Busca

... Title: The Role of Occupational Therapy in the Care of Children with Cortical/Cerebral Visual Impairment; a Narrative Review Daria Seccurro May, 2022 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, QIDP Abstract Objective: This paper describes functional impairments experienced by children with Cortical/Cerebral Visual Impairment (CVI) and how occupational therapists (OTs) play an important role in the evaluation of functional vision and intervention guided by the PersonEnvironment-Occupation (PEO) model. Background: Prevalence of CVI in children is increasing; however, there is lack of consensus on diagnostic practices and few studies evaluating interventions for children with CVI. Some papers discuss the difficulties children with CVI experience in areas such as self-care, play, education, and mobility, but there is minimal evidence to support OT efforts. Methods: A narrative literature review was conducted to identify relevant research. A comprehensive search was performed across multiple databases. Studies that met the inclusion criteria were synthesized for key findings. Discussion: Findings supported that children with CVI face challenges with functional vision impacting daily living skills. These daily skills fall within the OT scope of practice. Although evidence-based interventions specific to OT are limited for CVI, existing literature reports deficits in ADLs, IADLs, play, education, and social participation, emphasizing the need for OT specific interventions for children with CVI. Conclusion: Due to OTs focus on daily activities (occupations), environmental and activity modification, and emphasis on client-specific care, they have a distinct role in caring for this population. Key Words: Cortical Visual Impairment; Cerebral Visual Impairment; children; occupational therapy; rehabilitation Introduction Cortical/Cerebral Visual Impairment (CVI) is the leading cause of visual impairment among children in developed countries (McConnell et al., 2021). CVI is a brain-based visual disorder associated with damage to the posterior portion of the brain, causing the inability to process visual information (Lueck et al., 2019). More than 40% of the brain plays a role in vision and is responsible for visual processing (Dutton et al., 2006). As a result, the brain is unable to process the information coming in from the eyes causing impairments in visual functioning. The impairments associated with CVI vary and span a broad range of severities (Orbitus et al., 2011). The location and extent of the brain insult often plays a factor in the level of impairment (McConnell et al., 2021; Sakki et al., 2022). Vision is a vital sense used in daily activities to interpret the environment. Although most children impacted by CVI often have some level of visual functioning, visual dysfunction plays a significant role in a child's development, learning, mobility, and overall quality of life (Merabet et al., 2017). In addition, CVI profoundly impacts one's ability to complete daily activities which constitute a large portion of life. The daily activities and skills that makeup life are known by occupational therapists as occupations (American Occupational Therapy Association [AOTA], 2020). Within the occupational therapy profession, active engagement in occupations is what supports, facilitates, and promotes participation in life (AOTA, 2020). Occupational therapists have distinct knowledge, skills, and qualities that enhance the occupational process (AOTA, 2020). Contributors in this profession exhibit qualities to complement cornerstones of practice which include but are not limited to client-centered practice, occupation-based practice, evidence-informed practice, theory-based practice, and leadership and professionalism (AOTA, 2020). Occupations are core components to a clients health, identity and sense of competence that are meaningful and viable to that client (AOTA, 2020). Occupations are meaningful everyday activities and include things people need to, want to, and are expected to do (AOTA, 2020). However, a persons context, made up of both personal and environmental factors, largely influences engagement in occupations. Occupational therapists accept the idea that people who achieve full participation must function and engage comfortably in their own contexts (AOTA, 2020). As a person enters different stages of life, their occupations may shift depending on their roles and responsibilities. Occupations commence in infancy and develop throughout life. Although a childs occupations may look vastly different from those later in life, occupations are present across the entire lifespan. A child's daily activities and occupations involve learning, playing, exploring, eating, crawling, among many others. Unfortunately, CVI impacts a child's ability to perform these occupations. However, adapting the activity and/or environment can make it easier for children with CVI to visually process, and increase participation in the activity. The unique needs of children with CVI are often affected by their environment, impacting their ability to function; however even small changes in ones environment positively