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... 1 Providing Holistic and Preventative Wound Care Resources to Enhance Patient Education Shelby Hudson May 2023 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: Kelsey Peter, OTR 2 TABLE OF CONTENTS ABSTRACT.................................................................................................................................... 3 CHAPTER I. INTRODUCTION........................................................................................................ 4 II. BACKGROUND.......................................................................................................... 5 III. THEORY...................................................................................................................... 8 IV. PROJECT DESIGN & IMPLEMENTATION............................................................. 9 V. PROJECT OUTCOMES............................................................................................. 11 VI. DISCUSSION............................................................................................................. 13 VII. CONCLUSION........................................................................................................... 14 REFERENCES............................................................................................................................. 15 TABLES....................................................................................................................................... 18 FIGURES...................................................................................................................................... 19 APPENDIX................................................................................................................................... 22 3 Abstract Patient education is essential for increasing health literacy and compliance with plan-of-care approaches. The occupational therapist's role is to help preserve and restore participation in meaningful activities for increased quality of life by addressing the physical and psychological well-being of the individual. The purpose of this project was to create patient educational resources for enhanced knowledge and health literacy within the wound care population. This study utilized a survey methodology to collect knowledge and perceived knowledge scores from the patient population at MHP Wound Center regarding wound care prevention and management strategies before and after a six-week educational series. Participants demonstrated increased knowledge and perceived knowledge of holistic preventative techniques after completion of the educational series. The findings of the study supported the need for educating patients at the wound center on preventative and management techniques for increased health literacy and patient outcomes. Keywords: Patient education, knowledge, wound care, quality of life, preventative techniques 4 Introduction Major Health Partners (MHP) is an urban hospital located in Shelbyville, Indiana that has been providing services since 1942. The mission statement of MHP is to create and deliver superior health care solutions by providing [their] patients with optimal clinical and economic outcomeswe must also function as the communitys leader in upgrading the level of health and wellness in the community (Major Health Partners, 2022). The organization serves wound care patients by providing a holistic approach to focus on recovery and unique needs. Patients are seen weekly for debridement, casting, compression techniques, and dressing of wounds. This doctoral capstone experience (DCE) focuses on implementing patient education materials and videos on forming daily habits, learning about nutrition, incorporating physical activity, and performing off-loading techniques that can help improve ones overall health and health literacy by encouraging active participation in the plan of care. This will allow the patient to develop an understanding of how to self-manage symptoms and the long-term effects of their wound. Identification of these issues ensures that interventions promote appropriate support for MHPs mission statement and increase patient satisfaction (Gillespie, 2014). Throughout the project, a pre- and post-survey was given to collect data on the perceived knowledge of educational resources that will be available to patients. There was also a website with educational material and videos that the patient was able to access, as well as posters that were in each room with a QR code. Educating patients on how physical and psychosocial variables can impact the individuals day-to-day activities is important to the overall occupational performance and quality of life for the patient (American Occupational Therapy Association, 2018; Sen, 2019). This experience has allowed for increased patient education within the wound center and has enhanced the researchers skillset as a professional. 5 Background Within America, wounds affect around seven million patients. Absence of education, standards of care, and research has been challenging areas within this subject field and development of intervention approaches (Sen, 2019; Mahmoudi & Gould, 2020). The complexity of the wound environment combined with patient comorbidities and aging populations have also been challenges within the wound care population. Reduced mobility, weight loss, and chronic diseases are characteristics that may lead to the susceptibility for the development of a wound (Jaul et al., 2018). There are a wide variety of wound types and different ways to educate a patient on how to prevent/manage wounds. Chronic wounds occur when the wound is open for more than a month and has not advanced through the normal healing process. Acute wounds, such as surgical/traumatic wounds, abrasions, or superficial burns, appear when the cutaneous barrier of the skin is compromised (Sen, 2019). Another type of common wound is a pressure ulcer (PU), which is caused by unrelieved pressure in a localized area. Prevalence of this type of wound is approximately 12.3 percent across all facilities (Peterson et al., 2013). Immobility, poor perfusion, moisture, diabetes, and poor nutrition are all risk factors for the appearance of a PU or a diabetic ulcer. These wound types are often accompanied by pain, depression, and infection. Complications as such can have a detrimental impact on ones health and cause early mortality (Jaul et al., 2018). Older people are also more susceptible to wounds in general due to the increased incidence of mobility issues, incontinence, chronic health conditions, and malnutrition. These challenges can then lead to decreased fatty tissue, poor skin condition, limited strength, reduced participation in activities of daily living, and edema (Acton, 2013). Comorbidities, such as cardiovascular disease, diabetes mellitus, and neurodegenerative disorders, are common within 6 the wound care population. Low cardiac output, decreased oxygenation, decreased blood perfusion, dehydration, and peripheral ischemia, as seen in various cardiovascular diseases, have the potential to cause structural changes to the skin; thus, resulting in a PU. The prevalence of diabetes has increased in the past several decades. Not only does this co-morbidity increase the occurrence of diabetic foot ulcers due to diabetic neuropathy, but it also increases the risk for wounds beyond the feed due to drier, stiffer, and thinner skin everywhere. Individuals with neurodegenerative disorders tend to be immobile, have difficulties with swallowing, isolate themselves, and develop cognitive impairments, which can all contribute to and increase the vulnerability for a wound to occur (Jual et al., 2018). Although wounds affect nearly 2.5% of the United States population, there is limited literature on providing education to the patient and involving them in educational activities. This may be due to wounds not being identified as a disease; therefore, wounds can be treated by a wide variety of clinicians and nurses (as cited in Mahmoudi & Gould, 2020). Education targeted at patients and/or their caregivers and engaging patient awareness have been recognized as an important component regarding wound care interventions, especially in the outpatient setting (Mahmoudi & Gould, 2020; OConnor et al., 2021; Porter-Armstrong, 2018; Sen, 2019). There is evidence to support interventions aimed at enhancing health literacy of patients through increasing their capacity to self-manage, their awareness of risk factors in wound development, and their ability to act on the risk (OConnor et al., 2021). Interventions that include electronic modalities for education purposes have been shown to not only reduce costs for outpatient wound clinics but also increase the treatment success rate (Mahmoudi & Gould, 2020). Addressing the shortcomings of the literature, such as a lack of patient education and the psychosocial factors impacted by a wound, may allow for enhanced patient care. Wound care 7 patients can experience decreased motivation and adherence to individualized plans due to psychological and emotional stressors. The best practice and adherence for wound care should include developing an individualized, holistic approach regarding the needs of both the mind and body. Empowering the patient and/or caregiver will only allow for improved outcomes. Prevention of wounds is key for enhancing health within this population, and education is a way for these individuals to play an active role in their own health management (Shanley, 2019). By engaging the patient in the planning and implementation of the plan of care, they are more likely to participate and adhere to the intervention, which will lead to better patient outcomes. Actively managing and following through with the learning process will also help with patient adherence (Pollock et al., 2015). Developing patient educational packets, interventions, and videos for a newly established wound care clinic can promote increased patient satisfaction. Providing a multitude of learning platforms, which may include multimedia and verbal guidelines, will improve learning and the transfer of learning (Porter-Armstrong et al., 2018). Improving nutritional intake, participating in physical activity, relieving pressure, and forming daily habits and routines will allow individuals to enhance their occupational performance, maximize their independence, and increase their overall quality of life (QOL) (Sen, 2019). This project will not only demonstrate how occupational therapy can be beneficial for increasing patient education, but how it can also serve the patients through holistic interventions to increase overall well-being and quality of life. Implementing this project aligns with the professions vision to maximize independence, QOL, and well-being for all individuals through the engagement of meaningful activities (American Occupational Therapy Association, 2022). 8 Theory When working with wound care patients who have a variety of stages of wounds and addressing psychosocial challenges, the Person-Environment-Occupation-Performance (PEOP) model can be used to emphasize the importance of health promotion and enhancing ones wellbeing (Christiansen et al., 2015). The PEOP model focuses on the transactional relationship of these aspects and helps identify which intrinsic or extrinsic factors may be limiting the persons participation in meaningful daily activities (Figure 3) (Cole & Tufano, 2020). Discussing challenging factors with wound care patients and providing them with interventions and community resources to help overcome these barriers can help create a holistic environment for this target population within the local hospital and improve patient QOL (Petrusevicine et al., 2018). It will allow them to focus on how their environments are impacting their desired occupations. Using the psychodynamic frame of reference, occupational therapy interventions will focus on self-direction, self-awareness, self-management, self-identity, social identity, and relationships to increase occupational engagement and performance (Cole & Tufano, 2020). It would be beneficial for the patient to address concerns and potential barriers while they are undergoing a current plan of care or before they experience the physical, mental, and emotional challenges that may occur while having a wound. Having a more positive sense of self, consciously and unconsciously, will allow for more engagement in meaningful occupations within their environments despite the physical challenges they may be experiencing (Taylor et al., 2021). The change in ones beliefs will ultimately occur also through the expression of emotions and self-reflection, which will help support the individuals performance in their daily 9 activities (Figure 4) (Cole & Tufano, 2020). Expression of self was enabled by the researcher to promote self-awareness to enhance ones ability to self-direct and manage their wound care. Project Project Design After determining the overall need for education, it was decided to focus on patient education specifically within the facility. The learning process was guided by the andragogical approach embedded in the adult learning theory. Educational resources were delivered through the facilitation of learning, which allowed interventions to be person-centered and collaborative (Bouchrika, 2022). Occupational therapy can address these educational challenges by creating habits, roles, and routines to emphasize the importance of adhering to strategies and engaging the patient in their wound care management/prevention (Aranz, 2017). To evaluate the effectiveness of the provided educational resources, levels one and two of the Kirkpatrick Evaluation Model were used. Level one evaluation, known as the reaction evaluation, was used to determine if the materials were valuable and engaging. Level two evaluation is known as the learning evaluation; this level identifies how the participant has improved their knowledge and skills because of the training (Kirkpatrick & Kirkpatrick, 2016). Project Implementation The pre-screening and presurvey were created to gain a better understanding of the knowledge the patients had on wound care prevention strategies. Participants were provided with a written consent form and a verbal explanation of the project. A paper survey was provided to all of those who agreed to participate and served as the level one and level two evaluation methods. The paper survey was chosen versus an online survey for maximum patient participation due to the age and socioeconomic status of the patient population. 10 The pre-screening included four questions to determine if the patient would be able to participate in the online portion of the educational material (Table 1). The next part of the survey consisted of knowledge questions pertaining to wound care prevention/management techniques. The setup was like a quiz, and each question had three answer choices. This was administered pre and post educational resources to assess patient knowledge and health literacy and served as the level two learning evaluation (Appendix A) (Kirkpatrick & Kirkpatrick, 2016). The next section was a Likert scale, ranging from strongly disagree (1) to strongly agree (5), and consisted of 13 questions to assess their perceived knowledge of wound care prevention/management techniques (Appendix B). A higher score indicates the more belief the individual has that they have the appropriate knowledge to adhere correctly to the treatment guidelines. This was given pre and post educational resources to evaluate patient-perceived knowledge and served as the level one reaction evaluation (Kirkpatrick & Kirkpatrick, 2016). To make the pre-screening, presurvey, and postsurvey more accessible and inclusive, it was offered to participants to have the researcher read aloud the survey and fill it out for the patient, or the patient could fill it out independently. Project Outcomes The presurvey data was completed by 11 patients and was collected during weeks three and four of the project. During weeks nine and ten, postsurvey data was completed by 10 participants. collected. Only one participant did not complete all the education or postsurvey due to being discharged from services before the project could be completed. Participants completed the pre- and post-survey via paper and pencil at the beginning of their scheduled wound care appointment. Analysis of the surveys involved analyzing the knowledge items to determine the overall effectiveness and perceived improvement of each component of the survey. 11 All the participants received approximately 30 minutes of one-on-one sessions with the researcher once a week. Treatment sessions were based on the andragogical learning approach and the PEOP model to ensure holistic approaches were assumed. Each week the participant was provided with educational materials regarding exercise, nutrition, habit forming, and off-loading techniques and benefits in this order. After developing a therapeutic relationship with the patients, they were able to express more feelings and emotions to address the psychodynamic frame of reference to help individualize intervention sessions (The American Journal of Occupational Therapy, 2020). It was observed that most patients preferred the physical materials over the educational online website that was created; the physical hand-outs were more easily understood and accessible to this specific patient population. Upon completion of the project, it was observed that there was an increase in patient knowledge (Figure 1) of 68.75% and an increase in patient perceived knowledge (Figure 2) regarding wound care prevention and management by 38.48%. The knowledge portion included data from a total of ten patient participants. One participant was excluded from data analysis because the postsurvey was not completed due to them being discharged from services. As a general observation through discussion, patients who received the education were more apt to make healthier food choices at home and have better adherence to moving daily to increase blood flow for optimal healing. One challenge during the process was gathering participants. Many patients at the facility were not inclined to participate voluntarily due to not wanting to take more time out of their scheduled visit. Others did not want to go through the process because they believed they had all the resources and education needed for advanced wound healing rates. There was also limited time with some patients during the intervention sessions due to their schedules that day. Some 12 patients received 15 minutes of education while others received 30 minutes. Successes of the project have included making an online resource and educational handouts for the wound clinic to continue to use after the completion of the capstone project. Another success was improving patient health literacy to aid in the wound-healing process. Discussion Roughly 2.5% of the United States population, seven million people, are affected by a wide variety of wounds due to reduced mobility, weight loss, chronic diseases, and the inability to follow through with treatment plans (Jaul et al., 2018). To help serve this population, Major Health Partners Hospital opened a local wound care center in 2019 and has recently revamped the program. Patients are typically seen weekly for their wound care treatments, which consist of debridement, casting, compression techniques, and dressing of wounds. Challenging characteristics that lead to the susceptibility of a wound may arise from the lack of patient education regarding wound care prevention and management (Mahmoudi & Gould, 2020; OConnor et al., 2021; Sen, 2021). Through observation and continued research, it has been found that patient education regarding wound care prevention and management and patient health literacy has been neglected within this population, especially in rural areas. Developing and delivering educational resources using the PEOP model and psychodynamic frame of reference as a guideline should give patients the tools and knowledge while also providing interactive opportunities to incorporate education into their everyday lives. To gather a better understanding of current patient knowledge and resources at the MHP Wound Center, a survey consisting of a quiz and a Likert scale was given to voluntary patient participants. A website and binder were created with patient educational resources regarding exercise, nutrition, habit forming, and offloading for wound care prevention and management. 13 The same questions were then asked after patients had completed all their education. There was a 68.75% (Figure 1) increase in knowledge scores and a 38.38% (Figure 2) increase in perceived knowledge. This demonstrates the importance of patient education and increasing health literacy within this setting and population. Conclusion Overall, there is a general need for increased patient education and health literacy regarding wound care prevention and management to improve health literacy and knowledge for this unique patient population. Providing physical and digitized community resources and developing individualized educational approaches, this non-traditional setting would benefit from this specific project intervention. Applying occupational therapy services to the wound care clinic to address physical and psychological health can help increase the independence, social participation, and well-being of the patient. Promoting lifestyle changes and offering a holistic approach to treatment, occupational therapy can increase the functional capacity and engagement in meaningful activities for wound care patients and staff to improve overall QOL and practice. Patients were given the tools, knowledge, and interactive opportunities to learn and apply the education and resources to their daily lives Incorporating these materials upon patient admission or during one of their first visits will allow them to increase their understanding of how to selfmanage and have enhanced knowledge about physical and psychosocial challenges associated with their wound. Additionally, practitioners and nursing staff should continue to implement these resources via physical handouts and a website (Figure 5) to enhance the patients health literacy and knowledge with the hope to improve compliance and quality of life. A complete observation log can be found in Appendix C. 14 References Acton, C. (2013). Review of the importance of nutrition in wound healing. Wounds UK, 9(3), 6164. Retrieved January 10, 2023, from https://www.woundsuk.com/download/resource/695 American Occupational Therapy Association. (2022). About AOTA: Mission and Vision. AOTA. Retrieved March 30, 2022, from https://www.aota.org/about/mission-vision American Occupational Therapy Association. (2018). The role of occupational therapy in wound management. American Journal of Occupational Therapy, 72(Suppl. 2), 7212410057. https://doi.org/10.5014/ajot.2018.72S212 Aranz. How can patient engagement improve wound care outcomes? 2017. https://www.aranzmedical.com/uncategorized/outcomes-delivered-patient-engagementpatientshealthcare-providers (last accessed December 14, 2022) Bouchrika, I. (2022, September 27). The Andragogy Approach: Knowles' adult learning theory principles. Research.com. Retrieved February 1, 2023, from https://research.com/education/theandragogy-approach Christiansen, C., Baum, C., & Bass, J. (2015). The Person-Environment-OccupationPerformance (PEOP) model. In C. Christiansen & C. Baum (Eds.), Occupational therapy: Performance, participation, and well-being (4th ed.) (pp. 49-55). Thorofare, NJ: SLACK, Inc. Cole, M. & Tufano, R. (2020). Applied theories in occupational therapy: A practical approach. (2nd Ed.). SLACK Incorporated. Gillespie, B. M., Chaboyer, W. P., McInnes, E., Kent, B., Whitty, J. A., & Thalib, L. (2014). 15 Repositioning for pressure ulcer prevention in adults. The Cochrane database of systematic reviews, 2014(4), CD009958. https://doi.org/10.1002/14651858.CD009958.pub2 Jaul, E., Barron, J., Rosenzweig, J. P., & Menczel, J. (2018). An overview of co-morbidities and the development of pressure ulcers among older adults. BMC Geriatrics, 18(1), 111. https://doi.org/10.1186/s12877-018-0997-7 Kirkpatrick, J. D., & Kirkpatrick, W. K. (2016). Kirkpatrick's four levels of training evaluation. American Society for Training & Development. Mahmoudi, M., & Gould, L. (2020). Opportunities and challenges of the management of chronic wounds: A multidisciplinary viewpoint. Chronic Wound Care Management and Research, 7, 2736. https://doi.org/10.2147/cwcmr.s260136 Major Health Partners. (2022). Retrieved January 9, 2023, from https://www.mymhp.org/ O'Connor, T., Moore, Z. E., & Patton, D. (2021). Patient and lay carer education for preventing pressure ulceration in at-risk populations. The Cochrane database of systematic reviews, 2(2), CD012006. https://doi.org/10.1002/14651858.CD012006.pub2 Peterson, M. J., Gravenstein, N., Schwab, W. K., van Oostrom, J. H., & Caruso, L. J. (2013). Patient repositioning and pressure ulcer risk monitoring interface pressures of at-risk patients. The Journal of Rehabilitation Research and Development, 50(4), 477488. https://doi.org/10.1682/jrrd.2012.03.0040 Petruseviciene, D., Surmaitiene, D., Baltaduoniene, D., & Lendraitiene, E. (2018). Effect of community-based occupational therapy on health-related quality of life and engagement in meaningful activities of women with breast cancer. Occupational Therapy International, 113. https://doi.org/10.1155/2018/6798697 16 Pollock, R. V. H., Jefferson, A., & Wick, C. W. (2015). The Six Disciplines of Breakthrough Learning: How to Turn Training and Development into Business Results (3rd ed.). Pfeiffer. Porter-Armstrong, A. P., Moore, Z. E., Bradbury, I., & McDonough, S. (2018). Education of healthcare professionals for preventing pressure ulcers. Cochrane Database of Systematic Reviews, 2018(5). https://doi.org/10.1002/14651858.cd011620.pub2 Sen, Chandan K. Human Wounds and Its Burden: An Updated Compendium of Estimates. Advances in wound care 8,2 (2019): 39-48. doi:10.1089/wound.2019.0946. Shanley, E., Patton, D., Avsar, P., O'Connor, T., Nugent, L., & Moore, Z. (2022). The impact of the Shanley Pressure Ulcer Prevention Program on older persons' knowledge of, and attitudes and behaviors towards, pressure ulcer prevention. International wound journal, 19(4), 754764. https://doi.org/10.1111/iwj.13671 Taylor, C., Mulligan, K., & McGraw, C. (2021). Barriers and enablers to the implementation of evidencebased practice in pressure ulcer prevention and management in an Integrated Community Care Setting: A qualitative study informed by the theoretical domains framework. Health & Social Care in the Community, 29(3), 766779. https://doi.org/10.1111/hsc.13322 American Occupational Therapy Association. (2020). Occupational Therapy Practice Framework: Domain and process-fourth edition. American Journal of Occupational Therapy, 2020, Vol. 74(Supplement_2), 7412410010p17412410010p87. DOI: https://doi.org/10.5014/ajot.2020.74S2001 17 Tables Table 1 Pre-Screening Wound Care Patient Participants Numbers Descriptives Ye s No Q1 Do you have a camera on your phone? 10 0 Q2 Do you have access to the internet? 8 2 Q3 Do you agree to stay after seeing your wound care provider to complete activities? 3 7 Q4 Do you agree to have the student to help you navigate and set up your mobile device to enhance your learning experience? 10 0 18 Figures Figure 1 Patient Wound Care Prevention Knowledge Figure 2 Patient Perceived Knowledge 19 Figure 3 Person-Environment-Occupation-Performance (PEOP) Model 20 Figure 4 Psychodynamic Frame of Reference Figure 5 QR Code to Educational Website 21 Appendix A The quiz regarding wound care prevention and management techniques was given to patients pre- and post-implementation of educational materials. What happens when a person is sitting up in bed but then slides down? a) Pressure increases when the skin sticks to the surface. b) Friction increases when the skin sticks to the surface. c) Shearing increases when the skin sticks to the surface. Which statement is correct? a) Recent weight loss can increase the risk of pressure ulcers. b) Nutrition and age have no impact on skin tolerance when at a normal weight. c) Exercise does not affect any type of wound. The sitting position with the least pressure between the body and the seat is what? a) Upright sitting with both feet resting on the floor. b) Upright sitting with feet crossed. c) Upright sitting with both feet dangling in the air. Which statement is correct? a) Fats are the most essential nutrient for wound healing. b) Carbohydrates are the most essential nutrient for wound healing. c) Proteins are the most essential nutrient for wound healing. Exercising does what to the body? a) Increases oxygen and decreases inflammation to promote wound healing. b) Increases blood glucose and decreases oxygen to promote wound healing. c) Increases blood flow and decreases oxygen to promote wound healing. Habits and routines can to promote optimal wound healing. a) Increase stress and quality of life. b) Increase social connections and quality of life. c) Increase blood flow and quality of life. 22 Appendix B The Likert scale regarding perceived knowledge of wound care prevention and management techniques was given to patients pre- and post-implementation of educational materials. Statement I have the resources to form a daily routine and habits. I have the knowledge and resources to know how nutrition is related to wound prevention and management. I know the nutritional resources to build a grocery list and recipes to enhance my wound prevention/management skills. I have a good idea of my goals relating to wound healing. I have a good idea of how to reach said goals. I understand the benefits of offloading. I know how to off-load according to my wound type. I know how exercising can promote wound healing. I know what exercises to perform. I know various community resources that I can be a part of to enhance wound healing and overall health. Strongly Disagree (1) Disagree (2) Neutral (3) Agree (4) Strongly Agree (5) If you would like to be sent additional resources to enhance your learning opportunities, please provide your phone number, email, or ask for physical copies during your visit. 23 Appendix C The daily log of activities, goals, and objectives accomplished along with daily hours completed at the wound care center with dates. Date Type of Hours 01/09/2023 On-site 01/10/2023 On-site 01/11/2023 On-site Hours 7:30 am4:30 pm Description 7:00 am - 4:30 pm 6:45 am - 4:15 pm 01/12/2023 On-site 6:45 am - 4:15 pm 01/13/2023 On-site 6:45 am - 4:00pm Orientation to site introduction to staff Idea exploration for DCE project concepts with site mentor Talking about ideas with nurse practitioners at site Shadowing to gain knowledge about wound care assessments and treatments Running Hours Total 8.5 17.5 Review overall requirements and 26.5 complete timeline for DCE project/experience/etc. Shadowing to gain knowledge about wound care assessments and treatments. Discussing more ideas and details with site mentor Introduction to PRN staff and podiatry 35.5 staff members Attended a meeting with site mentor and nurse practitioner to discuss HBOT to other providers at the main hospital. Shadowing to gain knowledge about wound care assessments and treatments. Researching literature for project implementation Went to a local nursing home to complete rounds with nurse practitioner and wound care nurse. Researching literature for project implementation Reviewing collagen and antimicrobial materials for wound healing with the nursing staff 44 24 01/16/2023 On-site 6:45 am - 4:15 pm 01/17/2023 On-site 6:45 am - 4:15pm 01/18/2023 On-site 01/19/2023 On-site 6:30 am - 11:00 am 6:30 am - 4:00 pm Research and draft up materials for nutritional information and meal plans for patient resources and posters (recipes, grocery lists, diabetes related nutrition, education, etc.) Project idea development and review of information gathered with site mentor and nurse practitioners. Shadowing to gain knowledge about wound care treatments and informing patients why I am at the facility 53 Gathering community resource information through phone calls, emails, and other connections to utilize on websites and for patient education. Gathering and reviewing literature on how exercise can promote faster wound healing and serve as preventative/management techniques 66.5 Informational meeting on the details of how HBOT works and the prerequisites for getting into the chamber. Meeting with nursing staff to go over the new HBOT program for patients. Gathering and reviewing literature on how exercise can promote faster wound healing and serve as preventative/management techniques. Gathering more literature and intervention ideas regarding nutrition and wound healing for patients (diabetic nutritional education for prevention and management of foot ulcers, benefits of specific foods, calling and gathering resources from main hospital for patient education at wound center) 62 Gathering and reviewing literature on how exercise can promote faster wound healing and serve as preventative/management techniques. Developing intervention resources to complete with patients (AAROM, informative website materials, benefits poster) Gathering and reviewing literature on how exercise can promote faster wound 75.5 25 01/20/2023 On-site 6:30 am - 3:30 pm 01/23/2023 On-site 6:45 am - 4:15 pm 01/24/2023 On-site 6:30 am - 4:00 pm 01/25/2023 On-site 7:00 am - 12:00 pm healing and serve as preventative/management techniques. Shadowing the surgical podiatrist that comes to the clinic once a week to see his specialty involvement with wound care. Continued literature search supporting 84 intervention ideas for forming habits and exercise materials. Meeting with site mentor to go over development of project ideas and intervention ideas and survey created. Went to local nursing home to complete rounds with nurse practitioner and wound care nurse Attended a safety meeting regarding HBOT and the fire department to learn more about the safety precautions and procedures in case of a fire. Researched intervention and reviewed literature for forming habits and routines for patient education (time blocking schedules, benefits, and tips on methods to implement) Presented website development to nurse practitioners and asked for feedback. Reviewed compression wrappings and wound dressing with nursing staff during patient visits. Administered pre-screening/survey to patients who voluntarily consented. 93 Continued research for education to put on website (videos, additional resources, 107 Went to a local nursing home to complete rounds with nurse practitioner and wound care nurse. Researched intervention and reviewed literature for forming habits and how it can promote optimal wound healing. Shadowed patient visits and developed relationships. Administered pre-screening/survey to patients who voluntarily consented 102 26 01/26/2023 On-site 6:30 am - 4:00 pm 01/27/2023 On-site 6:45 am - 3:15 pm 1/30/2023 On-site 6:45 am - 4:15 pm 1/31/2023 On-site 6:30 am - 4:00 pm benefits of each topic, mechanics of how it promotes wound healing) Continued literature search to support intervention ideas Went to a local nursing home to 116 complete rounds with nurse practitioner and wound care nurse; learned about the importance and need of staff education. Administered pre-screening/survey to patients who voluntarily consented. Reviewed wound care follow up appointments and new patient visits. Attended a meeting with site mentor that involved the nephrology management team. Discussed possibility of leading a station at nursing education wound care day activity Went to a local nursing home to complete rounds with nurse practitioner and wound care nurse. Administered pre-screening/survey to patients who voluntarily consented. Reviewed wound care follow up appointments and new patient visits 124 Finished laminating posters and QR codes to hang in the waiting room. Researched learning theory for project Discussed challenges with implementation of project and how to get more participants with site mentor; projected meeting for tomorrow morning to problem solve together. 142 Implemented exercise activities with patients for project and provided educational benefits (~15-30 minutes spent with each patient) Laminated posters and QR codes to hang in the facility. Developed date, stations, and time set up for nurse education day regarding wound care with site mentor. Shadowed a couple of wound care follow up visits 133 27 2/1/2023 On-site 6:30 am - 4:00 pm 2/2/2023 On-site 6:45 am - 4:15 2/3/2023 On-site 7:00 am - 11:00 am 2/6/2023 On-site 6:45 am - 4:15 pm Implemented exercise activities with patients for project and provided educational benefits (~15-30 minutes spent with each patient) Implemented exercise activities with patients for project and provided educational benefits (~15-30 minutes spent with each patient) Problem solved patient participation with site mentor. Manually entered paper copies into google form survey. Administered survey to two new patients and explained project details. Recorded videos for offloading and put them on resource website. Reached out to resources about OT and billing for site mentor for future implementation. Meeting with Kelsey (4:30 pm) 151 Developed nutritional interventions to implement next week with patients. Organized interventions and patient plans in preparation for next week Implemented exercise activities with patients for project and provided educational benefits (~15-30 minutes spent with each patient) Shadowed patient visits to gather more wound care experience and knowledge 164 Implemented exercise activities with patients for project and provided educational benefits (~15-30 minutes spent with each patient) Had hands-on experience with compression wrapping. Developed ideas and educational resources for nursing education day and discussed ideas with site mentor. Attending vendor meeting about palliative care and the specific services that the company offers 160 Reviewed nutrition activities with patients for project and provided educational benefits for nutrition and 173 28 2/7/2023 On-site 6:45 am - 4:15 pm 2/8/2023 On-site 6:45 am - 4:15 pm 2/9/2023 On-site 6:45 am - 4:15 pm 2/10/2023 On-site & Remote 6:00 am - 8:30 am 9:00 am - wound healing (~15-30 minutes spent with each patient) (some patients did not have extra time today or had other major complications as to why they could not complete interventions on this date) Shadowed patient visits to gather more wound care experience and knowledge. Gathered nutrition interventions and patient session information to prepare for tomorrows schedule Reviewed nutrition activities with patients for project and provided educational benefits for nutrition and wound healing (~15-30 minutes spent with each patient participant) Shadowed patient visits to gather more wound care experience and knowledge. Hands-on experience with Coban wrapping for compression. Researched and gathered offloading information for patient education and nursing education day 182 Reviewed nutrition activities with patients for project and provided educational benefits for nutrition and wound healing (~15-30 minutes spent with each patient participant) Shadowed patient visits to gather more wound care experience and knowledge 200 Reviewed nutrition activities with patients for project and provided educational benefits for nutrition and wound healing (~15-30 minutes spent with each patient participant) Shadowed patient visits to gather more wound care experience and knowledge. Hands-on experience with Coban wrapping for compression (Coban 2) Attended wound nursing meeting 191 Called patients to reschedule them for the day due to the clinic being closed and learned scheduling system on computer with site mentor and receptionist. 204 29 10:30 am 2/13/2023 On-site 6:45 am - 4:15 pm 2/14/2023 On-site 6:30 am - 4:00 pm 2/15/2023 On-site 6:30 am - 4:00 pm 2/16/2023 On-site 9:00 am - 4:30 pm Developed habit/routine resources for patient intervention next week. Made physical handouts for patients Reviewed nutrition activities with patients for project and provided educational benefits for nutrition and wound healing (~15-30 minutes spent with each patient participant) Shadowed patient visits to gather more wound care experience and knowledge (saw my first pediatric patient) Delivered first post survey (patients wound was healed; he discharged) 213 Shadowed patient visits to gather more wound care experience and knowledge (saw my first pediatric patient) Created one patient/nursing handout for offloading education. Went to complete round at local nursing home (Ashford Place) Attended educational meetings by vendor regarding wound vacs for patient use 231 Reviewed nutrition activities with patients for project and provided educational benefits for nutrition and wound healing (~15-30 minutes spent with each patient participant) Shadowed patient visits to gather more wound care experience and knowledge (saw my first pediatric patient) Wrapped three compression wraps (Coban 2 and Coban Lite) Created one patient/nursing handout for offloading education 222 Reviewed nutrition activities with two patients for project and provided educational benefits for nutrition and wound healing (~15-30 minutes spent with each patient participant) Reviewed exercises activities with one patient for project and provided educational benefits for exercise and 238 30 2/17/2023 On-site 8:30 am - 3:00 pm 2/20/2023 On-site 6:30 am - 4:00 pm 2/21/2023 On-site 6:45 am - 4:15 pm wound healing (~30 minutes spent with patient) Shadowed patient visits to gather more wound care experience and knowledge. Attended informational meetings on L&R company for wound Shadowed patient visits to gather more wound care experience and knowledge. Wrapped 3 Coban wraps (Coban 2) Attended two meetings with site mentor regarding HBO therapy and video education for patients 244 Shadowed patient visits to gather more wound care experience and knowledge (learned more about fish skin grafts for wounds) Able to observe pediatric wound care visit (interacted with mother and talked with mother about her struggles, offered some of the resources that I have for other patients) Reviewed offloading information with one patient for project and provided educational benefits for offloading and wound healing (~30 minutes spent with each patient participant) 262 Shadowed patient visits to gather more wound care experience and knowledge. Reviewed nutrition activities with two patients for project and provided educational benefits for nutrition and wound healing (~30 minutes spent with patient participant) Reviewed routines/habits activities with one patient for project and provided educational benefits for routine formation and wound healing (~30 minutes spent with each patient participant) Planned the set dates and times for the nursing education day with site mentor (coordinated with other professions) Collected more resources for nursing education day (made flyers and gathered literature supporting nursing education) 253 31 2/22/2023 On-site 7:00 am - 4:30 pm 2/23/2023 On-site 7:00 am - 4:30 pm 2/24/2023 On-site 8:00 am - 12:00 pm Wrapped two Coban 2 wraps and one Unna boot for patients. Completed some charting during wound care patient visits Shadowed patient visits to gather more wound care experience and knowledge (observed a wound vac for the first time and was able to help apply it; learned about how it works and the benefit of one) Reviewed routines/habits activities with one patient for project and provided educational benefits for routine formation and wound healing (~30 minutes spent with each patient participant) Wrapped two Coban 2 wraps and one Coban Lite wrap. Completed some charting during wound care patient visits 271 Shadowed patient visits to gather more wound care experience and knowledge (learned specifically more about arterial wounds) Had a meeting with site mentor about how my experience and project was going; reminded her about my midterm as well. Had a meeting with site mentor and nurse practitioners at the facility to discuss the role of OT within the wound care clinic. Wrapped two Coban 2 compression wraps 284 Went to local nursing home to complete rounds with nurse practitioner and wound care nurse (helped with charting during rounds) Shadowed patient visits to gather more wound care experience and knowledge. Reviewed routines/habits activities with one patient for project and provided educational benefits for routine formation and wound healing (~30 minutes spent with each patient participant) 280 32 2/27/2023 On-site 6:45 am - 4:15 pm 2/28/2023 On-site 7:00 am - 4:30 pm 3/1/2023 On-site 7:00 am - 4:00 pm 3/2/2023 On-site 6:45 am - 3:45 pm Reviewed offloading information with one patient for project and provided educational benefits for offloading and wound healing (~30 minutes spent with each patient participant) Shadowed patient visits to gather more wound care experience and knowledge. Wrapped one Unna boot. 293 Shadowed patient visits to gather more wound care experience and knowledge. Went to local nursing home to complete rounds with nurse practitioner and wound care nurse (helped with charting during rounds) 310.5 Reviewed offloading information with one patient for project and provided educational benefits for offloading and wound healing (~30 minutes spent with each patient participant) Reviewed habits and routines information with one patient for project and provided educational benefits for wound healing (~30 minutes spent with each patient participant) Attended a meeting with site mentor about the development of bloodborne pathogen education. Shadowed patient visits to gather more wound care experience and knowledge (we healed out about 3 patients) Wrapped 4 Coban 2 wraps 302 Reviewed habits and routines information with one patient for project and provided educational benefits for wound healing (~30 minutes spent with each patient participant) Reviewed nutrition activities with two patients for project and provided educational benefits for nutrition and wound healing (~15-30 minutes spent with each patient participant) Shadowed patient visits to gather more wound care experience and knowledge. Attended meeting with site mentor about patient satisfaction 319 33 3/3/2023 On-site 7:00 am - 12: 00 pm 3/6/2023 On-site 7:00 am - 4:00 pm 3/7/2023 On-site 7:00 am - 4:30 pm 3/8/2023 On-site 7:00 am - 4:30 pm Shadowed patient visits to gather more wound care experience and knowledge. Completed two Coban 2 wraps. Reviewed offloading information with one patient for project and provided educational benefits for wound healing (~30 minutes spent with each patient participant) 324 Reviewed and completed an exit survey with one patient and received feedback on how education was presented and the type of education. Attended a new weekly huddle meeting with wound care nurses and site mentor. Completed four Coban 2 wraps and one Unna boot. Shadowed patient visits to gather more wound care experience and knowledge 341.5 Completed one Unna boot wrapping and one Coban Lite wrap. Shadowed patient visits to gather more wound care experience and knowledge (assisted in applying another wound vac to coccyx area) (interacted with nursing student as well during observations) Reviewed and completed an exit survey with one patient and received feedback on how education was presented and the type of education. Attended meeting with site mentor and nurse practitioner to review and present brief points about HBO therapy with FIM (family internal medicine) faculty 332.5 Completed two Coban 2 wraps and two Coban Lite wraps. Attended a vendor meeting about lymphedema pumps and reviewed the new requirements for patients to get them approved through Medicare. Attended meeting with site mentor and director of care management to discuss proposal of occupational therapy within the wound care clinic. Shadowed patient visits to gather more wound care experience and knowledge 350.5 34 3/9/2023 On-site 7:00 am - 5:00 pm 3/10/2023 On-site 8:00 am - 12:00 pm 3/13/2014 On-site 6:45 am - 5:15 pm 3/14/2023 On-site 6:45 am - 5:15 pm (observed lymphedema of the abdomen for the first time) Shadowed patient visits to gather more wound care experience and knowledge. Attended meeting with site mentor and both nurse practitioners to talk with lymphedema OT. Wrapped one Coban 2 wrap and one Profore wrap. Reviewed and completed an exit survey with one patient and received feedback on how education was presented and the type of education. Attended meeting with staff about how to take nasal glucose levels. Reviewed habits and routines information with one patient for project and provided educational benefits for wound healing (~30 minutes spent with each patient participant) 360 Shadowed patient visits to gather more wound care experience and knowledge (observed the first debridement of a hematoma wound on an anterior lower leg) Reviewed and completed an exit survey with one patient and received feedback on how education was presented and the type of education. Wrapped one Coban Lite wrap and aided in the application of a wound vac to the coccyx area) 374 Shadowed patient visits to gather more wound care experience and knowledge. Reviewed and completed exit survey with one patient and received feedback on how education was presented and the type of education 364 Wrapped three Coban2 wraps. Attended a meeting with site mentor about CPT billing codes. Shadowed patient visits to gather more wound care experience and knowledge. Finished data collection 384 35 3/15/2023 Onsite 6:30 am - 5:00 pm 3/16/2023 On-site 6:30 am - 5:00 pm 3/20/2023 On-site 6:45 am - 4:15pm 3/21/2023 On-site 6:45 am - 4:15 pm 3/22/2023 On-site 6:45 am - 4:15 pm Shadowed patient visits to gather more 394 wound care experience and knowledge. Went to local nursing home to complete rounds with nurse practitioner and wound care nurse (helped with charting during rounds) Attended a meeting with site mentor and chief of nursing about OT position within the wound care clinic. Wrapped two Profore, one Unna boot, and one Coban 2 compression wraps Shadowed patient visits to gather more wound care experience and knowledge. Went to local nursing home to complete rounds with nurse practitioner and wound care nurse (helped with charting during rounds) Attended vendor meeting with staff 404 Shadowed patient visits to gather more wound care experience and knowledge. Conducted meeting with site mentor regarding dissemination planning/finalizing and then discussed previous patient caseloads for lymphedema proposal. Wrapped two Coban 2 wraps 422 Shadowed patient visits to gather more wound care experience and knowledge (increased hands-on experience with handling supplies to aid in nurse practitioner debridement) Attended meeting with site mentor regarding patient care standards. Wrapped two Profore wraps. Followed up with one patient regarding educational materials and adherence with exercises, nutrition, and habit forming 413 Shadowed patient visits to gather more wound care experience and knowledge. Wrapped two Coban 2 wraps and one Unna boot. Helped fill out charts for the next day; had to read 431 36 3/23/2023 On-site 7:00 am - 4:30 pm 3/24/2023 On-site 3/27/2023 On-site 3/28/2023 On-site 3/29/2023 On-site 8:00 am - 12:00 pm 7:30 am - 6:00 pm 7:00 am - 4:30 pm 7:00 am - 3:00 pm 3/30/2023 On-site 7:00 am - 4:30 pm Went to local nursing home to complete 440 rounds with nurse practitioner and wound care nurse (helped with charting during rounds) Attended an HR meeting with site mentor to discuss onboarding information for new employees. Shadowed patient visits to gather more wound care experience and knowledge (had the opportunity to remove staples and sutures from amputation site; took vitals for patients) Wrapped two Unna boots and two Coban 2 wraps Shadowed patient visits to gather more wound care experience and knowledge. Wrapped two Coban 2 wraps 444 Shadowed patient visits to gather more wound care experience and knowledge (opportunity to help on the floor with vitals and in-take) Discussed further dissemination plan with site mentor 463.5 Shadowed patient visits to gather more wound care experience and knowledge. Went to local nursing home to complete rounds with nurse practitioner and wound care nurse (helped with charting during rounds) Wrapped two Coban 2 wraps, two Unna boots, and one Profore wrap 480 Shadowed patient visits to gather more wound care experience and knowledge. Attended and ran a booth at a health fair event with site mentor and nurse at local YMCA 454.5 Went to local nursing home to complete rounds with nurse practitioner and wound care nurse (helped with charting during rounds) Shadowed patient visits to gather more wound care experience and knowledge. Wrapped two Coban 2 wraps and one Coban Lite 471 37 3/31/2023 On-site 4/3/2023 On-site 4/4/2023 On-site 8:00 am - 12: 00 pm 7:00 am - 2:30 pm 7:00 am - 4:30 pm 4/5/2023 4/6/2023 On-site On-site 7:00 am - 2:30 pm 7:00 am - 4:30 pm 4/7/2023 On-site 4/10/2023 On-site 4/11/2023 On-site 7:30 am - 4:00 pm 7:00 am - 4:30 pm 7:00 am - 3:30 pm Shadowed patient visits to gather more wound care experience and knowledge. Wrapped two Coban 2 wraps 484 Shadowed patient visits to gather more wound care experience and knowledge. Wrapped two Coban 2 wraps, one Profore, and one Coban Lite Attended a meeting with site mentor regarding. Followed up with participants 500 Went to local nursing home to complete rounds with nurse practitioner and wound care nurse (helped with charting during rounds) Shadowed patient visits to gather more wound care experience and knowledge. Wrapped two Coban 2 wraps and one Profore. Received more patient feedback on project and impact on site 516 Shadowed patient visits to gather more wound care experience and knowledge. Wrapped one Profore, one Coban 2 wrap 533 Shadowed patient visits to gather more wound care experience and knowledge. Wrapped two Coban 2 wraps. Worked on dissemination project and paper 491 Shadowed patient visits to gather more wound care experience and knowledge. Disseminated to site and received feedback. Wrapped two Coban 2 wraps and one Profore 507 Shadowed patient visits to gather more wound care experience and knowledge. Wrapped four Coban 2 wraps and one Unna boot. Received more patient feedback on project and impact on site 524 Shadowed patient visits to gather more wound care experience and knowledge. 541 38 4/12/2023 On-site 8:00 am - 6:00 pm 4/13/2023 On-site 7:30 am - 4:30 pm 4/14/2023 On-site 7:00 am - 12:00 pm Completed advanced wound care prevention education for local nursing staff (home health, nursing home, inpatient, etc.) Wrapped one Coban 2 wrap and one Coban Lite Shadowed patient visits to gather more wound care experience and knowledge. Completed advanced wound care prevention education for local nursing staff (home health, nursing home, inpatient, etc.) Wrapped two Coban 2 wraps 550.5 Shadowed patient visits to gather more wound care experience and knowledge. Went to local nursing home to complete rounds with nurse practitioner and wound care nurse (helped with charting during rounds) 564 Shadowed patient visits to gather more wound care experience and knowledge. Went to local nursing home to complete rounds with nurse practitioner and wound care nurse (helped with charting during rounds) Wrapped two Profore wraps 559  ...

