three hand surgeons, and individuals being treated for upper extremity injuries. One client specifically was chosen for this project as he was seen previously by the student as a level II student and has continued therapy due to the nature of his complicated injury. This outpatient hand therapy clinic was chosen based on personal interest of the student. In order to conduct the review of literature, various resources were gathered and utilized. Evidence-based journal articles were found through a systematic search of the University of Indianapolis database. Search engines included EBSCOhost and OT search, along with Google Scholar, the sites database, American Journal of Occupational Therapy, and textbooks from previous coursework from the Doctorate of Occupational Therapy program. Key words used included: occupational therapy, hand therapy, gun shot wounds, traumatic hand injuries, hand injury statistics, and doctoral capstone occupational therapy. Articles were obtained and analyzed for relevant information pertaining to the purpose of my doctoral capstone project. OTS IN HAND THERAPY CLINIC 8 Additionally Jody L. Lee, MOT, OTR, CHT, a therapist and supervisor at this placement provided valuable resources that she has collected over the years. After the review of literature was collected and analyzed, it was evident that students are unaware of the expectations of a doctoral capstone student advancing clinical skills in a hand therapy clinic. A needs assessment was also conducted to determine any issues or needs that were important to the facility. After face-to-face interviews with the supervisor, the feedback was analyzed and written into goals. It was apparent that the facility was lacking written information and guidelines that new employees should follow. The facility would benefit from orientation manuals for new employees in the outpatient hand therapy clinic that consisted of documentation guidelines, modality competencies, and common diagnoses and protocols. To better understand the expectations, a goal attainment scale (GAS) was used to measure the students expectations during the capstone experience. A GAS is a way to measure progress towards identified goals (Krasny-Pacini, Evans, Sohlberg, & Chevignard, 2016). The GAS states five levels of goal attainment per goal addressed. The supervisor and student collaborated on the goals and expectations, as this was the first doctoral capstone student at this site. The GAS was utilized at the beginning and end of the doctoral capstone experience to determine whether or not the goals were met. As an entry-level clinical doctoral capstone student, the expectations were to observe initially, progress to hands-on treatment, then to treat multiple trauma clients with minimal assistance by the end of the 16 weeks. The expected outcome goal was to treat all shoulders and basic hand and elbow injuries with less than one verbal prompts by the end of the 16 weeks. Due to the students previous experience in the hand therapy clinic, the supervisor expected the student to gradually progress to the next levels of advanced injuries. The goals for less than expected were established by the expectations of a OTS IN HAND THERAPY CLINIC 9 level II student and the goals for more than expected were recognized as the expectations of an experienced hand therapist of more than 1 year. Figure 1 shows the goals and expectations listed. Assessments For the purpose of the case analysis, a pre- and post-test was administered to the client to measure his functional outcome and goals throughout his therapy sessions. The QuickDASH is an 11-item questionnaire that measures disabilities of the arm, shoulder, and hand (Southam, Driessens, Burton, Pope, & Thurnwald, 2016). It was chosen for this client for many purposes, 1) availability at the site, 2) applicable to the client, and 3) easy to administer. The QuickDASH was administered to the client at his initial evaluation with therapy and at the 50th visit. The QuickDASH was chosen for this client in an outpatient setting, however it may not be appropriate for an individual with a hand injury admitted in inpatient stay or skilled nursing facility. The QuickDASH follows a medical model that focuses on the disability, whereas the Canadian Occupational Performance Measure focuses on the whole person (Cole & Tufano, 2008; Van de Van-Stevens, 2015). Another assessment that would be appropriate for this client is the Canadian Occupational Performance Measure (COPM). The COPM can be used with a variety of client and diagnoses and does not generalize to a specific person. The COPM focuses on the whole person and looks at every aspect (Cole & Tufano, 2008; Van de Van-Stevens, 2015). Although the COPM focuses on the clients performance and satisfaction, the QuickDASH focuses on the level of disability and severity of the client, which is appropriate for the outpatient hand therapy setting. The QuickDASH also utilizes multiple-choice questions that allow quick and easy access to fill out when given a short amount of time. Client goals are set after the first visit, once the initial assessment is completed. At this facility, goals are already addressed for each client in the evaluation, but can be chosen OTS IN HAND THERAPY CLINIC 10 specifically for the client. Regarding the complex case analysis with a gunshot wound to the hand, all goals were chosen for this client. The goals chosen include: managing pain when completing tasks, independent in all self care tasks and work tasks, ability to don/doff clothing, ability to weight bear, ability to participate in desired leisure/activities, and ability to complete all activities of daily living including cooking, cleaning, and grooming. Implementation According to Kataria, Sharma, and Kanojia (2007), the unusualness of multiple fracture dislocations at the carpal-metacarpal joints is often associated with high-energy trauma. Individuals who experience multiple fractures have a high correlation with the ability to maintain employment and daily occupations, thus creating a socioeconomic barrier (Amini, 2016; Guike et al., 2018). This shows the need for occupational therapists to enable individuals to manage their pain and range of motion through rehabilitation, thus enabling a return to daily occupations. Under the biomechanical frame of reference, occupational therapists emphasize wound-healing procedures, provide scar management techniques, reduce edema, gain active range of motion (AROM) and passive range of motion (PROM), and provide strengthening exercises (Amini, 2016; Jack & Estes, 2010). The case analysis is intended to provide students and new graduates with education on implementation of an advanced hand injury. This will also be a resource for new graduates or therapists to educate clients on identifying what they can do functionally after surgery to promote successful recovery for occupational performance. For the case analysis and purposes of Health Insurance Portability and Accountability Act (HIPPA), the client is given the name John. OTS IN HAND THERAPY CLINIC 11 Interventions Johns gunshot wound injury to the hand is considered a section four multiple trauma injury with the expected outcome to be seen over multiple visits and taken close look at. John was evaluated for occupational therapy services two and a half weeks after his second surgery that consisted of a left wrist midcarpal fusion, bone graft of iliac crest to the left wrist fusion, removal of deep implant and antibiotic beads. Orders for therapy consisted of 1-2 times weekly for edema control with gauze, ACE wrap, and elevation, initiation of scar massage, initiation of AROM/PROM to the intrinsic muscles only, and custom fabricated wrist immobilization with metacarpals blocked. At the initial visit, the client was given a self-reported QuickDASH assessment to measure how well he is able to participate in the written descriptions of activities with his injured hand. The client scored a 0 on the QuickDASH, which refers to 100% disability. Ultrasound was recommended and initiated to the client to heal scar extensibility and temperature of the scar for the dorsal hand. Parameters were set to 100%, 1.0 mm., 3 mHz for 8 minutes after the initial screening due to the size and density of the scar. After few trials, the client and therapist collaborated to continue ultrasound to decrease the density and appearance of the scar. The client reported significant pain throughout the beginning of therapy and was sent home with a home exercise program after each visit. After two weeks with no significant improvement of range motion in the digits, John was provided with a neuromuscular electrical stimulation (NMES) unit to pull the tendons through, after understanding and consent. The NMES electrodes were placed on the extensor digitorum communis and flexor muscles with the orthotic in place to block the wrist from movement. A dynamic static progressive orthotic was also added to the clients home program to increase his range of motion of the metacarpals of the index, middle, and ring digits. OTS IN HAND THERAPY CLINIC 12 The third surgery took place three months after the second surgery for hardware removal, extensor tenolysis, and metacarpal caps. Two days after this surgery, the client was re-evaluated for continued therapy. Light compressive dressing and edema control was taken place to protect wound healing. AROM and PROM were also re-measured during the re-evaluation. The client has made slow progress but continues to have tightness in the digits. Significant pain continued to occur throughout the day and a transcutaneous electrical stimulation (TENS) unit was trialed during this session to subside the pain. Yet, the client continued to have complaints of pain with digital motion. A custom fabricated extensor resting pan orthotic was fitted for protection at nighttime. Ultrasound, scar massage, and NMES were trialed again to enhance the scar extensibility to the dorsal hand and range of motion in the digits. To enhance the clients range of motion, a static progressive metacarpal orthotic with dynamic flexion at the PIP joint was fabricated in the clinic for the index, middle, and finger digits for 20-30 minute intervals four times a day. A figure eight orthotic was also provided to the client for a reverse block and metacarpal block during the day to increase IP motion. The client was recently seen after his fourth surgery of a tendon transfer to the index and long digital intrinsics, metacarpals pinning in full flexion, and revision of tenolysis and metacarpal caps. Orders from the surgeon included extensor resting pan to safe position at night and between exercises, a fabricated P1 block during exercises, hold metacarpal movement and to initiate interphalangeal AROM/PROM. Ultrasound, scar massage, and NMES were continued to enhance the scar extensibility to the dorsal hand and range of motion in the digits. After four weeks, the client was given the ok by the surgeon to initiate slow AROM to the metacarpal joints. The client was educated to slowly decrease wearing time of orthotics over time to enhance functional mobility. At eight weeks post surgery, gentle strengthening was initiated with putty OTS IN HAND THERAPY CLINIC 13 and functional grasp. Functional grasp was assessed through the ability to pick up a cylinder lightweight jar and progressing to smaller items like blocks and beads. Education on how to adapt with significant trauma was provided throughout the duration of therapy. Over the duration of therapy, John lost his job due to aggressiveness hands-on skills that were required. At times John reported decreased motivation and hope of returning to work. According to Hannah (2011), intense emotions can arise immediately after an individuals severe hand injury and can continue throughout their life. By educating individuals with normal responses and positive attitude can help to enhance their psychosocial responses. Active participation and providing individuals with activities has been found to increase their overall attitude and independence (Hannah, 2011). Project After collaboration between the student and supervisor, orientation manuals were created for new employees at the outpatient hand therapy clinic. The orientation manuals consisted of checklists of general information including documentation guidelines, important phone numbers, location of modalities, types of splints fabricated, competency checklists, and guidelines for diagnoses. The facility previously made a template for the orientation manuals of new employees, but was altered and tailored towards both occupational and physical therapy by the student. Leadership As an entry-level clinical doctoral student, I have a better understanding of providing leadership skills and found that the overall experience has challenged my knowledge on hand, elbow, and shoulder protocols. With previous experience during the level II fieldwork rotation, I was able to advance my knowledge and provide leadership skills with treatment protocols earlier OTS IN HAND THERAPY CLINIC 14 than expected. As this being the first doctoral capstone experience at my site, I provided selfdirected skills and expectations with my therapist. I have been able to collaborate and communicate with multiple hand therapists, physical therapists, and surgeons throughout this process. Communication amongst these individuals has provided me with growth for professional development. With advanced clinical skills as my primary focus during the doctoral capstone experience, assistance and direction is required in order to provide best practice. With that being said, this experience also allows for some selfdirection to gain professional development with hand to shoulder injuries. The doctoral capstone experience has given me the opportunity to gain leadership skills and become an expert, as this is a specialized area that I have previous experience in during my level II fieldwork rotation. Staff Development There are many multidisciplinary team members that work at this facility. I have had the opportunity to connect with many therapists and surgeons at the hand therapy clinic. I was able to collaborate with occupational therapists, physical therapists, and surgeons to ensure best practice for the clients. It is vital to collaborate with these individuals to provide the best quality of care for the clients receiving treatment. I have also collaborated with the supervisor as I develop my own role as a staff member and doctoral capstone student to ensure the best learning experience. Collaboration and communication with the supervisor has enabled me to grow professionally and facilitate an independent work experience and manage my own clients. OTS IN HAND THERAPY CLINIC 15 Outcomes/Discontinuation Client Analysis Tenodesis is a frequent result of extensor tendon injuries (Browne & Ribik, 1989). Due to the nature of tenodesis on the extensor side, it can often cause tethering with flexion and decreased grip strength (Browne & Ribik, 1989). Functional grasp and strengthening exercises were initiated to John to increase his functional grasp due to the tenodesis. During the functional task activity, the client was able to pick up a jar, but had diminished sensation in the hand and fingers, thus causing it to be difficult to grasp the jar without concentration. John was able to grasp and hold a lightweight jar but demonstrated shaking during the functional grasp, indicating weakness. However, with the ability to hold a lightweight jar, John could return to opening/twisting/turning items with his nonaffected hand during daily activities. At this time, John was unable to pick up multiple small blocks and beads, without dropping, with his affected hand. John was instructed to practice fine motor activities for his home exercise program to improve his manipulation and dexterity that will be needed to perform daily tasks. Johns range of motion scores of his digits have improved significantly since the first visit. Table 2 shows the scores between the first visit and 50th visit. It has been found that early rehabilitation for post-traumatic tendon injuries is correlated with increased range of motion scores and an improved QuickDASH score (Buegja, Mifsud, & Zammit, 2016). By the 50th visit, the client was able to demonstrate increased independence with a score of 40, indicating 40% disability on the QuickDASH. At this time John has met a majority of his goals. Goals that have been achieved include grooming self, performing over-reaching tasks, fastening his seat belt, and donning/doffing clothing. He has partially met buttoning/zipping tasks, meal preparation, and pain management, OTS IN HAND THERAPY CLINIC 16 however continues to have difficulty achieving these goals. John continues to work on gripping and opening jars with the affected hand, weight bearing, lifting items, completing work tasks, and performing desired leisure activities. Due to the clients choice, John decided to take a break from therapy to improve his motivation and hope in finding a job. John was educated on the benefits of continuing therapy due to his range of motion deficits, decreased strength, and decreased scar extensibility. John was encouraged to apply to multiple businesses that required non-aggressive work and was given suggestions of settings that would be similar to his previous job and are also meaningful to him. Since John has taken time off from therapy, he has reported a possible job placement meaningful to him. The client also reported that he is expecting to seek services at this site in the near future following insurance coverage, to regain ROM and strength. Quality Improvement Throughout the doctoral capstone experience, the therapist reviewed the goal attainment scale to ensure the student maintained the expectations. With the capstone experience nearing the end, the student met the expected outcome goal to treat all shoulder and basic hand and elbow injuries with less than one verbal prompt. The student is now working towards meeting the expectations that were beyond initially expected. With the additional experience of having a level II fieldwork and doctoral capstone experience at the same site, the student was able to progress through the goals and meet the expectations. Needs of Society By providing clinical skills in a hand therapy clinic, a student must adapt to the needs of society by helping clients overcome obstacles. For the client analysis, the student was able to respond to the needs of society by helping the client increase his independence with functional OTS IN HAND THERAPY CLINIC 17 tasks. Providing the client with exercises, modalities to manage pain, and scar massage techniques helped to increase his independence. The student was also able to assist the client to return to work by providing a home exercise program that enables the client to continue working towards his goals. The student also responded to the needs of society by providing this paper analyses to educate individuals on a doctoral capstone student can gain additional clinical skills. Conclusion The paper analyses is a protocol intended to educate occupational therapy students and new graduates on how a doctoral capstone student in a hand therapy clinic can gain additional clinical skills. A clinical guide on an advanced hand injury client analysis was also provided. The clinical guide includes assessments and interventions implemented on the client and the results of the effectiveness of the intervention. This guide can also be effective for the site as a way to guide students during their fieldwork experience with the interventions provided. Overall Learning Overall, many learning goals were met and the student was able to enhance professional growth through communication. There were many opportunities to communicate with other health care providers, clients, and their families. Throughout the doctoral capstone experience, one-on-one time with the occupational and hand therapists was applicable with demonstration on splint making, modality overview, and protocols for injuries. Written communication was also provided through documentation, which enabled the therapists to provide feedback. There was close interaction with the hand and orthopedic surgeons to discuss the protocols and development of clients. Communication with the client and their families were achieved through intervention protocols and written instructions on a home exercise program. The supervisor was a great model on how to provide appropriate communication to the clients and other health care OTS IN HAND THERAPY CLINIC 18 providers. The supervisor offered effective communication, which enabled the student to provide appropriate nonverbal professional communication by listening to others with full attention and showing a positive attitude through facial expressions. With an interest in hand therapy, communication with clients and health professionals in a hand therapy clinic was effectively learned. For future practice, clinical learning skills that were developed during the doctoral capstone experience will be applied into a hand therapy clinic. Observation and interaction with therapists enabled the student to demonstrate positive attitude, effective communication, and effective time-management, which will be important for a good relationship with employees in future practice. OTS IN HAND THERAPY CLINIC 19 References American Occupational Therapy Association. (2014). The role of occupational therapy for rehabilitation of the upper extremity. [Fact sheet]. Retrieved from https://www.aota.org/~/media/Corporate/Files/AboutOT/Professionals/WhatIsOT/RDP/F acts/Upper%20Extremity%20fact%20sheet.pdf Amini, D. (2016). The unique role of the occupational therapy rehabilitation of the hand. [Fact sheet]. Retrieved from https://www.aota.org//media/Corporate/Files/AboutOT/Professionals/WhatIsOT/RDP/Facts/Hand%20 Therapy%20fact%20sheet.pdf Browne, E. & Ribik, C. (1989). Early dynamic splinting for extensor tendon injuries. The Journal of Hand Surgery, 14A(1): 72-6. Bugeja, M., Mifsud, M., & Zammit, J. (2016). Functional results following surgical repair of post-traumatic hand tendon injuries. Malta Medical Journal, 28(2), 27-35. Cheung, K., Hatchell, A., & Thoma, A. (2013). Approach to traumatic hand injuries for primary care physicians. Canadian Family Physician Medecin De Famille Canadien, 59(6), 614618. Cole, M. & Tufano, R. (2008). Applied theories in occupational therapy: A practical approach. Thorofare, N.J.: SLACK Inc. Commission on Education. (2015). Frequently asked questions about the entry-level masters and doctoral degrees for occupational therapy students. American Occupational Therapy Association. Retrieved from https://www.aota.org/- OTS IN HAND THERAPY CLINIC 20 /media/Corporate/Files/EducationCareers/Educators/COE/FAQ-on-Professional-EntryDegrees-2015.pdf Fowler, K., Dahlber, L., Haileyesus, T., & Annest, J. (2015). Firearm injuries in the United States. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4700838/pdf/nihms748353.pdf Guike, J., Leopold, B., Grozinger, D., Drews, B., Paschke, S., & Wachter, N. (2018). Postoperative treatment of metacarpal fractures: Classical physical therapy compared with a home exercise program. Journal of Hand Therapy: Official Journal of the American Society of Hand Therapists, 31(1), 20-28. doi: 10.1016/j.jht.2017.02.005 Hannah, S. (2011). Psychosocial issues after a traumatic hand injury: Facilitating adjustment. Journal of Hand Therapy, 24: 95-103. doi: 10.1016/j.jht.2010.11.001 Jack, J., & Estes, R. I. (2010). Documenting progress: Hand therapy treatment shift from biomechanical to occupational adaptation. American Journal of Occupational Therapy, 64, 8287. Kataria, H., Sharma, N., & Kanojita, R. (2007). Neglected, open multiple carpal-metacarpal fracture dislocations of the hand: An unusual entity and its management. J Orthop Trauma, 21(8). doi: 10.1097/BOT.0b013e318133477d Kerkar, P. (2016). Gunshot wound to the hand. [Fact sheet]. Retrieved from https://www.epainassist.com/personal-injury/gunshot-wound/hand-trauma OTS IN HAND THERAPY CLINIC 21 Krasny-Pacini, A., Evans, J., Sohlberg, M. M., & Chevignard, M. (2016). Proposed criteria for appraising goal attainment scales used as outcome measures in rehabilitation research. American Congress of Rehabilitation Medicine, 97: 167-170. Southam, M., Driessens, S., Burton, C., Pope, R., & Thurnwald, P. (2016). A retrospective cohort study of the QuickDASH scores for common acute trauma conditions presenting for hand therapy. Journal of Hand Therapy: Official Journal of the American Society of Hand Therapists, 30(1), 41-48. Doi:10.1016/j.jht.2016.07.004 Van de Van-Stevens, L. W., Graff, M. L., Peters, M. M., Van der Linda, H., & Geurts, A. H. (2015). Construct validity the Canadian occupational performance measure in participants with tendon injury and dupuytren disease. Physical Therapy, 95(5), 750-757. doi:10.2522/ptj.20130590 OTS IN HAND THERAPY CLINIC 22 Table 1 Goal Attainment Scale Level of Expected Outcome: Rating: MUCH MORE than EXPECTED Expected Outcomes: Expected Outcomes: Goal 1 Goal 2 2+ Student will treat all patients classified under section 4 with 2-3 verbal prompts per patient by the end of 16 weeks. Student will convert 100% of the materials/information requested by the supervisor into orientation manuals by the end of 10 weeks. MORE than EXPECTED 1+ Student will treat all patients classified under section 4 with minimal assistance by the end of 16 weeks. Student will convert 100% of the materials/information requested by the supervisor into orientation manuals by the end of 12 weeks. EXPECTED Outcome 0 Student will convert 100% of the materials/information requested by the supervisor into orientation manuals by the end of the 16 weeks. LESS than EXPECTED 1- Student will treat all patients classified under sections 1-3 with 1 or less verbal prompts per patient by the end of the 16 weeks. Student will treat all patients classified under sections 1-3 with 2-3 verbal prompts per patient by the end of the 16 weeks. MUCH LESS than EXPECTED 2- Student will treat all patients classified under sections 1-3 with minimal assistance per patient by the end of the 16 weeks. Student will convert 50% of the materials/information requested by the supervisor into orientation manuals by the end of 16 weeks. Student will convert 75% of the materials/information requested by the supervisor into orientation manuals by the end of 16 weeks. Table 1. Goal Attainment Scale. This table shows the goals addressed by the supervisor and student over the course of the 16 weeks. The sections of hand therapy injuries are stated below. Section 1: conservative/releases for basic diagnoses ex: CTR, CuTR, Trigger Finger, lateral/medial epicondylitis Section 2: basic fractures, basic tendon repairs, amputations, medial epicondlyectomy Section 3: shoulders injuries ex: impingement, rotator cuff tear Section 4: tendon transfers, arthroplasty, brachial plexus, CRPS, multiple traumas, bad crush injuries Verbal/physical prompt: therapist giving a verbal/physical correction during the treatment Minimal Assistance: helping with 25% of the treatment As part of a doctoral capstone student advancing skills in a hand clinic, it is expected for the student to ask the therapist any questions or protocols before treatment in order to ensure best practice. OTS IN HAND THERAPY CLINIC 23 Table 2 Digits Active Extension/Flexion ( /Passive Flexion) Index MP PIP DIP 1st Visit Held 25/45 ( /55) 15/15 ( /60) 50th Visit 5/75 ( /80) 15/80 ( /90) 0/60 ( /70) Difference TAM = 70 TPM = 80 TAM = 85 TPM = 145 TAM = 60 TPM = 130 1st Visit Held 30/40 ( /50) 15/25 ( /60) 50th Visit 15/70 ( /75) 15/70 ( /90) 5/45 ( /80) Difference TAM = 55 TPM = 75 TAM = 65 TPM = 140 TAM = 50 TPM = 140 1st Visit Held 35/45 ( /65) 5/25 ( /60) 50th Visit 5/70 ( /85) 10/95 ( /95) +5/25 ( /80) Difference TAM = 65 TPM = 85 TAM = 25 TPM = 30 TAM = 40 TPM = 140 1st Visit Held 10/40 ( /45) 10/20 ( /60) 50th Visit +5/70 ( /85) 0/85 ( /90) 0/60 ( /75) Difference TAM = 65 TPM = 85 TAM = 115 TPM = 135 TAM = 70 TPM = 135 Middle Ring Small Table 2. Range of motion of the patient from the initial evaluation to the 50th visit. TAM (Total Active Motion), TPM (Total Passive Motion).  ...

... Running head: PROTOCOL ANALYSIS OF JOINT REPLACEMENTS 1 Occupational Therapy Protocol Analysis: Acute Care Services for Elective Total Hip and Knee Replacement Patients Samantha Rush May 2018 A capstone project submitted in partial fulfillment for the requirements of the Doctor of Occupational Therapy degree from the University of Indianapolis, School of Occupational Therapy. Under the direction of the faculty capstone advisor: Brenda Howard, EdD, OTR PROTOCOL ANALYSIS OF JOINT REPLACEMENTS 2 A Capstone Project Entitled Occupational Therapy Protocol Analysis: Acute Care Services for Elective Total Hip and Knee Replacement Patients Submitted to the School of Occupational Therapy at University of Indianapolis in partial fulfillment for the requirements of the Doctor of Occupational Therapy degree. By Samantha Rush, OTS Approved by: Faculty Capstone Advisor Date Doctoral Capstone Coordinator Date Accepted on this date by the Chair of the School of Occupational Therapy: Chair, School of Occupational Therapy Date PROTOCOL ANALYSIS OF JOINT REPLACEMENTS 3 Abstract This paper summarizes the Doctoral Capstone Experience (DCE) that took place at Indiana University Health North Hospital (IUHNH) in which the student analyzed the occupational therapy protocol for patients following a total hip or total knee joint replacement. The purpose of this project was to identify modifications needed to improve care for this population and enhance patients independence with activities of daily living (ADLs) and instrumental activities of daily living (IADLs) following surgery. An evidence-based quality assurance questionnaire was designed and distributed to patients following their discharge from occupational therapy services. A total of 44 questionnaires were completed and returned to therapy staff. The questionnaire used a 3-point Likert scale and five open-ended questions to measure patients confidence levels, worries/concerns, and patients opinions of occupational therapy serves. Patient questionnaires indicated that the majority of patients are confident resuming their ADLs and overall have positive opinions of their occupational therapy services. As a result of this DCE, the student has shown IUHNHs total hip and knee joint replacement program has a well developed occupational therapy protocol with modification only needed in order to address confidence levels with higher level IADLs and patient specific activities. PROTOCOL ANALYSIS OF JOINT REPLACEMENTS 4 Occupational Therapy Protocol Analysis: Acute Care Services for Elective Total Hip and Knee Replacement Patients Literature Review The number of total hip replacements (THR) and total knee replacements (TKR) performed in the United States has continuously increased within the past decade (Kurtz, Ong, Lau, Mowat, & Halpern, 2007). According to projections formulated within this same study, the demand for primary THR and TKR is projected to grow 137% and 673% respectively by 2030 (Kurtz et al., 2007). The need for these surgeries often results from lower extremity osteoarthritis, associated chronic pain, stiffness, and mobility limitations (Cooke et al., 2016). Osteoarthritis and associated limb pain can often cause changes in individuals roles and social life, decrease independence with activities of daily living (ADLs), and reduce quality of life (Grant, St John, & Patterson, 2009). The recovery process for individuals following a hip or knee replacement can often be slow and affect various aspects of the persons life apart from their physical abilities (Grant et al., 2009). Although reclaiming physical capabilities is usually the main focus of therapists in the hospital setting, research has found that psychosocial issues are also an important aspect of the recovery process for this population (Grant et al., 2009). Furthermore, the recovery process would also benefit from a focus on re-establishing roles, relationships, and refocusing ones self (Grant et al., 2009). According to Kiefer and Emery (2006), skilled occupational therapy services in the acute care setting may increase patient performance in self-care, functional mobility transfers, and overall quality of life. Occupational therapy with the joint replacement population may also lead to improvements in functional mobility and occupational performance, as well as decrease activity restrictions and limitations (Richmond, 2016). Orthopedic procedures are often PROTOCOL ANALYSIS OF JOINT REPLACEMENTS 5 described as straightforward, having an anticipated plan of care, length of stay (LOS), and clinical outcomes that are expected (Prouty et al., 2006) However, multiple programs throughout the county have researched ways in which to modify current procedures to better prepare patients for both surgery and recovery (Naville, Volz, & Curry, 2009; Prouty et al., 2006). Pre-Operative Structures Currently in Place Pre-operative education provides multiple benefits when given to individuals undergoing a THR or TKR (Cooke et al., 2016). Research supports that pre-operative education allows the patient to assume a central role in their recovery promoting sustainable, long-term positive outcomes (Cooke et al., 2016). Naville et al. (2009) examined and modified the joint replacement pre-surgery structure at Baptist Hospital East in Louisville, Kentucky. Modifications to this program were followed by a survey distributed to patients, indicating that, they are pleased with the care they have received and would recommend this program to others (Naville et al., 2009, p. xx). These researchers discussed the importance of a free multidisciplinary presurgery class to provide education to patients and caregivers regarding what to expect throughout the entire recovery process (Naville et al., 2009). According to the study, the class is accompanied by a joint power aquatics course focused on increased strength and range of motion also addressing any fears or concerns individuals have regarding the upcoming surgery (Naville et al., 2009). Prouty et al. (2006) and Walker (2012) also supported the benefits of preoperative education, finding that it gave patients the opportunity to ask questions and hear a clear message from multiple disciplines before surgery. Current Postoperative Occupational Therapy within the Hospital Setting According to Naville et al. (2009), most patients spend approximately two to three hours in anesthesia care following joint replacement surgery, and are then moved to a post-operative PROTOCOL ANALYSIS OF JOINT REPLACEMENTS 6 care unit once medically stable. Depending on the program, most patients are evaluated by physical therapy either the day of surgery or on postoperative day one and evaluated by occupational therapy postoperative day three (Naville et al., 2009). Further studies support early therapy intervention following surgery, reporting rehabilitation done immediately after joint replacement patients arrive to the therapy floor positively affect function, range of motion, quality of life and the prevention of post-operative complications or blood clots (Jame Bozorgi, Ghamkhar, Kahlaee, & Sabouri, 2016; Naville et al., 2009). Grant et al. (2009) examined the recovery process as a whole following a THR. The researchers found that, recovery consists of three interrelated processes encompassing the physical, psychological, and social domains: reclaiming physical ability, re-establishing roles and relationships, and refocusing self (Grant et al., 2009, p. 1617). Naville et al. (2009) observed that therapy treatment sessions occurred in the patients room or in a therapy gym. Patients in this study were encouraged to have a support system, with one individual named a coach, present throughout the recovery process so that all therapy education could be done with both individuals (Naville et al., 2009). The coach was useful in helping assist and encourage the patient and resulted in an ultimate decrease in anxiety when discharging home. Grant et al. (2009) found similar results on the importance of having a good support system present during therapy. For the purpose of this study, adaptive equipment is defined as any device specifically used to enable individuals ability and ease to perform ADLs; such as reachers, sock-aids, longhandled sponges, elastic shoelaces, and elevated commode seats (Naville et al., 2009). According to Jame Bozorgi et al. (2016), the use of adaptive equipment following a joint replacement could reduce compressive forces on the joint and, in result, reduce the load applied to the newly PROTOCOL ANALYSIS OF JOINT REPLACEMENTS 7 replaced joint. This same study also found that patients who used adaptive devices increased self-confidence due to pain-free, active and independent performance of their ADLs (Jame Bozorgi et al., 2016). Occupational therapy treatment following a joint replacement surgery is primarily focused on examining the need for adaptive equipment, instructing the client in the use of that equipment, and educating patients on adaptive techniques in order to complete ADLs (Jame Bozorgi et al., 2016; Naville et al., 2009). McHugh and Luker (2012) conducted interviews with patients following lower extremity replacements in order to determine if their experience expectations were met. Participants reported disappointment in length of the recovery process compared to what medical professionals initially told them in regarding to returning to expected mobility level (McHugh & Luker, 2012). McHugh and Luker (2012), found there was a feeling that confidence was starting to be gained when participants stopped focusing so much on their hip, the fear of falling lessened and they began wanting to do things again. The article concluded that patients were frustrated with not being able to get back to normality and researchers found patients were hopeful to return to their leisure activities and hobbies as soon as possible (McHugh & Luker, 2012). Occupational Therapy Discharge Structures Most research regarding THR and TKR is in agreement that discharge planning should begin on the day of admission (Naville et al., 2009). According to Naville et al. (2009), all members of the orthopedic care team, which included occupational therapy, should actively participate in providing input for proper discharge to occur. US based research done by Mallinson et al. (2011) concludes direct discharge to home with home care was the optimal strategy for patients after total joint replacement surgery that were healthy and had social PROTOCOL ANALYSIS OF JOINT REPLACEMENTS 8 support. According to Grant et al. (2009), approximately 91% of patients over the age of 65 years old discharge directly to home following a joint replacement. This same research study found that patients who returned directly home were found to have increased control over their physical activity and increased confidence in their abilities due to familiarity of the living environment (Grant et al., 2009). This study also found that once patients were home, confidence levels correlated with the gradual relinquishing of mobility aids (Grant et al., 2009). Discharge preparation differs depending on whether patients are discharged home versus discharged to a rehab facility (Naville et al., 2009). Patients who returned directly home from the hospital continued their rehabilitation with either home health therapy or outpatient services (Naville et al., 2009). However, all research that discussed these services specify patients only receiving home health physical therapy services and not occupational therapy (Naville et al., 2009). For those remaining patients who are not deemed safe or appropriate to return directly home, discharge to either a subacute rehabilitation or acute rehabilitation facility where they continue both physical and occupational therapy (Naville et al., 2009). If patients are returning directly home, occupational therapy staff within the hospital assist the patient in obtaining any needed equipment and make recommendations regarding assistance needed for ADLs once home (Naville et al., 2009). This Doctoral Capstone Experience (DCE) focused on providing joint replacement patients with the highest quality of care and evidence-based occupational therapy interventions aligned with the latest research. Indiana University Health North Hospital (IUHNH) currently has an established joint replacement protocol; however, this project will aim to guarantee therapists are viewing patients using a holistic approach and truly using client-centered care; addressing not only physical impairments but also psychosocial aspects of recovery after a joint PROTOCOL ANALYSIS OF JOINT REPLACEMENTS 9 replacement. Therefore, the purpose of this study was to analyze the current occupational therapy joint replacement protocol and provide therapists with quality improvement suggestions in order to maximize outcomes and patient satisfaction within this population at IUHNH. The Model of Human Occupation The Model of Human Occupation (MOHO) is a systematic, holistic approach that focuses on the connection between the mind and body in order to provide care related to all aspects of the person and their environment (Cole & Tufano, 2008). The MOHO is client-centered in nature and appropriate to be used for individuals of all ages and diagnosis or conditions (Cole & Tufano, 2008). Lee, Taylor, Kielhofner, & Fisher (2008) analyzed occupational therapists use of the MOHO in everyday practice. The authors found that more than 80% of respondents indicated that they used MOHO in their practice at least some of the time (Lee et al., 2008). Results of this study found that therapists view the MOHO as holistic, occupation-focused, client-centered, and evidence- based practice (Lee et al., 2008). MOHO concepts are seen as useful for treatment planning and intervention and lack of knowledge regarding the model is seen as the only major barrier when using this model (Lee et al., 2008). MOHO will be utilized as a guide throughout this project to analyze and modify all aspect of the occupational therapy protocol with joint replacement patients while putting a greater emphasis on providing a holistic approach. MOHO will serve as a guide to visualize the interaction between internal motivation such as patients values, interests, and personal causation and external performance with this population in order to increase patients overall recovery once home. Screening and Evaluation Process PROTOCOL ANALYSIS OF JOINT REPLACEMENTS 10 IUHNH strives to provide the best care for their patients and focuses on returning their joint replacement patients to maximum function as quickly and as safely as possible following their surgery (A.B. Wolfgang, personal communication, January 16, 2018). This is displayed through their mission statement, Indiana University Health's mission is to improve the health of our patients and community through innovation and excellence in care, education, research and service(Indiana Health University, 2018). During an occupational therapy doctoral program rotation, located at IUHNH, the researcher worked under the clinical supervision of a licensed OTR to develop and perform all aspects of the OT process framework. While at this facility, the researcher was able to not only participate in therapy services but also observe all phases of care for patients following lower extremity joint replacements. During this rotation the researcher observed gaps within occupational therapy services. Specifically, noticing that patient education was significantly neglecting the emotional and psychosocial aspects involved in recovery. Interdisciplinary staff were preparing patients with functional mobility, transfers, and basic activities of daily living (BADLs); however, it was apparent that there was a lack in services addressing patients comfort level with these functions and with more advanced instrumental activities of daily living (IADLs). After the initial observation of potential gaps within the joint protocol, an official needs assessment was conducted. For the purpose of this study, a needs assessment is defined as any processes used to determine priorities and make improvements by identifying needs or gaps between a facility's current state and where the facility envisions itself in the future (Scaffa & Reitz, 2014). Therefore, a needs assessment was conducted at IUHNH to obtain information in order to determine gaps in the current protocol used for joint replacement patients. The researcher used a combination of methods to obtain information for the needs assessment, such PROTOCOL ANALYSIS OF JOINT REPLACEMENTS 11 as: observation and participation in treatment, direct contact including one-on-one interviews with multidisciplinary employee, and evidence-based research. The purpose of the needs assessment was to analyze the current protocol and to determine the priorities of the facility to improve occupational performance and quality of life. The researcher used information collected to break up occupational therapys current role within the joint replacement process at IUHNH into three main phases; pre-admission joint class, postoperative therapy evaluation and intervention, and discharge from therapy services. Pre-Admission Joint Class Two to three weeks prior to scheduled surgery, occupational therapys role within the joint replacement protocol begins during the pre-admission joint class (A.B. Wolfgang, personal communication, January 16, 2018) According to A.B Wolfgang, the orthopedic program coordinator for IUHNH, both TKR and THR patients are encouraged to attend this class which is run by a registered nurse (personal communication, January 17, 2018). Patients are encouraged to bring along family and friends that will act as their support system throughout the recovery process in order for both parties to be educated on all aspects of recovery (Indiana University Health, 2016, p. 17). Patients are given a total joint replacement education booklet as a valuable resource to prepare for their surgery (Indiana University Health, 2016). The booklet contains step-by-step details on what patients should expect before, during, and after surgery. (Indiana University Health, 2016, pp. 3-7) Booklet information and class education addresses multiple aspects including; preparing for surgery, your hospital stay, managing your health at home, activity guidelines, exercises, and lifestyle changes (Indiana University Health, 2016, pp. 3-7). Occupational therapys role within this class involves a short 2-5 minute presentation that briefly discusses occupational therapys involvement in patient recovery and expectations in PROTOCOL ANALYSIS OF JOINT REPLACEMENTS 12 regards to therapy treatment while in the hospital (L. Sanders, personal communication, January 16, 2018). L. Sanders, an occupational therapist at IUHNH, explained that this session includes disclosing to patients that they will be practicing toilet transfers, shower/tub transfers, and car transfers following their surgery before discharge from the hospital (personal communication, January 16, 2018). Therapists also request that patients bring loose and baggy clothing in order to practice dressing to familiarize patients with the adaptive equipment (L. Sanders, personal communication, January 16, 2018). Postoperative Occupational Therapy Process Post-operation, patients are moved to the post-anesthesia care unit (PACU) for approximately 1-3 hours based on their medical statues (Indiana University Health, 2016, p. 26). Once medically stable, patients are then moved up to a recovery room and will typically be seen by at least one therapy discipline day of surgery (L. Sanders, personal communication, January 16, 2018). Therapy services may be delayed till post op-day one pending the occurrence of any numbness, dizziness, blood pressure issues, or other health concerns (Indiana University Health, 2016, pp. 27-33). J. Thompson (personal communication, July 2017), physical therapist at IUHNH, stated that therapists may get patients up to the side of bed or ambulate with assistance if they believe it is safe to do so at this time. If patients are expected to leave the same day of surgery they must be seen by both occupational therapy and physical therapy prior to discharge (A.B. Wolfgang, personal communication, January 16, 2018). Occupational therapys focus within this stage of recovery, whether the patient is being seen day of surgery or the following days while at the hospital, is on instructing patients and their support system on how to safely complete ADLs while also abiding by any surgical precautions (J. Phillips, personal communication, May 2017). The current protocol in place involves PROTOCOL ANALYSIS OF JOINT REPLACEMENTS 13 therapists initially conducting an evaluation of patients functional mobility including bed mobility/positioning and toilet transfer, completion of ADLs, and understanding of surgical precautions (L. Sanders, personal communication, January 16, 2018). The evaluation process also involves occupational therapists determining the need for adaptive equipment in order to allow for patients to independently complete these tasks or complete them with increased ease and decreased pain (L. Sanders, personal communication, January 16, 2018). Following the initial evaluation, therapists will educate patients and their support system on safe toilet/shower/tub transfers, educate both parties on adaptive techniques for performing lower body dressing, and provide education on adaptive equipment if required (Indiana University Health, 2016, pp. 72-74). Verbal and visual instruction of shower/tub and vehicle transfers are completed, and physical practice of toilet transfers and dressing are performed (J. Phillips, personal communication, May 2017). Occupational Therapy Discharge Structure Discharge planning begins as soon as a patient schedules their joint replacement surgery (Indiana University Health, 2016, pp. 37-40). A large majority of patients discharge directly home with home or outpatient physical therapy services rather than transitioning to a post-acute or sub-acute facility (A.B. Wolfgang, personal communication, January 16, 2018). IUHNH believes that patients will be more comfortable during their recovery if they start taking care of themselves in their own home, allowing them to sleep in their own beds, be on their own schedule, and being at a decreased risk for infection due to having fewer germs in their own home (Indiana University Health, 2016, p. 37). Based on patients recovery statues, occupational and physical therapists make discharge recommendations. If a post-hospital rehabilitation stay is deemed necessary by therapists and/or the orthopedic surgeon, the patients case manager and PROTOCOL ANALYSIS OF JOINT REPLACEMENTS 14 social worker are responsible for finalizing arrangements to the facility (Indiana University Health, 2016, pp. 36). Compare & Contrast practice areas of OT Protocol for joint replacement patients may differ depending on the care setting in which a patient is currently located. After conducting a phone interview with the program director of a local sub-acute rehabilitation facility (SAR) and analyzing current literature, the researcher was able to identify a variety of similarities and differences between occupational therapy treatment within the hospital setting and the SAR setting for joint replacement patients (J. Krodel, personal communication, February 9, 2018). The occupational therapy treatment within the hospital setting and the SAR setting are found to generally have the same focus routed in ADL independence. However, several differences between the two settings were found such as length of stay, incorporation of IADL training, conduction of home visits, and differences in discharge planning. The phone interview occurring between the researcher and the program director of a local SAR allowed for the gathering of information on the joint protocol within this particular setting. According to this health professional, which is also an occupational therapist, the general focus of occupational therapy treatment in this setting is increasing independence and safety with completing of daily activities such as personal care and shower/tub, vehicle, and toilet transfers (J. Krodel, personal communication, February 9, 2018). These finding are similar to the focus of treatment within the hospital setting seen in research conducted by Naville et al., (2009) at a Kentucky hospital, which is described in greater detail throughout the literature review section of this paper. Between 50-66% of occupational therapy treatment in a SAR setting focuses on exercise, functional mobility, and dressing lower body (DeJong et al., 2009). Another similarity PROTOCOL ANALYSIS OF JOINT REPLACEMENTS 15 that is found between the SAR and hospital setting is the focus on restrictions and precautions education (J. Krodel, personal communication, February 9, 2018). Both settings stress a great deal of importance on patients understanding of precautions in order to prevent damage to the joint replacement (J. Krodel, personal communication, February 9, 2018). There are a variety of differences between therapy treatment within the hospital setting and SAR. The average length of stay for joint replacement patients at a SAR is between 5-14 days, which is significantly longer than the average hospital stay (J. Krodel, personal communication, February 9, 2018). Since patients at a SAR are often receiving therapy for a longer period, the therapists have more time to address advanced IADLs that are not usually discussed during the short time a patient is in the hospital (J. Krodel, personal communication, February 9, 2018). Specifically, activities such as cooking, doing laundry, household cleaning, and any other activities that are important to the patient are addressed due to the increased amount of therapy at a SAR (J. Krodel, personal communication, February 9, 2018). Also not done in the hospital setting, The SAR setting often conducts home visits where therapists go with the patient to their own home in order to provide home modifications and to allow practice with daily activities in their home environment, which is not done in the hospital setting (J. Krodel, personal communication, February 9, 2018. According to J. Krodel (personal communication, February 9, 2018) joint replacement patients that require further therapy after hospital discharge often had a prior list of significant comorbidities, leading to a harder recovery. Similarly, Mallinson et al. (2011), in an observational cohort study to examine patient outcomes across 3 post acute settings following a lower extremity joint replacement surgery, found that joint replacement patients who required further rehabilitation at a SAR were often more medically complex and having these patients PROTOCOL ANALYSIS OF JOINT REPLACEMENTS 16 attend a SAR improved their independence in self care activities and mobility (Mallinson et al., 2011). Although it is important to understand the differences seen between care in different settings, for the sake of this particular project, further evaluation of the occupational therapy joint replacement protocol will be specific to the acute care setting. Implementation After the completion of the needs assessment; including observation of the current joint replacement protocol, interviews with multidisciplinary staff, and a review of current literature, a post-joint replacement questionnaire was formulated. According to the needs assessment, therapists and other staff involved in the care of orthopedic patients desired to analyze patient perceptions of occupational therapy treatment while hospitalized at IUHNH. Therapists also desired to identify whether or not IADLs or higher-level occupations should be addressed while in the hospital. Program evaluation information collected during the needs assessment highlighted key factors in recovery as social support and psychological domains (Grant et al., 2009, p.1617). These findings were discussed with staff, who decided that the importance of these aspects on recovery should also be analyzed by interspersing social support and psychological domains throughout the questionnaire. The student, in collaboration with the therapy staff, created the questionnaire based on current literature and the established needs of the facility (See Figure 1). This DCE included both total hip and knee joint replacement patients who received their surgery at IUHNH. The questionnaires were given to adults of any age who received both inpatient acute OT and PT services following their surgery. Individuals who had a history of cognitive impairments such as dementia or altered mental status (AMS) were excluded from participating in this study. The questionnaire was given to each patient upon discharge from OT PROTOCOL ANALYSIS OF JOINT REPLACEMENTS 17 services. Therapists were educated on the proper technique to administer the questionnaire, including when to administer and the verbal explanation to utilize when administering. Staff was instructed to explain to patients the importance of answering the questions honestly and that results would remain confidential to be used to improve quality of care in the future. Therapists were instructed to provide the questionnaire to patients at the end of their last OT session and instructed to inform patients that another staff member would come by to pick up the completed questionnaire to ensure confidentiality. A different staff member collected each questionnaire in order to enhance patients comfort level and allow the patients to feel more open to sharing their truthful opinions. Data Analysis Data collection was completed by the student following the administration and collection of all questionnaires. 44 questionnaires were completed via paper copies; all containing 23 questions, and the researcher verified that no personal identifiers existed on any of the documents. Collected questionnaires were transcribed to the Excel program by the researcher within a week of their completion. The data was organized through a person by item table to allow the researcher to review both individual and group responses across all items (Bonnel & Smith, 2018, pp. 190-191). The organization of data in this manner allowed the researcher to review data for completeness, to identify any patterns in responses, and to review summative average responses for each item. Quantitative data analysis was used to organize confidence level item responses. Data collection for the final five items on the questionnaire was done via qualitative data analysis, specifically utilizing content analysis secondary to these questions being open-ended. The researcher reviewed all responses for these items to seek common themes PROTOCOL ANALYSIS OF JOINT REPLACEMENTS 18 in order to make the data meaningful. The collected data was stored on the researchers locked computer in a secured place in order to insure confidentiality of the data. Staff Development In order to ensure therapists at IUHNH would benefit from this DCE, collaboration occurred with multidisciplinary staff throughout the entire process. This allowed for not only the discovery of staffs particular needs and opinions, but also allowed the project to focus on developing ways in which therapists could improve overall quality of care for their patients. Once all data were collected and results were established, the information was used to develop official modifications and suggestions for IUHNH. The occupational therapy student planned and presented two presentations in order to educate staff on the results of the project. One presentation took place during a monthly Ortho Steering meeting, in which all department heads involved in the joint replacement protocol are present. This included the orthopedic program coordinator, orthopedic surgeons, and representatives from the therapy and nursing departments. The second presentation occurred during the monthly therapy staff meeting in order to share results with all of the therapy staff and allow for questions or concerns regarding the results found during the project. Leadership As a Doctoral student, the student continuously has strived to both establish and enhance professional skills throughout the rest of her education and throughout her future career. This experience has allowed the student an additional opportunity to grow currently obtained skills and further establish new skills to use in the future. This doctoral capstone specifically allowed the student to further grow leadership skills while planning, developing, organizing, and marketing all aspects of this project. Leadership skills were required during the initial creation of PROTOCOL ANALYSIS OF JOINT REPLACEMENTS 19 this DCE when the student organized ideas and collaborated with staff to officially create the project. The student utilized critical thinking and decision making in order to formulate expectations, goals, and objectives based off the needs of the facility and ACOTE requirements. The researcher worked alongside multidisciplinary staff on a daily basis in order to provide occupational therapists with the most beneficial project outcome in line with the needs of the facility. Collaboration with staff members provided the student with the opportunity to utilize a team oriented mindset and effective communication in order to advocate for patients best interests. Leadership skills were needed at the conclusion of the experience in order to advocate for the importance of the results found during the project. Specifically, during the two final presentations discussed above, the student educated hospital staff on suggested joint replacement protocol changes based off of the results found during the project. Leadership skills, advocacy skills, and confidence were needed in order to develop staff buy in and to communicate these changes in a professional and appropriate manner. Discontinuation and Outcome Phase The DCE took place on the IUHNH campus from January 9th to April 27th of 2018. During this time, the student established goals and objectives that were expressed within the Memorandum of Understanding (MOU) document. The overall goal addressed throughout this project was, filling the gaps from the time a patient decides they are getting a joint replacement until they fully recovered at home, in order to increase quality of occupational therapy care. The student followed the objectives created in order to accomplish this goal and modified/revised the objectives as necessary. As the project was developed, the original goal established was slightly modified in order to put a greater emphasis on the importance of patients confidence and comfort level upon returning home and resuming their daily activities. PROTOCOL ANALYSIS OF JOINT REPLACEMENTS 20 Quality Assurance Questionnaire The written post-joint replacement quality assurance questionnaire was administered two weeks following the start of the students DCE. The questionnaire was administered to 44 fortyfour total lower body joint replacement patients following their discharge from occupational therapy services and was discontinued after 8 weeks. A total of 28 TKR patients and 16 THR patients completed the questionnaires. Out of the THR patients who completed the questionnaire, eight patients were discharged the day of surgery (post-op day 0) and eight patients were discharges the day after surgery (post-op day 1). 3-point Likert scale items. The first section of the questionnaire addressed patients current confidence level completing a variety of activities using a 3-point Likert scale. This section consisted of 8 items that asked about a variety of transfers, dressing, adaptive equipment use and understanding of educational concepts (see Figure 1). Patients were asked to rank their confidence level for each item using a 3-point Likert scale as limited confidence, moderate confidence, or extreme confidence. If the patient selected either limited or moderate confidence, they were then asked to explain why they chose this answer; selecting from not clearly explained, need more practice, limited by pain, or writing in an addition reason that was not already an option to select. The results for this section are listed in Table 1 in the Appendix. Data was shown as percentages, displaying the percentage of THR & TKR patients who rated their confidence level completing ADLs & IADLs (See Figure 1). Values displayed within the table are separated between TKR and THR results. Results are summarized below as a whole in order to clearly and concisely describe the overall findings. ADLs. Ninety-three point eight percent of THR patients and 100% of TKR patients scored their confidence levels performing shower/tub transfers as either extreme or moderate PROTOCOL ANALYSIS OF JOINT REPLACEMENTS 21 confidence. Patients reported feeling similarly confident completing toilet transfers, with 100% of THR patients and 96.4% of TKR patients scoring extreme to moderate confidence with these activities. Patients confidence completing car transfers were shown as slightly lower than the toilet and shower/tub transfers with 50% of TKR patients ranking moderate confidence and 50% ranking extreme confidence. 87.6% of THR patients choose moderate to extreme confidence with car transfers. Only 3.6% of TKR patients reported feeling limited confidence performing lower body dressing, however 12.5% of THR patients reported limited confidence with this activity. When asked to explain, THR patients often described hip precautions limited their ability and confidence with this task, and they required more practice. All functional mobility and daily self-care activities physically performed and practiced while in the hospital scored higher overall than activities not performed. Overall results from the 3-Point Likert scale displayed confidence levels with all ADLs as extreme and moderate confidence levels. IADLs. The results shown for the questionnaire item holding items while using a walker demonstrated 43.8% of THR and 32.2% of TKR patients identified moderate and limited confidence completing this activity. 37.5% of THR and 42.9% of TKR patients scored the item meal prep/cleanup as moderate to limited confidence. Results for the item household cleaning displayed that 37.6% of THR and 57.1% of TKR patients felt only moderate to limited confidence completing these tasks at time of occupational therapy discharge. Overall, a higher percent of patients reported moderate or limited confidence with more advanced daily activities such as meal prep, household cleaning, and holding items while using a walker in comparison to ADLs that were practiced while in the hospital. These IADLs analyzed in the questionnaire were often not specifically addressed while in the hospital or were only briefly discussed if the patient brought up concerns. PROTOCOL ANALYSIS OF JOINT REPLACEMENTS 22 Open-ended items. The second section of the questionnaire consisted of five open-ended questions addressing patients perceptions of their occupational therapy treatment. The five questions addressed roles and responsibilities patients anticipate resuming once home, their feelings toward returning to these duties, the most beneficial and least beneficial aspects of their occupational therapy treatment, and concerns they currently had regarding resuming their daily activities. The student identified common themes regarding the responses for each of the final five open-ended items on the questionnaire. These themes illustrated the overall patient viewpoint of occupational therapy care within IUHNH. Roles and responsibilities/feeling toward these duties. When asked which roles and responsibilities patients anticipated when returning home from the hospital, all responses fit into two categories: ADLs & IADLs. Responses over both hip and knee joint replacement patient questionnaires had a primary theme regarding the importance of returning back to household cleaning and meal preparation as soon as possible. A variety of responses were categorized within these two activities, with multiple patients reporting, general light housekeeping, cleaning and meal prep, mainly cooking, keeping house, meal prep, and laundry. Although a majority of responses stressed the importance of returning to these activities as soon as possible, patients who will be returning home with family/friend support reported plans for their caregiver to complete these tasks until further recovered. This was expressed with replies such as, cooking my meals after 10 days, planning to rest and not going to do this until 2-6 weeks, may get help from husband to do cleaning. Others identified activities were personal hygiene, functional mobility tasks such as picking things off the floor or transporting items, and pet care. When asked about their feelings toward returning to these activities, responses were overall positive; with patients reporting they were, looking forward to it, eager, and feeling great about PROTOCOL ANALYSIS OF JOINT REPLACEMENTS 23 resuming the activities. Although the majority of responses were positive, there were some patients that expressed slight nervousness or a need to gain more confidence secondary to desiring more practice. Most beneficial. Patients impressions when asked, what part of occupational therapy was most beneficial? indicated that they viewed all aspects of occupational therapy treatment as beneficial or necessary. An overwhelming amount of replies reported that all activities and educational concepts were viewed as helpful. Specifically, the education on lower body dressing, use of adaptive equipment, and education on transfers to toilet, shower/tub, and vehicle were reported to be the most beneficial aspects of occupational therapy. Patients found it helpful when therapists used step by step instructions and when they were given verbal, written, and physical demonstrations of the educational concepts. Patients also found it helpful when they were able to practice the activities while in the hospital and the review what they should or shouldnt do when completing these activities. Least beneficial. Out of all collected questionnaires for hip and knee patients, only three patients reported specific activities that they believed to be the least beneficial. In regards to these three responses, each expressed the reasoning behind feeling this way toward an activity was due to having previous knowledge of the method taught due to a prior joint surgery or already did the task the way explains. All other responses reported, none or it was all good and helpful for this questionnaire item. Worries/concerns. When asked about what worries or concerns the patients had resuming daily activities post discharge, patients expressed not having any or having slight concern. The majority of responses identified no worries or concerns. However, with the responses that did address a specific activity, most activities were more advanced IADLs not normally addressed PROTOCOL ANALYSIS OF JOINT REPLACEMENTS 24 within the hospital setting. Examples of this are being able to care for my pet, being able to kneel for church, and being able to carry items while using the walker. Concerns were also expressed regarding completing activities in patients home environment versus practicing in the hospital. Outcomes Initially, the student developed the questionnaire, completed research analysis, and performed observation of current treatment protocol with plans for the project outcome to be giving the hospital staff a vast amount of suggested modifications and adjustments to their current joint replacement protocol. However, after analyzing the results from the questionnaire, results showed that the majority of patients expressed satisfaction with their care and overall confidence resuming most of their ADLs once home. Multiple patients reported worries and concerns that the student discussed with staff, however the overall view of the current procedure was positive. Results from the DCE will allow the student to demonstrate that current OT protocol, with exception of a few modifications, is fitting the needs of the majority of joint replacement patients. Ongoing quality improvement. Continuous Quality Improvement (CQI) was used by the student throughout the entire DCE. The student utilized CQI to analyze and modify the current occupational therapy joint protocol for THR and TKR to ensure quality of care met the needs and standards of both patients and staff. The student developed multiple modifications for the joint replacement protocol based off questionnaire results to ensure quality improvement. In order to increase confidence levels in areas that displayed lower than others, the student suggested that occupational therapists put emphases on IADLs that are not being addressed in the current protocol. These IADLs include meal preparation and clean up, household cleaning, and PROTOCOL ANALYSIS OF JOINT REPLACEMENTS 25 transporting items while using a walker. All of these specific activities were addressed within the questionnaire and a higher percentage of patients reported moderate to limited confidence completing these activities. The student also suggested that therapists put a greater emphasis on patient specific activities. This involved making sure therapists are using the occupational profile to build rapport in order to identify specific activities that are important to each individual patient. Making sure therapists identify and acknowledge activities important for each individual patient will allow therapy services to become more client-centered and improve overall patient care. In order to ensure ongoing quality improvement, the student presented the project and its findings to staff during two presentations. The overall response from staff during these presentations were positive. Therapists were also supportive of suggested changes in protocol made by the student. Specifically, the orthopedic surgeon expressed positive reactions and suggestions following the presentation. He conveyed that he loved how this project allowed for examining patients satisfaction and gathering patients viewpoint on their care (J. Hur, personal communication, April 13, 2018). Dr. Hur explained that IUHNH has a very specific clientele, only doing surgery on patients who have somewhat limited co-morbidities and have a confirmed plan for recovery and support. Therefore, he also provided suggestions for future projected, stating it would be beneficial to conduct a project similar to this at several other hospitals in order to compare results with populations that have different socioeconomic standing, comorbidities, etc. Overall feedback from staff members showed that suggested modification to the occupational therapy protocol would occur and results would continue to be supported by all members of the orthopedic team. The student plans to discuss with professors the possible continuation of the project at varies other hospitals during DCE projects in the future. PROTOCOL ANALYSIS OF JOINT REPLACEMENTS 26 Overall Learning Throughout this DCE project, the student was required to use program development, advocacy, and clinical practice skills in order to achieve the goals and objectives put into place prior to the start of the project. The focus put on these skills prepared the student for future practice and assisted the student to further develop and grow these skills for the future. The student utilized program development skills in order to analyze the current protocol in place and modify it in order to meet best practice. The student used critical thinking skills throughout the project to modify and adapt the goals and objectives of the project to meet the changing needs of the facility. The original plan for the DCE was to analyze the current protocol in place for joint replacement patients and then, using the results of the questionnaire, research, and observation, provide the therapy staff with suggestions and modifications in order to fill any gaps seen in the protocol regarding meeting all of the needs of the patient. Modifications to this plan had to be made once the results showed a very high percentage of patients reporting moderate to extreme confidence resuming daily activities and minimal worried or concerns returning home. Therefore, the focus of the project was then adapted to advocacy and allow the student to use these results in order to advocate for the IUHNH joint protocol. The hospital setting is quick paced and constantly changing due to modifications of schedules, patient refusals, and medical needs affecting treatment. This experience within such an environment allowed the student to develop skills in being able to adapt to change and develop more flexible within the patient care setting. This will be useful in future practice because the student intends to continue working in a hospital setting after graduation. The student also focused on research and evidence-based practice principles grounded in the MOHO PROTOCOL ANALYSIS OF JOINT REPLACEMENTS 27 model when working with patients and when developing the questionnaire used for the implementation phase. Communication Communication skills were extremely important throughout the entire DCE project. It was crucial for the student to practice proper non-verbal, written, and oral communication skills with all individuals in which she encountered. On a daily basis, the student strove to be a good active listener in order to be a good communicator. This involved always paying close attention to others and clarifying any questions that arose. An example of this occurred during patient care while making sure to truly listen to the patient, and make sure they knew they were being heard. While working in an interdisciplinary team, the student learned the importance of communicating in a respectful, confident, and friendly manner, especially when advocating for the sustainability of the project. Non-verbal communication with interdisciplinary staff, patients, and patients family members always utilized appropriate body language, eye contact, and hand gestures to help convey what the student wanted to express. The student used a respectful and friendly tone in order to always appear approachable and encourage trust. Written communication was completed mostly through documentation of services with patients. The student worked towards always making sure this communication was done in a clear and concise manner that allowed for the documentation to provide an accurate portrayal of the OT process provided with each patient. A specific time the student had to verify good written communication was during the development of the questionnaire. The student had to make sure all patients could understand the terminology used and that it was truly portraying what each question was intending to ask. PROTOCOL ANALYSIS OF JOINT REPLACEMENTS 28 Limitations Limitations of this study included the small sample size, the high chance of questionnaires not getting collected prior to patients discharge, and the study being restricted to only one particular hospital. The sample size was depended on how long of a time period the questionnaires could be pasted out. Since, this project had deadlines regarding each stage of the research, questionnaire distribution has to be concluded prior to reaching the desired number of questionnaires. Due to the quick nature of the acute care setting and discharges occurring sometimes less than an hour after questionnaires were originally distributed, some questionnaires were taken home by patients or thrown away after a patient has discharged. This caused several of the questionnaires to be missed by therapy staff. The final limitation noticed was the fact that the research only occurred at one particular hospital. This limits the results to a particular population with patients falling under similar socioeconomic groups that may vary from other hospitals. Conclusion This project allowed the student to identify modifications needed to improve care for the THR and TKR population in order to enhance patients independence with activities of daily living (ADLs) and instrumental activities of daily living (IADLs) following surgery. Results of patient questionnaires, a review of current literature, and observation done by the student indicated that IUHNHs total hip and knee joint replacement program has a well developed occupational therapy protocol with modification only needed in order to address confidence levels with higher level IADLs and patient specific activities. PROTOCOL ANALYSIS OF JOINT REPLACEMENTS 29 References Bonnel, W. & Smith, K.V. (2018). Proposal writing for clinical nursing and DNP projects, Second edition. New York: Springer Publishing Company. Cole, M.B., & Tufano, R. (2008). Applied theories in occupational therapy: A practical approach. Thorofare, NJ: SLACK, Inc. Cooke, M., Walker, R., Aitken, L. M., Freeman, A., Pavey, S., & Cantrill, R. (2016). Preoperative self-efficacy education vs. usual care for patients undergoing joint replacement surgery: a pilot randomised controlled trial. Scandinavian Journal of Caring Sciences, 30(1), 74-82. doi:10.1111/scs.12223 DeJong, G., Hsieh, C., Gassaway, J., Horn, S. D., Smout, R. J., Putman, K., & ... Foley, M. P. (2009). Characterizing rehabilitation services for patients with knee and hip replacement in skilled nursing facilities and inpatient rehabilitation facilities. Archives Of Physical Medicine And Rehabilitation, 90(8), 1269-1283. doi:10.1016/j.apmr.2008.11.021 Grant, S., St John, W., & Patterson, E. (2009). Recovery from total hip replacement surgery: "It's not just physical." Qualitative Health Research, 19(11), 1612-1620. doi:10.1177/1049732309350683 Indiana University Health. (2016). Total joint replacement patient education. Indianapolis, Indiana: IU Health. Indiana University Health. (2018). Mission, vision and values. Retrieved from http://iuhealth.org/about-iu-health/mission-vision-values/ Jame Bozorgi, A. A., Ghamkhar, L., Kahlaee, A. H., & Sabouri, H. (2016). The effectiveness of occupational therapy supervised usage of adaptive devices on functional outcomes and independence after total hip replacement in Iranian elderly: A randomized PROTOCOL ANALYSIS OF JOINT REPLACEMENTS 30 controlled trial. Occupational Therapy International, 23(2), 143-153. doi:10.1002/oti.1419 Kiefer, D., & Emery, L. (2006). Self-care and total knee replacement. Physical & Occupational Therapy in Geriatrics, 24(4), 5162. Kurtz, S., Ong, K., Lau, E., Mowat, F., & Halpern, M. (2007). Projections of primary and revision hip and knee arthroplasty in the United States from 2005 to 2030. Journal of Bone & Joint Surgery, 89(4), 780-785. doi:10.2106/JBJS.F.00222 Lee, S., Taylor, R., Kielhofner, G., & Fisher, G. (2008). Theory use in practice: A national survey of therapists who use the Model of Human Occupation. American Journal of Occupational Therapy, 62(1), 106-117. Mallinson, T. R., Bateman, J., Tseng, H., Manheim, L., Almagor, O., Deutsch, A., & Heinemann, A. W. (2011). A comparison of discharge functional status after rehabilitation in skilled nursing, home health, and medical rehabilitation settings for patients after lower-extremity joint replacement surgery. Archives of Physical Medicine and Rehabilitation, 92(5), 712-720. doi:10.1016/j.apmr.2010.12.007 McHugh, G. A., & Luker, K. A. (2012). Individuals' expectations and challenges following total hip replacement: A qualitative study. Disability and Rehabilitation, 34(16), 1351-1357. doi:10.3109/09638288.2011.644022 Naville, J., Volz, T., & Curry, J. (2009). A multidisciplinary approach to total joint replacement. Home Health Care Management & Practice, 21(6), 415-418. Prouty, A., Cooper, M., Thomas, P., Christensen, J., Strong, C., Bowie, L., & Oermann, M. H. (2006). Multidisciplinary patient education for total joint replacement surgery patients. Orthopedic Nursing, 25(4), 257-261. PROTOCOL ANALYSIS OF JOINT REPLACEMENTS 31 Richmond, T. (2016). Innovative occupational therapy practice for patients with lower extremity joint replacement. OT Practice, 10-11. Scaffa, M. E., & Reitz, S. M. (2014). Occupational therapy in community-based practice settings. Philadelphia, PA: F. A. Davis Company. Walker, J. (2012). Care of patients undergoing joint replacement. Nursing Older People, 24(1), 14-20. PROTOCOL ANALYSIS OF JOINT REPLACEMENTS Figure 1. Post-Joint Replacement Questionnaire 32 PROTOCOL ANALYSIS OF JOINT REPLACEMENTS 33 PROTOCOL ANALYSIS OF JOINT REPLACEMENTS 34 Table 1. Percentage of THR & TKR Patients Confidence Level Completing ADLs & IADLs Car Transfers Extre me 68.8% THR Results Modera te 18.8% Limite d 12.5% Extre me 50.0% TKR Results Modera Limite te d 50.0% 0.0% Shower/Tub 68.8% 25.0% 6.3% 64.3% 35.7% 0.0% Toilet Transfers 87.5% 12.5% 0.0% 71.4% 25.0% 3.6% Dressing LB 81.3% 6.3% 12.5% 82.1% 14.3% 3.6% 56.3% 31.3% 12.5% 67.9% 14.3% 17.9% 62.5% 12.5% 25.0% 57.1% 25.0% 17.9% 62.5% 18.8% 18.8% 42.9% 35.7% 21.4% 93.8% 6.3% 0.0% 92.9% 3.6% 3.6% Transfer clothing Holding Items while using walker Meal Prep/Clean-up Overall Household Cleaning Understanding Precautions  ...