impact a child (Tsirka et al., 2020) The principle of recognizing the environment's impact on participation in occupation provides a holistic perspective and distinguishes occupational therapists from other professionals trained to care for children with CVI. According to the Person-Environment-Occupation (PEO) Model, occupational performance is the outcome of the interaction between a person, their environment, and an occupation or task (Law et al., 1996). Assumptions from this model presume that the three components continuously overlap to enhance or impede ones ability to achieve occupational performance throughout life. In this model, the person is defined as a unique individual made up of various qualities, experiences, and skills that influence the capacity to engage in occupations and interact with the environment (Law et al., 1996). The person is viewed as an ever-developing individual made up of characteristics that can, in some cases, be responsive to change with intervention (Law et al., 1996). The environment is the context in which occupational performance occurs and can positively or negatively impact a person or an occupation (Law et al., 1996). An environment can affect occupational performance but is said to be more easily modified than the person. Last, occupations include the tasks and activities a person engages in across various environments to meet their needs (Law et al., 1996). In regard to the PEO model, the term occupation is described as a complex task or activity that a person engages in throughout the entire lifespan. These three components continuously overlap and adjust as the person, environment, and occupations change. In order to achieve optimal occupational performance in life, one must balance all three components to maximize the personenvironment-occupation fit (Law et al., 1996). The relevance of the PEO model and occupational therapy poses an avenue to help connect the dots to improve the lives of children with CVI and their families. Occupational therapists use the PEO model as a foundation in practice to encourage individualized, patientcentered care (Law et al., 1996). The needs of this population vary depending on the person, the environments they interact, and the occupations meaningful to them. The number of children diagnosed with CVI is increasing due to advances in medical care. Therefore, there is a need to better understand and gain consensus on the methods of diagnosis and increase evidence supporting interventions for this unique population. However, there is a lack of knowledge across the medical field about CVI and even less evidence on the role of occupational therapy practitioners in treating children with CVI. In order to understand the unique role of occupational therapy in children with CVI, one must first understand the needs of this population and the abilities of OT practitioners to meet those needs. This narrative review focuses on the challenges children with CVI face impacting their occupational performance and explores the specific role of occupational therapy in this unique population. Specifically, this narrative review aims to identify the needs of children with CVI that fall under the OT scope of practice which have been documented in previous literature, and explore how these deficits impact the person, environment, and occupation/task indicating an important role for OT in children with CVI. Background Visual processing is different in children with CVI compared to a child with typical vision. Due to the unique characteristics of CVI, this condition can be hard to diagnose and commonly unintentionally missed (Dutton et al., 2017; Williams et al., 2021). Traditionally, the diagnosis of CVI is given by ophthalmologists due to the impact on visual impairment, but neurological components may require involvement of neurologists (Pehere & Jacobs, 2019; Jackel, 2019). A comprehensive evaluation used to diagnose CVI consists of structured history taking to determine factors of predisposal, parent/caregiver reported observations and insights through interview, a functional vision assessment, eye examination, neurological assessment, and may include neuroimaging (Chang & Borchert, 2020; Itzhak et al., 2021). Children with CVI often present with abnormalities in visual processing that are not explained by the eye exam. Children affected by CVI commonly have a variety of comorbid medical conditions that take precedence early on. As a result, children with CVI demonstrate behaviors and characteristics attributed to their co-occurring medical conditions and are not further evaluated or assessed as disruptions in vision (McConnell et al., 2021; Tsirka et al., 2020). The uncertainties and lack of formal diagnostic protocol can sometimes cause a significant gap in receiving a diagnosis and ongoing care for children with CVI (Sakki et al., 2021). The most crucial time for intervention early in life to optimize brain plasticity (Chang & Borchert, 2020; Chokron & Dutton, 2016; McConnell et al., 2021). Therefore, children with CVI should be offered early intervention for the best outcome in visual processing (Roman-Lantzy, 2007). Martn et al. (2016) expressed