... POSTPARTUM PREVENTATIVE CARE RESOURCES 1 Providing Preventative Care Resources to Improve the Occupational Well-Being of Postpartum Women Morgan Herrmann May, 2023 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: Kelsey Peter, OTD, OTR POSTPARTUM PREVENTATIVE CARE RESOURCES 2 Abstract For my project, I created overuse injury prevention resources for postpartum women at Indiana Health University Hospital. Brief educational sessions were conducted with the women where I reviewed the resources and answered questions. A pre and post survey that assessed the participants' knowledge and attitudes regarding overuse conditions and their prevention was created to determine the effectiveness of the resources. Upon analyzing the survey results, a positive increase was found in the mean score for each item on the pre and post surveys. This indicated increased knowledge of overuse conditions and confidence in preventing them. The participants also collectively reported that they viewed educational resources as a useful method in preventing overuse conditions in the postpartum population. Following my project, the pelvic floor rehabilitation team added these resources to their postpartum rehabilitation packet and plan to incorporate this information into their postpartum visits in the hospital. POSTPARTUM PREVENTATIVE CARE RESOURCES 3 Providing Preventative Care Resources to Improve the Occupational Well-Being of Postpartum Women Indiana University Health North (IUHN) is a nonprofit hospital located in Hamilton County, Indiana. Their mission is to improve the health of our patients and community through innovation and excellence in care, education, research, and service (Indiana University Health, 2020). Their vision is to make Indiana one of the nations healthiest states (Indiana University Health, 2020). I completed my doctoral capstone project with postpartum women in the neonatal intensive care unit (NICU) at IUHN hospital. Pelvic floor dysfunction is often the focus of postpartum rehabilitation and physical therapists are usually providing these services. Pelvic floor rehabilitation is a crucial aspect of postpartum recovery, but other conditions are often overlooked and not adequately addressed prior to a womans discharge from the hospital. In addition, occupational therapists are often not included in the postpartum rehabilitation team despite the vital role they can play in postpartum recovery. Occupational therapists can assist with successful transitions from the hospital, address maternal role strain and accompanying stress, and reduce biomechanical and ergonomic risk factors associated with the occupation of mothering (Slootjes et al., 2016). These circumstances are no different at IUHN. The purpose of my project was to incorporate occupational therapy services into postpartum care and provide additional educational resources regarding overuse injury prevention. I provided my educational resources in the form of a handout and educated the mothers during therapy sessions in the NICU. In the following paragraphs I will detail a review of my needs assessment and prior research performed on this topic. I will then provide information regarding the development, implementation, and outcomes of my project. To conclude, I will summarize the translation of my project to my site and future implications for occupational therapists in this setting. POSTPARTUM PREVENTATIVE CARE RESOURCES 4 Background Giving birth to a child is a traumatic event for the human body. The recovery that must occur on a musculoskeletal level can leave postpartum women in a vulnerable state that makes them more susceptible to injury. There are various risk factors associated with caring for a new baby that can often be precursors to injury such as engaging in repetitive activities, static positioning, and forceful exertions with lifting (Otero, n.d.; Yazdanpanah et al., 2018). Thus, it is essential to provide preventative education to reduce the risk of overuse injury in this population. Fernandes et al. noted that hand and wrist pain are the most common musculoskeletal complaints of pregnancy, and they often occur from poor positioning and repetitive activities involved with childcare (2018). Balik et al. found a high prevalence of hand and wrist pain amongst postpartum women, and recommended preventative interventions to reduce the risk of injury from progressing to a chronic state (2014). Sit et al. also found a high prevalence of wrist pain amongst postpartum women, with most cases noted as moderate to severe (2017). Satoh et al. note that self-assessed hand and wrist pain in postpartum women can also significantly lower their quality of life (2022). Special attention should be given to older postpartum women, as Iwata et al. found that this population is more at risk for shoulder stiffness, back pain, and wrist pain within the first month after giving birth (2018). This research collectively indicates a need for preventative care for this population. Haley Krodel, an occupational therapist, and Kaylene Hernandez, a physical therapist, who both currently work at IUHN, provided their insight on my project during my initial needs assessment. Kaylene informed me that postpartum physical therapy sessions focused on posture, body mechanics, bowel and bladder health, pelvic floor recovery, education on diastasis recti, and safe return to exercise (K. Hernandez, personal communication, February 17, 2022). Haley POSTPARTUM PREVENTATIVE CARE RESOURCES 5 noted that the lactation consultants focused on the latching process and believed that I could provide additional education on breastfeeding positioning to prevent musculoskeletal disorders (H. Krodel, personal communication, February 11, 2022). Upon arrival at the site, I met with both Kaylene and Haley to revisit my needs assessment and discuss any changes. There were minimal updates, however, Kaylene provided me with a resource folder that the physical therapists distributed during their postpartum visits. When asked about what additional resources would be most beneficial, she stated something that we could add to the existing packet. Simple, everyday exercises they could complete (K. Hernandez, personal communication, January 11, 2023). She believed including common signs and symptoms of upper extremity conditions was important, as the original packet predominantly included information on pelvic floor rehabilitation. During my meeting with Haley, she noted that IUHN management added an occupational therapist to the pelvic health rehabilitation team, but she had not made any edits to the existing physical therapy resources. This meant that my resources would still be the first educational resources developed from an occupational therapy perspective in the postpartum unit (H.Krodel, personal communication, January 10, 2023). Visser et al. explored the specific role of occupational therapy in breastfeeding and found that occupational therapists can act as clinicians, consultants, educators, advocates, and facilitators throughout breastfeeding interventions (Visser et al., 2016). Previous researchers have also determined that ergonomic breastfeeding education can reduce the occurrence of musculoskeletal disorders in the postpartum population (Afshariani et al., 2019). In addition, several researchers have studied the impact of using occupation-based models in the care for postpartum women (Jaywant et al., 2020; Mandy Graham, 2020). Jaywant et al. studied the effectiveness of a Person-Environment-Occupation breastfeeding intervention model compared POSTPARTUM PREVENTATIVE CARE RESOURCES 6 to existing models that were not occupation-based (2020). The researchers found that the interventions designed according to the occupation-based model were more effective as there were significant differences between the intervention and control groups (Jaywant et al., 2020). Mandy Graham discussed the use of the Model of Human Occupation (MOHO) to determine the occupational needs of postpartum women (2020). Graham found that the use of this model enabled women to consider how the performance capacity required to carry out occupations related to childbearing impacted their motivation and other daily occupations (2020). Graham also discussed that the model prompted women to consider the environmental contexts impacting motherhood (2020). These findings further emphasize the importance of including occupational therapy in the postpartum care process as we offer a unique lens to treatment from an occupation-based perspective. Overuse injury prevention from an occupational therapy perspective is much more holistic and inclusive of all occupations a new mother may engage in. Few researchers have studied the effectiveness of preventative interventions in reducing overuse injury in postpartum women. Jung et al. studied the effect of wrist stabilization exercises combined with taping on wrist pain, disability, and quality of life for postpartum women suffering from wrist pain (2021). Based on the results of their study, they concluded that wrist stabilization exercises are beneficial and an effective strategy to manage wrist pain in postpartum women (Jung et al., 2021). There is a need for additional research to detail the impact of preventative exercises in overuse injury prevention protocols. In terms of breastfeeding, researchers have found occupational therapy interventions to improve the mothers self-efficacy and to support its continuation (Sponseller et al., 2021 & Franco-Antonio, 2022), however, limited research conveys the impact of ergonomic interventions in reducing overuse injuries associated with improper positioning. POSTPARTUM PREVENTATIVE CARE RESOURCES 7 Theory I chose the Person-Environment-Occupation-Performance (PEOP) occupation-based model to guide my capstone project (Cole & Tufano, 2020). According to this model, both intrinsic and extrinsic factors can influence our ability to perform our desired occupations (Cole & Tufano, 2020). Intrinsic factors can be physiological, cognitive, neuro-behavioral, spiritual, or psychological factors (Cole & Tufano, 2020). Extrinsic factors can be social support, social and economic systems, culture, and values, built environment and technology, and the natural environment (Cole & Tufano, 2020). The intersection between intrinsic factors, extrinsic factors, desired occupations, and performance is the persons overall occupational participation and performance. I plan to use this model to consider the extrinsic and intrinsic factors that are influencing the new mothers I will be working with, and how these factors will influence their new occupations associated with becoming a new mother. I plan to identify and address the intrinsic and extrinsic factors that are impeding their ability to engage in their new occupations, but also their other daily occupations as well. I also chose the Biomechanical frame of reference to guide my capstone project. The overarching goal of this frame of reference is to address body function deficits and how those deficits impede a persons engagement in their occupations (Cole & Tufano, 2020). I plan to use this frame of reference to guide the development of the preventative care resources that I plan to provide to the new mothers. I will need to address each mothers specific body functions and provide appropriate positioning recommendations or exercises to prevent injury. My goal is for each mother to achieve functioning according to this frame of reference and prevent deficits in body function from happening in the first place. POSTPARTUM PREVENTATIVE CARE RESOURCES 8 Project Design & Implementation This project was developed because postpartum care can be overlooked as the focus is often on the newborn. This is especially the case for women with newborns who are in the NICU. I wanted to ensure postpartum women are receiving the preventative care that they need. To develop this project, a literature review was conducted to determine what kinds of interventions have been found to be most effective for overuse injury prevention. Once on site, I met with the postpartum physical therapy team to review the current packet of resources and to discuss what areas they felt needed additional education. I also shadowed a physical therapist in the postpartum unit for one afternoon to see how my resources could be incorporated into their visits. Next, I shadowed and met with a lactation consultant to discuss what kind of education they were providing to postpartum women on the NICU floor. The purpose of the project was to not only reinforce what they were already teaching, but to also address any areas they were missing. For my outcome assessment, a knowledge and attitudes-based survey was developed and administered before and after the educational sessions. This survey provided data regarding the direct impact of the educational sessions, and if the results were different for first-time mothers compared to those who already had given birth. During the implementation phase of the project, I brought a folder with my resources into the private NICU rooms while my supervisor engaged in treatment sessions with the babies. If the mom was present, I would begin by verbally administering my pre-survey to gather baseline information prior to distributing my resources. I would then provide her the resources, engage in discussion, and ask if she had any questions regarding the material. After all questions were answered, I would verbally administer the same survey. This process was completed during weeks four through ten intermittently when mothers were available and present in the NICU. POSTPARTUM PREVENTATIVE CARE RESOURCES 9 One challenge I faced was finding an appropriate time to educate. The women were often stressed, tired, or sometimes not available when we would visit patient rooms. I had to ensure I was educating at an appropriate time, but also capitalize on the moments when the mom was present in the room. I also presented my resources in a virtual format to two postpartum support groups associated with IUHN. This presentation lasted approximately twenty to thirty minutes. The presurvey was presented electronically prior to the presentation, and then presented again at the end of the session. This was a great opportunity to reach more women in the postpartum population. This format was a great success as the women were in the comfort of their own home and were often more emotionally present for my presentation. These educational sessions often resulted in more questions and discussion than my one-on-one sessions in the NICU. Project Outcomes I created two surveys to receive feedback on and evaluate the effectiveness of my resources. The first survey I created was used during the piloting phase of my resources. I provided this survey electronically to the health professionals that reviewed my resources prior to their distribution to the postpartum women. This survey captured the health professionals attitudes towards my resources and offered them the opportunity to provide qualitative feedback. I developed a second knowledge and attitudes-based survey that I administered to each postpartum woman that I presented my resources to. This survey was used as a pre and post data collection method, as I administered it before and after my sessions to determine the direct impact of my educational intervention. I administered the attitudes survey electronically to the health professionals who reviewed my resources during the piloting phase of my project. I received six responses on this POSTPARTUM PREVENTATIVE CARE RESOURCES 10 survey, with 100% of the health professionals reporting positive attitudes towards my resources. I also included an option for open-ended responses to allow for constructive feedback, to which I received two responses. One respondent recommended that I include more than one picture in the breastfeeding positioning section. The second requested that I condense the information regarding signs and symptoms of common overuse conditions as she believed it was too wordy. This piloting phase was beneficial as I was able to make relevant edits to my resources prior to their distribution to the postpartum women. To analyze the results from the pre and post surveys I used IBM SPSS Statistics (Version 28) and set the alpha level of statistical significance at less than or equal to 0.05. I first ran descriptive statistics of the survey results, finding the mean of each response on the pre and post surveys. This gave me an overview of how the group of women collectively responded before and after my educational intervention. From this I was able to see that the participants had scored higher on each item of the survey after engaging in my educational session. Mean scores for each survey item can be found in Table 1. I then wanted to determine if there was a statistically significant difference between the pre and post survey scores, so I ran a paired t-test. After running the paired t-test, I was able to conclude that the participants' improvements on the first four items on the survey were statistically significant. The last item of the survey, regarding the participants opinion on the usefulness of educational resources, did not show a statistically significant change. This may be due to the participants high scores on this item on the pre and post survey. The participants all noted educational resources to be beneficial prior to engaging in my session, so there was not a significant change in their opinion on the post survey. Results of the paired t-test can be found in Table 2. POSTPARTUM PREVENTATIVE CARE RESOURCES 11 Lastly, I wanted to determine if there was a difference in survey scores between new and veteran mothers. To determine this, I ran an independent sample t-test. Through this analysis, I found that any differences between the two groups were not statistically significant. Results from this statistical analysis can be found in Table 3. Overall, I was able to conclude through my analysis that my resources were beneficial and effective for this population. The participants demonstrated increased knowledge and improved attitudes towards overuse injury prevention, as evidenced by the statistically significant differences on items one through four of the pre and post surveys. Summary Overall, there is evidence to support the role of occupational therapy in postpartum care but there is little research detailing the direct impact of occupational therapy interventions. Many researchers have studied the prevalence of common overuse conditions but have failed to study specific outcomes of preventative interventions. The pelvic rehabilitation team at IUHN was providing preventative interventions prior to my project implementation with a focus on the pelvic floor. My engagement in this project allowed me to identify and address a gap in care for the postpartum population at this site, adding upper extremity overuse education to their preventative intervention protocol. Through this project, I was able to conclude that my educational resources were beneficial for the postpartum population. The participants collectively had statistically significant increases in knowledge and confidence regarding overuse conditions and their prevention. They reported positive opinions of the usefulness of educational resources in injury prevention. My project was unique in that I understood and acknowledged the role of occupational therapy in postpartum care, but also facilitated preventative occupation-based interventions through my POSTPARTUM PREVENTATIVE CARE RESOURCES 12 educational resources. I encompassed each aspect of the postpartum experience to ensure I addressed all daily occupations. I not only advocated for the inclusion of occupational therapy services in the postpartum care process, but also provided explicit interventions through educational sessions and resources to facilitate primary prevention of overuse conditions in the postpartum population. Conclusion Overall, I was able to grow as a future practitioner during my doctoral capstone experience and project. I developed and implemented postpartum overuse injury prevention resources with women at IUHN. I learned the importance and value of providing preventative education to a vulnerable population. This hospital benefited from this project as it further enhanced the therapy teams resources and provided increased opportunity for outpatient referrals, as newly postpartum women will be more aware of signs and symptoms of injuries to the upper extremity. I also offered the opportunity for postpartum education to continue in the NICU setting. A brief in-service was conducted with the pelvic health rehabilitation team prior to the end of the capstone experience where final resources were presented and the therapists were educated on how they could incorporate this information into their postpartum sessions. Haley Krodel, my supervising occupational therapist, plans to continue using these resources in the NICU. She wants to continue educating women with babies staying in the NICU as not all women receive postpartum therapy visits at the surrounding hospitals. Limitations of this project include a small sample size and a limited amount of time. For two out of four weeks of implementation the census in the NICU was low, limiting my access to postpartum women. Limitations make my conclusions less generalizable, however, there were statistically significant improvements on the pre and post surveys. Given the findings of this project, future research is POSTPARTUM PREVENTATIVE CARE RESOURCES 13 needed on the retention of knowledge once women have returned home from the hospital. Future research on the impact of educational resources on outpatient therapy referrals would also be beneficial to determine the lasting impact of patient education, its ability to prompt selfidentification of symptoms, and patient willingness to independently seek treatment. POSTPARTUM PREVENTATIVE CARE RESOURCES 14 References Afshariani, R., Kiani, M., & Zamanian, Z. (2019). The influence of ergonomic breastfeeding training on some health parameters in infants and mothers: A randomized controlled trial. Archives of Public Health, 77(1). https://doi.org/10.1186/s13690-019-0373-x Balik, G., Sabri Balik, M., stner, I., Kaitci, M., ahin, F. K., & Gven, E. S. G. (2014). Hand and wrist complaints in pregnancy. Archives of Gynecology and Obstetrics, 290, 479 483. https://doi.org/10.1007/s00404-014-3244-2 Cole, M. & Tufano, R. (2020). Applied Theories in Occupational Therapy: A Practical Approach (2nd Ed.). Slack, Inc. Fernandes, J. G. (2018). Occupational Therapists Role in Perinatal Care: A Health Promotion Approach. The American Journal of Occupational Therapy, 72(5), 4. https://doi.org/10.5014/ajot.2018.028126 Franco-Antonio, C., Santano-Mogena, E., Chimento-Daz, S., Snchez-Garca, P., & CordovillaGuardia, S. (2022). A randomized controlled trial evaluating the effect of a brief motivational intervention to promote breastfeeding in postpartum depression. Scientific Reports, 12(1), 110. https://doi.org/10.1038/s41598-021-04338-w Indiana University Health. (2020). (rep.). 2020 Community Health Report. Retrieved March 4, 2022, from https://iuhealth.org/in-the-community/community-benefit Iwata, H., Mori, E., Maehara, K., Sakajo, A., Aoki, K., & Tamakoshi, K. (2018). Shoulder stiffness, back pain, and wrist pain: Are older primiparas more vulnerable?. International journal of nursing practice, 24 Suppl 1, e12654. https://doi.org/10.1111/ijn.12654 POSTPARTUM PREVENTATIVE CARE RESOURCES 15 Jaywant, S. S., Patil, S. S., & Shrivastav, D. S. (2020). To Analyze the Effect of PersonEnvironment- Occupation Intervention Model on Stress and Breast-Feeding Efficacy on Mothers of Preterm Neonates: A Randomized Controlled Study. 52(1), 7. doi: 10.1097/JNR.0000000000000217 Jung, K.-S., Jung, J.H., Shin, H.S., Park, J.Y., In, T.S., & Cho, H.Y. (2021). The Effects of Taping Combined with Wrist Stabilization Exercise on Pain, Disability, and Quality of Life in Postpartum Women with Wrist Pain: A Randomized Controlled Pilot Study. International Journal of Environmental Research and Public Health, 18(7), 3564. https://doi.org/10.3390/ijerph18073564 Mandy Graham; Use of the Model of Human Occupation (MOHO) to Understand the Occupational Needs of Mothers With Perinatal Mental Illness: A UK Grounded-Theory Study. Am J Occup Ther August 2020, Vol. 74(4_Supplement_1), 7411505250p1. doi: https://doi.org/10.5014/ajot.2020.74S1-PO9512 Otero, K. (n.d.). The Importance of Postpartum Ergonomics. SMPLY Therapy. Retrieved January 25, 2023, from https://www.smplytherapy.com/blogs/ergonomicsandpostpartum Satoh, T., Cadillo, L. R. H., Ohashi, K., & Onishi, T. (2022). Self-assessed hand and wrist pain and quality of life for postpartum mothers in Japan. British Journal of Midwifery, 30(8), 467475. https://doi.org/10.12968/bjom.2022.30.8.467 Sit, R. W. S., Tam, W.-H., Chan, D. C. C., Yip, B. H. K., Tam, L. W. Y., Chow, L. L. Y., Chung, V. C. H., Chung, R. Y., & Wong, S. Y. S. (2017). A Pilot Cross-Sectional Study of POSTPARTUM PREVENTATIVE CARE RESOURCES 16 Postpartum Wrist Pain in an Urban Chinese Population: Its Prevalence and Risk Factors. Pain Physician, 10. Slootjes, H., McKinstry, C., & Kenny, A. (2016). Maternal role transition: Why new mothers need occupational therapists. Australian Occupational Therapy Journal, 63(2), 130133. https://doi.org/10.1111/1440-1630.12225 Sponseller, L., Silverman, F., & Roberts, P. (2021). Exploring the Role of Occupational Therapy With Mothers Who Breastfeed. The American Journal of Occupational Therapy, 75(5), 7505205110. https://doi.org/10.5014/ajot.2021.041269 Visser, M., Nel, M., la Cock, T., Labuschagne, N., Lindeque, W., Malan, A., & Viljoen, C. (2016). Breastfeeding among mothers in the public health sector: The role of the occupational therapist. South African Journal of Occupational Therapy, 46(2), 6572. https://doi.org/10.17159/2310-3833/2016/v46n2a11 Yazdanpanah, P., Mousavizadeh, A., Mousavifard, P., & Vafaei, F. (2018). Comparison course of pregnancy related carpal tunnel syndrome in breastfeeding and non-breastfeeding women during the first 6 months after delivery. Annals of Physical and Rehabilitation Medicine, 61. https://doi.org/10.1016/j.rehab.2018.05.252 POSTPARTUM PREVENTATIVE CARE RESOURCES 17 Table 1 Average Scores for Each Survey Item Survey Item Pre Survey Mean Post Survey Mean Knowledge of Common Overuse Conditions 3.92 1.58 Knowledge of Signs & Symptoms of Common Overuse Conditions 3.92 1.58 Confidence in Ability to Position Self to Reduce Overuse Condition Occurrence 4.67 9.33 Confidence in Ability to Prevent Overuse Conditions Using Daily Strategies 4.67 9.33 Opinion on Usefulness of Educational Resources 1.50 1.33 Note. A lower mean for post-knowledge scores and opinion on resources was desirable as a lower number was coded to indicate a stronger agreement with the survey item. For the confidence items, a higher number mean was desired as a higher number indicated a higher amount of confidence. Participants had a positive opinion of educational resources prior to engagement in educational sessions, so a smaller difference was seen between pre and post surveys for question five. Table 2 Results of Paired T-Test Survey Item Difference in Means T-Value P-Value Knowledge of Common Overuse Conditions 2.33 10.38 <0.001 POSTPARTUM PREVENTATIVE CARE RESOURCES Knowledge of Signs & Symptoms of Common Overuse Conditions 2.33 18 9.12 <0.001 Confidence in Ability -4.67 to Position Self to Reduce Overuse Condition Occurrence -8.41 <0.001 Confidence in Ability to Prevent Overuse Conditions Using Daily Strategies -4.67 -8.85 <0.001 Opinion on Usefulness of Educational Resources .17 1.00 .34 Note. Differences in means were statistically significant for items one through four on the pre and post survey. Difference in means for questions one, two, and five were positive because the post survey average was lower than the first, with the desired response of strongly agree coded as a lower number. Difference in means for items three and four are negative because an increase in confidence was coded as a higher number, thus the difference of pre survey minus post survey with an increase in confidence would be negative. A greater t-value was found for question one, indicating that this question had the biggest significant difference between pre and post survey results. Table 3 Difference in First Time Moms vs Returning Moms Survey Item Levenes Test for Equality of Variances - Significance Value Associated P-Value (Equal variances assumed or not assumed) Knowledge of Common Overuse Conditions (Pre) .63 .45 POSTPARTUM PREVENTATIVE CARE RESOURCES 19 Knowledge of Common Overuse Conditions (Post) .17 .45 Knowledge of Signs & Symptoms of Common Overuse Conditions (Pre) .63 .45 Knowledge of Signs & Symptoms of Common Overuse Conditions (Post) .17 .45 Confidence in Ability to Position Self to Reduce Overuse Condition Occurrence (Pre) .02 .10 Confidence in Ability to Position Self to Reduce Overuse Condition Occurrence (Post) .14 .43 Confidence in Ability to Prevent Overuse Conditions Using Daily Strategies (Pre) .10 .56 Confidence in Ability to Prevent Overuse Conditions Using Daily Strategies (Post) .14 .43 Opinion on Usefulness of Educational Resources (Pre) .40 .26 Opinion on Usefulness of Educational Resources (Post) .32 .43 Note. Any differences that were found were not statistically significant. Appendix A Weekly Planning Guide The DCE planning guide was used on a weekly basis to ensure the completion of the project goals and objectives. POSTPARTUM PREVENTATIVE CARE RESOURCES 20 Table A1 DCE Weekly Planning Guide Week 1 DCE Stage (orientation, screening/evaluatio n, implementation, discontinuation, dissemination) Orientation Weekly Goal Objectives 1. Complete orientation by the end of the week 2. Complete updated needs assessment & update goals on MOU by end of the week. 3. Add at least one intervention strategy & justification to NICU intervention binder. Meet site mentor, introduce myself to other members in the NICU unit, get to know other student working in the unit Update MOU with site mentor Finalize questions for updated needs assessment Tasks Set up meeting(s) and receive contact information for updated needs assessment Finalize MOU Create DCE timeline Ensure all paperwork for orientation is complete Set up additional meeting(s) to begin receiving information to help develop resources Date complete 1/13/23 POSTPARTUM PREVENTATIVE CARE RESOURCES 2 Screening/Evaluati on 1. Complete first draft of resources for postpartum women for interprofessio nal review 2. Complete first draft of survey questions for interprofessio nal review 3. Add at least one intervention strategy & justification to NICU intervention binder. 3 Screening/Evaluati on 1. At least 70% of health professionals 21 Analyze/su mmarize findings from meeting with lactation consultant Pick website to create resources Develop draft(s) of resources Have plan set in place for week 3 for pilot implementa tion Have survey developed for attitudes of healthcare professiona ls piloting resources Receive feedback on Shadow lactation consultant to gather more information about breastfeeding positioning & most current education being provided Set up meeting(s) with health professionals on the unit during week 3 to pilot resources Perform additional research to support educational resources Research various websites/tools to best develop resources Research various survey methods, draft surveys, upload surveys into selected method 1/20/23 Send out resources via email for interprofessional review 1/28/23 POSTPARTUM PREVENTATIVE CARE RESOURCES who piloted my resources at IUHN will report positive attitudes towards my overuse injury and prevention resources on the provided survey after piloting their implementati on. 2. Add at least one intervention strategy & justification to NICU intervention binder. 4 Implementation 1. Complete final drafts of resources for postpartum 22 postpartum resources by end of week Analyze data from resource review by end of week Gain increased knowledge on items to change/incl ude in resources prior to distribution to postpartum population Gain more practice & knowledge working with postpartum population Make final edits of postpartum resources Send Qualtrics survey link for feedback on resources Analyze data by end of week with Qualtrics report Shadow pelvic health physical therapist in postpartum unit Complete additional shadowing with lactation consultants in NICU Finalize resources, print them out, and compile them into folder for distribution. 2/3/23 POSTPARTUM PREVENTATIVE CARE RESOURCES women with updates from feedback provided in week 3. 2. Add at least one intervention strategy & justification to NICU intervention binder. 23 based on feedback from healthcare professiona ls Become more confident with handling infants throughout treatment sessions Become more independen t with evaluations in NICU unit Meet with site mentor for final review of resources prior to printing and compiling into folders. Complete minimum of one treatment session a day in NICU POSTPARTUM PREVENTATIVE CARE RESOURCES 5 Implementation 1. Complete postpartum educational sessions in NICU with resources 2. Add at least one intervention strategy & justification to NICU intervention binder. 6 Implementation 1. Complete postpartum educational sessions in NICU with resources 2. Add at least one intervention strategy & 24 Begin postpartum educational sessions in NICU setting Stay up to date with data from pre/post surveys for postpartum women Increase confidence in performing treatment and evaluation sessions for NICU patients Conduct additional educational sessions with postpartum women Stay up to date with data from Conduct at least one educational session Complete minimum of two treatments a day in NICU 2/10/23 Conduct at least two educational sessions Seek out additional women outside of NICU for sessions Input responses from surveys to google spreadsheet Complete all NICU treatment sessions 2/17/23 POSTPARTUM PREVENTATIVE CARE RESOURCES justification to NICU intervention binder. 7 Implementation 1. Complete postpartum educational sessions in NICU with resources 2. Complete at least one sample intervention plan for a client in the NICU 25 pre/post surveys for postpartum women Continue to increase confidence with intervention s in NICU Conduct additional educational sessions with postpartum women Stay up to date with data from pre/post surveys for postpartum women Draft intervention plan and justification for supervisor review Discuss areas of Conduct at least two educational sessions Seek out additional women outside of NICU for sessions Input responses from surveys to google spreadsheet Discuss intervention justification with supervisor Complete all NICU treatment sessions Review CORE midterm with supervisor 2/21/23 POSTPARTUM PREVENTATIVE CARE RESOURCES 8 Implementation 9 Implementation 1. Complete postpartum educational sessions in NICU with resources 2. At least 70% of postpartum women in NICU who received my resources will report increased knowledge on overuse injuries and prevention on the provided survey. 3. Add at least one intervention strategy & justification to NICU intervention binder. 1. Add at least one intervention 26 growth/lear ning Conduct additional educational sessions with postpartum women Stay up to date with data from pre/post surveys for postpartum women Begin data analysis from postpartum surveys Finalize data analysis Conduct at least two educational sessions Seek out additional women outside of NICU for sessions Input responses from surveys to google spreadsheet Complete all NICU treatment sessions Present resources at postpartum support group (03/04/23) 3/4/23 Complete all NICU treatment sessions 03/10/23 POSTPARTUM PREVENTATIVE CARE RESOURCES strategy & justification to NICU intervention binder. 27 10 Implementation 1. Complete at least 75% of an evaluation for a client in the NICU. 2. Add at least one intervention strategy & justification to NICU intervention binder. 3. Develop two additional resources regarding occupational therapys role from surveys Continue gaining confidence and expertise in treatment sessions with NICU population Begin disseminati on planning Continue gaining confidence and expertise in treatment and evaluation sessions with NICU population Complete additional research on occupationa l therapy intervention s for Run statistical analysis of survey results Finalize date for dissemination presentation to site Complete all NICU treatment sessions Complete at least one evaluation in NICU Set date for dissemination at site Find at least two research articles for occupational therapy interventions 3/17/23 POSTPARTUM PREVENTATIVE CARE RESOURCES in postpartum care. 11 Implementation 1. Add at least one intervention strategy & justification to NICU intervention binder. 28 12 Discontinuation/Di ssemination 1. Present to relevant stakeholders at IUHN advocating for OT services within maternal care. 2. Add at least one intervention strategy & justification postpartum population Finalize disseminati on planning Continue gaining confidence and expertise in treatment and evaluation sessions with NICU Prepare for disseminati on Continue gaining confidence and expertise in treatment and evaluation sessions with NICU Practice disseminati on PowerPoint Complete all NICU treatment sessions Complete at least one evaluation in NICU Complete dissemination PowerPoint for pelvic rehabilitation team 3/24/23 Complete all NICU treatment sessions Complete at least one evaluation in NICU Disseminate project findings to pelvic rehabilitation team 3/31/23 POSTPARTUM PREVENTATIVE CARE RESOURCES to NICU intervention binder. 13 Discontinuation/Di ssemination 1. Add at least one intervention strategy & justification to NICU intervention binder. 14 Discontinuation/Di ssemination 1. Add at least one intervention strategy & justification 29 Prepare disseminati on handouts Finalize transfer of materials to pelvic health rehabilitatio n team Finalize transfer of materials to lactation consultants on NICU unit Continue gaining confidence and expertise in treatment and evaluation sessions with NICU Organize methods of future communica tion with Send digital copy of resources to 4/7/23 pelvic health rehabilitation team and lactation consultants for future distribution Connect pelvic health team with support group leaders for continued presentations Complete all NICU treatment and evaluation sessions Provide my email and phone number to supervisor and other relevant leaders at site to prompt continued communication about project 04/14/23 POSTPARTUM PREVENTATIVE CARE RESOURCES to NICU intervention binder. 30 supervisor and/or other members at site Continue gaining confidence and expertise in treatment and evaluation sessions with NICU Reflect on experience and areas to grow Complete all NICU treatment and evaluation sessions Complete and review CORE evaluation with supervisor  ...