... Occupational Therapy in Agriculture/Rural Communities: Bridging the Gap Between Health Professionals and Farmers/Ranchers Danyele Clingan, OTS April 14, 2018 A capstone project submitted in partial fulfillment for the requirements of the Doctor of Occupational Therapy degree from the University of Indianapolis, School of Occupational Therapy. Under the direction of the faculty capstone advisor: Dr. Jim McPherson, PhD, OTR A Capstone Project Entitled Occupational Therapy in Agriculture/Rural Communities: Bridging the Gap Between Health Professionals and Farmers/Ranchers Submitted to the School of Occupational Therapy at University of Indianapolis in partial fulfillment for the requirements of the Doctor of Occupational Therapy degree. By Danyele Clingan OTS Approved by: Faculty Capstone Advisor Date Doctoral Capstone Coordinator Date Accepted on this date by the Chair of the School of Occupational Therapy: Chair, School of Occupational Therapy Date OT IN AGRICULTURE/RURAL COMMUNITIES 3 Abstract Farming/ranching continuously ranks as one of the most dangerous jobs in the United States, however literature indicates current gaps in care between health professionals and farmers/ranchers. Typically, resulting from limited exposure and understanding of occupational demands on the farm/ranch. It has been suggested that increasing exposure, in educational curriculums for example, can be an effective first step. The purpose of this project is to increase awareness through educational opportunities in the classroom and/or continuing training courses used by health profession programs, individual rehabilitation facilities, or community programs. Based on the needs assessment, an initial presentation was developed and presented to four Indiana occupational therapy programs prior to design of an occupation specific course. Course effectiveness was measured through implementation of a modified lesson during general coursework in an occupational therapy program. Outcomes indicate presentations and curricular design to be effective in increasing feelings of competence of health professionals when working with farmers/ranchers. In turn, reducing gaps in care and promoting stronger therapeutic relationships. Further testing should be conducted to measure effectiveness of the designed course. Discussion will present the relationship between farming/ranching and rehabilitative services, description of the initial presentation, establishment of the Rehabilitation in Agriculture/Rural Communities Course, and outcomes, longevity, and limitations of the project. OT IN AGRICULTURE/RURAL COMMUNITIES 4 Acknowledgement This work would not be possible without the support and guidance of the National AgrAbility Project and Indiana AgrAbility Project staff. Sincere gratitude toward Dr. William Field, Project Director and Site Mentor, for ones dedication and commitment in providing additional educational opportunities and expertise throughout the doctoral capstone experience. Thank you to Dr. Jim McPherson, doctoral capstone faculty advisor, for the supervision of the experience, including the primary role of reviewing the doctoral capstone written project summary paper. Sincere appreciation to those family and friends who provided continuous encouragement and feedback toward various aspects of the doctoral capstone experience. Your presence never went unnoticed. The doctoral experience would not have been possible without those previously mentioned as well as degree peers, University of Indianapolis Occupational Therapy Department faculty, and past fieldwork educators. Thank you! OT IN AGRICULTURE/RURAL COMMUNITIES 5 Occupational Therapy in Agriculture/Rural Communities: Bridging the Gap Between Health Professionals and Farmers/Ranchers Introduction As evidenced, farming and/or farm work continues to be one of the most dangerous occupations in the United States due to the work environment and related farm tasks (National Safety Council, 2018). Farmers and ranchers are at increased risk for injuries including acute injuries, chronic conditions, and developmental conditions, in conjunction with associated secondary conditions related to age and work tasks affecting ones job performance (Jorge, 2006). Farming/ranching is viewed as more than a job, but rather a livelihood and a way of life typically passed down from generation to generation. As a result, farmers/ranchers value their work and are expected to return to the farm despite possible injuries and/or disabilities (Coles & OHare, n.d.). Although farm/ranch work is one of the most dangerous occupations, farmers/ranchers are determined to continue their work despite limitations. It is estimated that the number of farmers, ranchers, or agriculture personnel with a disability ranges from 1.04 million to 2.23 million (Deboy, Jones, Field, Metcalf, & Tormoehlen, 2008). While health care is ever evolving, it remains a goal to provide adequate services meeting the needs of the public. As occupational therapists, it is likely one will treat a farmer, rancher, or agriculture personnel at one point in their professional career demonstrating the role the profession should have within this setting. Problem Statement There is a disconnect between the agriculture community and the services provided by health professionals in terms of application to ones occupations, primarily farm related tasks (Cole and OHare, n.d.; Jorge, 2006; Waite, 2015). Literature suggests that, farmers and OT IN AGRICULTURE/RURAL COMMUNITIES 6 ranchers who undergo rehabilitation after injury are dissatisfied with the rehabilitation outcomes because the physical rehabilitative process does not necessarily assist them to return to farm life and agriculture work (Jorge, 2006, p. 61). In some cases, farmers have expressed that when seeking therapy services following a disability/injury, they felt their input and personal goals were not taken into consideration (Coles & OHare, n.d.). Furthermore, there is a need to address rehabilitation services in a culturally competent manner to meet the needs of farmers/ranchers (Jorge, 2006). As health professionals, this specific population is not typically addressed in coursework impacting professionals abilities to relate and tailor interventions applicable to farm/ranch related tasks. Occupational therapists strive to meet the needs of clients through occupation based, client centered, and holistic treatments to enhance individuals quality of life and continued engagement in desired occupations. It is crucial, as providers, to be competent in treating agriculture personnel to bridge the gap between health professionals and agriculture/rural communities. The purpose of this project is to further advocate for appropriate services of agriculture personnel and the role occupational therapy can serve. Discussion will include the implementation of an educational presentation for occupational therapy programs in Indiana and development of an agriculture/rural communities course, including outcomes, longevity of the project, and relevance to future work. Background Information/Literature Review Evidence has shown the disconnect between agriculture/rural communities and adequately receiving services to return to work on the farm (Jorge, 2006; Waite, 2015). This may be associated with health professionals training, interest, and/or ability to relate to the population OT IN AGRICULTURE/RURAL COMMUNITIES 7 (Mills & Millsteed, 2002; Russell, Clark, & Barney, 1996; Smallfield & Anderson, 2008). Programs have begun addressing the possible root of the concerns, including increased training and education within preexisting educational coursework. Perception of Services Coles and OHare (n.d.) report, the challenge facing healthcare is how services can be provided in rural settings, including the needs of personnel, most effective methods of implementation, and how health professionals, such as occupational therapists, can provide adequate services. Others have expanded upon this idea, reporting that health professionals typically only pursue employment in rural settings if they have lived in this type of area or due to positive educational and/or fieldwork experiences (Russell et. al., 1996; Strasser, 2005). This supports the idea that educational curriculums, such as occupational therapy, can aid as an avenue to encourage health professionals to serve agriculture/rural communities (Smallfield & Anderson, 2008). There continues to be reluctance of health professionals becoming involved in agriculture/rural communities despite positive experiences. Much of this reluctance stems from the limited opportunities and/or experiences of students during their educational curriculum. Due to this, practitioners do not feel adequately prepared to treat agriculture personnel, which has been noticed by the said population (Russell et al., 1996). Farmers have stated that services provided by health professionals are only effective if one truly understands the challenges and daily tasks farmers face (Coles & OHare, n.d.). As health professionals, it is critical to understand how to form therapeutic relationships with clients to assist in providing services that can be translated to work on the farm/ranch. A few rehabilitation programs have begun OT IN AGRICULTURE/RURAL COMMUNITIES 8 incorporating agriculture concepts into their curriculums to enhance student understanding and skills in treating agriculture personnel. Occupational Therapy Curriculums Millsteeds 1997 work, highlights the crucial aspect of education and training covering rural areas related to the occupational therapy profession. Including mandating in curriculum work to better prepare therapists for competence when working with rural personnel. Researchers, health professionals, and educators through the years have identified the importance of serving agriculture/rural communities, yet few efforts have been made to incorporate this practice area into degree curriculums and standards. As the occupational therapy profession continues to expand, discussion of agriculture should be addressed as a specialized area of practice. While no standards currently exist for continuing competency in agriculture, training can be embedded into occupational therapy curriculums. The School of Physical Therapy at Langston University saw the importance of addressing rural rehabilitation concerns. This resulted in a partnership with the Oklahoma AgrAbility Project to implement an educational component into their degree curriculum for additional occupational exposure (Jorge, 2006). Students in this program took part in a formal seminar about the culture of agriculture, common agricultural tasks, equipment, and the environment. Following the seminar, students participated in an on-site assessment discussing ideas such as accommodations. Students became more culturally competent in agricultural work and developed an understanding of the occupational demands on farmers and ranchers. Results also indicated expansion of student knowledge in application of intervention techniques that were relevant and meaningful to the population (Jorge, 2006). A more in depth, and expansive approach was taken by the University of South Dakota Occupational Therapy program OT IN AGRICULTURE/RURAL COMMUNITIES 9 (Smallfield & Anderson, 2008). A rural issues module was implemented throughout the entire curriculum in conjunction with other coursework. Students participate in numerous learning opportunities, each building off the next. This module begins with an introduction to agriculture lecture, including essential related topics tying to other coursework. Students then research and conduct presentations on various safety topics (such as equipment, chemicals, and livestock handling) and commonly used farm equipment/tools. To enhance understanding, students participate in farm and vendor visits as well as implement an on-site farm assessment. A threehour mental health in agriculture seminar is held. Advanced requirements include completion of one 12-week fieldwork rotation in a rural community and completion of a case study during the doctoral capstone experience. In turn students within the University of South Dakota Occupational Therapy program receive 30 plus hours of didactic coursework covering rural settings. It is noted that these opportunities have the potential to encourage more occupational therapists to practice in rural areas and demonstrate increased competency levels (Smallfield & Anderson, 2008). Agriculture personnel often express dissatisfaction in the services received from health professionals, in turn creating a gap in care. The hope is that increasing exposure to the relationship of occupational therapy within agriculture/rural communities will assist in providing more meaningful care and enhance a farmer/ranchers longevity in their desired occupation. Screening and Evaluation Occupational Therapys Relationship to Agriculture Little has been done to enhance the development and knowledge of health care professionals, like occupational therapists. Literature has shown that exposing occupational therapy students to various areas of practice or providing diverse educational opportunities OT IN AGRICULTURE/RURAL COMMUNITIES 10 influences ones career choices. Exposing students to rural settings can help individuals make more informed decisions in their career and interest in pursuing various practice settings (Brockwell, Wielandt, & Clark, 2009). According to Brockwell et al. (2009), undergraduate programs have the opportunity to mitigate challenges; however, there is minimal literature available regarding the adequacy of undergraduate education and its role in preparing occupational therapy graduates for practice (pg. 4). It is important that such settings be further discussed within graduate curriculums to adequately prepare students for more informed decisions, based on personal characteristics and interests. Occupational therapists practicing in rural settings reported that having a rural fieldwork placement ultimately influenced them to pursue this type of work and increased their comfort in this setting. (Brockwell et. al., 2009). Exposure to rural settings within the curriculum, may assist in changing the current perspective to one where occupational therapists view work in this area as challenging yet rewarding (Mills & Millsteed, 2002). Support in various settings, including rural settings, has been an indicator for retention rate while considering opportunities for networking, participation and communication in professional associations, attendance of local and regional meeting, and opportunities for continuing education (Stagnitti, 2008). Occupational therapy has a unique role in serving the agricultural population. Educational opportunities and training prepares practitioners and students to analyze activities, identify possible limitations, and further recommend modifications or adaptive techniques that meet the needs of clients and their occupational demands (Jorge, 2006; Smallfield & Anderson, 2008). While the profession of occupational therapy continues to promote holistic care, it continues to demonstrate limitations in meeting the needs of agricultural personnel. Many of the root issues stem from lack of exposure or experience during graduate curriculum work (Brockwell et. al., OT IN AGRICULTURE/RURAL COMMUNITIES 11 2009; Russell et. al., 1996; Smallfield & Anderson, 2008). Health professionals should be able to provide interventions that go beyond the typical approaches and relate directly back to ones occupation on the farm. Agriculture/rural communities view their work on the farm as their livelihood they are constantly emerged in and must return to despite injuries or limitations. This is compared to their counterparts who are able to separate work and personal obligations more easily. Teaching occupational therapy students early on the cultural differences and specific occupational demands, can enhance the relationship between health professionals and farmers/ranchers. Brittany Cowgill best summarizes the variance in approaches to rural settings compared to common areas of occupational therapy practice, by stating, One of the main themes from my research is that medical professionals didnt understand where farmers were coming from. They said you need to give up on farming. Just understanding that this is the persons identity can give occupational therapists a big edge. The key is to use therapeutic use of self and be aware that farming is more than a job (Waite, 2015, p. 15). Theoretical Framework Guiding Project Research and personal communications identified that an effective first step for addressing gaps in care was to educate and expose students to rural settings during curriculum work. The use of the models PRECEDE-PROCEED and Person, Environment, Occupation, and Performance (PEOP), served as guiding foundation during the screening and evaluation phase. The use of such models allows one to discover the major limitations faced by this population, gather relevant research, implement a program, and then evaluate the impact of the program. The stated models allow one to focus on holistic care with consideration of the specific occupation of farming in relation to the individuals overall performance (Reed, 2004; Cole, 2008). OT IN AGRICULTURE/RURAL COMMUNITIES 12 To make the gathered data more attainable, the Goal Attainment Scale was utilized. Refer to appendix A for use of this assessment tool relative to the project implementation. Implementation of Project Project Planning/Overview Little research has discussed the implementation of agriculture/rural practice in graduate rehabilitation curriculums, especially in the occupational therapy profession (Smallfield and Anderson, 2008). The construction of this project is designed to provide occupational therapy programs with a sample curricular design discussing the role of occupational therapy within agriculture/rural communities for specialized clinical skills of students. Construction of the course is based on previous research, current curricular designs, discussions with occupational therapists practicing in agriculture/rural communities, and suggestions from select Indiana occupational therapy students. The project seeks to increase awareness and education of agriculture/rural communities for current occupational therapy students to assist in increasing meaningful, relevant, and holistic care between health professionals and agriculture/rural communities. The ideal outcome is that based on the information, the profession will have a greater understanding of agriculture/rural communities to reduce the rehabilitative gaps in care. By increasing student exposure to this practice area, more students may seek employment in agriculture/rural communities and/or become more competent when treating agriculture personnel. Project Objectives/Methods Specific objectives have been formulated to guide the implementation of the project. Objectives include: development of an initial educational presentation, creation and implementation of a presentation evaluation tool, conduction of interviews with occupational OT IN AGRICULTURE/RURAL COMMUNITIES 13 therapists serving rural communities, review of the evaluation tool, and development of a course intended to be used by health professional programs, rehabilitation facilities, and/or community programs such as the National AgrAbility Project. Based on research and discussions with the National AgrAbility Project team members, an initial presentation was developed entitled, Occupational Therapy in Agriculture: Bridging the Gap Between Health Professionals and the Agriculture Community. The presentation discussed the relationship and relevance of occupational therapy services in agriculture/rural communities to eliminate the current gaps in services (refer to appendix B for initial presentation). The presentation was also intended to identify possible areas of expansion within the profession to better serve agriculture/rural communities. Five Indiana accredited occupational therapy programs were contacted and responded to have the presentation held during general coursework or a Student Occupational Therapy Association meeting. Information discussed included: the background of agriculture, Indiana specific agriculture, common injuries/conditions and risk factors, cultural philosophy, the National AgrAbility Project, and the relevance of occupational therapy services to agriculture communities (such as mental health, prevention of secondary conditions, and assistive technology/modifications). Additional resources were provided to students following the presentation (refer to appendix C). Approximately 169 students of various degrees (OTD, MOT, OTA) and years in the program (primarily first and second year students) participated in the presentations. A pre- and post-survey was provided to all participating individuals on a volunteer basis for understanding of the students current exposure to the topic area and competence level after the presentation. Recommendations from the surveys were utilized in developing the established course. OT IN AGRICULTURE/RURAL COMMUNITIES 14 Interviews were conducted with four occupational therapists associated with various state AgrAbility Projects serving agriculture/rural communities and two occupational therapy professors incorporating rural issues into their coursework. The purpose of the interviews was to gain specific examples on what is seen while working with the designated population and what may be important to include in a specialized course for health professionals. Interviews also allowed greater understanding as to what is currently being taught in the classroom on the topic. A course was developed incorporating the feedback provided by therapists and students. The designed course was established to be implemented and modified to fit various program needs as well as serve as a basis for continuing competency and outreach efforts. Course Development. The structure of the course serves as an example guide for health profession programs by allowing for modification of concepts which are best fit for ones current curriculum (refer to appendix D and E for the course outline and related materials). Individual programs may take specific lesson ideas and/or assignments to implement into a desired course or use as a guide to begin an elective course or online training program. Included in the course outline are specific readings, assignments, and webinars for various modes of conveying the lesson topic depending on program needs or individual learning styles. Also listed, are specific occupational therapy courses that a lesson may be implemented in if unable to incorporate the course on a larger scale. Based on student feedback from the pre- and post-surveys of the initial presentation, all survey participants reported preferring some type of hands on experience to convey the information. Participants indicated the most effective methods for conveying the topic and increasing competence levels was to participate in a farm visit (42.9%), interactive OT IN AGRICULTURE/RURAL COMMUNITIES 15 lectures/presentations (19%), and case studies (14.3%). Feedback from the students assisted in designing the course that would meet educational and competency needs. Further course development was based on the principles incorporated by occupational therapy program professors in their current coursework. For example, one Indiana professor incorporated farm specific assistive technology in the course she taught relative to modifications and adaptive devices. She also discussed musculoskeletal injuries/conditions related to agriculture work in another course (L. Jackson, personal communication, January 18, 2018). As part of the partnership with her state AgrAbility project, a Tennessee professor educated occupational therapy and physical therapy students on the role of AgrAbility and working with agriculture/rural communities in a community practicum course (C. Dennis, personal communication, January, 31, 2018). Other occupational therapists associated with academic work, have focused their efforts on portraying the information through research (C. Wilhite, personal communication, February 12, 2018). Course development was also guided by the report of Smallfield and Anderson (2008), with reference to the University of South Dakotas past and current rural issues curricular thread (A. Naber, personal communication, March 13, 2018). Therapists and students agree that not enough training is provided in curricular programs, leading to decreased feelings of competence and interest in seeking employment in this area of practice (personal communications). The use of the course outline allows health profession programs to begin implementing and advocating for a greater presence of working within agriculture/rural communities. The course is intended to provide ideas to programs as to how they can play a part in further educating students to increase competence when working with various client demographics. OT IN AGRICULTURE/RURAL COMMUNITIES 16 Development of Leadership Skills Through Project and Staff Development Participation in the doctoral capstone experience has allowed for increased professional development in terms of management and program development. Due to the nature and structure of the National AgrAbility Project, it has solely been the responsibility to complete designated tasks of the site in conjunction with academic requirements with little to no direction or assistance. This has promoted overall independence and freedom in completion of the doctoral project. Being of a different demographic and academic background, National AgrAbility staff members seek further opinions and input to verify holistic treatment is being applied to meet the needs of clients. Leadership skills have developed through being considered the expert in terms of health care and rehabilitation. It has been beneficial to participate in activities beyond those that directly correlate with personal interests or project intentions, but opportunities where professional development can be expanded upon. This has included participation in various agriculture specific events, presentations, and meetings. Further leadership was demonstrated by establishing and conducting an occupational therapy panel at the National Training Workshop and organizing a National AgrAbility presence at the American Occupational Therapy Association Conference. Each member of the National AgrAbility Project team has a specific and unique skill set requiring constant collaboration of the team where each member is viewed equally, regardless of experience or job title. The structure of the site has promoted confidence and allowed further practice serving as a leader, which will be translated to future professional engagement and leadership positions throughout ones career. Staff development has been a crucial aspect of successful implementation and longevity of the indicated project. Staff were initially educated on the role of occupational therapy and the OT IN AGRICULTURE/RURAL COMMUNITIES 17 unique role the profession can have to the program. This also included educating staff members on the services and the specific areas of the program that would benefit from having an occupational therapist perspective. Upon implementation of the indicated project, staff members were educated on how a training program for health professionals (occupational therapists, physical therapists, nursing, case management, etc.) may be modified from the discussed course. National AgrAbility staff members were provided with the outlined course and related materials, which could be used to create a general training program or for outreach efforts. Staff members of state AgrAbility projects were educated on ways to modify the course, based on demographic needs of health professionals, through a webinar posted on the National AgrAbility Project website. The webinar discussed the role of occupational therapy and how to participate in educational opportunities/outreach efforts. Discontinuation and Outcome of Project Project Outcomes Through extensive literature review and personal communications (with students, professors, and occupational therapists), it was found that there is typically no exposure to the occupations of farming/ranching embedded in current health profession curriculums. However, it is highlighted to be an important component of health professionals competence and professional development. Therefore, it is crucial to meet holistic and quality care for all clients treated to focus on enabling and enhancing participation in daily occupations (American Occupational Therapy Association, 2014). An initial presentation was given to Indiana occupational therapy programs to expose students to agriculture/rural communitys occupations, contributing to the development of the OT IN AGRICULTURE/RURAL COMMUNITIES 18 indicated course. A pre- and post-survey was provided to students on a volunteer basis for additional information. The purpose of the pre-survey was to gain a greater understanding of the current level of exposure to agriculture/rural occupations prior to the initial presentation; the post-survey was aimed to gather student perspective on the most effective ways to present agriculture/rural occupations topics during course development. Pre-survey results indicated that 83.5% (111/133 responses) of survey participants reported their educational curriculum does not currently provide exposure to agriculture/rural communities. For the remaining 16.5% of responses, survey participants expressed that the topic was presented in the form of case studies, student presentations, guest lectures (third parties working with the specific population), and/or previous fieldwork experiences. Each initial presentation was structured the same, however slightly altered to reflect the agriculture demographics of the area, degree program objectives, and current level of exposure to the setting. Following the initial presentation, students were then presented with a volunteer postsurvey, where 75.6% of respondents indicated feeling more adequately prepared to treat agriculture/rural community personnel as a result of the presentation. Survey participants reported heightened awareness of possible gaps in care, however expressed gaps can be reduced with increased exposure to this specific occupation and way of life. One survey participant stated, I think understanding the farming way of life is vital in delivering effective care (Anonymous). Responses further addressed increasing health professionals exposure to the occupation through educational opportunities in the classroom or through continuing education courses, such as an educational module. The most valuable information reported was further understanding the occupational demands of farming/ranching as well as the exposure to available resources, including AgrAbility services. Subsequent presentations were enhanced each time OT IN AGRICULTURE/RURAL COMMUNITIES 19 based on post-survey feedback by including specific client stories, intervention techniques, and how an occupational therapist can incorporate the occupation of farming/ranching into the clinic. Course Outcomes Upon completion of all initial presentations, the course outline was established. Course effectiveness was measured through implementation of a modified lesson which was presented to one accredited Indiana occupational therapy program during general coursework. Due to the limited time allotted, lesson 7 (Assistive Technology/Mobility Devices) was modified and implemented. Students were educated on various assistive technologies and mobility devices relative to farming/ranching (refer to appendix F and G). Lesson material was further reinforced by providing students the opportunity to design an assistive technology device based on a provided case study. Further course effectiveness was measured using a pre- and post-survey with results indicating increased scores of general assistive technology information from pre- to post-survey evaluation. Students also indicated a 4/5 score on the post-survey Likert scale of relevance to practice and increased competence for treating farmers/ranchers. No course or lesson suggestions were provided at the time. Quality Improvement and Impact on Society Literature and personal communications have indicated gaps in care due to the absence of exposure to farming/ranching occupations for health professionals (Jorge, 2006; Smallfield & Anderson, 2008; Waite, 2015). Researchers indicate farmers/ranchers are not adequately receiving the services they desire. Although health professionals are addressing rehabilitative needs, many are not addressing the relationship between the treatments and the translation to the farm/ranch occupation (Jorge, 2006; Smallfield & Anderson, 2008; Waite, 2015). Those returning home following rehabilitative stays, oftentimes, do not continue to seek outpatient OT IN AGRICULTURE/RURAL COMMUNITIES 20 services if they did not have a positive experience previously or did not see the benefit of rehabilitative services prior to returning to the farm/ranch. Some view their work on the farm/ranch to be more rehabilitative than actually receiving services (Coles & OHare, n.d.; E. Freudenburg, personal communication, February 6, 2018). To promote a more effective therapeutic relationship and stress the benefit of rehabilitative services, it is essential that health professionals be educated and competent on how to relate therapy to the farmer/ranchers desired outcomes and transition back to the farm. By establishing an educational course, various societal needs are met. Increased education and advocacy are initial steps in reducing gaps in care and meeting the population specific needs. Through educational opportunities, such as the established course discussed, health professionals may have a greater impact on agriculture/rural communities creating a cohesive bond between services available and their effectiveness. While the course outline is meant to serve as a guide, it is important to keep in mind individuals societal and demographic needs. This project was conducted with midwestern agricultural methods and demands in mind which may not translate to all regions or programs. A convenience sample was utilized when determining locations for initial presentations. Due to the limited time frame to complete the project, additional trials would be required to adequately measure the effectiveness of the course in meeting competence standards. It is expected that quality improvement will occur through further implementation of the course outline and will be based on needs and/or desires of the organization or program using the outline as a guide. Reflection of Doctoral Capstone Experience Relevance to Future Practice OT IN AGRICULTURE/RURAL COMMUNITIES 21 This project serves to expand upon current literature limitations, to provide increased educational opportunities and options for current and future health professionals when working with agriculture/rural communities. The course discussed serves as a guide for additional training and/or continuing competency options that can be easy implemented. The course also serves as a resource in providing a basic overview of the occupational demands and requirements associated with farming/ranching. The University of Iowas Department of Occupational and Environmental Health offers more extensive training and coursework for health professionals interested in agriculture personnels health and wellbeing (The University of Iowa, 2018). As leading rehabilitation professionals, it is our duty to ensure we are reaching clients of all demographics, ethnicities, cultures, age, and physical/psychosocial limitations to ensure adequate services are being delivered. Health professionals and students should feel component in tailoring intervention plans that will enhance agriculture personnels return to their livelihood, and reinforce the benefits of rehabilitative services. Occupational therapists have a distinct role in advocating and educating colleagues, communities, and clients, in efforts to meet the professions unique philosophy of enhancing independence for improved quality of life (American Occupational Therapy Association, 2018). One farmer suggested that, farmers are a unique kind in which they can collaborate with health professionals to achieve effective adaptations and equipment recommendations useful to ones occupation since they have a more thorough understanding of farming/ranching (Cole and OHare, n.d.). Future work should continue to explore the relationship and role rehabilitation specialists, specifically occupational therapists, have within farming/ranching occupations. This may include OT IN AGRICULTURE/RURAL COMMUNITIES 22 focusing on availability to receive services, occupation specific intervention techniques, and/or continuing competence options. Overall Learning Upon completion of the doctoral capstone experience several learning goals were met, directly correlated to the designed project and professional development. Specific project achievements are highlighted in appendix H. Overall, all initial project objectives were successfully completed and exceeded expectations. During the development of the designated project, numerous electronic and direct contacts were made with students, program faculty, occupational therapists, and AgrAbility staff members. These contacts required effective communication in expressing the needs of working with farmers/ranchers and the importance of occupational therapists better serving the population. Additional self-directed learning was required for curriculum development during formation of the course. Consideration was also given to project longevity. Although not able to fully develop the course into a training program to be left with the National AgrAbility program, staff were educated on how the course could be used to establish this program. It is the hope that the course will serve as a guide for various health profession programs, rehabilitative facilities, and AgrAbility projects to assist in creation of continual competence for health professionals. The outline is intended to be modified for various settings and presentation structures to create longevity of the established work. Further refinement of skills occurred during the doctoral capstone experience including implementation of theory/program development in specialized settings, leadership, advocacy, OT IN AGRICULTURE/RURAL COMMUNITIES 23 and education. All skills developed and/or further refined will set the foundation for future practice and work as an occupational therapist. Conclusion There are several possible reasons as to why there is mention of gaps in services for farmers/ranchers. With continual support and resources, efforts can be made to assist in creating a wholesome rehabilitative experience for farmers/ranchers. Providing additional resources and training, such as the developed course, serves to advance health professionals competence and feelings of confidence when providing services to farmers/ranchers. The goal is to encourage more individuals to pursue this practice setting to meet societal needs. OT IN AGRICULTURE/RURAL COMMUNITIES 24 References American Occupational Therapy Association. (2018). About AOTA. Retrieved from https://www.aota.org/AboutAOTA.aspx American Occupational Therapy Association. (2014). Occupational therapy practice framework: Domain and process (3rd ed.). American Journal of Occupational Therapy, 68(Suppl.1), S1S48.http://dx.doi.org/10.5014/ajot.2014.682006 Brockwell, D., Wielandt, T., & Clark, M. (2009). Four years after graduation: Occupational therapists work destinations and perceptions of preparedness for practice. Australasian Journal of Rural Health, 17(2), 71-76. Cole, M. & Tufano, R. (2008). Applied theories in occupational therapy: A practical approach Thorofare, NJ: SLACK Incorporated. Coles, J. and OHare, M. (n.d.). The role of occupational therapy in rural healthcare: A case study on farmers with disabilities. Retrieved from www.rdsjournal.org/index.php/journal/article/viewFile/16/54 Deboy, G. R., Jones, P. J., Field, W. E., Metcalf, J. M., & Tormoehlen, R. L. (2008). Estimating the prevalence of disability within the US farm and ranch population. Journal of Agromedicine, 13(3), 175-190. Jorge, M. (2006). AgrAbility: Doctor of Physical Therapy (DPT) students learning to advocate for farmers and ranchers with disabilities. Journal of Physical Therapy Evaluation, 20(3), 61-63. Mills, A. and Millsteed, J. (2002). Retention: An unresolved workforce issue affecting rural occupational therapy services. Australian Occupational Therapy Journal, 49, 170-81. Millsteed, J. (1997). The contribution of occupational therapy to the fabric of Australian rural and remote communities. Australian Occupational Therapy Journal, 44(3), 95-106. OT IN AGRICULTURE/RURAL COMMUNITIES 25 National Safety Council. (2018). Occupational injury and illness FAQs. Retrieved from www.nsc.org/learn/safety-knowledge/Pages/injury-facts-occupational-illness-injury faqs.aspx Reed, D. (2004). Understanding and meeting the needs of farmers with amputations. Orthopaedic Nursing, 23(6), 397-405. Russell, M., Clark, M., & Barney, T. (1996). Changes in attitudes and skills among occupational therapy students attending a rural fieldwork unit. Australian Occupational Therapy Journal, 43(2), 72-78. Smallfield, S and Anderson, A. J. (2008). Addressing agricultural issues in health care education: An occupational therapy curriculum program description. National Rural Health Association, 24(4), 369-374. Stagnitti, K. (2008). Occupational therapy practice in rural and remote South Australia. Australasian Journal of Rural Health, 16, 253-254. Strasser, R. (2005). Rural medical education comes of age. Australasian Journal of Rural Health,13, 263-264. The University of Iowa. (2018). MS in agricultural saftey and health. Retrieved from https://www.public-health.uiowa.edu/ms-agricultural-saftey-and-health/ Waite, A. (2015). A growing opportunity: OTs role helping farmers and ranchers. OT Practice, 12-16. OT IN AGRICULTURE/RURAL COMMUNITIES 26 Appendix A Goal Attainment Scale Based on Doctoral Capstone Project at AgrAbility Success Goal Goal Goal Goal Level of Number of Indiana Number of AgrAbility/Rural Community Effectiveness of Presentations Given to Resources Provided to Students, Predicted Occupational Therapy Occupational Therapists Reached to Occupational Therapy Schools Occupational Therapists, and Attainment Programs Reached to Give Provide Information Relative to Course Through Use of Pre/Post Surveys AgrAbility Presentation Regarding Design Occupational Therapy in Agriculture Much Less Presentation will be given to Contact will be made with 1 Thirty percent of all students reached A course was not designed. No Than 1/6 Indiana Occupational Occupational Therapist practicing in a will complete the pre- and post-survey additional resources provided to upon Expected Therapy Programs. rural setting to complete interview while indicating advanced learning discontinuation of doctoral experience. questions that will be used in developing and knowledge following the a course. presentation. -2 Somewhat Presentation will be given to Contact will be made with 2 Forty percent of all students reached A course will be outlined, however not Less Than 2/6 Indiana Occupational Occupational Therapist practicing in a will complete the pre- and post-survey fully developed to be shared Doctoral Expected Therapy Programs rural setting to complete interview while indicating advanced learning Paper Written Summary. questions that will be used in developing and knowledge following the a course. presentation. -1 Expected Presentation will be given to Contact will be made with 3 Fifty percent of all students reached A course will be designed including 0 3/6 Indiana Occupational Occupational Therapist practicing in a will complete the pre- and post-survey related activities to be shared in the Therapy Programs rural setting to complete interview while indicating advanced learning Doctoral Paper Written Summary. questions that will be used in developing and knowledge following the a course. presentation. Somewhat Presentation will be given to Contact will be made with 4 Sixty percent of all students reached A course will be designed including More Than 4/6 Indiana Occupational Occupational Therapist practicing in a will complete the pre- and post-survey related activities to be shared in the Expected Therapy Programs rural setting to complete interview while indicating advanced learning Doctoral Paper Written Summary in questions that will be used in developing and knowledge following the conjunction with creation of a handout. a course. presentation. +1 Much Presentation will be given to Contact will be made with 5 Seventy percent or higher of all A course will be designed including More Than 5/6 Indiana Occupational Occupational Therapist practicing in a students reached will complete the related activities to be shared in the Expected Therapy Programs rural setting to complete interview pre- and post-survey while indicating Doctoral Paper Written Summary in questions that will be used in developing advanced learning and knowledge conjunction with the creation of a a course. following the presentation. handout and webinar. +2 OT IN AGRICULTURE/RURAL COMMUNITIES Appendix B Initial PowerPoint presented to Indiana Occupational Therapy programs 27 OT IN AGRICULTURE/RURAL COMMUNITIES 28 OT IN AGRICULTURE/RURAL COMMUNITIES 29 OT IN AGRICULTURE/RURAL COMMUNITIES 30 OT IN AGRICULTURE/RURAL COMMUNITIES 31 Appendix C Resources provided in conjunction with initial presentation Arkansas AgrAbility. Increasing physical activity as we age: Exercises for low back injury prevention. Retrieved from www.agrability.org/wp-content/uploads/2015/11/FSFCS38-Low-Back-InjuryPrevention.pdf Clingan, D. (2018). Agricultural interventions/modifications. Retrieved from https://create.piktochart.com/output/27785480-new-piktochart Indiana AgrAbility Project. Cultivating independence for farmers and other rural residents with disabilities. Retrieved from https://engineering.purdue.edu/~bng/downloads/IN_AgrAbility_web.pdf National AgrAbility Project. Arthritis and agriculture: A guide to understanding and living with arthritis. Retrieved from www.agrability.org/wp-content/uploads/2015/11/Arthritis_and_Ag.pdf National AgrAbility Project. Arthritis and gardening: A guide for home gardeners and small scale producers. Retrieved from http://www.agrability.org/wpcontent/uploads/2016/04/Arthritis_Gardening_Web_sm.pdf National AgrAbility Project. Back on the farm, back in the saddle: a guide to back health in agriculture. Retrieved from www.agrability.org/wp-content/uploads/2015/11/Back_health_final.pdf National AgrAbility Project. Could arthritis be what is causing my pain. Retrieved from www.agrability.org/wp-content/uploads/2015/11/AgrAbility_Novela_En.pdf National AgrAbility Project. Cultivating assessible agriculture. Retrieved from www.agrability.org/wpcontent/uploads/2016/01/AgrAbility_brochure_accessible_PDF.pdf National AgrAbility Project. Evaluating agricultural workplace assistive technology for secondary injury hazards. Retrieved from www.agrability.org/wp-content/uploads/2015/11/SecInjryAssmtTool.pdf National AgrAbility Project. (2016). The Next Mission: Breaking down barriers for veterans in agriculture. [YouTube Video]. Retrieved from https://www.youtube.com/watch?v=vkqdhYMwDb0 PUExtension. (2011). AgrAbility: Its about hope. [YouTube Video]. Retrieved from https://www.youtube.com/watch?v=sI3vChVHdoc&t=4s OT IN AGRICULTURE/RURAL COMMUNITIES Appendix D Rehabilitation in Agriculture/Rural Communities Course: Outline 32 OT IN AGRICULTURE/RURAL COMMUNITIES 33 OT IN AGRICULTURE/RURAL COMMUNITIES 34 OT IN AGRICULTURE/RURAL COMMUNITIES 35 OT IN AGRICULTURE/RURAL COMMUNITIES 36 OT IN AGRICULTURE/RURAL COMMUNITIES 37 OT IN AGRICULTURE/RURAL COMMUNITIES 38 OT IN AGRICULTURE/RURAL COMMUNITIES Appendix E Rehabilitation in Agriculture/Rural Communities Course: Example Lesson PowerPoints 39 OT IN AGRICULTURE/RURAL COMMUNITIES 40 OT IN AGRICULTURE/RURAL COMMUNITIES 41 OT IN AGRICULTURE/RURAL COMMUNITIES 42 OT IN AGRICULTURE/RURAL COMMUNITIES 43 OT IN AGRICULTURE/RURAL COMMUNITIES 44 OT IN AGRICULTURE/RURAL COMMUNITIES 45 Appendix F Rehabilitation in Agriculture/Rural Communities Course: Modified Presentation of Lesson 7 (Assistive Technology/Mobility Devices)-PowerPoint Presentation OT IN AGRICULTURE/RURAL COMMUNITIES 46 OT IN AGRICULTURE/RURAL COMMUNITIES 47 OT IN AGRICULTURE/RURAL COMMUNITIES 48 OT IN AGRICULTURE/RURAL COMMUNITIES 49 OT IN AGRICULTURE/RURAL COMMUNITIES 50 Appendix G Rehabilitation in Agriculture/Rural Communities Course: Modified Presentation of Lesson 7 (Assistive Technology/Mobility Devices)-Supplemental Case Study OT IN AGRICULTURE/RURAL COMMUNITIES 51 Appendix H Final Results of Goal Attainment Scale Based on Doctoral Capstone Project at AgrAbility Success Goal Goal Goal Goal Level of Number of Indiana Occupational Number of AgrAbility/Rural Community Effectiveness of Presentations Resources Provided to Students, Predicted Therapy Programs Reached to Occupational Therapists Reached to Given to Occupational Therapy Occupational Therapists, and Attainment Give Presentation Regarding Provide Information Relative to Course Schools Through Use of Pre/Post AgrAbility Occupational Therapy in Design Surveys Agriculture Much Less Presentation will be given to 1/6 Contact will be made with 1 Thirty percent of all students A course was not designed. No Than Indiana Occupational Therapy Occupational Therapist practicing in a reached will complete the pre- and additional resources provided to Expected Programs. rural setting to complete interview post-survey while indicating upon discontinuation of doctoral questions that will be used in advanced learning and knowledge experience. developing a course. following the presentation. -2 Somewhat Presentation will be given to 2/6 Contact will be made with 2 Forty percent of all students reached A course will be outlined, however Less Than Indiana Occupational Therapy Occupational Therapist practicing in a will complete the pre- and post- not fully developed to be shared Expected Programs rural setting to complete interview survey while indicating advanced Doctoral Paper Written Summary. questions that will be used in learning and knowledge following developing a course. the presentation. -1 Expected Presentation will be given to 3/6 Contact will be made with 3 Fifty percent of all students reached A course will be designed including 0 Indiana Occupational Therapy Occupational Therapist practicing in a will complete the pre- and post- related activities to be shared in the Programs rural setting to complete interview survey while indicating advanced Doctoral Paper Written Summary. questions that will be used in learning and knowledge following developing a course. the presentation. Somewhat Presentation will be given to 4/6 Contact will be made with 4 Sixty percent of all students reached A course will be designed including More Than Indiana Occupational Therapy Occupational Therapist practicing in a will complete the pre- and post- related activities to be shared in the Expected Programs rural setting to complete interview survey while indicating advanced Doctoral Paper Written Summary in questions that will be used in learning and knowledge following conjunction with creation of a developing a course. the presentation. handout. +1 Much Presentation will be given to 5/6 Contact will be made with 5 Seventy percent or higher of all A course will be designed including More Than Indiana Occupational Therapy Occupational Therapist practicing in a students reached will complete the related activities to be shared in the Expected Programs rural setting to complete interview pre- and post-survey while Doctoral Paper Written Summary in questions that will be used in indicating advanced learning and conjunction with the creation of a developing a course. knowledge following the handout and webinar. +2 presentation. OT IN AGRICULTURE/RURAL COMMUNITIES 52  ...

... Running head: OT AND ENTREPRENEURSHIP 1 Occupational Therapy and Entrepreneurship: Working as a Consultant in a Community-based Setting Brittany Meyers, OTS August 3, 2018 A capstone project submitted in partial fulfillment for the requirements of the Doctor of Occupational Therapy degree from the University of Indianapolis, School of Occupational Therapy. Under the direction of the faculty capstone advisor: Dr. Jennifer Fogo, PhD, OTR, Faculty Capstone Advisor OT AND ENTREPRENEURSHIP 2 A Capstone Project Entitled Occupational Therapy and Entrepreneurship: Working as a Consultant in a Community-based Setting Submitted to the School of Occupational Therapy at University of Indianapolis in partial fulfillment for the requirements of the Doctor of Occupational Therapy degree. By Brittany Meyers, OTS Approved by: Faculty Capstone Advisor Date Doctoral Capstone Coordinator Date Accepted on this date by the Chair of the School of Occupational Therapy: Chair, School of Occupational Therapy Date OT AND ENTREPRENEURSHIP 3 Abstract Work is recognized as an integral component of most adults lives and personal identities, often viewed as being essential to gain economic self-sufficiency, social connectedness, and good quality of life (Dennis, & Gitlow, 2012). Adults with intellectual and developmental disabilities (I/DD) experience limited abilities to participate in meaningful occupations, including work, being unemployed at 85% in the United States (Anderson, Larson, & Wuorio, 2011). While decades of disability policy has influenced promoting employment first initiatives for adults with intellectual and developmental disabilities, fiscal budgets limit the ability to provide governmentfunded and non-profit essential services, requiring prioritization when allocating funds (DDRS, 2017; Honeycutt, & Stapleton, 2013). The continued gap in employment for adults with I/DD supports the need for alternative, sustainable, grassroot business models that promote employment for people with intellectual and developmental disabilities. This paper outlines a DCE graduate students development of a social enterprise to address occupational marginalization in work and employment settings for adults with I/DD.. Commented [JF1]: You need to tie in OT. You can make a sentence about marginalization and OTs role to remediate occupational injustice. This paper outlines a DCE students development of to address occupational injustice. ( or something like that) Commented [BM2R1]: What do you think of this to address occupational therapy? Keywords: business model, consultant, employment, entrepreneur, health, intellectual and developmental disabilities, occupational therapy, quality of life, social enterprise, wellness, work Commented [JF3R1]: Perfect! OT AND ENTREPRENEURSHIP 4 Occupational Therapy and Entrepreneurship: Working as a Consultant in a Community-based Setting The Role of Work as an Occupation The profession of occupational therapy emphasizes that engagement in occupations, including skill acquisition and mastery of roles and routines that individuals engage in throughout their lives, provides satisfaction, and improves health, well-being, and overall quality of life (Mee, Sumsion, & Craik, 2004; Minnes et al., 2002). From childhood through adolescence, primary roles and occupations are centered around play and education; as individuals transition from adolescence into adulthood, primary occupations shift from play and education to work and leisure (Maguire, 2009; Wysocki, & Neulicht, 2004). Work is widely accepted as an integral component of most adult lives, being a source of ones personal identity (Dennis, & Gitlow, 2012). Work is often viewed as being essential to gain economic self-sufficiency, including attainment of resources needed for everyday life (Burge, Ouellette-Kuntz, Lysaght, 2007; Dennis, & Gitlow, 2012). The context of work has been linked to providing a community that can promote belonging and social connectedness (Blessing, 2014; Burge, Ouellette-Kuntz, Lysaght, 2007). Participating in a positive work experience has been linked with promoting self-actualization, including establishing a purpose, developing self-esteem, and self-worth, and improving health, well-being, and overall quality of life (Dragula, 2009; Lawrence, Alleckson, & Bjorklund, 2010; Minnes et al., 2002). However, when work and the surrounding work environment are unable to support the needs of the employed individual, inequity and negative health implications can occur (Ahonen, Fujishiro, Cunningham, & Flynn, 2018; Wysocki, & Neulicht, 2004). OT AND ENTREPRENEURSHIP 5 While studies support the potential health benefits of participating in work when individuals are supported in their work environment, there is limited research within the public health community on the impact work in a socioeconomic context has on ones health and wellbeing. Work is not yet recognized as being a key component of ones health status (Ahonen, Fujishiro, Cunningham, & Flynn, 2018). Without specific research outcomes measuring the impact opportunity for work and its surrounding environment has on ones health, our society is limited in understanding the health inequities that individuals, groups, and populations can experience as a result from potential occupational marginalization (Ahonen et al., 2018; Hammell, 2017). Adults with intellectual and developmental disabilities (I/DD) often lack the opportunity to exercise autonomy when participating in meaningful occupations (known as occupational marginalization) (Hammell, 2017; Maguire, 2009; Minnes et al., 2002). Occupational marginalization specific to decreased work opportunities can lead to further social isolation and is associated with decreased self-determination, self-worth, health, and well-being (Hammell, 2017; Minnes et al., 2002). Conversely, participation in supported community employment has been linked to increased independence, self-efficacy, and self-esteem for adults with I/DD, while promoting community inclusion, acceptance, and a better understanding of disability (Cimera, 2012; Nord et al., 2013). Disability policy has developed a foundation to improve overall health and well-being of adults with I/DD via re-assessing disability within a social-ecological framework instead of medical model, recognizing that disability is not a pathological condition but rather an individual with an impairment that requires environmental modifications and supports to reduce occupational marginalization (Shogren, & Turnball, 2014). OT AND ENTREPRENEURSHIP 6 Through overarching disability policy, adults with I/DD are better adept to obtain and experience community integration, participation, and occupational engagement, but translating policy into effective practice with appropriate supports has proven to produce variability that allows for continued marginalization of this population (OBrien, & Callahan, 2010; Shogren, 2013; Shogren, & Turnbull, 2014). Adults with I/DD continue to experience barriers to work and employment opportunities despite these policies due to complex factors including workplace culture, workplace infrastructure, public and societal attitudes towards community and workforce integration, and challenges experienced transitioning from entitlement- to eligibility-based services (Burge et al., 2007; Hagner, Phillips, & Dague, 2014; Monteleone, 2016). Consequently, the purpose of this paper is twofold: to explore the complex surrounding contexts, environments, and policies impacting the opportunity for paid employment of adults with I/DD, and to demonstrate how a sustainable business model that supports integrated, community-based employment for adults with I/DD can address occupational marginalization and improve selfdetermination, occupational performance, community integration, social participation, and overall health and well-being. Theory: Occupational Participation, Work, Health, and Intellectual Disability The complex relationships between autonomy, self-determination, health, well-being, and occupational participation within the context of work for adults with I/DD is better understood when applied within a theoretical framework that highlights the multiple factors and contexts that impact the individual. By utilizing a culmination of social-ecological theories, including the Social Ecological Model of Health and the Ecology of Human Performance model, to provide a framework for analyzing the complex nature of overarching policies and programs, implications on employment for adults I/DD can be obtained (CTSA, 2011; Dunn, Brown, & McGuigan, OT AND ENTREPRENEURSHIP 7 1994). The term disability historically was viewed within a medical model as a pathological condition that prevented an individual from being able to participate in occupations. The World Health Organization (WHO) redefined disability within a social-ecological framework (Shogren, & Turnball, 2014). In doing so, the WHO recognized disability as an interaction that occurs between an individual with an impairment and the overarching social, cultural, and physical contexts and environments. This social-ecological model provided an international framework to address disability policy and implications, recognizing that disability can be socially perpetuated when an environment is not structured with supports that enhance the opportunity for success of the individual that has an impairment (Shogren, & Turnball, 2014). The Social Ecological Model of Health (SEMH) allows for assessing the variability in multiple contexts, environments, and overarching societal structures that influence an individuals roles, experiences, beliefs, relationships, health and well-being over time. The model acknowledges that one context or environment cannot be mutually exclusive of the other, but rather that they are interwoven and embedded within one another (CTSA, 2011). The SEMH recognizes that there are multiple factors that influence an individuals health and well-being. This model takes into consideration how an individual interacts with their surrounding environments and structures, including how the experiences available to them influences their ability to experience personal health, wellness, and quality of life (CTSA, 2011). Public health organizations utilize this model to implement research and disseminate information about populations and communities to improve health and wellness (CTSA, 2011). The Ecology of Human Performance model (EHP) further considers the impact that multiple contexts have on an individual, identifying a persons capabilities/abilities that are experienced within certain contexts (individual, interpersonal, community, and societal OT AND ENTREPRENEURSHIP 8 environments) and how the contexts influence the ability to participate in occupations and roles by performing tasks (e.g. participating in work by performing work-related tasks) (Dunn, Brown, & McGuigan, 1994). How the surrounding contexts and environments influence the individual further dictates a range of an individuals performance and capabilities (performance range) when accomplishing their desired occupations (Dunn, Brown, & McGuigan, 1994). An individuals performance range can be limited or expanded based upon the supports of their external contexts and environments (Dunn, Brown, & McGuigan, 1994). Other health professionals outside of the field of occupational therapy may not utilize this exact model to analyze contexts and environments on occupational performance with adults with I/DD, however professionals recognize that contexts impact performance capabilities and adapting or modifying an environment and supports allows for increased performance range capabilities. The American Association on Intellectual and Developmental Disabilities (AAIDD), the leading United States interdisciplinary organization providing advocacy, research, practice, and policy regarding individuals with I/DD, includes similar concepts within their framework of human functioning (AAIDD, 2018; Buntix, & Schalock, 2010). By placing the overarching SEMH within the EHP Model, a more structured framework for analyzing the complex dynamic of disability policy and the impact it has on creating and improving current employment services and opportunities for adults with I/DD within the community can be obtained. Review of national, state, and county demographics; disability policy and population statistics; and government-based supports and resources helps determine current employment opportunities available for adults with I/DD. As a result, it helps indicate the prevalence of this population experiencing work-related community integration, social OT AND ENTREPRENEURSHIP 9 engagement, and occupational participation with potential implications of improved overall health, and well-being. Intellectual and Developmental Disability, Policy, and (Un)Employment In the United States, there are over 4.7 million people with I/DD (Anderson et al., 2016). Less than one-third, 1.4 million people, are known to receive some type of government service support from a state I/DD agency, with over 60% of these individuals being 22 years old or older (Anderson et al., 2016). Two-thirds of these adults with I/DD receive services from a Medicaid waiver authority that provides long-term support services, including residential or in-home supports, day habilitation services, and supported employment services (Anderson et al., 2016). Access to long-term support services, including employment-based supports, have increased from disability policy advocating for equitable opportunities for people with disabilities, however accessibility and sustainability to supported, integrated, community employment continues to be a barrier for adults with I/DD. Approximately 85% of adults with I/DD are unemployed in the United States (Anderson, Larson, & Wuorio, 2011; Brady et al., 2010; Domin, & Butterworth, 2013; Friedman, & Rizzolo, 2017; Hall, Freeze, Butterworth, & Hoff, 2011; Monteleone, 2016). Variability in employment rates of adults with I/DD across the states is further complicated by the structure of the United States political governing system. Multi-tiered, states determine its own legislation to effectively delegate the implementation, allocation, and distribution of funds to services that substantiate overarching federal civil right policies (Monteleone, 2016). Due to variability in federal and state funding, service structures, and available resources across states, employment and other positive service-related outcomes for adults with I/DD are inconsistent and often unable to be comprehensive (Honeycutt, & Stapleton, OT AND ENTREPRENEURSHIP 10 2013). With Medicaid acting as the primary funding service for adults with I/DD, it is imperative to recognize that adults with I/DD that do not qualify for Medicaid are frequently disqualified from receiving support services, which are primarily funded through Medicaid waivers (Anderson et al., 2016; Hall, Freeze, Butterworth, & Hoff, 2011). Another complication young adults with I/DD experience transitioning into adulthood, including gaining meaningful employment, stems from a major paradigm shift with policy practices from youth to adulthood as services transition from entitlement to eligibility (Chapman, 2009). Young adults with I/DD are entitled to educational services until they have earned a diploma, a certificate of completion, or have aged out at the age of 22. When a young adult with I/DD no longer qualifies for entitlement-based services within the school system, the individual transitions to qualifying for eligibility-based services. Prior to this transition, an Individual Transition Plan (ITP) should have been implemented to help navigate this transition, although the viability and efficacy of the ITP may be unknown. Even though many adults with I/DD are able to receive eligibility-based services, an alarming number of adults with I/DD do not qualify (Anderson et al., 2016). This creates additional financial and social responsibility on family members of adults with I/DD, and often without any support to successfully navigate transitioning into adulthood (Anderson et al., 2016). Development of Disability Policy and Employment First Initiatives Historically, people with I/DD in the United States were removed from their respective communities and institutionalized to receive care and housing and they were placed in sheltered workshops, segregated from the rest of the community (Dague, 2012; Monteleone, 2016). It was not until the 1970s that services shifted from institutionalization to community based services with community providers and affirmative action plans to promote opportunities for people with OT AND ENTREPRENEURSHIP 11 disabilities (Monteleone, 2016). Disability policy continued gaining momentum in the 1980s, promoting community integration, self-determination, and employment opportunities. The Americans with Disabilities Act of 1990 (ADA) prohibited discrimination against people with disabilities in all areas of public life, including employment. The Workforce Investment Act of 1998 (WIA) developed national employment training services, which funded vocational rehabilitation services and other transition service programs for people with disabilities (Monteleone, 2016). Employment first initiatives for people with disabilities has been promoted at state levels, with Indiana recently passing legislation in 2017 to promote competitive, integrated employment as the first, preferred option for any individual of working age with a disability (Monteleone, 2016; General Assembly of the State of Indiana, 2017). Paradigm Shift in Employment-based Supports For many adults with I/DD that receive long term support services that have been developed from disability policy, there is a spectrum of employment and day program support settings available, funded primarily through Medicaid waivers and vocational rehabilitation services (Hall et al., 2011). This continuum of settings potentially provide a network of services that allow adults with I/DD to become integrated within the community while receiving additional supports with daily activities, self-care, independent living skills, and employmentbased initiatives individualized to appropriately support the adult with I/DD needs (Friedman, & Rizzolo, 2017). Recent disability policy supports employment first initiatives, encouraging people with disabilities to pursue competitive, integrated employment, shifting away from sheltered employment and day habilitation programs (General Assembly of the State of Indiana, 2017). OT AND ENTREPRENEURSHIP 12 In order to best understand the differentiation in the spectrum of employment opportunities available for adults with I/DD, it is beneficial to understand the nature of each employment setting, which will be defined below as noted by the law: Competitive integrated employment: paid employment including eligibility for benefits similar to employees without disabilities; employees with disabilities have opportunities for advancement that are similar to other employees without disabilities and have equal opportunity to earn fair wages (Rosas Law, 2017). Customized employment: strategies used to focus on individualized strengths and interests of the individual with disability, business needs of employer, and developing a working plan with employer to facilitate placement of individual with disability (Rosas Law, 2017). Extended employment: work within a non-integrated or sheltered setting for an organization that provides compensation with the Fair Labor Standards Act (Rosas Law, 2017). Extended services: ongoing services maintaining supported employment based on the needs of the individual with a disability, is supported through an individualized plan of employment. Extended services do not exceed four years or beyond the age of years old (Rosas Law, 2017). Supported employment: competitive integrated, customized employment, or short-term employment working towards competitive integrated, customized employment of individual with most significant disability with anticipation of achieving outcome within six to twelve months, Commented [BM4]: Somehow lost comment box. Adjusted and modified language. Uncertain if completed intext citations correctly. Used A.706 APA reference to legal materials to cite (p. 223) demonstrate progress towards competitive earnings (Rosas Law, 2017). Commented [JF5R4]: This is fine Government Structures to Promote Employment Multiple federal government programs provide systemic structure at the federal and state levels that address the issue of employment for adolescents and adults with I/DD including: the OT AND ENTREPRENEURSHIP 13 Department of Education (DOE); Department of Labor (DOL), including the Office of Disability Employment Policy, Office of Federal Contract Compliance Programs, Office of the Assistant Secretary for Administration and Management, Civil Rights Center, and Employment and Training Administration; the Federal Social Security Administration (FSSA); and Department of Health and Human Services (HHS), including the Administration for Community Living (FSSA, 2018a; United States Department of Labor, n.d.). Each of these larger, overarching federal departments work in conjunction with state level departments to manage designated allocation of funds into appropriate programs for its citizens. In the state of Indiana, employment-based services for adults with I/DD is managed under the Indiana Family and Social Services Administration (FSSA, 2018a). Two major departments, the Division of Disability and Rehabilitation Services (DDRS) Bureau of Developmental Disability Services (BDDS) and Vocational Rehabilitation Services (VRS) work in conjunction to promote employment first initiatives (FSSA, 2018a). The BDDS promotes services specifically designated to adults with I/DD to live as independently as possible in their communities (FSSA, 2018b). Promotion of these services are provided via eligibility for one of the available Medicaid waivers: Community Integration and Habilitation (CIH) waiver, Family Supports Waiver (FSW) or Supervised Group Living (SGL) waiver. While not every waiver provides support services for employment, the CIH and FSW provide opportunity for prevocational services and workplace assistance (FSSA, 2018b). However, recent changes in policy have eliminated extended supported employment followalong eligibility for adults with I/DD (FSSA, 2018c). Vocational Rehabilitation Services (VRS) is a program developed to provide individualized, employment-based services and supports to people with disabilities in order to OT AND ENTREPRENEURSHIP 14 obtain employment and promote independence within the work place (FSSA, 2018d). VRS provides a variety of services to help youth and adults with I/DD achieve meaningful employment, providing Pre-employment transition services (Pre-ETS) and vocational rehabilitation employment services through partnership with employment service providers, also known as community rehabilitation providers (FSSA, 2018d). Pre-ETS is one of the many programs designed from the Workforce Innovation and Opportunity Act (WIOA) of 2014, which has replaced WIA, derived from close collaboration of Commented [JF6]: Derived from is better terminology the Departments of Education, Labor, Health and Human Services, Agriculture, and Housing and Commented [BM7R6]: Agreed. Derived is more accurate and provides better clarity. Urban Development (Monteleone, 2016; United States Department of Labor, 2017). Through Pre-ETS students and youths with disabilities (ages 14-24) who are potentially eligible or eligible for VRS may receive services that promote post-school activities including postsecondary education, vocational training, competitive integrated employment, supported employment, independent living, and community participation (USDoE, 2017). VRS and PreETS partner with community rehabilitation providers (CRPs), employment network providers, and other government entities including Workforce One to promote employment opportunities for people with disabilities. These opportunities are funded using a combination of Medicaid waivers and VRS funding (Hall et al., 2011; United States Department of Labor, 2017). In Indiana, VRS and Pre-ETS have demonstrated efficacy providing employment and vocational services for people with I/DD, being the largest population served (55%) by VRS and CRPs (USDoE, 2017). VRS achieved an overall employment rate for individuals with I/DD under the age 25 receiving services in Indiana at ~48% compared to the national average of 56% in 2016 (USDoE, 2017). The majority of students and youths with disabilities (78%) obtained OT AND ENTREPRENEURSHIP 15 eligibility for VRS and received an individualized plan of employment (IPE) within 60 days of application, with the remaining 22% taking 2 months to a year to obtain an IPE (USDoE, 2017). Limitations of Funding Impacting Services Fiscal budget limitations impacts the ability to provide government-funded essential services, which may require prioritizing allocation of funds when there is high demand for its resources. While Indiana VRS has been able to serve the majority (78%) of its individuals with I/DD from application to eligibility within 60 days during the year 2016, only 69% of these individuals with I/DD obtained an Individual Plan of Employment (IPE) by the mandated WIOA standard of 90 days (USDoE, 2017). Literature has demonstrated that this waiting period negatively impacts individuals with I/DD seeking employment services, potentially causing economic distress with SSDI applicants and generating less favorable outcomes for employment (Honeycutt, & Stapleton, 2013; USDoE, 2017). In 2017, Indiana was the 35th state to implement an Order of Selection (OOS) due to limited funds and resources needed to serve all eligible individuals with disabilities (DDRS, 2017). VRS is mandated by WIOA to implement an OOS that prioritizes service to individuals with most significant disabilities (MSD) first, placing individuals with less significant disabilities on a waiting list for services when there are insufficient funds and resources to serve all eligible applicants (DDRS, 2017; Honeycutt, & Stapleton, 2013). Stagnant Growth in Community Based Employment No published reports directly reflect employment-based service outcomes after implementation of the 2017 Indiana VRS OOS. However, other VRS state agencies that have implemented an OOS have demonstrated applicants placed on wait lists may experience negative consequences. These consequences have included not obtaining employment via VRS services, OT AND ENTREPRENEURSHIP 16 and experiencing suspension or termination of SSDI or other eligibility-based benefits (Honeycutt, & Stapleton, 2013). Despite decades promoting employment first initiatives and disability policy, there has been limited growth in achieving improved employment and economic self-sufficiency outcomes for adults with I/DD in Indiana (Grossi, 2017). The Indiana Day and Employment Services Outcomes Systems Report (DESOS) is generated annually and reviews overall outcomes of support services provided by adult service provider agencies (also known as CRPs) to people with disabilities (Grossi, 2017). In 2017, approximately two-thirds of Indiana CRPs participated in reporting on DESOS data. This data revealed that there has been growth in non-employment day programs at a rate of 4% over the past five years, representing 23% of where time is spent the majority of their day for people with I/DD and other disabilities (Grossi, 2017). Sheltered employment and individual, competitive employment services comparatively grew at a rate of 2% each, representing 27% and 29% respectively of these settings (Grossi, 2017). With the majority of individuals served by CRPs having either mild I/DD (31%), moderate I/DD (17%), and Autism (11%), the limited variability and growth with obtaining outcomes of integrated, competitive employment or supported employment demonstrates the stagnancy in achieving improved employment outcomes despite employment first initiatives (Grossi, 2017). Employment, Earnings, and Work Opportunity Further concerns are perpetuated by the overwhelming representation in the Indiana DESOS data regarding earnings and paychecks: 40% of individuals did not receive a paycheck and 30% received paychecks from a CRP (Grossi, 2017). Only 30% received paychecks from their employer, demonstrating little improvement towards economic self-sufficiency via sustainable, earned wages that support employment and reduce dependence on federal and state Commented [JF8]: Fix sentence structure: Break down into smaller sentences. This was recommended in last version. Commented [BM9R8]: I must have missed that, sorry! Resetrctureed into multiple sentences. OT AND ENTREPRENEURSHIP 17 funding generated from taxpayer dollars (Anderson, Larson, & Wuorio, 2011; Grossi, 2017). Of the individuals served by CRPs that maintained employment, 80% received no fringe benefits from their employer (Grossi, 2017). National reports are grimly similar with less than 20% of adults with I/DD having any type of employment income and 25% of adults with I/DD having no personal income (Anderson, Larson, & Wuorio, 2011). Of the percentage of adults with I/DD that are able to obtain employment, 11% have paid community employment and 15% have paid time in a day program, with many of these individuals representing both employment settings (Anderson et al., 2016). Paid employment for adults with I/DD occurred most frequently in the following settings: piece work, assembly, and packaging (32%), facility maintenance and cleaning (19%), office work (16%), and food prep and service (14%) (Anderson, Larson, & Wuorio, 2011). Available work frequently provided limited hours making low, by-piece wages; or provided alternative volunteer, unpaid work located within sheltered workshops or facility-based employment sites (Anderson, Larson, & Wuorio, 2011; Domin, & Butterworth, 2012; Winsor et al., 2017). (Un)employment, Poverty, and Supplemental Income Individuals with disabilities are more likely to experience poverty than people without disabilities at a rate of 20% compared to 13%, with Indiana reporting individuals with disabilities under the poverty threshold line at ~27% (Erickson, Lee, & von Schrader, 2017; Kraus et al., 2018). The majority of adults with I/DD from the DESOS data qualify for supplemental government supports including social security income (SSI) (44%), social security disability income (SSDI) (26%), or Medicaid (71%), but often are unable to achieve economic selfsufficiency even with this income since such government benefits are set below the federal poverty threshold (Anderson, Larson, & Wuorio, 2011; Grossi, 2017; Hughes, & Avoke, 2010). OT AND ENTREPRENEURSHIP 18 Adults with I/DD living in poverty continues to increase despite increased funding for government long-term support services including employment (Hughes, & Avoke, 2010). This occurrence is likely due to limited funding focused on supported, integrated, community employment services; insufficient support services needed to serve all adults with I/DD; and due to policies that place adults with I/DD at risk of losing benefits like SSI, SSDI, or health care if an individual with I/DD gains employment that allows them to earn living wages that raise them above the poverty threshold (Hughes, & Avoke, 2010). Johnson County, Employment, and People with I/DD Johnson County is located in central Indiana, south of Marion County which houses the state capital Indianapolis. Johnson County, traditionally known for its farming and agriculture, has experienced a population growth at a rate of 10% between 2010-2017 (USDA, 2018). In 2017, the overall population for Johnson County was projected at 153,897 people (USDA, 2018). While the population of young adults with I/DD ages 18-24 for Johnson County is unknown, the population of young adults ages 18-24 represents approximately 9% of the total population, with 13,139 people (Stats Indiana, n.d.). There are approximately 1200 students that are of the transition age (ages 14-22) enrolled in Special Education services in Johnson County that have an Individualized Education Plan, Individualized Transition Plan, or 504, qualifying them for specialized accommodations within the public school system (Dwana Back, Director of PreETS Easterseals Crossroads, personal communication, May 8, 2018). These transition age students with disabilities comprise approximately 15% of the total student body in Johnson County (Dwana Back, Director of PreETS Easterseals Crossroads, personal communication, May 8, 2018). OT AND ENTREPRENEURSHIP 19 While there are services available for students with disabilities when enrolled in school due to entitlement-based services and WIOA, some of these students may be at risk of not receiving or qualifying for services due to variability with school corporation policies, limited resources with Pre-ETS and VRS, and pending eligibility status as they transition into adulthood (Anderson et al., 2016; Carla Orr, Adult & Child Manager Pre-ETS, personal communication, May 23, 2018). The Pre-ETS program, designed to supplement provision of transition services and pre-vocational skills, provides individual and group-based services to four of the six public schools in the county, but currently only serves 265 students (Carla Orr, Adult & Child Manager Pre-ETS, personal communication, May 23, 2018). Within Johnson County, there is only one community rehabilitation provider service that has a location housed within Johnson County: Gateway Services (Indiana Vocational Rehabilitation Services, 2018). Sixteen other CRPs serve Johnson County, however none have a location within Johnson County to increase ease of potential accessibility to community and employment-based services to help streamline services (Indiana Vocational Rehabilitation Services, 2018). Currently, no other CRPs may apply to be qualified by the state of Indiana to provide employment-based services to this population in Johnson County (FSSA, 2018d). With an increase in Johnson Countys overall population, CRPs being limited in both physical proximity and human resources to provide essential employment services across multiple counties, and VRS implementing an OOS that triages employment services based on most significant disabilities, youth and young adults with mild to moderate I/DD are at risk of experiencing occupational marginalization and social isolation without access to employment services. There is a significant need for a grassroots movement within Johnson County to promote social enterprise business models utilizing natural supports to assist adults with I/DD in OT AND ENTREPRENEURSHIP 20 obtaining and retaining successful, integrated community employment that contributes to the community. Grassroot Business Initiatives to Promote Work Opportunities for Adults with I/DD Business initiatives to support work opportunities for people with I/DD is not a novel concept. Disability policy over the past few decades has helped shape the course of promoting employment first initiatives, encouraging federal and state policy to shift from sheltered workshops to supporting competitive integrated employment that is customized to the person with a disability. Complex factors including societal and public attitudes, stigma, businesses unable or uncertain how to provide adequate, appropriate supports, and internal barriers such as inadequate work experience and lack of self-confidence all contribute to high levels of unemployment for people with I/DD (Anderson, Larson, & Wuorio, 2011; Trembath, Balandin, Stancliffe, & Togher, 2010). Similarly, societal and economic trends have shown there is an increasing demand for social enterprises, forming a new business model as our society seeks alternative solutions to help address societal problems and needs that are left unmet through traditional government, nonprofit, and private organization approaches (Hoefer, & Silva, 2016). A social enterprise is defined as an organization that address(es) a basic unmet need or solve(s) a social problem through a market-driven approach, often combining what is thought of as a traditional business model with a nonprofit organization social missions (Social Enterprise Alliance, 2018). A social enterprise utilizes its social mission and ethical values to design how a product or service is produced, how the business treats its employees, the consumers, and the environment, and how the business addresses social problems and demands based on its market-based approach to achieve sustainability (Wilson, & Post, 2013). OT AND ENTREPRENEURSHIP 21 Research surrounding businesses, employers, hiring processes, and people with disabilities demonstrates that the majority of employers express interest and desire in hiring and obtaining people with disabilities as employees, but demonstrate lower numbers employing people with disabilities (Siperstein, Romano, Mohler, & Parker, 2006). Employers acknowledged a lack of understanding about how to make appropriate accommodations or modifications to adequately support a person with a disability, often fearing associated costs (Kaye, Jans, & Jones, 2011; Siperstein et al., 2006). Some employers report not knowing what true work level performance a person with a disability may be able to obtain, fearing poor job performance and potential reprimands for firing a person with a disability. Even though there are a variety of services available for businesses and employers to obtain training and additional resources on how to successfully support employees with disabilities, businesses may not know how to obtain these services or feel that they have adequate time to participate in consequential training (Kaye, Jans, & Jones, 2011; Siperstein et al., 2006). A literature review of social enterprise business models was conducted, addressing business culture, ethical practice, and employment of people with I/DD. The most common evidence-based practices regarding efficacy of social enterprise development was discussed to better ascertain the process needed to effectively develop a social enterprise business model. Literature Review Alternative Business Models: The Rise of Social Enterprises Social enterprises (SE) are seeing rising growth in the business world as consumers demand more environmental and social expectations and responsibility from corporate businesses, valuing businesses roles as corporate citizens (Santos, Pache, & Birkholz, 2015). SE serve as hybrid business organizations, typically generating commercially run operations Commented [JF10]: Do not start sentences with while per APA. I have not corrected all of these in your paper. It is not typically an issue to do it occasionally, but you use while a lot. Reword this sentence with Even though Commented [BM11R10]: I am guilty of doing so. I will make sure to address these corrections. OT AND ENTREPRENEURSHIP 22 while maintaining goals of addressing larger societal, social problems within the mission of the business (Santos, Pache, & Birkholz, 2015). Due to its structure, SE must incorporate and achieve both financial sustainability while fulfilling their larger, social mission, managing what is acknowledged as a double bottom line (Katz, 2014). SEs often have a positive impact on society by addressing larger societal problems, however, they must be managed in a way that prevents mission drift while maintaining financial viability to prevent business failure (Santos, Pache, & Birkholz, 2015). Research on SE has currently been limited due to its more recent formal development and adoption within the business sector despite some long-standing historical existence of SE (Mandiberg, 2016). SE have shown a wide range of perspectives on business structure and management, including efficacy of outcomes based on ability to address the double bottom line (Katz, 2014; Smith, McVilly, McGillivray, & Chan, 2018). A review of the most current literature on SE employing people with disabilities was conducted to determine what business structures and strategies have demonstrated efficacy and