that now, more than ever, there is a great need for improved accuracy in diagnosing, assessing, and developing compelling education and rehabilitation programs for individuals with CVI. CVI is a dynamic diagnosis that impacts all areas of life making interdisciplinary care important to maximize support for this population (Jayaraman et al., 2021; Pehere & Jacob, 2019). Beyond receiving a diagnosis, interventions and treatments for CVI have been explored in pharmacology and neurology-based approaches but researchers feel evidence-based assessment and intervention strategies are still lacking (Tsirka et al., 2020). Children with CVIs care is managed by various professionals including ophthalmologists, optometrists, pediatricians, occupational therapists, and nurses (Philip & Dutton, 2014). Other medical and educational professionals who commonly provide support for children with CVI include speech-language pathologists, physical therapists, teachers of students with visual impairments (TVIs), assistive technology specialists and orientation and mobility specialists (Blackstone et al., 2020; Jayaraman et al., 2021; Kran et al., 2019). Initial literature searches revealed two studies that involve occupational therapists' caring for children with CVI. Therefore, the present review comprises literature that is not occupational therapy specific but will reflect on impairments and areas of occupation in which OT intervention could be impactful. Additionally, this review will compile previous researchers' findings on the challenges this population faces and explain how occupational therapy practitioners have the unique skill set to address the needs of this population through the lens of the PEO model. Since children with CVI experience complex challenges in many areas of life, greater attention must be brought to the complexity and extent CVI plays on childrens development. As a result, a comprehensive analysis of the functional challenges that commonly occur in children with CVI is needed to identify the methods which lead to acquisition and/or preservation of everyday skills. Finally, this narrative is intended to raise awareness and better inform healthcare professionals across all settings about the unmet needs of children with CVI and their families to inform quality care better. Method A narrative review methodology was used to conduct and report the research findings regarding the role of occupational therapy in children with cortical/cerebral visual impairment. A narrative review is a comprehensive synthesis of literature that has been previously published and aims to present the broad perspectives of a topic and serve as thought-provoking pieces of literature (Green, 2006). According to Ferrari (2015), narrative reviews do not present new data but intend to assess what is already published; therefore, this style is appropriate for the specific aims of this paper. There is relevant literature regarding children with CVI, but few OT-specific publications. However, discuss issues that could be improved by including OT intervention for children with CVI. Narrative reviews have been popular among authors and readers, making up the largest share of all medical text types and impacting doctors in their clinical practice and research, deeming them a staple of medical literature (Baethge et al., 2019). A structured and in-depth literature search focused on the role of occupational therapy in CVI. Due to the limited literature on this topic, no databases were excluded when searching for relevant literature. Similarly, since the current body of evidence on OT for children with CVI is limited and the objectives of this paper are broad, the inclusion and exclusion criteria for this review were flexible. The authors primary search terms included Cortical visual impairment OR cerebral visual impairment, OR brain based visual impairment, OR CVI, AND children, functional vision impairment, functional vision in children, pediatric, childhood. Articles were excluded if the target population included adults because the challenges, presentation, and prognosis for CVI in children are vastly different. Since research relevant to daily life skills and/or functional challenges is sparse in this population, foundational articles from the late 1980s and 1990s were included. Articles that reported on children with low vision or other visual impairments and CVI were included if an accurate definition of CVI was given. Similarly, articles that discussed exclusively children with low vision, ocular visual impairments, or visual acuity were excluded. Line-by-line examination was utilized during full-text review to identify articles with information that could be related to the role of OT in this population or the CVIspecific characteristics and/or challenges related to the OT scope of practice. Person Visual Characteristics in Children with CVI One of the most significant components in children with CVI are their functional vision deficits, noted in literature as early as 1987. Children with CVI have unique visual traits and behaviors that help them function and/or compensate for decreased visual abilities. One of the most