... DISABILITY AWARENESS TRAINING 1 Disability Awareness Training in the Workplace Jillian C. Heidenreich May 2023 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: Laura Aust, OTD, MS, OTR DISABILITY AWARENESS TRAINING 2 Abstract The goal of this project is to provide information on Project SEARCH and working with people with disabilities (PWD) in the hospital to healthcare managers and leaders where Project SEARCH students complete their rotations. The data suggests that there is a limited understanding of PWD in the workplace and disability awareness training is an effective way to provide a more inclusive environment to improve students occupational performance (Rochette et al., 2022). Thus, a video module was created to improve employees knowledge and understanding. A needs assessment was completed prior to help inform the determination of this project. Pretests and posttests were used to measure the healthcare workers attitudes and knowledge toward Project SEARCH and working with PWD. Interviews were also conducted on the students to gain their perspectives. Accomplishments include response and completion rates, increase in ratings between the pre and posttests, and the number of employees willing to provide feedback. Keywords: advocacy, occupational performance, workplace, people with disabilities (PWD), Project SEARCH DISABILITY AWARENESS TRAINING 3 Introduction Project SEARCH is a one-year immersive program that aims to prepare young people with disabilities the required skills for successful employment. It is an international program immersed in various hospitals and other businesses. The interns attend classes to learn workplace skills and complete three rotations in separate departments of the hospital. To apply, the candidates must be at least 18 years old, have high school requirements for graduation (or a certification), and have a documented disability, such as a developmental and/or intellectual disability (IDD). The end goal is for the interns to find paid employment and thrive in the workplace. The created project is a disability awareness program for department managers and employees within the hospitals affiliated with Project SEARCH interns. Unfortunately, there is a limited understanding about disabilities, including autism spectrum disorder (ASD), one of the common IDDs in Project SEARCH interns, thus leading to a limited understanding about individuals with ASD, their needs in the workplace (Nicholas, et al., 2019), and the knowledge and skills they can contribute to the workplace (Taggart, et al., 2021). Disability education and awareness training are effective ways to improve healthcare workers attitudes and their perceptions of people with disabilities (PWD), thus promoting inclusivity within various businesses (Noronha, 2019). This project can help spread awareness and provide an intern perspective to achieve a more diverse and inclusive workplace. In turn, this will help the interns make connections to feel respected, engaged, and motivated (Wynants & Dennis, n.d. p. 42), so they can be further involved in their learning experiences. Discussed below will include the background and importance of the project, the theories chosen and how these guided the project, DISABILITY AWARENESS TRAINING 4 the projects design and implementation, the outcomes, accomplishments, and future implications for occupational therapy will be explored. Background The target population for this project include the healthcare workers working alongside the interns with IDDs as they complete their internships in the hospitals. As mentioned above, autism is a common disability found among the interns. Individuals with autism can have various deficits, such as social communication deficits, which can negatively impact their connections with coworkers and experiences in the workforce (Albright et al., 2020). Unfortunately, this can lead to numerous concerns and misunderstandings within the workplace. Common misunderstandings include the uncertainty of whether PWD desire to be employed (Nicholas, et al., 2019) and their ability to be flexible in workplace environments that are constantly changing (Albright et al., 2020). A limited understanding of the interns disabilities contributes to limited knowledge on the interns needs, knowledge, and skills they can contribute (Nicholas, et al., 2019) (Taggart, et al., 2021). Moreover, PWD are employed at significantly lower rates, despite their ability and interest to work, thus making employment one of the largest gaps between people with and without disabilities (Friedman, 2020, p. 592). During initial interviews for the project, both site mentors want people in the hospital to treat the person with a disability the same (J. Rusk & A. Meuleman, personal communication, February 25, 2022). Further, the interns should be required to meet expectations just like everyone else but still have room for mistakes. Overall, the goal is to have a better understanding of working with PWD, thus leading to more employment opportunities for the interns within the hospitals. To understand the interns process during Project SEARCH and inform the determination of this project, a needs assessment was completed. First, candidates must be in their last year of DISABILITY AWARENESS TRAINING 5 high school or gone through graduation to apply. Then, to apply to Project SEARCH they must be eligible for vocational rehab (VR) services. To be eligible for services, an applicant must have a physical or mental impairment that impedes employment and requires VR services to assist with employment outcomes consistent with their abilities and interests (Family and Social Services Administration, n.d.). Once they are accepted, they complete training during the summer before Project SEARCH begins. During Project SEARCH, the interns are involved in three different rotations, each about 2 months long, at the hospital to learn workplace skills. During these rotations, they attend classes to build employment skills, interview skills, workplace etiquette skills, soft skills, health and nutrition, and other skills needed to maintain a job and increase independence. This process is unique and demonstrates how dedicated the interns are to prove their capability of obtaining paid employment. This information supports the projects purpose to spread awareness of the unique skills and characteristics Project SEARCH interns possess. Additional information was collected to help gain a better understanding of the work the interns are doing alongside healthcare professionals and the skills they learn. For instance, the interns tasks can include cleaning, stocking the gift shop, hosting in the cafeteria (helping with special diets, passing out menus, cleaning, etc.), helping in the supply rooms, delivering food to patients, working with materials management, putting together packets and welcome folders for new employee training, and much more. These jobs are repetitive, predictable, and often important tasks that higher-paid professionals do not have the time for but need to be done. Disability awareness training is recognized by the World Health Organization (WHO) and the World Bank as an effective way to provide a more inclusive social and attitudinal environment (Rochette et al., 2022). There have been various studies related to the effectiveness DISABILITY AWARENESS TRAINING 6 of a disability awareness project in the workplace and the effectiveness of hiring PWD. For instance, Lindsay et al., (2018) find that there are many benefits to hiring people with disabilities including improvements in profitability (employee loyalty, punctuality, company image, etc.), competitive advantage (diverse customers, customer loyalty, work ethic, etc.), inclusive work culture, and overall improved ability awareness. However, one of the studys limitations is that it did not describe the type of work that PWD were involved in. The Project SEARCH Disability Awareness Training differs because it measures the effectiveness of an awareness training program and includes the specific roles that the interns have excelled in and can get paid to do. Additionally, Noronha & Pawlyn, (2019) report that disability education and awareness training improve health care workers attitudes and their perceptions of PWD to promote inclusivity within various businesses (Noronha & Pawlyn, 2019). However, the Project SEARCH Disability Awareness Training differs because it includes interviews of those with IDDs to create a more intimate and personal experience during the training. Theory The Social Model of Disability states that although people have disabilities and impairments, the oppression, exclusion, and discrimination faced is caused by how society is organized; in other words, disabilities are created from the barriers that society creates and is a collective experience (Giri et al., 2022). Using this model, the key barrier identified at the hospitals where Project SEARCH is located is attitudinal, and the social and cultural attitudes about people with disabilities are what lead to prejudice and exclusion. One example of this is the stereotype that people with certain impairments cant work (The Social Model, 2015, p. 8). This model provides an understanding of how and why these attitudinal barriers exist as well as DISABILITY AWARENESS TRAINING 7 how to get rid of them through education and awareness. Therefore, the Social Model of Disability can help explain why PWD face discrimination in the workplace. The Kawa (River) Model addresses the requirements of diverse clients by creating a space where clients can move and live by getting rid of the barriers that prevent them from an overall harmony between the client and their context, allowing them to flow. In this context, barriers are preventing the interns from flowing in the hospital. Therefore, this awareness training is a utilization of resources to improve harmony and acceptance in the workplace (Cole & Tufano, 2008). The Social Disability and Kawa models helped guide the education portion of the training to help facilitate a more inclusive and diverse workplace. Project It has been identified that the interns coworkers are often not treating the interns the same as typical coworkers (Almalki, 2021). However, education and awareness training are the most effective approaches to facilitate positive relationships and reduce misunderstandings in the workplace (Dreaver, 2020). Therefore, the hope is that this disability awareness project will positively change healthcare workers attitudes, thus creating a more inclusive and diverse environment in the hospitals and making Project SEARCH a more successful transition program (Almalki, 2021). Goals for the awareness training include increased awareness for the challenges and needs of PWD, respect for their work and abilities, and support for their positions and future success (Hayward, et al., 2021). The outcome assessment chosen is pretest and posttest surveys, provided at the beginning and end of the awareness training. These tests will measure healthcare workers attitudes and knowledge towards Project SEARCH and working with PWD. This method was chosen because it can show an increase in knowledge numerically (1-10). This DISABILITY AWARENESS TRAINING training can be utilized as a future resource for continuous improvement in inclusion and to maximize the potential for PWD to gain employment in the hospital (Rashid & Nicholas, 2018). First, an initial email was sent out to department managers and other healthcare workers who are affiliated with Project SEARCH explaining the projects purpose and participation requirements. A pretest link was provided for those willing to participate. Afterward, the awareness training video was distributed and covered various topics including understanding a disability, common disabilities seen (Down Syndrome, Muscular Dystrophy, Cerebral Palsy, Autism Spectrum disorder, etc.), what Project SEARCH is, the process the students go through during their time there, the skills they master during their internships, appropriate language and etiquette, how to create an inclusive environment for applicants and employees, and the benefits of an inclusive environment and hiring PWD (Atchinson & Dirette, 2017). Finally, the posttest was provided and reflected the pretest for measurement. Challenges included limited time waiting for responses due to a delay in sending out pretests, different launch dates for the emails due to being at two different sites and finding the most up-to-date emails for the participants. Successes included quick response rates and a good number of people willing to participate. Project Outcomes The pretests were sent out via email to employees in the hospital who are part of the Project SEARCH contact list (provided by job coach and teacher at each site). Additional emails were sent out to operation team leadership attendees following a short presentation of the purpose of the project. The pretest included obtained consent, four questions on a linear scale to measure current knowledge and understanding of various topics, two additional questions regarding their affiliation to Project SEARCH, and an open-ended question for 8 DISABILITY AWARENESS TRAINING 9 requests on anything they wanted to know more about. A posttest was provided to complete after viewing the video. The posttest consisted of four questions on a linear scale that mirrored the pretest, a question regarding the relevance of the information, satisfaction questions, and any additional feedback or suggestions. Overall, 78 people were emailed and provided a link to the pretest. 36 people participated in the pretest which is a 46.15% response rate. Of those 36 participants, 31 people viewed the video and completed the posttest which is an 86.1% completion rate. Averages were calculated with the pretest and posttest responses using the questions on a linear scale (1-10) (only the participants who participated in the posttest were included in these calculations). The average for the knowledge and understanding of Project SEARCH on the pretest was 7.74. The average for the knowledge and understanding of intellectual and/ or developmental disabilities was 6.90. The average for the knowledge on the benefits of inclusion in the workplace was 7.81. The average for how the participants felt hiring or working alongside someone with an intellectual and/ or developmental disability was 8.19. The average for the knowledge and understanding of Project SEARCH on the posttest is 9.61. The average for the knowledge and understanding of intellectual and/ or developmental disabilities is 9.23. The average for the knowledge on the benefits of inclusion in the workplace is 9.52. The average for how the participants feel hiring or working alongside someone with an intellectual and/ or developmental disability was 9.45. The average for how relevant or useful the material is for the participants is 9.42. Therefore, all questions on the linear scale have increased, showing an increase in knowledge and understanding of the topics, see Figure 1. Participants provided lots of positive feedback and comments regarding the material. A thematic analysis was conducted on the satisfaction survey questions to develop themes and subthemes DISABILITY AWARENESS TRAINING 10 on what the participants learned, see Table 1. Lastly, 83.8% of participants stated they learned something new and 97.1% rated the modules relevancy and usefulness a nine or 10 (1-10 scale). Summary Unfortunately, there is a limited understanding of disabilities and working with PWD. This can lead to a significantly lower employment rate and decreased satisfaction among PWD at work (Friedman, 2020, p. 592). This project was created in hopes of promoting inclusivity, because education and awareness training have been successful in improving healthcare workers attitudes and perceptions of disabilities (Noronha, 2019). The hope is this project can help spread awareness on disabilities, information on Project SEARCH, and provide an intern perspective to improve hospitals diversity and inclusivity. A video module was created covering various topics, including types of disabilities and relevant information regarding Project SEARCH and its interns. Pretest surveys were sent out to employees in the hospital who are affiliated with Project SEARCH and to attendees at the operation team leadership meeting. Then, a posttest was provided to complete after viewing the video. A response rate, a completion rate, and averages for each question were calculated to measure knowledge and understanding. A qualitative analysis was conducted on the satisfaction portion of the posttest to identify themes in the participants responses. Each of the averages for the linear questions improved to at least a nine out of 10. There was a 46.15% response rate, an 86.1% completion rate, and 83.8% of participants stated they learned something new. Therefore, an increase in knowledge and understanding of people with disabilities and Project SEARCH was obtained. Conclusion DISABILITY AWARENESS TRAINING 11 Various managers and leaders were reached, via email or advertising, within the hospitals who are currently, or have the potential to, host a student during their work rotations. This is important because these employees are in positions to promote disability awareness in their department and help establish an inclusive and diverse environment. The response rate, completion rate, and feedback provided were successes and exceeded the participation goal. Finally, the linear questions all increased to at least a nine out of 10 which demonstrates an overall increase in knowledge. Various things were learned throughout the project. For instance, the difficulties and challenges PWD experience when transitioning out of school and finding and obtaining a job, the details that go into Medicaid and its services relevant to work, and how Project SEARCH works as a non-profit, its partners, including school districts and vocational rehab, and its advocacy efforts for recruitment. Most importantly, there is still a lack of awareness for working with PWD but, according to the feedback received, most people are willing to learn and keep an open mind for future interns and employees. The project was beneficial because of the number of people reached and the number of people who participated and learned from the video module which can hopefully translate to a more inclusive and diverse workplace. This was evident from the linear question answers and averages, and through the satisfaction and feedback. Implications for occupational therapy include continuing to advocate for PWD during their workplace transition to facilitate their occupational performance in the workplace, thus leading to occupational justice. This video is now used for Project SEARCH marketing purposes at various schools and is in the process of being used within the hospitals as a learning module on their employee site. DISABILITY AWARENESS TRAINING 12 References Albright, J., Kulok, S., & Scarpa, A. (2020). A qualitative analysis of employer perspectives on the hiring and employment of adults with autism spectrum disorder. Journal of Vocational Rehabilitation, 53(2), 167182. https://doi.org/10.3233/JVR-201094 Almalki, S. (2021). A qualitative study of supported employment practices in Project SEARCH. International Journal of Developmental Disabilities, 67(2), 140150. https://doi.org/10.1080/20473869.2019.1627793 Atchinson, B.J, & Dirette, D.K. (2017). Conditions in occupational therapy: Effect on occupational performance. (5th ed.). Wolters Kluwer. Cole, M. & Tufano, R. (2008). Applied theories in occupational therapy: A practical approach. Thorofare, N.J.: SLACK Inc. Dreaver, J., Thompson, C., Girdler, S., Adolfsson, M., Black, M. H., & Falkmer, M. (2020). Success Factors Enabling Employment for Adults on the Autism Spectrum from Employers Perspective. Journal of Autism and Developmental Disorders, 50(5), 16571667. https://doi.org/10.1007/s10803-019-03923-3 Family and Social Services Administration. (n.d.). Vocational rehabilitation services process. https://www.in.gov/fssa/ddrs/rehabilitation-employment/vocational-rehabilitationemployment/client-services/vocational-rehabilitation-services-process/ Friedman, C. (2020). The relationship between disability prejudice and disability employment rates. Work, 65(3), 591598. https://doi.org/10.3233/WOR-203113 Giri, A., Aylott, J., Giri, P., FergusonWormley, S., & Evans, J. (2022). Lived experience and the DISABILITY AWARENESS TRAINING 13 social model of disability: Conflicted and interdependent ambitions for employment of people with a learning disability and their family carers. British Journal of Learning Disabilities, 50(1), 98106. https://doi.org/10.1111/bld.12378 Hayward, L., Fragala-Pinkham, M., Schneider, J., Coe, M., Vargas, C., Wassenar, A., Emmons, M., Lizzio, C., Hayward, J., & Torres, D. (2021). Examination of the short-term impact of a disability awareness training on attitudes toward people with disabilities: A communitybased participatory evaluation approach. Physiotherapy Theory and Practice, 37(2), 257 270. https://doi.org/10.1080/09593985.2019.1630879 Lindsay, S., Cagliostro, E., Albarico, M., Mortaji, N., & Karon, L. (2018). A Systematic Review of the Benefits of Hiring People with Disabilities. Journal of Occupational Rehabilitation, 28(4), 634655. https://doi.org/10.1007/s10926-018-9756-z Nicholas, D., Mitchell, W., Zulla, R., & Dudley, C. (2019). Perspectives of employers about hiring individuals with autism spectrum disorder: Evaluating a cohort of employers engaged in a job-readiness initiative. Journal of Vocational Rehabilitation, 50(3), 353364. https://doi.org/10.3233/JVR-191018 Noronha, M., & Pawlyn, J. (2019). Caring for people with learning disabilities: The attitudes and perceptions of general nurses. Learning Disability Practice, 22(3), 2532. https://doi.org/10.7748/ldp.2019.e1970 Rashid, M., Thompson-Hodgetts, S., & Nicholas, D. (2018). Building employers capacity to support vocational opportunities for adults with development disabilities: a synthesis review of grey literature. Journal on Developmental Disabilities, 23 (3), 31-44. Rochette, A., Roberge-Dao, J., Roche, L., Kehayia, E., Mnard, L., Robin, J.-P., Sauv, M., Shikako-Thomas, K., St-Onge, M., Swaine, B., Thomas, A., Valle-Dumas, C., & DISABILITY AWARENESS TRAINING 14 Fougeyrollas, P. (2022). Advancing social inclusion of people with disabilities through awareness and training activities: A collaborative process between community partners and researchers. Patient Education and Counseling, 105(2), 416425. https://doi.org/10.1016/j.pec.2021.05.032 Taggart, L., Marriott, A., Cooper, M., Atkinson, D., Griffiths, L., Ward, C., & Mullhall, P. (2021). Developing curricularcontent and systemsrelated impact indicators for intellectual disability awareness training for acute hospital settings: A modified International Delphi Survey. Journal of Advanced Nursing. https://doi.org/10.1111/jan.15123 The Social Model of Disability. (2015). Inclusion London. https://www.inclusionlondon.org.uk/wpcontent/uploads/2015/05/FactSheets_TheSocialModel.pdf Wynants, S. A., & Dennis, J. M. (n.d.). Embracing Diversity and Accessibility: A Mixed Methods Study of the Impact of an Online Disability. Journal of Postsecondary Education and Disability, 30 (1), 33-48. DISABILITY AWARENESS TRAINING 15 Tables Table 1 Themes and Subthemes Retrieved from Survey Satisfaction Responses Theme: Subthemes: Quotes: Facts on disabilities Learning types of disabilities Project SEARCH Learning facts about disabilities Learning about Project SEARCH I learned more information about characteristics of different disabilities. Enjoying the intern perspective Assisting with interns and their skills Thank you for this education. I wish network would assign this video to all for inclusion. We all encounter project search interns at work and have multiple opportunities to make a difference when we see people with disabilities outside of work. Adding the perspective of the students was so powerful. Interacting with PWD Encountering interns at work Creating positive interactions Remembering personal space Empowering instead of solving in the workplace Asking before assisting The variety of different abilities in our workforce. I have a daughter in a wheelchair. I wish more people had this education so she would encounter more positive reactions in public. The different types of disabilities as well as etiquette. I learned the importance of empowering someone rather than solving issues for them. I also learned the importance of first asking someone if they want help, rather than just jumping in and trying to assist. DISABILITY AWARENESS TRAINING 16 Figures Figure 1 Average Answers on Linear Scale Questions on the Pretest and Posttest Surveys Average of rating on linear question (1-10) 12 10 8 6 Pre test averages Post test averages 4 2 0 Project SEARCH Intellectual and developmental disabilities Benefits of inclusion Confidence in hiring in the workplace or working alongside PWD Topic of the linear question on tests Note. This figure shows the average answers in the surveys, taken before viewing the disability awareness module, and after. The questions were asked to rate the participants knowledge and understanding of each topic. Only the participants who viewed the video and completed the posttest were included in the results. DISABILITY AWARENESS TRAINING 17 Appendix DISABILITY AWARENESS TRAINING Week 1 DCE Stage (orientation, screening/evaluation, implementation, discontinuation, dissemination) Orientation Weekly Goal Complete orientation at both hospitals 18 Objectives Tasks -Orient self to Project SEARCH and the interns roles and daily schedule -Shadow interns during their rotations -Finalize MOU goals and objectives 2 3 Screening/ evaluation Screening/ evaluation Get project approved by hospitals IRB. -Have draft of pretest to be approved Examine Project SEARCH advocacy efforts within schools. -Work on scholarly report Gather baseline data from healthcare professionals working alongside Project SEARCH -Have pretests sent out for disability awareness at both hospitals -Work on scholarly report Date complete 1/14 -Sit in during classes -Discuss goals and objectives with mentors -Make edits to MOU and search new literature -Discuss ways to reach out to relevant employees -Meet with hospital 1/21 IRB to discuss project -Continue to check on status of IRB -Sit in on department chair meetings for school district involved with Project SEARCH -Work on introduction draft -Gather appropriate emails from site mentors for training -Send out pretests to gathered healthcare workers by end of week via email with consent for project Unable to complete, waiting on IRB DISABILITY AWARENESS TRAINING 19 Complete introduction for scholarly report 4 Screening/ evaluation Gather baseline data from healthcare professionals working alongside Project SEARCH Complete background for scholarly report 5 Screening & Implementation Have completed training module to send out. -Meet with the person affiliated with hospitals IRB -Have pretests sent out for disability awareness at both hospitals -Work on scholarly report Examine advocacy 2/4 -Send out pretests to healthcare workers by end of week via email with consent for project -Begin working on training program -Work on background draft -Continue to gather baseline data -Organize pretest data in Complete spreadsheet design and and create implementation training for scholarly module report Understand advocacy efforts Project SEARCH uses at various sites. -Work on introduction and background drafts -Gather appropriate emails from site mentors for training -Work on design and implementation draft -Collect and organize data from pretests -Conduct interviews from interns -Work on design and implementation draft -Meet with Project SEARCH leaders on systemic barriers interns have -Continue to work on training program and make final edits -Attend Project SEARCHs open house for schools, 2/11 DISABILITY AWARENESS TRAINING 6 Implementation 20 efforts Project SEARCH does within schools involved. Examine trends - Begin and make gathering data comparisons from posttest among posttests and pretests employees, and job coaches. -Send out training module with posttest 2/18 -Analyze spreadsheet and compare data from pretest and posttest -Meet with stakeholders on barriers interns have when getting jobs at the hospitals 7 Implementation Examine trends and make comparisons among posttests and pretests. Recruit new participants from OLT meeting 8 Implementation Examine trends and make comparisons among posttests and pretests. Collaborate with DEI executive director/ ADA coordinator -Continue to gather data from posttest -Gather new participant information from pretests and posttests -Meet with DEI office to discuss barriers interns have when getting jobs at the hospitals 2/25 -Analyze spreadsheet and compare data from pretest and posttest -Send out pretest emails to attendees from OLT meeting -Continue to gather data from posttest -Work on scholarly report -Send out reminders -Analyze spreadsheet and compare data from pretest and posttest -Send out reminders -Show DEI executive director/ ADA coordinator around Project SEARCH East on 3/1 3/4 DISABILITY AWARENESS TRAINING 21 and Project SEARCH. -Send project video to school district teachers by site mentor to increase advocacy efforts and recruitment Increase advocacy efforts with schools involved with Project SEAERCH. 9 Implementation phase & Gather and program eval/ quality analyze assurance information. Examine ways Project SEARCH is looking to expand and advocate. -Continue to gather data from posttest -Work on scholarly report -Begin writing outcomes and analyzing data with response rates and averages to examine trends 3/10 -Fill in new data as participants complete post test -Attend meeting between Project SEARCH teacher and hospitals operations vice president 10 Implementation phase & Analyze program eval/ quality information assurance provided on the pretest and posttest. Complete outcomes for scholarly report Brainstorm on ways to disseminate data at both sites. -Work on scholarly report -Understand more advocacy efforts within Project SEARCH -Work on outcomes draft -Close posttests -Complete calculations for data: averages of questions on linear scales and response rates -Work on outcomes and draft -Work on dissemination plan -Examine Project SEARCH tours for 3/18 DISABILITY AWARENESS TRAINING 11 Examine advocacy efforts Project SEARCH does within schools involved. Implementation phase & Work on program eval/ quality displaying assurance data. Complete dissemination plan for scholarly report Collaborate with DEI executive director/ ADA coordinator and Project SEARCH. Pilot Project SEARCH curriculum. 22 various school district employees -Stay involved in Project SEARCH efforts to expand and keep up on evidence-based research for creating curriculum -Understand the challenges teachers are having with students and how OT can help. -Work on dissemination plan 3/25 -Show DEI executive director/ ADA coordinator around Project SEARCH North on 3/21 -Pilot coping skills curriculum at Project SEARCH both sites classrooms -Meet with Project SEARCH teachers in Massachusetts via zoom to learn what challenges they are having with students from an OTs perspective. -Grasp a better understanding of Project Serve as an OT SEARCH consult to creation and -Create resources and various Project implementation information for SEARCH sites of curriculum Riverview Project for their SEARCH teachers to challenges with utilize in their interns. classrooms. 12 Implementation phase & Work on program eval/ quality displaying data assurance for dissemination. Work on scholarly draft -Information gained from the results will be used to create helpful handouts and resources for healthcare workers -Work on abstract, summary, and conclusion for scholarly report -Create PowerPoint for displaying data to site mentors and other employees 4/1 DISABILITY AWARENESS TRAINING Serve as an OT consult to various Project SEARCH sites for their challenges with interns. 13 14 Completion, discontinuation phase, and dissemination Completion, discontinuation phase, and dissemination Display data and disseminate to site mentors. Provide flyer with resources to site mentors to utilize for advocating with Project SEARCH Display data and disseminate. 23 -Work to provide resources and tools for Project SEARCH sites to utilize - Continue to create resources and information for Riverview Project SEARCH teachers to utilize in their classrooms. -Resources will be provided to improve advocacy efforts in the hospital about Project SEARCH and workers with disabilities -Work on abstract, summary, and conclusion for scholarly report 4/8 Complete dissemination at both sites. -Work on abstract, summary, and conclusion for scholarly report 4/14 Complete Complete final abstract, evaluations. summary, and conclusion for scholarly report Doctoral Capstone Experience and Project Weekly Planning Guide  ...

... 1 More Than Capable: Facilitating Meaningful Independent Living for Individuals with Intellectual and Developmental Disabilities Hannah E. Harless May 1st, 2023 A capstone project submitted in partial fulfillment of 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. Lucinda Dale EdD, OTR, CHT, FAOTA FACILITATING MEANINGFUL INDEPENDENT LIVING Abstract 2 Objectives: This project aimed to facilitate an integrated, inclusive community that created a sense of belonging within the North End apartment complex and Carmel by providing individuals with intellectual and developmental disabilities the resources needed to live independently for the first time. Methods: I utilized a pre/post-survey, satisfaction survey, and Likert scale for outcome measures. The pre-survey determined future residents preferred interests and hobbies, which guided events I planned and businesses I contacted for partnerships. The post-survey determined residents likelihood of attending the events planned. Results: I created a resource binder based on results from the pre-survey, and several community members agreed to partner with North End by volunteering their time, resources, and talents to host or facilitate future events. Conclusion: Adults living with intellectual and developmental disabilities are an underserved population that has the potential to thrive living independently in their communities if provided with the necessary resources. Keywords: Community Integration, Advocacy, Independence, Inclusion FACILITATING MEANINGFUL INDEPENDENT LIVING More Than Capable: Facilitating Meaningful Independent Living for Individuals with 3 Intellectual and Developmental Disabilities The Village of Merici aims to create a safe, independent living option for adults with intellectual (ID) and developmental disabilities (DD) that allows their caregivers not to worry about their loved ones safety after they pass away. The Village of Merici strives to achieve this by (a) developing housing options for those with intellectual or developmental disabilities; (b) focusing on a strong sense of community to get a stronger sense of belonging in the Indianapolis area; and (c) providing social and community activities (The Village of Merici, 2023). The development of this independent living community is highly successful, which led to the Village of Merici partnering with Old Town Company to provide services to residents in the new North End apartments in Carmel. With this new location opening, neurotypical residents from the community will occupy 128 apartments, and the other forty apartments are reserved for those with ID and DD. The projects main goal was facilitating community integration within the North End apartment complex and in the Carmel community for individuals with ID and DD. I achieved this by planning the apartment complexs future weekly, monthly, and annual events. Additionally, I created a resource binder for future residents to access that provides them with information about interests, hobbies, employment, or leisure activities they can participate in within the community. I advocated for these new residents by educating local businesses around Carmel and employees of the North End apartments. My project was essential to creating an integrated, inclusive community, a sense of belonging, and a smooth transition from living with a family member as individuals live independently for the first time. FACILITATING MEANINGFUL INDEPENDENT LIVING Background 4 Inequalities in Housing Approximately 6.2 million people in the United States have an intellectual or developmental disability (CDC, 2019, para.1). Of those 6.2 million, 75% of these individuals are supported entirely by their families, and only 25% receive Medicaid or Medicare, which are publicly funded services (CDC, 2019, para.1). Due to advanced medical knowledge, improvement of non-institutionalized supports and services, and those with ID and DD outliving their parents, it is predicted that the life expectancy of these individuals will continue to increase, leading to increasing demands for independent community living. The only housing option for those with more severe and complex needs who cannot live with their families is institutional or residential care settings (ika et al., 2018, p. 4). Such dramatically high differentiation in statistics between those with ID and DD residing with their families and living out in the community is likely a lack of sufficient community-based support (ika et al., 2018, p. 4). There is continued inequality in society in the living situation and full inclusion of people with ID and DD into their communities. Therefore, the Village of Merici, Old Town Company, and the city of Carmel capitalized on the opportunity to partner in creating an independent housing option on the north side of Indianapolis to address this issue and better serve those in the community with an ID or DD. Social Interaction, Community Involvement, and Quality of Life Individuals with ID or DD typically struggle with social interactions, which hinders their ability to make new friends and integrate into their communities. Based on the needs assessment FACILITATING MEANINGFUL INDEPENDENT LIVING 5 with Colleen Renie, the site mentor, the most significant need at The North End was establishing community connections, planning social events, and other preferred activities at the new Carmel location. The residents biggest challenges at The North End are the newness and unique opportunities this complex provides. For many residents, it is their first time living independently, and they struggle to develop relationships within the apartment complex and the surrounding community. Structured and organized social inclusion creates better opportunities for social interaction and improves social skills (DaWalt et al., 2021; Hall, 2017: Louw et al., 2020). The authors also examined barriers to social inclusion, which consisted of (a) negative attitudes, (b) discriminatory behaviors, (c) feeling like they do not belong, (d) feeling excluded, (e) physical access to leisure events in the community, (f) transportation, (g) navigating the community independently, and (h) digital literacy skills for social media use. Two main components contributed to an improved quality of life for those with ID and DD: community involvement and a sense of belonging (DaWalt et al., 2021; Hall, 2017; Louw et al., 2020; Gilmore & Cuskelly, 2014). ika et al. (2018) determined that to have complete and meaningful inclusion in the local community and society, people with ID and DD need to be present, feel part of that community, and actively participate in and contribute to that community. Biggs and Carter (2016) examined the quality of life for young people with disabilities during adulthood and several other factors for overall well-being (p.5). They found that several factors should be understood and considered to determine the quality of life, including community involvement, religious faith, and character strengths. Spassiani et al. (2019), Asselt et al. (2015), and Cameron et al. (2021) examined a similar subject of those aging with ID and FACILITATING MEANINGFUL INDEPENDENT LIVING DD and their perceived quality of life, which had similar themes and results as Biggs and Carter 6 (2016). Dwyer et al. (2022), Jansen-van Vuuren & Aldersey (2020), Taylor-Roberts et al. (2019), and Wilson et al. (2017) discussed the importance of peer-to-peer mentorships with individuals who are neurodivergent. My project addressed this aspect as I organized a panel that will take place in the summer to allow future residents at The North End apartments and their families to ask questions to the residents who have lived independently at The Village of Merici for seven years. This time will allow families to interact and become a support system for each other to aid with the transition of their adult child to independent living. The Stigma of Intellectual and Developmental Disabilities The stigma and prejudice toward individuals with ID and DD were additional barriers for these residents in the surrounding community. Stigma and exclusion adversely affect participation, mental well-being, and quality of life (Merrells et al., 2019). The authors stated, The quality of relationships and interactions with others is more important than just being included or invited, and reciprocity and respect should characterize these relationships (Jansenvan Vuuren & Aldersey, 2020, p. 2). This project was vital in promoting a meaningful community, authentic acceptance, and frequent participation of individuals with ID and DD. A study completed by Dwyer et al. (2022) included authors who were neurodivergent as well as neurotypical. Recommendations from this study included providing neurodiversity training to everyone on the campus, with those who are neurodiverse leading the programming and training. Several companies fail to include training on neurodiverse populations during typical diversity, equity, and inclusion training. FACILITATING MEANINGFUL INDEPENDENT LIVING Theories to Guide Project 7 I utilized the Ecology of Human Performance (EHP) model to guide this project. Occupational therapists created this model to help change more of the environment rather than the person themselves. Ecology of Human Performance allowed me to focus on the context and environments influence on residents occupational performance (Cole & Tufano, 2020). The main components of the EHP model are to create, prevent, establish, alter, and modify the environment for task performance. This project aimed to create opportunities for inclusion and integration within the Carmel community and The North End apartment complex. I accomplished this goal by (a) preventing the isolation of future residents in their new community, (b) establishing relationships within the Carmel community and The North End apartment complex employees, (c) altering the mindset of the community to know how to provide an inclusive environment, and (d) modifying the subjective norms of the businesses and organizations in the new community. The second theory I utilized to guide my project was the Theory of Planned Behavior (TPB). The Theory of Planned Behavior is a cognitive theory that proposes that an individuals decision to engage in a specific behavior can be predicted by their intention to engage in that behavior (Brookes, 2021 para. 1). The three main components of the TPB are personal attitudes, subjective norms, and perceived behavioral control. The capstone project altered the personal attitude of the community of Carmel by educating them on how to interact and provide an inclusive environment for those with ID and DD. Secondly, my project modified the subjective norms of the surrounding businesses and organizations of the new Carmel community. FACILITATING MEANINGFUL INDEPENDENT LIVING Project Design 8 The executive director of The Village of Merici assisted in determining the highest needs for the North End apartment residents. The needs assessment results helped develop this project to provide ID and DD individuals with the resources to live independently. The North End apartment residents needed resources, community connections, and education provided to the surrounding Carmel community to ease their transition from living with a parent or caregiver to living independently. The residents on The North End waitlist received a pre-survey so they could indicate their interests, hobbies, and things they like to do in their free time. Based on the survey results, the executive director proposed a binder with helpful information for the residents to access, including local places to participate in hobbies and interests that potential residents indicated on the survey. The binder incorporated details such as the description of the location, the hours of operation, any discounts, the distance from their apartment, and whether they could walk there or would need transportation. Based on the survey results, I contacted businesses within the Carmel community to educate them about The North End apartments. I inquired if they would meet me in person to discuss further details. In-person meetings included discussions about becoming a volunteer partner for an event, club, or transportation. In addition, I planned several weekly, monthly, and annual activities based on the interest survey. I sent a satisfaction survey to the Village of Merici and Old Town employees to determine their satisfaction with the established resources. I sent a post-survey to the forty residents selected with ID and DD and those not selected regarding their likelihood of attending the planned events and activities. FACILITATING MEANINGFUL INDEPENDENT LIVING Implementation 9 For this project, I utilized a pre/post-survey, a satisfaction survey, and a Likert scale. A pre-and post-survey was the best option for this project and this site due to the needs assessment results and the projects demographic. I sent a pre-survey to 187 potential residents on the interest list. I determined from the survey the activities and hobbies the potential residents enjoyed, ensuring appropriate resources to add to the resource binder. I determined business and community members to contact by researching their activities and occupations that they offered that aligned with the residents interests in the survey. The initial plan was to send a post-survey determining the likelihood of attending events and group activities for the forty residents selected to live at North End. However, the site mentor decided I should send the post-survey to all 200 individuals with ID and DD to include community members not selected to live at North End in the events and group activities. A satisfaction survey was given to thirteen Village of Merici employees and four Old Town employees to complete. The survey evaluated employees satisfaction with the education, advocacy, and resources I provided through this project. During a seven-week period, I went to businesses related to activities on the interest survey to educate the employees and ask if they would be interested in partnering with The North End apartments to host classes or hire residents with ID and DD. In addition, resources were added to the resource binder each week, with helpful knowledge for the residents to access. The results indicated on the interest survey guided the selection of businesses visited and activities planned each week. FACILITATING MEANINGFUL INDEPENDENT LIVING Vast preference responses created a challenge in selecting planned activities and 10 businesses to visit. For example, 29% of individuals indicated that bowling was their favorite thing to do, while 16% indicated they disliked bowling. I determined the top twenty activities and events to focus on by comparing what percentage of individuals indicated they loved and liked the activity to the percentage that indicated they did not like the activity or were willing to try it. If the positive response percentage was 50% or higher, I selected the activity to focus my time on and add to the top twenty. Another challenge was that these individuals were all possible, not confirmed. Some of the individuals who responded may be someone other than those who will live in one of the forty affordable housing apartments. Challenges emerged with communication and clear expectations between partners: Old Town, Village of Merici, Lincoln Property Group, and Merchants Affordable Housing. These challenges were discussed and resolved through several in-person and virtual meetings. Successes of implementation included obtaining volunteers willing to help with programming, transportation, and education on communicating with and including those with ID and DD. Another success was the creation of a resource binder to assist those with ID and DD as they live independently for the first time. Project Outcomes During week two of the project, I utilized a Likert scale to assess my comfort level with communicating with business managers and advocating for those with disabilities. I determined that my comfort level was four out of ten during week two. I then utilized a Likert scale at the end of ten weeks to assess my progress in comfort level in communicating with business FACILITATING MEANINGFUL INDEPENDENT LIVING managers and advocating for those with disabilities. I determined that my comfort level was a 11 score of seven out of ten. Of the 187 potential residents who received the pre-survey, sixty-two completed the survey. The survey options were as follows; this is my favorite, I like it, I would like to try it, or not at all. Of the activities and hobbies listed, twenty activities or hobbies obtained the most votes for this is my favorite, or I like it. The top twenty activities and hobbies with data are in Appendix A. Based on the survey results in Appendix A, I met with several businesses and community members of Carmel and Hamilton County to establish relationships, recruit volunteers, plan events, and create the resource binder. I met with a local Carmel resident who has a child with a disability, and she provided great insight into the city and several places that are willing to hire those with disabilities. For transportation purposes, I met with Hamilton County Express and agreed with the company to have a fixed route at The North End apartment complex and grocery stores. Due to future residents indicating their interest in exercise, walking, and swimming, I met with The Monon Community Centers director of adaptive programming to gain knowledge of the types of classes they offer and pricing for memberships. I met with several churches interested in volunteering their time, resources, and talents to future residents. Some of the activities they volunteered for consisted of the weekly activities I planned, such as Merici city rides, helping residents move in, gardening club, art club, music club, book club, walking club, and summer camp. Monthly events included movie nights, game nights, dance trends, and a waterpark day. Annual events included holiday parties, barbeques, and social gatherings. I selected these events based on the activities with high positive percentages on the interest survey. FACILITATING MEANINGFUL INDEPENDENT LIVING 12 Forty-six of the 200 individuals with ID and DD that received the post-survey completed the post-survey to determine their likelihood of attending planned events. The surveys options were as follows; Not at all, I might try it, Maybe, Very Likely, and Absolutely, I am coming! See Appendix B for the results of the survey. Of the seventeen employees who received the satisfaction survey, thirteen employees completed the survey. The survey asked about the employees satisfaction level with various aspects of my project and had a space for comments. The surveys options were as follows; 1: very dissatisfied, 2: somewhat dissatisfied, 3: neutral, 4: satisfied, and 5: very satisfied. See Appendix C for the results of the survey. Summary There are scarce opportunities for individuals with ID or DD to live within a community that provides them with a sense of belonging and meaningful life. Most community living opportunities fail to provide individuals with ID or DD the proper resources to succeed at making new friends and integrating themselves into the community. The survey determined the potential residents top twenty interests and hobbies, aided in planning structured events, and guided what businesses I contacted for partnerships. These resources and pre-planned activities facilitate independence and meaningful relationships for the residents transitioning to living independently for the first time. The resources I created and the planned events will be used for years by the residents living in the North End apartments. By advocating for the residents to local Carmel businesses, employers and business owners now know how to communicate appropriately and effectively with individuals with ID or DD. In addition, these skills help them to create an inclusive environment. During these FACILITATING MEANINGFUL INDEPENDENT LIVING 13 advocacy