sustainability as a business. Social Enterprises: Promoting Successful Work Integration for People with Disabilities SE have successfully addressed employment for marginalized populations, including people with disabilities, because the primary social mission of the business is providing a service or product to the consumer market. In order for a SE to demonstrate efficacy navigating the double bottom line, the business must support employment of people with disabilities while developing a product or service that has the potential to generate a commercially viable business (Smith et al., 2018). Recommendations are explored to demonstrate strengths and barriers experienced by SE that have employed people with various disabilities. Commented [JF12]: Please read through this section and choose how to appropriately label this. Sometimes you just have SE, sometimes SE business models, sometimes SE business. I started to make it plural by just saying SEs, but I am not sure that is correct. Whatever you select, just be consistent through this section and the rest of your paper. Commented [BM13R12]: Yes, I did struggle with determining how to best discuss the topic. I will adjust and refer to social enterprises as SE. OT AND ENTREPRENEURSHIP 23 Many SE emphasize establishing interdisciplinary community development as means to develop community partnerships including beneficiaries during the SE development process as means to create mutually beneficial partnerships (Ersing, Loeffler, Tracy, & Onu, 2007). Through this process, the SE can assist in building assets in the community while improving quality of life and opportunity for integrated work as means of occupational engagement for people with disabilities. The International Labor Organization (ILO) identifies that establishing partnerships, promoting integration, exercising innovation, and promoting transferability are four integral components needed for SE that focus on people with disabilities (Ersing et al., 2007). Most business and service models that provide supported employment to people with disabilities similarly utilize the strategies identified by ILO. A SE offering employment opportunities for people with disabilities must ensure that they also promote: respect and dignity; skills and competence; presence and participation; and choice and control for its employees (Smith et al., 2018). Respect and dignity recognizes all individuals are employees within an integrated workforce. Individuals with disabilities must have a choice as to if they desire to be employed by the SE. All employees have the opportunity to progress into higher supervisory and management roles (Katz, 2014; Smith et al., 2018). Skills and competence incorporates strengths-based assessment methodology, mentorship, skill development, and intentional celebration of employee success when attaining and demonstrating mastery of skills. SEs address principles of presence and participation by insuring employees are integral to the success of the business, recognizing employees as valuable contributors to the community by providing a product or service. Choice and control encourages employees to partake in business planning and decision making within the business enterprise to the extent employees aspire to be involved (Katz, 2014; Smith et al., 2018). OT AND ENTREPRENEURSHIP 24 Barriers to Successful Development and Implementation of a SE Despite promising results from SE, there are common barriers experienced by social entrepreneurs that could cause a SE to not become viable. Clear, direct communication from social entrepreneurs and developers regarding how SE may serve as an alternative solution to employment models for people with I/DD is necessary (Katz, 2014). If the business model is convoluted, advocates for people with disabilities may misinterpret the business model as a sheltered workshop or a community service provider agency (Katz, 2014). Strong leadership must drive effective change management to advocate for the benefits and efficacy of an alternative business model that implements ongoing support strategies and promotes an intentional work culture of inclusion (Smith et al., 2018). This process requires cultivating key stakeholders in the community to assist with community partnerships and accessing community resources to achieve shared objectives developing the SE(Ersing et al., 2007; Fazzi, 2012). Without buy-in from community key stakeholders, access for community resources and capital for starting up a SEis incredibly challenging (Ersing et al., 2007). If there is no involvement from stakeholders that contribute to knowledge regarding business development and cultivation, the enterprise will likely suffer (Ersing et al., 2007). Development of a Social Enterprise Understanding the benefits, strengths, and barriers to a SE helps structure the foundation needed to make a SE economically viable, sustainable, and able to achieve its social mission. The graduate student worked as a consultant in the community during the course of the sixteen week Doctoral Capstone Experience (DCE), where she explored the complex surrounding contexts, environments, and policies impacting the opportunity for paid employment of adults with I/DD. In the process of completing a needs assessment of the Johnson County community, Commented [JF14]: Good transition, just rewrite so that it is not first person. Commented [BM15R14]: Thank you for the clarity. I know APA requires writing in third person. I should have confirmed this with you while writing my paper. OT AND ENTREPRENEURSHIP 25 the graduate student provided framework for developing a sustainable business model, outlining plans that supports integrated, community-based employment for adults with I/DD to improve self-determination, occupational performance, community integration, social participation, and Commented [JF16]: Again, great transition! overall health and well-being. Screening and Evaluation Initial development of the DCE opportunity at Johnson County Community Foundation (JCCF) derived from completing a University of Indianapolis School of Occupational Therapy Spring 2017 Fieldwork D experience focused on occupational therapy community-based practice. The eight week fieldwork experience was completed at JCCF, which required the completion of a basic needs assessment of Johnson County employment services and opportunities for adolescents and young adults with disabilities. The fieldwork experience was developed from the Chief Financial Officer, Thelma Slisher, after interacting with parents that have children with disabilities expressing concerns of post-secondary school opportunities and uncertainty how to assist their adult children obtain and retain employment. Thelma has successfully ran a basketball program for children with autism and other disabilities for over ten years. The basketball program allowed the children to thrive in an environment and learn how to play basketball when proper supports were in place. Determined from years of anecdotal evidence via coaching, Thelma desired to help improve the future outcomes of the aging children from the basketball program and other adolescents and young adults with intellectual and developmental disabilities (I/DD) within the community as they transitioned into adulthood. In the process, Thelma sought assistance from the University of Indianapolis School of Occupational Therapy to determine if there was a true need within the Commented [BM17R16]: Thank you! OT AND ENTREPRENEURSHIP 26 Johnson County community that validated the parents concerns about obtaining employment as these children with I/DD transitioned into adulthood. Through the course of the eight week fieldwork experience, a group of Doctorate of Occupational Therapy students completed a general needs assessment of Johnson County, determining that there was a need for additional supported employment opportunities for adults with I/DD in Johnson County. The group of students suggested as a final outcome for a Doctorate of Occupational Therapy student to continue working with JCCF during a sixteen week DCE to address program development surrounding supported employment for adults with I/DD in Johnson County. Preliminary meetings and project development for the DCE occurred during the winter and spring seasons of 2018. Thelma and the graduate student met to develop a Memorandum of Understanding between the University of Indianapolis School of Occupational Therapy and Johnson County Community Foundation regarding responsibilities of doctoral student intern and site mentor and address goals and objectives to be completed during the sixteen week DCE. During the development of goals and objectives, Thelma discussed wanting to explore various potential products and/or services that could create a viable business within the Johnson County community, including: flower shop/horticulture, agriculture/produce, and bed and breakfast. A steering committee was developed in February 2018 to brainstorm concepts for a business model, supporting exploration of Thelmas primary business products and services suggestions. The steering committee agreed to commit to monthly meetings to help drive the development of the business model and plan throughout the DCE, facilitating advisement and guidance during the entrepreneurial process as the student intern served roles as researcher and consultant. OT AND ENTREPRENEURSHIP 27 In order to best guide and manage the development process of serving as a consultant within a community-based setting focused on business entrepreneurship, the graduate student developed a Goal Attainment Scale with the site mentor addressing desired outcomes at end of the DCE. She developed phases of implementation during the DCE process to address various goals and outcomes anticipated for successful development of a business model. Phases Commented [JF18]: Avoid first person language. You need to say: This DCE student developed.. Commented [BM19R18]: Corrected all first person to third addressed during the DCE included: completing a needs assessment of Johnson County employment services for adults with I/DD, conducting market research of products and services in Johnson County, constructing an organized template regarding legal structure of nonprofit corporations, initiating development of a business model and business plan start-up, initiating exploration of viable financial models to obtain economic viability and sustainability, and initiating program development for effective supported employment services for adolescents and young adults with I/DD. Commented [JF20]: Make sure verb tense is consistent through this section. Needs Assessment Commented [BM21R20]: Scanned throughout sections to address verb tense. To determine the best recommendation for a business model providing supported, integrated community employment of adolescents and young adults with I/DD within the Johnson County community, a needs assessment was completed. The graduate student researched current policies and support structures for adults with I/DD, statistics and demographics of adolescents and adults with I/DD in Indiana and Johnson County, current gaps in service provisions, and identification of other effective organization or business models that provide supported, integrated community employment of adults with I/DD. A full report of the needs assessment titled Johnson County needs assessment: Report on employment for adolescents and young adults with intellectual and developmental disabilities was generated; refer to Appendix A. OT AND ENTREPRENEURSHIP 28 The graduate student collected primary and secondary data, gathering national, state, and county statistics and reports regarding people with disabilities, people with I/DD, and employment and vocational training demographics. She conducted interviews with multiple government and community rehabilitation agencies, including Directors and other leaders of employment and vocational training agencies to obtain clinical and program expertise as well as internal data used for specific program development outcomes. Refer to Appendix B for table of interviews and data obtained. She reviewed interviews and data obtained with the site mentor during the data collection process. Graduate student reviewed National reports and literature Commented [JF22]: See wording examples from above. This DCE student collected primary and secondary data.. She also conducted interviews Commented [BM23R22]: Corrected, using third person and active voice. Will delete word outcomes when comment resolved. regarding current overarching disability policies to determine current, relevant language used and supports driving design and implementation of employment and vocational training support structures within government and community rehabilitation agencies. The graduate student confirmed that the Johnson County population has been growing at rate of 10% from 2010-2017; young adults ages 18-24 comprised 9% of the total population at 13,139 people (Stats Indiana, n.d.). Transition age students with disabilities (ages 14-22) receive an Individualized Transition Plan (ITP), designed to assist parents and the student with a disability transition from school-based activities to community-based activities and services (IPAS, 2009). The ITP is a requirement for enrollment in Special Education services for students with disabilities (IPAS, 2009). An unpublished report from Easterseals Crossroads listed Johnson County public schools having a total of 1191 transition age students with disabilities enrolled in Special Education services (Dwana Back, personal communication, May 8, 2018). The National Center for Education Statistics reported that the total transition age student body population for Johnson County was 7956 students (n.d.). Using these statistics, the graduate student proposed 15% of Commented [JF24]: Commented [BM25R24]: Corrections made using third person. OT AND ENTREPRENEURSHIP 29 the total student body population was comprised of students with disabilities and enrolled in the Special Education program. When tabulating results from other surrounding counties, including Hamilton, Hancock, Hendricks, and Marion, Johnson County had the highest percentage of students with disabilities within the total student body, followed by Marion at 14.8%, Hancock at 14.0%, Hamilton at 10.8%, and Hendricks at 10.0%. No additional data were collected regarding private or charter schools, focusing analysis on mainstream and public services. Exploring current employment models and funding demonstrated that the United States government primarily funds employment models and employment first initiatives for adolescents and adults with I/DD through two major departments: Indiana Family and Social Services Administration, the Division of Disability and Rehabilitation Services (DDRS) Bureau of Developmental Disability Services (BDDS) and Vocational Rehabilitation Services (VRS) (FSSA, 2018a). The BDDS provides eligibility-based services to increase independence within the individuals community via Medicaid waivers (FSSA, 2018b). These waivers may provide Commented [BM26]: Is it okay for me to have this be present tense? This information is still current and I am not sure how to accurately discuss this within my paper if I cannot use present tense. support services for employment through VRS and community rehabilitation providers (CRPs), but are ineligible for extended supported employment follow-along services (FSSA, 2018c). VRS provides individualized, employment-based services and employment exploration services through the Pre-Employment Transition Services (Pre-ETS) program if an individual is potentially eligible or eligible for VRS (FSSA, 2018d; USDoE, 2017). Further exploration of funding sources demonstrated that not all adolescents and young adults with I/DD that need support services to transition into employment are able to obtain services based off current eligibility criteria. In 2016, adolescents and adults with I/DD were the largest population served by VRS (55%) and CRPs (36%) (USDoE, 2017). Of the people with I/DD served in VRS, that exited services in 2016, 48% obtained employment (USDoE, 2017). Commented [JF27R26]: Yes, This is fine to keep as present tense. OT AND ENTREPRENEURSHIP 30 No current data outcomes have been published since Indiana VRS implemented an Order of Selection (OOS) in 2017, which is likely to further impact successful employment outcomes (DDRS, 2017; Honeycutt, & Stapleton, 2013). Only one of sixteen CRPs approved by the Bureau of Rehabilitation Services (BRS) to provide vocational rehabilitation and employment services to adolescents and adults with I/DD is currently located within Johnson County (Indiana Vocational Rehabilitation Services, 2018). CRPs located outside Johnson County are able to provide vocational services to people with I/DD that qualify for services, but may require that these individuals travel to their agency for assistance (Dwana Back, personal communication, May 8, 2018). Overall, there has been limited growth in achieving improved employment and economic self-sufficiency outcomes for people with I/DD in Indiana despite promotion of employment first initiatives (Grossi, 2017). The needs assessment demonstrated that national and state concerns regarding unemployment statistics for people with I/DD accurately reflected concerns within Johnson County. Parents Perspectives on Employment as Their Student Transitions to Adulthood To further validate the outcomes from the needs assessment, the graduate student reviewed literature regarding parents perspectives on employment opportunities as their adolescent and young adult children transition from school to the community. After a person with I/DD is no longer able to receive entitlement-based and school-based services financial and social supports for people with I/DD may be available via eligibility-based criteria (Honeycutt, & Stapleton, 2013). However, these community habilitation and employment supports require adults with I/DD to complete an application process that can be time consuming and may leave some adults with I/DD ineligible for services (Honeycutt, & Stapleton, 2013).. Parents of children with I/DD often express perpetuating concerns including their childs quality of life and OT AND ENTREPRENEURSHIP 31 obtaining opportunities for social participation, community engagement, and meaningful employment when transitioning into adulthood (Gilson, Carter, Bumble, & McMillan, 2018) The graduate student developed a brief, ten question survey to determine if parent concerns reported in literature were also reflected by parents in the Johnson County community. Two community agencies that provide support services to adolescents and young adults with I/DD and their families, the INSPIRE program of Earlywood Education Services and Franklin College, and Johnson County Autism Support Group distributed the survey via e-mail, newsletter, and/or Facebook group to parents of adolescents and/or young adults with I/DD. The survey was designed to ensure anonymity and voluntary participation of parent participants. Questions were designed to obtain demographics regarding age of student and current transition services received to identify potential variation in parental concerns. Remaining questions asked parent to respond using a likert scale to indicate level of agreement with provided statements indicating responses from strongly to strongly disagree. One question analyzed the types of employment opportunities parents desired for their adolescent or young adult with I/DD to be able to pursue. Data were collected and analyzed two weeks after the Commented [JF28]: Data is always referred to as plural. survey was distributed. Nineteen parent completed the survey (N=19), demonstrating a small, Commented [BM29R28]: I did not know this. Thank you! convenience sample of parents of children with I/DD in the Johnson County community. Survey results demonstrated evidence supporting a need within the Johnson County community for an alternative business model that addresses vocational training and supported, community employment using natural supports and other evidence-based strategies that promote independence and meaningful employment within an integrated, diverse work environment. A thorough report, Parents perspectives on employment as their student transition to adulthood was generated, reviewing detailed survey results and is located in Appendix C. OT AND ENTREPRENEURSHIP 32 Evaluation of Phase One Final evaluation of the Johnson County needs assessment and results from the parent survey regarding Johnson County employment opportunities demonstrated an overwhelming need for a grassroots initiative surrounding alternative business models providing integrated, supported community-based employment for people with I/DD. Consultation with the site mentor was completed to review phase one results. Results confirmed proposed strategies to conduct market research to develop a viable non-profit business model that provides supported employment for people with I/DD while generating a business product and/or service to the Johnson County community. Three primary markets were researched: flowers/horticulture, agriculture/produce, and bed and breakfast. Implementation Occupational therapy is a diverse profession focused on improving holistic health and well-being through engagement in meaningful occupations that are client-centered and may be addressed working with individuals, groups, populations, or communities (AOTA, 2014). This process allows for occupational therapists to work in traditional, medical settings or other emerging, community-based settings. Occupational therapists may fulfill roles as rehabilitation specialists, program developers, community leaders, researchers, consultants, and entrepreneurs (AOTA, 2014). Through completion of the DCE, the implementation phase allowed the graduate student as a burgeoning occupational therapist to gain experience working as a researcher, consultant, and entrepreneur within a community setting. From previous business and management courses related to occupational therapy program development and business planning, she served as a consultant to the site mentor, recognizing the process needed to complete development of a business plan and proposal. Commented [JF30]: Good job with your evaluation section Commented [BM31R30]: Thank you! Commented [JF32]: OT AND ENTREPRENEURSHIP 33 Completion of a thorough needs assessment of the Johnson County community identified the need for an alternative business model that provides integrated, supported employment for people with I/DD in Johnson County. Most business models and programs addressing unmet needs of people with I/DD are designed to provide a service to people with I/DD, identifying the population as clients served by the organization or business model. In doing so, the business or organization obtains funding from government allocated funds (e.g. Medicaid waivers) to provide employment and other habilitation services to the client population, competing with each other and a limited pool of financial resources. Development of Business Model In order to determine efficacy of a SE that provides integrated employment to people with I/DD, a series of interviews were conducted with organizations and businesses that emphasize providing employment and/or other support services to people with I/DD. Some of these organizations or businesses offered a marketable product or service to the surrounding community while employing or training people with I/DD. Interviews with various Directors of community rehabilitation agencies, other non-profit organizations, and for-profit businesses revealed that the majority of agencies or organizations implemented programs providing supported employment for people with I/DD in a later phase of the organizations or business development. Multiple financial revenue streams from other programs were used to offset potential deficit costs from initiating the new program (See Appendix B). Some for-profit businesses were true start-ups, demonstrating strong economic viability and sustainability. However, these businesses did not promote true integrated, supported community employment. The businesses also had already obtained access to funding to start the new business enterprise. OT AND ENTREPRENEURSHIP 34 Due to little experience understanding and navigating business models outside community rehabilitation organizations and medical settings, the graduate student reviewed literature on economics and evidence-based business models and interviewed directors or employees of small business professional development centers to determine the best strategies for identifying a business model. In the process, she collaborated with a SCORE Association business mentor, Mike Crumbo, from the Johnson County community with experience in business entrepreneurship. Through forming these partnerships and exploring business literature, she was introduced to an alternative business model that is recognized as being a blend between for-profit businesses and non-profit organizations; the SE. Recognizing that the desired business model was being generated to address an unmet need within the surrounding Johnson County community by offering integrated, supported employment opportunities for people with I/DD without utilizing limited government funds, it was necessary to identify the products or services that could be provided by a business that would generate economic sustainability. It was determined that providing a product or service within a competitive market while generating integrated, supported employment opportunities for people with I/DD as a SE was practical. A SE typically generates commercially run Commented [JF33]: See above comments about consistency operations while maintaining its goals of addressing larger societal, social problems within the Commented [BM34R33]: Using SE throughout paper to maintain consistency. mission of the business (Santos, Pache, & Birkholz, 2015). Significant time was dedicated to completing market research to identify what a SE business in Johnson County could offer as a product or service to this target market (Katz, 2014). Most business and other professional literature discusses how to improve a process, program, or product that already exists. Generating market research to develop a business offering product or service need that uncertain required thinking abstractly. SCORE mentor Mike Crumbo OT AND ENTREPRENEURSHIP 35 recommended utilizing free SCORE resources, including the Canvas Business model, and exploring the concept of the lean startup method, an innovative business methodology used to develop new products or services, especially with startup businesses (Reis, 2011). Utilizing the Lean Startup Method Lean startup methodology and processes focus on entrepreneurs identifying the customer market and obtaining customer profiles, including demographics, to determine various customer demographics to ascertain a product-market fit (Gupte, 2015). The product or service that the business would provide is likely not built or designed before potential customer markets are identified (Gupte, 2015). A build-measure-learn principle is encouraged, demonstrating a feedback loop used to test hypotheses developed surrounding the customer market (Reis, 2011). This process allows entrepreneurs to obtain data regarding customer profiles and understanding the opportunities that may exist through securing customer feedback when testing hypotheses (Monds, 2015). The graduate student utilized the lean startup methodology, including the hypotheses feedback loop during the market research process to support evidence and validate learning required to initiate SE development. Hypotheses testing helps determining what potential problems customers may experience within their customer market (York, & Danes, 2014). This process requires testing generated hypotheses within potential target customer markets by collecting customer data related to the hypotheses and evaluating the results (York, & Danes, 2014). This method, referred to as validated learning, provides empirical data to confirm or reject hypotheses (Reis, 2011). If hypotheses are validated from empirical data collected through the feedback loop cycle, developing a first iteration of the product occurs (York, & Danes, 2014). This first iteration is commonly referred to as the minimum viable product (MVP) in business. After development OT AND ENTREPRENEURSHIP 36 of the MVP, the build-measure-learn feedback loop is utilized continuously to test the hypotheses of product-market fit and make appropriate corresponding adjustments to the prototype until a final product has been attained (York, & Danes, 2014). Outlined during market research, the graduate student demonstrated use of lean startup methodology to determine a viable service or product for a SE. Market Research and Competition Analysis Completing market research and competition analysis on potential products and services in the Johnson County area was necessary to determine economic viability and sustainability for a start-up SE business. Through collaboration with my site mentor, we discussed exploring three potential business markets: flower shop/horticulture business, produce/agriculture business, and bed and breakfast hospitality. Market research was completed in phases, with a flower shop, produce market, agriculture- and horticulture-related businesses explored first. Focus on these markets were completed due to our hypotheses that these businesses would have lower overhead costs compared to a bed and breakfast. Flower/horticulture and produce/agriculture businesses. Market research surrounding the concepts of a flower shop or horticulture-related business and produce, farm, or agriculture-related business was implemented in three phases: interviewing non-profit organizations operating a flower shop business or agriculture-related business while employing people with disabilities; utilizing a business database to obtain business demographics about local flower shop, horticulture, produce, and agriculture-related businesses; and surveying consumers from Johnson County farmers markets. Initial research was completed identifying business and/or organization models that provided some type of supported, community employment or vocational training to adults with I/DD. Interviews were coordinated and Commented [JF35]: Is this something that you did. Did you use this process or only investigate the process to determine that is was not appropriate for your project. Either way you need to state why you are describing it. Commented [BM36R35]: Adjusting for relevance. OT AND ENTREPRENEURSHIP 37 scheduled with organization and/or business leaders after utilizing personalized cold-calling strategies to initiate contact. Interviews of leaders within non-profit organizations revealed that the organization provided other services to people with I/DD prior to developing a business employing and/or supporting people with I/DD (See Appendix B). Development of the business was funded secondary to other previously established monies within the organization and/or business or charged a direct fee to support the people with I/DD. A Montana-based nonprofit organization developed a flower shop business by buying out a wholesale flower shop in the area that was going out of business, convincing the owner to continue working as a floral specialist for the organization. The Executive Director shared financial records so that the site mentor and graduate student could determine if there was feasibility developing a flower shop business plan in the desired geographic area. They used this information to review credits, debits, and how much income may have to be generated to obtain a sustainable business structure. Through this review, the site mentor and graduate student decided to continue with the market research to determine if Johnson County may have another product need they could base the business upon. A Michigan-based nonprofit organization developed a vocational and life-skills training program for adults with disabilities through agriculture and farming. The founders of the organization developed a small committee dedicated to creating the foundation for the organization. To initiate financial capital for the startup business, the founders networked, advocated, and developed large fundraising strategies to solidify startup funds. However, the organization charges the adults with disabilities a daily tuition rate and requires an annual financial commitment for participants to attend the organization. While the business model that was desired to be developed in Johnson County included employing people with I/DD with fair OT AND ENTREPRENEURSHIP 38 wages, strategies used to initiate a startup business were considered. The benefits and skills the adults with disabilities experienced while working in an agriculture setting, as reported by the organization, were determined significant and worthwhile pursuing further market research. Initial interviews and financial plans supported continuing to explore the flower shop (retail or wholesale), horticulture, produce, and agriculture-related businesses as a potential SE. Using a common small business reference tool called ReferenceUSA that is freely accessible at any Indiana local library, the graduate student researched local business demographics using both the North American Industry Classification System (NAICS) and the Standard Industrial Classification (SIC), codes that are used by the federal government to classify businesses for the purpose of tracking and analyzing statistics (Chapman, 2010). Both the NAICS and SIC are commonly used to identify the primary objective or activity of the business (Chapman, 2010). Through the ReferenceUSA database, the graduate student was able to generate rough estimates of businesses in Johnson County and nearby Indianapolis using search filters for zip codes and SIC codes. SIC codes for flower shops and related businesses generated the following primary SIC descriptions: ornamental floriculture and nursey productions; gift baskets and parcels; gift shops; plants to interior design and maintenance; nurseries to plants, trees, and etc. wholesale, grocers to retail, and florists: to retail; to wholesale. Primary SIC codes for produce, farm, and/or agriculture-related businesses generated primary SIC descriptions as follows: farms; farm produce; fruits and vegetables wholesale; fruits and vegetables and produce retail; grocers to retail; wholesale clubs. Using comparative statistics to examine preliminary information obtained through the business database helped to confirm that the target consumer market was likely saturated. Results generated from the filtered search for flower and horticulture-related businesses OT AND ENTREPRENEURSHIP 39 demonstrated that there were 21 businesses in Greenwood, 11 in Franklin, with another 278 reported to be located in nearby Indianapolis. When exploring business demographics from the initial search, the average business that generated an annual sales range of $500,000 to 1 million or less, the businesses were employing ten employees or less, with the majority supporting no more than four employees. Results generated from the filtered search for produce, farm, and agriculture-related businesses demonstrated that there were 21 businesses in the Johnson County area, with 15 businesses described by the primary SIC as farms. The average employee range for the businesses listed were listed as 1 to 4 employees, unless the retail business produced over one million dollars in annual sales. Survey development, implementation, and analyzing hypotheses. Preliminary results in the Johnson County area were not promising for a viable horticulture- or agriculture-related business due to a wealth of competition. To test these results, the graduate student developed a brief survey to collect customer demographics and opinions within the projected target customer market. The survey included identifying specific customer demographics (e.g. age range, size of household, and household location) and to answer five, simple binary questions surrounding shopping trends and preferences. Simple binary survey questions were selected due to evidence supporting that responses are considered equally reliable to Likert-style scales, but generates quicker responses, are less complex, and more likely for participants to answer (Dolnicar, Grn, & Leisch, 2011). Refer to Appendix D for the survey template used to collect data from target customer market. Basic market research was conducted at various local farmers markets in Johnson County during June 2018 using the above mentioned survey. Three different farmers markets in Johnson County (Bargersville, Franklin, and Greenwood) on four different dates generated a OT AND ENTREPRENEURSHIP 40 random, convenience sample (N=47) of 47 participants that fit the target customer market (people who shop at farmers markets). The site mentor and graduate student hypothesized that customers that shop at local farmers markets are more likely to support local, small businesses and farms that raise flowers or produce and are likely to support small, community-based initiatives. Market research from the farmers markets demonstrated no significant variance in responses based on customer demographics (refer to Appendix E for full report). Respondents valued knowing where they purchased their produce and flowers from, indicating supporting local farms and businesses was important to them. Most customers were willing to travel to local farms to purchase produce or flowers and valued businesses that addressed supporting specific social and/or philanthropic missions. Most customers from the target customer market indicated being satisfied with current produce and flower options available at the farmers market attended. This information validated that the local produce and flower market competition in Johnson County was saturated. However, all customers surveyed indicated willingness to support local businesses that employ people with disabilities at fair wages. This market research data from the target customer market reflected literature demonstrating overwhelming positive public views on supporting integrated, community-based employment for people with disabilities. Identifying a different produce or service was needed. Bed and breakfast businesses. Realizing that the horticulture and agriculture business sectors in Johnson County were already saturated and would likely not provide a variety of transferable skills for employed people with I/DD, a new business service was explored. Similar methods were used to implement initial market research on a bed and breakfast business: interviewing and researching non-profit organizations operating a bed and breakfast business while employing OT AND ENTREPRENEURSHIP 41 people with disabilities; obtaining local bed and breakfast business demographics using a business database and internet search engines; and interviewing local Johnson County event organizations and businesses to determine potential consumer market needs. Interviews were conducted similarly to previous market research conducted for agriculture- and horticulture-based businesses. Internet search engines were utilized to identify bed and breakfast businesses that provided supported employment for people with I/DD. The graduate student initiated cold-calling strategies to contact a Missouri-based organization that demonstrated a grassroot initiative to develop a start-up business model for a bed and breakfast using financial strategies independent of government-funding. See Appendix B . Via interview, the Director of the organization confirmed that the organization, while running a bed and breakfast as a business, also offered community-based living arrangements for adults with I/DD where both the adults with I/DD and their family members pay a monthly rate for the individual to live at the facility. Adults with I/DD that work at the bed and breakfast or restaurant on-site do receive supported employment and earn a fair, living wage. While the Missouri-based organization demonstrated a different business model, extending its services to address additional life opportunities and needs, the organization demonstrated viability to initiate and sustain a bed and breakfast. During the initial search for a bed and breakfast business model promoting employment for people with I/DD, the graduate student discovered bed and breakfasts that were advertised to provide vacations and getaways for parents of children with disabilities and/or families that have a family member with a disability. Even though there were not many bed and breakfast businesses that promoted this service to families that have a family member with a disability, it OT AND ENTREPRENEURSHIP 42 shifted consideration for a potential niche customer target market: universal design and accessibility. Local and regional business demographics were then explored to determine competition within the Johnson County business market. Using a google internet search engine, she searched for bed and breakfast businesses that were located in central to southern Indiana and within Johnson County, analyzing various demographics: location, number of rooms, average cost per night, and ADA regulated accessibility (See Appendix F). The initial search generated 24 bed and breakfast businesses located in central to southern Indiana. In Johnson County, there were two bed and breakfasts in Franklin and one whole-home property rental that was advertised as a bed and breakfast in Greenwood. None of the bed and breakfast properties in Johnson County were ADA accessible. Of the 24 bed and breakfast businesses searched, only nine businesses were listed as ADA accessible, with the majority having limited accessibility. To further examine a potential need for a bed and breakfast business within Johnson County, the graduate student researched zoning regulations and policies for bed and breakfast businesses within Johnson County and specific towns. Determining that Bargersville demonstrated recent significant growth and did not have a bed and breakfast, focus on researching this geographic area was prioritized due to limited market competition. The site mentor and graduate student interviewed city leaders, community event organizers, and other businesses to explore their hypothesis. A meeting with a leader from the Plan Commission in the town of Bargersville was conducted to determine the potential impact that future interstate development of I-69 from Indianapolis to Evansville may have on zoning regulations. The meeting leader expressed anticipating re-zoning along SR-37 as it transitions into I-69. Rezoning was projected to likely occur allowing future commercial growth, anticipating hotel and OT AND ENTREPRENEURSHIP 43 business development as increased traffic occurs due to a new interstate. The leader confirmed that the regulations for a Bargersville Bed and Breakfast in the Town of Bargersville Zoning Ordinance was current and could only be located within specific regions zoned as being an agricultural or moderate to rural residential districts (See Appendix B). The information generated from researching Bargersville zoning ordinances and regulations were used to further determine potential targeted zoning locations for a bed and breakfast business within the town of Bargersville. The graduate student searched a governmentbased, publicly accessible database that utilizes geographical information systems (GIS) to obtain information about parceled land properties within the targeted areas in the town of Bargersville. A map of parceled land properties were highlighted within the target area for a bed and breakfast, generating an agricultural comparables list of properties, including acreage, assessed value of property, and sale price and dates of recently purchased properties to identify potential owners and businesses that may be interested in becoming involved with developing a bed and breakfast or may be selling land properties. During this time, the site mentor and graduate student collaborated with the SCORE mentor, devising a plan for further market research and competition analysis for a bed and breakfast business model. They contacted and interviewed local Bargersville and surrounding Johnson County organizations and businesses to determine feasibility for a bed and breakfast business. An interview with the Director of Tourism for Festival Country Indiana procured a positive response for another bed and breakfast business in Johnson County, identifying that there are currently limited options available within the area and a new bed and breakfast could be successful if partnerships are developed with venues and other businesses to promote specials. OT AND ENTREPRENEURSHIP 44 Festival Country Indiana could assist in promoting the future business and advise in future marketing (See Appendix B). Interviewing a local travel agent and business owner in the Johnson County area that specializes in booking vacations for people with disabilities seeking accommodations while traveling generated further support for the business model. The travel agent discussed common barriers people with disabilities experience while traveling and seeking accommodations. They identified bathroom accessibility and navigating buildings that do not have zero entry spaces or open spaces as the most problematic (See Appendix B). Bed and breakfasts were discussed as not being commonly sought out as a travel destination for people with disabilities since most bed and breakfasts are conceptually designed within older homes that are typically inaccessible for a person with a disability. The travel agent mentioned having considered developing a bed and breakfast business model that promoted universal design and accessibility in the past and supported the proposed concept. Focusing within the specific geographical targeted area in Bargersville, an interview was conducted with the owner of Mallow Run Winery to discuss potential future plans and development in business services. Mallow Run Winery and the nearby Sycamore Event Center are large venues in the Bargersville area, generating multiple events monthly for the surrounding area. During the interview, the owner discussed no plans for developing future travel accommodations. Results from the initial market research, including information obtained from target market interviews, further supported developing an initial business plan for a bed and breakfast in Johnson County. Non-profit Business Research and Indiana Law OT AND ENTREPRENEURSHIP 45 Research surrounding non-profit business and organization structures, regulations, and local, state, and federal legislation was conducted to provide consultation on business development. The graduate student reviewed the Indiana Secretary of State regulations and policies that must be developed to establish a non-profit business in the state of Indiana. This information was used to create an organized, chronological template that can be followed to complete the initial filing process. (See Appendix G). Indiana laws specifically pertaining to nonprofit corporations were identified, saved, and archived for easy reference during future planning and development of the business model with the future board (See Appendix H). She developed an initial draft of the Articles of Incorporation and Bylaws for a proposed nonprofit business model (See Appendix I and Appendix J). The initial draft was reviewed by a law student from Valparaiso University that has experience with corporate law. Suggested revisions to initial drafts of Articles of Incorporation and Bylaws were completed with recommendations catalogued with documents for future reference. An initial, incomplete first draft business plan was compiled utilizing SCORE template resources and other procured, generated content from the evaluation and implementation phases (See Appendix K). Exemplification of Leadership Development during DCE As an Occupational Therapy student navigating a non-traditional internship role in a community-based setting that does not provide direct care or services to individuals, the graduate student was placed in a unique position to develop and demonstrate leadership at programmatic and organizational levels. While working at Johnson County Community Foundation (JCCF), she partnered with the site mentor to work on an independent project conducting research and developing a business model addressing integrated, supported employment for people with I/DD in Johnson County. During time working on the DCE project at JCCF, she had the OT AND ENTREPRENEURSHIP 46 responsibility of advocating and educating the board members and staff at JCCF regarding the DCE project, her internship role, and how the DCE project applies to the mission of JCCF. Throughout this process, she educated staff, business professionals, and the community at large about Occupational Therapy and the breadth and scope of its services outside of a traditional medical model. Being in a community-based setting where no other occupational therapist or other healthcare professional worked, the graduate student spent significant time improving her communication skills with other professionals and community members. When advocating for the DCE project and the potential impact it could have on the Johnson County community, she learned how to eliminate jargon and modify how she presented information based on its relevance to specific targeted audiences. She initiated, scheduled, and interviewed countless community leaders, business owners, and entrepreneurs. Throughout this process, the graduate student collaborated with many professionals and Johnson County community members to access pertinent information required to support various aspects of my DCE project. She developed leadership skills organizing and implementing steering committee meetings with guidance from my site mentor. She generated formal reports that concisely captured outcomes from the needs assessment and market research conducted to support the alternative business plan model. Lastly, she enhanced her communication skills by engaging with the JCCF board members, presenting the final outcomes of the DCE project at the July 2018 JCCF Board of Directors meeting. Outcomes Outcomes for the DCE project were influenced by the initial Memorandum of Understanding (MOU) goals between the site mentor and graduate student intern. The Goal Commented [JF37]: I read through this. You are definitely on the right path. I assume you will be converting this into past tense upon completion of these tasks. As you are writing up the outcomes, just be careful not to be redundant by describing things you have already described. You can always refer to appendices. Also as you score the GAS, you need to make sure your client/site mentor is the one providing the score. You can do it in collaboration, because you may need to help her identify the specific task you completed to address each goal, but she needs to be involved in the scoring. OT AND ENTREPRENEURSHIP 47 Attainment Scale (GAS) was utilized to develop and provide objective, quantifiable measurements to identify and evaluate final outcomes generated from the MOU goals. The GAS allows for measuring attainment of qualitative work, evaluating outcomes from a five point, standardized Likert scale ranking from -2 to +2 (Sharp, 2006). The outcome 0 yields the expected, anticipated outcome for the goal, with -2 demonstrating much less than expected and +2 demonstrating much more than expected (Sharp, 2006). With the MOU serving as a baseline to develop anticipated outcomes, six goals were generated and quantified using the GAS (located in Appendix L ). All goals from the GAS were scored upon completion of the DCE project, determining final outcomes attained from the projected initial MOU. Goal one of the GAS addressed completing a needs assessment of Johnson County supported employment services for adolescents and young adults with I/DD. The expected outcome required developing and generating a brief report on the projected gap of employment for adolescents and young adults with I/DD, the current Johnson County employment service providers and the provided services, and discussion surrounding the benefits of transition employment services. In addition to a brief needs assessment report that provided visual charts highlighting employment gaps for people with I/DD, a brochure and brief audio visual presentation reviewing details of the needs assessment was completed, achieving +2 as a final outcome. The needs assessment report and additional materials have been constructed to be utilized when presenting the need for an alternative business model to prospective future stakeholders and proprietors. Goal two of the GAS included conducting market research and competition analysis of products and services in Johnson County using primary and secondary data. The expected outcome required developing and implementing a survey on products and/or services, collecting OT AND ENTREPRENEURSHIP 48 projected Johnson County consumer data demographics, and generating a report that proposed a product and/or service to be provided by a social enterprise. The market research report was generated about products that were determined unfeasible to support a sustained social enterprise business. Outlined strategies and market research to support a bed and breakfast social enterprise business model was then constructed. Additional potential partnerships were then identified for proposed collaboration on continued development of the bed and breakfast social enterprise business model (See Appendix M). Attaining these outcomes demonstrated a +2 score for goal two. Goal three of the GAS focused on initiation of a business plan that was organized and developed as a nonprofit organization. Expected anticipated outcomes were not achieved, earning a score of less than expected (-1). A business plan was written, highlighting the executive summary, the companys mission, services, market analysis, and templates for cash flow, profit and loss tables, and balance sheets. However, no projected expenses were identified secondary to extensive time completing market research. Contacts have been initiated for business mentors to review the business plan and continue to help with collaboration and continued development of the bed and breakfast, including building design. A list of potential businesses and organizations has been generated to increase networking and marketing for prospective partnerships. Goal four of the GAS required completing a first draft for an Indiana nonprofit business application, including outlining the steps for the filing process and a first draft of the Articles of Incorporation and Bylaws. Articles of Incorporation and Bylaws were presented to the steering committee for review. The graduate student completed the first drafts, outlined references and steps to access business law information pertinent to the development of the social enterprise, OT AND ENTREPRENEURSHIP 49 and identified prospective local business attorneys that could provide counsel as the bed and breakfast continues to develop. Completing these goals indicated a score of +2, much more than expected. Goal five of the GAS focused on initiating the development of a life skills and employment training program for the bed and breakfast business. This goal resulted in a much less than expected score, -2. The graduate student initiated a brief report of the evidence-based employment and social skills training strategies. She did not have enough time to further develop organization policies, procedures, pre-requisite application, or individualized employment plans due to extended time focused on developing the SE business model. Goal six of the GAS required generating a brief report for nonprofit community fundraising, crowd funding, and grant funding strategies, including identifying potential guarantors. The goal was achieved at a level -2, much less than expected, with fundraising proposal strategies initiated but not completed. The graduate student focused substantial time on researching and generating the reports needed to support development and initiation for a SE. All components of research, including the needs assessment, market research, business plan and overall strategic plans were organized and presented within an electronic folder on a jump drive and in a printed binder to demonstrate overall completion of goals and objectives towards an alternative SE, including continued recommendations for next steps regarding strategic planning and additional collaborations for continued community and business-related partnerships. A SWOT analysis was completed at the end of the consultation period to identify current status, including threats and opportunities of the SE.. The completed binder of the student DCE project and outcomes was presented to the steering committee to review continued recommendations and propel continuation of SE development. OT AND ENTREPRENEURSHIP 50 Discussion Implications for OT Practice Outcomes from the DCE project demonstrated that there is a large need to generate alternative programs that continue to address quality of life for adolescents and adults with I/DD. Many programs that address outcomes for adolescents and adults with I/DD are focused on maximizing opportunities for independent living and integrated, competitive employment opportunities. However, when outcomes are evaluated for the efficacy of these client-centered programs, it is demonstrated that the government- and community-based programs designed to support adolescents and young adults with I/DD are not achieving these desired outcomes. While many community rehabilitation programs were designed to address supporting people with I/DD to obtain integrated employment, the majority of these clients served do not achieve these goals. Despite decades of disability policy, outcomes for people with I/DD obtaining integrated, community employment continues to demonstrate poor results (Grossi, 2017). Occupational therapists have commonly worked with people with I/DD, most frequently within pediatric or school-based settings, largely due to the IDEA act (AOTA, 2014). As children with disabilities, including I/DD, transition throughout school and achieve certain goals or outcomes directed in their plan of care or IEP, they may no longer need therapy-based services. Other children that need additional time to achieve outcomes but have not been able to meet certain goals are often forced to be discharged from receiving therapy services due to insurance regulations. Fewer services are offered to adolescents and young adults with I/DD as they age out of entitlement-based services that are protected to these individuals under the IDEA act. Services currently offered to these individuals as they transition from school to employment are typically supported through Vocational Rehabilitation Services or community rehabilitation OT AND ENTREPRENEURSHIP 51 providers. Research from the DCE project demonstrated that VRS and community rehabilitation providers alone cannot address this transition due to limited funds and resources. Occupational therapists have the ability to address this need by advocating for their roles and scope of practice. The profession of occupational therapy demonstrates competence supporting adolescents and adults with I/DD in comprehensive, holistic, client-centered interventions, but typically relies on insurance as payment for services, receiving referrals from physicians within a medical-based setting. Working within a community-based setting, occupational therapists can offer services framed within a health and wellness model. This possibility allows for occupational therapists to explore entrepreneurship and promoting services outside of a medical setting, focusing on providing services and supports that traditionally may not be supported due to lack of insurance coverage. Occupational therapists founding and directing social enterprises have the ability to serve a special social mission or marginalized population while providing a product or service to the community. This allows occupational therapists to address true, client-centered care using occupation as both a means and an end to populations that otherwise may not have access to services. Overall Learning Throughout the sixteen weeks of the Doctoral Capstone Experience project, the graduate student learned how to navigate a nontraditional role in a community-based setting working as a consultant, advocate, researcher, and entrepreneur. While she has always been passionate about community-based organizations and non-profit organization design, she has not had an opportunity to work with other professionals within a community-based setting, advocating for occupational therapy outside of a medical model and demonstrating professional leadership skills and expertise. With the support of Johnson County Community Foundation and mentorship OT AND ENTREPRENEURSHIP 52 from its members and staff, the graduate student had the opportunity to foster her professional development, utilizing effective leadership skills and interacting with other community members, business professionals, agency directors, and other community leaders through written and verbal communication. Due to the nature of the DCE project and unique opportunity to work with an individual that seeks to help address a larger societal problem, she learned how to advocate for the profession of occupational therapy within a community setting. Additionally, she learned how to drive project management development, navigate working independently, and network to complete interviews and coordinate meetings related to the DCE project. Through collaboration and leadership with JCCF colleagues and the site mentor, the graduate student improved her organization and time management skills as well as learned how to navigate leadership roles within the greater community. As a result, the graduate student demonstrated ability to work independently and be self-directed. She has developed a skill set for advocacy and leadership that will enhance her role as a burgeoning occupational therapist, articulating the needs for occupational therapy based services and improving community-based services. OT AND ENTREPRENEURSHIP 53 References Ahonen, E. Q., Fujishiro, K., Cunninghman, T., & Flynn, M. (2018). Work as an inclusive part of population health inequities research and prevention. American Journal of Public Health, 108(3), 306-311. doi:10.2105/AJPH.2017.304214 American Association on Intellectual and Developmental Disabilities (AAIDD). (2018). Mission. Retrieved from http://aaidd.org/about-aaidd/mission#.WvdqpExFzIU American Occupational Therapy Association (AOTA). (2014). Occupational therapy practice framework: Domain and process (3rd ed.). American Journal of Occupational Therapy, 68(Suppl. 1), S1 S48. http://dx.doi.org/10.5014/ajot.2014.682006 Anderson, L. L., Larson, S. A., Kardell, Y., Taylor, B., Hallas-Muchow, L., Eschenbacher, H. 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Journal of Small Business Strategy, 24(2), 21-39. OT AND ENTREPRENEURSHIP 62 Appendix A JOHNSON COUNTY NEEDS ASSESSMENT REPORT ON EMPLOYMENT FOR ADOLESCENTS AND YOUNG ADULTS WITH INTELLECTUAL AND DEVELOPMENTAL DISABILITIES PRESENTED BY: BRITTANY MEYERS, OTS UNIVERSITY OF INDIANAPOLIS SCHOOL OF OCCUPATIONAL THERAPY OT AND ENTREPRENEURSHIP 63 OT AND ENTREPRENEURSHIP 64 TABLE OF CONTENTS DEFINITIONS 2-3 EXECUTIVE SUMMARY 4-5 JOHNSON COUNTY DEMOGRAPHICS 5-6 CURRENT EMPLOYMENT M ODELS BUREAU OF DEVELOPME NTAL DISABILITY SERVICES VOCATIONAL REHABILI TATION SERVI CES PRE-EMPLOYMENT TRAN SITION SERVICES EFFICACY OF EMPLOYM ENT MOD ELS FUNDING STRUCTURE OF EMPLOYMENT MODELS JOHNSON COUNTY COMMU NITY REHABILITATION PROVID ERS EMPLOYMENT DEMOGRAPH ICS EMPLOYMENT SET TING AND INCOME EMPLOYMENT, INCOME, AND POVERTY SUMMARY REFERENCES 6 6 6-7 7 7-8 9 9 10 10 10-11 11 12-13 OT AND ENTREPRENEURSHIP 65 DEFINITIONS Community Rehabilitation Provider (CRP): An organization that provides various employment, volunteer, and day program services for adults with disabilities; receive primary funding from BDDS and VRS agencies Employment first initiative: Focus on integrated, community employment with competitive wages for people with and without disabilities Individualized Education Plan (IEP): plan that outlines a student with disabilitys goals and objectives for upcoming school year; developed in case review conference with parents, teachers, and student Individualized Transition Plan (ITP): specialized plan that is part of IEP; developed annually when student turns age of 14; guides development of special education and preparation for transition into adulthood; indicates if student will pursue a diploma or certificate of completion for graduation Individualized Plan for Employment (IPE): Specific, individual, person-centered plan for vocational training and employment-based supports and plan to help an individual with disabilities obtain and retain employment; typically developed by VRS and partner with CRP to provide necessary supports for individual with disabilities to obtain employment Medicaid: A state-based insurance program that provides medical coverage to adults with disabilities, adults, pregnant women, and children that qualify under specific financial eligibility thresholds Pre-Employment Transition Services (Pre-ETS): Services provided to students with disabilities who are eligible or potentially eligible for Vocational Rehabilitation Services, covering job exploration counseling, work-based learning experiences, post-secondary opportunities counseling, workplace readiness training, and self-advocacy instruction Poverty threshold (federal poverty level): Maximum income eligibility threshold used to determine specific, income-based eligibility services and benefits Social Security Disability Insurance (SSDI): An eligibility, cash benefit for people with disabilities who have previously worked and paid Social Security taxes to qualify or have a parent that is retired or deceased that has paid Social Security taxes Supplemental Security Income (SSI): An eligibility, needs-based income for adults who have disabilities that are unable to participate in work, or have low income and resources Special education: A component of the United States education system that provides fair, equitable, high-quality education and services to children with disabilities, from birth through 21, and their families Student with a disability: An individual with a disability in an education program, secondary, post-secondary, or otherwise recognized for education, and is eligible for receiving special education or related services under Part B of the Individuals with Disabilities Education Act (IEP, 504 plan) OT AND ENTREPRENEURSHIP 66 Transition age: An age range identified by IDEA that requires special education programs in public schools to provide a transition IEP or ITP to facilitate transition from school-based activities to community-based activities and services; initiated at age 14; ages 14-22 (federal) Vocational Rehabilitation Services (VRS): Individualized services to support people with disabilities as they prepare to obtain and/or retain vocational skills and employment to achieve a greater level of independence Workforce Innovation and Opportunity Act (WIOA): An act of legislation ensuring employment and training workforce services are qualitative, accessible, and improved competitive, integrated employment outcomes for individuals with disabilities, vulnerable, atrisk youth, and helps meet the market demand by working with employers to address workforce needs 504 plan: An education plan for students with disabilities and qualify under Section 504, but may not qualify for an IEP, to receive equal access and accommodations, allowing them to participate in school Definitions derived from: Indiana APSE. (n.d.). New Employment First Tool: VR Rates and Services. Retrieved from http://www.inapse.org/public-policy Indiana Protection and Advocacy Services. (2009). Transition Planning Handbook: A Checklist for Parents of Children with Disabilities. Retrieved from www.ipas.in.gov Individuals with Disabilities Education Act. (n.d.). The U.S. Department of Education. Retrieved from https://sites.ed.gov/idea/about-us-department-of-education/ Family and Social Services Administration. (2018). Vocational Rehabilitation Services. Retrieved from https://secure.in.gov/fssa/ddrs/2636.htm Family and Social Services Administration. (2018). Disability Determination Bureau. Retrieved from: https://www.in.gov/fssa/2634.htm Family and Social Services Administration. (2018). Welcome to Indiana Medicaid. Retrieved from https://www.in.gov/fssa/2634.htm Sunny Start. (2016). Section 504. Retrieved from http://fvindiana.org/Files/SS/FS_Section504.pdf The National Autism Resource and Information Center (The Arc). (n.d.). Employment Glossary. Retrieved from https://autismnow.org/on-the-job/employment-options/employmentglossary/#E United States Department of Labor. (n.d.). About WIOA. Retrieved from https://www.doleta.gov/WIOA/Overview.cfm OT AND ENTREPRENEURSHIP 67 EXECUTIVE SUMMARY The Johnson County Needs Assessment is an independent, academic, project-based report on employment for adolescents and young adults with intellectual and developmental disabilities (I/DD) in Johnson County, Indiana. This report is exploratory, analyzing, synthesizing, and evaluating current Johnson County demographics, federal, state, and county policies addressing employment, current organizations providing employment services, and overall employment outcomes for people with I/DD to determine needs of people with I/DD in Johnson County, Indiana. Methods of analysis used to generate the follow needs assessment report of Johnson County included primary and secondary data analysis and literature review, including evidence-based literature on intellectual and developmental disabilities, employment, poverty, and support strategies at county, state, and federal levels. Interviews with Directors from Community Rehabilitation Providers, Vocational Rehabilitation Services, and Bureau of Developmental Disability Services as well as Special Education teachers in Johnson County and Marion County were conducted to obtain data representative of Johnson County. Johnson County, Indiana, known for being a farming and agriculture community, had a population growth rate of 10% from 2010-2017 (USDA, 2018). Young adults ages 1824 comprise 9% of the total population, with 13,139 people (Stats Indiana, n.d.). The public school student body population for transition age students (ages 14-22) in Johnson County is 7956 people (NCES, n.d.). It was estimated that 15% of the total transition age student body represent special education enrollment, qualifying as students with disabilities based off an unpublished Indianapolis Easterseals Crossroads report and the National Center for Education Statistics (NCES). Primary models that support employment services for people with I/DD are funded through Vocational Rehabilitation Services and Medicaid waivers from the Bureau of Developmental Disability Services (cite). Outcomes from current employment service models at VRS demonstrate that less than half (48%) of people with I/DD obtain employment when exiting from services (USDoE, 2017). This outcome measurement was prior to implementation of the Order of Selection (OOS) which requires a federal mandate of prioritizing services to people with the most significant disabilities first (DDRS, 2017). Community rehabilitation providers (CRPs) may also provide employment services, serving people with I/DD at 36% (USDoE, 2017). Less than half of people with I/DD obtaining employment despite VRS, and only 30% of people with I/DD obtaining employment and earning a paycheck from an employer outside of VRS or CRP agency, demonstrates stagnancy in achieving improved employment outcomes despite current employment first initiatives (Grossi, 2017). Development of an alternative business model that does not rely primarily on funding from the government, that is sustainable by generating a viable product and/or service to the Johnson County and surrounding communities while providing integrated, supported employment for people with I/DD within the community can help bridge the employment gap for people with I/DD. Through use of evidence-based natural OT AND ENTREPRENEURSHIP 68 supports, outcome tools, and effective, comprehensive training on the business model and culture to all employees, achieving a sustainable business model can be obtained. It is Recommended: An alternative social enterprise business model be developed to address integrated, supported community employment for people with I/DD Market research is conducted to develop minimum viable product needed to generate sustainability of social enterprise business model Program development to support employment of people with I/DD is designed from evidence-based practices, utilizing natural supports from business and community, with professional development personalized to each employee with or without disabilities JOHNSON COUNTY DEMOGRAPHICS Johnson County is located in central Indiana, south of Marion County which houses the state capital Indianapolis. Johnson County, traditionally known for its farming and agriculture, has experienced a population growth rate of 10% from 2010-2017. As of 2017, Johnson County population was projected at 153,897 people (USDA, 2018). While the total population of young adults with intellectual and developmental disabilities (I/DD) ages 18-24 in Johnson County is unknown, the population of young adults ages 18-24 represents approximately 9% of the total Johnson County population, with 13,139 people (Stats Indiana, n.d.). According to an unpublished Indianapolis Easterseals Crossroads report from 2016, there are 1191 students that are of transition age (ages 14-22) enrolled in Special Education services in Johnson County that have an Individualized Education Program (IEP), Individualized Transition Plan (ITP), or 504 plan, qualifying them for specialized accommodations within the public school system. There are 7956 students that comprise the total transition age student body population in Johnson County (NCES, n.d.). Based off the unpublished report regarding transition age students with disabilities, these students comprise 15% of the total student body population in Johnson County. This percentage of students is the highest percent of students with disabilities of all the surrounding counties (refer to Figure 1). County Hamilton Hancock Hendricks Johnson Marion* Figure 1. Special Education Population (Ages 14-22) 1832 589 895 1191 5026 Total Student Body Population (Ages 14-22) 16923 4218 8908 7956 33887 Percentage of Special Education Population 10.8% 14.0% 10.0% 15.0% 14.8% OT AND ENTREPRENEURSHIP 69 Marion* Excludes students from Indiana School for the Deaf, Indiana School for the Blind and Visually Impaired, and RISE Learning Center. Both Indiana School for the Deaf and Indiana School for the Blind and Visually Impaired receive services outside of where provider service information from Easterseals Crossroads was obtained. RISE Learning Center student demographics were unable to be obtained. While there are services available for students with disabilities when enrolled in school due to entitlement-based services from IDEA and WIOA, some of these students may be at risk of not receiving or qualifying for services due to variability with school corporation policies, limited resources, and stringent eligibility standards with Pre-ETS, VRS, and other eligibility-based services (Anderson et al., 2016; Carla Orr, Adult & Child Manager Pre-ETS, personal communication, May 23, 2018). The Pre-ETS program, designed to supplement provision of transition services and prevocational skills, provides individual and group-based services to four of the six public schools in the county, but currently only serves 265 students that are eligible or potentially eligible to receive Vocational Rehabilitation Services (Carla Orr, Adult & Child Manager Pre-ETS, personal communication, May 23, 2018). CURRENT EMPLOYMENT MODELS Traditional employment models and employment first initiatives for adolescents and adults with I/DD are funded primarily through two major departments within the Indiana Family and Social Services Administration, the Division of Disability and Rehabilitation Services (DDRS) Bureau of Developmental Disability Services (BDDS) and Vocational Rehabilitation Services (VRS) (FSSA, 2018a). BUREAU OF DEVELOPMENTAL DISABILITY SERVICES The BDDS provides eligibility-based services designed for adolescents and adults with I/DD to increase independence within their prospective communities. Promotion of these services are provided via Medicaid waivers: Community Integration and Habilitation (CIH) waiver, Family Supports Waiver (FSW) or Supervised Group Living (SGL) waiver. While not every waiver provides support services for employment, the CIH and FSW provide opportunity for prevocational services and workplace assistance (FSSA, 2018b). However, recent changes in policy have eliminated eligibility for extended supported employment follow-along services for adults with I/DD (FSSA, 2018c). VOCATIONAL REHABILITATION SERVICES Vocational Rehabilitation Services (VRS) is a program developed to provide individualized, employment-based services and supports to people with disabilities in order to obtain employment and promote independence within the work place (FSSA, 2018d). VRS provides a variety of services to help adolescents and adults with I/DD achieve meaningful employment, providing Pre-Employment Transition Services (PreETS) and vocational rehabilitation employment services through partnership with OT AND ENTREPRENEURSHIP 70 Community Rehabilitation Providers (CRPs), many of which are also employment network providers (FSSA, 2018d). PRE-EMPLOYMENT TRANSITION SERVICES Pre-ETS is one of many programs designed from the Workforce Innovation and Opportunity Act (WIOA) of 2014, developed from close collaboration between the Departments of Education, Labor, Health and Human Services, Agriculture, and Housing and Urban Development (Monteleone, 2016; United States Department of Labor, 2017). Through Pre-ETS, students and youths with disabilities (ages 14-24) who are potentially eligible or eligible for VRS may receive services that promote postschool activities including post-secondary education, vocational training, competitive integrated employment, supported employment, independent living, and community participation (USDoE, 2017). VRS and Pre-ETS partner with community rehabilitation providers (CRPs), employment network providers, and other government entities including Workforce One to promote employment opportunities for people with disabilities. These opportunities are funded using a combination of Medicaid waivers and VRS funding (Hall et al., 2011; United States Department of Labor, 2017). EFFICACY OF EMPLOYMENT MODELS VRS and Community Rehabilitation Providers (CRPs), typically through Medicaid funding, provide services to people with disabilities (Hall et al., 2011). In Indiana, adolescents and adults with I/DD are the largest percentage of all populations served by these VRS (55%) and CRPs (36%) (USDoE, 2017). The Workforce Innovation and Opportunity Act (WIOA) of 2014 mandates that all individuals receiving services from VRS obtain an Individualized Plan for Employment (IPE) by 90 days after qualifying for VRS. The majority of students and young adults with disabilities that obtained eligibility for VRS received an IPE within 60 days of application approval (78%), and 93% obtained an IPE within 90 days. However, these percentages reflect IPE plans for individuals with any type of disability and is not exclusive to individuals with I/DD (USDoE, 2017). OT AND ENTREPRENEURSHIP 71 Type of Impairment Outcomes by Type of Impairment for Individuals with Disabilities under Age 25 at Exit from Indiana VRS Fiscal Year 2016 Psychosocial and Psychological - Without Employment Psychosocial and Psychological - Employment Intellectual and Learning Disability - Without Employment Intellectual and Learning Disability - Employment Physical - Without Employment Physical - Employment Auditory and Communicative - Without Employment Auditory and Communicative - Employment Visual Impairment - Without Employment Visual Impairment - Employment 302 213 569 517 119 76 58 69 37 17 0 100 200 300 400 500 Number of Individuals In 2016, achieved employment outcomes for individuals with I/DD compared to other individuals with disabilities under age 25 at exit from VRS in Indiana was 58% compared to the national average of 63% (USDoE, 2017). Of the total population served in Indiana that exited the VRS system, individuals with I/DD represented 55% of all persons with disabilities served. 48% of individuals with I/DD obtained employment at exit of VRS; the remaining 52% did not achieve employment outcomes (USDoE, 2017). Employment Outcomes of People with Intellectual and Learning Disabilities under Age 25 at VRS Exit Year 2016 52% 48% Intellectual and Learning Disability - Employment Intellectual and Learning Disability - Without Employment Numbers and percentages do not address individuals with I/DD outside transition age (ages 14-24). Employment of individuals with I/DD over age 25 is difficult to obtain due to no primary funding source or agency tracking and reporting data. Charts above were generated from data in the USDoE report: Fiscal year 2017: Monitoring report on the Indiana Bureau of Rehabilitation Services, Vocational Rehabilitation, and Supported Employment Programs. 600 OT AND ENTREPRENEURSHIP 72 FUNDING STRUCTURE FOR CURRENT EMPLOYMENT MODELS Fiscal budget limitations impacts the ability to provide government-funded essential services, which may require prioritizing allocation of funds when there is high demand for its resources. Literature has demonstrated that this waiting period negatively impacts individuals with I/DD seeking employment services, potentially causing economic distress with SSI/SSDI applicants and generating less favorable outcomes for employment (Honeycutt, & Stapleton, 2013; USDoE, 2017). In 2017, Indiana was the 35th state to implement an Order of Selection (OOS) due to limited funds and resources needed to serve all eligible individuals with disabilities (DDRS, 2017). VRS is mandated by WIOA to implement an OOS that prioritizes service to individuals with most significant disabilities (MSD) first, placing individuals with less significant disabilities on a waiting list for services when there are insufficient funds and resources to serve all eligible applicants (DDRS, 2017; Honeycutt, & Stapleton, 2013). There are no current published reports that directly reflect outcomes from the most recent changes of employment-based services after implementing the 2017 Indiana VRS OOS. Research from other VRS state agencies that have implemented an OOS have demonstrated that applicants placed on wait lists and do not obtain employment at VR closure experience negative consequences to other eligibility benefits, including suspension or termination of SSI/SSDI (Honeycutt, & Stapleton, 2013). Despite decades promoting employment first initiatives and disability policy, there has been limited growth in achieving improved employment and economic self-sufficiency outcomes for adults with I/DD in Indiana (Grossi, 2017). JOHNSON COUNTY COMMUNITY REHABILITATION PROVIDERS Employment service providers are synonymous with community rehabilitation providers (CRPs), organizations that are approved vendors to serve communities by providing rehabilitative and habilitative services to people with disabilities. The Bureau of Rehabilitation Services (BRS) approves CRPs to provide vocational rehabilitation in conjunction with VRS via a fee-for-service financial model (cite). There is only one community rehabilitation provider service that has a location housed within Johnson County: Gateway Services (Indiana Vocational Rehabilitation Services, 2018). There are sixteen other CRPs that serve Johnson County, however, none have a location within Johnson County to increase ease of potential accessibility to community and employment-based services to help streamline services (Indiana Vocational Rehabilitation Services, 2018). Currently, no other CRPs may apply to be qualified by the state of Indianas BRS to provide employment-based services to this population in Johnson County (FSSA, 2018e). OT AND ENTREPRENEURSHIP 73 EMPLOYMENT DEMOGRAPHICS EMPLOYMENT SETTING AND INCOME Indiana Day and Employment Services Outcomes Systems Report (DESOS) is generated annually, reviewing overall outcomes of support services provided by adult service provider agencies (also known as CRPs) to people with disabilities (Grossi, 2017). In 2017, approximately two-thirds of Indiana CRPs participated in reporting on DESOS data. Data revealed that non-employment day programs have grown at a rate of 4% over the past five years, while sheltered employment, and individual, competitive employment services have grown at a rate of 2% respectively. When analyzing which primary setting people with I/DD spend the majority of their days in, it was reported: 23% non-employment day programs, 27% sheltered employment, and 29% individual, competitive employment (Grossi, 2017). With the majority of individuals served by CRPs having either mild I/DD (31%), moderate I/DD (17%), and Autism (11%), the limited variability and growth with obtaining outcomes of integrated, competitive employment or supported employment demonstrates the stagnancy in achieving improved employment outcomes despite employment first initiatives (Grossi, 2017). The 2017 DESOS reported that of the individuals with disabilities that are employed and receiving earnings and/or paychecks: 40% of individuals did not receive a paycheck and 30% received paychecks from a CRP (Grossi, 2017). Only 30% received paychecks from their employer, demonstrating little improvement towards economic self-sufficiency via sustainable, earned wages that support employment and reduce dependence on federal and state funding generated from taxpayer dollars (Anderson, Larson, & Wuorio, 2011; Grossi, 2017). Of the individuals served by CRPs that maintained employment, 80% received no fringe benefits from their employer (Grossi, 2017). National reports are grimly similar with less than 20% of adults with I/DD having any type of employment income and 25% of adults with I/DD having no personal income (Anderson, Larson, & Wuorio, 2011). Of the percentage of adults with I/DD that are able to obtain employment, 11% have paid community employment and 15% have paid time in a day program, with many of these individuals representing both employment settings (Anderson et al., 2016). Paid employment for adults with I/DD occurred most frequently in the following settings: piece work, assembly, and packaging (32%), facility maintenance and cleaning (19%), office work (16%), and food prep and service (14%) (Anderson, Larson, & Wuorio, 2011). Available work frequently provided limited hours making low, by-piece wages; or provided alternative volunteer, unpaid work located within sheltered workshops or facility-based employment sites (Anderson, Larson, & Wuorio, 2011; Domin, & Butterworth, 2012; Winsor et al., 2017). OT AND ENTREPRENEURSHIP 74 EMPLOYMENT, INCOME, AND POVERTY Individuals with disabilities are more likely to experience poverty than people without disabilities at a rate of 20% compared to 13%, with Indiana reporting individuals with disabilities under the poverty threshold line at ~27% (Erickson, Lee, & von Schrader, 2017; Kraus et al., 2018). The majority of adults with I/DD from the DESOS data qualify for supplemental government supports including social security income (SSI) (44%), social security disability income (SSDI) (26%), or Medicaid (71%), but often are unable to achieve economic self-sufficiency even with this income since such government benefits are set below the federal poverty threshold (Anderson, Larson, & Wuorio, 2011; Grossi, 2017; Hughes, & Avoke, 2010). SUMMARY Through review of the data regarding CRPs, VRS, Pre-ETS, and Medicaid, it is clear there are primary resources available for adolescents and young adults with I/DD to receive support services to obtain employment. However, these resources alone are not viable to support all individuals with I/DD transition into adulthood and pursue employment. An increase in Johnson Countys overall population, combined with CRPs being limited by physical proximity and available human resources when providing employment services across multiple counties, and VRS limiting employment services to people with the most significant disabilities demonstrates current service agencies cannot meet the needs of all people with disabilities (DDRS, 2017; Stats Indiana, n.d.). Youth and young adults with mild to moderate I/DD are at risk of experiencing occupational marginalization and social isolation without having potential access to employment services (DDRS, 2017; Hammell, 2017; Stats Indiana, n.d.). There is a significant need for a grassroots movement within Johnson County to promote social enterprise business models utilizing natural supports to support adults with I/DD in obtaining and retaining successful, integrated community employment that contributes to the community. Adults with I/DD living in poverty continues to increase despite increased funding for government long-term support services including employment (Hughes, & Avoke, 2010). This occurrence is likely due to limited funding focused on supported, integrated, community employment services; insufficient support services needed to serve all adults with I/DD; and due to policies that place adults with I/DD at risk of losing benefits like SSI, SSDI, or health care if an individual with I/DD gains employment that allows them to earn living wages that raise them above the poverty threshold (Hughes, & Avoke, 2010). OT AND ENTREPRENEURSHIP 75 REFERENCES Anderson, L. L., Larson, S. A., Kardell, Y., Taylor, B., Hallas-Muchow, L., Eschenbacher, H. J., Hewitt, A. S., Sowers, M., & Bourne, M. L. (2016). Supporting Individuals with Intellectual or Developmental Disabilities and their Families: Status and Trends through 2014. Minneapolis: University of Minnesota, Research and Training Center on Community Living, Institute on Community Integration. Anderson, L. L., Larson, S. A., & Wuorio, A. (2011). 2010 FINDS National Survey Technical Report Part 1: Family Caregiver Survey. Minneapolis: University of Minnesota, Research and Training Center on Community Living. Division of Disability and Rehabilitative Services (DDRS). (2017). Vocational Rehabilitation Services Order of Selection Implementation. Retrieved from https://www.in.gov/fssa/files/Vocational%20Rehabilitation%20Services%20Order%20of %20Selection%20Implementation.pdf Domin, D., & Butterworth, J. (2013). The role of community rehabilitation providers in employment for person with intellectual and developmental disabilities: Results of the 2010-2011 national survey. Journal of Intellectual and Developmental Disabilities, 51(4), 215-225. doi: 10.1352/1934-9556-51.4.215 Erickson, W., Lee, C., & von Schrader, S. (2017). Disability Statistics from the American Community Survey (ACS). Ithaca, NY: Cornell University Yang-Tan Institute (YTI). Retrieved from Cornell University Disability Statistics website: www.disabilitystatistics.org Family and Social Services Administration (FSSA). (2018a). FSSA Main Menu. Retrieved from https://www.in.gov/fssa/2328.htm Family and Social Services Administration (FSSA). (2018b). Bureau of Developmental Disabilities Services. Retrieved from https://www.in.gov/fssa/ddrs/2639.htm Family and Social Services Administration (FSSA). (2018c). Application for Home and Community-Based Services Waiver. Retrieved from https://www.in.gov/fssa/files/IN.0378.R03.04.pdf Family and Social Services Administration (FSSA). (2018d). Vocational Rehabilitation Services. Retrieved from https://www.in.gov/fssa/ddrs/2636.htm Family and Social Services Administration (FSSA). (2018e). Vocational Rehabilitation Employment Services. Retrieved from: https://www.in.gov/fssa/ddrs/2636.htm Grossi, T. (2017). Indiana Day and Employment Services Outcomes Systems Report. Bloomington, IN: Indiana Institute on Disability and Community, Indiana University. Retrieved from https://www.iidc.indiana.edu/styles/iidc/defiles/CCLC/DESOS/DESOS2017finalSeptemb er.pdf Hammell, K. W. (2017). Opportunities for well-being: The right to occupational engagement. Canadian Journal of Occupational Therapy, 84(4-5), 209-212. doi: 10.1177/0008417417734831 Hall, A. C., Freeze, S., Butterworth, J., & Hoff, D. (2011). Employment funding for OT AND ENTREPRENEURSHIP 76 intellectual/developmental disability systems. Journal of Vocational Rehabilitation, 34, 1-15. doi: 10.3233/JVR-2010-0529 Honeycutt, T., & Stapleton, D. (2013). Striking while the iron is hot: The effect of vocational rehabilitation service wait times on employment outcomes for applicants receiving Social Security disability benefits. Journal of Vocational Rehabilitation, 39, 137-152. doi:10.3233/JVR-130645 Hughes, C., & Avoke, S. K. (2010). The elephant in the room: Poverty, disability, and employment. Research and Practice for Persons with Severe Disabilities, 35(1-2), 5-14. Indiana Vocational Rehabilitation Services. (2018). The Pick List: Choosing an Employment Provider in Johnson County. Retrieved from https://www.in.gov/fssa/files/Pick_List__Johnson_County.pdf Kraus, L., Lauer, E., Coleman, R., and Houtenville, A. (2018). 