considerable challenges associated with children with CVI is the variable visual abilities that can change from one day to the next (Jan et al., 1987). This concept was reported in 1987 by Jan et al. and has since been verified by many of CVIs top researchers (Chang & Borchert, 2020). However, in recent years, researchers have gained an understanding as to why performance of children with CVI appears to vary frequently and have associated reasoning for this phenomenon. In short, it is now understood that the childs ability to use vision depends greatly on their physical environment, biobehavioral state, performance demands of the task, motivation, and their familiarity with the objects and people in which they are interacting (Lueck et al., 2019). The article by Jan et al. (1987) is one of the earliest works of literature that describes the behavioral characteristics seen in children with CVI. Notable findings documented in this article include improved vision in a familiar environment, impaired visual attention and visual curiosity, and signs of fatigue with visual learning (Jan et al., 1987). More than half of children in this study were reported to use touch to supplement vision during exploration and bring items close to eyes to use vision. Other behaviors noted by the researchers include inaccurate depth perception, need for movement of objects, looking away when reaching, light gazing, and restricted visual fields (Jan et al., 1987). Orbitus et al. (2011) echoes similar findings also indicating the child may fatigue easily when using vision, struggles to maintain focus during tasks, and rely on other perceptions to implement for vision. Various studies have been published over the last 30 years reporting similar behaviors and characteristics in children with CVI. In a study by van Genderen et al. (2012) researchers found that more than 40% of the children with CVI in their sample had challenges using vision in complex visual scenes, 53% had impaired visual fields, and 30% had nystagmus. A Delphi study by Pilling (2022) obtained expert input on various skills and behaviors common in children with CVI. Among this list are behaviors such as the child positioning their head in distinct ways to use vision, looking out of the corner of the eye, avoiding visual input by looking away, and commonly bumping into things when walking (Pilling, 2022). Children with CVI often experience high level visual processing issues such as difficulty with visual discrimination, orientation and need for additional visual processing time (Philip & Dutton, 2014). Similarly, children with CVI often display challenges with delayed visual latency, difficulty with facial recognition, navigation challenges, and inability to process moving objects (Good et al., 2001). Philip and Dutton (2014) summarize the varying abilities of children with CVI fall into three categories including children with profound visual impairments, children with impaired functional vision combined with cognitive and sometimes motor challenges, and children who have impaired functional vision but are capable of working at or close to the expected level for their age (Philip & Dutton, 2014). The CVI Range (Roman-Lantzy, 2007) is an assessment tool as well as a method to understand the varying characteristics and abilities of children with CVI by describing functional vision through scores organized into levels. Children with a score 1-2 have minimal visual response, score 3-4 exhibit more consistent visual response, score 5-6 use vision for functional tasks, score 7-8 demonstrate visual curiosity, and score 9-10 spontaneously use their vision functionally during most activities (Roman-Lantzy, 2007). Co-occurring medical conditions and other visual impairments Along with the brain based visual challenges children with CVI face, researchers have revealed most children with CVI have additional diagnoses and/or comorbidities that challenge development. The most common cause of CVI is an injury to the brain due to a lack of oxygen during the birthing process or shortly after birth (Parajuli et al., 2020). Other associated medical conditions include Periventricular Leukomalacia (PVL), Hypoxic Ischemic Encephalopathy, Cerebral Vascular Accident (CVA), Traumatic Brain Injury (TBI), structural malformations, infection, and metabolic disorders (Chang & Borchert, 2020). CVI is also associated with children born premature, and those who have other neurodevelopmental disorders such as cerebral palsy and seizures disorders (Chang & Borchert, 2020). There have also been findings of children with autism spectrum disorder (ASD) (Chokron et al., 2020), hearing impairments (Matsuba & Jan, 2006) and developmental coordination disorder with CVI (Chokron & Dutton, 2016). Vision plays a significant role in learning motor skills. For children with CVI that have co-occurring motor diagnoses like cerebral palsy, physical performance may be impaired. Children with CVI may have difficulties with motor activities such as walking (Jayaraman et al., 2021) and reaching due to the demands of functional vision use (Baker-Nobles & Rutherford, 1995). Lack of motivation to interact with people