trips, I obtained certain community members to commit to partnering with the Village of Merici to volunteer their time, resources, and talents to future residents. Conclusion The Village of Merici benefited from this project from the new resource binder created for the forty residents selected to live at The North End apartments. The resource binder and events planned are not only supported by the surveys but also supported by the research of several databases in the past year. Through this project and my experience at the Village of Merici, I learned that there is a significant gap in services and resources for adults with ID and DD. Occupational therapy focuses heavily on pediatrics with ID and DD, but services and programs become scarce once they become adults. These individuals are adults longer than they are children, yet there are insufficient living opportunities for individuals unless it is with their parents. Many fail to realize that these individuals are more than capable of living independently when provided with the appropriate support. The North End apartments are a unique and rare opportunity for those with ID and DD to live independently and have a meaningful community with not only their peers but also other members of the Carmel community. There are limited resources and options for independent living for those with ID and DD in Indiana and within the United States. The North End project has an incredible opportunity to pave the way as an example of how these community settings can be practical and create an opportunity for the most fulfilling life for those with ID and DD. Occupational therapists belong in community-based settings like the Village of Merici and can change the lives of those with ID and DD and their families. FACILITATING MEANINGFUL INDEPENDENT LIVING References 14 Aldersey, H. M. (2019). Stigma, acceptance, and belonging for people with IDD across cultures. Current Developmental Disorders Reports, 7(3), 163-172. https://doi.org/10.1007/s40474-020-00206-w Asselt, G. A. E., Embregts, P. J. C. M., & Hendriks, A. H. C. (2015). Social networks of people with mild intellectual disabilities: characteristics, satisfaction, wishes, and quality of life. Journal of Intellectual Disability Research, 59(5), 450461. https://doi.org/10.1111/jir.12143 Biggs, E., & Carter, E. (2016). Quality of life for transition-age youth with autism or intellectual disability. Journal of Autism & Developmental Disorders, 46(1), 190204. https://doi.org/10.1007/s10803-015-2563-x Brookes, E. (2021). The theory of planned behavior. Simply Psychology. www.simplypsychology.org/theory-of-planned-behavior.html Cameron, L. A., Borland, R. L., Tonge, B. J., & Gray, K. M. (2021). Community participation in adults with autism: A systematic review. Journal of Applied Research in Intellectual Disabilities. https://doi.org/10.1111/jar.12970 CDC. (2019, November 19). Health Care for Individuals with Intellectual Disabilities. Centers for Disease Control and Prevention. https://www.cdc.gov/grandrounds/pp/2019/20191015-intellectual-disabilities.html Cole, M. & Tufano, R. (2020). Applied theories in occupational therapy: A practical approach. (2nd Ed.). Thorofare, N.J.: SLACK Inc DaWalt, L. S., Taylor, J. L., & Mailick, M. R. (2021). The transition to adulthood for individuals with intellectual and developmental disabilities. In L. M. Glidden, L. FACILITATING MEANINGFUL INDEPENDENT LIVING Abbeduto, L. L. McIntyre, & M. J. Tass (Eds.), APA handbook of intellectual and 15 developmental disabilities: Clinical and educational implications: Prevention, intervention, and treatment., Vol. 2. (pp. 281298). American Psychological Association. https://doi.org/10.1037/0000195-011 Dwyer, P., Mineo, E., Mifsud, K., Lindholm, C., Gurba, A., & Waisman, T. c. (2022). Building neurodiversity-inclusive postsecondary campuses: recommendations for leaders in higher education. Autism in Adulthood. https://doi.org/10.1089/aut.2021.0042 Gilmore, L., & Cuskelly, M. (2014). Vulnerability to loneliness in people with intellectual disability: an explanatory model. Journal of Policy & Practice in Intellectual Disabilities, 11(3), 192199. https://doi.org/10.1111/jppi.12089 Hall, S. A. (2017). Community involvement of young adults with intellectual disabilities: their experiences and perspectives on inclusion. Journal of Applied Research in Intellectual Disabilities: JARID, 30(5), 859871. https://doi.org/10.1111/jar.12276 Louw, J. S., Kirkpatrick, B., & Leader, G. (2020). Enhancing social inclusion of young adults with intellectual disabilities: A systematic review of original empirical studies. Journal of Applied Research in Intellectual Disabilities: JARID, 33(5), 793807. https://doi.org/10.1111/jar.12678 Merrells, J., Buchanan, A., & Waters, R. (2019). We feel left out: Experiences of social inclusion from the perspective of young adults with intellectual disability. Journal of Intellectual & Developmental Disability, 44(1), 13-22. https://doi.org/10.3109/13668250.2017.1310822 FACILITATING MEANINGFUL INDEPENDENT LIVING ika, J., Beadle-Brown, J., Kov, ., & umnkov, P. (2018). Social inclusion through 16 community living: current situation, advances and gaps in policy, practice, and research. Social Inclusion, 6(1), 94109. https://doi.org/10.17645/si.v6i1.1211 Spassiani, N. A., Meisner, B. A., Abou Chacra, M. S., Heller, T., & Hammel, J. (2019). What is and is not working: Factors involved in sustaining community-based health and participation initiatives for people aging with intellectual and developmental disabilities. Journal of Applied Research in Intellectual Disabilities: JARID, 32(6), 1465 1477. https://doi.org/10.1111/jar.12640 Taylor-Roberts, L., Strohmaier, S., Jones, F., & Baker, P. (2019). A systematic review of community participation measures for people with intellectual disabilities. Journal of Applied Research in Intellectual Disabilities: JARID, 32(3), 706718. https://doi.org/10.1111/jar.12565 The Village of Merici A Community for Adults with Developmental Disabilities in Central Indiana. (2023). https://villageofmerici.org/ Wilson, N.J., Jaques, H., Johnson, A., & Brotherton, M. L. (2017). From social exclusion to supported inclusion: Adults with intellectual disabilities discuss their lived experiences of a structured social group. Journal of Applied Research in Intellectual Disabilities, 30(5), 847-858. https://doi.org/10.1111/jar.12275 FACILITATING MEANINGFUL INDEPENDENT LIVING 17 Appendix A Table 1: Top 20 Most Liked Hobbies & Activities Activity Not at All Id Like to Try It I Like It My Favorite Board Games 14.8% 8.2% 63.9% 13.1% Exercise 6.5% 25.8% 58.1% 9.7% Cooking 3.3% 23.3% 60% 13.3% Puzzles 20% 28.3% 41.7% 10% Pets/Animals 22% 11.9% 37.3% 28.8% Holiday 6.5% 12.9% 48.4% 32.3% TV 3.2% 6.5% 45.2% 45.2% Music 3.3% 3.3% 52.5% 41% Movies 0% 9.8% 44.3% 45.9% Bowling 16.1% 12.9% 41.9% 29% Walking 11.3% 4.8% 59.7% 24.2% Swimming 11.7% 20% 53.3% 15% Dancing 21.3% 26.2% 36.1% 16.4% Activities FACILITATING MEANINGFUL INDEPENDENT LIVING 18 Drawing 29% 17.7% 43.5% 9.7% Video Games 20.3% 20.3% 33.9% 25.4% Traveling 11.3% 4.8% 59.7% 24.2% Picnic 16.4% 16.4% 52.5% 14.8% Legos Indicated by an open-ended question on the survey Swinging Indicated by an open-ended question on the survey FACILITATING MEANINGFUL INDEPENDENT LIVING 19 Appendix B Table 2: Events and Activities Survey Weekly Activities Not at all I might try it Maybe Very Likely Absolutely, I am coming! Walking Club 10.9% 19.6% 30.4% 28.3% 10.9% Dinner Group 2.2% 15.2% 30.4% 37% 15.2% Art/ Craft Group 18.2% 15.9% 29.5% 25% 11.4% Book Club 34.9% 20.9% 25.6% 7% 11.6% Adaptive Fitness Classes 11.6% 20.9% 25.6% 30.2% 11.6% Music Therapy 11.4% 20.5% 38.6% 15.9% 13.6% Technology Education 4.5% 27.3% 34.1% 18.2% 15.9% Adaptive Yoga 30.2% 18.6% 23.3% 18.6% 9.3% Swim Aerobics 22.2% 17.8% 28.9% 22.2% 8.9% Knitting / Crochet Group 59.1% 11.4% 18.2% 2.3% 9.1% Cooking Club 6.7% 13.3% 33.3% 26.7% 20% Zumba, Strength, 23.8% 16.7% 28.6% 21.4% 9.5% Drumstick, Kickboxing Class FACILITATING MEANINGFUL INDEPENDENT LIVING 20 Monthly Activities Not at all I might try Maybe Very Likely it Absolutely, I am coming! Movie Night 4.3% 13% 10.9% 37% 34.8% Dance Trends 24.4% 24.4% 28.9% 11.1% 11.1% Game Night 4.3% 10.9% 17.4% 52.5% 15.2% The Waterpark Day 11.1% 15.6% 24.2% 17.8% 31.1% Annual Holiday Activities Not at all I might try it Maybe Very Likely Absolutely, I am coming! New Years Party 8.7% 13% 23.9% 34.8% 19.6% MLK Day- Guest Speaker 26.7% 24.4% 33.3% 11.1% 4.4% Valentines Day Craft 26.7% 17.8% 20% 26.7% 8.9% Superbowl Party 6.7% 22.2% 26.7% 28.9% 15.6% St. Patricks Day Craft 24.4% 17.8% 26.7% 22.2% 8.9% March Madness Bracket 28.9% 17.8% 26.7% 15.6% 11.1% Easter Egg Hunt 26.7% 15.6% 26.7% 24.4% 6.7% Northview Prom 15.6% 11.1% 26.7% 17.8% 28.9% Challenge FACILITATING MEANINGFUL INDEPENDENT LIVING 21 Mothers Day Craft & Card 17.8% 17.8% 17.8% 31.1% 15.6% Memorial Day Barbeque & 8.9% 11.1% 20% 42.2% 17.8% Northview Summer Camp 18.6% 20.9% 20.9% 25.6% 14% Fathers Day Craft & Cards 20% 15.6% 20% 28.9% 15.6% 4th of July Barbeque & Yard 6.7% 13.3% 28.9% 33.3% 17.8% Labor Day Barbeque 6.8% 15.9% 27.3% 34.1% 15.9% NFL Season Kickoff 22.7% 20.5% 25% 25% 6.8% Pumpkin Patch 17.8% 15.6% 24.4% 31.1% 11.1% Halloween Costume Party 15.2% 17.4% 26.1% 19.6% 21.7% Thanksgiving Pitch in Meal 8.9% 15.6% 28.9% 28.9% 17.8% Christmas Door Decorating 22.2% 17.8% 31.1% 17.8% 11.1% 11.1% 13.3% 31.1% 28.9% 15.6% Pool Party Games Contest Secret Santa FACILITATING MEANINGFUL INDEPENDENT LIVING 22 Appendix C Table 3: Employee Satisfaction Survey Project Qualities 1: Very 2: Somewhat 3: Neutral 4: Satisfied Dissatisfied Dissatisfied Community Activities and 5: Very Satisfied 0% 0% 7.7% 7.7% 84.6% Resource Binder Created 0% 0% 7.7% 0% 92.3% Communication Skills 0% 0% 7.7% 7.7% 84.6% Contribution to Ideas 0% 0% 7.7% 7.7% 84.6% Interaction with Residents 0% 0% 7.7% 0% 92.3% Advocacy Skills 0% 0% 7.7% 0% 92.3% Educational Materials & 0% 0% 7.7% 7.7% 84.6% Interest Survey 0% 0% 7.7% 7.7% 84.6% Relationships & 0% 0% 7.7% 7.7% 84.6% 0% 0% 7.7% 0% 92.3% Events Planned Resources Created Volunteers with Community Members Collaboration with VOM, Old Town, & Lincoln FACILITATING MEANINGFUL INDEPENDENT LIVING 23 Week 1 DCE Stage (orientation, screening/evaluation, implementation, discontinuation, dissemination) Orientation Screening/ Evaluation 2 Screening / Evaluation Weekly Goal 1. Complete orientation by the end of the week. Objectives Meet with site mentor, employees, and residents to introduce myself and explain my project. 2. Complete online training by the end of Update MOU, and the week. discuss a weekly meeting plan. 3. Gaining knowledge from LADD & Get to know the site, Metzcore in resources, and routine. Cincinnati 4. Begin working on Pre-Survey Gather materials needed to begin presurvey on Microsoft Forms 1. Literature Search 2. Finalize and turn in MOU 3. Interest Survey 4. Begin Introduction Draft. 5. Increase Knowledge of affordable housing Meet with Colleen to ask some clarifying questions before submitting MOU. Finish the Interest Survey and Send it out. Tasks Make sure all paperwork is completed and health information is on file. Date complete 1/13/23 Make edits to MOU Travel to Cincinnati with the team to meet with LADD and tour a fully smart home. Complete mandatory training. Attend coaches and employee training sessions and introduce myself and my project. Watch a virtual presentation on affordable housing in Indiana. Download resources from Colleens email and place them into the VOM file. 1/20/23 1/23/23 1/22/23 FACILITATING MEANINGFUL INDEPENDENT LIVING 3 Screening/ Evaluation 1. Education Flyer 2. Community Relationship Development Meet with Katie, VOMs community liaison, to discuss her research and resources that may already be in place. Educate local businesses on the North End project. Ask about partnerships and volunteering 24 Complete the education flyer and give the mentor feedback. Go to Carmel to get an idea of the businesss distance from North End that fits the interests indicated on the survey. 1/27/23 1/25/23 Introduce the project to Indie Coffee Roasters and No Label at the Table 4 5 Implementation Implementation 1. ATIA Conference 2. Advocacy and Communication Skills 1. Resource Binder Development Gain advanced clinical skills in utilizing assistive technology. Gain OT advocacy skills and articulation skills. Educate local businesses on the Email Carmel businesses based on interests. I am attending the ATIA conference and gaining as much knowledge as possible in my future career. 2/3/23 Explain VOM to conference attendees Find a business based on the preferred activities indicated 2/10/23 FACILITATING MEANINGFUL INDEPENDENT LIVING 2. Community Relationship Development 3. Events and Club Development 4. Advocacy and Communication Skills North End project. Ask about partnership and volunteering. Plan at least one event Advocate for Old Town Employees through virtual meetings. 25 and then Google Map the distance from preferred activities to North End to add to the binder. Meet with St Christophers Episcopal Church - Willing to host an art group. - Book club - Help residents move in - Transportation 2/12/23 Attend virtual meetings with Old Town 6 Implementation 1. Resource Binder Development 2. Community Relationship Development 3. Events and Club Development 4. Advocacy and Communication skills Educate local businesses on the North End project. Ask about partnership and volunteering. Plan at least one event Communication with Coaches and Employees at VOM. Email Carmel businesses based on interests Find a business based on the 2/17/23 preferred activities indicated and then Google Map the distance from preferred activities to North End to add to the binder. Add any businesses that were visited the previous week. I am meeting with a Carmel resident with knowledge and insight into the town and the ID and DD population. 2/15/23 FACILITATING MEANINGFUL INDEPENDENT LIVING 26 Meeting with Monon Community Center director of adaptive programming 2/15/23 Email Carmel businesses based on interests. 7 Implementation 1. Resource Binder Development 2. Community Relationship Development 3. Events and Club Development 4. Advocacy and Communication skills Advanced Clinical Skills at Easter Seals Plan Peer Panel Go to Easter Seals to examine their lending library and take a tour. 2/20/23 Convert Excel resource binder into user-friendly, 2/24/23 creative, and engaging Canva pages. I worked virtually most of this week and focused on creating the Canva pages due to testing positive for Covid. Email Carmel businesses based on interests 8 Implementation 1. Resource Binder Development 2. Community Relationship Educate local businesses on the North End project. I discussed with Colleen that the peer panel would occur once everyone is moved in this fall. Convert Excel resource 3/3/23 binder into user-friendly, creative, and engaging Canva pages. FACILITATING MEANINGFUL INDEPENDENT LIVING Development 3. Events and Club Development 4. Advocacy and Communication skills 9 10 Implementation Implementation Ask about partnership and volunteering. Plan at least one event Advocate for Old Town Employees through virtual meetings. 1. Resource Binder Development 2. Community Relationship Development 3. Events and Club Development 4. Advocacy and Communication Skills Educate local businesses on the North End project. 1. Resource Binder Development 2. Community Relationship Educate local businesses on the North End project. Ask about partnership and volunteering. Plan at least one event Advocate for Old Town Employees through virtual meetings. 27 Meeting with Hamilton County Express. - Committed to fixed route at North End - Informed about their job program. 3/1/23 Email Carmel businesses based on interests Convert Excel resource 3/10/23 binder into user-friendly, creative, and engaging Canva pages. Email Carmel businesses based on interests. Meeting with Northview Christian Church - Gained information about Prom - Summer camp - Fruit picking - Willing to let us use their land. 3/8/23 Convert Excel resource 3/17/23 binder into user-friendly, creative, and engaging Canva pages. FACILITATING MEANINGFUL INDEPENDENT LIVING Development 3. Events and Club Development 4. Advocacy and Communication Skills Ask about partnership and volunteering. Plan at least one event 28 Advocacy lunch with North End property manager and community liaison for Old Town 3/13/23 Advocate Old Town and Lincoln Employees Attend Virtual Meetings with Old Town, Lincoln, and 3/12/23 Merchants Affordable Housing. Attend VOM administrative meetings. 3/16/23 Email Carmel businesses based on interests. Meet with potential residents families. 11 Implementation 1. Resource Binder Development 2. Events and Club Development 3. Advocacy and Communication Skills Plan at least one event Communication with parents and caregivers of future residents. Advocate Old Town and Lincoln Employees. Facilitate St. Patricks Day craft Convert Excel resource 3/24/23 binder into user-friendly, creative, and engaging Canva pages. Present two slides and check people into the North End informational meeting of 200 people. Attend VOM administrative 3/20/23 FACILITATING MEANINGFUL INDEPENDENT LIVING meeting 12 Implementation 1. Resource Binder Development 2. Events and Club Development 3. Advocacy and Communication Skills Plan at least one event Run booth at the job fair. Advocate Old Town and Lincoln Employees. Travel to Purdue to see how to utilize the security system 3/24/23 North End will use to train residents better. Convert Excel resource 3/31/23 binder into user-friendly, creative, and engaging Canva pages. I am attending and assisting with the lottery for North End residents. 3/25/23 Attend a job fair at IUPUI to advocate and communicate to individuals about VOM. 3/27/23 Attend VOM administrative meetings. 13 Implementation Discontinuation 1. Resource Binder Development 2. Advocacy and Communication Skills 3/23/23 Satisfaction Survey Meeting with future residents families. Combine all resources into one downloadable PDF file. Post-Survey Print all binder resources. Send out Satisfaction and Post Survey. Attend VOM administrative 3/30/23 4/7/23 29 FACILITATING MEANINGFUL INDEPENDENT LIVING 30 meetings. 14 Dissemination 1. Stakeholder Presentation 2. Scholarly Paper 3. Analyze Remaining Data Disseminate Project Abstract, Summary, and Conclusion Draft Analyze satisfaction survey and post-survey Facilitate Easter Craft Finish PowerPoint for dissemination. 4/13/23 Complete and turn in the draft. 4/10/23 Create tables for the Appendix in the scholarly paper. 4/12/23 Attend VOM administrative meeting Doctoral Capstone Experience and Project Weekly Planning Guide  ...

... 1 Client-Centered Resources to Support the Intergenerational Relationship Between Grandparents and Individuals with Down Syndrome Irelend Grace Greenwell May 01, 2023 A capstone project submitted in partial fulfillment for the requirements of the Doctor of Occupational Therapy degree from the University of Indianapolis, School of Occupational Therapy. Under the direction of the faculty capstone advisor: Taylor Gurley, MS, OTD, OTR RESOURCES TO SUPPORT INTERGENERATIONAL RELATIONSHIPS 2 Abstract Grandparents are widely underrepresented throughout existing literature and underserved in access to resources tailored to their specific needs (Snchez Gmez et al., 2021). This project aims to develop, implement and evaluate materials for grandparents of individuals with Down syndrome, including an informational resource guide and a support group. This project consisted of two phases. Phase I included semi-structured grandparent interviews that underwent thematic analysis to establish priorities/themes. Phase II focuses on creating, implementing, and evaluating the informational resource guide and the grandparent support group. Four main themes resulted from Phase I: support, information, the grandparent's role, and thoughts/feelings. The pre-post surveys administered in Phase II revealed significant changes indicating that the implementation of both interventions was successful. The continued implementation of both interventions has been recommended to DSI to increase grandparent access to information, support, and community. Keywords: grandparents, informational resource guide, support group, interviews, community resources RESOURCES TO SUPPORT INTERGENERATIONAL RELATIONSHIPS 3 Client-centered Resources to Support the Intergenerational Relationship Between Grandparents and Individuals with Down Syndrome Down Syndrome Indiana (DSI) is a state-wide, non-profit organization dedicated to being a one-stop shop for resources and information on Down syndrome (Down Syndrome Indiana, 2022). DSI offers resources and support to families, caregivers, employers, and professionals who play a role in the life of individuals with Down syndrome (Down Syndrome Indiana, 2022). The overall mission of DSI is to advise, educate, encourage, connect, include, and advocate to enhance the lives of individuals with Down syndrome and their families (Down Syndrome Indiana, 2022). Currently, there are no DSI support groups or resources tailored to the unique needs of grandparents. However, DSI has explained that numerous grandparents who would benefit from resources are involved with the organization. This doctoral capstone project intends to develop and evaluate a support group and an easily accessible collection of resources. Through the needs assessment, the researcher established that many grandparents are serving as caregivers and family support for individuals with Down syndrome who would benefit from creating and disseminating resources and programs targeted to meet the unique needs of this population. The goal is to fill the gap in programs and materials tailored to grandparents through painstaking investigation efforts, including grandparent interviews, outcome measurement tools, stakeholder meetings, and extensive research to ensure the materials are evidence-based and client-centered. Existing literature supports that grandparents can benefit individuals with disabilities (Meyer & Abdul-Malak, 2020; Snchez Gmez et al., 2021). However, researchers report that grandparents are underrepresented in research and underserved in access to resources/programs to support their unique needs (Meyer & Abdul-Malak, 2020; Snchez Gmez et al., 2021). This RESOURCES TO SUPPORT INTERGENERATIONAL RELATIONSHIPS 4 project will contain the creation, implementation, and evaluation phases. All phases will be conducted within the 14-week timeline (See appendix A). This project has theoretical guidance from Family Systems Theory and the PEO model. Thematic analysis of interview responses and existing evidence will inform the creation of resources. The researcher will measure the success of the grandparent support group, perceived helpfulness, and accessibility of resources through a pre-post survey. All results and created materials will remain with DSI to ensure continued use of resources and support groups for grandparents of individuals with Down syndrome once the doctoral capstone project is complete. Background Down Syndrome (DS) is often a trisomy of chromosome 21 originating from inaccuracies in cell division during neonatal development (Coppede, 2016). It is a common neurodevelopmental disorder with a prevalence of about 1:700-1:1000 live births (Coppede, 2016). Throughout their lifespan, individuals with DS may experience challenges such as comorbid health conditions, societal stigmas, and decreased community accessibility (Gdsf, 2023). However, with increased advocacy for access to education, healthcare, employment, and family support, individuals with DS are better equipped to combat these challenges to achieve stable, happy, and successful lives (Gdsf, 2023). It is well-reported throughout the existing literature that support from a grandparent, in addition to the nuclear family, can be beneficial for individuals with disabilities (Brown, 2015; George, 1998; Snchez Gmez et al., 2021). A grandparent does not often have primary responsibility for the grandchild and receives the unique opportunity to be more relaxed and objective in their relationship, creating an intergenerational bond that is often mutually beneficial in assisting both the grandchild and grandparent in developing life skills, self-esteem, and RESOURCES TO SUPPORT INTERGENERATIONAL RELATIONSHIPS 5 confidence (Fast facts on grandparenting & intergenerational mentoring, n.d; George, 1998 Meyer &Abdul-Malak, 2020). However, a grandparent's relationship with their grandchild and adult child can be complex due to the duality of their role (Brown, 2015). Grandparents play the unique, dual role of being involved in their grandchild's life while also being able to provide support for their adult child (Jalongo & Crawford, 2022). In the current research, a healthy family function is related to higher levels of sponsorship available (Povee et al., 2012). Many factors play a role in family functioning, such as family coping strategies, child-related factors, parent support, sibling support, extended family support [grandparents], social isolation, etc. (Hart & Neil, 2020; Povee et al., 2012). Further, how grandparents communicate their feelings, opinions, and wisdom can determine family function and adjustment (Brown, 2015). The duality of grandparent support is directly correlated with increased family resilience and healthy family functioning (Caples et al., 2018; George, 1998). Initially, grandparents report feeling a combination of confusion, anger, shock, grief, sadness, embarrassment, doubt, and frustration when learning of their grandchild's diagnosis (Schilmoeller & Baranowski, 1998). Additionally, these feelings of grief or worry double as the grandparent(s) foresight of the well-being of their adult child and grandchild (Jalongo & Crawford, 2022). Snchez Gmez et al. (2021) explain the reconstruction of initial feelings into a new grandparental identity includes adjusted expectations resulting from access to informational resources. Many grandparents yearn for information about their grandchild's condition but are wary of being an additional source of worry for their adult child (Brown, 2015). It is imperative that both grandparents and parents need support and information; however, it is essential to understand that the concerns of the grandparent are very different from those of a parent (Snchez Gmez et al., 2021; Hillman et al., 2017). RESOURCES TO SUPPORT INTERGENERATIONAL RELATIONSHIPS 6 Extended family members play a central role in supporting families of individuals with disabilities; however, grandparents are underrepresented in research and underserved in access to resources/programs to support their unique needs (Cuskelly et al., 2008; George, 1998; Meyer & Abdul-Malak, 2020; Snchez Gmez et al., 2021). Grandparents were found to receive little to no social support and often learn information about their grandchild's diagnosis by hearing it secondhand from their adult child (Snchez Gmez et al., 2021). The needs assessment established that there are currently no DSI support groups or resources tailored to the unique needs of grandparents. It is validated through literature that implementing support groups and increased access to informational resources will assist grandparents in demonstrating resilience and strengthen the intergenerational bond with their grandchild. (Hillman et al., 2017; Sanchez Gomez, 2021). DSI has developed numerous resources to educate and inform various individuals about the diverse needs and unique aspects of DS, such as support groups, resources, counseling, etc. DSI provides extensive new and current parent resources, which are easily accessible from their website and are commonly advertised throughout their social media (Down Syndrome Indiana, 2022). This information is tailored to the lived experiences of individuals with DS or their parents and rarely acknowledges the grandparent role. Responsibility often falls on the parent to share technical and valuable information about their child's diagnosis with interested extended family, traditionally the grandparents. The methodology of this doctoral capstone project will utilize interviews with grandparents to obtain information about their lived experience to develop client-informed and evidence-based programs and resources tailored to the unique needs of grandparents of individuals with DS. Clark et al. (2020) conducted a similar study on family sense-making following receiving a DS diagnosis that utilized unstructured, audio-recorded RESOURCES TO SUPPORT INTERGENERATIONAL RELATIONSHIPS 7 interviews that were subsequently transcribed, verified, and anonymized. Studies such as Clark et al. (2020) and Hillman et al. (2017) both recommend that professionals increase acknowledgment of the grandparent role and encourage the creation of informational resources and support groups. The goal of this DCE project is unique in that it aims to create, implement, and validate comprehensive resources informed by grandparent interviews and support groups that directly acknowledge the population's needs. Theoretical Guide Theoretical frames provide a better understanding of underlying causes and phenomena to guide clinical reasoning during program development or evaluation (Reeves et al., 2008). Cuskelly et al. (2008) introduced the importance of understanding Family Systems Theory when working with families of individuals with DS. The premise of this theory defines family as an emotional and relational system in which members can be influenced by or influence each other on many levels, including an intergenerational level (Erdem & Safi, 2018). Many events can affect the family system, such as the birth of a child with DS, that may influence microscopic and macroscopic familial interactions (Cuskelly et al., 2008). These various familial interactions can make a lasting impact on both the individual with DS and their families. It will be critical throughout the development, dissemination, and evaluation of resources to acknowledge the complexity and uniqueness of the family system. Theoretical backing is essential as a guide for best practice. The Person-Environment-Occupation (PEO) model contains the premise there are constant changes throughout the lifespan. PEO focuses on how well an individual's personal, environmental, and occupational factors overlap, intending to achieve a "best-fit" which correlates to an individual's occupational performance (Cole & Tufano, 2020). Creating and implementing programs and RESOURCES TO SUPPORT INTERGENERATIONAL RELATIONSHIPS 8 resources for grandparents will serve as a unique way to achieve the "best fit." Using peer support and consolidated information as extrinsic motivators will aim to amplify the grandparent's intrinsic motivation. For example, prior disconnect and anxiety may have resulted from environmental factors such as lack of support and access to information. If the ecological risk is reduced or taken away through the promotion of program participation, it, in turn, promotes occupational performance, and grandparents would achieve a balance in PEO factors. This balance reached will enhance occupational performance and participation. This DCE project aims to identify factors contributing to imbalance and introduce skills that help maintain the balance of PEO elements to enhance participants' experience in the grandparent role. Project Design This project aims to develop, implement and evaluate materials for grandparents of individuals with DS, including informational resources and a support group. This project will contain two phases that build on each other. Phase I being the interview phase, and phase II is the resource phase. To create comprehensive materials centered around the unique needs of grandparents, phase I will include brief, semi-structured interviews that the researcher will transcribe, code, and analyze for the identification of themes/priorities. In phase II, the articles from phase I will be combined with themes derived from the literature review to inform and structure resource development. Phase II will include two resource interventions: the informational resource guide and the grandparent support group. Participants from both interventions will complete a pre and post-study conducted via Google Forms. The researcher will measure the intervention's success by analyzing means derived from the pre-and post-Likert RESOURCES TO SUPPORT INTERGENERATIONAL RELATIONSHIPS 9 scale survey. The researcher will share the results with DSI staff and stakeholders. Recommendations will be made for the continuation or discontinuation of intervention methods. The researcher created a recruitment survey via google forms and sent it to obtain demographic and availability information from the participants for phases I and II (AOTA, 2020). A diverse sample was obtained and utilized for both phases. All participants identified having only one grandchild with DS; they are not the primary caregiver. Upon completion of the recruitment form for phase I, participants were emailed and notified of interview times and completed an interview consent/information release form electronically. This agreement stated that the interviews would be recorded and transcribed for thematic analysis. The recording will be stored securely and discarded appropriately upon project completion. Recruitment for phase II was conducted via email sent by the site mentor. Two participant pools were obtained, one for the informational resource guide and another for the grandparent support group. There was some crossover of participants for phase I: interviews and phase II: resources. Implementation Phase I: Grandparent Interviews Nine grandparents participated in interviews. Interviews were recorded by the researcher using Zoom video call or telephone audio call. Interviews lasted, on average, 30-45 minutes, and the interviewer utilized a guide of questions\ to ensure conversation flow. The investigator transcribed the interviews. Dedoose, a free platform for interview analysis, was used for the transcription, coding, and thematic analysis of grandparent interviews. The resultant themes were categorized and organized by prevalence. Phase II: Informational Resource Guide RESOURCES TO SUPPORT INTERGENERATIONAL RELATIONSHIPS 10 Seven grandparents completed the pre-survey for participation in the creation of the informational resource guide. The researcher acknowledged the identified themes/priorities from phase I, literature review evidence, and pre-survey information for creating the informative resource guide. All information was utilized to ensure the focus would be client-centered and evidence-based. The guide was designed to use the free platform Canva and was adapted to be accessible via the DSI website. Phase II: Grandparent Support Group Six grandparents participated in the pilot grandparent support group, and all completed the pre-survey. The information presented at the support group reflected the informational resource guide and themes/priorities identified in Phase I. Grandparents were invited to bring their grandchildren to encourage bonding. All participants participated in crafting activities and group discussions. Grandparents received printed materials. Following the support group, participants completed the post-survey to measure success. Outcomes Phase I: Grandparent Interviews Phase I used a descriptive qualitative design with semi-structured interviews and subsequent thematic analysis with eleven grandparents of various ages, races, sex, and years of experience as a grandparent. The doctoral capstone student transcribed interviews. The student used a web-based data analysis platform, Dedoose, to organize, code, and analyze the interview content. The main themes identified illustrate the perspective of a grandparent with a grandchild who has a DS diagnosis. Four main themes from the interviews were support, information, the grandparent's role, and thoughts/feelings. Table 1 identified key themes and subthemes resulting from the interviews. Themes and subthemes are organized from common to least common RESOURCES TO SUPPORT INTERGENERATIONAL RELATIONSHIPS 11 throughout the interview. These themes are best understood as priorities that support or hinder balance in occupational performance and participation in the grandparent role. Phase II: Participants completed a pre and post-survey for the grandparent support group (n=5) and informational resource guide (n=7). The doctoral capstone student created all pre-post surveys. Surveys were designed to address growth in areas necessary in the thematic analysis of phase I. Table 2 and Table 2 illustrate the change from pre-test to post-test following the implementation of the Grandparent Support Group and the Informational Resource Guide. Informational Resource Guide Following the creation of the informational resource guide, the participants in this portion of the project received the guide via email for review. The researcher instructed the participants to review the informative resource guide and complete the corresponding post-survey. Participant ratings were significantly higher in all categories assessed. The highest increase is preparedness at a 62% increase, and access to resources at a 60% increase (Table 2). The informational resource guide successfully achieved its goal and should be implemented further to ensure the unique needs of grandparents are supported. The implementation of this intervention shows the potential to strengthen the overall balance in PEO factors, increasing overall occupational performance and participation in the grandparent role. Grandparent Support Group Pre and post-survey data were compared following the implementation of the pilot grandparent support group. The results indicated significant change following participation (Table 3). The performance of the grandparent support group led to a substantial increase in all four areas assessed (Table 3). The highest percentage of changes was in preparedness, RESOURCES TO SUPPORT INTERGENERATIONAL RELATIONSHIPS 12 demonstrating that the implementation of a support group assisted grandparents in feeling more prepared to fulfill their role. The grandparent support group successfully achieved its goal, and effort should be made to continually offer this group to ensure grandparents have supported members of the DSI community. Summary Through the literature review, the investigators found that grandparents are often underrepresented throughout and underserved in access to resources tailored to their specific needs (Meyer & Abdul-Malak; Snchez Gmez et al., 2021). A needs assessment was conducted by the researcher and site mentor with DSI, where it was established that a large population of grandparents of individuals with DS would benefit from support and resources. DSI offers numerous programs and resources to caregivers, families, and individuals with DS; however, they do not offer anything dedicated to the needs of grandparents of individuals with DS. This DCE aims to develop, implement and evaluate informational resources and a support group for grandparents of individuals with DS. This methodology of the project consisted of two phases. Phase I utilized semi-structured interviews with eleven grandparents. Those interviews were transcribed, coded, and analyzed to uncover priorities/themes. Phase II focused on creating, implementing, and evaluating the informational resource guide and the grandparent support group. Seven grandparents participated in the informative resource guide the doctoral capstone student created, utilizing the established themes and information from the literature review. Six individuals completed the in-person support group where grandparents could find community and bond with their grandchild. Phase I and II were both successful. Following the thematic analysis of the interviews, four main themes resulted, including support, information, the grandparent's role, and RESOURCES TO SUPPORT INTERGENERATIONAL RELATIONSHIPS 13 thoughts/feelings. Pre-post surveys administered in Phase II revealed significant changes indicating that the implementation of both interventions was successful. The continued implementation of both interventions has been recommended to DSI as a successful method to increase Grandparent's access to information, support, and community. Conclusion The aim of this DCE is to develop, implement and evaluate informational resources and a support group for grandparents of individuals with DS. This doctoral capstone project met and accomplished its intended goals. The created materials included a comprehensive informational resource guide and support group for grandparents. These materials will allow DSI to recognize and support the unique needs of grandparents. DSI acknowledged the benefit this DCE brought to the site and participated in a collaborative conversation to ensure the longevity of carryover following DCE discontinuation. This project is not without limitations. Although the researcher made an effort, this DCE contains a relatively small sample size, limited minority perspectives, and time constraints that impeded the ability to hold multiple support groups. The researcher recognizes that grandparents of individuals with disabilities are underrepresented in research efforts. Future work should focus on researching and further understanding the intergenerational relationship between grandparents and grandchildren. RESOURCES TO SUPPORT INTERGENERATIONAL RELATIONSHIPS 14 Resources Brown, E. (2015). Everyone has a story to tell: The experiences of grandparents with a grandchild diagnosed with a genetic life-limiting condition. International Journal of Birth & Parent Education, 2(3), 1618. Caples, M., Martin, A.-M., Dalton, C., Marsh, L., Savage, E., Knafl, G., & Van Riper, M. (2018). Adaptation and resilience in families of individuals with Down Syndrome living in Ireland. British Journal of Learning Disabilities, 46(3), 146154. https://doi.org/10.1111/bld.12231 Clark, L., Canary, H. E., McDougle, K., Perkins, R., Tadesse, R., & Holton, A. E. (2020). Family sense-making after a down syndrome diagnosis. Qualitative Health Research, 30(12), 17831797. https://doi.org/10.1177/1049732320935836 Cole, M. & Tufano, R. (2020). Applied theories in occupational therapy: A practical approach. Thorofare, N.J.: SLACK Inc. Copped, F. (2016). Risk factors for down syndrome. Archives of Toxicology, 90(12), 29172929. https://doi.org/10.1007/s00204-016-1843-3 Cuskelly , M., Hauser-Cram, P., & Van Riper, M. (2008, July). Families of children with Down syndrome:What we know and what we need to know. Down Syndrome Research and Practice. Dsindiana. (2022, March 1). Down syndrome Indiana. Down Syndrome Indiana. Retrieved December 28, 2022, from https://dsindiana.org/ Erdem, G., & Safi, O. A. (2018). The cultural lens approach to Bowen family systems theory: Contributions of Family Change Theory. Journal of Family Theory & Review, 10(2), 469483. https://doi.org/10.1111/jftr.12258 RESOURCES TO SUPPORT INTERGENERATIONAL RELATIONSHIPS 15 Fast facts on grandparenting & intergenerational mentoring. Grandparenting Facts www.somethingtoremembermeby.org. (n.d.). Retrieved January 17, 2023, from https://www.legacyproject.org/specialreports/fastfacts.html#:~:text=About%201% 2F3%20of%20the,become%20great%2Dgreat%2Dgrandparents. Gdsf. (2023, January 9). FAQ and facts about down syndrome. Global Down Syndrome Foundation. Retrieved January 17, 2023, from https://www.globaldownsyndrome.org/about-down-syndrome/facts-about-down-s yndrome/ George, J. D. (1998). Therapeutic intervention for grandparents and extended family of children with developmental delays. American Association on Mental Retardation , 26(6), 369375. Hart, K. M., & Neil, N. (2020). Down syndrome caregivers' support needs: A mixedmethod participatory approach. Journal of Intellectual Disability Research, 65(1), 6076. https://doi.org/10.1111/jir.12791 Hillman, J. L., Wentzel, M. C., & Anderson, C. M. (2017). Grandparents experience of autism spectrum disorder: Identifying primary themes and needs. Journal of Autism and Developmental Disorders, 47(10), 29572968. https://doi.org/10.1007/s10803-017-3211-4 Jalongo, M. R., & Crawford, P. A. (2022). Intergenerational bonds: The contributions of older adults to young children's lives. Springer. Meyer, H. M., & Abdul-Malak, Y. (2020). Grandparenting children with disabilities. Palgrave Macmillan. RESOURCES TO SUPPORT INTERGENERATIONAL RELATIONSHIPS 16 Occupational therapy practice framework: Domain and processFourth edition. (2020). The American Journal of Occupational Therapy, 74(Supplement_2). https://doi.org/10.5014/ajot.2020.74s2001 Povee, K., Roberts, L., Bourke, J., & Leonard, H. (2012). Family functioning in families with a child with Down Syndrome: A mixed methods approach. Journal of Intellectual Disability Research, 56(10), 961973. https://doi.org/10.1111/j.1365-2788.2012.01561.x Reeves, S., Albert, M., Kuper, A., & Hodges, B. D. (2008). Why use theories in qualitative research? BMJ, 337. https://doi.org/10.1136/bmj.a949 Snchez Gmez, M. C., Martn-Sevillano, R., Martn-Cilleros, M. V., Marcos, J. J., & Garca-Pealvo, F. J. (2021). Nurturing grandchildren with Down Syndrome: A qualitative study on grandparents needs using digital tools. Frontiers in Psychology, 12. https://doi.org/10.3389/fpsyg.2021.661205 Schilmoeller, G. L., & Baranowski, M. D. (1998). Intergenerational support in families with disabilities: Grandparents' perspectives. Families in Society: The Journal of Contemporary Social Services, 79(5), 465476. https://doi.org/10.1606/1044-3894.7 17 RESOURCES TO SUPPORT INTERGENERATIONAL RELATIONSHIPS Table 1 Themes and Subthemes From Thematic Analysis Themes Subthemes Theme 1. Support (132) a. b. c. d. e. Giving Support (48) Support System (36) Receiving Support (21) Talking to Someone with Similar Experiences (18) Down Syndrome Indiana (9) Theme 2. Information (116) a. Gaining Information/Learning (36) b. Preparedness (28) i. ability to be prepared (12) ii. inability to be prepared (16) c. Access to Resources (22) d. Ability to Access Information (19) e. Additional Topics to Learn About (11) Theme 3. Grandparent Role (80) a. Understanding Role (36) b. Duality of Role (24) c. Advocacy (20) Theme 4. Thoughts/Feelings (68) a. b. c. d. e. Positive Thoughts/Feelings (23) Worries/Fears (16) Negative Thoughts/Feelings (12) Confidence in Knowledge (11) Hiding Emotions from Child/Grandchild (6) Table 2 Informational Resource Guide Outcome Measures: Informational Resources Mean Pre-Test Score N Mean Post-Test Score N Total Change (%) Access to Resources 1.7 (34%) 7 4.7 (94%) 6 + 3.0 (60%) Preparedness 1.4 (28%) 7 4.5 (90%) 6 + 3.1 (62%) 18 RESOURCES TO SUPPORT INTERGENERATIONAL RELATIONSHIPS Access to Support 2.4 (48%) 7 4.8 (96%) 6 + 2.4 (48%) Access to Information on the Grandparent Role 2.6 (52%) 7 4.3 (86%) 6 + 1.7 (34%) Confidence in Knowledge 2.2 (44%) 7 4.5 (90%) 6 + 2.3 (46%) Table 3 Grandparent Support Group Outcome Measures: Support Group Mean Pre-Test Score Mean Post-Test Score Total Change (%) N Access to Resources 3.0 (60%) 4.8 (96%) + 1.8 (36%) 5 Preparedness 1.8 (36%) 4.8 (96%) + 3.0 (60%) 5 Sense of Community 2.0 (40%) 4.6 (92%) + 2.6 (52%) 5 Connectedness (with child, grandchild, & other grandparents) 2.4 (48%) 4.6 (92%) + 2.2 (44%) 5 19 RESOURCES TO SUPPORT INTERGENERATIONAL RELATIONSHIPS Appendix A Week 1 2 DCE Stage Weekly Goal (orientation, screening/evalu ation, implementation , discontinuation, dissemination) Literature -Finish literature Review review (Off-site) -Create timeline for DCE Evaluation/Scr -Meet with eening Stephanie (Orientation) (Orientation to remote site) and informal needs assessment Objectives -Locate new articles -Create new literature review -Research the site stakeholders -Address any changes (if any) to MOU -finalize formal plan for project Tasks Date complete Set up meeting with Stephanie for next week 01/13/23 Check on IRB Finish literature Review - Finalize MOU -Meet with Stephanie to go over initial questions and clarifications -Create schedule and obtain stakeholder contact to set up interview about advocacy efforts -Obtain schedule on various programs that DSI hosts -Set date for implementation of grandparent interviews -Work on introduction of paper 01/20/23 20 RESOURCES TO SUPPORT INTERGENERATIONAL RELATIONSHIPS 3 Screening/Eval Develop recruitment uation survey for interview participation Begin contacting participants to set up interview time -Review interview recruitment email/form with site mentor - Begin learning about DSIs social media and advocacy effort -Establish/review pre-post method to measure success of the resources and program -Contact and begin to schedule interviews with grandparents 01/27/23 -Confirm outreach programs I will be attending with site mentor -Begin working on Background for the paper 4 Implementatio n Research Literature for Grandparent resources Research similar programs offered in US and by DSI -Contact participates and finalize interview times and meeting formats -Brainstorm and research possible areas of interest for grandparent resources (use interview to fill the gap) Finalize interview script, format, and method. Gather research articles to fill gap -Meet with various and inform stakeholder to resources learn more about DSI Begin developing outline for support group Obtain new parent packet and read it thoroughly to inform process for creating grandparent materials 02/03/23 21 RESOURCES TO SUPPORT INTERGENERATIONAL RELATIONSHIPS 5 Implementatio n Hold interviews and transcribe responses -Begin to create outline for grandparent resources and plan for support group Begin researching 02/10/23 topic areas introduced through interviews Begin researching how to do coding/analyzing for interviews Meet with site mentor to begin understanding website formatting 6 Implementatio n Continue interviews Build clinical and transcription and skills in advocacy begin developing and education grandparent resources plan learn about coding interviews 02/17/23 Attend at least one advocacy outreach program by this date Send formal pre-survey for informational resource guide and support group 7 Implementatio n continue interviews and begin grandparent resources Build clinical skills in advocacy and education Develop overall idea for research and create organizational guide (reviews with Stephanie) Begin to evelop grandparent resources in accordance with organization guide Find a website to complete thematic analysis on 02/2423 22 RESOURCES TO SUPPORT INTERGENERATIONAL RELATIONSHIPS Research best ways to create social media post for outreach to older generations 8 Implementatio n Create grandparent resources and develop plan for support group Build clinical skills in advocacy and education Create outline and solidify timeline for events during grandparent support group Develop grandparent resources in accordance with organization guide and research 03/03/23 Develop plan for grandparent support group Work on plan for adapting resources to DSI website 9 Implementatio n Create grandparent resources and develop plan for support group Build clinical skills in advocacy and education Finish all interview transcription Develop grandparent resources in accordance with organization guide research 03/10/23 Finalize creation of grandparent resources 10 Implementatio n Provide resources to grandparents at pilot support group with success determined through pre-post survey Build clinical skills in advocacy and education Email post survey for informational resource guide Begin to prepare 03/17/23 how to analyze pre and post survey results to determine program success Begin editing all resources 23 RESOURCES TO SUPPORT INTERGENERATIONAL RELATIONSHIPS 11 12 Implementatio n Discontinuatio n Make adaptations to resources as indicated by post-survey (if any) Build clinical skills in advocacy and education Draw conclusions from results Begin to develop any tables, graphs, or appendixes Establish the benefit of resources and program 13 14 Discontinuatio n Dissemination (Final Week) Complete analysis of data collection and beginning of conclusion/discussio n Disseminate project to site Thoroughly analyze information obtained through data collection -Reach out to site mentor and schedule a time to present Go over initial resources with site mentor Final edit of all resources Send finalized resources to all program participation -Complete adaptation of resources to a format compatible with DSIs online presence 03/31/23 -Finalize a detailed outline for the continuation of a grandparents program -Finalize any 04/07/23 social media or advocacy projects -Begin developing conclusions from results -Begin consolidating findings into a presentation format Present findings to site mentor -Begin writing the conclusion section -Schedule time to present findings (preferably in person) Present finding to all relevant stakeholders 03/24/23 -Formally discuss project result with site mentor to determine future recommendation for instating 04/13/23 24 RESOURCES TO SUPPORT INTERGENERATIONAL RELATIONSHIPS program and disseminating materials/resource s  ...