2017 Disability Statistics Annual Report. Durham, NH: University of New Hampshire. Monteleone, R. (2016). Employment for all: United States disability policy. Tizard Learning Disability Review, 21(3), 154-161. doi: 10.1108/TLDR-09-2015-0034 National Center for Education Statistics (NCES). (n.d.). Search for Public Schools. Retrieved from https://nces.ed.gov/ccd/schoolsearch/index.asp Stats Indiana. (n.d.). Johnson County, Indiana. Retrieved from www.stats.indiana.edu/profiles/profiles.asp?scope_choice=a&county_changer=18081 United States Department of Agriculture Economic Research Service (USDA). (2018). Population. Retrieved from https://data.ers.usda.gov/reports.aspx?ID=17827 United States Department of Education: Office of Special Education and Rehabilitative Services, Rehabilitation Services Administration (USDoE). (2017). Fiscal year 2017: Monitoring report on the Indiana Bureau of Rehabilitation Services, Vocational Rehabilitation, and Supported Employment Programs. Retrieved from https://www2.ed.gov/rschstat/eval/rehab/107-reports/fy2017-in.pdf United States Department of Labor. (2017). The Workforce Innovation and Opportunity Act: Rules. Retrieved from https://www.doleta.gov/wioa/Docs/WIOA_Factsheets.pdf Winsor, J., Timmons, J., Butterworth, J., Shepard, J., Landa, C., Smith, F., Domin, D., Migliore, A., Bose, J., & Landim, L. (2017). StateData: The national report on employment services and outcomes. Boston, MA: University of Massachusetts Boston, Institute for Community Inclusion. OT AND ENTREPRENEURSHIP 77 Appendix B Nonprofit Organization and/or Community Rehabilitation Provider Agency Adult and Child Services Carla, PreETS Manager corr@adultandchild.org AgrAbility Danyele Clingan, OT Intern clingand@uindy.edu Date Meeting Outcomes 5/23/18 Ariel Clinical Services Becky Hobart, CEO, Director bhobart@arielcpa.org Benjamins Hope Krista Mason, Director, CEO k.mason@benjaminshope.net Brandywine Creek Farms Sierra Nuckols sierra@brandywinecreekfarms.org Earlywood Education Services Stephanie Lawless slawless@earlywood.org ESC Pre-ETS Program Dwana Black, Program Mgr. dback@eastersealscrossroads.org Festival Country Indiana Ken Kosky Director of Tourism ken@festivalcountryindiana.com 317-903-1627 INSPIRE Program Franklin College and Earlywood Education Lisa Whitlow-Hall Lwhitlow-hall@earlywood.org Johnson County Autism Support Group Amanda Cooper, President acooper728@yahoo.com Joys House Leah Jones, Family Care Mgr. S.H.A.L.O.M. Kelly Lewis, Service Provider, OT lewiskellymichelle@gmail.com Special Dreams Farms Larry Collette, President & CEO lcollette@specialdreamsfarm.org 5/24/18 Efficacy of Pre-ETS implementation in Johnson County; data/statistics regarding current services and involvement of public schools Collaboration and education/resources on agriculture-related businesses, environmental modifications, strategies to support entrepreneurs and farmers with disabilities Discussion on organization model, implementation of vocational programs, how organization affords to run programs Discussion on organization model, strategies to develop nonprofit organization and how to use strategic planning to achieve outcomes Attempt initial contact to discuss potential collaboration regarding farming/agriculture; did not hear back from owner Collaboration to provide access for parent survey responses 4/18/18 4/25/18 5/31/18 5/29/18 5/8/18 7/2/18 Information regarding Pre-ETS services, provided data for Johnson County student IEP and special education statistics Information regarding potential business services and future collaboration when marketing bed and breakfast opportunities 5/29/18 Collaboration to provide access for parent survey responses Multiple meetings Collaboration to provide access for parent survey responses; helped provide contact information for additional interviews 2/15/18 Outlined content and expectations for community rehabilitation provider agencies Organization structure and model, including farming, sheep wool production, store; community rehabilitation provider agency Interview regarding start-up business/organization structures, how to complete fundraising, etc. 4/19/18 4/19/18 OT AND ENTREPRENEURSHIP Sycamore Services Virginia Bates, Day/Comm. Director vmbates@sycamoreservices.com UIndy School of Business Dr. Marcos Hashimoto mhashimoto@uindy.edu Dr. Timothy Zimmer zimmert@uindy.edu Valaparasio University Law Maxwell Boris maxwell.boris@valpo.edu Village of the Blue Rose Rose Gronemeyer 78 4/25/18 5/24/18 5/14/18 (573) 242-3539 West Mont Services Ashleigh Heimbach, Director aheimbach@westmont.org External Individual with Specialized Expertise Cardinal Point Farms Anne Young, Retired Special Education Teacher 4/12/18 JC Trading Post Steering Committee Kristina Watkins, Roger Graham, Thelma Slisher Retired Eli Lilly, Parent of Adolescent with I/DD Kelli Webb Government-Based Agency/Business or For-Profit Business Bargersville Town Meeting Multiple meetings Date Multiple meetings Date 6/26/18 Burea Developmental Disability Services (BDDS) Lisa Wilson Central Nine Nicole Otte, Director The Greater GO Becky Kirby rkirby@thegreatergo.com 7/2/18 Interview discussing structures of community rehabilitation providers and vocational rehabilitation services, how structures are funded, etc. Interviews with professors to discuss how to complete market research, business plan development, how to collect data to support or refute business plans Reviewed Articles of Incorporation and Bylaws, provided recommendations for draft Discussed organization structure of nonprofit bed and breakfast, provide services and employment but charge fee for cost of living/housing Interview regarding organization structure/model, efficacy of business services and supports provided to people with I/DD Meeting Outcomes Interview/discussion of experience developing special education program (Clark Pleasant Academy), how to run small farm, agreed to trial pilot program at farm with future outcomes Steering committee development/guidance on next steps for business plan, strategies to use throughout internship for future development Collaboration on how to develop business models, consideration of lean start-up techniques with lean six sigma methodology Meeting Outcomes Zoning regulations, variances, town meetings, future development and rezoning Bargersville Parent transition meeting discussing BDDS, Medicaid waiver, access to services, etc. Tour of facility, discussion on how provision of services completed, how projects are selected and implemented within community Interview/collaboration on ADA accessibility and regulations for bed and breakfasts, common barriers experience for people of disabilities when traveling OT AND ENTREPRENEURSHIP Small Business Development Center (SBDC) Andrew Carty acarty@isbdc.org Curtiss Quirin cquirin@isbdc.org SCORE Mike Crumbo, Mentor mike.crumbo@gmail.com Vocational Rehabilitation Services Jonathan Kraeszig, Director of Youth Services and Pre-ETS Jonathan.Kraeszig@fssa.in.gov Whiteland High School Special Education Teacher Emily Benhke ebehnke@cpcsc.k12.in.us 79 5/30/18 Limited collaboration and interview on strategies for business plan development and completing market research; identified unable to help with nonprofit start-up development, out of scope of services for SBDC 5/25/18 6/8/18 Free small business service, mentorship and guidance offered during development of business plan Interview regarding VRS and Pre-ETS program, initial implementation of Pre-ETS, outcomes, future development of VRS services and projected outreach strategies Discussion of Special Education services and programs available at high school, Certificate of Completion typically leaves individuals unable to apply for jobs that require a HS Diploma 5/31/18 5/18/18 OT AND ENTREPRENEURSHIP 80 Appendix C 06.29.18 REPORT ON EMPLOYMENT FOR ADOLESCENTS AND YOUNG ADULTS WITH INTELLECTUAL AND DEVELOPMENTAL DISABILITIES OT AND ENTREPRENEURSHIP 81 National statistics and literature demonstrate that adolescents and young adults with intellectual and developmental disabilities (I/DD) are unemployed at significantly higher rates than people with other disabilities or no disabilities. A brief survey was administered to parents of adolescent and/or young adult children with I/DD in Johnson County to determine if parents perceive their children to have significant opportunities to obtain employment in their community. R EP O R T O N EM P LOY M EN T FO R A DO LE SC EN T S A N D YO UN G A DULTS W I TH I N TE L LEC TUA L A N D D EV ELO P M EN TA L DI SA B I LI TI E S NATIONAL STATISTICS ON PEOPLE WITH INTELLECTUAL AND DEVELOPMENTAL DISABILITIES (I/DD) In the United States, there are over 4.7 million people with intellectual and developmental disabilities (I/DD) (Anderson et al., 2016). Less than one-third, 1.4 million people, are known to receive some type of government service support from a state I/DD agency, with over 60% of these individuals being ages 22 or older. Two-thirds of these adults with I/DD receive services from a Medicaid waiver authority that provides long-term support services, including supported employment (Anderson et al., 2016). While access to employment-based services has increased equitable opportunities for people with disabilities, accessibility and sustainability to supported, integrated, community employment continues to be a barrier for adults with I/DD; approximately 85% of adults with I/DD are unemployed in the United States (Anderson, Larson, & Wuorio, 2011; Brady et al., 2010; Domin, & Butterworth, 2013; Friedman, & Rizzolo, 2017; Hall, Freeze, Butterworth, & Hoff, 2011; Monteleone, 2016). Work gives us access and opportunities. Sunday Adelaja Benefits of Employment for People with I/DD Adults with I/DD often lack the opportunity to exercise autonomy when participating in meaningful occupations (daily activities, routines, tasks) (Hammell, 2017; Maguire, 2009; Minnes et al., 2002). Within occupational therapy, this lack of opportunity to exercise autonomy is called occupational marginalization (Hammell, 2017). Occupational marginalization with work opportunities leads to social isolation and is associated with decreased self-determination, self-worth, health, and well-being (Hammell, 2017; Minnes et al., 2002). Participation in supported community employment is linked to increased independence, self-efficacy, and self-esteem for adults with I/DD, promoting community inclusion, acceptance, and improved understanding of disability (Minnes et al., 2002; Nord et al., 2013; Nord, & Nye-Lengerman, 2015). Since work is widely accepted as an integral component of most adults lives, including gaining means to economic self-sufficiency, attaining resources, and providing a source of personal identity, it is imperative to address employment and its work environment to support the needs of its employees in order to prevent inequity and negative health implications (Ahonen, Fujishiro, Cunningham, & Flynn, 2018; Burge, Ouellette-Kuntz, & Lysaght, 2007; Dennis, & Gitlow, 2012; Wysocki, & Neulicht, 2004). OT AND ENTREPRENEURSHIP 82 PERSPECTIVES ON EMPLOYMENT OF PEOPLE WITH I/DD Historically, people with I/DD in the United States were removed from their respective communities and institutionalized to receive care or were placed in sheltered workshops, segregated from the rest of the community (Dague, 2012; Monteleone, 2016). It was not until the 1970s that services shifted from institutionalization to community-based services with community providers and affirmative action plans to promote opportunities for people with disabilities (Monteleone, 2016). Disability policy continued gaining momentum in the 1980s, promoting community integration, self-determination, and employment opportunities. The Americans with Disabilities Act of 1990 (ADA) prohibited discrimination against people with disabilities in all areas of public life, including employment. The Workforce Investment Act of 1998 (WIA) developed national employment training services, which funded vocational rehabilitation services and other transition service programs for people with disabilities (Monteleone, 2016). Employment first initiatives for people with disabilities has been promoted at state levels, with Indiana recently passing legislation in 2017 to promote competitive, integrated employment as the first, preferred option for any individual of working age with a disability (Monteleone, 2016; General Assembly of the State of Indiana, 2017). Business Perspectives on Employment of People with I/DD The majority of employers express desire in hiring and obtaining people with disabilities as employees, but demonstrate lower numbers employing people with disabilities (Siperstein, Romano, Mohler, & Parker, 2006). Many employers have acknowledged a lack of understanding how to make appropriate accommodations or modifications to adequately support a person with a disability, often fearing associated costs (Kaye, Jans, & Jones, 2011; Siperstein et al., 2006). Some employers report not knowing what true work level performance a person with a disability may be able to obtain, fearing poor job performance, liability, and potential reprimands for firing a person with a disability (Kaye, Jans, & Jones, 2011; Siperstein et al., 2006). Other employers have expressed concerns regarding work hours, flexibility, and the impact of other benefits the employee with I/DD may depend on for economic self-sufficiency (Irvine, & Lupart, 2008). There is no greater disability in society than the inability to see a person as more. Robert M. Hensel Public Perspectives on Employment of People with I/DD Public views on employment of people with I/DD has drastically shifted perspectives since the mid20th century, with increasing positive support towards integrated community employment (Burge, Ouellette-Kuntz, & Lysaght, 2007; Siperstein et al., 2006). Most participants from studies regarding public consumers beliefs reported having worked with a person with a disability and were favorable to supporting companies that promote inclusivity and diversity in the workforce, including people with disabilities. The majority of public and consumer attitudes reported they did not view people with disabilities causing problems in the workforce and promoted integrated community employment as being the best outcomes for people with I/DD (Burge, Ouellette-Kuntz, & Lysaght, 2007; Siperstein et al., 2006). OT AND ENTREPRENEURSHIP 83 Parent Perspectives on Employment of Their Family Members with I/DD Studies about parents perspectives on employment for adolescent or adult children with I/DD show a variety of concerns as the children transition into the workforce. Family members have expressed prioritization in their children with I/DD having access to inclusive, integrated workplaces where employment based off individualized interest was a priority (Gilson, Carter, Bumble, & McMillan, 2018). Concerns regarding accessibility and availability for supports within the workplace, including opportunities for on-the-job supports, and community supports, including reliable transportation and programming designed to help promote job supports and supported employment, were common themes for parents (Gilson et al., 2018). JOHNSON COUNTY EMPLOYMENT OPPORTUNITIES In order to determine if parents of adolescents and adults with I/DD in Johnson County, Indiana may reflect the concerns expressed in literature pertaining to people with I/DD obtaining employment and having access to employment opportunities, a brief, 10 question survey was developed and distributed to two community agencies that provide support services to adolescents and young adults with I/DD and their families: the INSPIRE program of Earlywood Education Services and Franklin College, and Johnson County Autism Support Group. Each organization distributed the survey via email, newsletter, and/or Facebook group. The survey was designed to ensure anonymity and voluntary participation. Prior to parent participation in the survey, parents were asked to review the following definitions to reduce confusion and address operationalization of vocabulary utilized within the survey. Definitions were presented as follows: To make better sense of the survey, please review these definitions prior to completing the survey: student: your adolescent or young adult child vocational training: any work-related training or skills Data was collected and analyzed two weeks after the survey was distributed. Total participants obtained from the survey were 19 parents (N=19), demonstrating a small, convenience sample of parents of children with I/DD in the Johnson County community. Questions were developed to determine where students currently were within the school to workforce transition, what ages the students were at the time of survey completion, and how parents perceive current vocational and employment related opportunities for their students in the Johnson County community. The 10 questions are listed on the following page with further review of results for each question in the report. Survey results of this exploratory study are discussed, reflecting similar themes to current literature about parents perspectives on employment opportunities for their adolescent and adult children with I/DD. The survey results demonstrate evidence supporting a need within the Johnson County community for social enterprise business models that address vocational training and supported, community employment using natural support and other evidence-based strategies that promote independence and meaningful employment within an integrated, diverse work environment. OT AND ENTREPRENEURSHIP 84 Question 1: Where is your student currently in the school to workforce transition? School-based vocational training and transition living skills (e.g. work, independent living) Work and employment related IEP Post-secondary educational plans: INSPIRE, community college, 4-year college/university Vocational training program: Project SEARCH, Pre-Employment Transition Services, Vocational Rehabilitation Services Independent community employment working in the community Community Rehabilitation Program Employment (organization that helps provide employment opportunities) (e.g. Easterseals Crossroads, Gateway Services, etc.) Non-work and volunteer-based programs: Community, organization, or independent Other Question 2: How old is your student currently? Question 3: I am concerned about my students work opportunities and community involvement as they transition into adulthood. Question 4: My student has adequate opportunities to obtain vocational training and/or employment. Question 5: It is important to my student that he/she gains meaningful employment. Question 6: It is important to me that my student gains meaningful employment. Question 7: It is important that my student earns a fair, competitive wage while employed. Question 8: My student requires assistance when completing new work or vocational related tasks/skills. Question 9: It is important to me to support businesses that promote community inclusion and employment opportunities for people of all abilities. Question 10: I would like to see my student work in an environment that encompasses which of the following (Please mark all that apply): Integrated, competitive employment with fair wages (Independent or minimal hours with job coach) Supported community employment with fair wages (Staff or ongoing supports) Supported community volunteer work Sheltered employment with wages (Employment within day program, etc.) Sheltered employment volunteer work Day program participation only Business entrepreneur Other OT AND ENTREPRENEURSHIP 85 Question 1: Where is your student currently in the school to workforce transition? Of the (N=19) total parent participants: 4/19 parents identified their student (ages 19-22) being in more than one setting within the school to workforce transition with the most commonly identified overlapping work settings being Community Rehabilitation Program Employment and Post-secondary Education Plans, both appearing 2/4 times. Additional settings that were obtained simultaneously included: Non-work and volunteer-based program, Work and employment related IEP, School-based vocational and transitioning living skills, and Vocational training program. These settings are frequently obtained simultaneously within the age range of young adults ages 19-22 due to eligibility to receive educational support services via an Individual Transition Plan mandated by the Department of Education until a student has obtained either a High School Diploma, Certificate of Completion, or has aged out of entitlement services. 2/19 parents identified their student did not fit within the listed settings, indicating other. OT AND ENTREPRENEURSHIP 86 # of Students Where is your student currently in the school to workforce transition? 5 5 3 3 2 2 2 1 TYPE OF SETTING Type of Setting School-Based Vocational and Transitiong Living Skills (e.g. work, independent living) Work and Employment Related IEP Plan Post-Secondary Education Plan: INSPIRE, community college, 4-year college/university Vocational Training Program: Project SEARCH, Pre-Employment Transition Services, Vocational Rehabilitation Services Independent Community Employment: Working in the Community Community Rehabilitation Program Employment (organization that helps provide employment opportunities/services) (e.g. Easterseals Crossroads, Gateway services) Non-work and Volunteer Based Program: Community, Organization, or Independent The most commonly reported settings were School-based vocational training and transitioning living skills and Independent community employment (N=5) each setting. Targeted age ranges for School-based vocational training and transitioning living skills encompassed ages 17-18 (N=2) and ages 19-22 (N=3). Independent community employment reflected age ranges 19-22 (N=3) and ages 23+ (N=2). OT AND ENTREPRENEURSHIP 87 Question 2: How old is your student currently? Parent respondents voluntarily participating in the school to workforce transition survey demonstrate a random, bell-curve distribution reflecting an appropriate age range of random, convenience sampling for the transition age targeted group, identified by the IDEA act as ages 14-22. 13/19 parent respondents reported their student was between the ages of 19-22, the targeted age range for implementing Vocational Rehabilitation Services and other school-to-work transition planning to obtain employment. Age Range of Student How old is your student currently? 0 2 13 23+ 19-22 3 17-18 (Upperclassmen) 14-16 (Underclassmen) 1 2 4 6 8 Number of Students 10 12 14 OT AND ENTREPRENEURSHIP 88 Question 3: I am concerned about my students work oppor tunities and community involvement as they transition into adulthood. 18/19 parents STRONGLY AGREE with this statement. 1/19 parents AGREE with this statement. "I AM CONCERNED ABOUT MY STUDENT'S WORK OPPORTUNITIES AND COMMUNITY INVOLVEMENT AS THEY TRANSITION INTO ADULTHOOD." Strongly Disagree 0% Disagree 0% Neither Agree nor Disagree 0% Agree 5% Strongly Agree 95% With all parent respondents demonstrating that they either STRONGLY AGREE or AGREE with the statement expressing concern for their students work and community integration opportunities as they transition into adulthood, it supports national statistics and literature demonstrating concerns parents have for their children with I/DD as they transition into adulthood. Adolescents and young adults with I/DD experience barriers, including high rates of unemployment and community integration compared to adolescents and young adults without disabilities. OT AND ENTREPRENEURSHIP 89 Question 4: My student has adequate oppor tunities to obtain vocational training and/or employment. Of the total (N=19) participants: 6/19 parents Strongly Disagree 6/19 parents Disagree 3/19 parents Neither Agree nor Disagree 4/19 parents Agree 0/19 parents Strongly Agree Two-thirds (66%) of parents that strongly disagree have children ages 19-22, and 83% of parents with children ages 19 or older strongly disagree. 63% of parents do not believe their children have adequate opportunities to obtain vocational training or employment. 16% of parents do not have a strong opinion and may be uncertain as to whether they believe their children have adequate opportunities for vocational training or employment. 100% of these parents have children ages 19-22. NUMBER OF RESPONSES "MY STUDENT HAS ADEQUATE OPPORTUNITIES TO OBTAIN VOCATIONAL TRAINING AND/OR EMPLOYMENT." 6 6 6 5 4 4 3 3 2 1 0 0 Parent Response Strongly Agree Agree Neither Agree nor Disagree Disagree Strongly Disagree The responses from parents reflect similar national surveys, demonstrating that there are a range of opinions regarding access to vocational training and employment opportunities of people with I/DD. Most parents express concerns that there are not adequate opportunities for their children to obtain employment. OT AND ENTREPRENEURSHIP 90 Question 5: It is impor tant to my student that he/she gains meaningful employment. 10/19 parents (53%) STRONGLY AGREE that their child values gaining meaningful employment. 15/19 parents (79%) AGREE or STRONGLY AGREE that their child values gaining meaningful employment. Question 6: It is impor tant to me that my student gains meaningful employment. 16/19 parents (84%) STRONGLY AGREE it is important to them that their child gains meaningful employment. 18/19 parents (95%) AGREE or STRONGLY AGREE it is important to them that their child gains meaningful employment. Importance of Gaining Meaningful Employment 18 16 Number of Parent Responses 16 14 12 10 10 8 5 6 3 4 2 1 2 1 0 0 0 0 Strongly Agree Agree Neither Agree nor Disagree Disagree Strongly Disagree Type of Parent Response Importance of Employment to Student Importance of Employment to Parent Results from the parent survey reflect similar national statistics and literature that employment and vocational opportunities that are meaningful provide significance that allow individuals to potentially obtain social connectedness, community inclusion, increased self-esteem, and improved quality of life. OT AND ENTREPRENEURSHIP 91 Question 7: It is impor tant that my student earns a fair, competitive wage while employed. Of the (N=19) participants: 14/19 parents STRONGLY AGREE 3/19 parents AGREE 1/19 parents NEITHER AGREE NOR DISAGREE 1/19 parents DISAGREE 0/19 parents STRONGLY DISAGREE "It is important to me that my student earns a fair, competitive wage." 0% 5% 5% 16% 74% Strongly Agree Agree Neither Agree nor Disagree Disagree Strongly Disagree 74% of parents expressed STRONGLY AGREEing, desiring their child to earn fair, competitive wages, approximately three-quarters of the entire sample respondents. 90% of parent respondents expressed desiring their child to earn fair, competitive wages while employed. 10% of parent respondents expressed either having no strong opinion or disagreeing with it being important for their children to earn fair, competitive wages while employed. These percentages reflect national survey results and literature, showing initiative to promote integrated, competitive employment with fair wages equal to that of people without disabilities completing similar work tasks. Variation in parent responses were not followed up to determine reasons it may not have been identified as important. Literature has demonstrated parents may feel more strongly about their children obtaining meaningful community participation, work-related OT AND ENTREPRENEURSHIP 92 experiences, or maintaining other eligibility-based benefits like SSDI, SSI, etc. that may be impacted by increased income. Question 8: My student requires assistance when completing new work or vocational related tasks/skills. Perspective of Student Assistance Level 0 69% parents STRONGLY AGREE 26% parents AGREE 5% parents NEITHER AGREE NOR DISAGREE "My student requires assistance when completing new work or vocational related tasks/skills. 0 0 1 5 13 2 4 6 8 10 12 14 Number of Parent Responses Strongly Disagree Disagree Neither Agree nor Disagree Agree Strongly Agree Of the (N=19) sample: 10/13 parents with children ages 19-22 STRONGLY AGREE 1/3 parents with children ages 17-18 STRONGLY AGREE 2/2 parents with children ages 23+ STRONGLY AGREE 3/13 parents with children ages 19-22 AGREE 2/3 parents with children ages 1-18 AGREE 1/1 parent with children ages 14-16 NEITHER AGREE NOR DISAGREE While there is a trend that demonstrates positive correlation of increased supports with increased age, this trend is limited by small convenience sampling OT AND ENTREPRENEURSHIP 93 and may be influenced at home much exposure a child may have currently obtained with exposure to learning new vocational skills. Question 9: It is impor tant to me to suppor t businesses that promote community inclusion and employmen t oppor tunities for people of all abilities. 18/19 parents STRONGLY AGREE 1/19 parents AGREE "It is important to me to support businesses that promote community inclusion and employment opportunities for people of all abilities." 5% Strongly Agree 0% 0% 95% 0% Agree Neither Agree nor Disagree Disagree Strongly Disagree From this small (N=19) sample, parents of children with intellectual and developmental disabilities demonstrate that they may be huge advocates and supporters of businesses that promote community inclusion and employment for individuals of all abilities. This data supports further literature that demonstrates society has an overwhelming positive outlook on supporting businesses that promote employment for people with all abilities. OT AND ENTREPRENEURSHIP 94 Question 10: I would like to see my student work in an environment that encompasses which of the following (Please mark all that apply): Parents were able to identify more than one work environment when expressing what type of work environments they would desire to see their child be employed. As a result, when totaling the number of responses over each setting, the responses total over 100%. When analyzing the most desired settings, the most frequently selected responses were: 15/19 Integrated, competitive employment with fair wages 7/19 Supported community employment with fair wages 7/19 Supported community volunteer work 5/19 Business entrepreneur All most frequently reported work environments, listed above, promote community integration and inclusion compared to further removed settings including sheltered employment and day program participation only. OT AND ENTREPRENEURSHIP 95 "I WOULD LIKE TO SEE MY STUDENT WORK IN AN ENVIRONMENT THAT ENCOMPASSES WHICH OF THE FOLLOWING (PLEASE MARK ALL THAT APPLY)" Integrated, competitive employment with fair wages Supported community employment with fair wages Supported community volunteer work Sheltered employment with wages Sheltered employment volunteer work Day program participation only 3 4 4 5 7 7 NUMBER OF RESPONDENTS 15 Business entrepreneur PARENT RESPONSES TO TYPE OF SETTING PARENT RESPONSES TO TYPE OF SETTING When examining parent responses where only ONE work environment was identified (N=8), responses were as follows: 7/8 identified desiring Integrated competitive employment 1/8 identified desiring Supported community employment When examining parent responses where TWO work environments were identified (N=4), responses were as follows: 4/4 identified desiring Integrated competitive employment as 1 of 2 settings 2/4 identified desiring Supported community employment as 1 of 2 settings 2/4 identified desiring Business entrepreneurship as 1 of 2 settings OT AND ENTREPRENEURSHIP 96 CONCLUSION Results Results from this small, convenience sample survey of 19 parents who have adolescent or young adult children with intellectual and/or developmental disabilities reiterates the concerns of parents of children with I/DD throughout the United States. While Johnson County offers some long-term support services and employment opportunities for adolescents and young adults with I/DD, most parents surveyed believed that there are not adequate opportunities and accessible supports in place to allow their children to obtain meaningful employment. Parent responses reflect that earning fair, competitive wages are a priority, but may not be as significant as obtaining meaningful employment within the community. Parents that have children with I/DD demonstrated overwhelming support towards businesses that prioritize community inclusion and employment opportunities for people of all abilities. While Johnson County does have overarching support services offered to adolescents and young adults with I/DD, these resources are largely based off eligibility which can leave certain individuals with I/DD unable to qualify for these services. Without additional community supports in place, these individuals with I/DD are susceptible to experiencing occupational marginalization and social isolation. Developing a business model that promotes community inclusion and diversity, emphasizes natural supports, and creates appropriate accommodations so that people of all abilities can have the opportunity for supported, community employment could help resolve some of the unmet community needs. OT AND ENTREPRENEURSHIP 97 REFERENCES Image References https://americasaves.org/organizations/downloads-and-resources/partner-resourcepackets/financial-wellness-for-people-with-disabilities-and-their-families References Ahonen, E. Q., Fujishiro, K., Cunninghman, T., & Flynn, M. (2018). Work as an inclusive part of population health inequities research and prevention. American Journal of Public Health, 108(3), 306-311. doi:10.2105/AJPH.2017.304214 Anderson, L. L., Larson, S. A., Kardell, Y., Taylor, B., Hallas-Muchow, L., Eschenbacher, H. J., Hewitt, A. S., Sowers, M., & Bourne, M. L. (2016). Supporting Individuals with Intellectual or Developmental Disabilities and their Families: Status and Trends through 2014. Minneapolis: University of Minnesota, Research and Training Center on Community Living, Institute on Community Integration. Brady, M. P., Duffy, M. L., Frain, M., & Bucholz, J. (2010). Evaluating work performance and needs in supported employment training programs: Correspondence between teachers ratings and students self-ratings? Journal of Rehabilitation, 76(3), 24-31. Burge, P., Ouellette-Kuntz, H., & Lysaght, R. (2007). Public views on employment of people with intellectual disabilities. Journal of Vocational Rehabilitation, 26, 29-37. Dennis, C. W., & Gitlow, L. (2012). Occupational justice and work. Special Interest Section Quarterly: Work & Industry, 26(2), 1-4. Domin, D., & Butterworth, J. (2013). The role of community rehabilitation providers in employment for person with intellectual and developmental disabilities: Results of the 20102011 national survey. Journal of Intellectual and Developmental Disabilities, 51(4), 215-225. doi: 10.1352/1934-9556-51.4.215 Friedman, C., & Rizzolo, M. C. (2017). Get us real jobs: Supported employment services for people with intellectual and developmental disabilities in Medicaid Home and Community Based Services waivers. Journal of Vocational Rehabilitation, 46, 107-116. doi: 10.3233/JVR160847 Gilson, C. B., Carter, E. W., Bumble, J. L., & McMillan, E. D. (2018). Family perspectives on integrated employment for adults with intellectual and developmental disabilities. Research and Practice for Persons with Severe Disabilities, 43(1), 20-37. doi: 10.1177/1540796917751134 Hall, A. C., Freeze, S., Butterworth, J., & Hoff, D. (2011). Employment funding for intellectual/developmental disability systems. Journal of Vocational Rehabilitation, 34, 1-15. doi: 10.3233/JVR-2010-0529 Hammell, K. W. (2017). Opportunities for well-being: The right to occupational engagement. Canadian Journal of Occupational Therapy, 84(4-5), 209-222. doi: 10.1177/0008417417734831 Irvine, A., & Lupart, J. (2008). Into the workforce: Employers perspectives of inclusion. Developmental Disabilities Bulletin, 36(1&2), 225-250. Kaye, H. S., Jans, L. H., & Jones, E. C. (2011). Why dont employers hire and retain workers with disabilities? Journal of Occupational Rehabilitation, 21, 526-536. doi: 10.1007/s10926011-9302-8 Maguire, S. (2009). Getting into employment. In M. Bollard (Ed.), Intellectual disability and social inclusion: A critical review (pp. 113-121). Edinburgh, UK: Elsevier Ltd. Minnes, P., Buell, K., Feldman, M. A., McColl, M. A., & McCreary, B. (2002). Community integration as acculturation: Preliminary validation of the AIMS interview. Journal of Applied Research in Intellectual Disabilities, 15, 377-387. Monteleone, R. (2016). Employment for all: United States disability policy. Tizard Learning Disability Review, 21(3), 154-161. doi: 10.1108/TLDR-09-2015-0034 OT AND ENTREPRENEURSHIP Nord, D., Luecking, R., Mank, D., Kiernan, W., & Way, C. (2013). The state of the science of employment and economic self-sufficiency for people with intellectual and developmental disabilities. Intellectual and Developmental Disabilities, 51(5), 376-384. doi: 10.1352/19349556-51.5.376 Nord, D., & Nye-Lengerman, K. (2015). The negative effects of public benefits on individual employment: A multilevel analysis of work hours. Intellectual and Developmental Disabilities, 53(4), 308-318. doi: 10.1352/1934-9556-53.4.308 Siperstein, G. N., Romano, N., Mohler, A., & Parker, R. (2006). A national survey of consumer attitudes towards companies that hire people with disabilities. Journal of Vocational Rehabilitation, 24, 3-9. Wysocki, D. J., & Neulicht, A. T. (2004). Work is occupation: What can I do as an occupational therapy practitioner? In M. Ross, & S. Bachner (Eds.), Adults with developmental disabilities: Current approaches in occupational therapy (pp. 291-328). Bethesda, MD: AOTA Press. 98 OT AND ENTREPRENEURSHIP 99 Appendix D Farmers Market Survey Age Range 18 29 30 39 40 49 50 59 60 + Household Size Single (self) Couple Small (1-2 children) Large (3+ children) Location Bargersville Edinburgh Franklin Greenwood Indianapolis Whiteland Johnson county Other Question 1 Yes No Question 2 Yes No Question 3 Yes No Question 4 Yes No Question 5 Yes No P1 P2 Location: __________________ P3 P4 P5 P6 P7 P8 P9 Date:________________ P10 P11 P12 P13 P14 P15 Question 1: Does it matter to you where your produce or flowers are grown/come from? Question 2: Would you travel to a farm to purchase fresh produce or flowers? Question 3: Would you be more inclined to purchase farm fresh produce or flowers if the business donates a portion of its products and/or proceeds to address food insecurity in Johnson county? Question 4: Would you be more inclined to purchase farm fresh produce or flowers if the business employs people with disabilities at fair wages? Question 5: Are you satisfied with the current options at the famers market? if no: What else would you like to have offered? OT AND ENTREPRENEURSHIP 100 Appendix E Market Research Farmers Markets In gathering secondary data for business concepts pertaining to a flower shop or produce market, basic market research was conducted at various local farmers markets in Johnson county during the month of June. Three different farmers markets (Bargersville, Franklin, and Greenwood) on four different dates generated a random, convenience sample (N=47) from 47 polled people. Data collection was based on basic consumer demographics (e.g. age range, household size, and household location) and five simple binary questions used to target basic consumer behavior within projected target markets. Question 1: Question 2: Question 3: Question 4: Question 5: Age Range 18-29 30-39 40-49 50-59 Grand Total Does it matter to you where your produce or flowers are grown/come(s) from? Would you travel to a farm to purchase fresh produce or flowers? Would you be more inclined to purchase farm fresh produce or flowers if the donates a portion of its products and/or proceeds to address food insecurity in Johnson County? Would you be more inclined to purchase farm fresh produce or flowers if the business employs people with disabilities at fair wages? Are you satisfied with the current options at the farmers market? Number of Responses 8 26 12 1 47 Location Number of Responses Bargersville 14 Franklin 8 Greenwood 12 Indianapolis 2 Other 9 Whiteland 2 Grand Total 47 Household Size Couple Large (3+ children) Self Small (1-2 children) Grand Total Number of Responses 6 10 1 30 47 Basic consumer demographics reflect the age ranges, household size, and household locations of random participants surveyed. This content provides information about the target consumer market. OT AND ENTREPRENEURSHIP 101 Question 1: Does it matter to you where your produce or flowers are grown/come(s) from? Question 1 100% YES ALL RESPONDENTS PARTICIPATING IN SURVEY ANSWERED THEY VALUED WHERE THEY PURCHASED PRODUCE AND FLOWERS, DESIRING TO SHOP LOCAL. No 0% Yes 100% Question 2: Would you travel to a farm to purchase fresh produce or flowers? Question 2 94% YES No 6% 44/47 PERSONS RESPONDED THEY WOULD TRAVEL TO A FARM TO PURCHASE FRESH PRODUCE. Yes 94% 3/37 PERSONS RESPONDED THEY USE FARMERS MARKETS TO SUPPLEMENT THEIR HOME GROWN FRESH PRODUCE. OT AND ENTREPRENEURSHIP 102 Question 3: Would you be more inclined to purchase farm fresh produce or flowers if the business donates a portion of its products and/or proceeds to address food insecurity in Johnson County? Question 3 15% MAYBE 7/47 PERSONS SURVEYED INDICATED THAT IT MATTERED TO THEM WHAT SPECIFIC ORGANIZATION WAS RECEIVING DONATIONS OR PROCEEDS WHEN ADDRESSING FOOD INSECURITY IN JOHNSON COUNTY. No 0% May Yes Question 4: Would you be more inclined to purchase farm fresh produce or flowers if the business employs people with disabilities at fair wages? Question 4 No 0% Yes 100% 100% YES ALL PARTICIPANTS SURVEYED WERE UNANIMOUS IN SUPPORTING A LOCAL BUSINESS THAT EMPLOYS PEOPLE WITH DISABILITIES AT FAIR WAGES. OT AND ENTREPRENEURSHIP 103 Question 5: Are you satisfied with the current options at the farmers market? Question 5 83% YES No 17% 39/47 PERSONS INDICATED BEING SATISFIED WITH OPTIONS AVAILABLE AT THE FARMERS MARKETS. 8/47 PERSONS INDICATED NOT BEING SATISIFIED WITH CURRENT OPTIONS AT THE FARMERS MARKETS. Yes 83% RESULTS Results from preliminary data collected from surveying 47 consumers at five farmers markets in Johnson County during the month of June 2018 indicated that: Consumers at farmers markets value where they purchase their produce and flowers, seeking to support local farms and businesses. Majority of consumers that value farm fresh produce and flowers are willing to travel to local farms to purchase products. Most consumers value supporting businesses that demonstrate philanthropic missions, including addressing food insecurity in Johnson County. Consumers value knowing specific social and philanthropic missions of businesses, influencing their purchasing practices. Consumers reflect literature, demonstrating overwhelmingly positive public views on supporting businesses that employ people with disabilities at fair wages. Majority of consumers attending the farmers markets are satisfied with current options for produce and flowers available. The target consumer market indicates that, while consumers are supportive of local business initiatives and philanthropic efforts, the current fresh flower and produce market is likely saturated in Johnson County with no overwhelming, unidentified product need indicated. OT AND ENTREPRENEURSHIP 104 Appendix F Bed and Breakfast Name Brick Street Inn Buck Creek Farm Nestle Inn Location Average Cost $ Per Night 189-229 150-300 169-289 ADA Accessibility Yes Limited No 139-159 No Fortville Columbus Indianapolis Indianapolis Indianapolis Speedway Columbus Nashville Nashville Nashville Nashville Nashville Number of Rooms 8 2 (3 BD suite) 6 (all private baths) 3 (2 - 1 BD suites) 3 5 7 7 10 6 4 7 23 4 6 5 Zionsville Indianapolis Indianapolis Harney House Inn Indianapolis Ivy House Inn at Irwin Gardens Looking Glass Inn Old Northside Stone Soup Inn Speedway Legacy Ruddick Nugent Allison House Artists Colony Oak Haven Lil Black Bear Brown County Getaways Yellowwood Rawhide Ranch Cabins & Candlelight Big Locust Farm Ashley-Drake Historic Inn Flying Frog Inn Corner at Broadway Acorn Ridge 145-165 185-300 109-149 135-215 89-179 125-? 94-134 125-195 92-195 75-215 119-199 200-350 No Limited No No No No No Yes Yes Limited Yes Yes Nashville Nashville Colfax 4 14 2 150-250 85-139 179-229 Yes No No Paoli Franklin 3 4 75-95 100-115 No No Franklin Greenwood Morgantown 4 7 4 Unlisted 400-500 ~125 No No No OT AND ENTREPRENEURSHIP 105 Appendix G Steps for Establishing a Nonprofit Business in Indiana 1. File with Indiana Secretary of State. a. Determine business name is distinguishable from others by completing a name availability check. File an application to reserve the name for 120 days or file documents to organize business under name. b. Register and create INBiz account (Access Indiana Account) to file with the Secretary of State. (INBiz.in.gov) 2. File for an Employer Identification Number (EIN) (aka Federal Tax Identification Number). https://www.irs.gov/businesses/small-businesses-self-employed/apply-for-anemployer-identification-number-ein-online This application process should be completed by the true principal officer/owner. The IRS will assume this individual to be the true responsible party, meaning the entity is responsible for controlling, managing, and directing the applicant entity and disposition of its funds and assets. 3. File for incorporation via Articles of Incorporation and Bylaws at the state and federal levels. (This officially marks beginning of corporation). Filing may be done on-line via INBiz portal. Access to documents for paper business forms located: https://www.in.gov/sos/business/2426.htm# a. Articles of Incorporation must include following: i. Name/address of Registered Agent 1. Cannot have P.O. Box address 2. Business cannot serve as own registered agent ii. Federal tax exemption: purposed clause and dissolution of assets provision iii. IC 23-17-3-2 iv. IC 23-17-22-5 b. Filing fee: $30 (Secretary of State) 4. File for tax exempt status with Internal Revenue Service (IRS). a. Form 1023-series application (I-XI) b. Form 8718 (User Fee for Exempt Organization Determination Letter Request) and user fee (check or money order payable to United States Treasury) $600 5. File for tax exempt status with Indiana Department of Revenue. Use INBiz portal. a. Application of Form NP-20A, Nonprofit Application for Sales Tax Exemption (<120 days after organizations formation). b. Include copy of federal nonprofit status determination letter from IRS with NP-20A if available. c. File annual report Form NP-20 with the department on or before the 15th day of the 5th month following the close of the taxable year. OT AND ENTREPRENEURSHIP 106 d. Complete Business Tax Application (BT-1) online. e. File business entity report annually. Due the month the corporation is incorporated. Fee: $10 6. File with Department of Workforce Development (DWD). Use INBiz portal. a. Must access DWD with each new hire employee completed. 7. File for local tax exempt status. (If necessary) 8. Determine if Need for solicitation license or Form 990 9. File a Certificate of Assumed Business Name with county recorder and Secretary of State (IC 23-15-1-1) to have business use name other than official name. 10. File business entity reports via INBiz portal (nonprofits required to file annually $10.00 filing fee). Access copies of certificates and renew certificates via website. 11. Use INBiz portal to manage any changes of the following: Articles of Amendment, Change of Registered Agent, Change of Registered Office, Change of Officer, or Change of Principal Address. If appropriate, register a trademark or service mark for the business to protect identification and symbols used to distinguish goods and services. Use INBiz portal to complete filing. OT AND ENTREPRENEURSHIP 107 Appendix H NONPROFIT CORPORATION AND BUSINESS LAW References for Indiana Business Law and Related Business Services Documents Nonprofit Corporation formation: must file Articles of Incorporation (see drafted Articles of Incorporation and printed, blank templates) o http://www.in.gov/sos/business/2428.htm o http://iga.in.gov/legislative/laws/2018/ic/titles/001 Nonprofit Corporation Business Forms o Located and may be filed on-line via INBiz Portal account (refer to Steps for Establishing a Nonprofit Business in Indiana o https://secure.in.gov/sos/business/2426.htm Indiana Department of Revenue Services o Addresses various taxes required when registering/operating a new business o https://www.in.gov/dor/3744.htm Internal Revenue Service: Required to obtain an EIN # o https://www.irs.gov/ Department of Workforce Development: Guides responsibilities and requirements of business owners with employees, including mandatory state and federal requirements, OSHA, etc. o https://www.in.gov/dwd/ Local Prospective Business Counsel Justia website: Business lawyers, profiles, years of experience, specializations, potential free consultation offered o https://www.justia.com/lawyers/business-law/indiana/johnsoncounty Cornell University Law School search engine: profile/website links o https://lawyers.law.cornell.edu/lawyers/businesslaw/indiana/johnson-county OT AND ENTREPRENEURSHIP 108 Appendix I ARTICLES OF INCORPORATION OF JC TRADING POST, INC. The undersigned, desiring to form a Corporation (hereinafter referred to as the Corporation) pursuant to the provisions of the Indiana Nonprofit Corporation Act of 1991 (hereinafter referred to as the Act), execute the following Articles of Incorporation: ARTICLE I Name and Location Section 1.1. Name. The name of the Corporation shall be JC Trading Post, Inc. Section 1.2. Location. The place in the state where the principle office of the Corporation is to be located at _________________ in the city of ______________, Johnson County, Indiana _____. ARTICLE II Statement of Purpose Section 2.1. Statement of Purpose. The Corporation shall be organized and operated at all times exclusively for charitable, religious, educational, literary, scientific and other purposes, the making of distributions to organizations that qualify as exempt organizations described in section 501(c)(3) of the Internal Revenue Code, or corresponding provisions of any subsequent federal tax code. (a) JC Trading Post, Inc. is organized exclusively for public, charitable purposes to create opportunities and maximize potential of youth and adults with disabilities by providing an inclusive, supportive, integrated, community work environment. ARTICLE III Type of Corporation and Purpose Section 3.1. Nonprofit Corporation and Purpose. (a) The Corporation is organized and operated exclusively as a public benefit corporation for public, charitable purposes. No net earnings of the Corporation shall inure to the benefit of any member, trustee, director, officer, or other private person, except that the Corporation shall be authorized and empowered to pay reasonable compensation for services rendered and to make payments and distributions in furtherance of the purposes set forth in Section 2.1 of these Articles. (b) No substantial part of the activities of the Corporation shall be the carrying on of propaganda, or otherwise attempting to influence legislation, and the Corporation shall not participate in, or intervene in (including the publishing or distribution of statements) any political campaign on behalf of or in opposition to any candidate for public office. OT AND ENTREPRENEURSHIP 109 (c) Notwithstanding any other provision of these articles, the Corporation shall not carry on any other activities not permitted to be carried on: i. By a corporation exempt from federal income tax under section 501(c)(3) of the Internal Revenue Code, or the corresponding section of any future federal tax code, or ii. By a corporation, contributions to which are deductible under section 170(c)(2) of the Internal Revenue Code, or section 2522(a)(2) of the Code, or the corresponding sections of any future federal tax code. ARTICLE IV Registered Agent and E-mail Address Section 4.1. Registered Agent. The name and street address of the Corporations registered agent and registered office for service of process are _______________, _________,__________, Indiana ____. Section 4.2. E-mail Address. The e-mail address of the registered agent at which the registered agent will accept electronic service of process is as follows: ___________________________. ARTICLE V - Members Section 5.1. Members. The Corporation shall have no members. ARTICLE VI Board of Directors Section 6.1. Qualifications. Membership on the Corporations Board of Directors shall be governed by these Articles of Incorporation and the Corporations Bylaws. Each director shall either reside or be employed in the State of Indiana and shall have such qualifications that may be specified from time to time in the Bylaws of the Corporation or required by law. Section 6.2. Number. The exact number of directors shall be specified from time to time in the Bylaws of the Corporation. The number of directors shall not be less than three (3) members, according to IC 23-17-12-3. Section 6.3. Name and Post Office Addresses of Directors. The names and post office addresses of the members of the Board of Directors that serve as the board members at the time of the adoption of the Articles of Incorporation are as follows: Name Post Office Address Brittany Meyers 1099 Coventry Ct. Apt 1101 Greenwood, IN 46142 Thelma Slisher 3760 North 75 West Franklin, IN 46131 OT AND ENTREPRENEURSHIP Kristina Watkins 110 864 Revere Ct Greenwood, IN 46142 Section 6.4. Bylaws. The Board of Directors shall have the power to adopt and amend the Bylaws of the Corporation, which may contain other provisions consistent with the laws of the State of Indiana, for the regulation and management of the affairs of the Corporation. ARTICLE VII Indemnification Section 7.1. Indemnification. The Corporation does indemnify any directors, officers, employees, and incorporators of the Corporation from any liability regarding the Corporation, including the affairs, debts or obligations of the Corporation in any nature whatsoever, nor shall any of the property of assets of any directors, officers, employees, and incorporators be subject to the payment of the debts or obligations of the Corporation, unless the person fraudulently and intentionally violated the law and/or maliciously conducted acts to damage and/or defraud the Corporation, or as otherwise provided under applicable statute. ARTICLE VIII - Other Provisions Section 8.1. Bylaws. Other provisions for the regulation of the affairs of the Corporation shall be set forth in the Bylaws. ARTICLE IX Duration and Dissolution Distribution of Assets Section 9.1. Duration. (a) The duration of the Corporation shall be perpetual until dissolution. (b) In the event the Corporation shall at any time be a private foundation within the meaning of Section 509(a) of the Code, then: i. The Corporation will distribute its income for each tax year at such time and in such manner as not to become subject to the tax on undistributed income imposed by section 4942 of the Code, or the corresponding section of any future federal tax code. ii. The Corporation will not engage in any act of self-dealing as defined in section 494l(d) of the Code, or the corresponding section of any future federal tax code. iii. The Corporation will not retain any excess business holdings as defined in section 4943(c) of the Code, or the corresponding section of any future federal tax code. iv. The Corporation will not make any investment in such manner as to subject it to the tax under section 4944 of the Code, or the corresponding section of any future federal tax code. OT AND ENTREPRENEURSHIP v. 111 The Corporation will not make any taxable expenditures as defined in section 4945(d) of the Code, or the corresponding section of any future federal tax code. Section 9.2. Dissolution Distribution of Assets. (a) Upon the dissolution of the Corporation, the Board of Directors, after paying or making provision for the payment of all the liabilities of the Corporation, shall turn over all of the assets of the Corporation, subject to any contractual or legal requirement, to one or more other organizations that have been selected by the Board of Directors that are organized and operated for purposes substantially the same as those of the Corporation and that are described in Section 501(c)(3) of the Internal Revenue Code, or the corresponding section of any future federal tax code, or shall be distributed to the federal government, or to a state or local government, for a public purpose. (b) Any such assets not so disposed of shall be disposed of by a Court of Competent Jurisdiction of the county in which the principal office of the corporation is then located, exclusively for such purposes or to such organization or organizations, as said Court shall determine, which are organized and operated exclusively for such purposes. In witness whereof, the undersigned incorporators of said Corporation executes this document, and verifies subject to penalties of perjury, that the facts contained herein are true, this ____ day of _________, 20___. Signature Printed This instrument was prepared by ______________________________, _____________________, ____________________, _______________, Indiana _______. OT AND ENTREPRENEURSHIP 112 Appendix J JC TRADING POST, INC. BYLAWS ARTICLE I NAME Section 1 Name: The name of the Corporation shall be JC Trading Post, Inc. It shall be a nonprofit organization incorporated under the laws of the State of Indiana. ARTICLE II PURPOSE Section 1 Purpose: JC Trading Post, Inc. is organized exclusively for public, charitable purposes to provide supported, community-based employment and pre-vocational skills to youth and adults with intellectual and developmental disabilities (I/DD) to increase social participation, occupational justice (i.e. opportunity to participate in meaningful activities), community inclusivity, personal and professional health and well-being. Section 2 Mission: To create opportunities and maximize potential of youth and adults with disabilities by providing an inclusive, supportive, integrated, community work environment. Section 3 Vision: To promote acceptance for people with disabilities as capable individuals by supporting their ability for meaningful contribution, participation, and purpose as active members in the community. ARTICLE III MEMBERS Section 1 Members: The JC Trading Post, Inc. shall not have members. ARTICLE IV BOARD OF DIRECTORS Section 1 Board role and size: JC Trading Post, Inc. shall have a Board of Directors consisting of not less than three (3) members as indicated in IC 23-17-12-3 and will not exceed ten (10) members. The number of members on the Board of Directors may adjusted in accordance with these bylaws. Section 2 Duties: The business and affairs of the Corporation shall be managed by the Board of Directors, with overall policy, direction, and delegation of responsibilities and operations of the Corporation to staff and committees determined by the board members. Section 3 Terms of office and qualifications: All board members, including the Executive Committee, except for the Executive Director, shall serve two-year terms, but are eligible for reelection by the Board of Directors at its annual meeting according to term year. Each board member shall hold office as long as he/she meets the qualifications to hold office, and until the term of his/her duly elected successor shall begin, or until resignation, or removal. The Executive Director shall serve at the discretion of the Board of Directors. OT AND ENTREPRENEURSHIP 113 Section 4 Board elections and nominations: New board members and current board members, including officers on the Executive Committee, shall be elected or re-elected by a majority vote of board members at the annual meeting, upon the year that board members are to be appointed or re-appointed. Nominations for new board members and current board members, including officers on the Executive Committee, shall be submitted to the Secretary prior to the annual meeting being held. Section 5 Election procedures: Officers and board members will be elected by a simple majority of members of the board present at the annual meeting. Prior to election during the annual meeting, nominations must be submitted to the Secretary with acceptance of nomination from appointed nominee. Section 6 Vacancies: Vacancies in the offices of Vice President, Secretary, or Treasurer may be filled for the balance of a non-expired term through appointment by the Board of Directors with two-thirds (2/3) vote. Vacancies in the office of President shall be filled by succession of the Vice President. Section 7 Resignation, termination, and absences: Any board member may resign by filing a written resignation with the Secretary. Resignation shall not relieve a board member of unpaid dues, or other charges previously accrued. Any board member, including an officer from the Executive Committee, can have their officer role terminated for just cause of significant harm to the organization by a two-thirds (2/3) vote of the Board of Directors. Any board member to be removed shall be advised in writing thirty (30) days in advance of such action or vote and shall have the right to be present and provide pertinent evidence or information for decision. Section 8 Officers and duties: Four officers serve as the board members of the Executive Committee, along with the Executive Director of JC Trading Post, Inc. consisting of the President, Vice President, Secretary, and Treasurer. Duties of officers shall include, but not necessarily be limited to the following: a. President 1. Preside at all meetings of the Board of Directors and the Executive Committee, 2. Convene regularly scheduled board meetings, 3. Arrange for other members of the Executive Committee to preside at each meeting in the following order: Vice President, Secretary, Treasurer, 4. Manage and supervise all the affairs of the Corporation, 5. Responsible for implementation of policies and procedures established by the Board of Directors, 6. Shall perform all the usual duties of the Chief Executive Officer (CEO) of the Corporation and such other duties as the Board of Directors may prescribe. b. Vice President 1. Assist the President in discharging duties of that office, 2. In the absence of the President, shall perform the duties of President, 3. Chair committees on special subjects as designated by the Board of Directors, OT AND ENTREPRENEURSHIP 114 4. Shall have other powers and duties as these bylaws or the Board of Directors may prescribe. c. Secretary 1. Responsible for keeping records of board actions, including overseeing the recording of the minutes of the meetings of Board of Directors and members, 2. Authenticating and maintaining the books and records of the Corporation, except for books of account and financial records, 3. Sending out meeting announcements, 4. Distributing copies of meeting minutes and the agenda to each board member during meetings of the Board of Directors, 5. Shall perform the usual duties of such a position and such other duties as the Board of Directors or President may prescribe. d. Treasurer 1. Deposit or cause to be deposited the funds of the Corporation with such depositaries as the Board of Directors shall designate, 2. Reports the financial budget of the Corporation at each board meeting, 3. Serves to assist in preparation of financial budget of the Corporation, 4. Prepare and maintain correct, complete records of account showing the financial condition of the Corporation, 5. Procure financial information to board members and the public, 6. Perform all duties pertaining to the office of treasurer as these bylaws or the Board of Directors may prescribe. e. Officers 1. May be appointed and elected to sit as board members on the Board of Directors, 2. Performing all duties as these bylaws, Articles of Incorporation, and Executive Committee may prescribe, 3. May be elected to assist other officers who shall have powers and duties as the officers whom they are elected to assist shall specify and delegate to them, or other powers and duties as the bylaws or Board of Directors may prescribe. Section 9 Compensation of Directors: No net earnings of the Corporation shall inure to the benefit of any board member, board director, officer, or other private person, except that the Corporation shall be authorized and empowered to pay reasonable compensation for services rendered and to make payments and distributions in furtherance of the purposes set forth in section 501(c)(3) of the Internal Revenue Code, or corresponding provisions of any subsequent federal tax code. ARTICLE IV MEETINGS OF DIRECTORS Section 1 Annual meetings of Directors: Annual meetings of the Board of Directors, Executive Committee, and Executive Director shall be held to preside over annual elections of terms of Board of Directors and Executive Committee, and be determined by the Board of Directors. Any other business which may be brought before the meeting may be considered for the annual meeting after elections have been completed. OT AND ENTREPRENEURSHIP 115 Section 2 Other regular meetings of Directors: Other regular meetings of the Board of Directors may be held upon resolution of agreement of the Board, and held whenever convenient for the Board of Directors. If a special, or emergency, board meeting may need to be called, either the President may address a meeting with permission of the Executive Committee, or by a majority vote of action from the Board of Directors. Section 3 Quorum: A quorum must be attended by at least one-third (1/3) of board members for business transactions to take place and motions to pass. ARTICLE V COMMITTEES Section 1 Committee formation: The Board of Directors may create and dissolve committees as needed, such as fundraising, data collection, public relations, advertising, etc. The board chair appoints all committee chairs. Section 2 Executive Committee: Except for the power to amend the Articles of Incorporation and bylaws, the Executive Committee shall have all the powers and authority of the Board of Directors in the intervals between meetings of the Board of Directors, and is subject to the direction and control of the full board. ARTICLE VI DIRECTOR AND STAFF Section 1 Executive Director: The Executive Director is hired by the Board of Directors. The Executive Director has day-to-day responsibilities for the organization, including carrying out the organizations goals and policies. The Executive Director will attend all board meetings, is responsible for bylaw revisions, reports on the progress of the organization, answers questions of the board members, and carries out the duties described in the job description. The Board of Directors can designate other duties as necessary. ARTICLE VII INDEMNIFICATION Section 1 Indemnification: The Corporation does indemnify any directors, officers, employees, and incorporators of the Corporation from any liability regarding the Corporation, including the affairs, debts or obligations of the Corporation in any nature whatsoever, nor shall any of the property of assets of any directors, officers, employees, and incorporators be subject to the payment of the debts or obligations of the Corporation, unless the person fraudulently and intentionally violated the law and/or maliciously conducted acts to damage and/or defraud the Corporation, or as otherwise provided under applicable statute. ARTICLE VIII - POLICIES AND PROCEDURES Section 1 Policies and procedures: The Board of Directors shall approve and adopt policies and procedures for the operation of the Corporation and management of its component funds as required by law and/or determined from time to time by the Board. All policies and procedures shall be consistent with the Federal tax laws applicable to public charities and any state law requirements. Policies and procedures shall be reviewed periodically and may be amended from time to by Board action. The Board may consult with outside advisors including accountants and attorneys as necessary to ensure compliance. OT AND ENTREPRENEURSHIP 116 Section 2 Conflicts of interest: The Board of Directors shall approve and adopt a Conflict of Interest Policy consistent with the requirements of the Internal Revenue Code as applicable to charitable organizations. The Conflict of Interest Policy shall apply to all Board members, officers, employees, volunteers, agents, and contractors of the Corporation. Board members shall be required to provide an annual acknowledgment and disclosure statement with respect to conflicts and potential conflicts. Section 3 Execution of contracts: Unless otherwise ordered by the Board of Directors, all written contracts and other documents entered into by the Corporation shall be executed on behalf of the Corporation by the President and Executive Director, and, if required, attested by the Secretary. ARTICLE IX AMENDMENTS Section 1 Proposed amendments: These bylaws and Articles of Incorporation may be amended when necessary by two-thirds (2/3) majority of the Board of Directors, and cannot be addressed exclusively by the Executive Committee. Proposed amendments must be formally written and submitted to the Secretary prior to the next meeting. The Secretary shall send out the proposed amendments with the regular board announcements prior to the next Board of Directors meeting. ARTICLE X DISSOLUTION OF THE ORGANIZATION Section 1 Dissolution: Upon the dissolution of JC Trading Post, Inc., the Board of Directors shall, after paying or making provision for the payment of all of the liabilities of the organization, dispose of all of the assets of JC Trading Post, Inc. in such manner, or to such organizations organized and operated exclusively for the benefit of persons with intellectual and developmental disabilities in the most liberal interpretation for charitable, educational, or scientific purposes as shall at the time qualify an exempt organization under section 501(c)3 of the Internal Revenue Code, as the Board of Directors shall determine. Any such assets not so disposed of shall be disposed of by the Court of Common Pleas of the County in which JC Trading Post, Inc. is then located, exclusively for such or to such organizations, as said Court shall determine, which are organized and operated for such purposes. CERTIFICATION These bylaws were approved, passed, and adopted at a meeting of the Board of Directors by a _______ vote on ____ day of _____________, _______. _______________________________________________ Chair, Board of Directors of JC Trading Post, Inc. Attest: _______________________________________________ Secretary, Board of Directors of JC Trading Post, Inc. OT AND ENTREPRENEURSHIP 117 Appendix K JC Trading Post, Inc. A Place to Hang Your Hat and Boots: A Bed & Breakfast with a Special Touch Business Plan Prepared by Brittany Meyers, OTS Contact Information Thelma Slisher thelmas@jccf.org 317-738-2213 X 105 www.jctradingpost.org Bargersville, IN OT AND ENTREPRENEURSHIP 118 OT AND ENTREPRENEURSHIP 119 Table of Contents 1.0 Executive Summary .............................................................................................. 120 1.1 Objectives .......................................................................................................... 121 1.2 Mission, Vision, and Values ............................................................................... 121 1.3 Keys to Success ................................................................................................ 122 2.0 Corporation Summary ........................................................................................... 122 2.1 Corporation Ownership ...................................................................................... 123 3.0 Services ................................................................................................................ 123 4.0 Market Analysis Summary ..................................................................................... 123 4.1 Market Segmentation ......................................................................................... 123 Table: Market Analysis ......................................................................................... 124 4.2 Target Market Segment Strategy ....................................................................... 124 4.2.1 Market Needs .............................................................................................. 124 5.0 Strategy and Implementation Summary ................................................................ 125 5.1 Competitive Edge .............................................................................................. 125 5.2 Sales Strategy ................................................................................................... 125 5.2.1 Sales Forecast ............................................................................................ 125 Table: Sales Forecast ....................................................................................... 126 6.0 Management Summary ......................................................................................... 126 6.1 Personnel Plan .................................................................................................. 126 Table: Personnel .................................................................................................. 126 7.0 Financial Plan ........................................................................................................ 127 7.1 Break-even Analysis .......................................................................................... 127 Table: Break-even Analysis ................................................................................. 127 7.2 Projected Profit and Loss ................................................................................... 127 This table is incomplete with projected information yet to be determined. ........... 127 Table: Profit and Loss .......................................................................................... 127 7.3 Projected Cash Flow .......................................................................................... 128 Table: Cash Flow ................................................................................................. 128 7.4 Projected Balance Sheet ................................................................................... 129 Table: Balance Sheet ........................................................................................... 129 7.5 Business Ratios ................................................................................................. 130 Table: Ratios ........................................................................................................ 130 Table: Sales Forecast ................................................................................................. 131 Table: Personnel ......................................................................................................... 131 Table: General Assumptions ....................................................................................... 131 Table: Profit and Loss ................................................................................................. 132 Table: Cash Flow ........................................................................................................ 132 Table: Balance Sheet .................................................................................................. 133 OT AND ENTREPRENEURSHIP 120 1.0 Executive Summary The Company JC Trading Post, Inc. is a start-up nonprofit corporation and social enterprise business developed to create opportunities and maximize potential of youth and adults with disabilities by providing an inclusive, supportive, integrated, community work environment. The corporation is founded upon the belief that meaningful employment and community connection provides meaning, purpose, and increases quality of life for people of all abilities. JC Trading Post, Inc. will implement its first phase by operating a ranch-style bed and breakfast in Bargersville, IN. The bed and breakfast is designed to provide guests with reasonable, affordable, accessible accommodations that allow our guests to feel at home. We value community, diversity, opportunity, acceptance, and relationships. We believe in providing an inclusive environment where all of our guests belong. After establishing and solidifying our first phase as a bed and breakfast, we will diverse into other ventures to ensure a steady flow of patrons (tourists and locals) through its doors, providing a variety of handmade goods through operating a general store. Our Services JC Trading Post, Inc. will be a ranch-style bed and breakfast that is designed to promote accessibility and inclusion for all our guests. We plan to create a warm, family-friendly bed and breakfast that proudly offers zero entry spaces; open, spacious guest suites with accessible bathrooms; a sensory garden; and a Snoezelen sensory room. We seek to provide and support accommodations for all of our guests, partnering with other community agencies and businesses to access additional accommodations as needed. Our cozy bed and breakfast offers four spacious rental suites with accessible, attached, private bathrooms to provide maximum comfort and relaxation for our guests. We serve breakfast daily to all guests, who may select if they would enjoy the company of our innkeeper, staff, and fellow guests while eating at our community-style farm table, or would prefer to enjoy their meals while relaxing in their private suites. Future plans project development of a general store where handmade goods are produced and sold to interested consumers. The Market The JC Trading Post, Inc. will provide quality, affordable, accessible lodging for guests interested in exploring the Johnson County agricultural community, agritourism, and surrounding beautiful, serene agrarian venues. This area, with the upcoming development of I-69 from Indianapolis to Evansville, is quickly developing OT AND ENTREPRENEURSHIP 121 and expanding with local businesses while preserving its agrarian roots. There are currently no local lodging opportunities available within the Bargersville community and no ADA accessible or family-friendly bed and breakfasts in Johnson County. Financial Considerations A comprehensive financial plan for JC Trading Post, Inc. is still being developed. Consideration for a small business administration (SBA) loan and bank mortgages are being explored. We are assuming some initial start-up capital for building and operating expenses. We are currently developing fundraising and crowdfunding strategies to support the nonprofit corporation business venture, including an initial down payment to purchase land and build the site. 1.1 Objectives 1. Open JC Trading Post, Inc. as a fully-accessible bed and breakfast located in Johnson County, Indiana. 2. Demonstrate a minimum of 50% occupancy averaged throughout Year one. 3. Increase exposure and marketing using the internet and direct advertising within Johnson County, Indiana, and the United States. 4. Through incentives, packages, and increased exposure on the internet, we hope to increase occupancy by 15% after the first year. 1.2 Mission, Vision, and Values The mission of JC Trading Post, Inc. is to create opportunities and maximize potential of youth and adults with disabilities by providing an inclusive, supportive, integrated, community work environment. The organization is founded upon the belief that meaningful employment and community connection provides meaning, purpose, and increased quality of life for people of all abilities. The JC Trading Post, Inc. is a bed and breakfast that was born out of our vision to promote acceptance for people with disabilities as capable individuals by supporting their ability for meaningful contribution, participation, and purpose as active members in the community. We believe that meaningful employment and community connection provides meaning, purpose, and increased quality of life for people of all abilities. Our ranch-style bed and breakfast is designed to promote accessibility and inclusion for all our guests. We plan to create a warm, family-friendly bed and breakfast that proudly offers zero entry spaces; open, spacious guest suites with accessible bathrooms; a sensory garden; and a Snoezelen sensory room. We seek to provide OT AND ENTREPRENEURSHIP 122 and support accommodations for all of our guests, partnering with other community agencies and businesses to access additional accommodations as needed. The JC Trading Post guest will be served breakfast daily at a community-style farm table. We pride ourselves on growing produce and supporting farms within our local Johnson County agricultural community. Guests will have a unique experience sharing a family-style breakfast made with fresh, quality ingredients and foods. We seek to support special dietary accommodations so that all guests may enjoy a meal together. Our nonprofit corporation values the importance of community, belonging, diversity, acceptance, opportunity, and relationships. We strive to promote an atmosphere of inclusion, acceptance, and comfort for all of our guests. As our bed and breakfast becomes more established, we plan to expand our services to include the Trading Post general store. The general store will offer a variety of handmade goods that will be available to purchase during general store hours or from our website. Guests of JC Trading Post, Inc. will want to explore local businesses throughout the Bargersville and surrounding Johnson County area, taking advantage of the unique experiences agritourism has to offer. In addition to providing information about different locations for agritourism, wineries, breweries, and other events in the area, we plan to collaborate with tourism agencies and businesses throughout the local area. Through these community partnerships, we plan to offer packages and special rates with in-kind incentives for the cooperating merchants. 1.3 Keys to Success In order to succeed, the JC Trading Post, Inc. will strive to achieve the following goals: Position JC Trading Post, Inc. as the only bed and breakfast in Indiana that has fully accessible accommodations throughout our facilities. Build strong market position among the local community, wedding parties, and families and/or travelers seeking specific accommodations. Maintain sound financial management of the venture as the organization grows and expands. 2.0 Corporation Summary JC Trading Post, Inc. is a start-up nonprofit corporation and social enterprise business. After establishing and solidifying its first phase as a bed and breakfast, we will diverse into other ventures to ensure a steady flow of patrons (tourists and locals) through its doors, providing a variety of goods and services. OT AND ENTREPRENEURSHIP 123 2.1 Corporation Ownership The JC Trading Post, Inc. will be a nonprofit corporation, overseen by a Board of Directors to advise and manage the structure and finances of the nonprofit corporation and its business ventures. An Executive Director will run and manage programming and staff to maintain the bed and breakfast business. 3.0 Services JC Trading Post, Inc. is a ranch-style bed and breakfast and general store in Bargersville, IN. JC Trading Post, Inc. is designed to provide guests with reasonable, accessible accommodations for people and families of all abilities. We value community, diversity, opportunity, acceptance, and relationships. We believe in providing an inclusive environment where all of our guests belong. 4.0 Market Analysis Summary The JC Trading Post, Inc. will focus on quality, affordable, accessible lodging for guests interested in exploring the Johnson County agricultural community, agritourism, and surrounding beautiful, serene agrarian venues. This area, with the upcoming development of I-69 from Indianapolis to Evansville, is quickly developing and expanding with local businesses while preserving its agrarian roots. There are currently no local lodging opportunities available within the Bargersville community. Our most important groups of potential customers are those who traditionally choose the bed and breakfast climate over the more traditional or popular surroundings of hotels, motels, and AirBnBs, and those who may opt out of traveling because they are unable to locate lodging that meets their necessary accommodation standards. We recognize and value the importance of these needs, and have designed a place to hang your hat and boots, a home away from home. 4.1 Market Segmentation Our major customer segments are tourists who are seeking specialized accommodations within the Johnson County area, and patrons who seek the cozy, specialized environment of a bed and breakfast while attending local area events. The table below outlines the total market potential for our business. Projections for rental unit price percentages within the competition market are yet to be determined. Bed and breakfast inn competitors in the Johnson County and surrounding communities average cost of lodging accommodations ranging from $129-198 per night. Within Johnson County, lodging accommodations range from $100-115 per night or requires the entire home to be rented at $400-500 per night. No bed and breakfast lodging accommodations in Johnson County are ADA accessible. OT AND ENTREPRENEURSHIP 124 Table: Market Analysis Market Analysis 2013 Potential Customers 2014 2015 2016 2017 Growth CAGR Tourists % % Local Patrons % % Total % % 4.2 Target Market Segment Strategy History of competing bed and breakfasts in Johnson County demonstrates that money can be made in this area simply by existing. We continue to see that Johnson County, in general, has a growing population with expanding agritourism and other events generating tourists to travel to the area. We plan to aggressively pursue marketing and community business partnerships to promote our bed and breakfast, advertising as a premiere, accessible, inclusive bed and breakfast and lodging accommodation that is suitable for all people. Subscriptions to various Web services will provide international exposure for nominal annual fees. 4.2.1 Market Needs Bed and breakfast customers seek relaxation, fun and stress-reduction management while on vacation, preferring accommodations in a cozy, family environment. These patrons are sociable, typically enjoying meeting and interacting with new people. Guests become temporary members of a larger family, allowing them to participate and share in the richness of a community, while still allowing whatever degree of privacy may be preferred. Travelers with disabilities and their families seek lodging accommodations that also provide relaxation, fun and stress-reduction management while on vacation. However, often these travelers are restricted to lodging that is ill-equipped to support additional accommodations, making traveling difficult. Most bed and breakfasts are unable to support customers that have disabilities, making their lodging not accessible by ADA standards. A variety of settings available in our bed and breakfast are situated to enable customers, whether individuals, families, or groups, to locate the perfect setting to support the mood or activity one is seeking. We have designed specific accommodations including a sensory garden and Snoezelen sensory room, to support our employees and guests that have specialized sensory needs. JC Trading Post, Inc. is designed to support all of the necessary facilities and accommodations to attract customers from all markets. OT AND ENTREPRENEURSHIP 125 5.0 Strategy and Implementation Summary We are committed to creating a wonderful lodging accommodation from the very beginning at JC Trading Post, Inc. As a brand new, innovative business and nonprofit corporation, we view all of our time and money spent developing a brandnew facility with amenities and accommodations that provides accessible lodging for all customers as a return on our investment. Our bed and breakfast employs people with and without disabilities. We implement natural support strategies and develop individualized employment plans to help all our employees develop personally and professionally; we recognize that each employee has unique needs and strive to provide a supportive work and community environment that allows for their success. We strive to provide lodging and amenities that are designed to accommodate the needs of our guests, recognizing that all people, whether it is our guests or our employees are happiest and most successful when their environment supports their needs, With the right exposure, we believe that an un-tapped market of vacationers can be enticed to JC Trading Post, Inc. Membership in various bed and breakfast, traveling, and lodging sites allows for promoting our unique lodging accommodations and amenities. Community, business, and event partnerships, including travel agencies, can help promote our bed and breakfast to an additional customer market. 5.1 Competitive Edge We have a critical competitive edge: there is no known competitor that can offer the convenience and facility accommodations that JC Trading Post, Inc. offers. Through collaboration with our Board of Directors and local community businesses and partnerships, we know how to create a climate that customers seek when shopping for bed and breakfast lodging. 5.2 Sales Strategy JC Trading Post, Inc. will advertise and book its rooms directly to customers or through travel agencies, which can be booked via our website www.jctradingpost.org. All reservations will be managed by the Executive Director or trained staff personnel. 5.2.1 Sales Forecast Current sales are forecasted based on the average cost of bed and breakfast lodging rates in Johnson County and surrounding areas assuming specific occupancy: OT AND ENTREPRENEURSHIP 126 Occupancy Rate - 50% Larger Unit (2)- $198 per unit/per night Smaller Unit (2)- $129 per unit/per night Table: Sales Forecast Sales Forecast Sales Larger Units Smaller Units Total Sales Direct Cost of Sales Larger Unit Smaller Unit Subtotal Direct Cost of Sales 2020 2021 2022 $71,280 $47,988 $119,268 $ $ $ $ $ $ 2020 2021 2022 $ $ $ $ $ $ $ $ $ 6.0 Management Summary JC Trading Post, Inc. will operate as a nonprofit corporation business with an Innkeeper living on-site, working closely with the Executive Director. Salary for the first year of operation is currently unknown, but will be indicated on the Personnel table. 