and objects may be a direct result of visual dysfunction (Fazzi et al., 2015). Many children with CVI are often delayed with fine motor skills such as reaching, grasping, and pointing because of the inability to process stimuli in the environment, limiting their ability to interact with objects though these skills (Fazzi et al., 2015; Chokron & Dutton, 2016). Similarly, researchers have reported how vision plays a large role in learning postural control and stability important for motor tasks in development (Chokron et al., 2021; Guzzetta et al., 2001). Children with CVI also have co-occurring diagnoses impacting cognition. Chokron and Dutton (2016) explain the impact vision has on all areas of development and how failure to address the visual needs of CVI leads to decreased learning and presents as an intellectual deficit. Matsuba and Jan (2006) reported in their study of 423 children, 86.7% also had cognitive impairments classified as moderate to severe. The researchers report that of the remaining children with high cognition had underlying learning difficulties (Matsuba & Jan, 2006). Finally, co-occurring visual impairments may be present in addition to CVI. Pehere et al. (2018) describe the most common disorders of eye movement control in children with CVI include: strabismus, nystagmus, unstable fixation, inaccurate fast eye movements (dysmetric saccades), deficient smooth pursuit movements, and paroxysmal deviations, in which the eyes intermittently deviate upward. The researchers in this study believe that due to the difficulty in examining childrens vision, many visual issues are often missed (Pehere et al., 2018). Sensory, Behavioral, Psychological Challenges When thinking about CVIs impact on a childs sensory system, vision is the most apparent sense associated. Since vision is impacted for these children, their other senses such as touch and sound are often heightened, and the children use them to compensate for their visual deficits and weak vision (Pehere & Jacob, 2019). Therefore, when the other senses are more easily stimulated children can experience sensory processing difficulties requiring minimizing sensory input in order to focus on use of vision (McKillop & Dutton, 2008). For example, some children with CVI may be sensitive to auditory stimuli, and face additional struggles in environments with a lot of auditory stimulation (Morse, 1999). Similarly, many children early on implement the use of other senses or multiple senses to compensate for a lack of vision to explore their environment (Pehere & Jacob, 2019). Adverse behaviors are another area that can be challenging for children with CVI. This is often attributed to external causes such as complex sensory environments, difficulties with communication, and mental health challenges such as frustration, anxiety, and issues with selfesteem (Goodenough et al., 2021; Lueck et al., 2019). Chokron et al. (2021) indicates how humans naturally adapt to the environment they are in, however if a person cannot see their environment, then they are unable to respond to it. Further, they describe how individuals react emotionally when faced with frightening or stressful events, requiring one to adapt behavior appropriately to overcome the circumstance (Chokron et al., 2021). Researchers connecting this scenario back to children with CVI explain that they are similar in the way they react; however it may be viewed as a behavior disorder or concern (Chokron et al., 2021). The difference between other children that display similar behaviors and children with CVI is that their impacted vision is causing these emotions and behaviors. For example, many children with CVI might be easily frustrated due to the constant visual challenges encountered and have been reported to become fearful when certain visual landmarks are removed that they use to help them identify the environment (Lueck & Dutton, 2015). This may lead to misinterpretation of their environment leading to confusion, fear, and being overwhelmed. There is also evidence that due to decreased ability to identify objects/people in public, children with CVI may also have heightened anxiety or fear of getting lost or injured (Lueck et al., 2019). Parents from Goodenough et al. (2021) indicated how anxiety regarding accessibility at school and in the community affected their child. As children with CVI age, many often struggle with self-concept and self-image challenges due to their experiences socially comparing themselves to other children and/or the expectations (Goodenough et al., 2021). Environment A child with CVIs ability to visually process is dependent on the set up and familiarity of their environment. In particular, children with CVI have more difficulty processing in environments that are new, complex, and stimulating. Physical Ones environment plays an important role in how they interact. Children with CVI are no different, except that environmental challenges and barriers are often more influential to their functioning and much harder to overcome. Physical environments most often associated with children are their homes, school, playground, or stores. However, even these frequently