... BUILDING THE FOUNDATION FOR PAWS-ITIVE CONNECTIONS Paws-itive Connections at PACE Building the Foundation for an Animal-Assisted Intervention Program Sarah Frisbie May 2023 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. Jenna Trost, OTD, OTR 1 BUILDING THE FOUNDATION FOR PAWS-ITIVE CONNECTIONS 2 Abstract As a member of the Program of All-Inclusive Care for the Elderly (PACE), Franciscan Senior Health and Wellness (FSHW) offers interdisciplinary services to help older adults remain in the community. Animal-assisted intervention (AAI) refers to activities that purposefully include animals to improve therapeutic outcomes. AAI can target many of the needs and goals of FSHW participants; however, despite interest from both staff and participants, barriers such as a lack of time and limited knowledge prevented the center from starting an AAI program. To address these barriers, Paws-itive Connections included education for staff, updated policy and procedure, and key administrative materials. Following the education, staff reported an increase in knowledge and confidence, and over half of staff reported no further barriers. The creation of Paws-itive Connections provided a solid foundation for an AAI program at FSHW and demonstrated how OTs can play the role of consultant during program development. BUILDING THE FOUNDATION FOR PAWS-ITIVE CONNECTIONS 3 Paws-itive Connections at PACE The Program of All-Inclusive Care for the Elderly (PACE) is a national program that offers interdisciplinary and comprehensive healthcare services to ensure older adults can remain living in the community. To enroll, participants must be over 55 years of age, live within the service area of a PACE location, be eligible for nursing home care, and be able to safely live in the community with PACE support (Franciscan Health, n.d.; National PACE Association [NPA], 2022). Once a participant is accepted, all healthcare services are provided through the program and covered by Medicaid and Medicare benefits (NPA, 2022). Franciscan Health refers to their PACE services as Franciscan Senior Health & Wellness (FSHW). Animal-assisted intervention (AAI) is an umbrella term that refers to structured and goal-oriented activities that directly or indirectly incorporate an animal for the purpose of therapeutic gain (International Association of Human-Animal Interaction Organizations [IAHAIO], 2018). Within AAI, there are various categories based on the level of formality, the level of contact with the animal, and the intended outcomes. Animal-assisted therapy (AAT) refers to formal, therapeutic activities that include an animal to improve physical, cognitive, or socioemotional function, while animal-assisted activity (AAA) refers to informal, recreational activities that focus on socialization, motivation, or education. When animals are included indirectly, it is animal-related engagement (ARE), which offers the benefits of AAI by invoking the feelings experienced when interacting with animals (Chastain, Fine, & Stewart, 2020). Animal-assisted programs can be time-consuming and complicated to develop, and the emerging nature of the field means it can be difficult to easily locate reputable sources on the benefits of AAI and evidence-based interventions. The purpose of Paws-itive Connections was to BUILDING THE FOUNDATION FOR PAWS-ITIVE CONNECTIONS 4 build the foundation for a program that can easily be implemented and sustained by educating staff, updating guidelines, and providing resources. Background Populations Staff The staff of FSHW are professionals and paraprofessionals representing a variety of disciplines (see Appendix A for more details). A survey distributed to all staff members revealed that most staff have limited experience with animal-assisted interventions but high interest in involvement (see Appendix B for full survey questions). Participants Individuals who receive services through FSHW are referred to as participants. The participants at the Indianapolis location of FSHW are primarily 60 years of age or older. They present with a variety of conditions including amputations, strokes, dementias, diabetes, and heart disease. According to the National PACE Association, the average PACE participant is an 80-year-old woman with eight medical conditions and limitations in three activities of daily living (n.d., para. 2). Needs Assessment The Indianapolis location of FSHW previously had a facility dog owned by a staff member. Despite staff and participant interest, they were unable to continue the program once the staff member and dog left. Informal discussion with staff and participants about the idea of animal-assisted services revealed an overwhelmingly positive response. The formal survey sent to all staff confirmed that most staff members (73%; n = 22) were interested in AAI and revealed that staff had varied prior experience with AAI. Staff were asked to report any barriers that had BUILDING THE FOUNDATION FOR PAWS-ITIVE CONNECTIONS 5 prevented them from engaging in AAI. One staff member noted the lack of consistent attention to setting up a program at PACE, and a common theme among responses was confusion around terminology and the actual role of the therapy animal (see Table C1).This need for more information reflects findings from other researchers that healthcare professionals want and need more education and training in the field of AAI (Dunlap et al., 2021; VanderBloomen, 2022). Staff reported high interest in education on using AAI in a variety of disciplines, understanding terminology, and reading dog body language; however, all six topics presented as options were selected consistently, reflecting one staff members comment that any and all information would be GREATLY appreciated [emphasis in original]. A review of the literature found little research on staff education on AAT; however, authors noted the need for clear and detailed policies that protect the health and welfare of participants, healthcare providers, visitors, and therapy animals during animal-assisted services (Murthy et al., 2015; Santaniello et al., 2021). Forget et al. (2021) found that clear explanations and education led to better adhesion among staff, and resources created for interested facilities recommended providing education and training for staff before starting AAI (Pet Partners, 2022; Human Animal Bond Research Institute [HABRI] & National Council on Aging [NCOA], 2018). Advantages of Animal-Assisted Programming According to one staff member, the biggest need for participants is meaningful interventions that focus on physical, socioemotional, behavioral, and cognitive functioning. The psychological, cognitive, physical, and social benefits of AAI can meet these needs in a unique way. The psychological benefits of AAI include a decrease in depressive symptoms (Borgi et al., 2020) as well as feelings of relaxation and independence (Chang et al., 2021). Speaking to a therapy animal may also improve cognition through mnemonic stimulation (Chang et al., 2021). BUILDING THE FOUNDATION FOR PAWS-ITIVE CONNECTIONS 6 Participating in AAI has the potential to provide the physical benefits of reduced cardiovascular stress, increased physical movement, and improved balance (Chang et al., 2021; Krause-Parello & Kolassa, 2016; Olsen et al., 2016). Research has also shown that AAI can improve social wellness and increase social interactions (Chang et al., 2021; Krause-Parello & Kolassa, 2016). Therefore, offering AAI would allow the FSHW staff to meet participant needs in a unique way. Barriers to Animal-Assisted Programming Despite the growing field of research demonstrating the benefits of AAI and the bond between humans and animals, there are many barriers that make it difficult for interested healthcare workers to begin AAI. There are concerns about hygiene and increased workloads (Forget et al., 2021), and the ambiguous terminology, anecdotal evidence, and minimal guidelines can make it hard to justify services with concrete evidence (Fine et al., 2019; Kazdin, 2019). Winkle and Ni (2019) recommend a 4-step approach for occupational therapists (OTs) interested in AAI, emphasizing the amount of work and research that should occur before services take place. Several national and international organizations have published guidelines, standards, and toolkits to assist providers in protecting the well-being of the animals (IAHAIO, 2018); creating a sustainable animal-assisted program in a facility (Pet Partners, 2022); and respecting the welfare of the animal, handler, provider, and participant (Animal Assisted Interventions International [AAII], 2018). The purpose of Paws-itive Connections was to address these barriers and build the foundation for a sustainable AAI program at FSHW. Guiding Theories Program development was guided by two theories: the Canadian Model of Occupational Performance and Engagement (CMOP-E) and constructivism learning. The CMOP-E is an occupation-based model that considers how the interactions between person, occupation, and BUILDING THE FOUNDATION FOR PAWS-ITIVE CONNECTIONS 7 environment impact occupational performance and engagement (Polatajko et al., 2007). Staff occupational performance in implementing AAI was impacted by person barriers, such as limited knowledge, and environmental barriers, such as vague policy and procedure (see Figure D1). For the participants of FSHW, there were multiple person and environment factors that impacted their performance of their desired occupation, safe and independent aging in place, and AAI offered a new way to target those areas (see Figure D2). The CMOP-E also revealed factors that support engagement for both staff and participants, such as interest in AAI, management support, and a love for animals stemming from the Franciscan Health namesake, Saint Francis. The other model, constructivism learning, is an educational theory that states students learn by constructing meaning (Bada, 2015). Information is processed through ones lived experiences, existing schema, prior learning, and personal beliefs, meaning each student constructs their own meaning for the information (see Figure D3). One key aspect of constructivism is that students must have the necessary foundational knowledge to build upon when learning. Constructivism also emphasizes that learning is an active and collaborative process; students learn best when they are involved in the learning process and encouraged to work together. Following constructivism, the education started with foundational knowledge and built up to application of the information through a case study. Project Design & Implementation Education The needs assessment, literature review, and survey results indicated there was a strong interest in AAI and a need for staff education. Responses to pre-survey question 11, which asked about education topics, revealed a high interest in all six topics with the top choices being Dog behavior (n = 16) and Terminology (n = 15; see Figure C1). Starting with the six possible BUILDING THE FOUNDATION FOR PAWS-ITIVE CONNECTIONS 8 topics, the content was organized through concept mapping to decide how much information would need to be covered. Using constructivist learning theory (Bada, 2015), the education was designed to support independent and group learning, encourage application of the information, and provide a foundation of knowledge. All materials for Paws-itive Connections were created using Canva, a graphic design program. The first part of the education was an 18-page manual with basic information on all six topics. The second part was an education session covering the benefits of AAI, AAI in practice, dog behavior, and the process of becoming a therapy dog handler. The manual was distributed to all staff by email, and the education session was scheduled twice to allow all interested staff to attend. Constructivism recommends hands-on and experiential learning when possible (Bada, 2015), so a prospective therapy dog-handler team was invited to each session to allow staff to witness and experience the socioemotional benefits of interacting with dogs. Policy and Procedure Update The FSHW policy and procedure for AAI were written for the prior facility dog and did not cover all aspects recommended or suggested by relevant professionals (Barker et al., 2019; Murthy et al., 2015; Serpell et al., 2020). The policy and procedure were updated using Franciscan Health templates, and the drafts were presented to the Operational Excellence subgroup to ensure the new policy and procedure were clear and comprehensive without being overly restrictive. Following approval by the Operational Excellence subgroup and the Director of FSHW, the updated documents were passed to other managers, the compliance officer, and the legal team for review. Once all relevant individuals have reviewed the files and made appropriate changes, the documents will be adopted, and the program can begin. BUILDING THE FOUNDATION FOR PAWS-ITIVE CONNECTIONS 9 Other Materials Additional materials were created to support the sustainability of Paws-itive Connections and address barriers reported by staff. A health record form for the therapy dog-handler teams was created to allow management to easily store key information like vaccine records, registration paperwork, and contact information. In collaboration with recreational therapy, an activity pack of dog-themed coloring pages and puzzles was created for ARE as it does not include direct interaction and can be offered to participants while the final steps of the program are executed. Other program materials also included a brochure that explained the program for participants, families, and caregivers; signs to place around the facility to alert visitors to the presence of therapy dogs; and a document outlining key information for starting partnerships with organizations that register therapy dogs. Outcomes After participating in one of the education sessions, staff completed a post-education survey to assess their confidence, knowledge, and likelihood of participating in AAI. (See Appendix E for full post-education survey). In the first section, staff reported their discipline, whether they completed the pre-education survey, which session they attended, and if they reviewed the manual prior to attending. In the next section, staff rated their knowledge and confidence before and after the education using 5-point Likert scales from 1 (Not at all knowledgeable/confident) to 5 (Extremely knowledgeable/confident) based on the Centers for Disease Control and Prevention (CDC) recommendations for effective post-education evaluation (CDC, 2019). There were six items on each knowledge scale and four items on each confidence scale. In the final section, staff reported their likelihood of using AAI, any barriers that remain for them, and their interest in being involved in the AAI program, Paws-itive Connections. BUILDING THE FOUNDATION FOR PAWS-ITIVE CONNECTIONS 10 Due to the small sample size, the data had to be analyzed using a nonparametric statistical test. The results of each Likert scale were summed for each staff member to produce a score of their knowledge and confidence before and after the education (see Table F1). All staff reported an increase on all items (see Figure F1); however, analysis could not confirm if the increase was statistically significant. The post-education scores were ranked and compared using Spearmans rank correlation. The test revealed a moderately positive correlation between knowledge and confidence scores post-education (rs(14) = .67, p = .004), indicating that staff who reported higher knowledge scores tended to also report higher confidence scores. To allow for comparison, the barriers reported on the pre-education survey were coded for themes (see Table C1). Four main themes arose: lack of knowledge (I just don't know enough about it), lack of time (Not enough time to pursue training), concerns about logistics (Figuring outwhere to have a dog in the building and how to get other work done while they are here.), and appropriateness to discipline (My position limits my ability to continue with this passion). Since the pre-survey had more responses than the post-survey (N = 22; N = 16), the change in barriers was analyzed by comparing frequencies. Following the education, over half of the staff reported no barriers (n = 9), with 25% (n = 4) noting time as a barrier. Concerns about knowledge and logistics decreased from approximately 31.8% (n = 7) and 18.2% (n = 2) to 12.5% (n = 4) and 0%, respectively (see Table F2). When asked about their likelihood of using AAI in their services, only two staff reported that it was not appropriate for their services. Of the other 14 staff, 10 staff members (71.4%) reported they are somewhat likely or very likely to use AAI in their services (see Table F3). When asked about being involved in the program, 12 staff members (75%) reported that they plan to be involved in some capacity, and four of those staff members (25% of all respondents) BUILDING THE FOUNDATION FOR PAWS-ITIVE CONNECTIONS 11 reported interest in being involved as a handler (see Table F4). Spearmans rank correlation was used to assess the relationship between total score after education and likelihood of using AAI. Post-education scores were calculated for each respondent, and likelihood responses were converted to numerical values (1 = Very Unlikely to 5 = Very Likely). Staff who chose N/A were excluded from this calculation. There was a moderately positive correlation (rs(12) = .64, p = .014), meaning staff who reported higher scores also tended to report a higher likelihood of using AAI. Summary As a PACE center, FSHW is committed to supporting aging in the community through comprehensive and collaborative care. The purpose of Paws-itive Connections was to build the foundation for a sustainable and effective AAI program at FSHW. AAI can be used to support improved outcomes in many established areas of need for FSHW participants such as balance, socialization, emotional health, and cognitive stimulation (Borgi et al., 2020; Chang et al., 2021; Krause-Parello & Kolassa, 2016; Olsen et al., 2016); however, barriers such as a lack of education and limited time to set up a program prevented the staff from offering AAI. These barriers to engagement were addressed by updating policy and procedure, educating staff on relevant topics, and completing various administrative tasks to develop Paws-itive Connections. Research on AAI and resources for starting programs recommended providing staff education and training during development to support program sustainability (Forget et al., 2021; Pet Partners, 2022; HABRI & NCOA, 2018). The education for Paws-itive Connections followed tenants of constructivist learning theory (Bada, 2015) and promoted independent and group learning. Following the education, staff reported fewer barriers overall, increased knowledge in key topics, and increased confidence in completing key tasks. BUILDING THE FOUNDATION FOR PAWS-ITIVE CONNECTIONS 12 The administrative side of the project involved updating the policy and procedure, creating key documents, and collaborating with management. The new policy and procedure provided well-defined and complete guidelines following recommendations from researchers (Murthy at el., 2015; Santaniello et al., 2021) and respected organizations (AAII, 2018; IAHAIO, 2018; Pet Partners, 2022). In conjunction with the education, these administrative tasks offered a solid foundation for Paws-itive Connections at FSHW by addressing barriers to engagement and providing tools to maintain the program. Conclusions Once the policy and procedure have been adopted, Paws-itive Connections will begin at FSHW. In the meantime, staff will use the brochure to explain the program to participants, families, and caregivers, and the activity pack will be used in the dayroom for ARE. To smoothly transition management of the program, all materials were shared with the proper individuals, and details were shared in writing as well as verbally. This process showed how OTs can play the role of consultant during program development by addressing barriers to engagement through adaptation, modification, and education. Program development requires creative problem solving and a holistic viewpoint, making OT an ideal fit for the role. Developing Paws-itive Connections highlighted some key items that facilities interested in AAI should consider. These include (1) creating clear and comprehensive policy and procedure; (2) educating staff on AAI; (3) developing a system for ensuring teams stay current on all requirements; (4) appointing an individual who can serve as the point of contact for teams and the requirement tracking system; (5) determining if the teams will be staff, volunteers, or both; and (6) identifying organizations that can provide volunteer teams and/or register staff teams. BUILDING THE FOUNDATION FOR PAWS-ITIVE CONNECTIONS 13 References Animal Assisted Intervention International. (2018). Standards of practice. https://aaiint.org/aai/standards-of-practice/ Bada, S.O. (2015). Constructivism learning theory: A paradigm for teaching and learning. IOSR Journal of Research & Method in Education, 5(6), 6670. https://doi.org/10.9790/738805616670 Borgi, M., Collacchi, B., Giuliani, A., & Cirulli, F. (2020). Dog visiting programs for managing depressive symptoms in older adults: A meta-analysis. The Gerontologist, 60(1), e66-e75. https://doi.org/10.1093/geront/gny149 Centers for Disease Control and Prevention. (2019). Recommended training effectiveness questions for postcourse evaluations user guide. https://www.cdc.gov/training/development/pdfs/evaluate/effectiveness-questions-508.pdf Chang, S., Lee, J., An, H., Hong, W., & Lee, J. (2021). Animalassisted therapy as an intervention for older adults: A systematic review and metaanalysis to guide evidence based practice. Worldviews On Evidence-Based Nursing, 18(1), 60-67. https://doi.org/10.1111/wvn.12484 Chastain, T., Fine A., & Stewart L.A. (2020). Animal-related engagement: Benefiting from the power of the human-animal bond when personal interaction is not possible [White paper]. Pet Partners. https://petpartners.org/animal-related-engagement/ Dunlap, K. B., Miller, K. D., & Kinney, J. S. (2021). Recreational therapists practice, knowledge, and perceptions associated with animal-assisted therapy. Therapeutic Recreation Journal, 55(4), 384-398. https://doi.org/10.18666/TRJ-2021-V55-I4-11058 BUILDING THE FOUNDATION FOR PAWS-ITIVE CONNECTIONS 14 Fine, A.H., Tedeschi, P., Morris, K.N., & Elvove, E. (2019). Forward thinking: The evolving field of human-animal interactions. In A.H. Fine (Ed.), Handbook on animal-assisted therapy: Foundations and guidelines for animal-assisted interventions (5th ed., pp. 2341). Academic Press. Forget, S., Pennequin, V., Agli, O., & Bailly, N. (2021). Brakes and levers to implement an animal-assisted intervention in nursing homes: Preliminary study. Complementary Therapies in Medicine, 56. https://doi.org/10.1016/j.ctim.2020.102591 Franciscan Health. (n.d.) Franciscan Senior Health & Wellness. https://www.franciscanhealth.org/fshw Human Animal Bond Research Institute & National Council on Aging. (2018). Older adults and animal programming: A handbook for senior centers. https://assets-us-01.kcusercontent.com/ffacfe7d-10b6-0083-2632-604077fd4eca/d36c1b61-2b12-43ea-9d9182b97e6097fc/HABRI-NCOA-Senior-Center-Handbook_updatedjune5_compressed.pdf International Association of Human-Animal Interaction Organizations. (2018). The IAHAIO definitions for animal assisted intervention and guidelines for wellness of animals involved in AAI [White paper]. https://iahaio.org/wp/wpcontent/uploads/2018/04/iahaio_wp_updated-2018-final.pdf Kazdin, A.E. (2019). Methodological standards and strategies for establishing the evidence base of animal-assisted interventions. In A.H. Fine (Ed.), Handbook on animal-assisted therapy: Foundations and guidelines for animal-assisted interventions (5th ed., pp. 2341). Academic Press. BUILDING THE FOUNDATION FOR PAWS-ITIVE CONNECTIONS Krause-Parello, C., & Kolassa, J. (2016). Pet therapy: Enhancing social and cardiovascular wellness in community dwelling older adults. Journal Of Community Health Nursing, 33(1), 1-10. https://doi.org/10.1080/07370016.2016.1120587 Murthy, R., Bearman, G., Brown, S., Bryant, K., Chinn, R., Hewlett, A., George, B. G., Goldstein, E. J. C., Holzmann-Pazgal, G., Rupp, M. E., Wiemken, T., Weese, J. S., & Weber, D. J. (2015). Animals in healthcare facilities: Recommendations to minimize potential risks. Infection Control & Hospital Epidemiology, 36(5), 495-516. https://doi.org/10.1017/ice.2015.15 National PACE Association. (n.d.). Eligibility requirements for Programs of All-Inclusive Care for the Elderly. Retrieved from https://www.npaonline.org/pace-you/eligibilityrequirements-programs-all-inclusive-care-elderly-pace%C2%AE National PACE Association. (2022, December). PACE by the numbers [Infographic]. https://www.npaonline.org/sites/default/files/PDFs/infographic/NPA-infographicdec2022.pdf Olsen, C., Pedersen, I., Bergland, A., Enders-Slegers, M., & Ihlebk, C. (2016). Effect of animal-assisted activity on balance and quality of life in home-dwelling persons with dementia. Geriatric Nursing, 37(4), 284-291. https://doi.org/10.1016/j.gerinurse.2016.04.002 Pet Partners. (2022). Facility toolkit: Pet Partners therapy animal program. https://petpartners.org/wp-content/uploads/2019/08/Facility-Tool-Kit_downloadversion.pdf Polatajko, H.J., Townsend, E.A., & Craik, J. (2007). Canadian Model of Occupational Performance and Engagement (CMOP-E). In E.A. Townsend & H.J. Polatajko (Eds.), 15 BUILDING THE FOUNDATION FOR PAWS-ITIVE CONNECTIONS 16 Enabling occupation II: Advancing an occupational therapy vision of health, well-being & justice through occupation. Ottawa: CAOT Publications ACE. Santaniello, A., Garzillo, S., Cristiano, S., Fioretti, A., & Menna, L. F. (2021). The research of standardized protocols for dog involvement in animal-assisted therapy: A systematic review. Animals, 11(9). https://doi.org/10.3390/ani11092576 VanderBloomen, M. (2022). Animal-assisted therapy in occupational therapy. Association of Animal-Assisted Intervention Professionals. https://aaaip.memberclicks.net/assets/docs/AAIinOTPaper_PDF.pdf?_gl=1*1ndy5xr*_ga *MTY0NTMzNTcwNi4xNjczNjI3Njg2*_ga_EJCYHWK9ES*MTY3NDc2Njk0My4zLj EuMTY3NDc2Njk1MS41Mi4wLjA. Winkle, M.Y., & Ni, K. (2019). Animal-assisted occupational therapy: Guidelines for standards, theory, and practice. In A.H. Fine (Ed.), Handbook on animal-assisted therapy: Foundations and guidelines for animal-assisted interventions (5th ed., pp. 23-41). Academic Press. BUILDING THE FOUNDATION FOR PAWS-ITIVE CONNECTIONS 17 Appendix A Disciplines Represented at Franciscan Senior Health and Wellness Note. Adapted from PACE by the numbers [Infographic], by National PACE Association, 2022 (https://www.npaonline.org/sites/default/files/PDFs/infographic/NPA-infographic-dec2022.pdf). Additional administrative roles at FSHW include secretary, quality improvement coordinator, patient scheduling representative, intake coordinator, and intake specialist. BUILDING THE FOUNDATION FOR PAWS-ITIVE CONNECTIONS 18 Appendix B Pre-Education Survey Staff completed the survey through Microsoft Forms. It was distributed by email and open for one week. The wording of some questions has been edited to protect anonymity. The survey began with the following message: Thank you for your participation in this survey! The purpose of this survey is to assess staff interest, knowledge, and experience with animal-assisted interventions (AAI). There are no right or wrong answers. Please note, AAI is an umbrella term for goal-oriented and structured services that involve a trained therapy animal, including animal-assisted therapy (AAT), animal-assisted activities (AAA), and animal-assisted education (AAE). This does not include service animals, emotional support animals, facility animals, and "pet therapy" animals, unless the animal in question is part of a trained therapy animal & handler team, and the services they are providing are structured and goal-oriented. Questions, concerns, or just excited about this idea and want to know how to be more involved? Contact me by email or send a message through Teams! By completing this survey, you are agreeing to allow the doctoral capstone student, Sarah Frisbie, to utilize the collected data in their scholarly report. No personally identifiable information will be reported and any references to staff members will use non-specific language that cannot be used to identify the exact staff member being referenced. BUILDING THE FOUNDATION FOR PAWS-ITIVE CONNECTIONS 1. Discipline ( ) Therapy services (Occupational therapy, Physical therapy, Recreational therapy) ( ) Social work ( ) Home care coordination ( ) Food & nutrition services (Dietitian) ( ) Transportation ( ) Clinic staff (Nursing, Physician, NP, MA, PCAs) ( ) Administration (Management, Intake, Quality, Front Desk, Scheduling, etc.) ( ) Other: __________________________________ 2. I am interested in being involved in animal-assisted services at PACE. ( ) Strongly agree ( ) Somewhat agree ( ) Neither agree nor disagree ( ) Somewhat disagree ( ) Strongly disagree 3. I am interested in learning more about the benefits of animal-assisted interventions. ( ) Strongly agree ( ) Somewhat agree ( ) Neither agree nor disagree ( ) Somewhat disagree ( ) Strongly disagree 4. I would be interested in further information on training my pet as a therapy animal. ( ) Strongly agree ( ) Somewhat agree ( ) Neither agree nor disagree ( ) Somewhat disagree ( ) Strongly disagree 19 BUILDING THE FOUNDATION FOR PAWS-ITIVE CONNECTIONS 20 5. I have previous experience with animal-assisted services and/or have done my own research on the topic. Please only count experience with [previous facility dog] if she was directly involved in your service delivery, such as being included in interventions or providing therapeutic support. ( ) Strongly agree ( ) Somewhat agree ( ) Neither agree nor disagree ( ) Somewhat disagree ( ) Strongly disagree 6. I believe that animal assisted interventions could be beneficial for my discipline. ( ) Strongly agree ( ) Somewhat agree ( ) Neither agree nor disagree ( ) Somewhat disagree ( ) Strongly disagree 7. I understand how animal-assisted interventions could be incorporated into the services that I specifically provide. ( ) Strongly agree ( ) Somewhat agree ( ) Neither agree nor disagree ( ) Somewhat disagree ( ) Strongly disagree 8. I believe that being involved in animal-assisted services would benefit me personally. ( ) Strongly agree ( ) Somewhat agree ( ) Neither agree nor disagree ( ) Somewhat disagree ( ) Strongly disagree BUILDING THE FOUNDATION FOR PAWS-ITIVE CONNECTIONS 21 9. There are a variety of reasons why interested individuals are not actively engaged in animal-assisted services. Please note any barriers that you have experienced. Some examples: - not enough time to pursue training/certifications - confusion regarding terminology - difficulty locating evidence-based research to justify using animals in your discipline ___________________________________________________________________________ ___________________________________________________________________________ 10. Do you have any allergies or other concerns that would prevent you from engaging in animal-assisted services? If so, please explain. Only provide as much detail as you are comfortable sharing. ___________________________________________________________________________ ___________________________________________________________________________ 11. Please review this list of potential topics for staff education on AAI and select the topic(s) that you believe will be most important to cover. Use the other option to include any topics not listed that you would like included. [ ] Terminology what is AAI, and how is it different from ESAs and service animals? [ ] Dog behavior reading body language and respecting boundaries [ ] Why AAI? the benefits of including dogs in therapy and healthcare services [ ] Becoming a handler the process of training and certification for therapy dogs [ ] AAI across the disciplines ideas and suggestions on how to actually include dogs in your services [ ] Logistics maintaining hygiene and following policy [ ] Other: __________________________________ 12. Please use this space for questions, concerns, ideas, or anything else that you think I should know! ___________________________________________________________________________ ___________________________________________________________________________ BUILDING THE FOUNDATION FOR PAWS-ITIVE CONNECTIONS 22 Appendix C Pre-Education Survey Data Table C1 Themes Present in Staff-Reported Barriers Barrier theme Example quote Lack of knowledge I just don't know enough about it Frequency, n (%) 7 (31.8) Not knowing exactly how to incorporate animal assisted therapy into my practice. Lack of time Not enough time to pursue training 7 (31.8) I have not taken the time to research the training/certification. Concerns about logistics Figuring outwhere to have a dog in the building and 4 (18.2) how to get other work done while they are here. Lack of consistent attention to setting up a program Appropriateness to discipline My position [in administration] limits my ability to 2 (9.1) continue with this passion. Note. Responses from pre-education survey question 9 (see Appendix B). Because this question allowed staff to type responses, some staff reported multiple barriers while others reported none. Since no staff member is currently involved in AAI, it was assumed that all staff had experienced some form of barrier unless they explicitly reported none. BUILDING THE FOUNDATION FOR PAWS-ITIVE CONNECTIONS 23 Figure C1 Staff Interest in Potential Topics for Education 15 16 14 14 11 Terminology Dog behavior Why AAI? Becoming a handler 10 AAI across the disciplines Logistics Note. Responses from pre-education survey question 11 (see Appendix B). Staff could select multiple options. Eighteen staff members chose more than one topic, and seven staff members chose all six. BUILDING THE FOUNDATION FOR PAWS-ITIVE CONNECTIONS 24 Appendix D Guiding Theories Models Figure D1 Applying the CMOP-E to FSHW Staff Note. This model shows how the Canadian Model of Occupational Performance and Engagement (CMOP-E) can be applied to the staff of Franciscan Senior Health and Wellness (FSHW). The occupation being analyzed is safe and effective use of AAI, as noted in the top rectangle. Enablers and barriers are listed on each side of the CMOP-E diagram, and they are color coded to indicate their place within CMOP-E (environment, person, spirituality). BUILDING THE FOUNDATION FOR PAWS-ITIVE CONNECTIONS 25 Figure D2 Applying the CMOP-E to FSHW Participants Note. This model shows how the Canadian Model of Occupational Performance and Engagement (CMOP-E) can be applied to the participants served by Franciscan Senior Health and Wellness (FSHW). Safe and independent aging in place is the occupation being analyzed as that is the overarching goal of FSHW. Enablers and barriers are listed on each side of the CMOP-E diagram, and they are color coded to indicate their place within CMOP-E (environment, person, spirituality). BUILDING THE FOUNDATION FOR PAWS-ITIVE CONNECTIONS 26 Figure D3 A Model of Constructivism Learning Theory Note. This model demonstrates the constructivism theory of learning. Each part is color coded to match the colors used in Figures D1 and D2. New information (environment) is processed by the student through a lens of their past experience, current knowledge, and personal beliefs (person). This allows the student to construct their own personal meaning of the information (spirituality), which is then integrated back into their cognitive schema. Each arrow represents a step in the learning process (occupation). BUILDING THE FOUNDATION FOR PAWS-ITIVE CONNECTIONS 27 Appendix E Post-Survey Questions Staff completed the survey through Microsoft forms and accessed it by email or by QR code at the end of each education session. The survey began with the following message: Thank you for your participation! The primary purpose of this survey is to assess staff knowledge, confidence, and likelihood of using AAI after completing the education. Please note, the education consisted of two parts: the education session and the manual. Be honest in your responses - there are no right or wrong answers, and your responses will be anonymous. Please read each question carefully before responding to ensure accurate results! Questions or concerns? Please contact me by email or send me a message on Teams! By completing this survey, you are agreeing to allow the doctoral capstone student, Sarah Frisbie, to utilize the collected data in their scholarly report. No personally identifiable information will be reported and any references to staff members will use non-specific language that cannot be used to identify the exact staff member being referenced. BUILDING THE FOUNDATION FOR PAWS-ITIVE CONNECTIONS Section 1 1. Discipline ( ) Therapy services (Occupational therapy, Physical therapy, Recreational therapy) ( ) Social work ( ) Home care coordination ( ) Food & nutrition services (Dietitian) ( ) Transportation ( ) Clinic staff (Nursing, Physician, NP, MA, PCAs) ( ) Administration (Management, Intake, Quality, Front Desk, Scheduling, etc.) ( ) Other: __________________________________ 2. Did you participate in the pre-survey? ( ) Yes ( ) No ( ) Unsure 3. Which education session did you attend? ( ) March 23 ( ) April 5 4. Did you review the manual before attending the education session? ( ) Yes, all of it ( ) Yes, some of it ( ) No 28 BUILDING THE FOUNDATION FOR PAWS-ITIVE CONNECTIONS 29 Section 2 For questions 5 and 7: 1 = Not at all knowledgeable 2 = Slightly knowledgeable 3 = Moderately knowledgeable 4 = Very knowledgeable 5 = Extremely knowledgeable For questions 6 and 8: 1 = Not at all confident 2 = Slightly confident 3 = Moderately confident 4 = Very confident 5 = Extremely confident 5. How would you rate your knowledge of the following topics before completing the education? 1 2 3 4 Common terminology in AAI ( ) ( ) ( ) ( ) The benefits of AAI ( ) ( ) ( ) ( ) How to use dogs for AAI ( ) ( ) ( ) ( ) Dog behavior and how it relates to therapy dogs ( ) ( ) ( ) ( ) The process of becoming of a therapy dog handler ( ) ( ) ( ) ( ) How to maintain health and safety during AAI ( ) ( ) ( ) ( ) 5 ( ) ( ) ( ) ( ) ( ) ( ) 6. How would you rate your confidence in performing the following tasks before completing the education? 1 2 3 4 Planning an AAI session ( ) ( ) ( ) ( ) Maintaining health and safety during AAI ( ) ( ) ( ) ( ) Leading an AAI session ( ) ( ) ( ) ( ) Finding credible sources to learn more about AAI ( ) ( ) ( ) ( ) ( ( ( ( 7. How would you rate your knowledge of the following topics after completing the education? 1 2 3 4 Common terminology in AAI ( ) ( ) ( ) ( ) The benefits of AAI ( ) ( ) ( ) ( ) How to use dogs for AAI ( ) ( ) ( ) ( ) Dog behavior and how it relates to therapy dogs ( ) ( ) ( ) ( ) The process of becoming of a therapy dog handler ( ) ( ) ( ) ( ) How to maintain health and safety during AAI ( ) ( ) ( ) ( ) 5 ( ) ( ) ( ) ( ) ( ) ( ) 5 ) ) ) ) 8. How would you rate your confidence in performing the following tasks after completing the education? 1 2 3 4 5 Planning an AAI session ( ) ( ) ( ) ( ) ( ) Maintaining health and safety during AAI ( ) ( ) ( ) ( ) ( ) Leading an AAI session ( ) ( ) ( ) ( ) ( ) Finding credible sources to learn more about AAI ( ) ( ) ( ) ( ) ( ) BUILDING THE FOUNDATION FOR PAWS-ITIVE CONNECTIONS 30 Section 3 9. Assuming access to therapy dogs is not an issue, how likely are you to use AAI in your services? Please select N/A if AAI is not appropriate for your discipline. ( ( ( ( ( ( ) Very likely ) Somewhat likely ) Unsure ) Somewhat unlikely ) Very unlikely ) Unsure 10. In the pre-survey, you were asked to list any barriers that kept you from being involved in AAI. What barriers, if any, still remain for you? Please use the "other" box to add barriers not listed in the options. [ [ [ [ [ [ [ ] No barriers Im good to go! ] Not enough time to continue the process ] Need more education/training ] Concerns about health and safety or other logistics ] AAI isnt appropriate for my discipline/position ] No interest ] Other: __________________________________ 11. Are you interested in being involved in Paws-itive Connections as a handler? Please select the option that best represents your current opinion. ( ( ( ( ( ) Yes, and Ive already started the process of becoming one. ) Yes, but I havent started the process yet. ) Maybe. I havent decided if I want to be a handler, but I do want to be involved. ) No, but I want to be involved in other ways. ) No, I would prefer to not be involved at all. 12. Please use this space for comments. ___________________________________________________________________________ ___________________________________________________________________________ BUILDING THE FOUNDATION FOR PAWS-ITIVE CONNECTIONS 31 Appendix F Outcomes Table F1 Pre- and Post-Education Scores Knowledge score a Confidence score b Pre Post Pre Post Pre Post 1 6 29 4 20 10 49 2 7 18 4 12 11 30 3 6 22 6 11 12 33 4 23 30 16 17 39 47 5 10 21 4 13 14 34 6 17 20 12 16 29 36 7 17 22 8 14 25 36 8 18 18 4 8 22 26 9 10 27 4 15 14 42 10 11 25 5 17 16 42 11 6 24 4 16 10 40 12 12 22 5 14 17 36 13 11 24 5 14 16 38 14 16 24 7 12 23 36 15 22 22 14 16 36 38 16 6 24 4 16 10 40 Response ID Total score Note. Responses from post-survey questions 5-8 (see Appendix E). Scores were calculated by converting the Likert options to 1-5 and summing each scale. a Includes 6 items. Possible score range of 6-30. b Includes 4 items. Possible score range = 4-20. BUILDING THE FOUNDATION FOR PAWS-ITIVE CONNECTIONS 32 Figure F1 Distribution of Responses for Individual Likert Items Before and After Education Common Terminology 50% 6% The Benefits of AAI 31% 6% 25% 19% 13% 19% 31% 6% Knowledge 31% 6% 31% 31% 31% 13% 25% 25% 63% 6% 19% 19% 31% 13% 19% 38% 6% 6% 75% Confidence Maintaining Health & Safety 50% Leading an AAI Session 19% 25% 69% 6% 25% 13% 19% Not at all 69% Slightly Moderately Note. Responses from post-survey questions 5-8 (see Appendix E). 31% 6% 13% 6% 13% Very 6% 6% 50% 31% 44% 19% Finding Credible Sources to Learn More 13% 50% 13% 19% 56% 25% Planning an AAI Session 13% 44% 44% How to Maintain Health & Safety 25% 56% 19% The Process of Becoming of a Handler 19% 50% 31% Dog Behavior & How it Relates to AAI 13% 63% 25% How to Use Dogs in AAI 6% 75% 13% 19% 6% 6% 6% 50% Extremely 31% PAWS-ITIVE CONNECTIONS: AAI AT PACE 33 Table F2 Change in Staff-Reported Barriers to Involvement Barrier Frequency, n (%) Pre-education a Post-education b Knowledge 7 (31.8) 2 (12.5) Time 7 (31.8) 4 (25.0) Logistics 4 (18.2) 0 (0.0) Discipline 2 (9.1) 0 (0.0) Interest 1 (4.6) 1 (6.3) None 4 (18.2) 9 (56.3) Note. Responses from pre-survey question 9 (see Appendix B) and post-survey question 10 (see Appendix E). a N = 22. Because staff could select more than one option, the totals exceed 22. b N = 16. One staff member selected Other and noted they do not own a dog. Since they did not select any other options, they were included in None. PAWS-ITIVE CONNECTIONS: AAI AT PACE 34 Table F3 Staff-Reported Likelihood of Using AAI Option Frequency (%) n All responses a Excluding N/A b Very likely 6 37.5 42.9 Somewhat likely 4 25.0 28.6 Unsure 2 12.5 14.3 Somewhat unlikely 1 6.3 7.1 Very unlikely 1 6.3 7.1 N/A 2 12.5 Note. Responses from post-survey question 9 (see Appendix E). a N = 16. b N = 14. PAWS-ITIVE CONNECTIONS: AAI AT PACE 35 Table F4 Staff Interest in Involvement Level of involvement Frequency, n (%) Handler Process started 1 (6.3) Process not started 3 (18.8) Potential handler 6 (37.5) Non-handler 2 (12.5) None 4 (25.0) Note. Responses from post-survey question 11 (see Appendix E). PAWS-ITIVE CONNECTIONS: AAI AT PACE 36 Appendix G Weekly Plan Week DCE Stage 1 (1/91/13) Orientation Weekly Goal 1) Complete orientation process by end of the week Objectives - - - Screening/ Evaluation 2) Begin work on interest surveys for participants and Tasks Date Finished Meet with site mentor and the rest of PACE staff to introduce myself and explain why Im here. - Review introduction - 01/11 - Locate new literature - 01/13 Meet participants and observe what a typical day is like here - Begin work on surveys - 01/11 - Complete EPIC training on 1/10 - 01/10 - Review PACE Manual from CMS 01/12 - Update MOU as necessary - 01/13 - Figure out options with Paws and Think - 01/13 Discuss project expectations, supervision plan, and MOU with site mentor - Complete sitespecific orientation process - Create rough draft of both surveys and review with site mentor PAWS-ITIVE CONNECTIONS: AAI AT PACE interest/experience surveys for staff 2 Screening/ (1/16- Evaluation 1/20) 3 Screening/ (1/23- Evaluation 1/27) 37 - 1) Update introduction Discuss options for how to distribute/collect 2) Begin survey of staff - Finalize survey for staff 3) Determine outcome assessment plan 1) Update background - Review with site mentor Review needs assessment and literature review - 2) Distribute survey to staff 3) Start updating policy and procedure - Develop a rough draft (focus on getting the necessary information in, edit later) Updated MOU due 1/20 01/19 - Begin re-writing introduction - 01/20 - Continue to locate new literature - 01/20 - Finalize survey and plan for distribution - 01/20 Introduction draft due 1/23 - 01/23 - Send survey through Forms - 01/26 - Review resources from manager - 01/25 - Rough draft of policy and procedure - 01/25 - 01/24 PAWS-ITIVE CONNECTIONS: AAI AT PACE 38 - 4 Implementation (1/302/3) 1) Finalize plan for project - Create detailed plan for project including goals for training and how I plan to complete them Continue to review literature Background draft due 1/30 01/30 - Work on project plan - 02/02 - Collect & analyze survey results - 02/03 Design/implement ation draft due 2/6 02/06 - Final plan on delivery format - 02/10 - Education concept map complete - 02/08 - Rough draft of policy - 02/10 - Rough draft of procedure - 02/09 - Rough draft of forms - 02/09 2) Write design/implementati on draft 3) Review survey results 5 (2/62/10) Implementation 1) Begin developing staff training - 2) Finish rough draft of policy/procedure in preparation for operational excellence subgroup meeting Organize important information and use NEED/NICE/NUTS to examine information Create policy, procedure, and forms documents based on Franciscan Health templates PAWS-ITIVE CONNECTIONS: AAI AT PACE 6 Implementation (2/132/17) 3) Begin interdisciplinary shadowing to understand role of other disciplines at PACE 1) Continue developing staff training 39 - - 2) Continue to collect resources for staff explaining the benefits of AAI 7 Implementation (2/202/24) 3) Continue networking with various disciplines - 1) Finalize staff training - Complete orientation modules on interdisciplinary teamwork at PACE to better understand IDT as a whole Finalize rough draft of all training materials, topics, etc. - Watch all 6 IDT modules - 02/10 - Operational excellence meeting on policy & procedure (02/13) 02/13 - Rough draft of training materials - 02/17 - Review resources for AAI - 02/17 Operational excellence meeting on policy & procedure (02/20) 02/20 Identify one staff member from each discipline who are open to me shadowing and/or having a discussion of their specific role in the interdisciplinary team Finish educational materials PAWS-ITIVE CONNECTIONS: AAI AT PACE 40 - Final drafts of training materials - 02/24 - Final draft of policy & procedure - 02/24 - Send email to schedule training - 03/03 2) Continue networking with various disciplines 8 Implementation (2/273/3) 3) Continue to collect resources for staff 1) Finalize training plan - - Email to center manager 2) Continue work on other materials - Finish brochure, visit sign(s), health record - Finalize brochure and visit sign(s) draft - 03/03 - Shadow at least one discipline this week - Rec therapy presentation (RT shadowing) - 03/01 - Get approval from manager and mentor - Manager approval - 03/06 - Mentor approval - 03/06 - 03/09 3) Continue networking with various disciplines - Continue reviewing resources Finish flyer for staff 4) Start post-survey 9 (3/63/10) Implementation 1) Finalize all materials PAWS-ITIVE CONNECTIONS: AAI AT PACE 41 - - Work with Marketing on printables - 3) Work on outcomes draft Finalize outcome assessment plan (post-survey) - 4) Start planning dissemination Write outcomes draft - Draft dissemination plan Outcomes draft due 3/13 2) Work on postsurvey 10 Implementation (3/133/17) 11 Implementation (3/203/24) Start process for printing brochure, visit sign(s) 1) Prep for education sessions - 03/10 - 03/10 - 03/07 03/13 2) Continue networking with various disciplines - Network with at least one discipline this week - Shadowing - 03/17 3) Policy and procedure process - Get approval from Ops Excellence Team - Ops Team meeting 03/13 03/13 - Draft dissemination plan Dissemination plan due 03/20 - 03/17 03/20 - Complete 03/23 education - 03/23 - Email survey to staff who attended - 03/23 4) Work on dissemination plan 1) Education session on March 23 2) Begin analyzing efficacy of training PAWS-ITIVE CONNECTIONS: AAI AT PACE 42 as survey is completed 3) Work on ARE activities 12 Discontinuation (3/273/31) Discontinuation Draft activity pack - 03/21 1) Continue to analyze survey data - Transfer data to Excel - Send reminder email 03/27 - 03/27 2) Final policy and procedure - Director review - Director Meeting 03/29 - 03/29 - Make edits based on meeting - 03/31 - Review Paws & Think agreement with Franciscan Hospice - 03/30 - Shadowing - 03/31 - 13 (4/34/7) - 3) Continue shadowing/ observation of disciplines 1) Work on writing up results 2) Finish policy and procedure process Partnership details - Education session on April 5 - Complete 04/05 education - 04/05 - Analyze survey data - Email survey to staff who attended - 04/05 - Final edits - - 04/03 - Partnership document Email all files to manager PAWS-ITIVE CONNECTIONS: AAI AT PACE 14 Dissemination (4/104/14) 43 3) Continue shadowing/ observation of disciplines - Shadowing - 04/07 4) Finish ARE activities - Final activities - 04/07 - Confirm contacts at other locations - Initiated 04/04 Exercise group w/ therapy dog 04/14 - 04/14 - Share with site manager & site mentor - 04/13 - OT Spotlight presentation - 04/10 5) Complete work necessary for dissemination 1) Wrap-up on site - - 2) Finish shadowing/ observation Finalize program kit for dissemination Organize materials for site on OneDrive  ...