6.1 Personnel Plan The Innkeeper will reside on the property while working closely with the Executive Director to perform necessary day-to-day management tasks. Additional staff will be hired and trained to help implement day-to-day operations at the bed and breakfast. The table below outlines a template for projected personnel plan yet to be determined for JC Trading Post, Inc. Table: Personnel Personnel Plan Executive Director Innkeeper Staff 1 Staff 2 Total People Total Payroll 2020 $ $ $ $ 4 2021 $ $ $ $ 4 2022 $ $ $ $ 4 $ $ $ OT AND ENTREPRENEURSHIP 127 7.0 Financial Plan A comprehensive financial plan for JC Trading Post, Inc. is still being developed. Consideration for a small business administration (SBA) loan and bank mortgages are being explored. We are assuming some initial start-up capital for building and operating expenses and are currently developing fundraising and crowdfunding strategies to support the nonprofit corporation business venture. 7.1 Break-even Analysis We estimate average monthly earnings to be projected at ~$9939 from occupancy based on 50% for two large units and two small units. Fixed average costs for expenses plus interest payments are yet to be determined. Peak and off-season will have significant impact on the monthly earnings. For the first three years, on-season revenues will offset off-season losses. As JC Trading Post, Inc. builds its market position among travelers and other local patrons, we anticipate projected growth with our off-season revenues. Further, a rate increase may be considered in future years due to inflation, competing markets, and continued area growth. Table: Break-even Analysis Break-even Analysis Monthly Revenue Break-even Assumptions: Average Percent Variable Cost Estimated Monthly Fixed Cost $ 0% $ 7.2 Projected Profit and Loss Below is JC Trading Post, Inc.s projected income statement for the next three years. As mentioned above, we recognize earnings are subject to seasonal fluctuations, but have projected a baseline occupancy assuming 50%. We believe that JC Trading Post, Inc.s market position among the local community will support the bed and breakfast business during the low season, and thus offset the negative impact of the season. This table is incomplete with projected information yet to be determined. Table: Profit and Loss OT AND ENTREPRENEURSHIP 128 Pro Forma Profit and Loss 2020 2021 2022 $119,268 $ $ $ $ $ $ $ $ $ $ $ $ % $ % $ % Payroll Sales and Marketing and Other Expenses Depreciation Insurance Telephone Security Duties & Subscriptions Mortgage Room/Housecleaning Groceries Payroll Taxes Other $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ Total Operating Expenses $ $ $ Profit Before Interest and Taxes EBITDA Interest Expense Taxes Incurred $ $ $ $ $ $ $ $ $ $ $ $ $ % $ % $ % Sales Direct Cost of Sales Other Total Cost of Sales Gross Margin Gross Margin % Expenses Net Profit Net Profit/Sales 7.3 Projected Cash Flow The table below outlines the projected cash flow yet to be determined for the bed and breakfast. Table: Cash Flow Pro Forma Cash Flow 2020 2021 2022 $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ Cash Received Cash from Operations Cash Sales Cash from Receivables Subtotal Cash from Operations Additional Cash Received Sales Tax, VAT, HST/GST Received New Current Borrowing New Other Liabilities (interest-free) New Long-term Liabilities Sales of Other Current Assets Sales of Long-term Assets OT AND ENTREPRENEURSHIP 129 New Investment Received Subtotal Cash Received $ $ $ $ $ $ 2020 2021 2022 $ $ $ $ $ $ $ $ $ Sales Tax, VAT, HST/GST Paid Out Principal Repayment of Current Borrowing Other Liabilities Principal Repayment Long-term Liabilities Principal Repayment Purchase Other Current Assets Purchase Long-term Assets Dividends Subtotal Cash Spent $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ Net Cash Flow Cash Balance $ $ $ $ $ $ Expenditures Expenditures from Operations Cash Spending Bill Payments Subtotal Spent on Operations Additional Cash Spent 7.4 Projected Balance Sheet The table below outlines the projected balance sheet of JC Trading Post, Inc. yet to be determined for Fiscal Year 2020-2022. Table: Balance Sheet Pro Forma Balance Sheet 2020 2021 2022 $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ 2020 2021 2022 Accounts Payable Current Borrowing Other Current Liabilities Subtotal Current Liabilities $ $ $ $ $ $ $ $ $ $ $ $ Long-term Liabilities Total Liabilities $ $ $ $ $ $ Paid-in Capital Retained Earnings $ $ $ $ $ $ Assets Current Assets Cash Accounts Receivable Other Current Assets Total Current Assets Long-term Assets Long-term Assets Accumulated Depreciation Total Long-term Assets Total Assets Liabilities and Capital Current Liabilities OT AND ENTREPRENEURSHIP 130 Earnings Total Capital Total Liabilities and Capital $ $ $ $ $ $ $ $ $ Net Worth $ $ $ 7.5 Business Ratios The following table provides projected industry information for Trading Post, Inc. based on the Standard Industry Classification (SIC) Index, 7011 Hotels and Motels, which includes bed and breakfast inns. Ratios are to be determined. Table: Ratios Ratio Analysis 2020 2021 2022 Industry Profile % % % % Accounts Receivable Other Current Assets Total Current Assets Long-term Assets Total Assets % % % % % % % % % % % % % % % % % % % % Current Liabilities Long-term Liabilities Total Liabilities Net Worth % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % 0 0 % % % 0 0 % % % 0 0 % % % 0 0 % % % Additional Ratios 2020 2021 2022 Net Profit Margin Return on Equity % % % % % % n.a n.a 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 n.a n.a n.a n.a n.a 0 0 0 0 0 0 n.a n.a Sales Growth Percent of Total Assets Percent of Sales Sales Gross Margin Selling, General & Administrative Expenses Advertising Expenses Profit Before Interest and Taxes Main Ratios Current Quick Total Debt to Total Assets Pre-tax Return on Net Worth Pre-tax Return on Assets Activity Ratios Accounts Receivable Turnover Collection Days Accounts Payable Turnover Payment Days Total Asset Turnover Debt Ratios Debt to Net Worth Current Liab. to Liab. OT AND ENTREPRENEURSHIP 131 Liquidity Ratios Net Working Capital Interest Coverage $ 0 $ 0 $ 0 n.a n.a 0 % 0 0 0 0 % 0 0 0 0 % 0 0 0 n.a n.a n.a n.a n.a Additional Ratios Assets to Sales Current Debt/Total Assets Acid Test Sales/Net Worth Dividend Payout Table: Sales Forecast Sales Forecast Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Larger Units $5,940 $5,940 $5,940 $5,940 $5,940 $5,940 $5,940 $5,940 $5,940 $5,940 $5,940 $5,940 Smaller Units $3,999 $3,999 $3,999 $3,999 $3,999 $3,999 $3,999 $3,999 $3,999 $3,999 $3,999 $3,999 Total Sales $9,939 $9,939 $9,939 $9,939 $9,939 $9,939 $9,939 $9,939 $9,939 $9,939 $9,939 $9,939 Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Larger Unit $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 Smaller Unit $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 Subtotal Direct Cost of Sales $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 Dec Sales Direct Cost of Sales Table: Personnel Personnel Plan Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Executive Director $ $ $ $ $ $ $ $ $ $ $ $ Innkeeper $ $ $ $ $ $ $ $ $ $ $ $ Staff 1 Staff 2 $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ Total People 4 4 4 4 4 4 4 4 4 4 4 4 Total Payroll $ $ $ $ $ $ $ $ $ $ $ $ Table: General Assumptions General Assumptions Plan Month Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec 1 2 3 4 5 6 7 8 9 10 11 12 OT AND ENTREPRENEURSHIP Current Interest Rate Long-term Interest Rate Tax Rate Other 132 % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % 0 0 0 0 0 0 0 0 0 0 0 0 Table: Profit and Loss Pro Forma Profit and Loss Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec $9,939 $9,939 $9,939 $9,939 $9,939 $9,939 $9,939 $9,939 $9,939 $9,939 $9,939 $9,939 Direct Cost of Sales $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 Other $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 Total Cost of Sales $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 Gross Margin $9,939 $9,939 $9,939 $9,939 $9,939 $9,939 $9,939 $9,939 $9,939 $9,939 $9,939 $9,939 Gross Margin % 100.00 % 100.00 % 100.00 % 100.00 % 100.00 % 100.00 % 100.00 % 100.00 % 100.00 % 100.00 % 100.00 % 100.00 % Payroll $ $ $ $ $ $ $ $ $ $ $ $ Sales and Marketing and Other Expenses Depreciation $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ Insurance $ $ $ $ $ $ $ $ $ $ $ $ Telephone $ $ $ $ $ $ $ $ $ $ $ $ Security $ $ $ $ $ $ $ $ $ $ $ $ Duties & Subscriptions Rent $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ Room/Housecleanin g Groceries $ $ $ $ $ $ $ $ $ $ $ $ Sales Expenses $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ Total Operating Expenses $ $ $ $ $ $ $ $ $ $ $ $ Profit Before Interest and Taxes EBITDA $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ Interest Expense $ $ $ $ $ $ $ $ $ $ $ $ Taxes Incurred $ $ $ $ $ $ $ $ $ $ $ $ Payroll Taxes Other % Net Profit $ $ $ $ $ $ $ $ $ $ $ $ Net Profit/Sales % % % % % % % % % % % % Table: Cash Flow OT AND ENTREPRENEURSHIP 133 Pro Forma Cash Flow Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ Cash Received Cash from Operations Cash Sales Cash from Receivables Subtotal Cash from Operations Additional Cash Received Sales Tax, VAT, HST/GST Received New Current Borrowing New Other Liabilities (interest-free) New Long-term Liabilities Sales of Other Current Assets Sales of Long-term Assets New Investment Received Subtotal Cash Received 0.00% Expenditures Expenditures from Operations Cash Spending Bill Payments Subtotal Spent on Operations Additional Cash Spent Sales Tax, VAT, HST/GST Paid Out Principal Repayment of Current Borrowing Other Liabilities Principal Repayment Long-term Liabilities Principal Repayment Purchase Other Current Assets Purchase Long-term Assets Dividends Subtotal Cash Spent Net Cash Flow Cash Balance Table: Balance Sheet Pro Forma Balance Sheet Assets Current Assets Cash Accounts Receivable Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ Starting Balances $ $ OT AND ENTREPRENEURSHIP Other Current Assets Total Current Assets 134 $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ Long-term Liabilities Total Liabilities $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ Paid-in Capital Retained Earnings Earnings Total Capital Total Liabilities and Capital $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ Net Worth $ $ $ $ $ $ $ $ $ $ $ $ $ Long-term Assets Long-term Assets Accumulated Depreciation Total Longterm Assets Total Assets Liabilities and Capital Current Liabilities Accounts Payable Current Borrowing Other Current Liabilities Subtotal Current Liabilities OT AND ENTREPRENEURSHIP 135 Appendix L Level of Attainment GOAL 1: Needs GOAL 2: Market Assessment Johnson Co research and employment services competitive analysis for products Johnson Co GOAL 3: Initiate business plan and nonprofit organization development Much More Than Expected +2 Report on gap, brochure, visual chart, develop brief audio visual presentation of DCE project with overview of gap and need for business model Generate report, outline strategies to develop social enterprise product, identify potential partnerships to collaborate social enterprise production Rough draft business plan with all components completed, present rough draft business plan to be reviewed by 3 business mentors, establish potential partnership with student or business owner for further business plan development More Than Expected +1 Report on gap, brochure, develop visual charts of projected employment gaps within Jo. Co. community Generate report, initiate identifying and outlining potential strategies to develop social enterprise product Rough draft business plan with components completed, present rough draft business plan to be reviewed by 3 business mentors Expected 0 Brief, structured report of current Johnson county employment service providers, projected gap of employment for young adults with IDD, and benefit of transition employment services Implement survey, collect projected Johnson Co consumer data, and generate report using primary and secondary market research to suggest proposal for social enterprise product Create initial rough draft business plan, with components of executive summary, initial start-up, overhead, staff, and projected expenses completed Less Than Expected -1 Structured report does not include one or more components listed Report of market research and competitive analysis complete, but does not include primary research (survey, questionnaire, and/or interviews) Initial rough draft business plan without any projected expenses completed Much Less Than Expected -2 Structured report of Johnson county not completed Report of market research and competitive analysis not completed for business Initial rough draft business plan does not have executive summary or projected OT AND ENTREPRENEURSHIP 136 plan expenses completed Level of Attainment GOAL 4: Conduct research on 501(c)(3) status and application GOAL 5: Initiate development life skills and employment training program GOAL 6: Develop initial structure nonprofit funding and recruitment Much More Than Expected +2 Nonprofit application and steps, business law info, locate prospective attorneys for business counsel Brief report, develop rough draft life skill prerequisite application, initiate rough draft individualized employment development plan Proposal, outline grant writing application steps, complete mock grant application More Than Expected +1 Nonprofit application and steps, outline references/steps for business law info Brief report, develop rough draft life skill prerequisite application Proposal, outline grant writing application steps Expected 0 Complete rough draft for nonprofit application, including articles of incorporation, and outline steps for filing Generate brief report of evidenced-based employment and social skills training strategies, outline plans for potential organization policies, procedures, and natural support program strategies Create brief proposal on strategies for community fundraising, crowd funding, grant funding, and identify 5 potential guarantors Less Than Expected -1 Complete rough draft for nonprofit application, including articles of incorporation Generate brief report of evidenced-based employment and social skills training strategies, no organization policy outlined Create brief proposal on strategies for community fundraising, crowd funding, and grant funding Much Less Than Expected -2 Nonprofit application rough draft incomplete or does not give instruction on how to complete Initiate brief report of evidenced-based employment and social skills training strategies Initiate proposal for fundraising, but do not complete OT AND ENTREPRENEURSHIP 137 Appendix M JC TRADING POST, INC. STRATEGIC PLAN JULY 2018 OT AND ENTREPRENEURSHIP 138 SOCIAL ENTERPRISE BUSINESS DETAILS Name: JC Trading Post, Inc. Address: TBD Business location: Bargersville, Indiana Web address: www.jctradingpost.org HISTORY AND PROFILE JC Trading Post, Inc. is a social enterprise business plan for a bed and breakfast in Bargersville, a small town in Johnson County, Indiana. The bed and breakfast was born out of a vision to create an alternative, sustainable business model that provides integrated, supported, community employment for adolescents and young adults with intellectual and developmental disabilities (I/DD) to promote meaningful employment, community connection, meaning, purpose, and increased quality of life. The concept to develop a social enterprise business originated from Thelma Slisher after running and implementing a successful basketball program for children with I/DD for over 10 years. Parents and family members of children with I/DD expressed concerns about their childrens future outcomes, including employment opportunities as they transitioned into adulthood. Concerned about a lack of available opportunities, Thelma recruited the University of Indianapolis School of Occupational Therapy to investigate employment opportunities in Johnson County with intentions to develop an alternative business model addressing employment for adolescents and young adults with I/DD. ABOUT THIS PLAN This strategic plan has been developed by UIndy School of Occupational Therapy graduate student intern Brittany Meyers during her doctoral capstone project of summer 2018. It recognizes that there are and will be changes made to the outlined strategic plan as the steering committee continues pursuit and development of the proposed social enterprise. The plan begins by documenting the goals during the doctoral capstone project, a SWOT analysis of the projected social enterprise at end of the internship, followed by strategic planning for future development of the social enterprise based off initial goals and outcomes: MISSION STATEMENT To create opportunities and maximize potential of youth and young adults with disabilities by providing an inclusive, supportive, integrated, community work environment. VISION To promote acceptance for people with disabilities as capable individuals by supporting their ability for meaningful contribution, participation, and purpose as active members in the community. VALUES Community, Belonging, Diversity, Acceptance, Relationships, Opportunity OT AND ENTREPRENEURSHIP 139 OBJECTIVES 1. 2. 3. 4. To develop and operate a nonprofit social enterprise To be financially viable and sustainable To increase acceptance and awareness of people with disabilities as meaningful contributors to the community for their abilities To operate a family-friendly bed and breakfast that is accessible to all people regardless of ability DOCTORAL CAPSTONE PROJECT GOALS Complete needs assessment of Johnson County employment services that provide additional supportive employment services to adults with intellectual and developmental disabilities. Conduct market research and competition analysis of products/services in Franklin and surrounding Johnson County area to be produced by employment-based nonprofit business. Initiate business plan and organization development for nonprofit business in Johnson County. Conduct research on nonprofit organizations, 501(c)(3) status, and application process. Initiate developing a life-skills and employment-based training program for nonprofit business. Develop initial structure for nonprofit funding and recruitment. OT AND ENTREPRENEURSHIP 140 SWOT ANALYSIS of JC TRADING POST, INC. STRENGTHS (Internal Business) Business model focused around supporting, accepting, and respecting people of all abilities Bed and breakfast business centered around providing family-friendly and inclusive environment Passionate steering committee Experience with NPO accounting and financial management WEAKNESSES (Internal Business) Business currently generated as start-up without any financial capital No current facility, space, or land for development Generate outstanding debt/borrowing to initiate social enterprise business Lack of experience: nonprofit management, running and implementing bed and breakfast OPPORTUNITIES (External Environment) No known social enterprise business in Johnson County area addressing specific mission Large target population to address social mission of bed and breakfast business Few bed and breakfast businesses are ADA accessible Few bed and breakfast businesses are familyfriendly Few bed and breakfast businesses within Johnson County (three) Supportive surrounding community with concerns regarding employment and other transitional living outcomes for adults with I/DD Burgeoning development Bargersville area THREATS (External Environment) Other bed and breakfasts, hotels, and motels that drive market and set competitive service rates Financial instability, lack of accessible, diverse funding sources Potential lack of understanding and support from current supported employment providers Potential business regulations and lack of understanding navigating business ventures Potential transportation challenges to location site for employees/visitors/customers Community concerns on business development in agricultural zoned areas Community concerns regarding safety and regulations with bed and breakfast business OT AND ENTREPRENEURSHIP 141 GOAL 1: Complete needs assessment of Johnson County employment services that provide additional supportive employment services to adults with intellectual and developmental disabilities. Key Results Generated needs assessment and report based off most current state of Indiana demographics, government, and community-based agencies that serve Johnson County during summer 2018 Future Steps Strategies Actions 1. Meet with local community rehabilitation provider Gateway Services 2. Review Department of Workforce Development (DWD) service provision model Discuss organizations current service provision strategies and statistics relevant to desired population served Form potential collaborative partnership for business plan and outcomes Identify number of individuals with I/DD served in Johnson County through DWD OT AND ENTREPRENEURSHIP 142 GOAL 2: Conduct market research and competition analysis of products/services in Franklin and surrounding Johnson County area to be produced by employment-based nonprofit business. Key Results Identified Johnson Countys floral, agricultural, and horticultural-based business markets are saturated (refer to Market Research report) Identified there are three bed and breakfast businesses in Johnson County No bed and breakfast businesses in Johnson County are ADA accessible Bargersville and surrounding areas within Johnson County are projected to grow with I-69 development between Indianapolis and Evansville Future Steps Strategies Actions 1. Identify projected average costs of running a bed and breakfast business. 2. Generate proposed bed and breakfast blueprint model. 3.Identify costs to attain land and build bed and breakfast. Explore small business research tools using SIC codes to identify demographics in Johnson County and surrounding southern/central Indiana: bed and breakfasts, hotels, and motels. Identify average costs for business commercial services and utilities in Bargersville agricultural zones. Outline structure and design of bed and breakfast, referring to Bargersville zoning regulations, special accommodations requirements, and standard ADA accessible design measurements. Locate community partner to draw first draft of bed and breakfast blueprint model based off listed requirements. Research land value and property costs within targeted Bargersville zoning areas identified. Locate local building contractors for projected estimated cost of building bed and breakfast blueprint. OT AND ENTREPRENEURSHIP 143 GOAL 3: Initiate business plan and organization development for nonprofit business in Johnson County. Key Results Created first draft of Articles of Incorporation and Bylaws have been created and presented to steering committee for review. First draft of business plan has been generated, reviewing initial bed and breakfast market research and potential forecasted lodging rates to remain competitive within local customer market. Future Steps Strategies Actions 1. Develop financial plan for JC Trading Post, Inc., including bed and breakfast. 2. Identify projected profit and loss anticipated based on projected occupancy of bed and breakfast and potential seasonal fluctuations. 3. Identify projected cash flow and balance sheet for bed and breakfast. Research qualifications required to obtain SBA and other loans, including bank mortgages. Determine time required to obtain funding and build bed and breakfast before operating to identify feasibility of proposed business venture. Identify projected monthly costs and expenses for operating bed and breakfast to identify potential gross margin. Identify seasonal market fluctuation to project variation in monthly margins. Establish projected cash flow based on operations, sales, borrowed funds, and other assets. OT AND ENTREPRENEURSHIP 144 GOAL 4: Conduct research on nonprofit organizations, 501(c)(3) status, and application process. Key Results Outlined steps to pursue filing for nonprofit business with the state of Indiana Provided resources and quick access to Indiana legislation regarding nonprofit corporations Future Steps Strategies Actions Locate and communicate with attorney to review documentation associated with starting a nonprofit business. Review site for registered agents to select potential registered agent for business and associated costs. Select person responsible for incorporation of nonprofit business. 1. Identify costs and counsel associated with pursuing starting a business. 2. Identify registered agent and incorporator. OT AND ENTREPRENEURSHIP 145 GOAL 5: Initiate developing a life-skills and employment-based training program for nonprofit business. Key Results Outlined strategies for program development regarding life-skills and employment-based training supports for adolescents and adults with I/DD Initiated collection of evidence-based research addressing various potential life-skills and employment-based training services Future Steps Strategies 1. Complete literature review on supported employment and life-skills training strategies for people with I/DD. Actions 2. Identify work assignments and employee responsibilities. 3. Create business policies, procedures, and training program. Review current literature collected. Collected additional relevant, evidence-based literature and review. Generate brief report on life-skills and employment-based strategies. Generate research and design template of prerequisite skills needed for new hire employees. Outline roles and responsibilities of employees, including titles. Write new hire training program outlining business model, mission, values, policies, and procedures. Create basic natural support strategies from evidence-based review to increase independence of employees work-related tasks. OT AND ENTREPRENEURSHIP 146 GOAL 6: Develop initial structure for nonprofit funding and recruitment. Key Results Initial research outlined to propose various routes to pursue nonprofit funding and recruitment strategies Future Steps Strategies Actions Collaboration over potential fundraising strategies after identifying target financial capital goal for pursuing business application and building bed and breakfast. Complete grant applications to support mission of social enterprise business model. 1. Review outlined strategies with steering committee. 2. Research potential grant opportunities.  ...

... NUTRITIONAL INFORMATION AT UINDY By Audra L. West An Honors Project submitted to the University of Indianapolis Honors College in partial fulfillment of the requirements for a Baccalaureate degree with distinction. Written under the direction of Dr. Matthew Beekley and Dr. Jennifer Camden. March 27, 2015 Approved by: __________________________________________________________________ Dr. Matthew Beekley, Faculty Advisor __________________________________________________________________ Dr. Jennifer Camden, Faculty Advisor ______________________________________________________________ Dr. Amy Allen Sekhar, Executive Director, Honors College ______________________________________________________________________ First Reader ______________________________________________________________________ Second Reader Abstract 2 The purpose of this project was to develop a system in the University of Indianapolis campus cafeteria that would provide students with information regarding the nutritional value of their food, thus allowing them the opportunity to make a more informed decision. This is relevant because of the prevalence of obesity in the world today. Obesity has been a health issue in the United States since the end of the 20th century. Research has demonstrated that things such as lifestyle modification, physical activity, and dietary changes have been successful in reducing the prevalence of obesity. An increase in nutritional awareness is one technique that has had some success as well. My goal was to come up with a system of providing the information that was both relatively easy to understand for students as well as easy to implement for the staff in the cafeteria. By working in contact with the cafeteria manager, Dianne Szalai, as well as with the cafeteria executive chef, Sean Emrick, I was able to perform a comparison of the eating decisions students made with and without the nutritional information postings. In order to do this, information had to be gathered from a meal without any information posted first. After this, an identical menu was provided, with the only difference being the provision of nutritional information for the main entrees of the meal. The comparison was based on changes in the amount of each entree type that was selected by students. By looking at any changes in the entrees students choose to eat, we were able to determine the amount of influence that the nutritional labels had on students eating decisions. We selected a meal that provided a sufficient variety of relatively healthy (Blackened Tilapia, Grilled Spanish Flank Steak) and less healthy entree options (Stuffed Shells, Patty Melts) so that a comparison could be made. During the meal in which the nutritional information was provided, I provided surveys to 100 students to gather information regarding their thoughts and opinions of the system. The final product of this project 3 is a full report and analysis of the data gathered comparing the eating decisions students made with and without provision of nutritional information. 4 Special thanks to: My advisor, Dr. Matthew Beekley, for his time and assistance dedicated to helping perform research, develop a posting system, and performing statistical analyses for the purpose of this project, as well as for his support and encouragement along the way. My advisor, Dr. Jennifer Camden, for her time and guidance dedicated to the composition of the project proposal as well as the project manuscript, as well as her constant support, encouragement, and wise wisdom along the way. Dr. Amy Allen Sekhar, Director of the Honors College, for her guidance throughout the completion of this project. Diane Szalai, Cafeteria Manager, for her contribution of time and advice during the completion of this project. Sean Emrick, Executive Cafeteria Chef, for his willingness to assist with the meal planning and providing the information of sales for the benefit of this project. Dan Phillips, Assistant Director of Food Services, for his contribution of time and knowledge to the project. 5 Table of Contents Cover Page 1 Abstract 2 Special Thanks 4 Table of Contents 5 Statement of Purpose 6 Literature Review 8 Project Procedure 18 Product Produced 21 Reflection 36 References 37 6 Statement of Purpose My honors project was a combined service and research project that involved developing a system for displaying nutritional information to University of Indianapolis students in an effort to motivate them to make more informed eating decisions in the campus cafeteria. I met directly with the cafeteria manager, Diane Szalai, as well as the Executive Chef, Sean Emrick, and the Assistant Director of Food Services, Dan Phillips. Through communication with each of these individuals, I was able to develop a system for displaying the nutritional value of the food options that would be easy for the cafeteria employees to set up as well as easy for students to read and understand. The display system on the serving line provided students with basic nutritional information in order to make their immediate eating decisions. I had also intended to create a database regarding the detailed nutritional information of the cafeteria food option, but it was removed from the project plan. As I began communicating with the new cafeteria manager, a couple of concerns were raised. I quickly realized that this was not a realistic goal due to the cafeteria undergoing many changes with the change in management, which has resulted in many ongoing changes to the cafeteria menu. It was also made clear to me that there are many ingredients involved in each menu item, as most if not all are prepared in the cafeteria and not frozen. This led me to recognize that I was not qualified to interpret the complexity of information regarding the nutritional value of the foods prepared in the cafeteria. This was 7 something discussed with the manager, and it was agreed that for the purposes of this project it was not likely to be completed. I was able to complete most of the planning stages of this project throughout the remainder of the 2014 calendar year, and then began implementing the plan at the start of the 2015 calendar year (Second Semester of the 2014 -2015 academic year). I was able to determine the effectiveness of this nutritional awareness system based on a comparison of the amount of each menu item that was consumed throughout the course of a meal with the menu compared to without the menus. The information for this was provided by the cafeteria. I was also able to distribute surveys to students to determine their opinions of the system, as well as obtain any suggestions they had on how it could be adapted or improved. Through comparing the data from two identical meals before and after the intervention, I was able to observe changes in the amount of consumption of each observed entree item. The analysis of this data allowed me to gauge the effectiveness of providing nutritional information to students at the University of Indianapolis, and the results were reassuring. 8 Literature Review Introduction As obesity has continued to present issues for the health of society, people have turned to nutrition as a possible solution. First Lady Michelle Obamas campaign for healthier school lunches and the law that now requires chain restaurants to provide nutritional content of food to their customers are just two examples of how increasing consumer awareness of the nutritional value of the foods they eat has been used as a means to combat obesity. The University of Indianapolis has made small attempts toward joining the movement, but no data had been collected to determine the effectiveness of these interventions. These interventions included things such as posting the number of calories in the meal options on a TV monitor in the cafeteria, but methods such as these were lost in the transition to the new cafeteria management. I met personally with the previous cafeteria staff as well as the incoming cafeteria staff in order to prevent my plans for this project from getting lost as well. Using this project as a field test, I would like to propose a more direct approach that I hope the cafeteria will implement more extensively. Providing all of the nutritional information of the foods served by the University of Indianapolis cafeteria, as well as presenting a system of shapes, colors, or symbols that indicates the healthfulness of the foods places the knowledge in the hands of the students. My project provided students with immediate information regarding of the nutritional value of the foods 9 using a very simple system on the display line in the cafeteria for students to easily determine how healthy the food options are. As a result, students were better equipped with the nutritional information to make their meal decisions. Obesity Epidemic Obesity is defined by the National Institutes of Health as being at least thirty percent over the recommended weight for an individuals given height. The most basic underlying cause of obesity is overconsumption, i.e. taking in more calories than you are expending. (Understanding Obesity). According to 2012 statistics provided by the CDC, approximately 35% of American adults are obese (Adult Obesity Facts). Obesity was ranked by the U.S. Centers for Disease Control and Prevention as the fifth highest health risk in America in 2009 (Obesity and Overweight). One reason behind this high ranking is that obesity increases the risk of developing other health conditions such as type II diabetes, heart disease, hypertension, and metabolic syndrome (Understanding Obesity). Portion Sizes vs Serving Sizes: A Reason Behind the Weight Gain According to a 2010 study performed by the Research And Development Corporation (RAND), portion sizes for the average American meal have increased to four times the size they were in the 1950s (Schocker). In order to understand the importance of this statistic one needs to differentiate between a serving size and a portion size. A serving size, as defined by the American Dietetic Association, is the recommended amount of food to be consumed at one time. 10 This recommendation is calculated by the United States Department of Agriculture, and is based on nutritional content, average portion sizes in food consumption surveys, and estimation based on common measuring utensils (Herring). The American Dietetic Association defines a portion size as being the amount of food you choose to eat at any one time-which may be more or less than a serving. (Serving Size vs. Portion Size). Too often the portion size we choose to eat is far greater than the recommended serving size. A simple online search of the phrase serving size results in many web pages stating that the current serving sizes are laughably small and the Food and Drug Administration (FDA) and United States Department of Agriculture (USDA) need to change the standards in effort to force food makers to include more realistic servingsize information on their labels. (OConnor). These serving size recommendations are currently being debated, and there is a proposal by the FDA that they be updated. These updates will include an adaptation to the serving sizes based on the amount of food people are actually eating as opposed to the amount they should be eating. However, the real issue at hand is not that the serving sizes are too small, but rather that the American appetite is outgrowing them (Ledikwe). The tendency to overeat comes partially as a learned habit. People are unaware of what a true healthy portion size is because of the exposure to large and unhealthy portions that are presented at almost every out-of-home meal venue because most restaurants, from fast food to family style, provide consumers with food that often contains almost one half of the amount of calories, fats, and/or sodium that a person should consume in an entire day (Ledikwe). Because a 11 majority of students have been exposed to meals of this type for a bulk of their lives, they come to see the portion sizes as normal, and this is reflected in the portion sizes they choose to put on their plates in the cafeteria. If this type of meal is consumed even just once a week, it could amount to over 30,000 surplus calories a year, which is the equivalent of roughly nine pounds (Zinczenko). These statistics just further emphasize the logic behind Americas expanding waistline. College Meals and The University of Indianapolis College is an ideal place for an individual to become more knowledgeable on the nutrition of his or her everyday diet because this is often the first opportunity for an individual to experience significant freedom, including making independent food choices as they are eating away from home on a daily basis (Fraisure). College students are developing eating habits that will continue into the rest of their lives after graduation. College students who develop the habit of overeating will experience weight gain during school, and this weight will continue to grow after they graduate as their habit of overeating becomes their lifestyle (Anderson). I believe we should break this habit in order to prevent our college students from becoming a part of the increasing obesity statistic. The University of Indianapolis is an ideal sample location for implementing different techniques that could help college students become more informed about nutrition. The University of Indianapolis provides a serve yourself buffet dining venue for its students known as The Marketplace. The cafeteria places no limitations on the amount of food 12 students can eat per meal, forcing them to approximate the serving sizes based on what they know. Because exaggerated portion sizes have become what Americans believe to be the correct serving size, this approximation tends to be oversized as well. In the fall semester of 2012, I performed a survey on 100 students at the University of Indianapolis to estimate the number of students who are aware of the serving sizes they should be consuming. It was distributed by myself to students in the cafeteria during a lunch time meal. The survey I conducted included simple questions about common food items offered in the University of Indianapolis cafeteria, such as macaroni and cheese, grilled chicken, chicken wings, spaghetti, among others, as well as questions regarding year in school, whether or not the individual was a student athlete, gender, and ethnic background. However, according to the survey results, it appeared that regardless of age, ethnicity, gender, and level of activity, students at the University of Indianapolis were unaware of what a true serving size is. Only 7 percent of the students could accurately estimate the serving sizes for a majority of the foods listed on the survey. Approximately 64 percent of the participants estimated double the actual serving size for the foods provided. The remaining 29 percent still overestimated the servings, but not quite so drastically. The survey demonstrated that when students do not have a knowledge base as to how much they should be eating, they overestimate their portion sizes. If the University of Indianapolis wants to become a more nutritionally aware and healthier campus, the students must become more informed about the food they are consuming. 13 Posting information Some colleges have implemented methods of presenting nutritional information to students to increase their awareness and allow the opportunity to make a more informed decision regarding food choices based on the nutritional value of the food. Some schools, such as Ohio State, have tried providing nutritional information to students. These schools have used a method of providing information by posting small cards by each food option that show the number of calories, and the grams of carbohydrates, fat, and protein. Kent State also provided the nutritional information to students by posting it online. Cafeteria directors and chefs said that they believe that the information postings have been helpful, but they do not have any measurable evidence that the postings have been successful, and instead only mention that they have noticed students paying attention to the postings and taking the time to read and use the information to make their choices (Theiss). However, The Ohio State University performed a study to compare sales of food items from before nutrition postings to after. The results showed that the students began eating foods with fewer calories following the nutrition intervention, but sales did not suffer as a result (Chu). Another study performed at San Jos State University used a Fuel Your Life campaign in which healthful foods were identified with display tags that featured the campaign 14 logo. The results of this study showed that sales increased for the tagged food items, though the increase in sales was not significant according to statistical tests (Freedman). Posting information point of sales, specifically in restaurants, has been demonstrated to be ineffective, or at least to have mixed results (Gill). This is crucial to my project because it needs to be recognized that posting nutrition information is not always a successful endeavor. It also helped me to realize that simply adding a number value to the buffet line for the number of calories is not an effective way of communicating to and influencing the consumption decisions of consumers. In order to reach the consumers, something extra has to be done. My goal was to expand on the calorie posting approach through the development of a system of shapes, symbols, or colors that distinguishes foods as healthy or not based on some aspect such as fat content, nutrient content, or another factor which is to be researched during the developmental phase of the project. My project also expands on this by providing a system rather than a single logo to designate the nutritional value of foods. Measuring effectiveness In order to determine the effectiveness of the posting implementation, I obtained information from the cafeteria regarding the amount of each menu item that was consumed throughout the meal. When gathering this information, I was able to set-up a specific menu with Chef Dan Phillips and the rest of the cafeteria staff and then afterward I gathered the statistics of the sales during the meal. This included information such as the number of people who came 15 through the cafeteria during the meal and the number of each menu item that was taken from the buffet line. I then implemented the nutrition labels and collected the same data a second time on the exact same menu, at the same meal time, and on the same day of the week. This was relatively easy for the cafeteria staff to accommodate because their current menu is one that rotates through on a cycle. Thus I only had to wait until the selected meal cycled back through. Collecting the data from an identical menu, at the same meal time, and on the same day of the week was critical to the project. This allowed me to control variables such as population size and type, which will allow the two meals to be as comparable as possible. The data obtained provided information regarding the effectiveness of the nutrition posting system in two ways. I was able to determine the average amount of each food option taken per person by comparing the amount of each food option that was taken from the serving line before the nutrition postings divided by the number of people who came through the cafeteria during that meal. This provided the average amount of each food option that each student took. The same calculations were performed on the data from the meal with the nutrition postings, and values were compared. From this information, I was able to determine if students began choosing more of some of the healthier alternatives compared to the less healthy options as a result of nutritional awareness. Another way that I was able to measure the effectiveness of the project was through survey responses. During the meal in which the nutritional labels were posted, I walked around 16 the cafeteria and distributed surveys to students. This survey, shown in Figure 1, allowed me to gain insight from the students about the postings and the influence it had on their eating decisions. This information is beneficial not only to the completion of this project, but also to the cafeteria as a guide if they choose to implement a similar system. Figure 1: The Survey Summary As a result of the obesity epidemic, nutrition and consumer knowledge of nutrition have become increasingly important. A number interventions have been made to provide information to consumers such as the ones discussed above. For this honors project, I intended to determine the effectiveness nutritional awareness would have on the consumption decisions of University of Indianapolis students in the UIndy cafeteria. Using the staggering results from the serving size survey I conducted in 2012 as evidence for need of nutritional knowledge on UIndys campus, I researched to determine the most appropriate method to communicate the information to 17 students. The sections to follow outline the final protocol as well as results from the nutritional awareness intervention. 18 Project Procedures Subjects The participants in this study were students, approximately 750 for each meal, and faculty at the University of Indianapolis who eat in the university cafeteria, the Marketplace. No details or personal information was gathered regarding the participants. The students surveyed during the meal were selected at random, and the surveys remained anonymous as well. Procedures The first phase of this honors project was to develop a simplistic and informative system of providing the nutritional information to the students. I had to do research regarding what is the most effective method of portraying this information in the display line (i.e. color coded, shape coded, smile//frown, etc). Through my research, I found that some methods of posting were some seemingly more effective than others (Theiss, Gill, Freedman). The methods I researched needed to be easy to understand and quick to interpret because students flow through the buffet line relatively quickly. During this process, I was able to work alongside the cafeteria staff in analyzing various meal menus provided to students, in order to select a suitable meal for the project. The meal needed to provide a variety of both relatively healthy and relatively unhealthy entree options in order to be feasible for the project. For this part of the project I was able to 19 access the menus currently in use by the cafeteria in the meal menu rotation. Using the meal and menu selected, I then had to perform a pre-evaluation of student consumption in the cafeteria. This required working with the cafeteria staff in order to record the amount of each of the selected entrees that students consumed. Following the meal I was able to gather the information necessary to determine how much of the healthy and unhealthy entrees were selected by gathering the data provided by the cafeteria staff concerning the number of menu items that were taken as well as the number of students who ate in the cafeteria. The second phase of my project was to implement the system I had researched and developed in the first phase by actually posting the developed system. The same meal selected during the first phase was used to ensure direct comparison was possible. This required working again with Chef Dan to recreate the exact same meal and ensuring that it was served on the same day of the week and at the same meal time. This minimized error due to a different type and size of the sample population being observed. During the meal in which the system was posted, the same statistical information regarding the amount of each food item served was collected. I was also present during this meal to distribute surveys to 100 random students in the cafeteria to determine their thoughts and opinions regarding the system. Once I had obtained all of this data I was able to perform an analysis to determine any statistical changes in consumption from pre- to post-implementation. Based on this analysis I was able to gauge the effectiveness of providing students with nutritional knowledge concerning the foods they eat. This effectiveness was based 20 both on changes in the types of food students choose to eat as a result of nutritional awareness and on the survey responses obtained. 21 Product Produced The final product of this honors project is an analysis of the researched and developed system of posting. These results provide information regarding the response of the students to the implementation of the system. The results of this project are useful to the cafeteria staff if they intend to implement a system of nutritional posting sometime in the future. Using the results of my research project, they will have some guidance and baseline information from which they can expand. When developing a plan for comparing the amount of each entree selected by students. Dr. Matthew Beekley and developed a mathematical equation that would produce a single number to be used for comparison. This equation, shown in Figure 2, provided a means for us to take into account the total number of servings of each observed menu item and the total number of students who came through the cafeteria. Figure 2: The Equation 22 The nutrition labels that I decided to use for this project were color coded traffic light labels based on the system instituted by the Food Standards Agency in the United Kingdom (Traffic-light food labelling, 2008). These labels can be seen in Figure 3. Entre items that were considered to be unhealthy were labeled using a red light (Patty Melts and Stuffed Shells), entre items considered healthy were labeled using a green light (Grilled Spanish Flank Steak and Blackened Tilapia), and the entre items that fell somewhere in between were labelled with a yellow light. I felt that this style of label would be the most effective because it is a common object that most students would be familiar with, and that could be easily interpreted. I had also communicated with a nutritional cafeteria director from the downtown Lily building, and she said they used a system in which the serving utensils were color-coded as red, yellow, or green (Buettner). She informed me that this system was beneficial because those colors are respectively associated with stop, proceed with caution, and go. This allows the employees to easily distinguish which foods they should be consuming. Using the traffic light labels allowed me to draw from these color associations as well. On the traffic light nutrition labels, I decided to display only the number of kilocalories per serving. This information is the most general, but also the most familiar to students as a result of the kilocalorie postings in places such as restaurants as well as on nutrition labels from store bought food items. An example of the nutrition labels is provided in Figure 3. 23 Figure 3: The traffic light nutrition labels used for the intervention Results The data gathered from the meals was provided on information sheets which the cafeteria staff fills out regularly with each meal. See Figure 4 below for an example of this. This sheet includes values regarding the amount of each menu item to be prepared, the amount of each item used, and the amount of each item remaining at the end of the meal. The amount of each item used was the value I primarily needed from this sheet. The other necessary piece of information 24 was the relative number of students who came through the cafeteria on the night of the meal. For the meal without the traffic light nutrition labels, I was unable to have an exact value. Thus an estimation was used instead based on the typical number of students who come through the cafeteria. The value from the meal in which the traffic light nutrition labels were posted was a recorded value from the cafeteria staff. Dividing the number of servings of each entree item taken from the serving line by the number of students who came through the cafeteria would provide a value for the number of servings of each menu item taken per person. This allowed the values from the two meals to be compared more directly. 25 Figure 4: Sample Cafeteria Data Collection Sheet Based on the raw information gathered, there were a series of comparisons that could be made between the meal with and the meal without the traffic light nutrition labels. The number of chicken parmesan servings, the yellow light entree item, increased from 160 servings without the traffic light nutrition labels to 260 servings with the traffic light nutrition labels. The servings of stuffed shells, a red light food item, remained constant at 120 servings for both meals. The servings of the grilled spanish flank steak, a green light food item, also remained constant at 300 servings for both meals. The blackened tilapia servings, a green light food item, decreased from 26 180 servings without the traffic light nutrition labels to 165 with them. The patty melt servings, a red light menu item, were cut in half with the traffic light nutrition labels compared to without the labels (n = 120, n with = 240). These results are depicted in graphical form in Figure without Figure 5: Comparison of Number of Servings with and without the labels. The comparison of the calculated average number of servings of each entree item per student also provided some adequate information. The chicken parmesan serving average per student increased from 0.27 servings/ student to 0.43 servings/ student when the traffic light nutrition labels were used. The stuffed shells serving average per student remained constant at 0.20 servings/ student. Similarly, the grilled spanish flank steak average number of servings per student stayed at roughly 0.50 servings/ student both with and without the traffic light nutrition labels. The blackened tilapia value actually dropped slightly from around 0.3 servings per person without to 0.27 servings per person with the traffic light nutrition labels. The patty melts saw the most significant change in the average number of servings per person with a decrease from 0.4 27 servings per person without the labels to 0.20 servings per person with them. The results of this comparison can also be found in graphical form in Figure 6. Figure 6: Average number of servings per person with versus without the labels The responses of the survey regarding the nutritional postings I developed had a series of results that provided valuable information. The first thing to note is that of the 100 students I surveyed, almost 40% of the students did not even see the traffic light nutritional postings (n=39). The remaining 61 students surveyed did notice the traffic lights. Of the 61 students who did see the traffic light nutrition, 88.5% of the students understood how to use the labels (n = 54). The remaining 7 students who did see the labels indicated that they were unsure of their meaning or usage. From the pool of students who indicated that they both saw and understood the traffic light nutrition labels (n=54), less than half of these individuals indicated that their eating decisions were influenced by the labels (n =21). The remaining 33 students from this pool all marked that the labels did not have an influence on the entree they selected. These results are depicted below in Figure 7. 28 Figure 7: Comparison of Yes versus No responses for the survey questions The survey also provided a space for students to leave comments or suggestions regarding the traffic light nutrition labels used. A total of 14 students provided some feedback on this portion of the surveys. From the students who did not see the labels at all, suggestions were to make the labels more visible (3 students) and to put the labels in front ot the food as opposed to above the food. Of those students who saw the labels but did not understand them, the only suggestion was to make the font size larger. The students who both saw and understood the labels, but did not utilize them to make their eating decisions also had several suggestions. Two students indicated that they supported the labels and would like to see them continued. Two other students suggested adding the amount of things like trans fats, sugars, and % daily calories instead of just the number of calories per serving. One other student recommended adapting the traffic light labels so that they would be more accessible to color blind individuals. Finally, the students who saw the labels, understood the labels, and felt that their eating decisions were influenced by the labels left a couple of suggestions as well. 3 of these students wrote that they 29 loved the idea, another student indicated that the traffic light labels were not needed but the calorie count was helpful. Discussion The results of the traffic light nutrition label intervention presented above provide a variety of implications. The raw data from the meal indicated that the number of servings of chicken parmesan increased for the meal with the traffic light nutrition labels. This item was marked with a yellow traffic light label, and thus I had not anticipated a large change in the number of servings. A potential explanation for this increase might be the increase in the availability of the item during the meal with the labels present. The stuffed shells and the grilled spanish flank steak saw no change. This is likely due to the fact that both of these entree items ran out by the end of the meal time. The blackened tilapia actually decreased by about 15 servings with the traffic light nutrition labels posted. This is change is relatively small and could be simply the result of any change to the circumstance such as weather, diets, etc that may influence the students eating decisions. The patty melts raw value for total number of servings was cut in half. This could have been a result of the postings, but other factors again such as weather, diets, etc could have accounted for this change as well. The fact that these were a red light item is supportive of the traffic light intervention because the red light was meant to discourage students from eating too much of that item. Some interesting information came from the average number of servings per student calculations that I performed as well. The first red light item, stuffed shells, and green light item, grilled spanish flank steak, values did not undergo any change from the meal without labels to the meal with the labels. The yellow light item, chicken parmesan, however, did see a large increase (from 0.27 servings per student to 0.43 servings per student). The blackened tilapia, 30 another green light item saw a slight decrease of 0.03 servings per student, but this value is relatively small. The other red light item, patty melts saw a 0.2 servings per person decrease. These reductions in average number of servings per student may be an explanation for the increase in the chicken parmesan servings per person. If this is the case then that would indicate that students opted for the yellow light, chicken parmesan, as a substitute for the less healthy red light item, the patty melt. The results of the survey have their own set of implications regarding the traffic light nutrition label intervention. The fact that 40% of the students surveyed did not even notice the labels indicates that the labels need to either be designed in such a way as to better catch the eye or placed in a more optimal location. Design could be changed easily, however the location, on top of the display glass as seen in Figure 8 is really the only available space for the labels to be placed as point of selection labels. Another reason students may have not noticed the labels is that they are moving through the line at a relatively quick rate and thus have little time to be observant to the environment. One method of helping resolve this issue would be to also provide small traffic light colored labels by the entree items on the menu posted by the entrance to the cafeteria. The cafeteria manager, Diane Szalai, indicated that this would be something the cafeteria would consider doing. 31 Figure 8: Photo of the traffic light nutrition labels in place. The number of students who saw the traffic light nutrition labels but neither understood and therefore were not influenced by them, was relatively small at only 7 students. This was actually reassuring to me because it suggested that a large majority of the individuals who did 32 see the labels were able to interpret them on their own (88.5%). These values tell me that the style of the labels was effective in communicating the necessary information. Of those students who both saw and understood the labels, roughly 40% suggested that their eating decisions were influenced by the traffic light nutrition labels. While this value may be less than half, I still felt it was supportive of the intervention. This reassured me that knowledge of nutritional information does have an impact on students eating choices. Finally, the written suggestions on the survey provided some positive criticism and support for the traffic light nutrition label intervention. The responses to continue the labels and the comments that students loved the idea indicated that students liked having information about the foods they eat. The comments to recommending I place the labels in a more obvious location are not easy to address because of the reasons discussed above. However, having the traffic light colors labelling the items on the menu list at the entrance could help reduce the number of students who did not notice the labels. The suggestion to add more information to the labels such as trans fats, sugars and % daily values was also noted. Adding sugar and trans fats would be beneficial, but not all students are as familiar with this type of nutritional information. This additional information on the traffic light label might also result in cluttering the label with too much information for it to be efficient. This could result in overwhelming the students because they are unable to absorb that amount of information in the short amount of time they have in the line. The % daily value recommendation is not all that realistic because this value will be different for each individual based on factors such as gender, body composition, and level of activity. The last recommendation, to make the labels more accessible to color-blind individuals, was more difficult to address. The traffic light is based on the differentiation of red, yellow, and green from top to bottom respectively. Individuals with color-blindness would still 33 be familiar with the top to bottom set up of the traffic lights. Therefore, the labels might need to be adapted so as to emphasize this aspect of the traffic light, but that would be an easy alteration to make. The suggestions from the surveys seemed very supportive of the program overall. This was reassuring for me, and potentially beneficial for the cafeteria if they choose to go forward with the implementation of this or another food labelling system. Limitations There were several limitations to this intervention. The first issue was inability to obtain an exact value for the number of students who came through the cafeteria the night in which the traffic light nutrition labels were not used. Having to use an estimate as opposed to the actual value could skew the data. Another limitation was the fact that some of the food ran out during the meal. This limits the intervention because we do not know whether students coming to the cafeteria after they ran out would have selected those items or not had the options been available. Another limitation was that I did not advertise the traffic light labels before the intervention, and thus students had no prior information to prepare them or instruct them on how to use and interpret the information on the traffic lights. Had I communicated efficiently with students prior to the traffic light nutrition label intervention, the percent of students who did not notice the labels would have likely been reduced. Conclusion The results of this intervention indicate that providing students at the University of Indianapolis with nutritional information regarding the information they eat in the cafeteria can influence students eating decisions. This was supported by the decrease in the amount of red light food item, patty melts, that were served with the labels posted as well as by the students responses to the survey I distributed. These results indicate that a similar system to this one 34 might be beneficial for the cafeteria to use. The system used by the cafeteria would need to address the issues and limitations of the traffic light intervention, as discussed above. Reflection I believe this project effectively allowed me to strengthen my skills that are important to my professional development. Performing research was the first skill that I got to practice when the project began. Being an exercise science major, I was already familiar with the process of searching for and reviewing journal articles, dissecting them for the key points and relevant information. After this I was able to work on my communication skills during the planning stages while I was working with the cafeteria staff as well as my advisors on developing the intervention to be used. Self-leadership became the skill I found myself practicing most often, and I felt that this was an important part of the honors project, as it is meant to be an independent study project. Throughout the duration of the project I came across several challenges. Time constraints and time management, as I quickly realized, were key to this project being completed. Because there was no rigidly structured time allotted for this project in the way that classes typically are, I had to prepare a schedule for myself. I had not realized how difficult this part of the process would be because I have grown accustomed to having my schedule laid out for me. But this honors project allowed me to improve my time management abilities. Another challenge I faced during this project was my lack of experience, and therefore incapacity to perform portions of the project. For example, I had originally intended to create a database of all the offered menu items in the cafeteria. However as I began speaking with the cafeteria staff and learning about the food served, I realized quickly how unequipped I was for 35 the task of developing a nutritional database. First there was the issue of the changes being made to the menu with the transition from Ted Polk, the old cafeteria manager, to Diana Szalai, the new cafeteria manager. Secondly, a majority of the menu items served in the cafeteria are prepared using a combination of various ingredients. My nutritional knowledge did not extend as far as to analyze food at this level, and thus I was incapable of fulfilling this goal I had originally outlined for myself. Finally, I learned several things about myself as well; my strengths and weaknesses. This was one of the most important parts of the learning process for me for the duration of this project. I learned that I sometimes overestimate my abilities, which may allow me to challenge myself regularly, can also result in biting off more than I can chew so to speak and leave me overwhelmed. I learned that my time management skills needed some improvement, and that communication is one of the most important factors in the success of a project. This project not only allowed me to expand my educational and professional development, but my personal development as well. I believe that the results gained from my project are relevant, and potentially useful to the cafeteria if they choose to move forward with nutrition labels long term. References "Adult Obesity Facts." Centers for Disease Control and Prevention. Centers for Disease Control and Prevention, 16 Aug. 2013. Web. 36 Anderson, D.A., Shapiro, J.R., Lundgren, J.D.. (2003). The freshman year of college as a critical period for weight gain: an initial evaluation. Eating Behaviors, 4, 363-367. Buettner, A. RDN, CD. Personal Communication, Dec. 16, 2014. Chu YH, Frongillo EA, Jones SJ, Kaye GL. (2009) Improving patrons meal selections through the use of point-of-selection nutrition labels. Am J Public Health 99: 20012005. Traffic-light food labelling. (2009). Faculty of Public Health. Frasieur, A.M.. "Posting Point of Sale Nutrition Information in a College Dormitory Food Court: Impact on Students Food Choice Motives and Venue Sales." Thesis. Oregon State University, 2009. Web. Freedman, M. R., and Connors, R. "Point-of-Purchase Nutrition Information Influences FoodPurchasing Behaviors of College Students: A Pilot Study." Journal of the American Dietetic Association 111.5 (2011): S42-46. Gill, T. P., & Boylan, S. (2012). Public health messages: why are they ineffective and what can be done?. Current Obesity Reports, 1(1), 50-58. Herring, D., Britten, P., and Davis, C.. "Serving Sizes in the Food Guide Pyramid." Nutrition Insights 22 (2000): n. pag. USDA Center for Nutrition Policy and Promotion. Web. Ledikwe, J.H., Ello-Martin, J.A., Rolls, B.J.. (2005) Portion Sizes and the Obesity Epidemic Journal of Nutrition, 135(4), 905-909. "Obesity and Overweight." World Health Organization. N.p., Mar. 2013. Web. 07 Mar. 2014. O'Connor, Anahad. "The Problem With Serving Sizes." The New York Times. The New York Times Company, 2 Aug. 2011. Web. Schocker, Laura. "Restaurant Portion Size: Nearly All Entrees Exceed Nutrition Recommendations." The Huffington Post. TheHuffingtonPost.com, 22 May 2012. Web. 37 "Serving Size vs. Portion Size: Is There a Difference?" .eat right. Academy of Nutrition and Dietetics, Feb. 2010. Web. "The White House and FDA Announce Proposed Updates to Nutrition Facts Label." The White House. The White House, 27 Feb. 2014 Theiss, Evelyn. "Colleges Hope Students Use Nutritional Information to Build Good Eating Habits for a Lifetime." Cleveland.com. Northeast Ohio Media Group, 11 Apr. 2011. Web. "Understanding Obesity." Obesity In America. Matrix Group International Inc., n.d. Web. 02 Mar. 2014. Zinczenko, David. "Stuffed: The Weighty Truth behind Restaurant Portion Sizes." TODAY.com. NBC NEWS, 1 Sept. 2010. Web. 38 dsfsdfsdfsdfdsfasdf 39 Figure 3: The traffic light nutrition labels used for the intervention 40 Results The data gathered from the meals was provided on information sheets which the cafeteria staff fills out regularly with each meal. See Figure 4 below for an example of this. This sheet includes values regarding the amount of each menu item to be prepared, the amount of each item used, and the amount of each item remaining at the end of the meal. The amount of each item used was the value I primarily needed from this sheet. The other necessary piece of information was the relative number of students who came through the cafeteria on the night of the meal. For the meal without the traffic light nutrition labels, I was unable to have an exact value. Thus an estimation was used instead based on the typical number of students who come through the cafeteria. The value from the meal in which the traffic light nutrition labels were posted was a recorded value from the cafeteria staff. Dividing the number of servings of each entree item taken from the serving line by the number of students who came through the cafeteria would provide a value for the number of servings of each menu item taken per person. This allowed the values from the two meals to be compared more directly. 41 Figure 4: Sample Cafeteria Data Collection Sheet 42 Based on the raw information gathered, a series of comparisons could be made between the meal with and the meal without the traffic light nutrition labels. The number of chicken parmesan servings, the yellow light entree item, increased from 160 servings without the traffic light nutrition labels to 260 servings with the traffic light nutrition labels. The servings of stuffed shells, a red light food item, remained constant at 120 servings for both meals. The servings of the grilled spanish flank steak, a green light food item, also remained constant at 300 servings for both meals. The blackened tilapia servings, a green light food item, decreased from 180 servings without the traffic light nutrition labels to 165 with them. The patty melt servings, a red light menu item, were cut in half with the traffic light nutrition labels compared to without the labels (nwith= 120, nwithout= 240). These results are depicted in graphical form in Figure 5. Figure 5: Comparison of Number of Servings with and without the labels. 43 The comparison of the calculated average number of servings of each entree item per student also provided some adequate information. The chicken parmesan serving average per student increased from 0.27 servings/ student to 0.43 servings/ student when the traffic light nutrition labels were used. The stuffed shells serving average per student remained constant at 0.20 servings/ student. Similarly, the grilled spanish flank steak average number of servings per student stayed at roughly 0.50 servings/ student both with and without the traffic light nutrition labels. The blackened tilapia value actually dropped slightly from around 0.3 servings per person without to 0.27 servings per person with the traffic light nutrition labels. The patty melts saw the most significant change in the average number of servings per person with a decrease from 0.4 servings per person without the labels to 0.20 servings per person with them. The results of this comparison can also be found in graphical form in Figure 6. Figure 6: Average number of servings per person with versus without the labels 44 The responses of the survey regarding the nutritional postings I developed had a series of results that provided valuable information. The first thing to note is that of the 100 students I surveyed, almost 40% of the students did not even see the traffic light nutritional postings (n=39). The remaining 61 students surveyed did notice the traffic lights. Of the 61 students who did see the traffic light nutrition, 88.5% of the students understood how to use the labels (n = 54). The remaining 7 students who did see the labels indicated that they were unsure of their meaning or usage. From the pool of students who indicated that they both saw and understood the traffic light nutrition labels (n=54), less than half of these individuals indicated that their eating decisions were influenced by the labels (n =21). The remaining 33 students from this pool all marked that the labels did not have an influence on the entree they selected. These results are depicted below in Figure 7. Figure 7: Comparison of Yes versus No responses for the survey questions 45 The survey also provided a space for students to leave comments or suggestions regarding the traffic light nutrition labels used. A total of 14 students provided some feedback on this portion of the surveys. From the students who did not see the labels at all, suggestions were to make the labels more visible (3 students) and to put the labels in front ot the food as opposed to above the food. Of those students who saw the labels but did not understand them, the only suggestion was to make the font size larger. The students who both saw and understood the labels, but did not utilize them to make their eating decisions also had several suggestions. Two students indicated that they supported the labels and would like to see them continued. Two other students suggested adding the amount of things like trans fats, sugars, and % daily calories instead of just the number of calories per serving. One other student recommended adapting the traffic light labels so that they would be more accessible to color blind individuals. Finally, the students who saw the labels, understood the labels, and felt that their eating decisions were Commented [1]: Include your survey as an appendix. 46 influenced by the labels left a couple of suggestions as well. Three of these students wrote that they loved the idea, another student indicated that the traffic light labels were not needed but the calorie count was helpful. Discussion The results of the traffic light nutrition label intervention presented above provide a variety of implications. The raw data from the meal indicated that the number of servings of chicken parmesan increased for the meal with the traffic light nutrition labels. This item was marked with a yellow traffic light label, and thus I had not anticipated a large change in the number of servings. A potential explanation for this increase might be the increase in the availability of the item during the meal with the labels present. The stuffed shells and the grilled spanish flank steak saw no change. This is likely due to the fact that both of these entree items ran out by the end of the meal time. The blackened tilapia actually decreased by about 15 servings with the traffic light nutrition labels posted. This is change is relatively small and could Commented [2]: To bolster your analysis and give you more concrete (clearly significant or insignificant) results, you might consider running a paired sample t-test. be simply the result of any change to the circumstance such as weather, diets, etc that may influence the students eating decisions. The patty melts raw value for total number of servings was cut in half. The fact that these were a red light item is supportive of the traffic light intervention because the red light was meant to discourage students from eating too much of that item. However, other factors again such as weather, diets, etc could have accounted for this change as well. Commented [3]: Present an interpretation related to your hypothesis first, then give alternatives. 47 Some interesting information came from the average number of servings per student calculations that I performed as well. The first red light item, stuffed shells, and green light item, grilled spanish flank steak, values did not undergo any change from the meal without labels to the meal with the labels. The yellow light item, chicken parmesan, however, did see a large increase (from 0.27 servings per student to 0.43 servings per student). The blackened tilapia, another green light item saw a slight decrease of 0.03 servings per student, but this value is relatively small. The other red light item, patty melts saw a 0.2 servings per person decrease. These reductions in average number of servings per student may be an explanation for the increase in the chicken parmesan servings per person. If this is the case then that would indicate that students opted for the yellow light, chicken parmesan, as a substitute for the less healthy red light item, the patty melt. The results of the survey have their own set of implications regarding the traffic light nutrition label intervention. The fact that 40% of the students surveyed did not even notice the labels indicates that the labels need to either be designed in such a way as to better catch the eye or placed in a more optimal location. Design could be changed easily; however the location, on top of the display glass as seen in Figure 8 is really the only available space for the labels to be placed as point of selection labels. Another reason students may have not noticed the labels is that they are moving through the line at a relatively quick rate and thus have little time to be observant to the environment. One method of helping resolve this issue would be to also provide 48 small traffic light colored labels by the entree items on the menu posted by the entrance to the cafeteria. The cafeteria manager, Diane Szalai, indicated that this would be something the cafeteria would consider doing. Figure 8: Photo of the traffic light nutrition labels in place. The number of students who saw the traffic light nutrition labels but neither understood and therefore were not influenced by them, was relatively small at only 7 students. This was actually reassuring to me because it suggested that a large majority of the individuals who did 49 see the labels were able to interpret them on their own (88.5%). These values suggest that the style of the labels was effective in communicating the necessary information. Of those students who both saw and understood the labels, roughly 40% suggested that their eating decisions were influenced by the traffic light nutrition labels. While this value is less than half, I still felt it was supportive of the intervention. This reassured me that knowledge of nutritional information does have an impact on students eating choices. Finally, the written suggestions on the survey provided some positive criticism and support for the traffic light nutrition label intervention. The responses to continue the labels and the comments that students loved the idea indicated that students liked having information about the foods they eat. The comments to recommending I place the labels in a more obvious location are not easy to address because of the reasons discussed above. However, having the traffic light colors labelling the items on the menu list at the entrance could help reduce the number of students who did not notice the labels. The suggestion to add more information to the labels such as trans fats, sugars and % daily values was also noted. Adding sugar and trans fats would be beneficial, but not all students are as familiar with this type of nutritional information. This additional information on the traffic light label might also result in cluttering the label with too much information for it to be efficient. This could result in overwhelming the students because they are unable to absorb that amount of information in the short amount of time they have in the line. The % daily value recommendation is not all that realistic because this value 50 will be different for each individual based on factors such as gender, body composition, and level of activity. The last recommendation, to make the labels more accessible to color-blind individuals, was more difficult to address. The traffic light is based on the differentiation of red, yellow, and green from top to bottom respectively. Individuals with color-blindness would still be familiar with the top to bottom set up of the traffic lights. Therefore, the labels might need to be adapted so as to emphasize this aspect of the traffic light, but that would be an easy alteration to make. The suggestions from the surveys seemed very supportive of the program overall. This was reassuring, and potentially beneficial for the cafeteria if they choose to go forward with the implementation of this or another food labelling system. Limitations There were several limitations to this intervention. The first issue was inability to obtain an exact value for the number of students who came through the cafeteria the night in which the traffic light nutrition labels were not used. Having to use an estimate as opposed to the actual value could skew the data. Another limitation was that some of the food ran out during the meal. This limits the intervention because we do not know whether students coming to the cafeteria after they ran out would have selected those items or not had the options been available. Another limitation was that I did not advertise the traffic light labels before the intervention, and thus students had no prior information to prepare them or instruct them on how to use and interpret the information on the traffic lights. Had I communicated efficiently with students prior to the Commented [4]: Could you not have tried it a different night? I might have missed this, but make clear why this happened if you have not already. The food running out- is that something to cafeteria is addressing (they ran out of the healthy stuff!)? 51 traffic light nutrition label intervention, the percent of students who did not notice the labels would have likely been reduced. Commented [5]: If the university were to implement this, there would obviously need to be a significant awareness campaign. I think this would help greatly! Conclusion The results of this intervention indicate that providing students at the University of Indianapolis with nutritional information regarding the food they eat in the cafeteria can influence students eating decisions. This was supported by the decrease in the amount of red light food item, patty melts, served with the labels posted as well as by the students responses to the survey I distributed. These results indicate that a similar system to this one might be beneficial for the cafeteria to use. The system used by the cafeteria would need to address the issues and limitations of the traffic light intervention, as discussed above. Reflection I believe this project effectively allowed me to strengthen my skills that are important to my professional development. Performing research was the first skill that I practiced when the project began. As an exercise science major, I was already familiar with the process of searching for and reviewing journal articles, dissecting them for the key points and relevant information. After this I was able to work on my communication skills during the planning stages while I was working with the cafeteria staff as well as my advisors on developing the chosen intervention. 52 Self-leadership became the skill I found myself practicing most often, and I felt that this was an important part of the honors project, as it is meant to be an independent study project. Throughout the duration of the project I came across several challenges. Time constraints and time management, as I quickly realized, were key to this project being completed. Because no rigidly structured time was allotted for this project in the way that classes typically are, I had to prepare a schedule for myself. I had not realized how difficult this part of the process would be because I have grown accustomed to having my schedule laid out for me. But this honors project allowed me to improve my time management abilities. Another challenge I faced during this project was my lack of experience, and therefore incapacity to perform portions of the project. For example, I had originally intended to create a database of all the offered menu items in the cafeteria. However as I began speaking with the cafeteria staff and learning about the food served, I realized quickly how unequipped I was for the task of developing a nutritional database. First there was the issue of the changes being made to the menu with the transition from Ted Polk, the old cafeteria manager, to Diana Szalai, the new cafeteria manager. Secondly, a majority of the menu items served in the cafeteria are prepared using a combination of various ingredients. My nutritional knowledge did not extend as far as to analyze food at this level, and thus I was incapable of fulfilling this goal I had originally outlined for myself. 53 Finally, I learned several things about myself as well; my strengths and weaknesses. This was one of the most important parts of the learning process for me for the duration of this project. I learned that I sometimes overestimate my abilities, which may allow me to challenge myself regularly, can also result in biting off more than I can chew and leave me overwhelmed. I learned that my time management skills needed some improvement, and that communication is one of the most important factors in the success of a project. This project not only allowed me to expand my educational and professional development, but my personal development as well. I believe that the results gained from my project are relevant, and potentially useful to the cafeteria if they choose to move forward with nutrition labels long term. References "Adult Obesity Facts." Centers for Disease Control and Prevention. Centers for Disease Control and Prevention, 16 Aug. 2013. Web. Chu YH, Frongillo EA, Jones SJ, Kaye GL (2009) Improving patrons meal selections through the use of point-of-selection nutrition labels. Am J Public Health 99: 20012005. Traffic-light food labelling. (2009). Faculty of Public Health. Frasieur, Amy M. "Posting Point of Sale Nutrition Information in a College Dormitory Food Court: Impact on Students Food Choice Motives and Venue Sales." Thesis. Oregon State University, 2009. Web. Commented [6]: Which style guide are you using? Looks like a bit of APA and MLA? Maybe it's a style guide I am not aware of. Just be sure you are consistent in whatever you choose to use. 54 Freedman, Marjorie R., and Rachel Connors. "Point-of-Purchase Nutrition Information Influences Food-Purchasing Behaviors of College Students: A Pilot Study." Journal of the American Dietetic Association 111.5 (2011): S42-46. Gill, T. P., & Boylan, S. (2012). Public health messages: why are they ineffective and what can be done?. Current Obesity Reports, 1(1), 50-58. Herring, David, Patricia Britten, and Carole Davis. "Serving Sizes in the Food Guide Pyramid." Nutrition Insights 22 (2000): n. pag. USDA Center for Nutrition Policy and Promotion. Web. "Obesity and Overweight." World Health Organization. N.p., Mar. 2013. Web. 07 Mar. 2014. O'Connor, Anahad. "The Problem With Serving Sizes." The New York Times. The New York Times Company, 2 Aug. 2011. Web. Schocker, Laura. "Restaurant Portion Size: Nearly All Entrees Exceed Nutrition Recommendations." The Huffington Post. TheHuffingtonPost.com, 22 May 2012. Web. "Serving Size vs. Portion Size: Is There a Difference?" .eat right. Academy of Nutrition and Dietetics, Feb. 2010. Web. "The White House and FDA Announce Proposed Updates to Nutrition Facts Label." The White House. The White House, 27 Feb. 2014 55 Theiss, Evelyn. "Colleges Hope Students Use Nutritional Information to Build Good Eating Habits for a Lifetime." Cleveland.com. Northeast Ohio Media Group, 11 Apr. 2011. Web. "Understanding Obesity." Obesity In America. Matrix Group International Inc., n.d. Web. 02 Mar. 2014. Zinczenko, David. "Stuffed: The Weighty Truth behind Restaurant Portion Sizes." TODAY.com. NBC NEWS, 1 Sept. 2010. Web.  ...