visited places can propose environmental barriers based on external factors. For example, crowding and complexity in the environment can have a negative impact on children with CVI (Philip & Dutton, 2014; Roman-Lantzy, 2007). Environmental complexity proposes too many visual stimuli to process at once for the child and complicates use of functional vision. This frequently leads to visual shutdown in children with CVI or other adverse behaviors. For example, a busy playroom with toys all over the floor is very hard for children with CVI to function (Pehere & Jacob, 2019; Philip & Dutton, 2014). Challenges in an environment like this are hard for children with CVI to focus and are overwhelming to visually process. They often experience additional challenges in unfamiliar environments especially during navigation and often prefer familiar toys and faces (Good et al., 2001; Roman-Lantzy, 2007). Other environmental barriers that can create challenges for children with CVI to use their vision are the level of lighting (too low or bright), low contrasting of colors, and noisy environments (Roman-Lantzy, 2007). Children with CVI often need objects and stimuli brought close to them and struggle to function with stimuli at a distance (Baker-Nobles & Rutherford, 1995; Swift et al., 2008). This especially creates challenges in environments like school and stores. Social, Cultural, and Institutional Researchers from an article by Goodenough et al. (2021) facilitated interviews of parents of children with CVI. In this study parents expressed that many medical professionals do not recognize CVI as an actual condition, nor do they understand challenges associated with CVI (Goodenough et al., 2021). This same sentiment was echoed by Pehere et al. (2018) indicating that awareness about CVI needs to increase in the ophthalmic community and also in general society. The same concept was echoed later in the study when a parent explained that within the childs institutional environment at school, there was lack of training and support from staff and professionals causing more challenges for the child (Goodenough et al., 2021). Further, parents from this study go on to reflect the large amount of time they spent communicating and educating others about their childs needs, as well as taking time off work to create and supply learning materials and resources for their child to use in school (Goodenough et al., 2021). In a follow up study, it was reported that children with CVI can also be greatly affected by their social and cultural environment. Socially, the lack of awareness and understanding of CVI can create barriers for this population, as well as unmet expectations from parents and/or teachers (Lueck & Dutton, 2015). Occupations Our daily activities and tasks change throughout life and continue to develop and change. Children with CVI face barriers in various aspects of life affecting their ability to participate in tasks, activities, and occupations. Occupational therapy practice categorizes occupations as activities of daily living (ADLs), instrumental activities of daily living (IADLs), health management, rest and sleep, education, work, play, leisure, and social participation (AOTA, 2020). ADLs The challenges associated with CVI impact daily activities that prevent children from interaction and participation in various tasks. Commonly, children with CVI face more challenges with everyday activities such as dressing, grooming, toileting, bathing, and eating. Challenges associated with dressing include orientating garments correctly while putting them on, locating and/or fastening buttons, finding clothing in a pile or closet, locating and putting on shoes and socks, and localizing the position of lower body dressing to put legs in the correct holes (Philip & Dutton, 2014; Salavati et al., 2015). Other tasks associated with dressing such as tying shoes have also been reported as challenging in this population (Orbitus et al., 2011). Other self-care activities that may be problematic include brushing teeth, due to struggles during application of toothpaste, orienting toothbrush correctly, and locating toothbrush on similar colored surfaces (Salavati et al., 2015). Additionally, challenges with brushing hair might also occur if they cannot locate all areas needing brushing or struggle to position brush correctly in relation to their body (Salavati et al., 2015). Toileting is another skill that occurs daily and can be troublesome for children with CVI. Most commonly, navigation to the bathroom, correct orientation of body in relation to toilet (sitting and/or standing), and challenges with adequately performing toileting tasks (Salavati et al., 2015). Functional skills related to bathing may cause obstacles for children with CVI. For example, navigating placement of bath time materials (soap, washcloth, towel, etc.), not being able to determine the height of the bathtub/shower, need for additional lighting, and failing to rinse soap adequately can all cause disturbances during bathing (Philip & Dutton, 2014; Salavati et al., 2015). Children with CVI may also experience adverse challenges associated with feeding and eating