... Family Education Program in Caring for an Individual with Down Syndrome and Dementia Drew Flynn May 1, 2023 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: Alissia Garabrant, OTD, MS, OTR Assistant Professor, Fieldwork Coordinator Abstract In recent years, the prevalence of dementia in individuals with Down syndrome has increased due to the increased life span (Barnes, 2010; Maaattaa et al., 2011). However, there is a lack of information available for caregivers experiencing this with their loved ones (Barnes, 2010). The purpose of this project is to increase knowledge on the topic, caregiver confidence, ability to find resources and awareness of caregiver burnout. Six individuals participated in a three-part Dementia and Down Syndrome Training Series, which consisted of three different topics. Through a pre and post survey, the main findings of this study revealed increased family education leads to improved knowledge, confidence, and ability to find resources for caregivers providing for individuals with Down syndrome and dementia. Down Syndrome Indiana (DSI) is an organization that helps advocate and provide abundant resources for people with Down syndrome. The organization serves the greater Indianapolis area, Terra Haute, and South Bend. Their mission statement is Dedicated to enhancing the lives of individuals with Down syndrome (Dsindiana, 2022). The DSI programs intend to promote the inclusion of individuals with Down syndrome in their greater community. Down syndrome designs programs that offer support and resources to families, caregivers, educators, employers, and professionals who serve individuals with Down syndrome (Dsindiana, 2022). One new issue that has recently come to DSIs attention is that According to the National Down Syndrome Society, about 30% of people with Down syndrome who are in their 50s have Alzheimers dementia. About 50% of people with Down syndrome in their 60s have Alzheimers dementia (Alzheimers Association, 2022). Due to this report, DSI wants to focus serving the older Down syndrome and have a program that would be able to share knowledge and resources of Down syndrome and dementia. This Doctoral Capstone Experience (DCE) will focus on developing a program that will provide knowledge and resources on how to take care of an individual with Downs syndrome and Dementia. The program is a three-part training series where family members and caregivers will learn knowledge and resources so they can provide better care to their loved one. The purpose of my DCE will share the outcome of how the family training program will increase confidence in the ability to care for an individual with Downs Syndrome and Alzheimers disease, raise awareness of caregiver burnout, and the increase the ability to find resources for care. Background Correlation between Down Syndrome and Alzheimers Down syndrome is a common genetic disorder caused by a third copy of the twentyfirst chromosome leading to intellectual disability and comorbidities (Santoro et al., 2021). In recent years, as medical technologies have advanced, the lifespan of people with Down syndrome has grown, unfortunately leading to older adults with Down syndrome being diagnosed with dementia at a high rate (Barnes, 2010; Maaattaa et al., 2011). The pathology of dementia in Down syndrome is unknown; however, a correlation on why individuals have such a high rate of dementia in older age can be made. The amyloid precursor protein is believed to be the reason for the increased rate due to the third chromosome twenty-one producing more amyloid precursor protein, which creates plaque in the brain (Santoro et al., 2021). With the rise in dementia in individuals with Down syndrome, one would assume that there would be a rise in resources, yet research states there is a lack of resources (Barnes, 2010). Barnes mentions when discussing the cases of dementia and Down syndrome, different needs that need to be assessed, such as the lack of tools assessing dementia in individuals with intellectual disabilities, the need for dementia care education in the community living/group home settings, and the lack of funding for staff to meet the needs of seniors with Down syndrome and Alzheimers (2010, p 10). The high rate of dementia in Down syndrome and the low rate of resources and care guides the focus of my Doctoral Capstone Experiences. Caregivers are confused about what dementia looks like in people with Down syndrome and if there are any treatments. Santoro et al. (2021) found that some symptoms of Alzheimers in people with Down syndrome included memory loss, impaired executive function, and inhibiting previous existing skills (p.4501). Castro et al. (2017) discuss how the effects of dementia start way before symptoms start showing. Castro et al. discuss deeper that the effect of Alzheimers happens earlier due to the amyloid precursor protein in people with Down syndrome, making it much more difficult to find a treatment. (2017, p 804). Fonseca et al. (2016) discuss how most instruments used for dementia were developed from studies of individuals with normal intellectual development (p124). The literature addressed parents concerns about their loved one with Down syndrome. To further develop my DCE, I researched ways of caring for individuals with Down syndrome and dementia. Dementia and Down Syndrome Family Training Series In developing a training series program for families and caregivers, the literature became the training series content guidelines. The literature included experiences and information on the following: staff experience with individuals with Down syndrome and dementia care in group homes, lifestyle factors of people with Down syndrome and dementia versus only Down syndrome, caregiver response, and a program called Positive Approach to Care that increased understanding of caring for an individual with only dementia. One study of shared staff experiences in caring for people with Down syndrome and Alzheimers found the staff had a limited understanding of Alzheimers diseases impact on Down syndrome and used an ad hoc approach to developing strategies to better care for the impacted individuals (Iacono et al., 2014). The literature also showed the importance of lifestyle factors in individuals with Down syndrome and Alzheimers and induvial with only Down syndrome. That study found a significant difference between the two groups on where the participants lived. The findings showed that people with Alzheimers lived in an institutionalized setting while people with just Down syndrome lived in an independent/supported setting (Kenshole et al., 2017). This may suggest that moving someone with Down syndrome who is developing Alzheimers into an institution may be the best way to support them (Kenshole et al., 2017). Literature also found that caring for someone with Down syndrome and Alzheimers may also fall on one person, harming their well-being (Solmina & Hawkins, 1998). Literature also found specific impressions that parents have that include parents concerned about who will care for their loved one in an absence. A study also stated that a person with Down syndrome and dementia would have an increased need, the caregiver would have decreased independence, and make difficult decisions (Post, 2002). The literature supports the idea that caregivers could be experiencing different troubles and that this population could benefit from the training series my DCE developed. A gap in the literature was that no specific applications would support families and help them care for an individual with Down syndrome and Alzheimers. There is little research to support this specific population, meaning it is essential to address these service gaps further. (Carling-Jenkins 2012). An important aspect found in the literature was implementing a course called Positive Approach to Care, created by an occupational therapist named Teepa Snow (Ehlman, 2018). I earned the certification of this course through past employment. I knew that the key content of this course, which is used for dementia only, would be able also to relate to dementia and Down syndrome. Ehlman et al. found that the certification course can improve knowledge and facilitate change in how to care for a person with dementia (2018). I was able to use the content of the course to construct the training series content better and strengthen my DCEs effectiveness. Literature has made it clear that the need for support and resources for families caring for a loved one with Down syndrome and Alzheimers are needed. Through my Doctoral Capstone Experience, I will develop a program that works with the caregivers of people with Down Syndrome and Alzheimers and teach them occupationally focused ways to improve their care for their loved one and ease their occupational performance for themselves. The program will be a three-part series addressing the signs and symptoms of Alzheimers in people with Down syndrome, what to do when their loved one is diagnosed with Alzheimers, and how to find care in the late stages of Alzheimers. The Person-Environment-OccupationalPerformance model (PEOP) will guide the training series and analyze the occupational performance of individuals with Down syndrome and dementia and their caregivers. Using Allens Cognitive level will address the individual with Down syndrome and dementia cognitive disability. The theory and frame of reference will be used to construct a pre-and post-survey to collect the participants outcome measures. Project Design and Implementation Draft After analyzing the needs assessment, assessing the research, and meeting with stakeholders, there was evidence of a lack of resources and information to care for someone with Down syndrome and dementia. This lack of resources leads to strain on families and the inability to properly care for an individual with such a unique need. My DCE addressed the issues by holding a three-part training series to address various topics relating to Down syndrome and dementia. This online series over Zoom will meet in the evening to give out information and provide a welcoming space to prompt discussions. The first step in developing this program was to advertise for the series. My project was featured in the weekly newsletter that Down Syndrome Indiana sends out to participants across the state. The advertisement included information such as a brief personal background of myself, the purpose of my project, a summary of what the series will cover, the dates of meetings, and my contact information. I received emails from people interested in my series, and most would also share their stories in the email. Next, a list was created of all the people interested, and I sent them the meeting link and specific reminders of meeting dates. Next, I began creating the content I would present. The first presentation was the signs and symptoms of dementia in people with Down syndrome. The first presentation is structured to be more of an introduction to what Dementia and Alzheimers disease is and what it would look like in an individual with Down syndrome. The second talk focuses on specifics on what to do if your loved one is diagnosed with dementia; this focuses on handling specific situations and tips caregivers should know. The last session focuses on finding care and resources, especially for late-stage Alzheimers. All resources used in the sessions are from research, specific dementia training I have received, and resources given to me by my site mentor. The three outcome measures are increasing confidence in caring for an individual with Down syndrome and Alzheimers, increased caregiver awareness, and increased ability to access resources or care. The outcome measures will be recorded through a pre-survey and post-survey given at sessions one and three. In week 12 of DCE, I shared the finding of the participants results from the pre-and post-survey with the staff of DSI. All presentations were recorded, and the videos and other resources were posted to the Down Syndrome Indiana website. The goal will be for future families to come to Down Syndrome Indiana for information about dementia and be able to find it all on the website. Project Outcomes I created a pre-training and post-training survey to provide the participants of the Down Syndrome and Dementia Training Series. The reason was to collect four outcome factors; the current knowledge of Down syndrome and dementia, confidence in caring for an individual with Down syndrome, awareness of caregiver burnout, and the ability to find resources. Research has suggested that there is evidence that people with Down syndrome and dementia require a specific demand, yet there is little outside support causing a crisis response in the family home (Carling-Jekins et al. 2012). Since there is a problem in the family home, I wanted to keep this project client-centered (the family and the caregivers) by giving them outside resources to increase their knowledge and help give them support. The pre-survey and post-survey were distributed via email with a prompt and a link to a Google form questionnaire. The pre-survey was emailed out a week before the first training series date, and the post-survey was emailed out a week after the last training series date. The pre-survey and post-survey used the same questions asking the participants to rate themselves to questions on a Likert scale from 1-10, 1= the least and 10 = the most. Four questions related to the target outcome factors; confidence, knowledge, awareness, and ability. Question 1 addresses the self-reflection on the knowledge of Down syndrome and dementia. Question 2 addresses confidence in caring for an individual with Down syndrome and dementia. Question 3 addresses the awareness of caregiver burnout. Question 4 addresses the ability to find resources for dementia. There was also an option to ask any questions or add any additional thought, which allowed the participant to ask any questions, tell them what they enjoyed, or give a suggestion. Participants were informed that the survey would be used to show how effective Down Syndrome and Dementia Training Series would have on the participants, hoping to continue sharing this information. The pre-survey had 6 participants, and the post-survey had 3 participants. The purpose of the pre-and post-survey was to see a change in the participants confidence, knowledge, awareness, and ability. The participants answered the same four questions before and after the training. Question 1 (Knowledge) from the pre-survey had an average answer of 6.8, and from the post-survey, an average answer of 8.6, a 26% increase (see Table 1). Question 2 (Confidence) from the pre-survey had an average response of 5.8, and the post-survey had an average answer of 8, resulting in a 38% increase (see Table 1). Question 3 (Awareness) had an average answer of 9.3 from both the pre-and post-survey, resulting in no change (see Table 1). Lastly, Question 4 (Ability) had an average response of 6 for the pre-survey and 9 for the post-survey resulting in a 50% increase (see Table 1). From these results, the Dementia and Down Syndrome Family Training series effectively teaches people about Down syndrome and dementia to feel better about providing care to their loved ones. Summary The life expectancy of individuals with Down syndrome has increased, but the prevalence of dementia has also increased (Barnes, 2010; Maaattaa et al., 2011). Unfortunately, there is a lack of information available for caregivers experiencing this, which leads to decreased confidence and ability to care for their loved ones (Barnes, 2010). According to Post (2002) individuals with both Down syndrome and Alzheimers will have an increase in dependence, which will ultimately lead to a decrease in caregiver independence. This project aimed to increase knowledge on the topic, caregiver confidence, ability to find resources and awareness of caregiver burnout. Though a three-part training series, participants learned about the signs and symptoms of dementia in someone with Down syndrome, how to care for them, and how to find resources. Each topic was presented separately via live Zoom meetings. Pre and post surveys were provided to measure four factors including knowledge of Down syndrome and dementia, confidence in caring for these individuals, awareness of caregiver burnout, and ability to find resources. Using the pre- and post-survey, participants answered four questions rating themselves on a scale of 1-10, 1 being the least and 10 being the most, for each of the above factors. Table 1 shows the results of the surveys, and the percent change after the participants have completed the training. The results of the survey show the following three factors had an increase in change; knowledge of Down syndrome and Dementia, confidence in caring for these individuals, and ability to find resources for caregivers providing for individuals with Down syndrome and Dementia. The results of the survey show that the training series was an effective way to help families and caregivers provide for their loved ones with Down syndrome and dementia. Conclusion The Down Syndrome and Dementia Family/Caregiver Training Series is effective in improving the knowledge, confidence, and ability to find resources for caregiver providing for individuals with Down syndrome and dementia. Through educational training sessions participants gained information about the signs and symptoms of dementia in Down syndrome, how to care for these individuals, and the ability to find resources. In the meetings participants expressed how this training was beneficial and helped them gain an understanding on a specific problem in the Down syndrome community. Participants expressed in the surveys and over Zoom how helpful they found the information provided. Hopefully this training series is just the start of the resources that DSI will create. All the presentations and information are posted on the DSI website with the goal that future families that need help can be led to the information. My site mentor and project coordinator of DSI, Stephanie Gardner, along with the rest of the DSI staff, will update the webpage with new information related to Down syndrome and dementia. The future for the occupational therapy profession has many opportunities that could be started or continued at DSI as it pertains to Down syndrome and dementia, whether it is continuing the training series or starting a program where someone could physically meet with the families. As research continues, occupational therapists should continue to engage with this population experiencing this increasing problem and increase education and awareness for families and caregivers providing for their loved ones with Down syndrome and dementia. References Alzheimers Association, (2022) Down syndrome and Alzheimer's disease. Alzheimer's Disease and Dementia. Retrieved March 11, 2022, from https://www.alz.org/alzheimers-dementia/whatis-dementia/types-of-dementia/down-syndrome Barnes I. (2010). The challenge of providing dementia care for people with Down syndrome. Canadian Nursing Home, 21(1), 410. Carling-Jenkins, R., Torr, J., Iacono, T., & Bigby, C. (2012). Experiences of supporting people with Down syndrome and Alzheimers disease in aged care and family environments. Journal of Intellectual & Developmental Disability, 37(1), 5460. https://doi.org/10.3109/13668250.2011.645473 Castro, P., Zaman, S., & Holland, A. (2017). Alzheimers disease in people with Downs syndrome: the prospects for and the challenges of developing preventative treatments. Journal of Neurology, 264(4), 804813. https://doi.org/10.1007/s00415-016-8308-8 Cleveland Clinic. (2019). Caregiver burnout; causes, Symptoms & Prevention. Cleveland Clinic. Retrieved February 21, 2023, from https://my.clevelandclinic.org/health/diseases/9225caregiver-burnout#:~:text=is%20caregiver%20burnout%3F,Caregiver%20burnout%20is%20a%20state%20of%20physical%2C%20emotional%20and% 20mental,are%20able%2C%20physically%20or%20financially. Dsindiana. (2022, March 1). Down syndrome Indiana. Down Syndrome Indiana. Retrieved March 8, 2022, from https://dsindiana.org/ Ehlman, M. C., Nimkar, S., Nolan, B. A. D., Thomas, P., Caballero, C. E., & Snow, T. (2018). Health Workers Knowledge and Perceptions on Dementia in Skilled Nursing Homes: A Pilot Implementation of Teepa Snows Positive Approach to Care Certification Course. Journal of Continuing Education in the Health Professions, 38(3), 190197. https://doi.org/10.1097/CEH.0000000000000216 Fonseca, L. M., Yokomizo, J. E., Bottino, C. M., & Fuentes, D. (2016). Frontal lobe degeneration in adults with Down syndrome and Alzheimers disease: A review. Dementia and Geriatric Cognitive Disorders, 41(34), 123136. https://doi.org/10.1159/000442941 Iacono, T., Bigby, C., Carling-Jenkins, R., & Torr, J. (2014). Taking each day as it comes: Staff experiences supporting people with Down syndrome and Alzheimers disease in group homes. Journal of Intellectual Disability Research, 58(6), 521533. https://doi.org/10.1111/jir.12048 Kenshole, A. V., Gallichan, D., Pahl, S., & Clibbens, J. (2017). Lifestyle factors and Alzheimers disease in people with Down syndrome. Journal of Applied Research in Intellectual Disabilities, 30(Suppl 1), 5866. https://doi.org/10.1111/jar.12369 Mtt, T., Mtt, J., Tervo-Mtt, T., Taanila, A., Kaski, M., & Iivanainen, M. (2011). Healthcare and guidelines: A population-based survey of recorded medical problems and health surveillance for people with Down syndrome. Journal of Intellectual & Developmental Disability, 36(2), 118126. https://doi.org/10.1080/13668250.2011.570253 Moran J. et al., (2018), Alzheimers Disease & Down syndrome: Practical Guidebook for Caregivers, National Down Syndrome Society, 1st edition Snow, T.. (2012).The GEMS: Brain change model. Positive Approach to Care. https://teepasnow.com/about/about-teepa-snow/the-gems-brain-change-model/. Snow, T. (n.d.) Positive Approach care Training, Written/Oral (Slides 1-48) LCC, https://teepasnow.com/ Soliman A, & Hawkins D. (1998). Clinical. The link between Downs syndrome and Alzheimers disease: 2. British Journal of Nursing, 7(14), 847850. https://doi.org/10.12968/bjon.1998.7.14.5638 Appendix Table 1. Outcomes Factors Pre-survey Post-survey Percentage Change (Avg) (Avg) (%) Knowledge 6.8 8.6 26% Confidence 5.8 8 38% Awareness 9.3 9.3 0% 6 9 50% Ability DCE Timeline at Down Syndrome Indiana Week DCE Stage Weekly Goal (orientation, screening/ evaluation, implementation, discontinuation, dissemination) 1 Orientation 1.) Complete Orientation Objective Tasks -Start on detailed timeline -Brainstorm meeting dates for Big group meeting with site mentor -Discuss Goals -Complete and Objectives Orientation process with Site mentor -Complete Orientation video -Organize Capstone Folder with old needs assessment, goals and objectives, and MOU -Finalize MOU Date complete 1/13 2 Evaluation 1.) Complete updated Literature Review/Needs Assessment 2.) Finalize Timeline 3.) Start on Intro and Background of Paper -Establish Outcome measures -Create pre- and post- survey for participants -Continue to find/create content that would -Complete Need contribute to the Assessment/SWOT family training Analysis -Continue researching updated articles - Confirm meeting dates for large group discussion -Discuss with site mentor what individualized meetings would look like -From gathered information, 3 Evaluation 1.) Complete Literature Review -Finalize Outcome measures -Finalize what resources will be created 1/20 -Finalize question for Needs Assessment -Gather any current resources from the company and analysis with SWOT. -Email/introduce yourself to possible families -create a talking point pamphlet and log what common questions/concerns are present -From gather 1/27 information from needs assessment and literature review, start creating content that would help family engage in caring for their loved ones with ADLS -Discuss with site mentor/faculty mentor on what data would be most beneficial to collect. 4 Evaluation/ Implementation 1.) Finalize Content that will be shared 2.) Finalize how Data will be collected 3) Host Round Table discussion meeting -Organize information that is gathered into categories -Talk with site 2/3 mentor about possible categories and what to focus on -Add/complete any research from -Finalize pre and site mentor post survey and get suggestion it approved by site mentor and facility -Find a way to mentor. analyze the data -Prepare for Round table discussion, could be this week or could be Week 5, discuss with site mentor on what would work best 5 6 7 8 9 10 Implementation Discontinuation 1.) Schedule a second -look to expand to and third round table as many people as meeting. possible Group meeting dates: -Meeting #1: 2/8 -Meeting #2: 2/22 -Meeting #3: 3/8 -Hand out postsurvey -Organize all data 1.) Begin Dissemination that is collected and meet with site Process 2.) Hand out Post mentor about data collected survey 3.) Process Date -Start collecting post-survey 3/13. -Show interest in wanting to meet with families individually -Hand out presurvey (finalize if this will be a google link, word doc, or something else, discuss with site mentor) -Create content could be split into two meetings -Respond to emails and create a handout for families that -complete any follow up task related to individual meetings -start creating webpage -Send out reminders 2/10 2/17 2/24 3/3 3/10 3/17 11 12 13 Preparing for dissemination 1.) Continue dissemination process 14 Dissemination 1.) Disseminate -Once all data is collected process the data -set up a meeting with staff and volunteers of DSI to disseminate -Create webpage so there can be a transfer to site responsibility of DCE Complete poster and paper -finish web page Disseminate at Monday Morning Staff meeting -Create table to show collected data -Add information from content and from data that was collected. - -Complete all task related to objectives. 3/24 3/31 4/7 4/14  ...