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... MEDIA PRESENTATIONS OF CRIME By Courtney Ryan An Honors Project submitted to the University of Indianapolis Strain Honors College in partial fulfillment of the requirements for a Baccalaureate degree with distinction. Written under the direction of Dr. Kevin Whiteacre. May 06, 2017 Approved by: __________________________________________________________________ Dr. Kevin Whiteacre, Faculty Advisor ______________________________________________________________ Dr. James B. Williams, Interim Executive Director, Strain Honors College ______________________________________________________________________ First Reader ______________________________________________________________________ Second Reader C Ryan ii Abstract The purpose of this study was to explore how crime is presented in local media. I hypothesized that white collar crime is under-represented in media and that it is viewed as less serious than street crime. Using content analysis I read and coded 151 news articles from the Indianapolis Star. I recorded all of my data with a code sheet. I divided my variables into manifest and latent variables, so I could adequately test my hypothesis. After running statistical tests in SPSS, my biggest finding was that white collar crime only made up 4% of the data I collected, however white collar crime actually makes up much more than 4% of crime today. While we cannot give an exact percentage of white collar crime due to underrepresentation, the data that we do have tells us in my findings that white collar crime was under-represented in Indianapolis media. C Ryan iii List of Tables Table 1: Manifest Variables...15 Table 2: Manifest Content by Crime Type..16 Table 3: Latent Variables...18 Table 4: Latent Content by Crime Type..19 C Ryan iv Table of Contents Cover Pagei Abstractii List of Tables..iii Statement of Purpose...1 Introduction..1 Literature..2 Methods9 Analysis......13 Results....13 Conclusion.19 References..22 Appendix A: Code Sheet...25 C Ryan 1 Statement of Purpose The goal of this project was to have a clearer understanding of how crime is presented in the Indianapolis Star. I wanted to know if white collar crime is presented by the media in the same way as other crimes. My hypothesis was that white collar crime is under-represented in media and is viewed as less serious. I tested my hypothesis by conducting a content analysis of Indianapolis news articles to determine if white collar and blue collar crime were equally reported, and to determine if one type of crime was presented as more serious than the other. Introduction White collar crime is a term originally coined in the 1940s by sociologist Edwin Sutherland (Podgor, 2007). Sutherland (1949) (as cited in Podgor, 2007) defined white collar crime as crime committed by a person of respectability and high social status in the course of his occupation. On the other hand, blue collar crime is the opposite, often referred to as street crime. Blue collar crime or street crime generally includes drug crimes and the UCR Index I offenses, such as violent crimes, burglary, and larceny. In searching the terms white and blue collar crime, I found notable differences in the way the general public views these types of crime. As stated by Piquero, Carmichael, and Piquero (2008), we have a norm in our culture of how we view crime. The topic I will be reviewing is related to how the media presents crime today. I have found much research over the topic of white collar crime in general, but have had much difficulty in finding research comparing the two crime types. I hypothesize, mostly based C Ryan 2 on news and media coverage, that street crime receives more coverage and is represented as more serious than white collar crime. Literature When Sutherland first used the term white collar crime, he did not formally define it. Eventually Sutherland (1949) (as cited in Cliff and Desilets, 2014) defined it as crimes committed by a person of respectability and high social status in the course of his occupation". This definition was completely offender-based, which at the time was alright because it was just used as a label (Cliff and Desilets, 2014). Although this definition was useful for the field of sociology, it needed to be developed a bit more for the field of criminal justice in order to answer practical questions, such as how often this crime is occurring and what prevention tools are working. In 1970, Herbert Edelhertz, a criminologist known for his studies of white collar crime, defined the term as an illegal act or series of illegal acts committed by nonphysical means and by concealment or guile, to obtain money or property, to avoid the payment or loss of money or property, or to obtain business or personal advantage (Cliff and Desilets, 2014). In contrast to Sutherlands definition, this definition is focused on the crime itself, and ignores the offender. Because of this, this definition could be applied to lower class citizens (Cliff and Desilets, 2014). Edelhertz put white collar crime into four categories: personal crimes, trust crimes, business crimes, and con game crimes (Cliff and Desilets, 2014). Today, the FBI defines white collar crime as: C Ryan 3 those illegal acts which are characterized by deceit, concealment, or violation of trust and which are not dependent upon the application or threat of physical force or violence. Individuals and organizations commit these acts to obtain money, property, or services; to avoid the payment or loss of money or services; or to secure personal or business advantage (Cliff and Desilets, 2014, pg. 3). This definition is written to fit both the Uniform Crime Report (UCR) and National IncidentBased Reporting System (NIBRS) to more easily collect data and generate statistics (Cliff and Desilets, 2014). According to Cliff and Desilets (2014), white collar crime is being committed more often than in the past, and also in comparison to blue collar crime. One reason for this is that white collar crime is simply becoming easier to commit. The skills and education that are needed to commit white collar crime are much more common, and in fact 61% of the workforce has the ability to commit this type of crime (Cliff and Desilets, 2014). For example, compared to the past, many more people are in positions today where embezzlement, fraud, money laundering, and tax evasion are possible. Computers are making white collar crimes easier to commit. Some of the information we save on our computers or put on the internet holds more value to us than our tangible items. With todays use of computers, that valuable information can easily be accessed or hacked (Cliff and Desilets, 2014). Essentially, computers are creating new ways to commit white collar crime. C Ryan 4 Sutherlands original definition of white collar crime must be revisited due to the difficulty in reporting white collar crime. Rather than defining the crime by the type of offender, as Sutherland did, the FBI must define the crime by the offense in order to be able to measure it (Barnett, 2000). The only information available on white collar crime are arrest reports, because they are not index crimes (Barnett, 2000). Unfortunately, arrest records are not reliable means of measuring crime (Barnett, 2000). Some assume that the people who are typically committing white collar crimes are of higher social class, are typically wealthier, and could use that wealth to their advantage, possibly even to keep them from being arrested. However, Gottfredson and Hirschi (1990) disagree. They claim although by definition one must be in the white-collar world to be a white-collar offender, not all white-collar workers enjoy the power, income, and prestige to be found at the top of this world. In fact, most have little power, not much income, and only moderate prestige (Gottfredson & Hirschi, 1990). Media Presentations of Crime Kohm, Waid-Lindberg, Weinrath, OConnor Shelley, and Dobbs (2012) tell us that crime in both Canada and the United States, especially of violent nature, is decreasing, yet fear has not. Individuals start to feel like they are at risk for victimization because of the medias representation of crime (Kohm et al., 2012). Todays news stations main focus is profit. The media is a capitalistic industry, therefore news programs will focus on whatever brings in the most viewers. Psychology Today has a piece titled If it Bleeds, it Leads, promoting the idea C Ryan 5 that the news will present to us what they need to get viewers. In this article the author, Dr. Deborah Serani (2011), claims: The success of fear-based news relies on presenting dramatic anecdotes in place of scientific evidence, promoting isolated events as trends, depicting categories of people as dangerous and replacing optimism with fatalistic thinking (pg. 1). She tells us that media groups edit the presentation factors of the news stories to get the results they want, and some news stations even use pre-scripted topics that contain misleading information to produce fear and anxiety in the viewer. Again, this furthers the idea that the media is aiming for profit, not equal representation and truthfulness. Unfortunately, this form of media is a norm of our culture. In the past, white collar crime has not been portrayed in the media as often as street crime (Levi, 2008). Research has shown that when reporting crime, the media exaggerates serious violence or possibility of it, focuses on crime scenarios that are not typical, and increases fear of crime (Levi, 2008). Crime media is slightly skewed, not 100% accurate. The media tends to focus on stories that incite fear or anxiety. White collar cases do not make the news media as often as violent crimes (Levi, 2008). Levi (2008) also notes that recently, the media tends to focus on white collar crimes only if they are committed by individuals or groups that are part of popular culture. Another study claims that typically news coverage over white collar crimes focus on the initial allegation, and nothing further, whereas street crime coverage focuses on the punishments and the criminal justice system processes (Benediktsson, 2010). C Ryan 6 The media also affects how individuals see crime. George Gerbners cultivation theory claims that those who watch television for more than four hours a day, tend to believe that they live in a society full of crime and also believe more in the television programs than actual real life (Boda & Szabo, 2011). It appears that fiction genres of television programs have a bigger effect than non-fiction (Boda & Szabo, 2011). Boda and Szabo (2011) made an interesting observation though. Those who watched more TV and news television say that they are more able to trust the police and government, whereas those who typically did not watch those programs lacked trust in the police and government (Boda & Szabo, 2011). Boda and Szabo (2011) admit though, that the correlation they found was weak, therefore it is possible that it is not a matter of causation, but simply the type of people that watch news TV are the type of people that already tend to have more trust in the government. They also found that those that watched more news TV were more fearful of crime (Boda & Szabo, 2011). This idea that news media is not accurate and creates fear and anxiety in the public is an important concept because it shapes society's perceptions of crime (Boda & Szabo, 2011). Piquero et al. (2008) studied the perceptions of white collar and blue collar crime on the public and criminal justice system personnel. From their research, they found that norms of crime seriousness were different throughout different parts of society (Piquero et al., 2008). Overall, white collar crime was not viewed as more serious than blue collar crime (Piquero et al., 2008). It was not considered a serious crime at all. However, later research shows that might not be the case. One study Piquero et al. (2008) mentioned, said that injuries made a difference. When there were injuries, seriousness increased (Piquero et al., 2008). And when they looked at C Ryan 7 perceptions from criminal justice system personnel, due to their higher level of education, they were more thorough and in-depth in their ratings of crime seriousness (Piquero et al., 2008). Piquero et al. (2008) looked at two studies that suggest that white collar crime probably receives less attention than blue collar crime because the type of person committing white collar crime could be the ones that influence our views of crime. The authors conducted their own study by phone interviews using a random-digit dialing system, and the respondents were asked to choose which crime situation presented to them was more serious, or if they were equally as serious. Four out of six comparisons showed that white collar crime is viewed as more serious (Piquero et al., 2008). The others do note that this study does not look at which crimes are more harmful or wrongful, and they believe the research should continue in that direction. Overall, this study shows that the public is increasingly of the belief that white collar crime is more serious and the public wants harsher punishments (Piquero et al., 2008). This study also noted that public opinion likely changes after a big scandal has been released, which I believe to be very important. Ellen Podgor takes a bit of a different view in her article, The Challenge of White Collar Sentencing. In general, Podgor claims that white collar sentences are too long and should be reevaluated because they fail to look at the background of the offender (Podgor, 2007). She points out that in Sutherlands definition of white collar crime, he really aimed to make the point that these wrongdoings are criminal acts, and the individuals need to be punished as criminals. Because he wanted to emphasize that point, you can conclude that in the past wealthy people or C Ryan 8 people in positions of power typically got out of legal trouble (Podgor, 2007). Podgor (2007) focuses on the challenges of sentencing the offenders, stating that there is no specific list of crimes that are considered white collar. Therefore, when the FBI looks at the crimes based on type of offense and not offender, as mentioned earlier, some crimes could be questionable (Podgor, 2007). Gottfredson and Hirschi argue, though, that any crimes committed by people with power and influence, could also be committed by someone not in that position (Gottfredson & Hirschi, 1990). Podgor believes that white collar criminals have more to lose by their harsh sentences. She mentions things such as not being able to return to their type of work, losing their social status, being put in the media, etc (Podgor, 2007). Where Podgor fails here is in comparison to blue collar crime. She claims that white collar criminals have more to lose, (assuming she means compared to other criminals), but does not explain why they have more to lose because all effects listed are able to happen to street criminals as well. Her conclusion is biased, considering she does not address the issues and consequences faced by blue collar offenders. She claims that sentences are too long for white collar criminals because if many of them cannot return to their positions at work, they are not likely to re-commit. But Frank Perri, author of White Collar Criminals: The Kinder, Gentler Offender? argues that white collar criminals tend to show similar mindsets to blue collar criminals (Podgor, 2007) (Perri, 2011). Again, Podgor only addresses the consequences for white collar criminals, but fails to discuss the longer sentences and permanent effects of a blue collar criminal. C Ryan 9 Overall I found that there is a lot of information about white collar crime but believe more research needs to be done discussing the seriousness of it compared to street crime. Much literature is available over white collar crime, but it was difficult to find research comparing the two crime types. I hope that my research aids in showing the differences of how white collar crime is represented by the media in comparison to street crime. I also intend to highlight that more research is needed on white collar crime and its representation in the media. Methods The intent of my research is to explore some of the differences in how white collar and street crime are represented in local media. I expect to find that not only is white collar crime covered less than street crime, but also that it is represented as less serious than street crime. I expect to see an offender mentioned in news covering street crime at a higher rate than in news covering white collar crime. Additionally, I expect to find a victim mentioned in more street crime news articles, as a way to entice sympathy in the reader. I also expect to find that the news articles covering street crime may sometimes discuss the crimes in a way that presents them as more serious than street crime. Ways that the street crimes are presented as more serious may include the language used to discuss the crime. For example, I expect to often find words and adjectives describing the street crimes as heinous, brutal, tragic, and other like words. I use these expectations as guidelines to choose my manifest and latent variables. I used content analysis as my method of research. With media being a big part of our culture today, I find content analysis to be the best fit for a research method because I want to C Ryan 10 look at how our local media portrays these types of crime in a relevant social context. A code sheet was constructed to be used in analyzing each article. Sample I used the Indianapolis Star database, which provides coverage from 1991 to present, to retrieve my articles (ProQuest). I chose this source because I wanted to use local news media and because it is one of Indianas largest news sources, with over half of a million readers (Daily Newspapers USA, 2015). The Indianapolis Star is broken up into sections, including national and world news, local news, sports, opinion, weather, and multiple others. A very large majority of my articles share the setting of Indiana, but a few are set elsewhere. I chose to include these articles because even though they do not take place in Indiana, they are being represented in Indianapolis media, which is the focus of my research. I used crime as my search word, because I wanted to know how crime is presented in Indianapolis without limiting my results. I looked at articles for a timespan of one year, from January 1, 2015 to December 31, 2015. Searching crime with these parameters produced 753 articles. I selected 20% of the articles (n = 151), using systematic random sampling. I picked every 5th article to read and code. Some articles were not used due to relevance, which I defined as articles that did not discuss crime or a specific case, but simply use the word crime. For example, one of the articles I had to reject discussed a football game, but it appeared in my search because the author referred C Ryan 11 to one of the players as a criminal due to his mistake in the game. When an article was not used due to relevance, then I instead used the following article. Measures Manifest vs. Latent Content In the past, content analysis mostly only consisted of manifest content, but recent research has included latent content as well (Neuendorf, 2002). Manifest content is the tangible or countable content, and latent content contains the deeper meanings in messages (Neuendorf, 2002). Manifest Content # of search results Article location: Section and page number of the article Article length: word count Crime type: blue collar, white collar, or other I will define white collar crime as fraud, embezzlement, money laundering, and tax evasion because summarized, Cornell University Law School labels these as the top white collar crimes (White-collar crime, 2016). If an offender is mentioned and the number of offenders mentioned If a victim is mentioned and the number of victims mentioned Who (if anyone) is interviewed about the crime C Ryan 12 Latent Content Articles may not explicitly address the seriousness of a type of crime but nevertheless make implicit judgments. Therefore latent content is important in my research in order to identify those implicit messages. I look for how the crime is described and if there are specific words/adjectives used and if those words/adjectives suggest seriousness of the crime or are relieving of the crime. For example, some articles described the crimes mentioned at tragedies, which implies that the crime mentioned is a serious crime. I also look for if they give a rationale or reasoning for the crime. Reliability In order to address the reliability of my variables and coding, Dr. Whiteacre and I each coded four cases (3% of the total sample) separately. Arguably, because I was the only coder for this study, reliability (or consistency) is not really an issue either way, so to code more than the small sample of four cases was deemed unnecessary. We then calculated the percentage of agreement in the codes. For the four cases, we coded the same in 98% of the variables. 90% agreement is considered sufficient according to Neuendorf (2002). We coded differently in only one observation, which was a latent variable. We discussed the difference, and Dr. Whiteacre agreed my code was the correct one. Given the high rate of agreement, I continued to code the remainder of the cases. C Ryan 13 Analysis After selecting my 151 articles, I read each one and coded them with a coding sheet that included all of my variables (see appendix A). Some of the articles mentioned more than one crime, so in total I coded 159 crimes. I then created a database in SPSS and transferred my data from the code sheets to the database. In SPSS I ran frequencies for each of my variables to get the means. I made tables for each of my variables showing the means for each variable, and also comparing means for certain variables. Results As I read and coded the articles, I realized that my results did not come back how I expected. While I did expect most of my articles to be referencing street crime, I was surprised when I found that street crime made up 96% of my articles. It was difficult to make conclusions about white collar crime, because it only made up 4% of my coded articles. While at first I was disappointed to find that my results came back with such a small number of white collar crimes, I realize that this is a significant finding. Of 159 crimes analyzed, only 6 were white collar crimes, which tells me that white collar crime is not being reported equally. I did expect to see less white collar crime than street crime, but if they were reported equally we would see much more white collar crime than this, because according to Cliff and Desilets (2014), white collar crime is increasing. White collar crime is being committed more often than it was in the past, and it is increasing in comparison to street crime as well (Cliff and Desilets, 2014). John Wibey (2015), C Ryan 14 tells us that from 2013 to 2014, fraud complaints increased 16%, and this does not include any of the other forms of white collar crime. That was 339,357 fraud complaints in just one year (Wihbey, 2015). According to the FBI, securities and commodities fraud (market manipulation, investment fraud, broker embezzlement, etc.) investigations have increased by 52% since 2008 (Financial Crimes Report 2010-2011). And that statistic is only relevant to investigations, so that does not include the crimes being committed that are not investigated. Federally insured financial institutions provide the FBI with suspicious activity reports to detect mortgage fraud, and these reports increased from 6,936 reports in 2003 to 93,508 reports in 2011, totaling a large increase of 86,572 reports in just 8 years (Financial Crimes Report 2010-2011). That is an average of 10,822 reports each year. The FBI has had to continue increasing the number of special agents assigned to these white collar crimes due to such a large and rapid increase (Financial Crimes Report 2010-2011). Its also important to note that of the 6 white collar crime articles, 50% (n = 3) referenced the same case, an infamous insurance fraud case from 2015. If it was not for that case making big headlines, I would have been left with even less coverage on white collar crime. While the results did not come back as I had hoped, this alone suggests that white collar crime is not receiving much coverage in the Indianapolis Star, particularly in relation to street crime. After running frequencies using SPSS, I found that each article contained an average of 675 words. The majority (81%, n = 122) of articles were found in newspaper section A (sections ranged from A-D). Sixty-three percent (n = 100) of the articles mentioned a victim, while 57% of C Ryan 15 articles mentioned an offender. Tables 1 and 2 below provide the frequencies listed for each variable. Table 1. Manifest Variables Word Count Page Number Section A B C D Victim Mentioned Yes No Victim Interviewed Yes No Offender Mentioned Yes No Offender Interviewed Yes No Crime Type Street crime White collar crime 675 (mean) 598 (median) 52 (mean) 3 (median) 81% (n = 122) 17 (n = 26) 1 (n = 2) 1 (n = 1) 63% (n = 100) 37 (n = 59) 0% (n = 0) 100 (n = 159) 57% (n = 90) 43 (n = 69) 0% (n = 0) 100 (n = 159) 96% (n = 152) 4 (n = 6) C Ryan 16 Table 2. Manifest Content by Crime Type Word Count Page Number Section A B C D Victim Mentioned Yes No Victim Interviewed Yes No Offender Mentioned Yes No Offender Interviewed Yes No Street Crimes (n = 152) 677 (mean) 592 (median) 5 (mean) 3 (median) White Collar Crime (n = 6) 586 (mean) 667 (median) 3 (mean) 3 (median) 80% (n = 122) 17 (n = 26) 1 (n = 2) 1 (n = 1) 83 % (n = 5) 17 (n = 1) 0 (n = 0) 0 (n = 0) 62% (n = 94) 38 (n = 58) 100% (n = 6) 0 (n = 0) 0% (n = 0) 100 (n = 159) 0% (n = 0) 100 (n = 159) 55% (n = 84) 45 (n = 68) 100% (n = 0) 0 (n = 0) 0% (n = 0) 100 (n = 159) 0% (n = 0) 100 (n = 159) t = .46 sig. = .65 t = 1.13 sig. = .26 Chi-sq = 3.62* sig. = .06 Chi-sq. = 4.91* sig. = .03 Street crime has an average of 677 words per article and on average appears on the 5th page. White collar crime on the other hand has an average of 586 words per article and on average appears on the 3rd page. This is interesting because I would have expected street crime to appear on a lower section number, or first in the newspaper in comparison to white collar crime. For street crime, 62% of the articles (n = 94) mentioned a victim and for white collar crime, 100% (n = 6) mentioned a victim. C Ryan 17 For street crime, 55% of the articles (n = 84), mentioned an offender and for white collar crime, 100% (n = 6) mentioned an offender. This is a marginally significant finding at .06. For street crime, 62% (n = 94) mentioned the victim, and for white collar crime, 100% (n = 6) mentioned the victim. This finding was significant at .03. While white collar crime is represented far less than street crime, these findings can tell us that in order for a white collar crime to be represented in media, it needs to be a serious case. While manifest content made up a large part of my findings, I also coded for latent content. The latent content is important for my research to help me identify the implicit messages of seriousness in each article. Tables 3 and 4 break down my latent content codes. In each article I looked for words, adjectives, phrases, etc. used to describe the crime. I looked at those words and also coded for if they were suggesting seriousness or if they were relieving of the crime. Based on what we know about the media manipulating the truths about crime, I expected many articles to include subjective descriptors of the crimes. I expected that street crimes would have a higher percentage of articles with words used that suggested seriousness, while white collar would have a higher percentage of articles with words used that are relieving of the crime. What I actually found was that only 11% (n = 16) of the articles contained any sort of words to describe the crime. After researching how the media presents crime, I was surprised to find that many of the articles were very objective and contained nothing more than facts about the crimes. Of these 16 articles that use subjective descriptors, 100% (n = 16) of the cases were suggesting seriousness. C Ryan 18 Table 4 shows that of these articles suggesting seriousness, 100% (n = 16) were street crime. I also coded for if a rationale or reasoning was given for the crimes, and I was surprised to find that only 1% (n = 2) of the articles contained any rationale or reasoning. Of these 2 articles, 100% (n = 2) of them were also street crime. Ultimately, many of the articles coded were very matter of fact about the crimes mentioned, and there were no significant findings in my latent content. Table 3. Latent Variables Words or adjectives used to describe the crime Use words/adjectives to describe crime Do not use words/adjectives to describe crime Are words/adjectives suggesting seriousness or relieving of the crime? Seriousness Relieving Is a rationale or reasoning given? Yes No 11% (n = 16) 89 (n = 135) 11% (n = 16) 89 (n = 135) 1% (n = 2) 99 (n = 149) C Ryan 19 Table 4. Latent Content by Crime Type Words or adjectives used to describe the crime Use words/adjectives to describe crime Do not use words/adjectives to describe crime Of articles including words/adjectives: Are words/adjectives suggesting seriousness or relieving of the crime? Seriousness Relieving Is a rationale or reasoning given? Yes No Street Crimes (n = 152) White Collar Crime (n = 6) 11% (n = 16) 0% (n = 0) 89 100 (n = 6) (n = 136) Chi-sq. = .75 100% (n = 16) 0 (n = 0) 0% (n = 0) 0 (n = 0) Chi-sq. = .75 1% (n = 2) 99 (n = 150) 0% (n = 0) 100 (n = 6) Chi-sq. = .08 Conclusion White collar crime is definitely happening and increasingly, too (Wihbey, 2015). But is that how the media presents it? After reading and coding 151 articles from the Indianapolis Star using the search term crime, I found far more coverage of street crimes than white collar crimes. Ninety-six percent (n = 152) of all crimes analyzed were street crimes. Only 6 of 159 (4%) crimes were white collar. Not only did the white collar crimes make up such a small number, exactly half of the articles that mentioned a white collar crime discussed the same C Ryan 20 crime. If it had not been for the infamous Richmond Hill insurance fraud case of 2015, I would have lost 50% of the white collar cases 1. White collar crime statistics are hard to obtain due to the lack of data. Because of this, white collar crime statistics are pulled together from a range of sources, such as governmental agencies, financial reports, newspapers, journals, etc (Friedrichs, 2009). Corporate crime is only reported once it has been escalated and not immediately after the crime has been committed (Friedrichs, 2009). While street crimes are reported to the FBI by police departments, white collar crime is not (Friedrichs, 2009). Due to these challenges in measuring white collar crime, we cannot say what exact percentage of crime is white collar. However, the statistics we do have tell us that white collar crime definitely exceeds 4%, proving that the results I received in fact were not proportionate to actual crime. In February 2017, the Bureau of Prisons reported that 0.3% of inmates were in prison for banking and insurance, counterfeit, and embezzlement and 6.5% of inmates were in prison for extortion, fraud, and bribery (Federal Bureau of Prisons, 2017). In total, almost 7% of inmates were in prison for white collar crimes (Federal Bureau of Prisons, 2017). As mentioned above, we also know that fraud complaints increased 16% in the timespan of just one year and securities and commodities fraud investigations alone have increased 52% since 2008 (Financial Crimes Report 2010-2011) (Wibey, 2015). 1 This crime could have been removed as it is an outlier, but was kept in the research because it further supports my point that white collar crime does not get the same coverage. This crime was so widespread due to the fact that it turned into a violent crime. C Ryan 21 Having such a small number of white collar cases made this research difficult, but it still came back with important findings. It is clear through these numbers that white collar crime is not widely reported and represented in Indianapolis. Through the process of completing this research I faced some limitations. First of all, I did not expect to have to reject as many articles that I did because they were not relevant to my research. Also, while I did not expect to get an exact 50/50 of street crime cases to white collar crime cases, I also did not expect to get such disproportionate results. This is an important finding, and it alone tells us that white collar crime is not being equally presented, however it caused some challenges. With only having 6 white collar cases, or 3 if you do not include those referencing the same crime, it made it difficult to find any correlations. Another limitation to this research is that 50% of the white collar cases mentioned were in reference to the same crime, due to large media exposure. Continuing this research, it would be interesting to see the differences if a more specific search term was used. My method used a more broad term to not limit my results. Using the search terms robbery and fraud, a larger crime for each crime type, it would be interesting to see how the results would change. I believe more research needs to be done on the lack of media exposure of white collar crime and it would be interesting to see if white collar crime simply had more media exposure and were represented equally, if the general public would then deem it as equally serious. C Ryan 22 References Barnett, C. (2000). The measurement of white-collar crime using uniform crime reporting (ucr) data. Retrieved from https://www.ncjrs.gov/app/abstractdb/AbstractDBDetails.aspx?id=202866 Benediktsson, M. O. (2010). The deviant organization and the bad apple ceo: Ideology and accountability in media coverage of corporate scandals. Social Forces, 88(5), 2189-2216. Boda, Z., & Szabo, G. (2011). The media and attitudes towards crime and the justice system: A qualitative approach. European Journal of Criminology, 8(4), 329-342. Cliff, G., & Desilets, C. (2014). White collar crime: What it is and where its going. Notre Dame Journal of Law, Ethics & Public Policy, 28, 481-523. Daily newspapers usa: Readers of the indianapolis star, 2015. (n.d.). Retrieved from https://www.statista.com/statistics/229726/readers-of-the-indianapolis-star-in-dailyedition/ Federal Bureau of Prisons. (2017). Retrieved from https://www.bop.gov/about/statistics/statistics_inmate_offenses.jsp Financial Crimes Report 2010-2011. (n.d.). Retrieved from https://www.fbi.gov/stats services/publications/financial-crimes-report-2010-2011 Friedrichs, D. O. (2009). Trusted criminals: White collar crime in contemporary society. Belmont, CA: Cengage Learning. Gottfredson, M. R., & Hirschi, T. (1990). White collar crime. In A General Theory of Crime. Stanford, CA: Stanford University Press. C Ryan 23 Kohm, S. A., Waid-Lindberg, C. A., Weinrath, M., Shelley, T. O., & Dobbs, R. R. (2012). The impact of media on fear of crime among university students: A cross-national comparison. Canadian Journal of Criminology & Criminal Justice, 54(1), 67-100. Latest crime statistics released. (2016). Retrieved from https://www.fbi.gov/news/stories/latest-crime-statistics-released Levi, M. (2008). White-collar, organised and cyber crimes in the media: Some contrasts and similarities. Crime, Law & Social Change, 49(5), 365-377. Neuendorf, K. A. (2002). The content analysis guidebook. Thousand Oaks, CA: Sage Publications, Inc. Perri, F. S. (2011). White collar criminals: The kinder, gentler offender? Journal of Investigative Psychology and Offender Profiling, 8(3), 217-241. Piquero, N. L., Carmichael, S., & Piquero, A. R. (2008). Assessing the perceived seriousness of white-collar and street crimes. Crime & Delinquency, 54(2), 291-312. Podgor, E. S. (2007). The challenge of white collar sentencing. The Journal of Criminal Law and Criminology, 97(3), 731-758. ProQuest. (n.d.). Retrieved from http://search.proquest.com.ezproxy.uindy.edu/indianapolisstar?accountid=28917 Serani, D. (n.d.). If it bleeds, it leads: Understanding fear-based media. Retrieved from https://www.psychologytoday.com/blog/two-takes-depression/201106/if-it-bleeds-itleads-understanding-fear-based-media White-collar crime. (2016). Retrieved from C Ryan 24 https://www.law.cornell.edu/wex/white-collar_crime Wihbey, J. (2015). Rates of fraud, identity theft and scams across the 50 states: FTC data. Retrieved from https://journalistsresource.org/studies/government/criminal justice/united-states-rates-fraud-identity-theft-federal-trade-commission C Ryan 25 Appendix A Code Sheet Code Sheet for Crime News Content Analysis Case Number Click here to enter text. Date Section/Page# Crime Type Blue collar Crime Click here to enter text. Victims Victim(s) Mentioned? White collar Click here to enter text. Crime Click here to enter text. Number of Victims Offenders Offender(s) Mentioned? Newspaper Indianapolis Star Number of Offenders State Indiana Word count Click here to enter text. Article Name Other Click here to enter text. Crime Click here to enter text. Interviewed? If interviewed, how many times did he/she speak? Interviewed? If interviewed, how many times did he/she speak? Words/adjectives used to describe the crime/Are the adjectives suggesting seriousness or relieving of the crime: Word/Adjective Suggesting Seriousness/Relieving Is a rationale or reasoning given? Yes/No  ...

... Improving the Efficiency of Natural Dye Sensitized Solar Cells By Caitlin N. Behme An Honors Project submitted to the University of Indianapolis Strain Honors College in partial fulfillment of the requirements for a Baccalaureate degree with distinction. Written under the direction of Dr. Brad M. Neal April 10, 2017 Approved by: __________________________________________________________________ Dr. Brad M. Neal, Faculty Advisor __________________________________________________________________ Dr. James B. Williams, Executive Director, Strain Honors College __________________________________________________________________ First Reader __________________________________________________________________ Second Reader C. Behme ii Abstract Solar energy has the potential to be a major source of energy for the world if an effective means can be produced to harness it. Various methods of converting solar energy into electrical energy have been explored, including photovoltaic devices. In order for these devices to be viable for large scale production, it is important to improve the efficiency of the devices in terms of both effectiveness and cost. The construction of these devices will be discussed, as well as the trials performed in order to evaluate the performance of the devices. The construction of an instrument built in-house to analyze these solar cells will also be discussed. Dye-sensitized solar cells are an alternative to traditional silicon-based photovoltaic cells and if their efficiencies can be improved, they have the potential to be another viable option for solar energy utilization. Focus will be given to the impact of the different components used to construct the solar cells, the decision to build an instrument to better analyze these cells, and the differences in the observed properties when different sensitizing dyes and electrolyte solutions are used. The products of this project include an instrument to be utilized by future solar cell research students, a better methodology for fabricating the solar cells, and a better methodology for testing the solar cells; as well as preliminary conclusions of the best electrolyte and dye combinations based on completed trials. C. Behme iii Acknowledgement I would like to thank my main honors project advisor, Dr. Brad M. Neal, and my secondary research advisor, Dr. David Styers-Barnett, for their dedication to helping me with this project. They were both instrumental in my completion of this project as well as helping me grow academically and personally throughout my career at the University of Indianapolis. I would also like to acknowledge Dr. Stephen Spicklemire, from the physics department, for his support and instruction throughout the process of building my new instrument. I extend gratitude to James Hall and the Sigma Zeta Research Grant Fund for financial support of this project. Finally, I would like to thank family and friends for their support throughout the course of this project as well as my academic career. Without the support of these people, and others not listed, I would not have been able to produce a project of this caliber, so again I offer my gratitude to them. C. Behme iv List of Tables Table 1: DSSC Variables . 23 Table 2: Prefabricated Cell Data .. 62 Table 3: Blackberry #4 Data .... 64 Table 4: Blueberry #8 Data .. 66 Table 5: Blackberry #11 Data .. 68 Table 6: Blackberry #18 Data .. 70 Table 7: Open Circuit Voltage, Short Circuit Current, and Max Power for All Trials ... 71 C. Behme v List of Figures and Equations Equation 1: Efficiency Calculation .. 14 Figure 1: IV and Power Curve with Important Features Highlighted 15 Figure 2: Fill Factor Calculation .. 16 Figure 3: Silicon Prefabricated Solar Cell ... 18 Figure 4: Natural Dye Sensitized Solar Cell 18 Figure 5: How a DSSC Works . 20 Figure 6: Titanium Dioxide Nanoparticle Solution . 25 Figure 7: Nanoparticle Layer Preparation .... 26 Figure 8: Dry Nanoparticle Layer 27 Figure 9: Counter Electrode . 28 Figure 10: Dye Sensitization 29 Figure 10b: Stained Titanium Dioxide Nanoparticle Layer 29 Figure 11: Garlock Gasket on Glass 30 Figure 12: Fully Assembled DSSC .. 31 Figure 13: Fully Assembled DSSC with Binder Clips .... 31 Figure 14: Ferrocene Crystals .. 33 Figure 15: Ferrocenium Hexafluorophosphate Crystals .. 33 Figure 16: 3-Methoxypropionitrile ...... 34 Figure 17: Schlenk Line Set-Up .. 35 Figure 18: Circuit Diagram .. 37 Figure 19: Block Diagram 1 .... 38 C. Behme vi Figure 20: Block Diagram 2 38 Figure 21: Front Panel . 39 Figure 22: LabView IV and Power Curve ... 41 Figure 23: Back Plate of Instrument 42 Figure 24: Front Plate of Instrument 42 Figure 25: DAQ Board and Circuit .. 43 Figure 26: Instrument Wires Connected to Solar Cell ..... 43 Figure 27: Instrument Set Up ... 45 Figure 28: Example Instrument File Names ... 46 Figure 29: Parafilm Gasket .. 49 Figure 30: Garlock Gasket ... 51 Figure 31: DSSC Test Method 1 .. 52 Figure 32: DSSC Fabricated on Old Glass .. 53 Figure 33: DSSC Fabricated on New Glass . 54 Figure 34: New Glass vs. Old Glass Side by Side Comparison .. 54 Figure 35: Emission Spectrum of the Sun ... 55 Figure 36: Emission Spectrum Grow Lamp 56 Figure 37: Emission Spectrum Projector . 57 Figure 38: Prefabricated Cell IV and Power Curve . 60 Figure 39: Representative IV & Power Curve for Iodine Electrolyte & Blackberry Dye 63 Figure 40: Representative IV & Power Curve for Iodine Electrolyte & Blueberry Dye 65 C. Behme vii Figure 41: Representative IV and Power Curve for Ferrocene Electrolyte and Blackberry Dye .. 67 Figure 42: Representative IV and Power Curve for Ferrocene Electrolyte and Blueberry Dye ...........69 C. Behme viii Table of Contents Cover Page .. i Abstract .............................................................................................................................. ii Acknowledgement ............................................................................................................ iii List of Tables .................................................................................................................... iv List of Figures .................................................................................................................... v Table of Contents ............................................................................................................ viii Statement of Purpose ....................................................................................................... 10 Introduction ...................................................................................................................... 12 Types of Solar Cell Measurements ......................................................................... 14 Types of Solar Energy Available ............................................................................ 17 How DSSCs Work ................................................................................................ 19 How to Read IV and Power Curves ........................................................................ 20 Methods ............................................................................................................................ 23 Overview of Approach ... 23 Preparation of Solar Cells ... 24 Preparation of the Ferrocene/Ferrocenium Electrolyte .. 32 Making the Instrument 36 Testing the Solar Cells 44 Creating the IV and Power Curves . 46 Progression of Project ...................................................................................................... 48 Results and Analysis 60 C. Behme ix Conclusion ....................................................................................................................... 73 Reflection ......................................................................................................................... 75 References ........................................................................................................................ 77 Appendices ....................................................................................................................... 78 Appendix A: IV and Power Curves ....................................................................... 78 Appendix B: Instrument Manual 90 Appendix C: Grant Proposal ................................................................................. 105 Appendix D: CITI Training .................................................................................. 110 C. Behme 10 Statement of Purpose Alternative and renewable forms of energy (known as green energy) are currently being explored by scientists around the world as a way to reduce dependence on oil and coal as a source for energy. Solar energy is a forerunner in potential, sustainable energy. Before solar energy can be used, though, it must be captured, which is where photovoltaic devices (PV devices), also known as called solar cells, come into play. There are many kinds of PV devices which are commercially available and have been used in practice for years, however, their use is not wide spread due to some key issues. One of the problems with traditional solar energy capture is that it is usually done using silicon-based cells. The best silicon solar cells are expensive to fabricate and are susceptible to damage by the elements, such as hail, if used outdoors. The cost of these cells and their durability limit their deployment on large scales without significant financial investment. An alternative to silicon cells are dye-sensitized solar cells (DSSCs). A major issue with DSSCs is that they are not yet efficient enough to be considered as a viable option. There is work being done to address this though, as will be discussed herein. Ultimately, these DSSCs may prove to be more effective than their silicon counterparts if the proper effectiveness to cost ratio can be produced, i.e. one higher than silicon cells have. Many dye-sensitized solar cells are made with a potassium iodide/tri-iodide electrolyte and stained with a dye made from the juice of crushed blackberries. This combination is currently seen as the gold standard for natural dye-sensitized solar cells but has not proven to be as efficient as scientists had hoped. To be able to evaluate solar cells, a variety of parameters must be evaluated. While measuring the technical definition of C. Behme 11 efficiency for solar cells was deemed to be out of the scope of this honors project, the maximum power and current driven by the cell were decided to fall within the scope of being able to record and evaluate. The main focus of this project is to look at different electrolyte and berry dye combinations to determine the best combination to produce the maximum amount of power. An additional benefit of this project was the creation of a new instrument for testing solar cells fabricated by future undergraduate students in their own research projects. C. Behme 12 Introduction Scientists around the globe have reached a consensus that humans are consuming oil and coal to produce energy faster than the Earth can reproduce these resources.1 The Environmental Protection agency finds coal fired power plants excessively harmful to the environment and is working to reduce the dependence on energy gotten from coal and it has been determined that between 2008 and 2035 the global electricity generation is expected to increase 2.2% per year to sustain energy demands by the growing populations.1 One form of renewable energy that scientists are focusing their research on is solar energy.2, 3, 4, 5 The sun provides an abundant supply of solar energy to the Earth at a rate of 3.0 x 1024 joules per year, which is more energy than the population of the earth currently consumes per year.1 If this energy can be harnessed, particularly with the use of low cost solar cells using renewable components such as organic dyes, the worlds energy demands can be met at a lower price with less potential environmental repercussions, including exhausting the supply of natural resources. Scientists are working hard to improve the efficiency of all kinds of solar cells to maximize the energy converted while reducing the cost to fabricate these cells. Michael Grtzel, known widely as the father of dye-sensitized solar cells (DSSCs), was one of the first scientists to begin working with DSSCs in an attempt to improve their energy conversion efficiencies to the point where they could be substituted for silicon solar cells. These cells are assembled with nano-crystalline inorganic oxides, ionic liquids (electrolytes), and an organic dye with a hole conductor.6 Although Grtzel has managed to make great improvements in the DSSCs he fabricates; they still are not viable when C. Behme 13 compared to silicon cells in terms of energy conversion efficiency. Also, Grtzel is one of few scientists who have managed to reach the higher end of DSSC efficiency, near 11%2 compared to 40%7 for a typical silicon solar cell. There are many different and important measurements and calculations that must be made when testing and analyzing the results of the solar cell experiments.7 Open-circuit voltage, short-circuit current, and maximum power of the cells are important measurements and calculations to make during the test cycle. Energy conversion efficiency, fill factor, incident photon to current efficiency, diffusion coefficient and the nanoparticle layer thickness are a few of these measurements and calculations made during analysis. These factors are used to grade solar cells as good or bad and comparable to accepted literature values or not comparable. At the beginning of this honors project it was hoped that all or most of these measurements could be recorded or calculated in order to compare the results of the experiments to published results. It was quickly realized that not all were possible with available equipment, so decisions were made of what measurements were most important and how they could be obtained on a low-cost budget. For this reason, a new instrument was built to record some of these more important measurements and calculations, including open-circuit voltage, short-circuit current, and maximum power, which will be described below. C. Behme 14 Types of Solar Cell Measurements The basic idea of solar cell efficiency is that it is a ratio of energy output from the solar cell to energy input from the sunlight.7 This means that the number of photons from the sun directly influences the ability of the solar cell to convert energy. Cloud cover, temperature, and angle of light can also greatly affect the power outcome, or energy produced, of the solar cell. For this reason, although efficiency is an important calculation, it is not the sole measurement that should be taken. Also, testing conditions must be carefully noted so that proper comparison can be made when referencing published results from other experiments. Efficiency is calculated using the open-circuit voltage, shortcircuit current, fill factor and the power input from the sun, which can be seen below in Equation 1. Power input can be directly calculated using available instrumentation, the other factors can be more difficult to obtain. Due to the complexity of calculating efficiency, it was decided this would not be a measurement focused on in the course of this honors research project. Equation 1: Efficiency Calculation = ()() () Equation 1: This equation shows how the calculation for efficiency is performed, where n is the efficiency, V(OC) is the open circuit voltage, I(SC) is the short circuit current, FF is the fill factor, and P(IN) is the power output of the light source. Three measurements of the solar cell can be found using IV (current-voltage) and Power Curves, as shown in Figure 1 below for an example of an IV curve. The first measurement, the short-circuit current, is the maximum current produced from a solar cell, C. Behme 15 it can be found where the IV curve crosses the y-axis.7 The second measurement is the open-circuit voltage, which is where the solar cell produces maximum voltage. This can be found where the IV curve crosses the x-axis.7 The problem with both the open-circuit current and open-circuit voltage is that at these points the power produced by the solar cell is zero. The reason the power is zero is that where the maximum current (open-circuit current) is found is that the voltage is zero and the opposite is true for the open-circuit voltage.7 Power is the product of the current and voltage multiplied, so when one is zero the power is zero. The third measurement is found on the Power Curve portion of the graph; it is the data point where the y-value (power) is at its highest (also known as y-max).7 To find where the maximum power output of the solar cell occurs the fill factor (FF) is determined, and a larger fill factor can mean a higher maximum voltage produced by the solar cell.7 Fill factor is a derivative of the maximum power taken with respect to voltage and setting it equal to zero. An easier way to determine fill factor is to take the ratio of two areas of the IV curve, this can be seen below in Figure 2.7 It is also further discussed below C. Behme 16 in the section titled How to Read IV and Power Curves. For this research project, fill factor was not a calculated measurement due to limited resources and being unable to accurately determine some of the measurements. Incident Photon to Current Efficiency (IPCE) is another way to measure the efficiency of the solar cell at converting solar radiation into electrical energy. IPCE is a way to relate the ratio of measured electrons as current in the test circuit to the photon flux at one wavelength that reaches the cell.8 It includes measurements of the efficiency of the solar cell at harvesting light at a specific wavelength, the number of electrons that leave the sensitizer and reach the conduction band of the semiconductor oxide, and the efficiency of collecting electrons. IPCE is an important measurement, but it is another difficult measurement to make with limited resources and a complex equation so it was decided to forgo attempting to calculate IPCE.8 C. Behme 17 The above-mentioned measurements are not the only types of measurements discussed in literature. However, other measurements, such as diffusion coefficients and nanoparticle layer thickness, were deemed out of the scope of this research project from the beginning and thus were never studied in depth. Although these types of measurements may be important depending on the variables being tested, they are not considered the most important measurements and it was determined that not pursuing them would not diminish the results of this honors project. Types of Solar Energy Available There are two main types of solar cells currently on the market or being tested by researchers. The first is the type of solar cell that typically comes to mind when people talk about solar energy, silicon cells.7 They are made using special doped silicon and must be made in a clean lab for this reason, as shown in Figure 3 below. Thus far, they have reached the highest energy conversion efficiencies of any solar cell, around 40% efficient.7 However, these cells are expensive to fabricate due to the cost of material and the clean lab is needed for manufacturing. Another type of solar cells, the ones many researchers are currently focusing their efforts on, are natural dye-sensitized solar cells, as shown in Figure 4 below. These solar cells are much cheaper to fabricate, as the materials needed are abundant and no clean lab is needed for most of their fabrication and manufacturing. The main problem with these solar cells is that the maximum-recorded efficiency is just over 11% and most efficiencies hover between 1-7%.1 This is not high enough for this type of cell to be considered a viable option for consumers to rely on. Scientists are working hard C. Behme 18 to rapidly improve this energy conversion efficiency in the hopes that solar energy will be a more attainable option for more consumers in the near future. How DSSCs Work C. Behme 19 Dye-sensitized solar cells have several important parts that come together to form a working solar cell, as seen in Figure 5 below. Briefly, a sensitizer (the berry dye) is attached to the titanium dioxide (oxide) layer so that when photo-excitation of an electron due to a photon (from the sun) occurs the electron can be transferred to the conduction band of the oxide.6 This electron transference can only occur when the energy of the photon striking the berry dye closely matches the energy gap of the dye molecules. This energy gap, also called a band gap, is the energy difference between the highest occupied molecular orbital (HOMO) and the lowest unoccupied molecular orbital (LUMO).9 What this means is that energy transferred from the photon must be enough for the electron sitting in the HOMO to be excited and jump levels to the LUMO.9 The dye is then regenerated with an electron from the electrolyte/ionic liquid which contains a reduction-oxidation system.10 Regenerating the dye prevents it from recapturing the excited electron, it also allows the reduced electrolyte to oxidize itself at the counter electrode. This step completes the circuit and allows electron migration through the system. This process produces a voltage and a current that can be measured with a multimeter when wired between the cathode and counter electrode.6 C. Behme 20 How to Read IV and Power Curves IV and Power curves contain the necessary components to determine important information about the solar cells. Although they contain several parts, these curves are not difficult to interpret, as shown in Figure 1 above for a representative IV and Power curve from this project and Figure 2 for an IV and power curve from the literature. The first measurement that can be determined is from the IV curve and is the short circuit current produced by the solar cell.7 This can be found by looking at the flat portion of the curve. This flat portion extends to the left until it crosses the y-axis; the point at which it crosses is the short circuit current, seen on Figure 1 above. This is also the maximum y-value in the data set; it is marked on the figure with a circle around the data point.7 C. Behme 21 The second measurement that can be determined from the IV curve is the open circuit voltage produced by the solar cell. This voltage can be found by determining where the sloped portion of the curve crosses the x-axis, which is to the right on the curve in Figure 1.7 This is the maximum x-value in the data set. The third measurement is one that can be determined from the Power curve, it is the maximum power produced by the solar cell. This is the data point with the largest y-value in this data set.7 It is found where the Power curve slope changes from positive to negative and it is also typically a harsh turn, not a slow change. Both of these measurements are also marked on the IV and Power curves shown on Figure 1, with a circle around the data points.7 The information gained from these curves can then be used to determine the fill factor and eventually the efficiency of the solar cell. Determining two areas under the curve can do this, as seen above in Figure 2. The first area is the square area of the IV curve, it will be larger than the actual area under the curve, but multiplying the short circuit current and open circuit voltage together will determine this area.7 The second area is the square area based on the maximum power of the solar cell. This area can be calculated by multiplying the voltage and current at the maximum power point of the IV curve. This area will be slightly less than the actual area of the curve. Fill factor is a ratio of the second area divided by the first area.7 This fill factor can then be used in the equation to find the efficiency. The equation involves multiplying the short circuit current, open circuit voltage, and fill factor then dividing by the total power input into the solar cell.7 Without the IV and Power curves, these measurements would be difficult or not possible to obtain. These measurements are important if the solar cells fabricated in the C. Behme 22 honors research project are to be compared to those found in literature so to that end, a new instrument was designed and constructed as part of this project. Due to an improvement that needs to be made to the new instrument, which is explained below, these measurements will need further investigation. However, because this instrument has been built, research students at the University of Indianapolis are several steps closer to being able to make all the above-mentioned measurements, instead of just being able to measure the short circuit current, open circuit voltage and the maximum power. C. Behme 23 Methods Overview of Approach A method for building and testing the solar cells was modified from a University of Kansas inorganic chemistry laboratory experiment.12 Table 1, below, lists the different variables tested, and where the variables came from, meaning whether they were bought or synthesized. Before the chemicals were used in any trials, they were stored in the chemical preparation room under proper storage conditions. Proper storage was critical to ensure no chemical contamination occurred, as well as reducing the potential for harm caused by the potent chemicals. Chemicals that were synthesized in the lab were stored in glass volumetric flasks and disposed of according to material safety standards after their use. Excess electrolytes, berry dyes, and titanium dioxide nanoparticle suspensions prepared were disposed of immediately and properly after each trial instead of being reused in later trials. This was to ensure a known concentration of each solution was used as well as reduce the potential for contamination between trials. In addition, experiments showed degradation of the electrolytes and titanium dioxide nanoparticle suspension over time, which reduces the efficiency of the solar cells at converting energy. Software built during the latter portion of this project was ultimately used to collect the data from each trial and quantitatively determine the IV curve and maximum power output of each cell. Table 1: DSSC variable combinations tested ELECTROLYTE Iodine Iodine Ferrocene Ferrocene BERRY DYE Blackberry Blueberry Blackberry Blueberry Table 1: Chart of electrolyte and berry dye combinations used during the trials C. Behme 24 Preparation of Solar cells12 There are three important and distinct parts to fabricating and assembling the natural dye-sensitized solar cells. The first part is preparing the titanium dioxide nanoparticle layer and sensitizing it with the dye created from crushed berries. The second part is preparing the counter electrode and the final part is assembling the solar cell using the first two parts and an electrolyte. Care must be taken when preparing solar cells, if not assembled correctly the solar cells will be useless and the chemicals used can be dangerous if not handled properly. For fabrication of the first part in making the solar cells a piece of conductive glass is coated with a titanium dioxide (TiO2) nanoparticle layer, which is doped with benzene1,3,5-tricarboxylic acid, also known as trimesic acid, to help it create a stronger adhesion between the TiO2 with the glass. The titanium dioxide used is a fine, low-density white powder and 0.75 grams was weighed into a weigh boat using an analytical balance before being placed into a mortar. Trimesic acid is a bulky, clear crystalline solid and 0.0075 grams was weighed into a new weigh boat, using an analytical balance, before being placed into the mortar with the titanium dioxide. 4.25 Milliliters of deionized water was poured into the mortar. This mixture was then ground together for 15-20 minutes, creating a uniform consistency and viscosity within the mixture, as shown in Figure 6 below. The glass slide to be coated with titanium dioxide was connected to a digital multimeter using alligator clips touching one surface of the glass. The ground clip and the positive clip must both be touching the same side of one piece of glass to complete the circuit and obtain measurable reading. The Ohms setting is used, this is a measure of resistance through the C. Behme 25 circuit across the glass slide. The side of the glass that has a finite resistance is the conductive side; the nonconductive side will return an overload value to the multimeter. Figure 6: Titanium Dioxide, trimesic acid, and water that has been ground together with a mortar and pestle. Once the conductive side is determined the glass must be cleaned before proceeding. Acetone was poured over the glass and the glass was allowed to dry completely. Once dried, the glass must be prepared for the titanium dioxide nanoparticle layer. Four pieces of tape were used to create a well for the titanium dioxide solution to sit in while drying. Three pieces of the tape were placed along the edge of the glass slide, covering about 2-3 millimeters of the edges. The fourth piece of tape was placed long the last edge, covering about 5 millimeters of the edge. This fourth edge is important for offsetting the assembled solar cell to allow alligator clips to be attached for testing. The tape must be pressed firmly to the glass to create a tight seal, with special care taken at the corners where the tape meets. Using a glass stir rod, 5 drops of the titanium dioxide suspension were placed on the glass C. Behme 26 inside the well of tape. One drop was placed near each corner of the well and one drop was placed near the center. A razor blade was then dragged across the titanium dioxide suspension to create a more even coating and the suspension was allowed to dry for 30 minutes. Dragging the suspension is important to create a dried nanoparticle layer with a smoother, rather than ridged, surface as the smooth surface allows for easier electron flow. The nanoparticle suspension on the conductive glass can be seen below in Figure 7. After the suspension dries enough to pull the tape off, it was carefully removed and the slides were placed in an oven for at least 6 hours. The dried titanium nanoparticle layer can be seen in Figure 8 below. C. Behme 27 The second part of fabricating solar cells is preparing the counter electrode. To do this, the conductive side must be determined using the same manner as previously described. Once found, the conductive glass must be cleaned and prepared for its carbon coating. To clean the glass, it was rinsed with acetone and allowed to dry. To prepare it for the carbon coating it was then rinsed with reagent alcohol, which is a solution of 95% ethanol and 5% methanol. A tea candle was lit and the glass slide was held conductive side down over the candle using a pair of tongs. The glass slide should be slowly moved back and forth across the flame from the candle to evenly coat the conductive slide with a layer of soot. This carbon soot forms the counter electrode for the solar cell and is shown in Figure 9 below. C. Behme 28 While the glass slides were cooling after being removed from the oven, another mortar and pestle were obtained and 4 berries (blackberries or blueberries, depending on the trial) were crushed to release the juice. It is important to crush the berries well to release as much juice as possible while also breaking up large berry chunks. Large chunks tend to stick to the titanium dioxide nanoparticle layer and when removed can often pull some of the nanoparticle layer with them, which reduces the surface area viable for electron excitation to occur. Once cooled, the slides were rinsed with deionized water then acetone, lightly to ensure the titanium dioxide coating was not removed. The slide was then placed titanium dioxide nanoparticle layer side down in the berry dye for 15 minutes to sensitize the oxide layer, as shown below in Figure 10. After removing the glass slides from the stain, they are rinsed with acetone again and lightly blotted dry with a kimwipe, as shown C. Behme 29 below in Figure 10b. It is important to dry the glass after each step to ensure no water or other chemicals get sealed into the cell, as this could affect the productivity of the cell. Once dry, the first and second parts of the solar cell are ready to be assembled together in the third part of the fabrication process. A piece of Garlock Gylon PTFE gasket was used to form a seal between the two pieces of conductive glass. The gasket is cut to C. Behme 30 match the size of the conductive glass, however on one edge it is cut about 2 millimeters short to allow for the offset glass and alligator clip connection. Once this rectangle is cut out, a rectangular hole is cut out of the middle. This rectangular hole leaves an opening where the titanium dioxide nanoparticle layer on the one piece of conductive glass is located. The gasket is then placed on the titanium dioxide coated glass slide and pressed down, as shown below in Figure 11. Three drops of the chosen electrolyte solution (in this project either the iodide/tri-iodide electrolyte or the ferrocene/ferrocenium electrolyte) are dropped into the newly formed well, covering the titanium dioxide nanoparticle layer. Next, the carbon coated counter electrode was placed on top of the gasket to complete the solar cell. It is placed slightly offset from the other conductive glass to leave an overhang on either side of the cell, as shown in Figure 12 below. This is to allow for the alligator clips to attach to the cell during testing. Two binder clips are attached to the solar cell to compress the gasket and make a tight seal, which can be seen in Figure 13 below. C. Behme 31 These binder clips are placed on the two flush edges, but they must not cover the titanium dioxide nanoparticle layer, or else productivity of the cell will be reduced. When the binder clips are attached, some electrolyte will leak from the edges. A kimwipe is used to remove the excess electrolyte as well as clear the carbon coating off the overhang from the counter electrode. Here, it is important to dry the two electrodes well so that when the alligator clips are attached the liquid does not short the circuit out. Preparation of the Ferrocene/Ferrocenium Electrolyte C. Behme 32 The ferrocene/ferrocenium electrolyte was synthesized with the help of the honors research advisor. If not handled with caution, this synthesis can be dangerous. Ferrocene can cause eye, skin, intestinal, and respiratory irritation with prolonged exposure.13 If exposure occurs the area should be flushed and a physician contacted. Ferrocenium hexafluorophosphate can cause eye, oral, intestinal, skin, and respiratory irritation with prolonged exposure.14 If exposure occurs the area should be flushed and a physician contacted. 3-methoxypropionitrile can cause eye, skin, respiratory, and intestinal irritation with prolonged exposure.15 If exposure occurs the area should be flushed and a physician contacted. Ferrocene is a rust colored crystal that provides the reduced state of the electrolyte; its crystals can be seen below in Figure 14. A 0.10 molar ferrocene solution was prepared from 0.1863 grams of ferrocene and 10.00 mL of deionized water.16 Ferrocenium hexafluorophosphate is a dark blue crystal that provides the oxidized state of the electrolyte; its crystals can be seen below in Figure 15. A 0.10 molar ferrocenium hexafluorophosphate solution was prepared from 0.3309 grams of the ferrocenium hexafluorophosphate and 10.00 mL of deionized water. 