... 1 Health Management Programming Among Community-Dwelling Aging Adults Becca Endicott, OTD and MS Aging Studies Student May 2023 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: Beth Ann Walker, PhD, MS, OTR, FAOTA 2 Abstract The purpose of this scholarly report is to examine how the implementation of health management programming among community-dwelling aging adults inspired by Lifestyle Redesign can create higher levels of self-efficacy to successfully manage chronic health conditions to remain aging in place. Four thirty to sixty-minute health management workshops were implemented over the course of four weeks. The topics for these workshops included: arthritis management, energy conservation, physical activity, and nutrition. To measure the increase in knowledge and confidence a pre- and post-test were delivered during each workshop. Data from the pre and post-test provided that the implementation of health management education increased the knowledge and confidence about health management topics and how they impact the participant's everyday routines. The findings from this research provide further support for continued occupational therapy practitioners in the role of health management among community-dwelling aging adults. Keywords: Lifestyle Redesign, Health Management, Community-Dwelling Aging Adults, Chronic Health Conditions 3 Introduction By 2030, it is expected that the number of aging adults is estimated to be around 74 million people which accounts for 21 percent of the total United States population (Centers for Disease Control, 2016). Research supports the idea that a vast majority of older adults ages 65 and older want to remain in their homes and chosen communities to continue to age in place (CDC, 2016). For aging adults to successfully age in place within their homes and communities, it is crucial they have the needed services and support systems to maintain their overall well-being to continue to age in place. One crucial area for older adults to remain successfully aging in place is managing their chronic health conditions. It is estimated that 80 percent of older adults have at least one chronic health condition (CDC, 2016). If older adults do not successfully manage their chronic health conditions, it can lead to functional impairments that can prohibit them from remaining in their homes and communities to continually age in place. For the purposes of my doctoral capstone project, I created health management programming for the senior program at Flanner House. Flanner House is a non-profit social services agency that offers many services across the lifespan. A needs assessment concluded that an area of interest for the seniors at Flanner House is health management programming (D. White, personal communication, March 2, 2022). Within the scope of occupational therapy, health management is defined as activities related to developing, managing, and maintaining health and wellness routines, including self-management, with the goal of improving or maintaining health to support participation in other occupations (American Occupational Therapy Association, 2020, p. 32). Increased health promotion among community-dwelling aging adults allows for continued aging in place as well as continued participation in meaningful occupations. 4 Background Aging adults, ages 65 and older, value the ability to age in place. Aging in place is defined as remaining living in the community, with some level of independence, rather than in residential care (Wiles et. al, 2012, p. 357; Davey, Nana, de Joux, & Arcus, 2004, p. 133). An inevitable reality in aging adults is functional decline. Functional decline relates to the decrease or absence of physical, social, or thinking capacity (Bosch-Farr et al., 2020, p. 1803). Considering functional decline as an inevitable part of the aging process is crucial when considering the barriers and facilitators to successful aging in place. In a qualitative study, thematic analysis was utilized to understand the key elements that aging adults feel are necessary for successful aging in place (Bosch-Farr et al., 2020, p. 1804). The thematic analysis concluded that aging adults felt these eight categories were imperative to successful aging in place: health, information, practical assistance, finance, activity, company, transport, and safety (Bosch-Farr et al., 2020, p. 18061808). For the purposes of my doctoral capstone project and experience, the barrier to successful aging in place I will be focusing on is the functional decline of an aging adult's health. The functional decline of an aging adults health is related to the chronic conditions that aging adults acquire throughout the aging process (Arbesman & Mosley, 2012). The National Council on Aging reports that aging adults are immensely impacted by chronic conditions such as arthritis, diabetes, and heart disease (2021). The profession of occupational therapy is well suited to address the needs of aging adults as it relates to their decline in health. Health management is an instrumental activity of daily living (IADL) that occupational therapists can assist aging adults in developing routines that help enhance self-efficacy in illness management (Arbesman & Mosely, 2012, p. 278). 5 An intervention approach that can be utilized for chronic condition self-management is Lifestyle Redesign (Scaffa & Reitz, 2020). Lifestyle Redesign is defined as the process of developing and enacting a customized routine of health-promoting and meaningful daily activities (Scaffa & Reitz, 2021, p. 505). Lifestyle Redesign was developed based on the University of Southern California (USC) Well Elderly Study (Jackson et al., 1998). This Seminole research provided insight into the benefits of preventative occupational therapy (OT) for the wellness of aging adults (Jackson et al., 1998). The implications of Lifestyle Redesign born out of the Well Elderly study support that increased awareness and adoption of meaningful and health-promoting routines effectively slows down the declines associated with aging (Florence Clark, F., 2015, p. 4). The population of the Senior Program at Flanner House consists of approximately 5-10 aging adults. The demographics of the aging adults in the senior program are predominantly black women, the youngest being in their late 70s with most members being in their late 80s to early 90s. Individuals in the senior program live independently in the communities of Indianapolis, Indiana that are in close proximity to Flanner House. Concluded through a needs assessment, the seniors reported enjoyment in engaging in health management programming (D. White, personal communication, March 2, 2022). Some of the chronic conditions that the aging adults in the senior program at Flanner House reported having include: high blood pressure, arthritis, sleep apnea, chronic kidney disease, chronic obstructive pulmonary disease, vertigo, and congestive heart failure. Previously Flanner House had a partnership with the Marion County Health Department to provide free health screenings to seniors. The only health management programming that the aging adults at Flanner House have access to is the annual Indiana Public Health Department Black Expo where they receive free preventative health screenings (D. White, personal communication, 6 March 2, 2022). There is a need and an interest among the aging adults at Flanner House for additional health management programming to help better manage chronic health conditions for continued aging in place within the Indianapolis community. Previous literature supports the role of occupational therapy in the health promotion of community-dwelling aging adults. A systematic review of the effectiveness of health promotion, management, and maintenance within the scope of OT determined that there is strong evidence to support the use of group, individual, or a combination of both in improving occupational performance and quality of life (Berger et al., 2018). Brim et al. (2021) discussed self-reported barriers to aging in place. Of the self-reported areas, personal health was one of the biggest concerns for being able to age in place. Health promotion interventions are necessary as well as effective. Research supports the need for community-based occupational therapy in order to create and promote healthy habits that allow for continued aging in place (Turcotte et al., 2015). Although many programs have been developed from the occupational therapy scope to help manage chronic conditions of community-dwelling aging adults, my programming for my doctoral capstone project is unique in addressing the health management needs of black urban community-dwelling aging adults. Prior research has validated that community-dwelling black aging adults are more likely to have unmet needs or under-met needs when compared to white aging adults (Berridge & Morr, 2018, p. 1428). Black aging adults are also disproportionately impacted by chronic health conditions such as hypertension, diabetes, dementia, strokes, and cancer which can lead to lower life expectancies (American Psychological Association, n.d.). My doctoral capstone programming is intended to positively impact and equip black aging adults living with chronic health conditions with the health management tools necessary for continued aging in place while preventing further disability. 7 Theory and Frame of Reference The occupation-based model I will be using to guide my doctoral Capstone experience (DCE) is the Ecology of Human Performance (EHP) model. The EHP model examines the interrelationship between humans, and their environment, and how that relationship contributes to a person's occupational performance and engagement (Cole & Tufano, 2020). This model will help guide my thinking about how the population at my capstone site is currently functioning within their context, with the skills and abilities they have, and with their current task demands. More specifically, this theory will allow me to assess and evaluate how to improve the health management of aging adults at my capstone site to allow them to age in place while managing chronic health conditions continually and successfully. The frame of reference I have chosen to guide my doctoral capstone project and experience is the Lifespan frame of reference. The Lifespan Frame of Reference encompasses understanding the normal developmental tasks within each life stage (Cole & Tufano, 2020). Within this framework, change is facilitated through the adoption of new skills (Cole & Tufano, 2020). The purpose of using the lifespan frame of reference is to empower individuals through education in new skills for managing health. By adopting these new skills, it is hoped that it will allow the aging adults to prolong their health and functional status to remain aging in place for as long as possible. Project Design and Implementation My health management programming consisted of four, thirty-minute to sixty-minute workshops covering health conditions or skills vital to successfully managing ones health. To decide the topics for the health management workshops, an additional needs assessment was completed with the aging adult population at Flanner House. This needs assessment consisted of thirteen questions provided in Table 1 to understand how well the target population currently 8 manages their health. The additional needs assessment also allowed the primary research investigator (myself) to identify the topics the aging adults were interested in learning more about as it relates to managing their chronic health conditions. After collecting the needs assessment data, the aging adults demonstrated the highest interest in the following content areas: Arthritis management, energy conservation, physical activity, and nutrition. For each workshop, an outline for each session was created based on the methods of program delivery from the USC Lifestyle Redesign Program Model (Jackson et al., 1998). As shown in Figure 1 under the methods of program delivery, each health management workshop was structured to include didactic presentation, peer exchange, direct experience, and personal exploration (Jackson et al., 1998). The topics chosen for the health management workshops correlate to some of the original topics for the well-elderly study. However, due to time constraints of programming as well as indicated areas of interest from the aging adults, the workshops utilized Lifestyle Redesign as a guide to developing the program but did not closely follow the criteria that was implemented in the original Well Elderly Study. Resources for the workshops include some interactive worksheets from the book titled Lifestyle Redesign: the intervention tested in the USC well elderly studies by Florence Clark (2015). Other information for developing the program was gathered from research articles from the University of Indianapolis Library databases, the American Occupational Therapy Associations website, Pedrettis Occupational Therapy Practice Skills for Dysfunction textbook (Pedretti et al., 2018), and the Occupational Therapy and Community Health textbook (Scaffa & Reitz, 2020). The project was conducted for a total of four weeks with one thirty-minute to sixty-minute session per week. Attendance records were kept from each session to know which aging adults 9 attended. A pre- and post-survey was given at each workshop. The pre- and post-survey measured if there was an increase in knowledge and confidence with the topics presented. The survey also asked for additional feedback about the structure of the workshops for insight into how these workshops could be improved or sustainable for the site. Challenges included intermittent attendance, absences due to illness or inclement weather, difficulty scheduling programming with multiple doctoral capstone students on site working with the aging adult population, and a small number of participants overall at this site. The successes of the program were interest in the topics, active participation, and flexibility of the participants. Project Outcomes To evaluate outcomes, before and after each of the health management workshops, a pretest was given to participants before content delivery and a post-test was administered after content delivery. The pre and post-test were administered to measure if there was an increase in knowledge or confidence about the following topics: arthritis management, energy conservation, physical activity, and nutrition. The pre and post-test utilized a Likert scale for the participant to rate their knowledge of the workshops topic and how it impacts their everyday routine as well as the participants confidence about the presented topic for each workshop. The participants were informed that 0 was equivalent to no knowledge or confidence and 10 was equivalent to extreme knowledge and confidence. Participants were also given a third question on the pre- and post-test to provide the opportunity to write about something they hope to learn on the pre-test and were encouraged to give feedback about what could be improved on the post-test. This method for evaluating outcomes was chosen due to the inconsistent attendance of members. For each of the four workshops, it was documented that there were 5-6 participants present per workshop but not the same participants were in attendance for each workshop. 10 Administering the pre and post-test for the participants in attendance allowed for data to be collected to measure individual participants increase in knowledge and confidence as well as the group as a whole. In order to protect the confidentiality of the participants, each member was given the code name participant followed by a number. Provided in Tables 2-9, demonstrate each participants results from the pre and post-tests administered for each workshop. Across all health management workshops, participants reported an increase in knowledge and confidence pertaining to each health management topic. Collectively, for the topic of arthritis management, 4 out of 5 participants reported an increase in confidence and 3 out of 5 participants reported an increase in knowledge. For the topic of energy conservation, 4 out of 5 participants reported an increase in confidence and 2 out of 5 participants reported an increase in knowledge. For the topic of physical activity, 4 out of 6 participants reported an increase in confidence and 4 out of 6 participants reported an increase in knowledge. Lastly, for the topic of nutrition, 3 out of 6 participants reported an increase in confidence and 2 out of 6 participants reported an increase in knowledge. Out of the 7 total participants who attended the workshops, 4 of the participants reported that everything went well when asked for feedback about the workshops. One participant reported the nutrition workshop was enjoyable. Overall, many of the participants were able to state various things they learned from the workshops and identify strategies that could be implemented into their daily life to manage their health status. Summary Overall, the increase in knowledge and confidence across all the health management workshops provides additional support to the role of occupational therapy in providing health management education to community-dwelling aging adults (Berger et al., 2018; Jackson et al., 1998; Scaffa et al., 2020; Turcotte et al., 2015). Increased knowledge and confidence about health 11 management skills can lead to increased self-efficacy among community-dwelling-aging adults (Mountain et al., 2008). The more self-efficacy community-dwelling-aging adults have about being able to manage their current chronic health conditions provides a higher likelihood that there will be a carryover of the education and interventions provided about health management topics (Gage et al., 1994; Mountain et al., 2008). Higher levels of self-efficacy can contribute to increased occupational performance to allow aging adults to successfully remain aging in place for as long as possible (Berger et al., 2018; Gage et al., 1994; Mountain et al., 2008). Higher levels of selfefficacy in aging adults can also help to mitigate the perceived self-barriers to successful aging in place such as personal health (Brim et al, 2021). Attainment of higher self-efficacy related to the knowledge and skills acquired from community-based occupational therapy in cohesion with moderate physical activity, aging adults can reduce their risk of falls, increase mental wellness, and prevent cognitive decline (Gage et al., 1994). Community-based occupational-based occupational therapy can also help provide health management intervention to aging adults that are underserved and at risk for occupational deprivation due to low accessibility of resources (Gage et al., 1994). Lifestyle Redesign can be a successful tool to increase the self-efficacy of community-dwelling aging adults' health management routines to promote increased occupational performance within the homes aging adults choose to reside (Clark, 2015; Gage et al.,1994; Scaffa et. al, 2020). Conclusion In conclusion, this research can be utilized to advocate for the continued utilization of occupational therapy in a community-based setting to provide health management interventions. Occupational therapists are well-suited to provide health management education to establish/restore, alter, adapt, promote, and create interventions tailored to community-dwelling 12 aging adults' needs for maintenance of occupational performance while aging in place (Cole & Tuffano, 2020; Jackson et al., 1998). Community organizations, such as Flanner House, benefit from this type of programming to reduce the risk of aging adults' occupational deprivation, increase knowledge and access to educational materials that otherwise might not be obtained, and increase self-efficacy of aging adults to implement newly acquired skills/ behaviors for successful chronic health management. Through the use of occupational therapy, community-dwelling aging adults have an increased chance of continuing to remain aging in their homes while successfully managing chronic health conditions. 13 References American Occupational Therapy Association. (2020). Occupational therapy practice framework: Domain and process (4th ed.). American Journal of Occupational Therapy, 74(Suppl. 2), 7412410010. https://doi. org/10.5014/ajot.2020.74S2001 American Psychological Association. (n.d.). African American older adults and race-related stress. Retrieved January 31, 2023, from https://www.apa.org/pi/aging/resources/africanamerican-stress.pdf Arbesman, M., & Mosley, L. J. (2012). Systematic review of occupation- and activity-based health management and maintenance interventions for community-dwelling older adults. American Journal of Occupational Therapy, 66, 277283. http://dx:doi.org/10.5014/ajot.2012.003327 Berger, S., Escher, A., Mengle, E., & Sullivan, N. (2018). Effectiveness of health promotion, management, and maintenance interventions within the scope of occupational therapy for community-dwelling older adults: A systematic review. American Journal of Occupational Therapy, 72, 7204190010. https://doi.org/10.5014/ajot.2018.030346 Berridge, C., & Mor, V. (2018). Disparities in the Prevalence of Unmet Needs and Their Consequences Among Black and White Older Adults. Journal of Aging & Health, 30(9), 14271449. https://doi.org/10.1177/0898264317721347 Bosch-Farr, C., Malagn-Aguilera, M. C., Ballester-Ferrando, D., Bertran-Noguer, C., Bonmat-Toms, A., Gelabert-Vilella, S., & Juviny-Canal, D. (2020). Healthy Ageing in Place: Enablers and Barriers from the Perspective of the Elderly. A Qualitative Study. International Journal of Environmental Research and Public Health, 17(18). https://doi.org/10.3390/ijerph17186451 14 Brim, B., Fromhold, S., & Blaney, S. (2021). Older Adults Self-Reported Barriers to Aging in Place. Journal of Applied Gerontology, 40(12), 16781686. https://doi.org/10.1177/0733464820988800 Center for Disease Control. (2016, November). Healthy Aging in Action: Advancing the National Prevention Strategy. https://www.cdc.gov/aging/pdf/healthy-aging-in-action508.pdf Clark, F. (2015). Lifestyle redesign: The intervention tested in the Usc well elderly studies. AOTA Press. Cole, M. & Tufano, R. (2020). Applied theories in occupational therapy: A practical approach (2nd Ed.). SLACK Incorporated. Gage, M., & Polatajko, H. (1994). Enhancing occupational performance through an understanding of perceived self-efficacy. American Journal of Occupational Therapy, 48(5), 452452. Jackson, J., Carlson, M., Mandel, D., Zemke, R., & Clark, F. (1998). Occupation in lifestyle redesign: the well elderly study occupational therapy program. The American Journal of Occupational Therapy : Official Publication of the American Occupational Therapy Association, 52(5), 326 Mountain, G., Mozley, C., Craig, C., & Ball, L. (2008). Occupational therapy led health promotion for older people: feasibility of the lifestyle matters programme. British Journal of Occupational Therapy, 71(10), 406413. https://doi.org/10.1177/030802260807101002 15 Pedretti, L. W., Pedretti, L. W., Pendleton, H. M. H., & Schultz-Krohn, W. (2018). Pedretti's occupational therapy: Practice skills for physical dysfunction - 8th. Ed. Elsevier. Scaffa, M. E., & Reitz, S. M. (2020). Occupational therapy in community and Population Health Practice. F.A. Davis. The National Council on Aging. (2021, January 1). Get the Facts on Healthy Aging. The National Council on Aging. Retrieved January 30, 2023, from https://www.ncoa.org/article/get-the-facts-on-healthy-aging Turcotte, P.-L., Carrier, A., Desrosiers, J., & Levasseur, M. (2015). Are Health Promotion and prevention interventions integrated into occupational therapy practice with older adults having disabilities? insights from six community health settings in Qubec, Canada. Australian Occupational Therapy Journal, 62(1), 5667. https://doi.org/10.1111/14401630.12174 16 Table 1 Needs Assessment for Aging Adults at Flanner House Guiding Questions What are your biggest fears/ concerns about taking care of your health? What motivates you to take care of your health? What are tasks in your everyday routine that relate to taking care of your health? What are the barriers (if any) you experience that affect how you are able to manage your health? Does your home/ community have environmental barriers that impact your ability to manage your health? Do you have to manage one or more health problems or conditions? How do your health conditions/problems impact your ability to do the things you want or need to do on an everyday basis? How confident do you feel about your ability to take care of your health at home? Rate your confidence on a scale of 0 to 10? (0= not confident at all, 10= extremely confident) Do you receive help from family members or caregivers to manage your health conditions/ problems? How satisfied are you with your ability to take care of your health? Rate your satisfaction on a scale of 0 to 10. (0= not confident at all, 10= extremely confident) Areas I struggle with when taking care of my health include (circle all that apply); managing my medications, preparing meals that make me feel nourished/energized, physical activity, not having enough energy, stress management, physical barriers, other (list) I am interested in learning the following topics (circle all that apply); diabetes management, heart health management, medication management, physical activity/exercise, healthy nutrition, sleep, home modifications, energy conservation, chronic pain management, arthritis management, mental health management Are there other areas not listed above that you would like to learn more about regarding your health/ health conditions? 17 Table 2 Arthritis Management Pre and Post-Test Results for Confidence Table 3 Arthritis Management Pre and Post-test Results for Knowledge 18 Table 4 Energy Conservation Pre and Post-test Results for Confidence Table 5 Energy Conservation Pre and Post-test Results for Knowledge 19 Table 6 Physical Activity Pre and Post-test Results for Confidence Table 7 Physical Activity Pre and Post-test Results for Knowledge 20 Table 8 Nutrition Pre and Post-test Results for Confidence Table 9 Nutrition Pre and Post-test Results for Knowledge 21 Figure 1 Lifestyle Redesign Programming Model Description: This figure was taken from Jackson et al. (1998) from the Seminole research of the Well Elderly Study that created the Lifestyle Redesign programming. 22 Appendix A Doctoral Capstone Experience Weekly Planning Guide Week 1 2 3 DCE Stage (Orientation, screening/evaluation, implementation, discontinuation, dissemination) 1.) Orientation 2.) Screening/evaluation Screening/evaluation Screening/evaluation Weekly Goal Objectives Tasks Date complete -Orient to site -Orient to the population -Build rapport/relationships with the aging adults -Develop understanding of the health management needs of the population 1/15/23 -Develop understanding of the health management needs of the aging adult population -Write intro/ searched new literature -Administer survey inquiring about health management needs and topics of interest to guide program development -Spent time with the aging adult population engaging in conversation and their meaningful occupations -Developed a survey to understand the health management needs of the population -Researched Lifestyle design -Administered survey to aging adults Wednesday and Friday -Start to work on background information and have project design solidified -Understand program design -Understand areas of interest for health management programming 1/20/23 -Reviewed literature and wrote introduction -Chose health management workshop topics from survey info -Developed pre/post surveys for programming 1/29/23 23 4 Screening/evaluation -Finalize first health management workshop -Finalize Arthritis Management Workshop 5 Implementation -Complete first health management workshop -Implement Arthritis Management Workshop 6 Implementation -Complete second health management workshop -Implement Energy Conservation workshop 7 Implementation -Complete third health management workshop -Implement Physical Activity Workshop 8 Implementation -Complete fourth health management workshop -Implement Nutrition workshop -Information gathering 9 Implementation Community resource creation -Create community resource handout for -Completed background draft -Finalized first workshop for implementation next week -Begin working on gathering community health management resources to design flyers -Implemented workshop -Administered pre/post surveys to measure increase in knowledge and confidence -Implemented workshop -Administered pre/post surveys to measure increase in knowledge and confidence -Implemented workshop -Administered pre/post surveys to measure increase in knowledge and confidence -Implemented workshop -Administered pre/post surveys to measure increase in knowledge and confidence -Began gathering info for flyers about the Arthritis Foundation & Marion County Health Department -Created resource -Worked on outcomes draft 2/3/23 2/10/23 2/17/23 2/24/23 3/3/23 3/10/23 24 10 Implementation Community resource creation 11 Discontinuation & Plan Dissemination Dissemination Planning 12 Plan dissemination 13 Dissemination -Dissemination presentation -Begin work on abstract/ summary/ conclusion -Dissemination presentation -Community Resource Sharing 14 Dissemination -Provide site workshop materials -Complete VoiceThread/ poster draft -Finalize abstract, summary, and conclusion Marion County Health department -Create community resource handout for the Arthritis Foundation -Schedule dissemination with site -Dissemination PowerPoint for site presentation -Presentation of community resources of Marion County Health Department and the Arthritis Foundation to aging adults -Complete dissemination to site -Provide site workshop materials for Flanner House website -Created resource -Began dissemination planning 3/17/23 -Finalized dissemination plan with site -Worked on dissemination PowerPoint for site 3/24/23 -Completed dissemination to site 4/7/23 3/31/23 -Completed Community resource sharing -Worked on abstract, summary, conclusion -Finalized Abstract, summary, and conclusion -Provided site capstone project materials for sustainable use -Began finalizing VoiceThread and poster draft 4/14/23  ...

... OVERCOMING CRCI ORGANIZATIONAL SELF-MANAGEMENT Title: Overcoming CRCI Through Organization Self-Management Strategies Kayla Elstien April 24th, 2023 A capstone project submitted in partial fulfillment for the requirements of the Doctor of Occupational Therapy degree from the University of Indianapolis, School of Occupational Therapy. Under the direction of the faculty capstone advisor: Katie Polo, DHS, OTR, CLT-LANA 1 OVERCOMING CRCI ORGANIZATIONAL SELF-MANAGEMENT 2 Abstract Chemo brain is often used to describe the brain fog that cancer patients experience, yet the correct term is cancer-related cognitive impairments (CRCI) which can happen to anyone diagnosed with cancer, not just those receiving chemotherapy. Due to the limited teachings of this, a 3-part educational program was developed to teach those with CRCI organizational selfmanagement strategies. Three main goals were created which consisted of an increase in participant knowledge, confidence, and resource utilization into daily activities following the completion of the program. The workshops were held using a hybrid model as 90-minute sessions once a week for three weeks addressing the main themes of: time management, physical decluttering, and mental organization. Results indicated a significant increase in all three goals following each presentation theme. The findings from this program highlight the role of OT in providing effective education to cancer patients and survivors experiencing CRCI. Keywords: CRCI, OT, organization, self-management OVERCOMING CRCI ORGANIZATIONAL SELF-MANAGEMENT 3 Introduction Cancer Support Community (CSC) is a non-profit organization with over 175 locations nationwide that provides educational programs and psychosocial support to cancer patients, survivors, and loved ones alike at no cost. The overall mission behind CSC is to ensure that all people impacted by cancer are empowered by knowledge, strengthened by action, and sustained by community (Cancer Support Community Indiana, 2022). It is with their mission in mind that led to the development of my doctoral capstone project which is to create a three-part educational workshop series for cancer survivors involved in CSC who are experiencing cognitive impairments as a result of their treatments, impacting their ability to engage in organization self-management activities of daily life. Research has found that approximately 70% of cancer survivors experience CRCI effects during chemotherapy with a remaining 30% of individuals noting long-term cognitive effects post-treatment (Bolton & Isaacs, 2018; Green et al., 2019, & Wolf et al., 2016). Cancer-related cognitive impairments, (CRCI), are typically noted in areas affecting memory, thinking, and executive function; resulting in further problems related to problem solving, organization, and planning. Therefore, the development of this program is necessary to meet both the needs of cancer survivors involved in CSC struggling with organizational management and the needs of cancer survivors alike experiencing CRCI impacting their abilities to participate in ADLs. The goal of this project is to provide education through an OT lens on organization self-management strategies to improve participation in daily activities that are affected by CRCI. This paper will continue to explore evidence-based findings pertaining to CRCI and the role of OT in cancer survivorship, the design and implementation of the educational workshops, and the outcomes of the program and the impact on both the CSC members apart of the program and the profession as a whole. OVERCOMING CRCI ORGANIZATIONAL SELF-MANAGEMENT 4 Background Cancer Support Community (CSC) began over 40 years ago when Dr. Harold Benjamin had a vision to create a community that would provide free social and emotional support to cancer patients and their loved ones (Cancer Support Community, 2023). What once began as a call to action is now a global community with hundreds of programs and resources available to cancer patients, survivors, caregivers, and loved ones affected by cancer. In 2016, Cancer Support Community conducted a study titled, Access to Care in Cancer 2016: Barriers and Challenges involving 982 CSC members who have a history of cancer with significant results indicating detriments of the healthcare system in providing the care necessary to cancer patients (Cancer Support Community, 2016). Specifically, related to access to service and treatment decision making, 25% of respondents did not feel confident that they received the care they need, 53.5% of respondents reported not receiving social or emotional support services (Cancer Support Community, 2016). Such findings align with existing literature which reports the most frequent unmet need specific to this population was comprehensive care, followed by medical care (Giuliana et al., 2016). Additionally, 22% of respondents reported skipping recommended treatments to maintain out-of-pocket costs (Cancer Support Community, 2016). At Cancer Support Community in Central Indiana, I was informed that about 75% of members were between 60-65 years of age with the remaining 25% under 30 years of age and there is a 3:1 ratio of women to males involved in CSC. Following, most CSC members are at a middle-low income level, hence the necessity of maintaining programs as most clients cannot comfortably afford continuous supportive services. These findings indicate how vital it is to have a global non-profit organization such as Cancer Support Community to provide free educational and supportive services to a underrecognized population. OVERCOMING CRCI ORGANIZATIONAL SELF-MANAGEMENT 5 During my population needs assessment, I conducted a formal interview with my site mentor to determine what my project would be that would fill the greatest need at CSC Central Indiana. When asked, what is the common challenge CSC members are facing and would like additional resources on, my site mentor, Lora Hays, informed me that she has consistently been told by members that they are struggling to stay organized both physically and mentally, feeling overwhelmed (L. Hays, personal communication, March 6, 2022). Based on this common concern, my project was created to develop an educational program focused on overcoming CRCI through organizational self-management strategies. The program would be held as a mini workshop series in which I would provide education and resources on physical and emotional organization ideas in addition to time management strategies. The main outcome goal of this educational program is to see an increase in self-help and satisfaction with the CSC members participants through the resources provided (L. Hays, personal communication, March 6, 2022). When combining the goals from my needs assessment with previous literature, occupational therapy has the potential to play a vital role in cancer survivorship. Researchers Pergolotti and colleagues (2016) emphasized that OT is relevant when cognitive decline has affected ADL/IADL ability, self-care, and activity participation (Pergolotti et al., 2016). This particular study demonstrates the role of OT in cancer care and for my role offering education on CRCI impacts in organization. Following, additional research has suggested interventions focused on increasing knowledge via pamphlets, memory logs and planners, and other adaptations such as home modifications and work-related changes have all been found to improve CRCI and daily functions of cancer patients and survivors (Abraham et al., 2020, Bernstein et al., 2018, Amidei, 2018; & Green et al., 2019). Each of the above interventions have been incorporated into the design of the program. Following, one particular study conducted by OVERCOMING CRCI ORGANIZATIONAL SELF-MANAGEMENT 6 Newman and colleagues (2019), examined CRCI effects in cancer survivors and their ability to independently manage their daily routines while providing strategies to increase occupational engagement through an OT model. While a different program design was utilized, there are similarities in the implementation of the program by offering workshops focused on OT management for CRCI, compensatory strategies, problem-solving, and action planning (Newman et al., 2019). Results from the study indicated significant increases in quality of life, cognitive function, occupational performance, and goal setting (Newman et al., 2019). This study alone shines a promising light on the potential benefits of the educational program created here on improving organizational self-management for those with CRCI. While research in cancer care and survivorship is starting to increase, there is still an overall lack of research addressing CRCI both cancer patients and survivors often experience, supporting the necessity for my educational program to fill the gaps in literature. This program has the ability to add to the limited network of information available on the aftermath of cancer involving CRCI while increasing independence in organizational skills for improved quality of life and participation in daily activities for the participants involved in this program. Program Development Individualized Needs Assessment In order to develop a focused plan for creating the mini educational program lecture series, I conducted an informal interview where participants answered a series of 14 open-ended background questions in addition to 45 4-point Likert scaled questions on various subcategories of executive functioning. This informal interview acted as a second needs assessment at an individual level where only participants who are or have experienced cancer-related cognitive impairments could take-part in in order to develop a more specialized and purposeful workshop OVERCOMING CRCI ORGANIZATIONAL SELF-MANAGEMENT 7 series. Such background questions consisted of, where are you at in your journey with cancer and what type of treatments have you received? how are some of your cognitive struggles impacting your ability to maintain organization?, and what are your biggest strengths and weaknesses when it comes to organization? As for the 45 questioned 4-point Likert scale, 6 questions were based on planning and prioritizing, 10 questions on organization, 9 on memory, 6 on attention, 8 on time management, and 7 on limbic dysfunction and emotional regulation as those were the common areas of dysregulation during and post cancer treatments. The Likert Scale consisted of 1 being strongly disagree to 4 being strongly agree Overall, the questions where more than 80% of individuals reported a 4 were incorporated into the workshop series. Refer to table 1 in the appendix for individual needs assessment data collected and which workshop focused on providing education and resources to such questions and concerns. From this information, I developed my 3-part workshop series with a focus on time management, physical decluttering and organization, and mental and emotional organization. Theoretical Model and Frame of Reference The development of my educational program stemmed from the Dynamic Interactional Model which focuses on highlighting cognition as a continuous, dynamic component between the individual, task, and environment. The models intent is to provide a foundational understanding of function and dysfunction in cognition to develop treatments for adults with brain-injuries (Toglia & Abreu, 1987 ). While not all cancer is specific to the brain, cancer of any kind, any intensity, and any size can have drastic effects on cognition, making this an appropriate occupation-based model to provide an overview for the necessity of my educational program. Additionally, the model specifically assesses structural capacity, metacognitive processes, and learner characteristic. These individual characteristics interact with the environment and task, OVERCOMING CRCI ORGANIZATIONAL SELF-MANAGEMENT 8 and all require a higher set of cognitive skills, such as executive functioning, in order to process information and adapt to the demands of the task at hand. The entire program is based on CRCI where executive dysfunction is a major area of concern, hence the 45 Likert scaled questions during the individual interview portion based on executive functioning to address such issues impacting task completion in the individuals personal and professional environments. Due to the cognitive impairments cancer patients and survivors taking part in my educational workshop have experienced, I adopted a self-management frame of reference to guide my workshops into promoting effective use of self in increased time management, physical organization, and emotional organization skills. Self-management involves six key principles: problem-solving, decision making, resource utilization, patient-provider partnership, action planning, and selftailoring (Lorig & Holman, 2003). All of my workshops emphasized these six core skills by providing education, strategies and resources, and weekly homework to incorporate the newly learned strategies into their daily routines and reflect on the successes and failures of each to increase self-awareness. Goals for the Program The overall goal of this program is to educate cancer patients and survivors at CSC who are or have experienced CRCI on organizational self-management. To achieve this goal, there are three additional goals which are to increase: (1) knowledge, (2) confidence, and (3) access and utilization of available resources into daily routines. The three stated goals will be met via the development, presentation, and outcome evaluation of each educational workshop lecture. Refer to Program Design and Implementation for more information regarding the objectives and components of each workshop. OVERCOMING CRCI ORGANIZATIONAL SELF-MANAGEMENT 9 Program Design and Implementation All individualized interviews were completed prior to the start of the workshop series in order to design each PowerPoint presentation specific to the group needs. The project was carried out once a week as a hybrid in-person and virtual program for three weeks straight to increase inclusivity as not every member can or is comfortable leaving their homes. During each workshop, a pre-test and a post-test was given to assess the goals and objectives of the workshops along with a 1-page homework assignment asking participants to write down three strategies they would want to try to implement into their daily routines to address the principles of self-management. Refer to table 2 in the appendix for a specific outline of workshops. Program Evaluation Participant Demographics All 12 participants that completed the individualized needs assessment completed the first workshop presentation and 9 responded to both the pre-test and post-test. Following, there was one participant who discontinued the program due to personal illness, resulting in 11 participants and 8 responses on both the pre-test and post-test for the second and third workshop presentations. As for the summative final survey, 7 participants out of the 11 completed the questionnaire through Google Forms. Formative Outcome Results For each workshop, a pre-test and post-test was provided to assess the three main goals which are that participants will have an increase in knowledge, confidence, and resource availability and utilization following each workshop topic. To determine this, I created a Google Form with a mixture of standard agree/disagree questions and a 7-point Likert scale questions with 1 being strongly disagree, 4 being neutral, and 7 being strongly agree. The standard OVERCOMING CRCI ORGANIZATIONAL SELF-MANAGEMENT 10 agree/disagree questions pertained to straight forward knowledge questions such as I know what cancer-related cognitive impairment means. For all knowledge-based agree/disagree questions, all participants reported agree that they now know what CRCI is, what OT does, what time management means, what physical organization means, and what mental and emotional processing and organization means following each workshop, respectively. In other words, 100% of participants reported an increase in knowledge in each of the educational-based questions in every workshop, achieving the first goal of the educational program which is to increase knowledge. Moving forward, to address the other two main goals of the educational program: increase in confidence and resource allocation and utilization, the Likert scale questioning was applied. For these questions, a mean score rating of 5 or higher, slightly-strongly agree on the Likert scale, was applied in addition to computing a difference in scores from pre-test to posttest. The difference is the post-test mean minus the pre-test mean. Refer to the table below for specific workshop results in regard to each additional program goal, increased confidence and resource allocation and access. Refer to table 3 in the appendix for statistical outcomes. Summative Outcome Results Following the completion of the mini workshop lecture series, I created a summative report on Google Forms to assess the overall success of the workshop. This survey consisted of a 25 questions with a mixture of agree/disagree statements, open-ended paragraph questions for free versed writing, and another 7-point Likert scale questions with 1 being strongly disagree, 4 being neutral, and 7 being strongly agree. The survey consisted of questions based on the overall content of the workshop, the quality of the workshops and speaker, and the successes and changes participants would like to see if the program were to run again in the future. Overall, 7/7 participants reported they strongly agree that they gained valuable information from this OVERCOMING CRCI ORGANIZATIONAL SELF-MANAGEMENT 11 workshop, the speaker answered all the questions appropriately and in a timely manner, the presentations were well-designed and engaging, and would take this workshop series again or recommend the series to another individual. As for the open-ended questions, significant findings consisted of the program itself and changes participants would like to see, if any. When asked, What specific topics of the workshop series did you find most valuable, answers ranged from information provided in the first workshop all to the final workshop, highlighting the unique differences of each cancer patient or survivor and the effects they personally are experiencing from CRCI effects. As for the strategies discussed and utilized, 100% of participants who completed the survey stated they would continue to utilize the strategies and resources provided from this educational program series and benefitted from the weekly homework to continue to practice and incorporate such strategies into their daily routines. When asked, What would you like to see more of next time if this workshop were to continue, participants mainly stated they would like to have more group discussion time, another workshop added, and longer workshop session in order to cover more material. Summary Cancer Support Community (CSC) is a non-profit organization dedicated to serving cancer patients, survivors, and loved ones through free educational and psychosocial supportive programs. To add to the mission of CSC, I developed an educational program for cancer patients and survivors who are experiencing cancer-related cognitive impairments (CRCI) as it is a common concern for over two-thirds of those diagnosed with cancer. More specifically, after conducting my needs assessment for CSC, it was determined my program would be presented to those with CRCI who are experiencing difficulties with organizational self-management. When developing my educational program as a mini workshop lecture series, I found a significant gap OVERCOMING CRCI ORGANIZATIONAL SELF-MANAGEMENT 12 in evidence-based literature on occupational therapys role in cancer survivorship and in education on CRCI or organizational self-management. Therefore, the development of my program filled both the gaps in literature and in member satisfaction and independence at CSC. It was from the limited research and importance of providing the most useful information to meet my participants organizational needs that I conducted an individual needs assessment. After assessing the individual needs from the 14 open-ended questions along with the 45 4-point Likert scaled questions focused on executive functioning, I created my three-part workshop series focused on three themes: CRCI and time management, physical decluttering and organization, and mental and emotional organization. The three main goals of this educational program were to increase knowledge, confidence, and access and utilization of available resources into daily activities. Each workshop focused on one of the three themes and presented utilizing a hybrid model for 90-minute sessions. For each workshop, a pre-test and post-test was given, respectively, to assess all three of my main goals along with discussion time. Additionally, homework was provided following each workshop to address self-management principles of problem-solving, decision-making, and taking action to incorporate the strategies taught in the workshops into their daily activities. When evaluating my program, results indicated a significant increase in knowledge, confidence, and resource access following each specific workshop, demonstrating success. Along with this, 100% of participants who completed the summative survey stated they gained valuable information from the workshop series and would take this program again or recommend it to another individual in need. Conclusion Overall, my educational program on overcoming CRCI effects through organizational self-management significantly increased participants knowledge, confidence, and resource OVERCOMING CRCI ORGANIZATIONAL SELF-MANAGEMENT 13 access and utilization through various strategies outlined in the workshop series to be incorporated in daily routines. Approximately 70% of cancer patients and survivors experience CRCI while an additional 30% continue to experience these effects long-term yet there is limited education and research on the topic. This program addresses the individual participants needs through the informal interview provided, the site needs through the needs assessment conducted, and the communitys need by paving a pathway for continued research and OTs role in providing care to cancer survivors struggling with CRCI to find new strategies to improve independence and engagement in daily activities. Future work should consist of adding onto this outlined program of different areas that can be affected by CRCI within our OT scope of practice such as sleep and rest, work employment and involvement, social participation, and more detailed information regarding strategies for increased engagement in IADLs. OVERCOMING CRCI ORGANIZATIONAL SELF-MANAGEMENT 14 References Abreu, B. & Toglia, J. (1987). Cognitive rehabilitation: A model for occupational therapy. American Journal of Occupational Therapy, 41(7): 439-448. Abraham, E., Khan, B., Ling, E., & Bernstein, L. (2020). The development and evaluation of a patient educational resource for cancer-related cognitive dysfunction. Journal of Cancer Education, 37: 111-119 Amidei, C. (2018). Symptom-based interventions to promote quality survivorship. Neuro Oncology, 20(S7): 27-39. Baxter, M., Newman, R., Longpre, S., & Polo, K. (2017). Occupational therapys role in cancer survivorship as a chronic condition. American Journal of Occupational Therapy, 71: 1-7. Bernstein, L., McCreath, G., Young, J., Dissanayake, D., & Rich, J. (2018). A brief psychoeducational intervention improves memory contentment in breast cancer survivors with cognitive concerns: Results of a single-arm prospective study. Supportive Care in Cancer, 26: 2851-2859. Bolton, G & Isaacs, A. (2018). Women's experiences of cancer-related cognitive impairment, its impact on daily life and care received for it following treatment for breast cancer. Psychology, Health, and Medicine, 23(10): 1261-1274. Cancer Support Community (2023). About Us. Retrieved on January 28th, 2023, from: https://www.cancersupportcommunity.org/about-us Cancer Support Community. (2016). Access to Care in Cancer: Barriers and Challenges. Retrieved on January 28th, 2023, from: https://www.cancersupportcommunity.org/article/access-care-cancer Cancer Support Community. (2023). Our mission. Retrieved on January 21st, 2023 from: OVERCOMING CRCI ORGANIZATIONAL SELF-MANAGEMENT 15 https://cancersupportindy.org Cole & Tufano (2020). Applied Theories in Occupational Therapy: A Practical Approach (2nd Ed.). Green, H., Mihuta, M., Ownsworth, T., Dhillon, H., Tefay, M., Sanmugarajah, J., Tuffaha, H., Ng, S., & Shum, D. (2019). Adaptations to cognitive problems reported by breast cancer survivors seeking cognitive rehabilitation: A qualitative study. Psycho-Oncology, 28: 2042-2048. Giuliani, M., McQuestion, M., Jones, J., Papadakos, J., Le, L., Alkazaz, N., Cheng, T., Waldron, J., Catton, P., & Ringash, J. (2016). Prevalence and nature of survivorship needs in patients with head and neck cancer. Head and Neck, 1097-1103. Green, H., Mihuta, M., Ownsworth, T., Dhillon, H., Tefay, M., Sanmugarajah, J., Tuffaha, H., Ng, S., & Shum, D. (2019). Adaptations to cognitive problems reported by breast cancer survivors seeking cognitive rehabilitation: A qualitative study. Psycho-Oncology, 28: 2042-2048. Lorig, K. & Holman, H. (2003). Self-management education: History, definition, outcomes, and mechanisms. Annals of Behavioral Medicine, 26(1): 1-7. Newman, R., Lyon, K., Coster, W., Wong, J., Festa, K., & Ko, N. (2019). Feasibility, acceptability, and potential effectiveness of an occupation-focused cognitive selfmanagement program for breast cancer survivors. British Journal of Occupational Therapy, 82(10): 604-611 Pergolotti, M., William, G., Campbell, C., Munoz, L., & Muss, H. (2016). Occupational therapy for adults with cancer: Why it matters. The Oncologist, 21: 314-319. Polo, K. & Smith, C. (2017). Taking our seat at the table: Community cancer survivorship. OVERCOMING CRCI ORGANIZATIONAL SELF-MANAGEMENT 16 American Journal of Occupational Therapy, 71: 1-5. Ulfers, S. & Berg, C. (2017). Occupational therapists with oncology exposure: Perceived Needs of adults and older adults with cancer-related cognitive impairments. OTJR: Occupation, Participation, and Health, 37(3): 149-154. Wolf, T., Doherty, M., Kallogjeri, D., Coalson, R., Nicklaus, J., Ma, C., Schlaggar, B., & Piccirillo, J. (2016). The feasibility of using metacognitive strategy to improve cognitive performance and neural connectivity in women with chemotherapy-induced cognitive impairment. Oncology, 91: 143-152. OVERCOMING CRCI ORGANIZATIONAL SELF-MANAGEMENT 17 Appendix Table 1: Executive Functioning Skills: Pre-Workshop Focused Group Challenges Category Data Collected Subtype Workshop Correlated Planning and 1. I struggle to plan my day ahead of time Workshop Prioritizing 2. When I have a lot to do, I struggle to focus on what 1&2 is important 3. I feel overwhelmed with a busy schedule Organization 1. I often lose or misplace items Workshop 2. I struggle to keep my workspace or headspace clear 1, 2, 3 3. I rarely use supports to help me (physical, technological, friend) Memory 1. I struggle to remember names, dates, places, details Workshop 3 2. I often need reminders or repeated instructions Attention 1. I have a hard time dividing attention Workshop 2. I often feel distracted 1, 2, 3 3. When interrupted, I lose my train of thought Time 1. I have trouble started or finishing projects Management 2. I do not have enough time to accomplish daily tasks Workshop 1 3. Things seem to take longer than expected Limbic Dysfunction 1. I feel my fatigue and pain impacts my ability to stay organized Workshop 3 OVERCOMING CRCI ORGANIZATIONAL SELF-MANAGEMENT and Emotional Regulation 18 2. I feel overwhelmed and stress thinking about organization Table 2: Education Program Workshop Series Outline Workshop Objectives and Components Duration and Title 1: Get Date 1. Obtain completed individual needs assessments and Presentation Organized! interviews from participants prior to educational Length: 90 Time series mins Management and Energy Conservation 2. Introduce the series and incorporate a group ice breaker 3. Provide and discuss workshop pre-test/post-test 4. Define and educate on cancer-related cognitive impairments (CRCI) signs and symptoms, role of OT, time management strategies, and energy conservation 5. Allot time for Q&A at the end of the session 6. Discuss the purpose and objectives of the weekly homework 7. Follow-up with all members via email and provide all materials from presentation (i.e., PowerPoint PDF, additional list of, weekly homework) Date: 02/13/2023 OVERCOMING CRCI ORGANIZATIONAL SELF-MANAGEMENT 19 2: Get 1. Review weekly homework as a group Presentation Organized! 2. Provide and discuss workshop pre-test/post-test Length: 90 Physical 3. Define and educate on physical space and home mins Decluttering organization, S.P.A.C.E strategy, and home and modifications Organization 4. Allot time for Q&A at the end of the session Date: 02/20/2023 5. Reiterate weekly homework objectives 6. Follow-up with all members via email and provide all materials from presentation (i.e., PowerPoint PDF, additional list of resources, weekly homework) 3: Get 1. Review weekly homework as a group Presentation Organized! 2. Provide and discuss workshop pre-test/post-test Length: 90 Mental and 3. Define and educate on mental and emotional mins Emotional organization, direct and indirect effects of cancer Processing treatments on emotion, and strategies to improve Date: and headspace 02/27/2023 Organization 4. Allot time for Q&A at the end of the session 5. Reiterate weekly homework objectives 6. Follow-up with all members via email and provide all materials from presentation (i.e., PowerPoint PDF, additional list of resources, weekly homework) OVERCOMING CRCI ORGANIZATIONAL SELF-MANAGEMENT 20 Table 3: Workshop Goals: Confidence and Resource Availability Program Results Pre-Test Post-Test (M)* (M)** Difference Workshop 1: CRCI Effects & Time Management Strategies Confidence (number/8) 2.6 5.0 2.4 Resource Availability 3.4 5.9 2.5 Confidence (number/7) 4.3 6.0 1.7 Resource Availability 3.7 6.1 2.4 Confidence 3.7 5.7 2.0 Resource Availability 4.0 6.3 2.3 Workshop 2: Physical Decluttering & Organization Workshop 3: Emotional Processing & Mental Organization *Mean values were calculated from 8 participants from workshop **Mean values were calculated from 7 participants from workshop 2-3. OVERCOMING CRCI ORGANIZATIONAL SELF-MANAGEMENT Wee k 1 21 DCE Stage (orientation, screening/evaluatio n, implementation, discontinuation, dissemination) Weekly Goal Objectives Tasks Date complete Orientation 1. Complete orientation by the end of the week 2. Complete evidencebased literature search 3. Guest Speak at Educational Program Nurse Navigation meeting Meet with site mentors, staff, and other personnel on-site at CSC and introduce myself, my role, and the upcoming program I am implementin g Complete a walk-through of CSC 01/10/23 Prepare short introduction of myself, the role of OT, and the purpose and plan for my educational workshop series to present at the Nurse Navigation meeting Refer back to literature search done in class and 01/11/23 Develop a short introduction of my role, the role of OT, and the purpose of my 01/13/23 educational workshop to present to the 01/12/23 Nurse Navigator meeting and for all future meetings Update evidencebased literature Set time aside to meet with site mentors, Lora Hays and assistant Hunter Stafford to discuss future meeting OVERCOMING CRCI ORGANIZATIONAL SELF-MANAGEMENT review new evidencebased research added since last checked utilizing UIndy databases 22 times and schedule Review my work schedule, hours, and weekly meeting times 2 Screening/Evaluatio n 1. Continue web search for upcoming workshops 2. Complete Introduction draft of Scholarly Report 3. Attend staff and program meetings Document web search findings for intervention ideas and for background information on CRCI signs and symptoms Review site and purpose of my education program Ensure speech for staff and program meetings is rehearsed Create a google drive for my capstone and folders with necessary information and findings from web search Draft Introduction section of Scholarly Report Write out speech for staff and program meetings and save in google drive to refer back to 01/17/23 01/29/23 01/16/23 01/19/23 OVERCOMING CRCI ORGANIZATIONAL SELF-MANAGEMENT 3 Screening/Evaluatio n 1. Continue web search for upcoming workshops 2. Develop interview questions for CSC members participatin g in workshop series 3. Practice and take Distresser Screening 4. Rough draft of outlines for upcoming workshops 5. Complete Background draft for Scholarly Report Document web search findings for intervention ideas and for time managemen t strategies 23 Meet with Lora on Thursday to determine next weeks plan (scheduled meetings are on Thursdays) All 01/26/23 documentatio n completed prior to Thursdays 01/26/23 meeting Create a rough draft Document of interview web search questions for prebefore establish Thursdays screening meeting to tools and review assessments questions that focus with site on executive mentor functioning Create Plan a time rough draft to meet to of interview learn what questions the Distress screen is, Meet with how to take advisor to it, and how practice and to send it to take the participants Distresser screening Create a assessment rough draft of all 3 Develop a workshop rough draft outlines and of workshop have them outlines finalized and 01/26/23 01/27/23 01/29/23 01/29/23 OVERCOMING CRCI ORGANIZATIONAL SELF-MANAGEMENT Review scholarly articles and evidencebased research for my background portion of my scholarly report 4 Screening/Evaluatio n 1. Finalize interview questions 2. Complete as many phone call interviews as possible 3. Reach out x2 to each member by the end of the week for those who have not answered 4. Update CSC member information to keep track of all phone calls made and missed 5. Begin my PowerPoint presentation for my first workshop Finalize interview questions in order to begin making phone calls to CSC members interested Begin phone call interviews to CSC members interested in workshop series Quantify and qualify all answers received from phone calls and send out a follow-up email after each call 24 stored in the appropriate Google folder Draft Background section of Scholarly Report Begin to plan phone call interview times Meet with 01/30/23 Katie Polo Monday morning to ensure interview questions are 01/31/23appropriate, 02/03/23 meaningful, and effective Refer to Microsoft Excel sheet to contact CSC members interested and mark each as complete when the interview is finished Re-assess all information received during the phone calls made and 01/31/2302/03/23 02/03/23 02/05023 OVERCOMING CRCI ORGANIZATIONAL SELF-MANAGEMENT 6. Complete Project draft for Scholarly Report Update all CSC member information in Microsoft Excel to track member interview completion Create at least half of my PowerPoint for my first workshop Complete the Project draft of my Scholarly Report for class 5 Screening/Evaluatio n 1. Continue to complete phone call interviews 2. Complete my PowerPoint for the first workshop series Continue phone call interviews in order to have as much information going into series as possible 25 send out a follow-up email to each individual with their results from my questions without the notes added. Separate the notes and questions into different documents and store all in Google drive folder dedicated to CSC Interview Completions Develop part of my PowerPoint for the first workshop series Draft the Project section of the Scholarly Report Meet with Hunter Stafford to discuss successes and challenges with phone call interview process 02/07/202 3 02/06/202 302/12/202 3 OVERCOMING CRCI ORGANIZATIONAL SELF-MANAGEMENT 3. Update CSC information to keep track of all phone calls made and missed 4. Open CSC on Saturday independent ly 6 Screening/Evaluatio n& Implementation 1. Present first workshop series 2. Ensure PowerPoint is ready to be presented Complete PowerPoint and send to be reviewed Update all CSC member information in Microsoft Excel to track member interview completion 26 Refer to Microsoft Excel sheet to determine when to recontact CSC member who I was unable to get a hold of prior to workshop Re-assess all information received from Review interviews Saturday and send a program follow-up itinerary and email to each protocols participant when completed Finalize all PowerPoint details Set-up the room I will be Open CSC independentl y Saturday, set up the center and all rooms being utilized by various groups, close the center with everything armed and locked Review PowerPoint prior to presenting Complete room set-up including all 02/06/202 302/12/202 3 02/11/202 3 02/13/202 3 02/13/202 3 OVERCOMING CRCI ORGANIZATIONAL SELF-MANAGEMENT and working as planned 3. Wrap-Up final phone call interviews if leftover 4. Begin and complete my second PowerPoint for the following workshop 5. Send out a thank you email for attending with all relevant information attached 7 Implementation 1. Present second workshop series 2. Ensure PowerPoint is ready to be presenting in Update all CSC member information in Microsoft Excel Update all information, interviews, and surveys in Google Drive Draft Second PowerPoint Have second PowerPoint reviewed and finalized 27 technology with hybrid course layout Draft 2nd PowerPoint in order to get it assessed by Katie Polo and Hunter Attend weekly meeting on Thursday with PowerPoint draft completed Send out all thank you, list of interventions , weekly homework, and Send out PowerPoint thank-yous, PDF to all list of members additional intervention Answer all s, and emails within weekly 24 hours of homework receiving from members Finalize all Review PowerPoint PowerPoint details prior to presenting Set-up the room I will Complete be room set-up including all 02/14/202 302/15/202 3 02/16/202 3 02/14/202 3 02/14/202 302/19/202 3 02/20/202 3 02/20/202 3 OVERCOMING CRCI ORGANIZATIONAL SELF-MANAGEMENT presented and working as planned 3. Begin and complete my third PowerPoint for the following workshop 4. Send out a thank you email for attending with all relevant information attached 5. Complete Midterm Evaluation 8 Implementation & Discontinuation 1. Present third and final workshop series 2. Ensure PowerPoint is ready to presenting in Update all CSC member information in Microsoft Excel Update all information, interviews, and surveys in Google Drive Draft Third PowerPoint Have third PowerPoint reviewed and finalized 28 technology with hybrid course layout Draft 3rd PowerPoint in order to get it assessed by Katie Polo and Hunter Attend weekly meeting on Thursday with PowerPoint draft completed Send out all thank you, list of interventions , weekly Send out homework, thank-yous, and list of PowerPoint additional PDF to all intervention members s, and weekly Answer all homework emails within 24 hours of receiving from members Finalize all Review PowerPoint PowerPoint details prior to presenting Set-up the room I will Complete be room set-up including all 02/21/202 302/22/202 3 02/23/202 3 02/21/202 3 02/21/202 302/26/202 3 02/28/202 3 02/28/202 3 OVERCOMING CRCI ORGANIZATIONAL SELF-MANAGEMENT 3. 4. 5. 6. 7. be presented and working as planned Begin and complete my third PowerPoint for the following workshop Send out a thank you email for attending with all relevant information attached Go to food pick-up for new initiative Tuesday with CSC staff member into the community Meet with Katie Polo virtually to discuss program measureme nts and outcomes Finalize condensed PowerPoint to present at CSC Bloomingto n presenting in Update all CSC member information in Microsoft Excel Update all information, interviews, and surveys in Google Drive 29 technology with hybrid course layout Attend weekly meeting on Thursday to discuss program Send out all thank you, list of interventions , weekly homework, Send out and thank-yous, PowerPoint list of PDF to all additional members intervention s, and Answer all weekly emails within homework 24 hours of receiving Offer 1-1 from coaching members session to all Contact participants George and ensure our Go with times George, CSC staff, Meet to assist in virtually with food Katie Polo initiative on food pantry Wednesday pick-up to discuss program Meet with measurement Katie Polo s, outcomes, on and data Wednesday 03/02/202 3 02/28/202 3 02/28/202 303/06/202 3 02/28/202 3 03/01/202 3 03/03/202 3 OVERCOMING CRCI ORGANIZATIONAL SELF-MANAGEMENT 9 10 Dissemination Dissemination 1. Begin to help and work at the front desk T/Th 2. Meet with Katie Polo on Tuesday virtually 3. Meet with Hunter for our weekly meeting on Thursday to check-in 4. Begin to research for Family Day event ideas 5. Start to assess disseminati on plans 1. Begin to help and work at the front desk T/Th 2. Meet with Katie Polo Complete and send Katie Tremel, CSC Bloomingto n, condensed organization PowerPoint Work the front desk Tuesday and Thursday from 9:3011am Meet with Katie virtually Tuesday to discuss theories and frame of reference Meet with Hunter for weekly check in Start to research Family Day ideas for organization for children and parents Work the front desk Tuesday and Thursday from 9:3011am 30 Complete and send condensed organization PowerPoint to CSC Bloomington Attend front desk duties and answer all phone calls during my shift Meet with Katie on Tuesday, plan for next meeting Meet with Hunter and discuss a summative survey Begin research for Family Day event April 29th Attend front desk duties and answer all phone calls during my shift 03/07/202 3 03/09/202 3 03/07/202 3 03/09/202 3 03/08/202 303/10/202 3 03/14/202 3 03/16/202 3 03/14/202 3 OVERCOMING CRCI ORGANIZATIONAL SELF-MANAGEMENT on Tuesday virtually 3. Send summative survey 4. Attend supportive staff meeting on Thursday 5. Start to assess disseminati on plans and work on disseminati on plan worksheet Meet with Katie virtually Tuesday to discuss disseminatio n plans and data format 31 Meet with Katie on Tuesday and discuss disseminatio n plans Create and send to all Create CSC summative members survey and summative send to CSC google form participants survey Attend Supportive Staff meeting on Thursday Attend monthly supportive staff meeting on Thursday with Lora back! 03/14/202 303/15/202 3 03/16/202 3 03/15/202 303/17/202 3 Work on disseminatio Complete n plan and worksheet disseminatio n plan worksheet and review previous paper submission and re-edit 11 Dissemination 1. Continue to help and work at the front desk T/Th 2. Meet with Katie Polo virtually 3. Review summative Work the front desk Tuesday and Thursday from 9:3011am Attend front desk duties and answer all phone calls during my shift Meet with Katie virtually and Hunter in- Meet with Katie and Hunter to discuss 03/21/202 3 03/23/202 3 03/21/202 3 OVERCOMING CRCI ORGANIZATIONAL SELF-MANAGEMENT 4. 5. 6. 7. survey results Meet with Hunter Stafford inperson Tuesday Complete resource binder for CSC Open for CSC Saturday Finish disseminati on plan and continue to work on scholarly report person about my project and scholarly report Review summative survey results and randomly select 2 winners for completing the report Complete resource binder for CSC for all my work Come to CSC by 9am to open the building for support program on Saturday 32 disseminatio n plans and scholarly report Analyze summative survey results and randomly select 2 winners Start and finish resource binder for CSC Open CSC on Saturday from 9am12pm and greet all guests for supportive programs 03/20/202 303/23/202 3 03/21/202 303/22/202 3 03/25/202 3 03/20/202 303/25/202 3 Complete disseminatio Complete n plan disseminatio worksheet n plan and and work on submit drafts for scholarly Work on report drafts of scholarly report to be reviewed by Katie 12 Dissemination 1. Continue to help and work at the Work the front desk Tuesday and Thursday Attend front desk duties and answer all phone 03/28/202 3 03/30/202 3 OVERCOMING CRCI ORGANIZATIONAL SELF-MANAGEMENT 2. 3. 4. 5. front desk T/Th Ensure my PowerPoint presentation is ready for CSC in Bloomingda le Present my condensed organizatio n workshop at CSC Bloomingto n on Wednesday Hold Coffee and Coloring on Thursday for Hunter Continue to work on scholarly report from 9:3011am calls during my shift Review PowerPoint for Wednesday and make sure Katie at Bloomingto n can access Review and present PowerPoint at Bloomington CSC on Wednesday Drive and present Get Organized! Workshop to Bloomingto n Wednesday Lead Coffee and Coloring Thursday since Hunter will be out of office and stay actively on Zoom with participants Lead Coffee and Coloring on Thursday 10-11am Continue to work on drafts of scholarly report to be reviewed by Katie 13 Dissemination 1. Continue to help and work at the front desk Th only (remote T) 2. Finalize Family Day Event Get Organized workshop 33 Work the front desk Thursday Finalize Family Day Event PowerPoint on organization for families 03/29/202 3 03/30/202 3 03/27/202 304/02/202 3 Continue to work on drafts for scholarly report and begin to discuss plans for SIS Quarterly Attend front desk duties and answer all phone calls during my shift Complete Family Day PowerPoint to send to 04/06/202 3 04/03/202 3 OVERCOMING CRCI ORGANIZATIONAL SELF-MANAGEMENT 14 Dissemination 34 3. Meet with Hunter Thursday for my final evaluation 4. Continue to work on scholarly report, specifically abstract, summary, and conclusion since the drafts are due this week and teenagers 1. Continue to help and work at the front desk T/Th 2. Meet with Katie virtually on Wednesday 3. Continue to edit scholarly report if needed Work the front desk Tuesday and Thursday from 9:0011am Attend front desk duties and answer all phone calls during my shift Meet with Katie to discuss SIS Quarterly and any edits to scholarly report Meet with Katie from 11:30 virtually on Wednesday for scholarly report questions Meet with Hunter to complete final evaluation Continue to work on scholarly report for edits and contact Katie to meet next week to focus more on SIS Quarterly as the scholarly report will mainly be finished Hunter to review for April 29th 04/06/202 3 Meet Hunter Thursday in the conference room to 04/03/202 discuss and 3complete 04/8/2023 final evaluation and complete mine on CSC following Continue to work on drafts for scholarly report and start to look into SIS Quarterly more intensely with meeting time set-up with Katie 04/11/202 3 04/13/202 3 04/12/202 3 OVERCOMING CRCI ORGANIZATIONAL SELF-MANAGEMENT 4. Meet with Lora on Thursday 5. Outline and write SIS Quarterly draft 35 and SIS Quarterly Continue to make edits Meet Lora in as needed for scholarly her office from 3-4 report Thursday to Meet with wrap up my time at CSC Lora to catch-up Continue to with my capstone edit scholarly ending report as needed and Outline and write SIS write SIS Quarterly Quarterly 04/13/202 3 04/10/202 304/14/202 3  ...

... TIC COMPETENCY 1 Peyton Manning Childrens Hospital (PMCH) Trauma-Informed Care (TIC) Competency Hannah Droste, OTS, PCBIS May 2023 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: Kelsey Peter OTD/OTR Under the direction of the site mentor: Christian Chenae Van Zee, MS, OTR/L, C/NDT TIC COMPETENCY 2 Abstract The purpose of this doctoral capstone project was to fill a gap in the pediatric competency at Peyton Manning Childrens Hospital. The intention of the pediatric competency was to fulfill a requirement set by the Joint Health Commission: the competency must educate providers with the most recent evidence-based information to ensure the highest quality of care. During the needs assessment, the pediatric manager recognized that the pediatric competency was not up to date. This gap was filled by developing and implementing a fifty-minute educational module on Trauma-Informed Care and related subjects for the interdisciplinary therapy staff over three weeks. A pre- and post-module survey based on Schmitz et al (2019) was utilized to assess the effectiveness of the module on the staff. The outcomes of this project found an increase in confidence and ability to discuss/apply these topics to practice following the educational module, which was deemed effective. Implications for the future suggest that occupational therapists and other professionals working in pediatrics should complete a comprehensive TIC module customized to meet the specific needs of their profession and population. Keywords: trauma-informed care, pediatric, competency, interdisciplinary therapy TIC COMPETENCY 3 Peyton Manning Childrens Hospital (PMCH) Trauma-Informed Care (TIC) Competency Peyton Manning Childrens Hospital (PMCH) embodied the mission of the Ascension St. Vincent Indianapolis Foundation: Rooted in the loving ministry of Jesus as healer, we commit ourselves to serving all persons with a special attention to those who are poor and vulnerable. Our Catholic health ministry is dedicated to spiritually centered, holistic care, which sustains and improves the health of individuals and communities. We are advocates for a compassionate and just society through our actions and our words. (Ascension St. Vincent Foundation, n.d.). The idea for the capstone project developed from a need that the Pediatric Manager, Patterson, readily identified. The onboarding process at PMCH required new hires, including physical therapists (PT), occupational therapists (OT), and speech-language pathologists (SLP), to meet competency in areas that were relevant when working with the pediatric population. An area that was relevant but had not yet been addressed with the interdisciplinary staff at PMCH is Trauma-Informed Care (TIC). Accordingly, this project resulted in the staff becoming extensively competent in TIC through the in-depth educational module on TIC and related topics. Additionally, a pre- and post-module survey was in place to measure the effectiveness of the module. The capstone captured the mission of PMCH and filled the current gap by deeming interdisciplinary staff (inpatient and outpatient) competent in TIC, meeting Joint Health Commission (JHC) requirements, and indirectly influencing patients at PMCH likely to be more susceptible to trauma due to their demographics and/or hospital experience. TIC COMPETENCY 4 Background In 2020, Indianapolis was by far the largest city in Marion County with a population covering 90.9% (STATS Indiana, 2020). It was estimated that there were 7.1% and 17.0% of preschool (0-4) and school-age (5-17) children who resided in Marion County, respectively (STATS Indiana, 2020). Regarding race distribution, it was estimated that there were 29.5% Black people, 62.8% White people, 11% Hispanic people, and 4% Asian people (STATS Indiana, 2020). Most people in the county lived alone at 37.7%, 13.5% of people were married with children, and 11.1% of people were single parents (STATS Indiana, 2020). These statistics were relevant to the population served at PMCH as the hospital was located in this county. The needs assessment interview provided more in-depth information about the demographics of patients treated at PMCH. The pediatric manager mentioned that their 86th Street location served approximately 70% of low-income patients on Medicaid and the other 30% were considered middle class (E. Patterson, personal communication, March 9, 2022). Most of the patient population consisted of Hispanics, and they occasionally treated refugees as well (E. Patterson, personal communication, March 9, 2022). Researchers found that the Hispanic and Latinx population were more at risk than the general population for adverse childhood experiences, or ACEs (Melndez Guevara et al., 2021). Additionally, refugees experienced higher rates of trauma and ACEs due to systematic racism, social upheaval, violence in their country of origin, transitional living arrangements and displacement from homes, uncertainty of the future, loss of family members, and poverty stressors (Sala-Hamrick et al., 2021). Evidence indicated that one who experienced four or more ACEs was at a significantly increased chance to develop chronic diseases including cancer, heart disease, diabetes, health risk behaviors, and potentially early death (Boullier & Blair, 2018). Therefore, one reason TIC was needed at PMCH TIC COMPETENCY 5 was to improve healthcare for the Hispanic and Latinx population, which comprises the majority of patients, but also all children served that were susceptible to trauma. Another purpose was to fulfill a regulation that the Joint Health Commission (JHC) required; this enterprise accredited and certified Ascension St. Vincent (The Joint Commission, 2022). JHC provided an unbiased assessment of organizations by evaluating patient care and safety (The Joint Commission, 2022). JHC required staff to be deemed competent in relevant areas, such as TIC (E. Patterson, personal communication, March 9, 2022). Patterson believed that TIC impacted most patients at PMCH and was important to the professions of PT, OT, and SLP (E. Patterson, personal communication, March 30, 2022). The synthesis of the literature on TIC indicated that healthcare providers who received training on this topic had increased beliefs, knowledge, self-efficacy, confidence, frequency of discussion, empathy, understanding of the complex nature of trauma responses, and sought further trauma training (Berg-Poppe et al., 2021; Dublin et al., 2021; Schmitz et al., 2019). Despite the literature on TIC training and its beneficial outcomes, Alisic et al. (2017) found that providers were least aware that majority of children experienced posttraumatic stress following an injury. In comparison, Bruce et al. (2018) noted that most providers were aware that adult patients who were seriously injured had at least one traumatic stress reaction to follow. The implication of this comparison was profound and revealed the need for terms, like pediatric medical traumatic stress (PMTS), to be taught to healthcare providers (Stenman et al., 2019). PMTS was defined as a set of psychological and physiological responses of children and their families to pain, injury, serious illness, medical procedures, and invasive or frightening treatment experiences (Stenman et al., 2019, p.8). These psychological and physiological symptoms included: intrusive thoughts, hyperarousal, avoidance of trauma-related stimuli, and TIC COMPETENCY 6 negative thoughts or feelings (Stenman et al., 2019, p.8). Another relevant term was one identified by Hoysted et al. (2018) and Price et al. (2016), the peri-traumatic period. This was described as the period immediately following an injury, considered to be a critical period, that included an initial Potentially Traumatic Event (PTE) (Price et al., 2016). A PTE was defined as situations like transportation to the hospital, invasive medical procedures, or communication of a life-threatening injury or illness (Price et al., 2016). It was recommended that the peri-traumatic period was the best time for providers to prevent traumatic stress (Hoysted et al., 2018; Price et al., 2016). Price et al. (2016) found that pediatric injury and cancer offered the largest number of estimated prevalence of PMTS, both of which were treated at PMCH. If providers had knowledge of PMTS and PTE, the childrens behaviors that arise from trauma could be better understood. Brown et al. (2017) found that children who experienced trauma reacted to healthcare differently than if they did not have trauma. These reactions might include anxiety, aggression, anger, and similar expressions of emotion due to a lack of environmental control (Lerwick, 2016). Additionally, Lyons (2021) stated that children with trauma perceived sensory input through a lens of safety and defense because they were in survival mode rather than typical exploration. Children with trauma could act in inapt ways, therefore providers observation and caregiver report of unfitting behaviors might indicate that the child was experiencing trauma or stress and require further treatment. Given that the current literature extensively covered TIC and its program development, there have not been many shortcomings. However, the development of this specific program for PMCH was directed toward their patient demographics and synthesized previous studies creating an extensive competency for the interdisciplinary staff. TIC COMPETENCY 7 Theory The Person-Environment-Occupation-Performance, or PEOP, Model was an appropriate fit for the TIC Competency at PMCH. The model followed a general guideline when applied to organizations like PMCH. The PEOP steps included: needs assessment, determining occupational needs and the role of OT, defining the goals of the organization, finding a match between organization wants and accomplishing pre-determined goals via OT services, identifying the intrinsic and extrinsic factors that supported or inhibited occupational performance, developing a plan, implementing the plan, and evaluating the outcome (Christiansen, Baum, & Bass, 2011). This approach helped guide the project design, implementation, and evaluation through a step-by-step process that met the occupational performance goals for PMCH. In addition to PEOP, the Lifespan Development Frame of Reference (FOR) by Lela Llorens was applicable to this capstone project. Llorens viewed development as both horizontal and longitudinal. By updating the competency with evidence-based TIC, the interdisciplinary staff were able to treat their patients through a trauma-informed lens leading to further growth of the patient, both horizontally and longitudinally. The combination of the PEOP Model and Lifespan Development FOR encompassed the impact that the competency had on both the staff and the patients (Appendix A). Project Design & Implementation This project was developed with the intention to fulfill JHC competency requirements at PMCH. TIC was a pertinent topic that met the needs of this requirement and the population served. The outcome assessment chosen to evaluate the educational module was based on the Schmitz et al (2019) pre- and post-module survey. This article was selected as the basis for the TIC COMPETENCY 8 outcome assessment since their study was similar to this project. Schmitz et al. researched the impact of a self-directed module about ACEs, TIC, toxic stress, and resiliency on the perceived importance, confidence, and frequency of discussion about these topics for pediatricians (2019). They suggested that this type of module could be applied to other healthcare professionals, which supported this projects competency with interdisciplinary staff (Schmitz et al., 2019). The project was carried out in a systematic order that was defined in the Memorandum of Understanding. Although the sequencing of the project was consistent with this plan, the timeline differed. The timeframe for the schedule moved forward as I was able to complete tasks faster than originally planned. The order of tasks included pre-survey development and implementation, the outline of the module, the content of the module, voice-over recording for the module, implementation of the module, and development and implementation of the postsurvey, correspondingly (see Appendix B). Another reason for the success of the project was that the manager made the surveys and educational module mandatory for the staff to complete; this likely contributed to the large number of responses received for the surveys. One of the challenges in the execution phase of the project was that the interdisciplinary staff worked in varying office locations. This caused some changes, as I initially planned on introducing myself at a lunch and learn and having the staff complete the pre-survey while at the event. Although I was unable to introduce myself to all the staff, I introduced myself and my project to the Carmel, IN outpatient location which helped build rapport with staff at this location. Another challenge was that an employee presented on the topic of Trust-Based Relational Intervention (TBRI) around the same time as my project implementation. It could be possible that this affected some of the pre-survey answers if employees had attended her presentation prior to taking the pre-survey. It also could have affected the post-survey results as TIC COMPETENCY 9 the staff might have generalized their knowledge between the TBRI presentation and the TIC educational module. Although it could have affected the data of the surveys, the additional education from the TBRI training could reinforce the concepts provided in the educational module. It was expected that the combination of the two deemed the staff more competent than if they received the educational module alone. Outcomes The assessment tool was constructed from the Schmitz et al (2019) pre- and post-module surveys (see Appendix C and D, respectively). The pre-survey received 55 responses, while the post-survey received slightly fewer responses at 44. Question 1 (Figure 1, Figure 2) regarded the staffs confidence in their knowledge of TIC and ACEs. Most responded in the pre-survey as not confident, slightly confident, and neutral. The post-survey showed an increase in confidence with the majority of responses rated between somewhat confident and very confident. Question 2 (Figure 3, Figure 4) also pertained to the confidence of these topics regarding discussion of them rather than knowledge. The responses in the pre-survey indicated that most were not confident and slightly confident while the post-survey indicated that most were neutral and somewhat confident, indicative of an increase in confidence of discussion. In response to the third question (Figure 5) about the current discussion of ACEs and TIC, most people answered in the pre-survey no visits and rare visits. Whereas in the postsurvey, 50% of respondents answered some visits, and the second highest percentage at 27.3% answered most visits. The fourth question (Figure 6) regarding the frequency of clinical decision making, showed most initial responses as never, rarely, and occasionally. Following the module, the responses were split relatively evenly between usually and always. The fifth question (Figure 7) inquired about the importance of discussing these topics; the majority replied neutral, TIC COMPETENCY 10 somewhat important, and very important in the pre-survey, while most responded somewhat important and very important in the post-survey. Lastly, according to Figure 9, 96.4% of staff thought that becoming more competent in ACEs and TIC could benefit them as practitioners. These outcomes indicated increased confidence of knowledge, discussion, and importance of ACEs and TIC. It also suggested that staff members could engage in discussion of these topics more frequently and that it could have a greater effect on clinical decision making than it did prior to the competency. The effectiveness of this training module on clinical decision making was rated by most as somewhat effective, with the second highest rated as very effective. 95.5% of staff would recommend this training module to others (Figure 10). Most of the staff who completed this educational module planned to seek further information on the topics at 67.4% (Figure 12). The main finding of the outcomes was that this educational module was deemed effective, recommended to others, and increased staff members' confidence in their knowledge, discussion, and importance of TIC and related topics. Summary The needs assessment performed on March 9, 2022, revealed gaps within the pediatric competency at PMCH. A regulation that many hospitals were accredited and certified by, including Ascension St. Vincent, was the JHC (The Joint Commission, 2022). The JHC required the competency to be up to date to ensure that providers were delivering the highest quality of care (E. Patterson, personal communication, March 9, 2022). To fulfill the JHC requirements while meeting the needs of the population served, the competency was updated to include a 50minute educational module on TIC for interdisciplinary therapy staff. The educational module was composed of TIC, including its assessment and intervention, and related subjects like ACEs, toxic stress, resilience, PMTS, and secondary traumatic stress. TIC COMPETENCY 11 To evaluate the educational module, the project included a pre- and post-survey based on past research that investigated the impact of a self-directed module on TIC and connected subjects created for pediatric residents (Schmitz et al., 2019). Following the implementation of the PMCH TIC Competency, the results of the surveys were analyzed. The results indicated an overall increase in staffs confidence in their knowledge, discussion, and importance of TIC and ACEs. Additionally, the frequency of discussion and the effect of these topics on clinical decision making increased following the training. This educational module was found to be effective, and 95.5% of staff reported that they would recommend it to others. Most staff planned to or already had continued their education on these topics by seeking further information. The main finding was that this educational module was considered effective, increased knowledge that led to changes in practice, and prompted staff to seek supplementary information. For a more in-depth look at the procedures of the project, please refer to the weekly planning guide in Appendix B. Conclusion The pre- and post-surveys demonstrate the success of the outcomes of the TIC Competency at PMCH. To support this, one of the comments from the post-survey states: It has changed the way I approach children and their families. Another factor that I will heavily consider when treating and evaluating. The site also benefits from the project by deeming current therapy staff competent in TIC and related subjects. To translate the TIC Competency to the site, it is added to the overarching pediatric competency that educates new hires. PMCH typically assesses new hires' competence through post-tests; therefore, a post-test to assess ones knowledge following the educational module is in the pediatric competency. Lastly, following TIC COMPETENCY 12 the dissemination of positive outcomes, the site managers can translate the procedures of the TIC Competency to improve future competencies. The results of this project are in alignment with previous research findings, indicating comparable implications for the profession. Most relevantly, this study supports the Schmitz et al (2019) finding that suggests an increase in providers' confidence and ability to discuss/apply these topics to practice following the educational module. Specifically, to the occupational therapy profession, the results of this project indicate a need for therapists working in all settings of pediatrics to obtain extensive training in TIC. Comparable to the Schmitz et al (2019) implications, this research also supports that other professionals working in pediatrics (nursing, child life specialists, and music/art therapists) will benefit from a module that addresses TIC and its fundamental concepts. If this is replicated, it will be valuable to evaluate the patients, or caregivers of patients, directly to determine if there was an indirect effect on them. This data will be beneficial as it will potentially support the purpose behind providing this education: to create sustainable change in patient care. TIC COMPETENCY 13 References Alisic, E., Tyler, M. P., Giummarra, M. J., Kassam-Adams, R., Gouweloos, J., Landolt, M. A., & Kassam-Adams, N. (2017). Trauma-informed care for children in the ambulance: International survey among pre-hospital providers. European Journal of Psychotraumatology, 8(1). https://doi.org/10.1080/20008198.2016.1273587 Ascension St. Vincent Foundation. (n.d.). Ascension St. Vincent Foundation. Mission & History - St. Vincent Hospital Foundation. Retrieved March 6, 2022, from https://give.stvincent.org/mission Berg-Poppe, P., Anis Abdellatif, M., Cerny, S., LaPlante, K., Merrigan, M., & Wesner, C. (2021). Changes in knowledge, beliefs, self-efficacy, and affective commitment to change following trauma-informed care education for pediatric service providers. Psychological Trauma: Theory, Research, Practice, and Policy. https://doi.org/10.1037/tra0001083 Boullier, M., & Blair, M. (2018). Adverse childhood experiences. Paediatrics and Child Health, 28(3), 132-137. Brown, J. D., King, M. A., & Wissow, L. S. (2017). The central role of relationships with trauma-informed integrated care for children and youth. Academic Pediatrics, 17(7), S94S101. Bruce, M. M., Kassam-Adams, N., Rogers, M., Anderson, K. M., Sluys, K. P., & Richmond, T. S. (2018). Trauma Providers Knowledge, Views, and Practice of Trauma-Informed Care. Journal of Trauma Nursing : The Official Journal of the Society of Trauma Nurses, 25(2), 131138. https://doi.org/10.1097/JTN.0000000000000356 TIC COMPETENCY 14 Christiansen, C., Baum, C. & Bass, J. (2011). The Person-Environment-OccupationalPerformance (PEOP) model. In E. Duncan (Ed.), Foundations for practice in occupational therapy (5th ed.) (pp. 93-104). Edinburgh, Scotland: Churchill Livingstone Elsevier. Dublin, S., Abramovitz, R., Katz, L., & Layne, C. M. (2021). How do we get to trauma-informed practice? Retention and application of learning by practitioners trained using the core curriculum on childhood trauma. Psychological Trauma: Theory, Research, Practice and Policy, 13(2), 258262. https://doi.org/10.1037/tra0000982 Hoysted, C., Babl, F. E., Kassam-Adams, N., Landolt, M. A., Jobson, L., Van Der Westhuizen, C., Curtis, S., Kharbanda, A. B., Lyttle, M. D., Parri, N., Stanley, R., & Alisic, E. (2018). Knowledge and training in paediatric medical traumatic stress and trauma-informed care among emergency medical professionals in low- and middle-income countries. European Journal of Psychotraumatology, 9(1), 1468703. https://doi.org/10.1080/20008198.2018.1468703 The Joint Commission. (2022). Accreditation & Certification. The Joint Commission. Retrieved March 18, 2022, from https://www.jointcommission.org/ Lerwick, J. L. (2016). Minimizing pediatric healthcare-induced anxiety and trauma. World journal of clinical pediatrics, 5(2), 143. Lyons, K. (2021). Nature, sensory integration, and pediatric occupational therapy. In N. J. Harper & W. W. Dobud (Eds.), Outdoor therapies: An introduction to practices, possibilities, and critical perspectives. (pp. 134145). Routledge/Taylor & Francis Group. https://doi.org/10.4324/9780429352027-13 TIC COMPETENCY 15 Melndez Guevara, A. M., Lindstrom Johnson, S., Elam, K., Hilley, C., Mcintire, C., & Morris, K. (2021). Culturally responsive trauma-informed services: A multilevel perspective from practitioners serving Latinx children and families. Community Mental Health Journal, 57(2), 325-339. Price, J., Kassam-Adams, N., Alderfer, M. A., Christofferson, J., & Kazak, A. E. (2016). Systematic review: A reevaluation and update of the integrative (trajectory) model of pediatric medical traumatic stress. Journal of Pediatric Psychology, 41(1), 86-97. Sala-Hamrick, K. J., Isakson, B., De Gonzalez, S. D. C., Cooper, A., Buchan, J., Aceves, J., ... & Waggoner, D. M. (2021). Trauma-informed pediatric primary care: Facilitators and challenges to the implementation process. The journal of behavioral health services & research, 1-19. Schmitz, A., Light, S., Barry, C., & Hodges, K. (2019). Adverse childhood experiences and trauma-informed care: an online module for pediatricians. MedEdPORTAL, 15, 10851. STATS Indiana. (2020). STATS Indiana: Indiana's Public Data Utility. InDepth Profile: STATS Indiana. Retrieved March 6, 2022, from https://www.stats.indiana.edu/profiles/profiles.asp?scope_choice=a&county_changer=18 018 Stenman, K., Christofferson, J., Alderfer, M. A., Pierce, J., Kelly, C., Schifano, E., ... & Kazak, A. E. (2019). Integrating play in trauma-informed care: Multidisciplinary pediatric healthcare provider perspectives. Psychological Services, 16(1), 7. TIC COMPETENCY 16 Figure 1. Pre/Post-Survey Question 1a Figure 2. Pre/Post-Survey Question 1b 25 20 15 10 5 0 How confident do you feel in your knowledge of TIC? Number of Responses Number of Responses How confident do you feel in your knowledge of ACEs? Pre-Survey Post-Survey 30 25 20 15 10 5 0 Post-Survey Answer Choices Answer Choices Figure 3. Pre/Post-Survey Question 2a Figure 4. Pre/Post-Survey Question 2b 30 25 20 15 10 5 0 How confident do you feel discussing TIC with patients and families? Number of Responses Number of Responses How confident do you feel discussing ACEs with patients and families? Pre-Survey Post-Survey Answer Choices 20 10 Pre-Survey 0 Post-Survey Answer Choices Number of Responses Number of Responses 30 Most All Visits Visits Post-Survey How frequently does/will your knowledge of ACEs and TIC affect your clinical decision making and visit for the patient? 40 Some Visits Pre-Survey Figure 6. Pre/Post-Survey Question 4 How often do you currently/will you discuss ACEs and TIC with patients and families? Rare Visits 30 25 20 15 10 5 0 Answer Choices Figure 5. Pre/Post-Survey Question 3 No Visits Pre-Survey 25 20 15 10 5 0 Pre-Survey Post-Survey Answer Choices TIC COMPETENCY 17 Figure 7. Pre/Post-Survey Question 5 Figure 8. Post-Survey Question 6 25 20 15 10 5 0 Pre-Survey Post-Survey Answer Choices Figure 9. Pre-Survey Question 8 Figure 12. Post-Survey Question 8 How effective did you find the training module in changing your clinical decision making and considering patient's ACEs, TIC, Number of Responses Number of Responses How important is it to discuss or address ACEs and TIC with families of the patient? 30 20 10 0 Post-Survey Not At All Slightly Effective Effective Neutral Somewhat Very Effective Effective Answer Choices Figure 10. Post-Survey Question 7 TIC COMPETENCY 18 Appendix A Theory Visual Diagram TIC COMPETENCY 19 Appendix B Weekly Planning Guide TIC COMPETENCY 20 Appendix C Pre-Survey Questions 1. How confident do you feel in your knowledge of Adverse Childhood Experiences (ACEs) or Trauma Informed Care (TIC)? a) Adverse Childhood Not Confident Experiences Slightly Confident Neutral Somewhat Confident Very Confident b) Trauma Informed Not Confident Care Slightly Confident Neutral Somewhat Confident Very Confident 2. How confident do you feel discussing ACEs or TIC with patients and families? a) Adverse Childhood Not Experiences Confident Slightly Confident Neutral Somewhat Confident Very Confident b) Trauma Informed Not Confident Care Slightly Confident Neutral Somewhat Confident Very Confident 3. How often do you currently discuss ACEs and TIC with patients and families? No visits Rare visits Some visits Most visits All visits 4. How frequently does your knowledge of ACEs and TIC affect your clinical decision making and visit for the patient? Never Rarely Occasionally Usually Always 5. How important is it to discuss or address ACEs and TIC with families of the patient? Not Important Slightly Important Neutral Somewhat Important Very Important 6. What type of setting do you work in? Outpatient Inpatient Other 7. How long is your typical visit with a patient? <10 minutes 10-20 minutes 20-30 minutes >30 minutes 8. Do you think becoming more competent in ACEs and TIC will benefit you as a practitioner? Yes No Other TIC COMPETENCY 21 Appendix D Post-Survey Questions 1. How confident do you feel in your knowledge of Adverse Childhood Experiences (ACEs) or Trauma Informed Care (TIC)? a) Adverse Childhood Not Confident Experiences Slightly Confident Neutral Somewhat Confident Very Confident b) Trauma Informed Not Confident Care Slightly Confident Neutral Somewhat Confident Very Confident 2. How confident do you feel discussing ACEs or TIC with patients and families? a) Adverse Childhood Not Experiences Confident Slightly Confident Neutral Somewhat Confident Very Confident b) Trauma Informed Not Confident Care Slightly Confident Neutral Somewhat Confident Very Confident 3. How often will you discuss ACEs and TIC with patients and families? No visits Rare visits Some visits Most visits All visits 4. How frequently will your knowledge of ACEs and TIC affect your clinical decision making and visit for the patient? Never Rarely Occasionally Usually Always 5. How important is it to discuss or address ACEs and TIC with families of the patient? Very Somewhat Important Important 6. How effective did you find the training module in changing your clinical decision making and considering patients ACEs, TIC, Toxic Stress, and Resiliency? Not Important Not at all effective Slightly Important Slightly effective Neutral Neutral Somewhat effective Very effective 7. Would you recommend this training module to other staff? Yes No 8. Did you seek further information on ACEs, TIC, Toxic Stress, and Resiliency following the completion of the training module? Yes No  ...