16 3-methoxypropionitrile was bought as a solution and was not diluted in any way, as shown below in Figure 16.16 C. Behme 33 C. Behme 34 To prepare the electrolyte, 10 milliliters of the ferrocene solution, measured out with a volumetric flask, and 10 milliliters of the ferrocenium hexafluorophosphate solution, measured out with a volumetric flask, were mixed in an Erlenmeyer flask with excess 3methoxypropionitrile, then mixed with a stir bar on a stir plate until a consistent solution is formed, which took approximately 10 minutes.16 When the ferrocenium hexafluorophosphate and ferrocene were combined with the 3-methoxypropionitrile the solution turned a dark green/blue color. After mixing, the solution was bubbled with nitrogen to remove oxygen molecules from it. Putting a rubber tube on a nitrogen tank and affixing a capillary tube to the end did this. This capillary tube was then placed into the C. Behme 35 volumetric flask with the solution and allowed to bubble the nitrogen through the solution for 10 minutes. The Schlenk line can be seen below in Figure 17.16 The electrolyte was used immediately in the solar cells and tested. Excess electrolyte was kept isolated in a gas hood, originally to be used in later experimental trials. It was determined through trial and error that if any flasks containing the solution are agitated the solution crashes, which means the ferrocene and ferrocenium hexafluorophosphate solutions precipitate and a color change of the remaining solution occurs. It was hoped that excess electrolyte could be used in future experimental trials, but after several days isolated in a gas hood the solution was also susceptible to crashing and precipitating. Therefore, it was determined that the ferrocene/ferrocenium electrolyte must be freshly synthesized every time it is to be used in the fabrication process. C. Behme 36 Making the Instrument A new instrument was built and a computer program was created to make a solar cell current-voltage (IV) curve based on a paper written by a Bowling Green State University research student.17 The first part of the experiment was to build a circuit, illustrated below in Figure 18, that the solar cell could be hooked into for testing. The circuit was designed to send a voltage into the positive terminal of the operational amplifier using a data acquisition (DAQ) board to do so. The operational amplifier then demands the negative terminal of the circuit to match the current produced by the voltage going into the positive terminal. The solar cell is attached to the negative side of the operational amplifier in the circuit. This means that the voltage producing the current from the conversion of sunlight into electrical energy from the solar cell must match the current from the DAQ board. A transistor is contained within the circuit to ensure the current flows the correct way through the circuit into the operational amplifier. Resistors are used in the circuit to scale the current and voltages to those that match the current and voltage going into the operational amplifier. The computer program that was built to control the circuit takes into account the resistors and scale factors when calculating and measuring the current and voltage. C. Behme 37 A LabView computer program was written to control this new instrument; the block diagrams and front panel can be seen in Figures 19, 20 and 21, below. The purpose of the computer program is to drive the circuit by controlling a DAQ board as well as create the graphical representation of the recorded data. The program is split into three parts; the first one that sets the voltage of the positive of the operational amplifier, the second one that measures the voltage and current produced by the solar cell to match, and the third one that writes the IV and Power curves after the trial is completed. This instrument is important in reducing measurement error and increasing comparability of results, which moved this honors project forward. C. Behme 38 C. Behme 39 The first part of the program uses the computer to send a message to the DAQ board. This message tells the DAQ board to send a voltage to the positive terminal of the operational amplifier. The purpose of the operational amplifier is to match the current coming into the positive and negative terminals. The program is designed to run in iterations, starting at zero volts and increasing stepwise. It tells the DAQ board to send the proper voltage to reach the current needed for that iteration of the program. The maximum voltage the DAQ board can provide is a +5 volt but the program will rarely, if ever, send that high of a voltage to the circuit. The researcher sets the maximum current the circuit receives from the DAQ board as well as the number of steps the program will run to reach the maximum current. C. Behme 40 The second part of the program tells the DAQ board to read the digital input channel for the voltage and current coming into the negative terminal of the operational amplifier. This terminal is connected to the solar cell, so the voltage and current readout are those being produced by the solar cell. After each step the program pauses to allow the solar cell to react to the increase in current to the operational amplifier. After this pause, the DAQ board reads the new voltage and current, this cycle continues until the maximum current set by the researcher is reached. The third part of the program was designed to write the two graphs, the IV and Power curves. The computer records each data point collected from the second part of the program and compiles them together on a single graph with two y-axes. These curves can be seen below in Figure 22. The IV curve is built from the current and voltage collected from the digital input. The voltage is graphed on the x-axis and the current on the y-axis. The data points are connected by a smooth marked line. The power curve is built from the current times the voltage and the voltage. The voltage is graphed on the x-axis and the currentvoltage, also called the power, is graphed on the y-axis and the data points are connected by a smooth marked line. This graph will show up automatically on the front panel of the program but will not be exported with the .lvm file that the program saves the experimental trial as. These graphs must be recreated when analyzing the results using Excel. C. Behme 41 The instrument is contained in a small plastic box of dimensions 3.5 inches wide by 7.0 inches long, with a metal plate at the front and back ends of the box. Only the necessary cables come out of the front and back of the instrument, all wiring and electronics are otherwise housed within the box for safety and protection from damage. A LabJack U6 DAQ board was chosen and wired into the instrument. A hole was drilled into the back plate for the USB cable from the DAQ board to connect the instrument to the computer; this can be seen in Figure 23 below. The computer is connected to a power source and must be powered on for the instrument to work. Two holes were drilled into the front plate and two Bayonet Neill-Concelman (BNC) connectors were attached, as shown in Figure 24 below. The circuit is connected to the BNC connectors and the DAQ board, which can be C. Behme 42 seen in Figure 25 below. One wire is attached to each BNC connector and at the end of each wire is an alligator clip. One wire gets connected to the positive terminal of the solar cell and one wire gets connected to the negative of the solar cell, these wires are properly labeled for ease of use and are shown in Figure 26 below. After the instrument was assembled and tested, the top plate of the box was screwed into the bottom to complete the instrument. C. Behme 43 C. Behme 44 Testing the Solar Cells Before the instrument can be used to test the solar cells fabricated in the experimental trial the computer must be plugged into its power source and powered on. Before opening LabView, the USB cable from the instrument should be plugged into the proper channel on the computer. LabView will open with a menu of program files, select the Solar Cell Curve Generator file and wait for the front panel to open. The block diagram of the LabView program should never be opened during normal solar cell testing. The only time it should be opened is if an instrument malfunction occurs and it must be determined if the problem is contained within the circuit or the computer program. Ensure the program recognizes the DAQ board is connected. If LabView does not acknowledge the DAQ board refer to the instrument manual, which is attached in Appendix B, for troubleshooting. If everything is in order, connect the solar cell to the instrument using the labeled alligator clips coming from the front of the instrument. The red alligator clip gets connected to the positive of the solar cell, or the titanium dioxide coated piece of glass. The black alligator clip gets connected to the negative of the solar cell, or the carbon coated counter electrode. Ensure both alligator clips are tightly connected so that if the table or solar cell is bumped the connection will not be lost. Turn the overhead projector on, but use caution, as this light is bright and can harm the eyes if care is not taken to avoid looking directly at the source. Place the solar cell under this light with the titanium dioxide coated glass piece facing the light. Care should be taken to ensure that the solar cell is always placed in the same distance and angle from the light source to C. Behme 45 decrease variability between trials. Figure 27, below, shows how the instrument looks when set up for testing DSSCs in the laboratory. On the front panel of the instrument important information about the trial should be noted in the text box; including the solar cell identifier, the resistor used for the curve generation, what experiment the cell belongs to, and any other pertinent information that will help the researcher when analyzing the results. After this step has been completed the auto save button can be turned on, which can be verified if the auto save button is green. The button to run the program can now be pressed so that the curves will be generated. This button is a white arrow with a black outline and can be found towards the top control panel of the front diagram. After the program finishes running the instrument, it will automatically save the file and ask the researcher to name it. The trial should be saved to the researchers personal folder inside the solar cell research folder under this title format: Researcher Initials_Date of Experiment_Lab Notebook Page Number_Cell Identifier (note that no spaces should be used in the title between words and the underscore should be used C. Behme 46 between sections), and example can be seen in Figure 28 below. This file should be saved as an .lvm file so that it can later be exported to an excel file for analysis. Creating the IV and Power Curves After all of the solar cells have been tested LabView can be shut down and the overhead projector light turned off. The files can now be opened in Excel and the IV and Power curves can be generated. The IV curve is a current versus voltage graph where the data points come directly from the results at the end of each iteration of the program. The Power curve is a voltage versus voltagecurrent (voltagecurrent is equivalent to power) graph where the data points came from the product of the current and voltages from each iteration of the program graphed versus the current at which the resulting power occurred at. Both of these curves should be generated using a smooth marked scatter plot with no C. Behme 47 trend line, slope equation, or R2 value added. Both generated curves should be plotted on the same graph with the same x-axis, however they should be plotted on separate y-axes. The same x-axis is used because both curves are graphed against voltage, and the voltage values for each data point will be the same. The separate y-axes are used to allow for proper scaling of each curve to ensure ease of readability. The graphs should have major and minor tick lines on each axis but it is up to the researcher to decide if background lines should show up on the graph or if they should be left out. For this honors project the tick lines were used on the axes but not behind the curves. Once the curves have been generated the Excel file can be re-saved under the same file name. The IV curve allows the researcher to easily find the open-circuit voltage and shortcircuit current values produced by the solar cell during energy conversion. The Power curve allows the maximum power output of the solar cell to be determined, as well as the voltage at which this power occurs. These two curves are easy to read and understand and the information they provide is important in the analysis of the productivity of the experimental solar cells. This instrument is also important in allowing the solar cells built at the University of Indianapolis to be compared to those built by other researchers who have published their findings. This is an important step forward if this research is to be continued by other research students. C. Behme 48 Progression of the Project The original goal of this honors project was to test three different dyes obtained from crushed berries and three different electrolytes for a total of 9 different combinations to determine which combination of electrolyte and dye would produce the highest energy conversion efficiency. The berries were chosen based on local availability and the relative darkness of dye produced, which was determined visually. The idea is that dyes from a darker berry, such as a blackberry, absorb more wavelengths of visible light and therefore allow more solar energy conversion due to more electrons being promoted to their LUMO and falling into the channel created by the titanium dioxide nanoparticle layer. Blackberries, blueberries, and strawberries were chosen, this gave a dye with a darker color, one with a medium color, and one with a lighter color. The dyes produced by the crushed berries can be seen below in Figure 28. By using a berry that provides a dye in each of the relative darkness categories, it can be determined if the original ideas about wavelength absorption had an effect. The electrolytes chosen were a two-step oxidation-reduction iodide/tri-iodide electrolyte, a one step oxidation-reduction reaction ferrocene/ferrocenium electrolyte, and a one step oxidation-reduction reaction cobalt electrolyte. The iodide electrolyte is commonly used in literature, so it was chosen as the gold standard electrolyte to compare the results of the ferrocene and cobalt electrolytes to. The ferrocene and cobalt electrolytes were chosen for their one step oxidation-reduction reaction in the hopes that a higher energy conversion efficiency will occur because of a lower amount of energy needed to drive the crucial oxidation-reduction cycle of the electrolyte. Premade iodide electrolyte C. Behme 49 was used in the cells but it was decided that the ferrocene and cobalt electrolytes would be synthesized in-house alongside the project research advisor. While working on the honors project proposal, a semester was spent on preliminary research to prepare for completing the honors project, if accepted. This preliminary research was necessary to prepare for the research to be done for the honors project. This semester was spent mastering the solar cell fabrication process to ensure reproducibility from trial to trial. During this time, it was realized that even the best solar cells produced by the methods described previously lasted only a few hours before their gasket failed and the majority of the electrolyte leaked from the cell. Once the electrolyte leaks out the solar cell is rendered useless, which is a problem that needed to be fixed before any work on the honors project could begin. At the time, a parafilm gasket was previously used in the solar cell fabrication process; an example can be seen in Figure 29 below. Parafilm is a type of pliable plastic often used to cover beakers and Erlenmeyer flasks. This parafilm gasket did not create a tight seal and even with the pressure applied from the binder clips could not keep the electrolyte in the well. C. Behme 50 After researching many other types of gasket, it was decided to test a type of gasket called Blue Gylon Style 3504, which is a polytetrafluoroethylene (PTFE) material with aluminosilicate microspheres contained within it. An example of this gasket can be seen below in Figure 30. This gasket is a product of Garlock, a major gasket producing company located in New York. This Gylon gasket is made from thicker and sturdier material, which makes it easier to work with than the previous parafilm gasket. This gasket allows more of the electrolyte to sit in the well it creates as well as creates a tighter seal between the two pieces of conductive glass. Using this gasket increased the longevity of the solar cells from only a few hours to several weeks. Most cells created using the new gasket material were still viable after 7 weeks and several lasted as long as 9 weeks. This new gasket also streamlined the fabrication process, as it decreased the time it took to assemble the solar cells, and increased ease of assembly, as the Gylon gasket is much easier to place into between the conductive glass slides than the flimsy parafilm gasket. Increasing the longevity and ease of assembly of these solar cells was an important step forward during the preliminary research period and would prove vital to the honors project research. If the solar cells last less than one day, few results can be obtained and they will never be viable as a potential source of renewable energy for consumers. C. Behme 51 In addition to finding a new gasket to use in fabrication of the solar cells, the preliminary research period was also spent creating a more standardized method to testing the solar cells after fabrication. The original method used a digital multimeter was attached to the solar cells using alligator clips, one on the anode and one on the cathode. Other than those instructions, no official procedure was in place to ensure consistency between trials. This would reduce the validity of any results obtained during the honors project research. To collect meaningful data, a method of irradiating the solar cells with a consistent light source needed to be developed. To this end, a variety of options were evaluated. Previous work by other students had focused on using a plant grow lamp as a light source. It was chosen as it was supposed to mimic the spectral output of light produced by the sun. As such, this lamp was incorporated into this work toward a new standardized test procedure. A box, made of foam core poster board and metal sewing pins, was built to house the new lamp and solar cells during testing. The box was made to fully enclose the lamp and block ambient light from the overhead lamps and sunlight through the windows. By blocking C. Behme 52 ambient light, it can be ensured that the only source of light causing energy conversion in the solar cells was the light coming from the plant grow lamp. This new box allows more consistent testing and results from each trial of fabricated solar cells, which is vital to the honors project research if accurate analysis is to be performed. This test set-up can be seen below in Figure 31. The new standardized procedure included putting the plant grow lamp into the new box and plugging it into a power source. The solar cell was placed on the taped x on the lamps holder. The solar cell was placed with the titanium dioxide coated side upwards facing the lamp. The red alligator clip was attached to the cathode and the black alligator clip attached to the anode. The front door of the box was shut with the solar cell inside while measurements are being recorded. The lamp was left off and the digital multimeter C. Behme 53 is used to measure the voltage and current produced by the internal chemistry of the solar cell. The lamp was then switched on and the current and voltage were again measured with the digital multimeter. These measurements were recorded and later compared between cells. At the end of the semester, the honors proposal was accepted and the preliminary research was incorporated into the start of the honors project research. It was determined that the current and voltage produced by the solar cells was still lower than expected. It was hypothesized that the glass used in the cells had worn out after being reused multiple times. Supporting evidence for this came in the form of the internal resistance increasing over time presumably because the glass sides were becoming more difficult to clean properly due to TiO2 and carbon soot being stuck to the glass. New glass was ordered, and after a trial to compare the results with the old glass it was determined that some diminished energy conversion was resulting in the old glass. A DSSC assembled with the old glass can be found below in Figure 32, a DSSC assembled with the new glass can be found below in Figure 33, and a side-by-side comparison of the glass can be found in Figure 34, seen below. C. Behme 54 Although the results were slightly better, after several trials with the new glassware the results were still not as high as previously expected. It was then hypothesized that the light source being used was not putting off the expected wavelength spectrum. To test this theory a red tide emission spectrometer was borrowed from the physics department to determine the wavelengths of light produced by the plant grow lamp. C. Behme 55 The red tide emission spectrometer measures the intensity of light from all wavelengths in the visible and ultraviolet light spectra. If the grow lamp produced a wavelength spectrum similar to that of the sun, it would show up as a fairly smooth curve with intensities for every wavelength of light in these two regions, there would be no large, distinct peaks. However, the spectrum from the grow lamp had distinct peaks at the red, blue, and yellow wavelengths, which can be seen below in Figure 35. These wavelengths match those put off from individual light emission diodes better than those of the sun, which can be seen in Figure 36. Although these wavelengths can be considered some of the more important ones, they are not the only ones that the berry dyes absorb at and therefore only using those wavelengths diminished the solar cells ability to convert light into electrical energy and its maximum capacity. Additionally, this does not mimic the emission spectrum of the sun seen in Figure 35. C. Behme 56 The red tide emission spectrophotometer was used to look at other available light sources to determine if any of them had an emission spectrum more similar to that of the sun than the grow lamp. When an overhead projector lamp was tested, it had a smooth emission spectrum, with no distinct peaks having higher emission intensity than others. This smooth curve can be seen below in Figure 37. It was decided that moving forward, the overhead projector would be used when testing solar cells instead of the plant grow lamp and the test box. It was hoped that this change would help greatly increase the voltage and current produced by the solar cells when converting energy during trials and better mimic true working conditions for a solar cell being outdoors. C. Behme 57 The next task was to focus on synthesizing the two new electrolytes and comparing them to the iodide electrolyte. Due to unforeseen circumstances, only one electrolyte was synthesized. These syntheses are time intensive and require direct supervisor supervision due to potentially dangerous chemicals that need proper handling and it was difficult to find the sufficient blocks of time to complete these syntheses. It was decided to synthesize the ferrocene/ferrocenium electrolyte first. After completion of this electrolyte synthesis was complete, testing under normal conditions was performed. After testing, it was realized that proper measurements to calculate efficiencies could not be recorded due to the instrument capabilities at the time. Work toward finding a better method to collect voltage and current data from the solar cells was then prioritized to help move the honors project forward. Eventually, a paper was found where the researchers built an instrument and a computer program to run the instrument which could collect the necessary data from the C. Behme 58 cells. It was decided to properly understand the results from the cells being created, a detour from the original proposal of the honors project would be necessary. This detour would be to build an instrument that records better measurements for better analysis of the fabricated solar cells. If the instrument could be built and properly tested, the original goal of the honors project would be resumed and enhanced. The prototype for this instrument was built during a three-week summer research internship under the direction of Dr. David StyersBarnett and with the help of Dr. Stephen Spicklemire. This instrument contains a circuit and a computer program that work in conjunction to produce a current-voltage curve and a power curve. The graph the instrument produces provides data for the open-circuit maximum, the open-voltage maximum, and the maximum power obtained, as well as shows at what voltages the solar cell produces the highest current flow. A full description of the instrument and how it works and its capabilities can be found above in the methodology section. After testing the prototype instrument to determine if it worked as expected, a semester was spent building the standalone instrument and making improvements to both the circuit and computer program. Problems were encountered at this point and most of the semester was spent troubleshooting a new piece of the circuit and the part of the computer program that controls it. This piece would allow for a digital switch (created using a multiplexor) to choose the proper resistance to be used in the circuit depending on which solar cells were being tested. After spending a majority of the semester working on this piece, it was the determined that the digital switch method would not work as according to plan, so an analog switch method was considered for use. In the end, it was decided that C. Behme 59 adding the switch was not as high a priority as testing the variables, so the switch was left out and the resistors were changed by hand depending on the solar cell being tested by the instrument. These improvements to how the fabrication and testing of solar cells allow for maximum efficiency of the instrument and ease of use for future undergraduate research students working with solar cells. An instrument manual was prepared to store with the instrument in case questions arise of how to use it in the future. After the instrument was finished, the original goals of the project were resumed and testing the different berry dye and electrolyte combinations began. Due to time before graduation being a factor, it was decided to test only one new electrolyte, the ferrocene/ferrocenium electrolyte. It was also decided to test only two of the berry dyes, as the berry dyes are a simple variable to exchange because they require no synthesis and little preparation. C. Behme 60 Results and Analysis The prefabricated solar cell was tested at the beginning of each experimental trial to ensure the instrument was working properly. The IV and Power curves for this cell can be found below in Figure 38. The open circuit voltage for the first trial was found to be 0.5598 V, the short circuit current was found to be 10.1511 mA and the maximum power was calculated to be 5.4758 mW. Based on tests using a digital multimeter on the prefabricated cell that returned a voltage of 0.55 V it can be concluded that the instrument is working, with only the minor tweaks explained above needing to be made. This solar cell IV curve cannot be compared to the DSSCs prepared in lab because they are not made of the same materials, however, as it is a prefabricated and sealed cell it acts as a good control test cell to ensure the instrument is working properly. It is important to note that the instrument measures the prefabricated solar cell current in milliamps and power in milliwatts, whereas it measures the fabricated DSSC current in microamps and power in microwatts. When the IV and Power curves are created, Excel is used to convert the current into milliamps and the power into milliwatts. C. Behme 61 Table 2, shown below, represents the results obtained for the prefabricated solar cell from the Solar Cell IV Curve Generator without manipulation, other than exporting the file into a readable format. These data files contain information pertinent to the solar cell identifier and the conditions under which the trial was run. The first column of data is the measured voltage, the second is the measured current, and the third is the calculated power. These headings do not appear when exported from the instrument file so they are added to the columns before graphing the results. C. Behme 62 Table 2: Prefabricated Cell Data Voltage 0.559769 0.559571 0.558623 0.557675 0.549303 0.546223 0.545433 0.539431 0.534929 0.533508 0.529164 0.522766 0.522055 0.516843 0.510209 0.509419 0.507839 0.498441 0.497098 0.496624 0.486199 0.485725 0.48454 0.474747 0.472851 0.472851 0 Current 0 0.265688 1.488868 3.533203 5.457111 7.479694 9.520955 10.151145 10.151145 10.151145 10.151145 10.151145 10.151145 10.151145 10.151145 10.151145 10.151145 10.151145 10.151145 10.151145 10.151145 10.151145 10.151145 10.151145 10.151145 10.151145 10.151145 Power Comment 50 mA; 1 Ohm ai2 resistance; Prefab Solar Cell 0.148671 0.831716 Area B 1.97038 2.99761 4.085583 5.193047 5.475842 5.430143 5.415712 5.371617 5.306676 5.299461 5.246546 5.179201 5.171183 5.155149 5.059742 5.046113 5.041302 4.935474 4.930663 4.918637 4.819222 4.799981 4.799981 5.682296286 Table 2: Data collected from the instrument for the prefabricated solar cell and exported into Excel without manipulation. The graph shown below in Figure 39 shows a representative IV and Power curve of a DSSC fabricated with the factory synthesized iodine electrolyte and blackberry dye. In this specific curve, the short circuit current was measured to be 0.0102 mA and the open circuit voltage was measured to be 0.173066 mV. The maximum power of this specific DSSC was calculated to be 0.00404 mW. For the entire data set, the short circuit current C. Behme 63 was the same and the open circuit voltage range was 0.1128 mV and 0.2633 mV. The maximum power ranged from 0.0140 mW to 0.0963 mW. These IV and Power curve graphs can be found in Appendix A. Table 3, shown below, represents the results obtained for DSSC Blackberry #4 from the Solar Cell IV Curve Generator. These data files contain information pertinent to the solar cell identifier and the conditions under which the trial was run. The first column of data is the measured voltages, the second and third are the measured currents, and the fourth and fifth are the calculated powers. These headings do not appear when exported from the instrument file so they are added to the columns before graphing the results. C. Behme 64 Table 3: Blackberry #4 Data Voltage 0.173066 0.172097 0.168858 0.165146 0.162303 0.159934 0.158275 0.156301 0.154642 0.153221 0.151799 0.150377 0.149351 0.148008 0.146823 0.146033 0.14477 0.143664 0.143032 0.141768 0.1409 0.14011 0.139004 0.138135 0.137504 0.136556 0 Current 2.34E-05 0.000102 0.000102 0.000102 0.000102 0.000102 0.000102 0.000102 0.000102 0.000102 0.000102 0.000102 0.000102 0.000102 0.000102 0.000102 0.000102 0.000102 0.000102 0.000102 0.000102 0.000102 0.000102 0.000102 0.000102 Current (m) 0 2.34E-02 1.02E-01 1.02E-01 1.02E-01 1.02E-01 1.02E-01 1.02E-01 1.02E-01 1.02E-01 1.02E-01 1.02E-01 1.02E-01 1.02E-01 1.02E-01 1.02E-01 1.02E-01 1.02E-01 1.02E-01 1.02E-01 1.02E-01 1.02E-01 1.02E-01 1.02E-01 1.02E-01 1.02E-01 1.02E-01 Power Power (mW) 4.04E-06 1.71E-05 1.68E-05 1.65E-05 1.62E-05 1.61E-05 1.59E-05 1.57E-05 1.56E-05 1.54E-05 1.53E-05 1.52E-05 1.50E-05 1.49E-05 1.48E-05 1.47E-05 1.46E-05 1.45E-05 1.44E-05 1.43E-05 1.42E-05 1.41E-05 1.40E-05 1.40E-05 1.39E-05 4.04E-03 1.71E-02 Area B 1.68E-02 1.65E-02 1.62E-02 1.61E-02 1.59E-02 1.57E-02 1.56E-02 1.54E-02 1.53E-02 1.52E-02 1.50E-02 1.49E-02 1.48E-02 1.47E-02 1.46E-02 1.45E-02 1.44E-02 1.43E-02 1.42E-02 1.41E-02 1.40E-02 1.40E-02 1.39E-02 Comment 0.5 mA; 100000 Ohm ai2 resistance; Blackberry #4 1.77E-02 Table 3: Data collected from the instrument for the Blackberry #4 solar cell and exported into Excel without manipulation. The graph shown below in Figure 40 shows a representative IV and Power curves of a DSSC fabricated with the factory synthesized iodine electrolyte and blueberry dye. In this specific curve, the short circuit current was measured to be 0.0102 mA and the open circuit voltage was measured to be 0.1624 mV. The maximum power of this specific DSSC C. Behme 65 was calculated to be 0.0159 mW. For the entire data set, the short circuit current was the same and the open circuit voltage range was 0.0967 mV and 0.2510 mV. The maximum power ranged from 0.0090 mW to 0.0250 mW. These IV and Power curve graphs can be found in Appendix A. Table 4, shown below, represents the results obtained for DSSC Blueberry #8 from the Solar Cell IV Curve Generator. These data files contain information pertinent to the solar cell identifier and the conditions under which the trial was run. The first column of data is the measured voltages, the second and third are the measured currents, and the fourth and fifth are the calculated powers. These headings do not appear when exported from the instrument file so they are added to the columns before graphing the results. C. Behme 66 Table 4: Blueberry #8 Data Voltage 0.162356 0.161118 0.156222 0.150535 0.14706 0.143506 0.141058 0.138609 0.137109 0.135292 0.133081 0.131343 0.130079 0.129053 0.127394 0.126209 0.125499 0.124077 0.12305 0.12226 0.121076 0.120049 0.119417 0.118233 0.117364 0.116811 0 Current 2.06E-05 0.000102 0.000102 0.000102 0.000102 0.000102 0.000102 0.000102 0.000102 0.000102 0.000102 0.000102 0.000102 0.000102 0.000102 0.000102 0.000102 0.000102 0.000102 0.000102 0.000102 0.000102 0.000102 0.000102 0.000102 Current (mA) 0 2.06E-02 1.02E-01 1.02E-01 1.02E-01 1.02E-01 1.02E-01 1.02E-01 1.02E-01 1.02E-01 1.02E-01 1.02E-01 1.02E-01 1.02E-01 1.02E-01 1.02E-01 1.02E-01 1.02E-01 1.02E-01 1.02E-01 1.02E-01 1.02E-01 1.02E-01 1.02E-01 1.02E-01 1.02E-01 1.02E-01 Power Power (mW) 3.32E-06 1.59E-05 1.53E-05 1.49E-05 1.46E-05 1.43E-05 1.41E-05 1.39E-05 1.37E-05 1.35E-05 1.33E-05 1.32E-05 1.31E-05 1.29E-05 1.28E-05 1.27E-05 1.26E-05 1.25E-05 1.24E-05 1.23E-05 1.22E-05 1.21E-05 1.20E-05 1.19E-05 1.19E-05 3.32E-03 1.59E-02 Area B 1.53E-02 1.49E-02 1.46E-02 1.43E-02 1.41E-02 1.39E-02 1.37E-02 1.35E-02 1.33E-02 1.32E-02 1.31E-02 1.29E-02 1.28E-02 1.27E-02 1.26E-02 1.25E-02 1.24E-02 1.23E-02 1.22E-02 1.21E-02 1.20E-02 1.19E-02 1.19E-02 Comment 0.5 mA; 100,000 Ohm ai2 resistance; Blueberry #8 1.66E-02 Table 4: Data collected from the instrument for the Blueberry #8 solar cell and exported into Excel without manipulation. The graph shown below in Figure 41 shows a representative IV and Power curve of a DSSC fabricated with the laboratory synthesized ferrocene/ferrocenium electrolyte and blackberry dye. In this specific curve, the short circuit current was measured to be 0.0102 mA and the open circuit voltage was measured to be 0.0103 mV. The maximum power of this specific DSSC was calculated to be 0.00572 mW. For the entire data set, the C. Behme 67 short circuit current was the same and the open circuit voltage range was -0.0015 mV and 0.0982 mV. The maximum power ranged from -0.00572 mW to 0.00455 mW. These IV and Power curve graphs can be found in Appendix A. An anomaly occurred during this trial, many of the voltages measured by the instrument were negative, which is indicative of an error. Possible errors here could include a defective cell, possibly from a short within the cell or possibly the electrolyte solution not working correctly. Future studies should work to clarify this. Table 5, shown below, represents the results obtained for DSSC Blackberry #11 from the Solar Cell IV Curve Generator. These data files contain information pertinent to the solar cell identifier and the conditions under which the trial was run. The first column of data is the measured voltages, the second and third are the measured currents, and the fourth and fifth are the calculated powers. These headings do not appear when exported from the instrument file so they are added to the columns before graphing the results. C. Behme 68 Table 5: Blackberry #11 Data Voltage Current 0.0103 -0.003238 2.07E-05 -0.056391 0.000102 -0.056707 0.000102 -0.057023 0.000102 -0.057023 0.000102 -0.05647 0.000102 -0.057181 0.000102 -0.056865 0.000102 -0.056786 0.000102 -0.057418 0.000102 -0.057023 0.000102 -0.05647 0.000102 -0.057418 0.000102 -0.056944 0.000102 -0.056786 0.000102 -0.057418 0.000102 -0.056707 0.000102 -0.056786 0.000102 -0.057576 0.000102 -0.057734 0.000102 -0.056944 0.000102 -0.05726 0.000102 -0.057497 0.000102 -0.057181 0.000102 -0.057497 0.000102 Current (mA) 0 2.07E-02 1.02E-01 1.02E-01 1.02E-01 1.02E-01 1.02E-01 1.02E-01 1.02E-01 1.02E-01 1.02E-01 1.02E-01 1.02E-01 1.02E-01 1.02E-01 1.02E-01 1.02E-01 1.02E-01 1.02E-01 1.02E-01 1.02E-01 1.02E-01 1.02E-01 1.02E-01 1.02E-01 1.02E-01 Power -6.70E-08 -5.72E-06 -5.76E-06 -5.79E-06 -5.79E-06 -5.73E-06 -5.80E-06 -5.77E-06 -5.76E-06 -5.83E-06 -5.79E-06 -5.73E-06 -5.83E-06 -5.78E-06 -5.76E-06 -5.83E-06 -5.76E-06 -5.76E-06 -5.84E-06 -5.86E-06 -5.78E-06 -5.81E-06 -5.84E-06 -5.80E-06 -5.84E-06 Power (mW) -6.70E-05 -5.72E-03 -5.76E-03 -5.79E-03 -5.79E-03 -5.73E-03 -5.80E-03 -5.77E-03 -5.76E-03 -5.83E-03 -5.79E-03 -5.73E-03 -5.83E-03 -5.78E-03 -5.76E-03 -5.83E-03 -5.76E-03 -5.76E-03 -5.84E-03 -5.86E-03 -5.78E-03 -5.81E-03 -5.84E-03 -5.80E-03 -5.84E-03 Table 5: Data collected from the instrument for the Blackberry #11 solar cell and exported into Excel without manipulation. The graph shown below in Figure 42 shows a representative IV and Power curve of a DSSC fabricated with the laboratory synthesized ferrocene/ferrocenium electrolyte and blueberry dye. In this specific curve, the short circuit current was measured to be 0.0102 mA and the open circuit voltage was measured to be 0.0029 mV. The maximum C. Behme 69 power of this specific DSSC was calculated to be 0.00125 mW. For the entire data set, the short circuit current was the same and the open circuit voltage range was -0.0093 mV and 0.0658 mV. The maximum power ranged from -0.000249 mW to 0.00116 mW. These IV and Power curve graphs can be found in Appendix A. An anomaly occurred during this trial, many of the voltages measured by the instrument were negative, again indicating some kind of error. Please see the previous example for possible reasons. Table 6, shown below, represents the results obtained for DSSC Blueberry #18 from the Solar Cell IV Curve Generator. These data files contain information pertinent to the solar cell identifier and the conditions under which the trial was run. The first column of data is the measured voltages, the second and third are the measured currents, and the fourth and fifth are the calculated powers. These headings do not appear when exported from the instrument file so they are added to the columns before graphing the results. C. Behme 70 Table 6: Blackberry #18 Data Voltage Current 0.002874 -0.000632 -0.012321 -0.012479 -0.012479 -0.012637 -0.012716 -0.012795 -0.012953 -0.012874 -0.013032 -0.01319 -0.013111 -0.01319 -0.013348 -0.012953 -0.01319 -0.013506 -0.01319 -0.013269 -0.013584 -0.013348 -0.013427 -0.013821 -0.013427 -0.013506 2.35E-05 0.000102 0.000102 0.000102 0.000102 0.000102 0.000102 0.000102 0.000102 0.000102 0.000102 0.000102 0.000102 0.000102 0.000102 0.000102 0.000102 0.000102 0.000102 0.000102 0.000102 0.000102 0.000102 0.000102 0.000102 Current (mA) 0 2.35E-02 1.02E-01 1.02E-01 1.02E-01 1.02E-01 1.02E-01 1.02E-01 1.02E-01 1.02E-01 1.02E-01 1.02E-01 1.02E-01 1.02E-01 1.02E-01 1.02E-01 1.02E-01 1.02E-01 1.02E-01 1.02E-01 1.02E-01 1.02E-01 1.02E-01 1.02E-01 1.02E-01 1.02E-01 Power -1.49E-08 -1.25E-06 -1.27E-06 -1.27E-06 -1.28E-06 -1.29E-06 -1.30E-06 -1.31E-06 -1.31E-06 -1.32E-06 -1.34E-06 -1.33E-06 -1.34E-06 -1.35E-06 -1.31E-06 -1.34E-06 -1.37E-06 -1.34E-06 -1.35E-06 -1.38E-06 -1.35E-06 -1.36E-06 -1.40E-06 -1.36E-06 -1.37E-06 Power (mW) Comment Blueberry #8, 100,000 Ohm -1.49E-05 resistor AI2 -1.25E-03 , max current 0.5 mA -1.27E-03 -1.27E-03 -1.28E-03 -1.29E-03 -1.30E-03 -1.31E-03 -1.31E-03 -1.32E-03 -1.34E-03 -1.33E-03 -1.34E-03 -1.35E-03 -1.31E-03 -1.34E-03 -1.37E-03 -1.34E-03 -1.35E-03 -1.38E-03 -1.35E-03 -1.36E-03 -1.40E-03 -1.36E-03 -1.37E-03 Table 6: Data collected from the instrument for the Blackberry #18 solar cell and exported into Excel without manipulation. In table 7, shown below, the open current voltage, open circuit current, and maximum power for all fabricated DSSCs are shown. This table was compiled to more easily compare the results of the two trials to determine which electrolyte and dye combination produced the best results. In this table, Blackberry cells 1-5 and Blueberry C. Behme 71 cells 6-10 were fabricated with the iodine electrolyte and Blackberry cells 11-15 and Blueberry cells 16-20 were fabricated with the ferrocene electrolyte. From this table, several things can be determined. As far as the iodine electrolyte is concerned, neither berry dye appears to be better than the other. As far as the ferrocene electrolyte is concerned, it failed so no conclusion can be drawn. Overall, the iodine electrolyte performed better because it did not fail during trials. In order to draw further conclusions, trials should be replicated and statistical analysis should be performed on the resulting data. Table 7: Open Circuit Voltage, Short Circuit Current, and Max Power for All Trials Prefabricated Blackberry 1 Blackberry 2 Blackberry 3 Blackberry 4 Blackberry 5 Blueberry 6 Blueberry 7 Blueberry 8 Blueberry 9 Blueberry 10 Blackberry 11 Blackberry 12 Blackberry 13 Blackberry 14 Blackberry 15 Blueberry 16 Blueberry 17 Blueberry 18 Blueberry 19 Blueberry 20 Open Voltage Open Current Max Power 0.5598 10.1511 5.4758 0.1960 0.1020 0.0194 0.1128 0.1020 0.0963 0.2633 0.1020 0.0260 0.1731 0.1020 0.0171 0.1424 0.1020 0.0140 0.1721 0.1020 0.0170 0.2510 0.1020 0.0250 0.1624 0.1020 0.0159 0.1705 0.1020 0.0149 0.0967 0.1020 0.0090 0.0103 0.1020 -0.0057 0.0002 0.1020 -0.0002 -0.0015 0.1020 -0.0001 0.0982 0.1020 0.0045 -0.0004 0.1020 -0.0001 0.0002 0.1020 0.0000 -0.0009 0.1020 -0.0002 0.0029 0.1020 -0.0013 0.0658 0.1020 0.0012 0.0239 0.1020 0.0005 Table 7: Table with the open circuit voltage, short circuit current, and maximum power for all trials to consolidate the most important information into one data table. Due to the fact that the short circuit current for almost every trial run was 0.0102 mA, this suggests that there is potentially a minor issue with the instrument that was built C. Behme 72 for this project. Although the instrument is fully functional, the results returned are hovering around the detection limits of the instrument. This means that the measured current output of the solar cell under load potentially does not cover the full range of currents produced by the solar cell. A 1.5 V battery was added to the original instrument design to help avoid this limit of detection issue, but it appears that it was still not enough to boost the performance of the DSSCs enough to exceed the limit of current detection of the instrument. For this reason, although the results obtained from this project are acceptable, they cannot be used to determine the fill factor or the efficiency of the solar cell. Only the open circuit voltage and maximum power output can reliably be analyzed with confidence. The short circuit current measured can be reported, but not with confidence that the value is as accurate as had previously hoped it would be. This problem is discussed further in the conclusion with respect to the future direction of this research project with new research students. C. Behme 73 Conclusion This honors project made an important step forward for undergraduate solar cell research at the University of Indianapolis. This new instrument will make testing the solar cells easier as well as streamline the process. It will also greatly improve the readability and reproducibility of the results by creating the IV and Power curves. Never before has a solar cell research student at the University of Indianapolis been able to measure current and voltage produced by the solar cell concurrently to produce these graphs. In the past, only open circuit voltage and short circuit current could be measured. Therefore, great improvement for the future direction of this project has been made as a result of this project. It will allow students to gain results that are more easily comparable to published values, rather than having to do complicated mathematical manipulation or being unable to analyze collected data. This instrument will allow future student researchers to focus on testing other variables rather than constantly needing to improve the testing conditions of the solar cells. Although great advances were made to this solar cell research project with the creation of Solar Cell IV Curve Generator, future students should continue improving this instrument. One adjustment that needs to be made is improving the sensitivity of the instrument. Trouble-shooting has revealed that this problem is most likely with the circuit design, not a problem with the design or fabrication of the solar cells. Future research students should work with Dr. Styers-Barnett and Dr. Stephen Spicklemire to determine if an improvement can be made to the circuit to increase the limit of detection and obtain results over the full range of currents under differing amounts of load on the solar cell. This C. Behme 74 will lead to the ability to confidently determine the short circuit current, fill factor, and efficiency of DSSCs fabricated in the laboratory. The results of the electrolyte and dye experiments also made an important step forward, for this honors project and for the future directions of this research project. Although the results are promising, more trials should be done in the future using electrolytes synthesized on campus. Until then, the data must be considered inconclusive. The synthesis method should be improved to increase the stability of the electrolyte after synthesis, including both the shelf life and the electrolyte in the solar cell. The ferrocene electrolyte seems to be problematic, possibly due to exposure to oxygen, which can disrupt the redox cycle of this electrolyte.16 While care was taken for reduce exposure to air, future work can utilize air-free techniques to possibly provide better, more meaningful data. Other electrolytes should also be synthesized in the laboratory. Each synthesized electrolyte should be tested with a variety of berry dyes, both on their own and co-sensitized (mixed) with each other to determine. The dye and electrolyte combination can greatly affect the energy conversion of the solar cell and to find the highest efficiency many combinations should be tried. Another research student should continue this research, as the results could be important to societys future in using solar energy to replace that of fossil fuels. C. Behme 75 Reflection Throughout my academic career I have gained extensive theoretical knowledge about chemical reactions and chemistry concepts. Through the completion of this honors project I have learned how to apply this theoretical chemistry knowledge to real world applications that could potentially benefit consumers. The oxidation-reduction chemistry learned in general and inorganic chemistry courses proved important in understanding the mechanism of the electrolyte replacing the lost electron form the berry dye. Knowledge of organic chemistry and the absorption spectra of organic molecules were important for understanding how the different berry dyes would absorb photons. Knowledge gained in inorganic chemistry on molecular orbitals and band gaps proved useful in understanding how electrons become promoted in their orbitals and how they flow through the circuit when they fall back to their ground state. These chemistry courses were vital to my ability to complete this honors project and provide accurate results and analysis. Throughout this honors project I encountered roadblocks and setbacks. I learned how to overcome these roadblocks by looking at my research from different perspectives, talking to my advisor as well as other professors, and doing more research on the different topics relating to solar cells and the chemistry that runs them. Overcoming the roadblocks were important to the success of the honors project, but more importantly learning to overcome roadblocks was vital to my growth as a student and a person. Throughout the rest of my academic career and my future career, there will be times when I will have to overcome struggles and setbacks to succeed, and participating in this honors project showed me that I have the ability to do so. C. Behme 76 During the preliminary literature review and throughout the course of the project I improved my skills in reading primary literature for understanding. I also learned how to apply previous research done with a different set of variables to the research I was interested in completing. This research project also helped me hone my problem-solving skills. These skills will transfer well to my future studies and career as a doctor. If I were to complete this project again there are several things I would do differently. First, I would have begun the instrument build as the first mini-project. This would have given me more time to test a greater number of the variables I was most interested in researching. I also would have obtained new glassware and electrolytes earlier in the project. The final major thing I would have done differently is doing the red tide emission spectrometer tests as soon as we procured the plant grow lamp so that we could have replaced it with the overhead projector sooner. Overall, I am extremely proud of the results and products of this honors project. I gained invaluable experience in learning to apply theoretical knowledge to real world applications, problem solving effectively when setbacks arise, and working alongside local experts in other departments to create a multidisciplinary product. I have grown tremendously as a student, researcher, and person throughout the course of this honors project and feel that it will play a role in my future successes. I am grateful for the opportunities partaking in this project has brought me and the dedication I had to creating a finished product that will continue benefitting the university after I have graduated. C. Behme 77 References 1 Ze Yu (2012). Liquid Redox Electrolytes for Dye-Sensitized Solar Cells, ISBN: 978-917501-231-5, KTH Chemical Science and Engineering. 2 Mosconi, E.; Yum, J. H.; Kessler, F.; Garci, C. J. G.; Zuccaccia, C.; Cinti, A.; Nazeeruddin M. K.; Grtzel M.; Angelis, F. Cobalt Electrolyte/Dye Interactions in Dye-Sensitzed Solar Cells: A Combined Computational and Experimental Study. J. Am. Chem. Soc. [Online] 2012, 134, 19438-19453. 3 Daeneke, T.; Kwon, T. H.; Holmes, A. B.; Duffy, N. W. Bach, U.; Spiccia, L. HighEfficiency dye-sensitized solar cells with ferrocene-based electrolytes. Nat. Chem. [Online] 3, 211-215. 4 Chung, I.; Lee, B.; He, J.; Chang, R. P. H.; Kanatzidis, M. G. All-solid-state dyesensitized solar cells with high efficiency. Nature. [Online] 485, 486-489 5 Hardin, B. E.; Snaith, H. J.; McGehee, M. D. The renaissance of dye-sensitized solar cells. Nature [Online] 2012, 6, 162-169. 6 Grtzel, M.; Solar energy conversion by dye-sensitized photovoltaic cells. Inorg. Chem. 2005, 44, 6841-6851. 7 Honsberg, C.; Bowden, S. PVEducation http://www.pveducation.org/ (accessed Feb 27, 2017). 8 Klahr, B. M.; Hamann, T. W. Outer-Sphere Redox Couples as Shuttles in DyeSensitized Solar Cells. Performance Enhancement Based on Photoelectrode Modification via Atomic Layer Deposition. J. Phys. Chem. C 2009, 113 (31), 1404014045. C. Behme 78 9 Yang Jiao, Fan Zhang and Sheng Meng (2011). Dye Sensitized Solar Cells Principles and New Design, Solar Cells - DYe-Sensitized Devices, Prof. Leonid A. Kosyachenko (Ed.), ISBN: 978-953-307-735-2, InTech. 10 Boschloo, G.; Hagfeldt, A.; Characteristics of the Iodide/Triiodide Redox Mediator in Dye-Sensitized Solar Cells. Accounts of Chemical Research. 2009, 42, 1819-1826. 12 Neal, B. University of Indianapolis, Indianapolis, IN. Unpublished work. 2013. 13 Material Safety Data Sheet Ferrocene. Acros Organics. Northwest Missouri University. 14 Ferrocenium hexafluorophosphate 388297. Sigma Aldrich. 15 Material Safety Data Sheet 3-Methoxypropionitrile sc-226123. Santa Cruz Biotechnology, Inc. 16 Correa Baena, J. P.; Agrios, A. G. Antimony-doped tin oxide aerogels as porous electron collectors for dye-sensitized solar cells J. Phys. Chem. C 2014, 118 (30), 1702817035. 17 Mayer, E. A.; Powell, A. L.; A low-cost laboratory experiment to generate the I-V characteristic curves of a solar cell. Am Soc Engineering Edu. 2011. C. Behme 79 Appendices Appendix A: IV and Power Curves 0.120 0.030 0.100 0.025 0.080 0.020 0.060 0.015 0.040 0.010 0.020 0.005 0.000 0.15 0.16 0.17 0.18 0.19 0.2 Power (mW) Current (mA) IV and Power Curve Blackberry 1 Current (mA) Power (mW) 0.000 Voltage (mV) Figure 43: DSSC Blackberry #1 fabricated with the iodine electrolyte and blackberry dye. The 100,000 Ohm resistor was used and 0.5 mA was set as the maximum current draw. 0.010 Current (mA) 0.100 0.012 0.080 0.008 0.060 0.006 0.040 0.020 0.000 0.055 0.004 0.065 0.075 0.085 0.095 Voltage (mV) 0.105 0.002 Power (mW) 0.120 IV and Power Curve Blackberry 2 Current (mA) Power (mW) 0.000 0.115 Figure 44: DSSC Blackberry #2 fabricated with the iodine electrolyte and blackberry dye. The 100,000 Ohm resistor was used and 0.5 mA was set as the maximum current draw. C. Behme 80 0.035 0.03 Current (mA) 0.1 0.04 0.08 0.025 0.06 0.02 0.015 0.04 0.02 0 0.22 Power 0.12 IV and Power Curve Blackberry 3 Power 0.01 0.23 0.24 0.25 Voltage (mA) Current 0.005 0 0.27 0.26 Figure 45: DSSC Blackberry #3 fabricated with the iodine electrolyte and blackberry dye. The 100,000 Ohm resistor was used and 0.5 mA was set as the maximum current draw. 0.020 Current (mA) 0.100 0.080 0.015 0.060 0.010 0.040 0.005 0.020 0.000 0.13 0.14 0.15 0.16 Voltage (mV) 0.17 Power 0.120 IV and Power Curve Blackberry 4 Current Power 0.000 Figure 46: DSSC Blackberry #4 fabricated with the iodine electrolyte and blackberry dye. The 100,000 Ohm resistor was used and 0.5 mA was set as the maximum current draw. C. Behme 81 0.120 Current (mA) 0.100 0.080 0.060 0.040 0.020 0.000 0.09 0.1 0.11 0.12 0.13 Voltage (mV) 0.14 0.018 0.016 0.014 0.012 0.010 0.008 0.006 0.004 0.002 0.000 0.15 Power IV and Power Curve Blackberry 5 Current Power Figure 47: DSSC Blackberry #5 fabricated with the iodine electrolyte and blackberry dye. The 100,000 Ohm resistor was used and 0.5 mA was set as the maximum current draw. 0.020 Current (mA) 0.100 0.080 0.015 0.060 0.010 0.040 0.020 0.000 0.13 0.005 0.14 0.15 0.16 Voltage (mV) 0.17 Power (mW) 0.120 IV and Power Curve Blueberry 6 Current Power 0.000 0.18 Figure 48: DSSC Blueberry #6 fabricated with the iodine electrolyte and blueberry dye. The 100,000 Ohm resistor was used and 0.5 mA was set as the maximum current draw. C. Behme 82 IV and Power Curve Blueberry 7 0.120 0.035 Current (mA) 0.025 0.080 0.020 0.060 0.015 0.040 0.020 0.000 0.215 Power 0.030 0.100 Power 0.010 0.225 0.235 Voltage (mV) 0.245 Current 0.005 0.000 0.255 Figure 49: DSSC Blueberry #7 fabricated with the iodine electrolyte and blueberry dye. The 100,000 Ohm resistor was used and 0.5 mA was set as the maximum current draw. IV and Power Curve Blueberry 8 0.120 Current (mA) 0.015 0.080 0.060 0.010 0.040 0.005 0.020 0.000 0.11 0.12 0.13 0.14 0.15 Voltage (mV) 0.16 Power 0.020 0.100 Current Power 0.000 0.17 Figure 50: DSSC Blueberry #8 fabricated with the iodine electrolyte and blueberry dye. The 100,000 Ohm resistor was used and 0.5 mA was set as the maximum current draw. C. Behme 83 0.120 Current (mA) 0.100 0.080 0.060 0.040 0.020 0.000 0.1 0.12 0.14 Voltage (mV) 0.16 0.020 0.018 0.016 0.014 0.012 0.010 0.008 0.006 0.004 0.002 0.000 Power IV and Power Curve Blueberry 9 Current Power Figure 51: DSSC Blueberry #9 fabricated with the iodine electrolyte and blueberry dye. The 100,000 Ohm resistor was used and 0.5 mA was set as the maximum current draw. 0.010 Current (mA) 0.100 0.012 0.080 0.008 0.060 0.006 0.040 0.020 0.000 0.035 0.004 0.045 0.055 0.065 0.075 Voltage (mV) 0.085 0.095 0.002 Power 0.120 IV and Power Curve Blueberry 10 Current Power 0.000 0.105 Figure 52: DSSC Blueberry #10 fabricated with the iodine electrolyte and blueberry dye. The 100,000 Ohm resistor was used and 0.5 mA was set as the maximum current draw. C. Behme 84 7 6 Current (mA) 10 8 8 5 4 6 3 4 0.48 0.5 0.52 Voltage (V) 0.54 Current Power 2 2 0 0.46 Power 12 IV and Power Curve Prefabricated Cell 1 0 0.56 Figure 53: Prefabricated silicon solar cell tested with a 1.0 Ohm resistor and a maximum current draw of 10.0 mA. IV and Power Curve Blackberry 11 0.0000 -0.0010 0.1000 -0.0020 0.0800 -0.0030 0.0600 -0.0040 0.0400 -0.0050 0.0200 0.0000 -0.08 -0.06 -0.04 Votlage (mV) -0.02 0 Current (mA) Power (mW)s Current (mA) 0.1200 Power (mW) -0.0060 -0.0070 Figure 54: DSSC Blackberry#11 fabricated with the ferrocene electrolyte and blackberry dye. The 100,000 Ohm resistor was used and 0.5 mA was set as the maximum current draw. C. Behme 85 IV and Power Curve Blackberry 12 0.0000 0.1000 -0.0001 0.0800 -0.0001 0.0600 -0.0002 0.0400 0.0200 0.0000 -0.0025 Current (mA) Power (mW) Current (mA) 0.1200 -0.0002 -0.002 -0.0015 -0.001 Voltage (mV) -0.0005 0 -0.0003 Figure 55: DSSC Blackberry #12 fabricated with the ferrocene electrolyte and blackberry dye. The 100,000 Ohm resistor was used and 0.5 mA was set as the maximum current draw. Current (mA) 0.1200 0.1000 0.0800 0.0600 0.0400 0.0200 0.0000 -0.2 -0.15 -0.1 Voltage (mV) -0.05 0 0.0000 -0.0020 -0.0040 -0.0060 -0.0080 -0.0100 -0.0120 -0.0140 -0.0160 -0.0180 Power (mW) IV and Power Curve Blackberry 13 IV Power Figure 56: DSSC Blackberry #13 fabricated with the ferrocene electrolyte and blackberry dye. The 100,000 Ohm resistor was used and 0.5 mA was set as the maximum current draw. C. Behme 86 Current (mA) 0.1200 0.1000 0.0800 0.0600 0.0400 0.0200 0.0000 0.03 0.04 0.05 0.06 0.07 Voltage (mV) 0.08 0.0050 0.0045 0.0040 0.0035 0.0030 0.0025 0.0020 0.0015 0.0010 0.0005 0.0000 0.09 Power (mW) IV and Power Curve Blackberry 14 IV Power Figure 57: DSSC Blackberry #14 fabricated with the ferrocene electrolyte and blackberry dye. The 100,000 Ohm resistor was used and 0.5 mA was set as the maximum current draw. IV and Power Curve Blackberry 15 0.1000 -0.0001 0.0800 -0.0001 0.0600 -0.0002 0.0400 0.0200 0.0000 -0.002 IV 0.0000 Power (mW) Current (mA) 0.1200 Power -0.0002 -0.0015 -0.001 Voltage (mV) -0.0003 -0.0005 Figure 58 : DSSC Blackberry #15 fabricated with the ferrocene electrolyte and blackberry dye. The 100,000 Ohm resistor was used and 0.5 mA was set as the maximum current draw. C. Behme 87 IV and Power Curve Blueberry 16 0.0000 0.0000 0.1000 0.0000 0.0000 0.0800 0.0000 0.0000 0.0600 -0.0001 0.0400 -0.0001 -0.0001 0.0200 -0.0001 -0.0001 0.0000 -0.0010 -0.0008 -0.0006 -0.0004 -0.0002 0.0000 0.0002 Voltage (mV) IV Power (mW) Current (mA) 0.1200 Power Figure 59: DSSC Blueberry #16 fabricated with the ferrocene electrolyte and blueberry dye. The 100,000 Ohm resistor was used and 0.5 mA was set as the maximum current draw. IV and Power Curve Blueberry 17 Current (mA) -0.0001 0.1000 -0.0001 0.0800 -0.0002 0.0600 -0.0002 0.0400 0.0200 0.0000 -0.0033 -0.0003 -0.0028 -0.0023 -0.0018 Voltage (mV) -0.0013 Power (mW) 0.0000 0.1200 IV Power -0.0003 -0.0004 Figure 60: DSSC Blueberry #17 fabricated with the ferrocene electrolyte and blueberry dye. The 100,000 Ohm resistor was used and 0.5 mA was set as the maximum current draw. C. Behme 88 IV and Power Curve Blueberry 18 IV 0.0000 -0.0002 0.1000 -0.0004 0.0800 -0.0006 0.0600 -0.0008 -0.0010 0.0400 -0.0012 0.0200 0.0000 -0.015 -0.01 -0.005 Voltage (mV) 0 Power (mW) Current (mA) 0.1200 Power -0.0014 -0.0016 Figure 61: DSSC Blueberry #18 fabricated with the ferrocene electrolyte and blueberry dye. The 100,000 Ohm resistor was used and 0.5 mA was set as the maximum current draw. IV and Power Curve Blueberry 19 0.1000 0.0800 0.0600 0.0400 0.0200 0.0000 -0.02 0 0.02 Voltage (mV) 0.04 0.0014 0.0012 0.0010 0.0008 0.0006 0.0004 0.0002 0.0000 -0.0002 -0.0004 -0.0006 -0.0008 0.06 IV Power (mW) Current (mA) 0.1200 Power Figure 62: DSSC Blueberry #16 fabricated with the ferrocene electrolyte and blueberry dye. The 100,000 Ohm resistor was used and 0.5 mA was set as the maximum current draw. C. Behme 89 IV and Power Curve Blueberry 20 0.0016 0.0014 0.1000 0.0012 0.0800 0.0010 0.0008 0.0600 0.0006 0.0400 0.0004 0.0200 0.0000 0.01 0.015 0.02 Voltage (mV) 0.0002 Power (mW) Current (mA) 0.1200 IV Power 0.0000 0.025 Figure 63: DSSC Blueberry #16 fabricated with the ferrocene electrolyte and blueberry dye. The 100,000 Ohm resistor was used and 0.5 mA was set as the maximum current draw. C. Behme 90 Appendix B: Instrument Manual SOLAR CELL IV CURVE GENERATOR Instruction Manual Caitlin Behme University of Indianapolis 2017 C. Behme 91 Table of Contents 1. Introduction .. 1 2. Safety Precautions .. 2 3. Installation .... 4 3.1 Power ............................................................................................................ 4 3.2 Computer ....................................................................................................... 4 3.3 Solar Cell Connection ................................................................................... 4 3.4 Starting the Instrument .................................................................................. 5 4. Test Procedure 6 4.1 Purpose ......................................................................................................... 6 4.2 Instrument Installation ................................................................................... 6 4.3 Reference Cell .............................................................................................. 6 4.4 Preparation of Test Cell ................................................................................ 6 4.5 Instrument Procedure ................................................................................... 6 5. Interfacing Accessories .............................................................................................. 11 6. Upgrading .................................................................................................................. 11 7. Software . 12 7.1 Introduction .................................................................................................. 12 7.2 General Overview .........................................................................................12 7.3 Starting the Software ................................................................................... 12 7.4 Instrument Menu .......................................................................................... 13 7.5 Measuring Short Circuit Current .................................................................. 13 7.6 Measuring Open Circuit Voltage .................................................................. 13 7.7 Power Calculation ........................................................................................ 13 7.8 Available Techniques .................................................................................. 14 C. Behme 92 1. Introduction The Solar Cell IV Curve Generator is the latest solar cell curve generator designed by Caitlin Behme to enable scientists to conduct cutting edge solar cell research experiments in the laboratory. It has updated hardware, updated software, a greater range of measurable currents and voltages, and an improved user interface from prototype models. This manual is intended to aid the scientist in utilizing the Solar Cell IV Curve Generator to its greatest potential. Additional accessories are not currently available. Specifications: Current Sink: Data Acquisition Board: LabJack U6 Data Acquisition Board Minimum PC Requirements: Windows 7 or higher Installed LabView Program 512 MB RAM 50MB available hard drive space USB port Power Requirements: 120V Power Outlet C. Behme 93 2. Safety Precautions The following safety precautions must be observed during all phases of operation, service, and repair of this instrument. Failure to follow these instructions, warnings, or cautions provided in this manual could impair the protection provided by the equipment. Warnings and cautions will be made clear. Noncompliance could also violate safety standards and intended use if this instrument. Caitlin Behme and the University of Indianapolis do not assume liability for scientists failure to comply with instructions, warnings, and cautions. Ground the instrument to avoid shock. For outdoor use: ensure dry conditions. DO NOT exceed the input voltage and current levels appropriate for the computer, instrument, or solar cell. Electrostatic discharge can damage the circuit in the instrument. This is most likely to occur when connecting or disconnecting the instrument. Ground yourself to discharge static buildup by touching the grounded chassis before connecting or disconnecting. DO NOT place the solar cell, instrument box, or computer in fluid or expose internal circuit elements to fluid. DO NOT operate in an explosive atmosphere. Keep away from live circuits, DO NOT replace components with the power cable connected to the computer. Internal adjustments must be made by qualified personnel. The USB (power) cord should be disconnected and circuits discharged before the instrument circuit can be touched. Do not substitute parts or modify the instrument. Modifications could alter the instrument and pose new safety concerns. If any of the following abnormal conditions are noticed, terminate operation of the instrument and disconnect the power cable. Contact a professor for repair of the instrument. There is potential danger to the instrument or user if precautions are not taken. Instrument operates in unusual manner Instrument emits noise, smoke, smell, or spark C. Behme 94 Instrument generates high temperatures or electrical shock during use Battery begins to charge (battery will get hot to touch) USB (power) cord or wires and cables on instrument are damaged Foreign Substance/liquid has penetrated the instrument cover Throughout this manual, the following symbols will be used to note important function: WARNING- This signifies extreme hazard. Not following instructions could cause serious injury. CAUTION- Following information relates to a hazard. If instructions are not followed the instrument may be damaged. C. Behme 95 3. Installation Connections to the cell are made on the front panel of the instrument using the wires connected to the BNC. The USB (power) cord is on the rear panel. 3.1 Power The computer requires a grounded power supply of 120VAC provided by its power cord. The DAQ board requires a power supply from the computer provided by the USB cord. The circuit requires a +5V power supply from the DAQ board. There is no power button, if the instrument is plugged into the computer and the computer is plugged into its power supply the instrument is powered on. 3.2 Computer The instrument requires a laptop computer running Windows 7 or later with available hard drive space. Connect the standard USB cord from the back of the instrument to any USB port on the laptop. The instrument is run by a LabView program, which was written specifically for the instrument and includes necessary codes to run each component of the instrument and create the Excel file needed to reproduce the Current-Voltage (IV) Curve. The name of this program is Solar Cell Curve Generator and the most updated program version has been downloaded. The program is preloaded on the designated computer but can be transferred to any computer installed with LabView. 3.3 Solar Cell Connection The solar cell connection can be found on the left hand side of the front panel of the instrument. Two alligator clips have been wired to two BNC cables that connect to the instrument. The alligator clips will be connected to the solar cell to connect the cell into the circuit. The RED lead goes to the cathode of the solar cell (the glass side coated with titanium dioxide) and the BLACK lead goes to the anode of the solar cell (the glass slide C. Behme 96 coated with carbon). If the clips are connected to the wrong side of the solar cell the graph will be incorrect. WARNING: Do not adjust the cell leads during an experiment as this will break the circuit and invalidate results and could results in harm to the instrument or operator. 3.4 Starting the Instrument Turn the computer on using the power button; ensuring the computer is attached to its power supply. Plug the NAME into the USB port on the computer and open the Solar Cell Curve Generator LabView software. The software automatically connects to the instrument. If the following error message is displayed when the software is opened, check the power supply and USB connections (this requires opening the instrument box). If the connection is broken after it has been established the program will need to be closed and reopened after reconnecting the instrument. C. Behme 97 4. Instrument Test Procedure 4.1 Purpose The purpose of this test procedure is to ensure the instrument is functioning properly. This test will provide the user with an IV Curve calculated for a reference solar cell and is to be used to ensure the user can properly operate the instrument. The test procedure with the reference cell is to provide the user with an IV Curve that will look similar to the shape of their solar cells, but is not to provide an exact replicate, as each solar cell will have different current and voltage outputs. This test procedure will help the user verify the instrument is working correctly as well as gain operation experience. 4.2 Instrument Installation Please follow the installation instructions from the beginning of the manual. This instrument should not be moved to avoid disconnecting internal parts. 4.3 Reference Cell A sealed silicon solar cell is provided as a test cell for this procedure. 4.4 Preparation of Test Cell 1. Ensure the seal is not broken on the cell 2. Ensure the wires or insulation of the cell are not broken 3. Connect to instrument before running the program 4.5 Procedure 1. Connect the power cord to the computer and the USB from the instrument to the computer. C. Behme 98 2. Open the LabView software by clicking the LabView icon. Open the Solar Cell Curve Generator. The software will automatically connect to the instrument. 3. Connect the alligator clip leads to the reference solar cell. Red goes to the cathode and black to the anode. 4. Set the desired number of steps (25 is standard). 5. Set the desired maximum current (1 mA is standard). 6. Set the AI2 resistance by choosing the desired current range of the data (<10 mA is standard for the reference cell). 7. Ensure Auto Save is enabled (button will be green). 8. Record file details in the text box, including the solar cell identifiers and what experiment it came from, the steps, max current, and AI2 resistance as well as any other information deemed important. 9. Click the Run button (white arrow at the top of the screen). C. Behme 99 10. Wait for instrument to complete all cycles. 11. Save file as an Excel file with file name: Initials_Date_Lab Notebook #_Page #_Cell Identifier. If this is not done the program will save it as a LabView (.lvm) file and it will be unable to be reopened and analyzed at a later time. C. Behme 100 12. Open the Excel file. 13. Create column headings with proper units for the data (first column is the Current, second is Voltage, and third is Power) 14. Use the data to create a scatter plot with lines connecting the data points (ensure the line is a straight line not a curved line or this will alter the graph and render it unusable). Graph Current vs. Voltage on one Y-axis and Power vs. Voltage on a second Y-axis. C. Behme 101 15. Save changes to the document. This completes the procedure test. C. Behme 102 5. Interfacing Accessories Accessories are not available for this instrument. Such use of any third party accessories could damage the delicate electronics of the instrument and render it useless. Use of these accessories could also result in injury to the user of the instrument. The creator of the instrument assumes no liability for any injury or damage resulting from the use of third party accessories. 6. Upgrading Upgrades are not available from the creator of this instrument, either for the instrument software or for the instrument design. Any upgrades wished to be made to either the instrument software or instrument design must be approved by the research advisor or creator of this instrument before implementation. C. Behme 103 7. Instrument Software 7.1 Introduction A detailed description of the experimental techniques and how to perform them using the included software is provided below. The functions of this instrument are available from the front panel of the instrument software. If you are new to the instrument it is suggested you perform the test procedure using the step-by-step guide to an example experiment and after installation familiarize yourself with the basic functions of the software. The step-by-step guide can be found above. 7.2 General Overview The NAME software runs on the Windows operating system. It is compatible with Microsoft Windows 7 and above. It is important to note there is only one version of the software available and the only configuration differences are based on the specifications of the solar cell being tested. 7.3 Starting the Software After installing the software for LabView (which should already be pre-loaded onto the designated solar cell research computer) it can be opened by clicking the icon on the desktop or found in the applications list. The specific VI for this instrument can be downloaded after LabView has been properly installed on the laptop (again, it should already be preloaded and named Solar Cell Curve Generator). The software should automatically connect with the instrument once it is powered on. If it fails to connect or is disrupted, close the VI program and reconnect the USB cord before re-opening the program. If this does not work, disconnect the instrument from its power source and open the instrument panel to ensure there are no broken connections. C. Behme 104 7.4 Instrument Menu The instrument menu is the front panel of the computer program. This panel allows various instrument settings to be altered for a specific experiment. Some settings available to be set by the user are (but not solely limited to) number of steps, desired max current, and the current range of the data output. CAUTION: some settings are hard wired into the program to avoid changes that will cause the program or instrument to malfunction. Some settings are not hard-wired in, but if set incorrectly can also cause the program or instrument to malfunction. 7.5 Measuring Short Circuit Current The computer program automatically measures the short circuit current of the instrument while it runs. This data point is displayed as the y-intercept of the IV curve. 7.6 Measuring Open Circuit Voltage The computer program automatically measures the open circuit voltage of the instrument while it runs. This data point is displayed as the x-intercept of the IV curve. 7.7 Power Calculation The instrument automatically calculates the power for each data point by multiplying the current by the voltage for each step of the circuit. The maximum power output can be found at the maximum of the power curve (graphed on a second y-axis). C. Behme 105 7.8 Available Techniques The only available techniques are the ones described in above sections. The computer program automatically measures and records each of the three data points for each step and records them on a graph with two plots (and therefore two y-axes), one is current vs. voltage (the IV curve) and one is power vs. voltage (which is used to find efficiency). C. Behme 106 Appendix C: Grant Proposal Caitlin Behme, behmec@uindy.edu Dr. David Styers-Barnett, styersbarnett@uindy.edu, 317788-2061 Development of Instrumentation and Software to Economically Measure Solar Cell Properties C. Behme 107 Dye sensitized solar cells are an attractive option for viable 1,2 renewable energy production. The proposed project is to increase the testing capacity of the University of Indianapolis Department of Chemistrys dye-sensitized solar cell project. The previous method of testing proved to be inaccurate, difficult, and 3 incomparable to literature standards. The project will build an instrument allowing for measurement of standard current-voltage 4 (I-V) curves, resulting for better analysis of the solar cells. Without the proposed instrumentation, only individual measurements of voltage and current produced by the cell in dark and light conditions could be collected, but no measurements of the cells under various loads could be performed. The results were incapable of being compared to literature values, and actual 3,4 efficiencies could not be determined. The new test method will improve the ease of testing solar cells, as well as provide the opportunity to perform statistical analysis and create graphical representations of the data. These results can then be compared to the literature values to determine if improved efficiency has 3,4 occurred. This project contains two parts: a computer program was written over the summer using LabView to interface with a data 5 acquisition board and generate I-V curves. These curves allow for calculating various important data including (but not limited to) the maximum power point, the open circuit current values and the open circuit voltage values. This computer program is a modified version of one found in the literature and has been shown effective 5 in initial testing. The second part of this project is physical construction the 5 new instrument. A working prototype including an electron sink circuit has been constructed using borrowed parts. A data C. Behme 108 acquisition board that interfaces the computer program to the circuit is essential for successful operation. The data acquisition board is involved with both sending and receiving information to the circuit in order to produce the data described above. These curves are what can be compared between cells to determine what 5 set of variables produced the most efficient solar cell. The money from this grant, if received, will go towards buying the major components needed to build the finished, standalone model which will be used for years to come in the chemistry department both in research and laboratory coursework. The crucial pieces needed for completion of the instrument are a dedicated data acquisition board and a variable power supply for testing the circuit and solar cells, along with various electrical components. If these can be purchased, a final, working model will be constructed in such a way that it will create a lasting, functional instrument that can be run with minimal training by any person who needs it. As such, I am requesting funds to aid in completion of my project. C. Behme 109 Works Cited 1 Green, M. A., Emery, K., Hishikawa, Y., Warta, W., Dunlop, E. D., Progress in Photovoltaics. 2015, 23, 1-9. 2 Boschloo, G.; Hagfeldt, A.; Accounts of Chemical Research. 2009, 42, 1819-1826. 3 Ze Yu (2012). Liquid Redox Electrolytes for Dye-Sensitized Solar Cells, ISBN: 978-91- 7501-231-5, KTH Chemical Science and Engineering. 4 Grtzel, M.; Solar Energy Conversion by Dye-Sensitized Photovoltaic Cells. Inorg. Chem. 2005, 44, 6841-6851. 5 Mayer, E. A.; Powell, A. L., A low-cost laboratory experiment to generate the I-V characteristic curves of a solar cell, presented at ASEE Vancouver, BC, 2011, 1842. C. Behme 110 Expected Timeline of Project: October: Collect parts that are currently available from the chemistry department November: Order parts needed to complete the project, Improve computer program interface December: Build permanent circuit and DAQ board inside of box, update computer program to work with electronics from the box January: Test solar cell variables from honors project with new instrument Budget of Expenses: Item, Unit Cost, Quantity LabJack U6 DAQ Board, $299.00, 1 Tekpower TP3005T Variable Linear, $79.95, 1 Miscellaneous Electronic Components, $50.00, 1 Total Cost: $428.95 C. Behme 111 Appendix D: CITI Training COLLABORATIVE INSTITUTIONAL TRAINING INITIATIVE (CITI PROGRAM) COURSEWORK REQUIREMENTS REPORT* * NOTE: Scores on this Requirements Report reflect quiz completions at the time all requirements for the course were met. See list below for details. See separate Transcript Report for more recent quiz scores, including those on optional (supplemental) course elements. Name: Caitlin Behme (ID: 4703198) Email: behmec@uindy.edu Institution Affiliation: Institution Unit: University of Indianapolis (ID: 473) Chemistry Phone: 812-746-8015 Curriculum Group: Human Research Course Learner Group: Stage: Group 1.Biomedical Research Investigators and Key Personnel. Description: Stage 1 - Basic Course The biomedical track is applicable when the majority of your human research studies involve therapeutic or diagnostic agents. Report ID: Completion Date: Expiration Date: Minimum Passing: Reported Score*: 15375342 03/10/2015 03/09/2017 75 76 REQUIRED AND ELECTIVE MODULES ONLY C. Behme 112 Belmont Report and CITI Course Introduction Students in Research History and Ethics of Human Subjects Research Basic Institutional Review Board (IRB) Regulations and Review Process Informed Consent Social and Behavioral Research (SBR) for Biomedical Researchers Records-Based Research Populations in Research Requiring Additional Considerations and/or Protections Research and HIPAA Privacy Protections Conflicts of Interest in Research Involving Human Subjects DATE COMPLETED 02/21/15 02/21/15 03/10/15 03/10/15 03/10/15 03/10/15 03/10/15 03/10/15 03/10/15 03/10/15 For this Report to be valid, the learner identified above must have had a valid affiliation with the CITI Program subscribing institution identified above or have been a paid Independent Learner. CITI Program Email: citisupport@miami.edu Phone: 305-243-7970 Web: https://www.citiprogram.org COLLABORATIVE INSTITUTIONAL TRAINING INITIATIVE (CITI PROGRAM) COURSEWORK TRANSCRIPT REPORT** ** NOTE: Scores on this Transcript Report reflect the most current quiz completions, including quizzes on optional (supplemental) elements of the course. See list below for C. Behme 113 details. See separate Requirements Report for the reported scores at the time all requirements for the course were met. Name: Email: Institution Affiliation: Institution Unit: Phone: Curriculum Group: Course Learner Group: Stage: Description: Report ID: Report Date: Current Score**: Caitlin Behme (ID: 4703198) behmec@uindy.edu University of Indianapolis (ID: 473) Chemistry 812-746-8015 Human Research Group 1.Biomedical Research Investigators and Key Personnel. Stage 1 - Basic Course The biomedical track is applicable when the majority of your human research studies involve therapeutic or diagnostic agents.  ...

... Running Head: OUTREACH PROGRAM 1 Implementation of an Outreach Support Program for Individuals with Addiction, Family, and Community Members: A Doctoral Capstone Experience Mariah Haffner May, 2018 A capstone project submitted in partial fulfillment for the requirements of the Doctor of Occupational Therapy degree from the University of Indianapolis, School of Occupational Therapy. Under the direction of the faculty capstone advisor: Sally Wasmuth, PhD, OTR 2 OUTREACH PROGRAM A Capstone Project Entitled Implementation of an Outreach Support Program for Individuals with Addition, Family, and Community Members: A Doctoral Capstone Experience Submitted to the School of Occupational Therapy at University of Indianapolis in partial fulfillment for the requirements of the Doctor of Occupational Therapy degree. By: Mariah Haffner Doctor of Occupational Therapy Student Approved by: Faculty Capstone Advisor Date Doctoral Capstone Coordinator Date Accepted on this date by the Chair of the School of Occupational Therapy: Chair, School of Occupational Therapy Date OUTREACH PROGRAM 3 Abstract Nearly half a million people died from drug overdoses between 2000-2014, an average of 78 Americans each day (Costa, 2016). Today, Indiana is ranked 15th in the nation for drug overdose (Indiana House Democratic Caucus, 2017). The effect of the epidemic is impacting and impairing the occupational performance of individuals with addiction, their family members, and communities. Occupational therapy (OT) can play a vital and unique role with addiction recovery utilizing a holistic outlook to help individuals recognize the effects that addiction has on their life and assist in identifying ways to replace addiction with meaningful occupations. The purpose of this Doctoral Capstone Experience (DCE) project was to implement an outreach support program at A Better Life Briannas Hope (ABLBH), an addiction support and recovery group, utilizing occupational therapy foundations, implications, and theories as a guide to expand resources available, provide awareness and education, promote community involvement, and increase the sustainability of ABLBH. After completion of a needs assessment and literature, it was determined to include multiple levels of practice within the outreach program including individual/members, the organization, and community. This paper describes the need for implementation of the outreach program, the outcomes, and the discontinuation process for quality improvement of services and sustainability following the DCE. Outcomes for each level of practice included increased education and understanding on life skills for individuals, resulting from a 5-week occupation-based wellness workshop titled Rediscovering Life; improved organizational sustainability resulting from leadership training and financial gains; and increased prevention, education, and resources provided to the community through Connecting the Links, a resource fair that included 27 individuals as vendors and 60 attendees (87 total). OUTREACH PROGRAM 4 Literature Review and Background There has been a drug epidemic spreading and progressing throughout the United States with more deaths in the U.S. from overdose in 2014 than ever recorded in history (Rudd, Aleshire, Zibbell, & Gladden, 2016). Since 2000, the number of overdose-related deaths has increased 137%, including a 200% increase in the rate of overdose deaths involving opioids (Rudd et al., 2016). According to the Substance Abuse and Mental Health Administration (SAMHSA) (2016), In 2014, an estimated 22.5 million Americans aged 12 and older selfreported needing treatment for alcohol or illicit drug use. Nearly half a million people died from drug overdoses between 2000-2014, an average of 78 Americans each day (Costa, 2016). The increase in drug abuse and addiction is impacting not only the individuals with the addiction themselves, but their families and communities as well. There is a need to intervene to reduce the risk of drug addiction and the secondhand factors impacting communities. A Better Life - Briannas Hope (ABLBH), a participant-based, faith-based, and compassion-filled addiction support and recovery group serving people with addiction and their families throughout east central Indiana, saw a vast need for intervention (ABLBH, 2017). The non-for-profit organization established in 2014 and created their foundations off of a prayer found written on a piece of paper by a local young woman who went missing, and whose remains were found months later. The prayer speaks to God asking to help her create a better life because she had struggled to overcome addiction. ABLBHs mission is to provide hope through Christ to individuals and communities battling addiction using support, encouragement, and collaboration (ABLBH, 2018). ABLBH provides a non-judgmental environment while promoting honesty, transparency, and vulnerability to allow individuals to heal through sharing. What started as a support group for the womans local hometown has grown to currently consist OUTREACH PROGRAM 5 of 25 chapters serving 15 Indiana counties, one Ohio county, and continuously growing. ABLBH has been blessed with the opportunity to assist more than 450 people with finding and receiving detox and/or rehabilitation services that they otherwise would not have been able to afford (ABLBH, 2018). Research has shown that Indiana is ranked 15th in the nation for drug overdoses (Indiana House Democratic Caucus, 2017). ABLBH has seen where there is potential to make an impact and reduce the amount of drug abuse and effects. The National Institute on Drug Abuse (NIDA) (2014) defines drug addiction as the following: A chronic, relapsing brain disease that is characterized by compulsive drug seeking and use, despite harmful consequences. It is considered a brain disease because drugs change the brainthey change its structure and how it works. These brain changes can be longlasting, and can lead to the harmful behaviors seen in people who abuse drugs. There are a multitude of factors that could be the reason why individuals seek and use drugs; for example, they may use to feel good, to cope, as a pain reliever, peer pressure, etc. (NIDA, 2014). With the drug epidemic, it is important to intervene immediately and effectively, which requires a better understanding of the lifestyle. The American Occupational Therapy Association (AOTA) (2014) defines occupational performance as the ability to carry out activities of daily life (areas of occupation). To further clarify the term occupation in this sense, it is defined as the following: activities people complete, individually, with family, or as part of the community, to fulfill their time and provide one with purpose, meaning, identity, and volition (AOTA, 2014). People with addiction often experience decreased occupational performance and difficulty with performing activities of daily living, such as working a job or caregiving, while actively emerged in drug abuse because the addiction itself becomes their primary occupation. OUTREACH PROGRAM 6 The individual loses the skills necessary to function in life and ultimately exchanges living for his or her addiction (Martin, Bliven, & Boisvert, 2008). Researchers found that it is common for individuals with addiction to experience a decrease in occupational performance and quality of life (QOL) within the first 4-6 months of recovery (Martin et al., 2008). Most of the time this is the result of the individual leaving the supportive, yet restrictive, environment that a treatment center or a halfway house provides and re-emerging into their familiar environment that is filled with triggers and past routines (Gordon, 2003). Triggers can include old friends, hangouts, spouses, significant others, or family members who are unsupportive, promote unhealthy habits or surroundings, or familiar smells, sights, or sounds that trigger the individual to relapse (Gordon, 2003). It is not uncommon for addicts to fall into a familiar routine because it allows avoidance of overcoming everyday obstacles and hardships, utilizing challenging or new life skills, or living life sober. Wasmuth, Crabtree, and Scott (2014), reiterated the concept of addiction as a primary occupation noting when a person with addiction enters into recovery, they begin to face challenges that any individual could experience when not able to participate in their primary occupation. Possible difficulties include understanding their purpose in life, identifying their roles, creating routines, or coping with loss or change (Wasmuth et al., 2014). Another major obstacle in the way of recovery that most individuals with addiction face is learning to function and complete activities of daily living while sober. It is not uncommon for an individual with addiction to live with their addiction as their primary occupation for an extended amount of time, increasing the difficulty to remove that activity and environment from their life and replace it with a healthy occupation and new environment. These individuals often face many barriers when attempting to overcome their addiction and create a new, healthy, and supportive OUTREACH PROGRAM 7 environment to sustain their sobriety. Occupational therapy (OT) has the ability to incorporate a therapeutic role in addiction recovery utilizing a wellness approach to promote an improved wellbeing, prevent drug use, and reduce risk of relapse (Scaffa, Reitz, & Pizzi, 2010). The profession utilizes a holistic outlook to analyze an individual in terms of their environment, occupations, strengths, weaknesses, goals, and limitations, as well as how all factors of their life coincide. OT is uniquely positioned to assist people who are struggling to recover from substance abuse, by helping them to reestablish the roles and identities most meaningful to them (Opp, 2018). For an individual with addiction, OT services could help them identify roles and meaningful occupations and redesign their everyday routine to allow them to focus on and carry out what is important to them. According to Stoffel, We want people to find the activities that are meaningful to them and at just the right level of challenge so that, as they redesign their lifestyle, they tap into those things that allow them to move into a state of wellbeing. This is where OT can really make a difference in helping people stay in long-term recovery (Opp, 2018). Occupational therapists use models and theories to help guide their thinking and reasoning. Those models and theories are used to find the strengths of clients, as well as, potential barriers that could lead to dissatisfaction and lack of success. The Kawa is an occupation-based model that focuses on addressing the rehabilitation requirements of diverse clientele and on the connections of environment, nature, deity, and persons in the frame of life (Iwama, Thomson, & MacDonald, 2009). It uses a river metaphor to exemplify an individuals daily life and pinpoint issues disrupting the flow of their river or day. Every individual has various factors that impact their life, both internal (self) and external OUTREACH PROGRAM 8 (physical and social environment). An individuals goal is to have a smooth flowing river, free from impediments, indicating that there is good and positive interaction between environment, nature, deity, and others. Removing impediments allows space for the flow of river to improve. In order for one to create space, they first have to identify the issues blocking the flow of their river, learn ways and methods to overcome or remove the issue, and apply the modifications to remove the issue from blocking the flow of their river. Water, rocks, driftwood, and river walls are used to represent the various factors that make up ones river and impact ones flow. The water stands for life flow and those things that are going well for one. The river walls represent the physical, social, and cultural environments and dictate the volume of water. Rocks represent problems, difficulties, and obstacles one is experiencing, and lastly, driftwood acts as factors that can have either a negative or positive influence on life. Motivation to remove the impediments and improve flow of river comes from the individual seeking harmony, balance, and interaction of the focus components (Iwama et al., 2009). Completion of the Kawa is very self-driven, requires self-analysis and can assist in personal goal-setting. The Kawa is applicable to recovering individuals with addiction, or even individuals struggling with their addiction, for it is easily understandable and gives one a visual to see how a negative environment or poor support is impacting their flow of life. On the other hand, it also helps them identify the positive aspect of their life, which is important for confidence and motivation. ABLBH, unknowingly, incorporated an occupational-based foundation within the corporation that also goes hand in hand with the beliefs of the Kawa model. The director of ABLBH stated that he shares with all members, In order to become clean and stay clean, one must change their persons, places, and things (R. Davis, personal communication, January 2, 2018). The organization instills in the recovering individuals with OUTREACH PROGRAM 9 addiction the importance of creating a healthy and supportive environment and filling ones time with meaningful occupations. ABLBH, being participant-based, is able to make a difference by focusing on the priority needs of individuals with addiction to help them become sober and by providing the support to stay sober. The purpose of this doctoral capstone project is to assess the needs of ABLBH, then program plan to create an outreach program addressing those needs utilizing the Kawa model as a foundation to analyze and guide the project. Screening and Evaluation To analyze and assess the needs of ABLBH, it was determined through reviewing literature and comparing screening options that the strengths/weaknesses/opportunities/threats (SWOT) analysis should be utilized as the evaluation framework. The SWOT analysis allows one to gather and organize input about an organization as a whole or for each program within an organization (Allison & Kaye, 2014). The purpose of completing a SWOT analysis is to evaluate the strengths/weaknesses (internal factors) and opportunities/threats (external factors) involved within the organization. It can also involve careful analysis of program evaluation information, competitive analysis, and financial sustainability implications (Allison & Kaye, 2014). Utilizing the SWOT analysis can promote inter-professional practice or group engagement by having multiple board members or staff complete the analysis together. To further assist in completing the SWOT analysis, the SWOT Analysis Grid is an additional exercise to use to organize input and visualize new opportunities for a program. The grid can help make visible some important dynamics that influence an organizations strategic choices (i.e., the intersection of strengths, weaknesses, opportunities, and threats), and can offer suggestions about actions the organization should consider undertaking (Allison and Kaye, 2014). OUTREACH PROGRAM 10 The SWOT analysis was completed by two occupational therapy students and the director of ABLBH to determine the needs and how to best use identified strengths and opportunities to overcome weaknesses and threats. After completion of the discussion and SWOT analysis grid, it was determined that ABLBH would benefit from implementing additional programs to further meet the needs of the participants, family members, and the community (refer to Appendix A for completed SWOT analysis grid). There is a need to reach outwardly towards multiple levels of practice (individual, family members, community, organization, and state). To determine the needs at each population, additional evaluations were needed. Further determination of needs was completed through attending ABLBH meetings, engaging with the participants and family members, attending community drug prevention coalition meetings, research and literature reviews, and additional discussions with the director of ABLBH. When discussing ABLBH with the director, the main concerns for the organization were sustainability, maintaining support, communication between chapters, and staying true to ABLBHs mission. The organization is self-funded, relying primarily on donations and grants. ABLBH relies heavily on community support and volunteers to operate, which is a strength, weakness, opportunity, and threat within itself. Utilizing volunteers is a no-cost opportunity to promote community involvement and education, but there is a threat for burnout amongst volunteers. Another threat is the relapse of leaders, given multiple chapter leaders are individuals in addiction recovery. ABLBH is also rapidly expanding, going from one to 26 chapters within three years, which requires increased numbers in support. The vast growth again proposes a strength, weakness, opportunity, and threat within itself. Expanding provides the opportunity to reach more individuals, but the amount of growth achieved was originally not of plan to the founder. The unplanned growth led to an organizational structure that does not suit OUTREACH PROGRAM 11 the size of ABLBH. The director is aware of this and has a plan to propose to the board to minimize the threats and maximize opportunities. This plan includes electing a smaller executive board, improving communication across chapters, and providing increased training to leaders. He believes this plan will be a step towards becoming more sustainable, but he still has concerns for financial sustainability given they are non-for-profit. ABLBH does have opportunities through grants to address multiple needs. Grants could provide improved financial sustainability and offer potential for paid employees, training for leaders, and funds to assist more individuals in receiving detox and treatment. Those factors would greatly benefit weaknesses currently experienced at ABLBH. There are needs to expand and provide increased opportunities and resources for members and leaders, and the director desires to fulfill those needs, but they have currently lacked the time and resources to be able to. Through completion of a literature review, SWOT analysis, and speaking to members of ABLBH, it was concluded that there are a lack of resources and assistance amongst participants and family members. Referring back to the concept of addiction as primary occupation, people with addiction are unaware of how to replace their addiction with healthy occupations (Wasmuth et al., 2014). These individuals also have a tendency to have difficulty maintaining a job, executing roles, managing money, and experience impairments to their rest and sleep (Brown & Stoffel, 2011). Many participants agreed that they could benefit from workshops to improve their knowledge in these areas. Family members spoke out about a lack of support for families and resources, indicating a huge opportunity for ABLBH to expand to include these services. From attending community meetings, it became apparent that there is a need for increased awareness, education, and resources. OUTREACH PROGRAM 12 After completion of the screening and evaluation of ABLBH, the following concludes the priority needs for whom ABLBH serves. There is a lack of community outreach and support, education, and action addressing the needs of individuals with addiction and their families. The drug epidemic is also increasing costs of communities and impacting the safety and lives of children (Indiana House Democratic Caucus, 2017). Many times individuals with addiction and their families do not intervene early enough because they are uneducated on the severity of addiction, resources available, or are unaware of healthy coping skills. It is found that communities that do not offer assistance to reduce alcohol and/or drug abuse and to provide opportunities to engage in meaningful opportunities are inadvertently facilitating the isolation or estrangement of people from healthy occupations (Scaffa, Reitz, & Pizzi, 2010). Based off of the priority needs, it was determined that the purpose of this DCE project would be to create an outreach support program partnering with A Better Life - Briannas Hope to expand resources available through the organization, provide awareness and education, promote community involvement, and increase the sustainability of ABLBH. ABLBH has no set screening process within their organization, for now they only offer support and recovery group meetings and education to schools when asked. The organization saw a need amidst the drug crisis and decided to intervene by becoming an additional option compared to a 12-step program, in hopes to relate and connect to those who needed a secondary option. While ABLBHs main focus is on drug addiction, they open their doors to any individual. There are no set guidelines on who can or cannot participate or join their meetings. They also strive to connect to youth in schools, families, and the communities they are involved in. Given the wide variety of populations impacted, utilizing the SWOT analysis as the primary screening and evaluation process provided the ability to consider all factors of ABLBH as an organization OUTREACH PROGRAM 13 and the multiple populations in need. Completion of the SWOT isnt just about fixing the things that are wrong but also about nurturing what goes right. During the strategic planning process, the organization wants to figure out how it can best use its resources to take advantage of strengths and opportunities and to overcome weaknesses and threats (Allison & Kaye, 2014). To fully evaluate ABLBH, utilizing evidence-based literature and informal occupational profiles in addition to the SWOT were a huge part in gathering a holistic view of ABLBH and in analyzing how individuals with addiction experience occupational performance and participation. OT emerged and established it roots and foundations within the mental health setting (Brown & Stoffel, 2011). Overtime, OT adapted into a medical model approach and lost vision of its roots. OT is now re-emerging within the setting of mental health, which is largely influenced by the drug epidemic the U.S. is currently experiencing. Since ABLBH does not have a licensed occupational therapist on staff, it was not appropriate within this DCE project to complete individualized or group occupational therapy evaluations for the participants of the organization. Screening and evaluating ABLBH as a whole through the lens of OT to determine the needs of who they serve was appropriate to be able to program plan and implement OT based programs to further meet the needs found. In a traditional OT setting, where direct OT services are provided in regards to drug abuse and addiction, occupational therapists are able to evaluate an individual's ability to function in everyday tasks and their likelihood of relapse (AOTA, 2002). There is a vast amount of assessment tools available, including tests, instruments, questionnaires, or systematic interactions such as interviews and observations, to assist in the evaluation process for all different settings and populations. Assessment tools can come in standardized or non-standardized formatting. The use of evaluation and screening tools is OUTREACH PROGRAM 14 commonly found in settings and at facilities where direct care is performed by occupational therapists, such as, hospitals or inpatient and outpatient therapy clinics (Scaffa & Reitz, 2014). Occupational therapists are trained on multiple methods and encouraged to investigate assessment tools available to determine the appropriate fit for the population being served to meet their needs (Duggan, Gaston, Barr, Lizcano, & Lannigan, 2016). An individual is referred to OT if they are experiencing a developmental delay, physical impairment, mental or behavior limitation, or any factor decreasing their occupational performance and ability to perform meaningful activities. Occupational therapists utilize the different screening and evaluation tools to assess client factions, identify ones occupations, occupational performance, strengths, and limitations, and to distinguish areas of need for interventions. The evaluation tools used are often dependent on the practice setting and reason for OT referral. For example, if one was referred to OT with decreased occupational performance as a result of addiction it would important to complete an evaluation that identified healthy occupations meaningful to them, to assess their mental health status, and their readiness for change. The Canadian Occupational Performance Measure (COPM) would be an appropriate selection because it is a client-centered tool that aids an individual in identifying and prioritizing everyday issues that restrict or impact their performance in everyday living through a semistructured interview (Scaffa, Reitz, & Pizza, 2010). The COPM is designed to initiate conversation with a client about what problems arre being experienced and hindering their occupational performance. Once problem areas are identified, the client rates the importance of occupations. It then guides intervention planning by having the client choose the top five most important occupations to them and rating their level of performance and satisfaction with performance of each. Another example is the AUDIT, a questionnaire that assists in assessing the OUTREACH PROGRAM 15 effects of ones drinking habits. An occupational profile should be utilized as a secondary method to make the evaluation more holistic, to further understand the client factors, and their occupational performance (Scaffa, Reitz, & Pizza, 2010). Certified Community Behavioral Health Centers (CCBHC) recognized the benefits and skills offered by occupational therapy when SAMHSA included licensed occupational therapists as a profession that states might require as part of CCBHC staff, in order to best meet the service and quality requirements of the demonstration program (Duggan et al., 2016). Occupational therapists are trained to view individuals with a holistic outlook, to look beyond their diagnosis, but to also understand mental health diagnoses to better apprehend the client. Their role within an interdisciplinary team is to assess specific occupational based challenges impairing ones performance resulting from behavioral health disorders (Duggan et al., 2016). CCBHCs are required to provide comprehensive diagnostic and treatment planning evaluation(s) for all their consumers. The process of evaluation through occupational profiles allows therapists to create client-centered goals, treatments, interventions, and outcome that facilitate health and wellness (Duggan et al., 2016). Swarbrick, an occupational therapist, created a wellness model that can be utilized to evaluate an individual or group. He defined wellness as a conscious, deliberate process that requires a person to become aware of and make choices for a more satisfying life and of adapting patterns of behavior that lead to improved health in the wellness dimensions (Swarbrick, 2006, p. 311). The wellness approach when used to evaluate and treat individuals with serious mental health diagnoses provides the opportunity for occupational therapists to perform occupation based, client-centered, and holistic evaluations by looking at the 8 domains of wellness: OUTREACH PROGRAM 16 emotional, financial, social, spiritual, occupational, physical, intellectual, and environmental (Swarbrick, 2006). Within the context of community based settings, which would include ABLBH, the evaluation process will differ compared to direct care services. Completion of a needs assessment is necessary to prioritize issues and facilitate the development of interventions to address community concerns (Scaffa & Reitz 2014). Scaffa and Reitz (2014) also highlight the important of profiling the community collecting demographics to better understand the population, identify gaps, and develop a program plan. A common theme seen throughout all screening and evaluation strategies, when completed by an occupational therapist, is maintaining a holistic view, choosing a method that best meets needs of client or population, and creating plans to improve ones overall wellbeing. Implementation Dunn (1988) defines three service provision models utilized by occupational therapists: direct, monitoring, and consultation. Direct service is providing specific techniques and approaches to a single individual or small group. Monitoring service requires diagnostic skills to identify needs, planning of programs to address identified needs, and teaching and supervisory skills to assist individuals working in the immediate environment carry out the program. Consultation service model is the last service model and is the least utilized in traditional OT. With the consultation service, the therapist utilizes their expertise to address all needs involved in a system (Dunn, 1988). Occupational therapy knowledge is used efficiently when it is applied through consultation approaches to adapt environments and alter teaching and learning strategies to facilitate better outcomes (Dunn, 1988). The consultation service model was the primary model used to guide this DCE project by focusing on meeting the needs of the OUTREACH PROGRAM 17 organization, members of ABLBH, and surrounding community. The monitoring service model will be utilized as a secondary method once chapter leaders begin to implement the training material. The screening and evaluation process at ABLBH indicated the need for further program development to address needs at three different levels of practice: individual/member, organization, and community. The director, secretary, intern, and writer (OT student) collaborated to determine programs and projects that would best fit the needs at each level. It was important to address each level of practice to maintain the holistic perspective of OT and to incorporate OT foundations within the programs. Program Planning for Each Level of Practice Members of ABLBH. A main concern voiced by the chapter leaders and members of ABLBH was the lack of training available for individuals with addiction to assist their recovery, promote increased knowledge, skills, and improved occupational performance. To address this identified need, creation and implementation of a 5-week workshop titled Rediscovering Life was performed. Rediscovering Life is aimed to improve participants wellness and life skills through training and education. This 5-week workshop curriculum was based on the eight dimensions of wellness as defined by Substance Abuse and Mental Health Service Administration (SAMHSA): emotional, environmental, financial, intellectual, occupational, physical, social, and spiritual (2017). It is important to ones quality of life to have a healthy balance in each wellness category. The dimensions go hand-in-hand and contribute to each other. The workshop was designed to assist individuals in becoming aware of their current perceived quality of life, identifying areas of personal strengths and weaknesses, and utilizing occupation-based sessions along with life skills training to improve their overall wellness. Each OUTREACH PROGRAM 18 session covered two areas of wellness for the first four weeks and then the fifth week was an overall reflection and reassessment on the topics. An outline of Rediscovering Life can be found in Appendix B. To measure the outcome of the workshops, a short, internally developed pre/post survey was given the four weeks assessing the participants confidence level in their abilities with regards to that sessions topic (Appendix C). For example, session ones survey asked How confident are you in your ability to self evaluate?, and week two asked How confident do you feel in your ability to create a budget and manage money? and "How confident do you feel in creating a resume?. There is a 3-point rating scale in response to the survey questions: not confident, somewhat confident, or I got this down. There is also an open ended question of What did you learn? at the end of each survey. For the fifth and final week of the workshop, an internally developed satisfaction and effectiveness survey was created (Appendix D). In addition to hosting the workshop at two different chapter sites, a curriculum guide over Rediscovering Life was developed for sustainability. The curriculum guide describes the purpose of the workshop and provides a consistent outline session to session. Each session outline includes description of the formation, supplies and equipment needed, purpose and goals of group, warm up/icebreaker, educational concept, and questions to facilitate discussion. The curriculum guide is to serve as a resource for leaders by preparing them on important topics and concepts and providing quick access of useful tools to assist the members of ABLBH. Organization. Increasing sustainability of ABLBH was of high importance to the director. A local United Way grant was completed to increase funding and sponsorship as part of the DCE project. The grant, if approved, will increase funds to allow for expansion of programs offered at the organization and improved financial sustainability. The United Way OUTREACH PROGRAM 19 grant is intended to be used for a community outreach program on behalf of ABLBH for funding that would allow eight individuals to be sent to detox and treatment, and that would also cover the costs of hosting workshops, a secondary program called High Impact, promotional products, and food for events. To further assist with financial sustainability, a fundraiser was planned partnering with State of the Heart Care for April 28, 2018 in which half of the proceeds will go directly to ABLBH. Also, for the organization, leadership training for chapter leaders was offered and completed. The training focused on the Rediscovering Life Workshop Curriculum Guide created for the organizational use. The training session went over the information, education, and resources provided within curriculum guide allowing the leaders to have hands on experience with the material. In addition, it provided the chapter leaders the opportunity to ask any questions in regard to the material. The training session allowed for a great opportunity to advocate for OTs role in mental health and addiction. An internally developed 5-point Likert scale post survey (Appendix E) was provided to participants over the training to assess the relevance of material, handouts, and workshop. There was also an open-ended section on the post survey for participants to free write any additional comments, suggestions, or feedback. Furthermore, per request of the director, the office staff has been working hard to update the ABLBH website to include more information and resources. The remodel of the website has included offering immediate access to pertinent information such as Indiana and out of state treatment centers, homeless shelters, and sober living facilities. These resources play a huge role in the recovery of individuals with addiction and having the information readily available can benefit the health and wellness of individuals with addiction, family members, and persons working with the population. Another section added to the website is an informational section OUTREACH PROGRAM 20 with details of services provided, including new programs and events offered. To benefit the chapter leaders of ABLBH, a password protected link was added to the website that allowed leaders access to important documents of the company including financial documents, outlines and training guides for session topics, and resources to benefit them. Lastly, a video was added to advocate for OT and provide education on the role of occupational therapists in the mental health field, specifically with addiction. Community. Across the state, there is a lack of knowledge that brings stigma and poor associations to addiction. ABLBH will be hosting a community event titled "Connecting the Links" in March, 2018. Connecting the Links will be a community resource fair with the goal to provide all community members education, awareness, and resources offered through local organizations. Connecting the Links is also aimed at promoting community involvement, decreasing stigma on addiction, and increasing community members knowledge and understanding on addiction by having various speakers share their personal experience with addiction and/or working with the population. At the event, there will also many be resources available including information packets on Indiana treatment centers, sober living homes, homeless shelters, and support meetings for individuals with addiction and family members, as well as any additional information the vendors provide. ABLBH believes there is power in connecting as community organizations to help individuals gain the tools and resources to live a meaningful and purposeful life. The outcome of the event will be measured through attendance and a satisfaction survey (Appendix F). Leadership Beginning the DCE in an emerging field at an organization with abundant room for growth, it was no question that leadership would play a large part of the project. To conduct OUTREACH PROGRAM 21 successful projects at ABLBH, it has been a requirement to branch out and become involved as a representative of ABLBH throughout the community. To make connections that allow opportunities for partnerships and assistance, I have attended monthly Drug Prevention Coalition meetings and the Communitys Resource and Systems of Care meetings. These meetings have pushed me to improve my leadership skills by overcoming my fears of speaking out and by improving my communication skills to be effective. These meetings have also provided a great opportunity to promote and practice inter-professional collaboration. The various meetings involve a great deal of collaboration between multiple disciplines to discuss the needs of the town and how each organization can play a role. Planning the community event, Connecting the Links, has required a lot of organization and planning. I have had to make a lot of connections and advocate for myself, ABLBH, and the benefits of being a part of the community event. I have had to complete a lot of research to have up to date information on resources throughout the state and community and be able to justify the need to intervene. The event has required organizational skills, time management, and marketing in order to complete the necessary components in a timely manner, to have available resources to meet the needs of community, and to promote the event to bring awareness. The hosting of workshops has provided a new experience and practice of leadership skills. It required a shift of being a student, relying on the teachers for information and resources when in need, to being the teacher or lead role. To fulfill the role as leader at the workshops, I have had to prepare myself to be confident and competent in material. I have had to be flexible, open-minded, and provide consistent empathy to best meet the needs of the participants in the moment. Staff Development OUTREACH PROGRAM 22 Promoting staff development and increasing the opportunities available for staff was established need by the director of ABLBH and the chapter leaders. It been a request heard over and over again by the director but the organization has not had the means, time, or opportunity to increase the amount of training available to staff. This was an aspect appropriate to include as part of the DCE project and therefore became a priority. To promote staff development, a colleague and myself offered a training session to all chapter leaders at ABLBH over the Rediscovering Life Workshop Curriculum Guide. The training included providing education on each topic, discussing the need to complete the workshops with individuals with addiction, and hands on experience completing the activities to build competence with the material. Evidenced-based literature was incorporated throughout the training course and curriculum guide. Implementing evidence-based practice with the leaders will promote them to utilize it within their chapters, helping the leaders to focus on needs and having interventions and topics to increase the occupational performance of their participants. Another staff training will take place in April discussing the benefits of narrative based medicine. This training again increases the resources available, increases their knowledge, and provides an opportunity to include evidencebased practice at the support meetings. Discontinuation and Outcomes The main focus of this DCE and project was program planning and providing education with long-term goals to improve practice, ensure quality services, and increase organizational sustainability. After determining the needs of the organization and completing a literature review to assess needs in regards to the current drug epidemic being experienced, it was determined that creation of an outreach support program addressing needs at multiple levels of practice could fulfill the goals of the DCE project and needs of ABLBH. It was necessary to OUTREACH PROGRAM 23 plan accordingly with the outreach support program to provide and include continuous quality improvement (QI) within the programs and ongoing sustainability following the completion of the DCE. QI is an ongoing effort to address and document outcomes to improve the health of the community (Bonnel and Smith, 2018, p. 46). QI is an ongoing process involving multiple components such as reflecting and evaluating, receiving feedback, teamwork, and responding to changing needs (Bonnel and Smith, 2018). Outcome Measure Analysis To incorporate QI and ensure improved practice, creating and completing outcome analysis for the different implemented projects was necessary. Outcome measures are a vital part of QI for they allow one to assess the effectiveness and benefits of programs; they can help one identify challenges and means for improvement. Completion of outcome measures allow one to identify appropriate modifications to best fit the needs of the population being served. Rediscovering Life Workshop. Rediscovering Life consisted of a 5-week workshop focused on educating and practicing on important life skills. The goal of the workshop was to assist members of ABLBH learn and practice life skills to improve their occupational performance and overall wellness. The first four sessions consisted of a short, internally developed pre/post-survey assessing the participants confidence on the skills addressed (Appendix C). The participants could respond to the survey questions with not confident, somewhat confident, or I got this down. There was an additional open-ended question on each survey asking, What did you learn?. Session one focused on emotional and environmental aspects of wellness utilizing the Kawa river activity and SWOT analysis to help participants self-analyze and set personal goals. Session one had the pre/post question, How confident are you in your ability to self evaluate?. OUTREACH PROGRAM 24 Eighty percent of participants maintained the same level of confidence and the remaining 20% noted an increased confidence level. Session two focused on financial and intellectual aspects of wellness and activities which included budgeting and money management practice, review of resume building and interview skills, and providing information on where to apply for continuing education courses or the High School Equivalency (formerly known as GED). The first question was How confident do you feel in your ability to create a budget and manage money?. Fifty-seven percent noted an increase in confidence. The remaining 43% remained at same confidence level. The second question was How confident do you feel in creating a resume?. Fifty-seven percent noted an increase in confidence. The remaining 43% remained at same confidence level. The third question was How confident do you feel in your interview skills?. Forty-three percent noted an increased confidence level. Fifty-seven percent remained at current confidence level. Session three focused on occupational and physical wellness with activities including completion of a roles checklist and activities wheel for time management practice, as well as a discussion of the importance of replacing addiction with a routine of healthy occupations. Session two included two survey questions with the first question asking, How confident are you in your ability to identify your roles and routines?. Sixty percent noted an increased confidence level. The second question asked, How confident are you with time management?. Seventy percent remained at same level of confidence and 30% the noted increased confidence. Session four focused on social and spiritual aspects of wellness with the activities focused on identify coping skills and emotional regulation. The first survey question asked, How confident do you feel on balancing your social and spiritual wellness?. Thirty-six point four percent noted increased confidence with the remaining 63.6% maintaining same level of OUTREACH PROGRAM 25 confidence. The second question was, How confident are you on your ability to cope and regulate emotions?. Fifty-four point five percent experienced an increased confidence level and 45.5% remained the same. Refer to Appendix F for full outcomes and the open-ended what did you learn? responses. Session five focused on discussion of the changes of stage and completing the University of Rhode Island Change Assessment (URICA) questionnaire to assist the participants in identifying the stage of change being experienced. Each member created a goal to assist in carryover of the information presented to them throughout the sessions. Participants were provided an overall post workshop survey (Appendix D) to complete. The survey included a 5point Likert scale for nine statements and four open ended questions to analyze the benefits of attending, the effectiveness of Rediscovering Life, and areas for change to improve the workshop. Appendix H shows the results of post survey. Through completion of the workshop, outcome analysis, and review of feedback, it was determined that modifications to the original curriculum guide were needed to include more information. The modifications included further explaining educational concepts to meet the identified needs of participants and include additional specific topics that were not well explained in the original curriculum guide. The updated curriculum guide was distributed to all chapter leaders of the organization. Leaders were asked to review the updated guide and to ask any questions if necessary. QI was utilized through the modification of the curriculum to adjust the material to better meet the participants need, provide increased education on concepts to leaders, and increase the effectiveness for future use within the organization. Connecting the Links. Connecting the Links was a Jay County community resource fair hosted on March 17, 2018 that included 19 local organizations serving as vendor booths with OUTREACH PROGRAM 26 resources and information on assistance available, as well as seven speakers providing education and sharing their experience relative to addiction. To assess the outcome of the event, a satisfaction survey (Appendix F) was developed and attendees were encouraged to complete it when leaving. Forty individuals (46%) completed and returned the survey. Eighty percent noted they were completely satisfied with the event. The satisfaction survey included four open-ended questions to gather input and opinions on the event to better understand the benefits for events and note areas for improvement for future reference. Appendix I shows the detailed outcomes from the survey. Leadership Training. ABLBH chapter leaders were offered training over the Rediscovering Life workshop curriculum guide led by two OT students, including the writer. The curriculum guide was created for the leaders to have the opportunity to implement the workshop at their chapter as appropriate or needed. Training over the curriculum guide took place following a quarterly board meeting. Ten leaders participated in the training and completed an internally developed survey (Appendix C) to assess effectiveness of training. The survey contained a 5-point Likert scale for ten statements and three open ended questions (outcomes in Appendix J). Ensuring Quality Practice Ensuring quality practice was completed through the previously described events and training but also through creating adaptations to administration aspects were also completed to improve the service delivery at ABLBH. This included modifying the organizations website by updating details about the organization, ABLBHs mission statement and foundational document, as well as contact information to various in-state and out-of-state treatment center OUTREACH PROGRAM 27 options, homeless shelters, and sober-living homes. Making this information quickly accessible can be a huge asset to the individuals they serve and their families and to the community as well. Another way to ensure quality practice and increase sustainability was through completion of a United Way grant. United Way approved $4,000.00 to assist in providing detox and rehab for individuals and for promotional products, meals for members, and office supplies including the required ink and paper needed to print the Rediscovering life materials and guide. To also increase the financial sustainability, a benefit quarter auction partnering with State of the Heart Care will take place April 28, 2018. Half of the proceeds will go directly to ABLBH to use as needed. The profits gained from both the grant and fundraiser allow ABLBH to be more secure. Lastly, providing education, resources, and training in multiple ways provided a way to promote accurate carryover following completion of the DCE. These aspects also allowed implementation of OT foundations and evidenced-based implications to improve quality of services. Implementing a variety of programs and events aimed at different level of practice allowed the ability to meet societys changing needs from various angles and perspectives. As part of the DCE it was important to incorporate OT, which was initiated immediately utilizing an occupation-based model to assess the needs and guide the implementation phase of the program. Completing the DCE project as a student OT consultant with the Kawa as primary guide allowed for the needs of members, staff, communities, and the organization to be continuously identified and addressed. Overall Learning Communication was a key to being effective throughout all aspects of the DCE. Within all the completed projects, it was required to utilize different forms of communication with a OUTREACH PROGRAM 28 variety of individuals and populations. During the Rediscovering Life workshop, it was important to be able to demonstrate verbal and non-verbal communication to provide empathy and sincerity to build rapport and connect with the members and their families who were being transparent and vulnerable. It was necessary to provide efficient and professional written communication via emails to colleagues, other disciplines, and the public to promote events, provide education and awareness, and maintain a professionally acceptable manner. Written communication was also utilized through advertisement, flyers, the organizational website, and the local newspaper. Oral communication was demonstrated through speaking at events, training, hosting workshops, and phone calls. The opportunity was provided to advocate for the need of OT within this field by connecting with and having direct interaction with individuals such as Mr. Jim McClelland, Indianas Executive Director for Drug Prevention, Treatment, and Enforcement, and Mr. Ortiz from Senator Donnellys office. I had to learn to be calm and speak slowly to be more effective and understandable. I had to remember the benefits of utilizing multiple forms of communication to connect, earn respect, and be heard. Completing the DCE at ABLBH was highly beneficial to me, personally and professionally. Through the time spent at the organization, I was able to further develop and gain invaluable skills such as effective communication, building rapport, empathy, management skills, and leadership skills. Working directly with the individuals recovering from addiction has provided the chance to improve my client-centered skills and flexibility in both direct and indirect service delivery. Multiple times I would have to adjust and adapt the plan to accommodate for the in-the-moment needs while maintaining client-centered, occupation-based, and evidenced-based services. The projects I collaboratively created and implemented boosted my leadership skills and confidence immensely. Prior, I struggled with confidence relative to my OUTREACH PROGRAM 29 education, knowledge, and skills, but through leading workshop courses and being the host of events, I had to learn to trust in myself and my abilities. The population ABLBH serves allowed me to see hands on how the environment plays a huge role with ones occupational performance. ABLBHs director, the chapter leaders, and members all advocate and encourage one another to change their people, places, and things to improve their environment and support to decrease the likelihood of relapse. To me that is highly occupation-based, whether it was intended to be or not. Relating to the Kawa river model, often times people, places, and things make up the bulk of the barriers disrupting ones river flow, or in other words, decreasing their occupational performance. I have had ample amounts of experience advocating for the profession, the role of OT, and providing education to explain the concept of addiction as occupation. To be able to explain the profession to various populations, it has required speaking clinically and in laymans terms. This is a skill that can be useful in future practice. The skills developed and improved during the DCE at ABLBH have brought me to a new level professionally. Every experience through program planning and implementation can carryover to future practice for the skills are now ingrained within me and have bettered me. Therapeutic use of self, open-mindedness, empathy, and providing a nonjudgmental environmental are priceless life skills that have improved, on top of leadership and management skills, communication skills, as part of completion of the DCE. OUTREACH PROGRAM 30 References ABLBH. (2018). Home. A Better Life - Briannas Hope. Retrieved from https://www.ablbh.org Allison, M., & Kaye, J. (2014). Strategic planning for nonprofit organizations: A practical guide and workbook (3rd ed.). Hoboken: John Wiley & Sons. American Occupational Therapy Association (AOTA). (2002). Overcoming drug and alcohol abuse. American Occupational Therapy Association. Retrieved from: https://www.aota.org/~/media/Corporate/Files/AboutOT/consumers/MentalHealth/Drugs/ SubAbuse.pdf American Occupational Therapy Association. (2014). Occupational therapy practice framework: Domain and process (3rd ed.). American Journal of Occupational Therapy, 68(Suppl. 1), S1-S48. Bonnel, W. & Smith, K.V. (2018). Proposal writing for clinical nursing and DNP projects, Second edition. New York: Springer Publishing Company. Brown, C & Stoffel, V. (2011). Occupational therapy in mental health: A vision for participation. Philadelphia, PA: F.A. Davis Company. Costa, D. (2016). Occupational therapys role in countering opioid addiction. OT Practice, 22(1), 1216. Duggan, E., Gaston, A., Barr, W., Lizcano, E., & Lannigan, E. (2016). Occupational therapy service outcome measures for certified community behavioral health centers (CCBHCs): Framework for occupational therapy service with rationale for outcome measures selection and listing of occupational therapy outcome measure tools. American Occupational Therapy Association. Retrieved from: OUTREACH PROGRAM 31 https://www.aota.org/~/media/Corporate/Files/Practice/MentalHealth/occupationaltherapy-outcome-measures-community-mental-health-services.pdf Dunn, W. (1988). Models of occupational therapy service provision in the school system. American Journal of Occupational Therapy, 42(11), 718-723. doi:10.5014/ajot.42.11.718 Gordon, S. M. (2003). Relapse & recovery: Behavioral strategies for change. Wernersville, PA: Caron Foundation. Indiana House Democratic Caucus. (2017). The facts on Indianas opioid crisis. Retrieved from Trent Deckard, Chief of Staff, Indiana House of Representatives via personal communication. Iwama, M., Thomson, N., & MacDonald, R. (2009). The Kawa model: The power of culturally responsive occupational therapy. Disability and Rehabilitation, 31(14), 1125-1135. doi: 10.1080/09638280902773711 Martin, L. M., Bliven, M., & Boisvert, R. (2008). Occupational performance, self-esteem, and quality of life in substance addictions recovery. OTJR: Occupation, Participation And Health, 28(2), 81-88. doi:10.3928/15394492-20080301-05 National Institute on Drug Abuse. (2014). Drug abuse and addiction. National Institutes of Health. Retrieved from https://www.drugabuse.gov/publications/drugs-brains-behaviorscience-addiction/drug-abuse-addiction Opp, A. (2018). Recovery with purpose: Occupational therapy and drug and alcohol abuse. American Occupational Therapy Association. Retrieved from: https://www.aota.org/About-Occupational-Therapy/Professionals/MH/Articles/Recovery WithPurpose.aspx OUTREACH PROGRAM 32 Rudd, R., Aleshire, N., Zibbell, J., & Gladden, M. (2016). Increases in drug and opiate overdose death United States, 2000 2014. Centers for Disease Control and Prevention, 64(50), 1378-82. Scaffa, M and Reitz, S. (2014). Occupational therapy in community-based practice settings (2nd ed.). Philadephia, PA: F.A. Davis Company. Scaffa, M., Reitz, S., Pizzi, M. (2010). Occupational therapy in the promotion of health and wellness. Philadelphia, PA: F.A. Davis Company. Substance abuse and mental health service administration (SAMHSA). (2017). The eight dimensions of wellness. Substance Abuse and Mental Health Service Administration. Retrieved from https://www.samhsa.gov/wellness-initiative/eight-dimensions-wellness Swarbrick, M, (2006). A wellness approach. Psychiatric Rehabilitation Journal, 29(4), 311-314. http://dx.doi.org/10.2975/29.2006.311.314 Wasmuth, S., Crabtree, J. L., & Scott, P. J. (2014). Exploring addiction-as-occupation. The British Journal of Occupational Therapy, 77(12), 605-613. doi:10.4276/030802214X14176260335264 OUTREACH PROGRAM 33 Appendix A SWOT Analysis Grid of an A Better Life Briannas Hope STRENGTHS - What advantages does your organization have? - What can you offer that other organization do not? - What unique or lowest-cost resources can you draw upon that others can't? - What do people in your market see as your strengths? - What is unique about your organization? WEAKNESSES - What could you improve? - What should you avoid? - What are people in your market likely to see as weaknesses? - What factors negatively impact your organization? o o o o o o o o o o passion from chapter to chapter for growth- 25 chapters as of January 8, 2018 they are originally, timely, and where the action is able to provide meals at each meeting nonjudgmental, accepting previous addicts as leaderships allow for ability to relate financially transparent director is able to train leadership in each chapter designed on the need of the individual participant driven no set curriculum community support and availability o o o o o o o OPPORTUNITIES - What good opportunities can you spot? - What interesting trends are you aware of? - Useful opportunities can come from such things as: Changes in technology and markets on both a broad and narrow scale. Changes in government policy related to your field. Changes in social patterns, population profiles, lifestyle changes, and so on. Local events. o o o o o grants 3 paid employees trainings for benefits funds for detox/treatment placement sustainability partnering with other agencies to provide more services interns continuously growing due to dire need Structuring need structure to meet all needs Company grew beyond vision Budgeting trainings per quarter ability to provide resources no set curriculum financially self-sustaining support for family relapse of individuals placing bad name on brand THREATS - What obstacles do you face? - What are your competitors doing? - Are quality standards or specifications for your job, products or services changing? - Is changing technology threatening your position? - Do you have bad debt or cash-flow problems? - Could any of your weaknesses seriously threaten your business? o o o o o o loss of funding leadership relapse financial transparency burnout in leadership decrease in volunteer support decreased community support OUTREACH PROGRAM 34 Appendix B Session Outline for Rediscovering Life Session 1: Rediscovering Life: The Dam to the River 1. Spiritual Wellness Expanding a sense of purpose and meaning in life 2. Environmental Wellness Good health by occupying pleasant, stimulating environments that support well-being SWOT- identify strengths/weaknesses and opportunities/threats Kawa river of life metaphor and visual Personal goal setting Understanding ones sense of purpose Session 2: Rediscovering Life: The Balance of Life and Money 1. Financial Wellness Satisfaction with current and future financial situations 2. Intellectual Wellness Recognizing creative abilities and finding ways to expand knowledge and skills Budgeting and money management Education on HSE and further education Resume building and interview skills Session 3: Rediscovering Life: Active and Busy 1. Occupational Wellness Personal satisfaction and enrichment from ones work 2. Physical Wellness Recognizing the need for physical activity, healthy foods, and sleep Identifying roles and routines Time management Discussion: Importance of replacing addition with new healthy roles and occupations Session 4: Rediscovering Life: The Power of Positive Thinking 1. Social Wellness Developing a sense of connection, belonging, and a well-developed support system 2. Emotional Wellness Coping effectively with life and creating satisfying relationships Discussion: o Importance of healthy and supportive relationship o Creating positive social experiences o Coping skills and emotional regulation Session 5: Realizing How Well You Are: Life in Balance Reflection of previous sessions Re-evaluate Kawa river from session 1 Discuss stages of change Complete URICA questionnaire Celebrate through fellowship OUTREACH PROGRAM 35 Appendix C Pre/Post-Survey Questions for Rediscovering Life Sessions SESSION 1: How confident are you in your ability to self evaluate? Not Confident Somewhat Confident I Got This Down - What did you learn? SESSION 2: How confident do you feel in your ability to create a budget and manage money? Not Confident Somewhat Confident I Got This Down How confident do you feel on creating a resume? Not Confident Somewhat Confident I Got This Down How confident do you feel in your interview skills? Not Confident Somewhat Confident I Got This Down - What did you learn? SESSION 3: How confident are you in your ability to identify your roles and routines? Not Confident Somewhat Confident I Got This Down - What did you learn? SESSION 4: How confident do you feel on balancing your social and spiritual wellness? Not Confident Somewhat Confident I Got This Down How confident are you on your ability to cope and regulate emotions? Not Confident Somewhat Confident I Got This Down - What did you learn? OUTREACH PROGRAM 36 Appendix D Rediscovering Life Post Survey EFFECTIVENESS OF THE WORKSHOP 1 Strongly Disagree 2 Disagree 3 Neutral 4 Agree The workshop sessions were relevant to me. The workshop sessions were interesting. The workshop content was meaningful to me. The content was related to the skills and knowledge needed in recovery. The topics made me think about my own actions. The sessions motivated me to take action. The training provided me the confidence to use the knowledge gained in the workshops. The handouts/material provided in the workshops are found to be beneficial and useful. I was satisfied with the overall workshop. How did the workshops help you? What are your big takeaways? What should we do differently next time with the workshops (How could we improvement it)? What other topics do you feel would be beneficial to include? 5 Strongly Agree OUTREACH PROGRAM 37 Appendix E Rediscovering Life Workshop Curriculum Post Training Survey QUESTIONS ON THE EFFECTIVENESS OF THE CURRICULUM TRAINING 1 Strongly Disagree The training was relevant to me. The training was interesting and effective. The training content was meaningful to me. The training met my purpose in attending. The training content was related to the skills and knowledge needed as an ABLBH chapter leader. The training made me think about my own actions. The sessions motivated me to take action. I want to tell others about what was presented. The training provided me the confidence to use the knowledge gained and conduct the workshop. The training has given me ways to make my chapter more sustainable. The handouts/material provided in the guide are found to be beneficial and useful. What are the strengths of the workshop? How could the workshops be improved? Additional comments/suggestions/feedback: 2 Disagree 3 Neutral 4 Agree 5 Strongly Agree OUTREACH PROGRAM 38 Appendix F Connecting the Links Satisfaction Survey Thank you for attending Connecting the Links! We hope the event met your reason for coming. Please take a second to complete this survey to help us better understand what we did right and how we could improve. How did you hear about this event? Radio Newspaper Employer Family/friend Facebook Word of mouth Other: _______________ What interested you in attending? Speakers Vendors Both Food Other: _______________ Please check your age range: 12 - 17 45 - 54 18 - 24 55 - 64 25 34 65 - 74 35 - 44 75 & older How satisfied were you with the overall event? (Circle one) Completely Satisfied Somewhat Satisfied Somewhat Dissatisfied Completely Dissatisfied What was your favorite part of the event? Was there anything about the event you think we could have done better? How did you benefit from attending Connecting the Links? Additional Comments/Suggestions: OUTREACH PROGRAM 39 Appendix G Rediscovering Life Pre/Post-Survey Outcomes Rediscovering Life Pre/Post-Survey Outcomes for Sessions 1-4 # of Completed Surveys Session 20 out of 23 participants 1 Pre/Post Question/s How confident are you in your ability to self evaluate? Participants: 2 leaders 2 volunteers 2 family members 17 recovering individuals % of Increased Confidence % of Maintained Confidence 20% (n=4) 80% (n=16) 4 increased from 12 remained at somewhat somewhat confident to I got confident this down 4 remained at I got this down What did you learn quotes another way to evaluate pros and cons Just about the Kawa River of Life example That this meeting was much needed Listen to your heart and mind Today I learned to follow my heart and to keep on pushing. As long as I do that I can make anything happen Its not gonna be an easy journey but keep going and be true & honest to myself & others It will be overwhelming but it will be worth it How to analyze my life know faults/strengths, carry on 7 individuals in recovery out 16 participants 2 Participants: 4 leaders 2 volunteers 3 parents 1 spouse 10 individuals with addiction How confident do you feel in your ability to create a budget and manage money? 57% (n=4) 2 increased from not confident to somewhat 2 increased from somewhat confident to I got this down 43% (n=3) 1 remained at somewhat confident 2 remained at I got this down How confident do you feel on creating a resume? 57% (n=4) 1 increased from not confident to I got this down 3 increased from somewhat confident to I got this down 43% (n=3) 1 remained at somewhat confident 2 remained at I got this down How confident do you feel in your interview skills? 43% (n=3) 1 increased from not confident to I got this down 2 increased from somewhat 57% (n=4) 2 remained at somewhat confident 2 remained at I got this down. I learned that we need to realize what is important needs and what isnt important. Some things we can live without like our internet & TV OUTREACH PROGRAM 40 confident to I got this down 3 10 (2 family members and 8 individuals in recovery) out of 27 participants Participants: 2 future leaders in training 3 leaders 1 volunteer 3 family members 18 individuals with addiction 4 11 individuals in recovery out of 25 participants Participants: 2 leaders 2 volunteers 6 family members 15 individuals with addiction How confident are you in your ability to identify your roles and routines? 60% (n=6) 2 increased from not confident to somewhat confident 4 increased from somewhat confident to I got this down 40% (n=4) 3 remained at somewhat confident 1 remained at I got this down How confident do feel about time management? 30% (n=3) 1 increased from not to somewhat confident 2 increased from somewhat confident to I got this down 70% (n=7) 1 remained at not confident 5 remained at somewhat confident 1 remained at I got this down. How confident do 36.4% (n=4) 63.6% (n=7) you feel on 3 from not to 1 remained at not balancing your somewhat confident social and spiritual confident 4 remained at wellness? 1 from somewhat somewhat confident to I got confident this down 2 remained at I got this down How confident are 54.5% (n=6) you on your ability 5 increased from to cope and not to somewhat regulate emotions? confident 1 increased from somewhat confident to I got this down 45.5% (n=5) 3 remained at somewhat confident 2 remained at I got this down Spend time wisely, work on goals/roles I learned to always have positive things to do with your idle time. Find positive Hobbies. Also take an hour out for yourself everyday to relax and rest your mind & give yourself a Break. Make time for yourself. Find your interests Anything can occupy your time you just have to do it Have to keep myself busy with positive things Things I can do to be more productive so that I dont have the chance to use and what ways I can do if I get a craving and have the want to use. How my relationships are toxic for me and my recovery I try. People, places, and things Use journal to collect data to try to figure triggers out How others see me OUTREACH PROGRAM 41 Appendix H Rediscovering Life Overall Effectiveness/Satisfaction Outcomes 9 completed surveys Statement Outcomes Statement % strongly agree % agree % neutral % disagree % strongly disagree The workshops were relevant to me. 22.2% 44.4% 33.3% 0 0 The workshop sessions were interesting. 33.3% 55.5% 11.1% 0 0 The workshop content was meaningful to me. 33.3% 55.5% 11.1% 0 0 The content was related to the skills and knowledge needed in recovery. 33.3% 33.3% 33.3% 0 0 The topics made me think about my own actions. 22.2% 55.5% 11.1% 11.1% 0 The sessions motivated me to take action. 22.2% 55.5% 11.1% 11.1% 0 11.1% 66.6% 11.1% 11.1% 0 22.2% 44.4% 33.3% 0 0 44.4% 44.4% 11.1% 0 0 The training provided me the confidence to use the knowledge gained in the workshops. The handouts/material provided in the workshops are found to be beneficial and useful. I was satisfied with overall workshop. Open-ended Responses How did the workshop help you? Listening to others Helped me realize Im on the right path Helped me think, gave knowledge and resources What are your big takeaways? Triggers, and overcoming them. What to do with free time I can change, I can cope Work on budget They helped me understand myself a lot better Money management, goal setting/achievements, etc Look at money management That improvement is up to me Realize my problems and help me to make my next step Keep focused on triggers They made me think about the person I want to be What should we do differently What other topics do you feel next time with the workshops would be beneficial to to improve them? include? Add more hands on No other topics needed activities, less surveys Introductions to recognizing More skittles More powerpoints Nothing, Mariah and Aubri were AWESOME Keep it same Nothing loved it Examples of how to get into another life style OUTREACH PROGRAM 42 Appendix I Connecting the Links Outcomes How satisfied were you with the event? Vendors Attendees Connecting the Links Event Satisfaction Survey Outcomes Completely satisfied Somewhat satisfied Somewhat dissatisfied 12 4 0 20 3 0 Age Range: Attendees 18-24 2 25-34 3 35-44 2 45-54 6 55-64 6 65-74 4 How did you hear of the event? Attendees Radio Newspaper Family/friend Facebook other 1 2 10 6 Word of mouth 4 Themes for improvement: Shorter time frame Better marketing Different tables for vendors Smaller venue/less chairs Host in better weather How did you benefit from event Themes: Vendors Networking Providing education Connecting to those in need Better understanding of addiction Agency exposure Attendees Receiving help Increased knowledge/information on resources Made connections Increased understanding of addiction What was your favorite part of event Themes: Vendors Networking Speakers Testimonies Informing/educating Attendees Speakers Fellowship Obtaining info/ vendors Organized Connecting with others who care/ understand Completely dissatisfied 0 0 8 OUTREACH PROGRAM 43 Appendix J Leadership Training Outcomes 10 completed surveys Statement Outcomes Statement % strongly agree % agree % neutral % disagree % strongly disagree The training were relevant to me. 100% 0 0 0 0 The training sessions were interesting. 100% 0 0 0 0 The training content was meaningful to me. 100% 0 0 0 0 The training met my purpose in attending. 100% 0 0 0 0 90% 10% 0 0 0 60% 40% 0 0 0 The training motivated me to take action. 80% 20% 0 0 0 I want to tell others about what was presented. 100% 0 0 0 0 70% 30% 0 0 0 80% 20% 0 0 0 100% 0 0 0 0 The content was related to the skills and knowledge needed as an ABLBH chapter leader. The trainings made me think about my own actions. The training provided me the confidence to use the knowledge gained in the workshops. The training has given me ways to make my chapter more sustainable. The handouts/material provided in the workshops are found to be beneficial and useful. Open-ended Responses What were the strengths of the workshop training? Showing struggles How to prioritize and be responsible Info How could the workshop training be improved? Maybe broken it down into groups w/more individual time Additional comments/suggestions/feedback: Very well done!  ...