due to the inability to see food on plate, using utensils and vision together to obtain food, or seeing a spoon or bottle as it approaches when being fed (Lam et al., 2010; Philip & Dutton, 2014). Other challenges are drinking from a cup with a straw, and frequently spilling food and drinks (Philip & Dutton, 2014; Salavati et al., 2015). Good et al. (2001) reports that another element of feeding that may be impacted in this population is chewing. Due to chewing being partially learned through vision during early development, this can cause challenges with feeding that may lead to other medical issues such as aspiration (Good et al., 2001). Proper positioning during mealtime is also important and may be challenging for children with CVI due to having to focus intensively on vision use, especially when paired with co-occurring motor challenges (Lam et al., 2010). IADLs When performing IADLs, safety is one of the largest areas of concern in children with CVI. Children with CVI may experience problems that could hinder safety such as not seeing traffic because of impaired movement perception, experience difficulty identify the family car in a parking lot, and getting easily lost in crowds or malls due to too much visual input (Philip & Dutton, 2014; Salavati et al., 2015). Similarly, grocery shopping can cause distress from the overwhelming visual and auditory environment combined, inaccurately navigating locations due to inability to interpret signs (Lam et al., 2010; Pehere & Jacobs, 2019; Philip & Dutton, 2014). Education Research also indicates children with CVI struggle with education activities. Some studies that are specific to children with CVI in the school system have shown children experience issues with school related tasks such as reading depending on complexity of books, writing, viewing materials on a board, loud sensory environment of a room, among others (Philip & Dutton, 2014; Swift et al., 2008). Chokron et al. (2021) reviews the common obstacles children with CVI face and the impact they have on issues with reading. Issues in the classroom may also include slower processing time, struggling to see worksheets, trouble staying in the lines, and difficulty copying items from the board (Philip & Dutton, 2014; Swift et al., 2008). Literature indicates most children with diagnosed CVI have an IEP (Jayaraman et al., 2021) and often receive services from a TVI within the school system. Jackel (2019) conducted a survey on parents of children with CVI and found that parents felt their TVI was competent in treating CVI but other school professionals and staff were not. The same study reports that most parents indicated receiving appropriate accommodations for their child within the school system to be very challenging (Jackel, 2019). Researchers from Goodenough et al. (2021) reiterates similar experiences in their study and reports the importance of the parent in the childs success at school. Also not indicated in literature but an issue to think about is the challenges kids have at school with eating, toileting, navigation, and play which also take place at school every day. Some children with CVI need technological accommodations and work better on tablet/ipad/computer (Baker-Nobles & Rutherford, 1995; Swift et al., 2008). It is important to consider that if accommodations are not made at school and in classrooms, children have a decreased chance to learn and gain knowledge (Goodenough et al., 2021; Jackel, 2019). Social Participation Although occupational struggles are not well studied in children with CVI, an occupation that is often mentioned in professional level works is the challenge this population faces with social participation. Pehere and Jacob (2019) explain how most people identify and recognize people through use of vision, as well as gain information about their emotions from body language and facial expression paired with tone of voice. Children with CVI often have difficulty making eye contact and often miss social cues or fast facial expressions impacting social functioning (Morse, 1999; Philip & Dutton, 2014). They may also struggle to look at someone or something while listening at the same time, leading to either looking away or inability to divide attention (Philip & Dutton, 2014). Literature also shows children with CVI often frequently position themselves in unique ways to use their vision best and may not see a hand presented for a handshake if placed in a non-preferred visual field, further leading to embarrassment and/or appearing rude (Philip & Dutton, 2014). Children with CVI struggle to recognize faces, which is one of the largest documented factors associated with their social struggles; therefore, sometimes even recognizing family members or friends can be challenging (Fazzi et al., 2009; Orbitus et al., 2011; Philip & Dutton, 2014). Socially, parents have reported children with CVI have anxiety surrounding unfamiliar social environments due to fear of getting lost or not being able to find their friends (Philip & Dutton, 2014). Functional Mobility Another large area that impacts children with CVI is functional mobility and navigation. Children with CVI often struggle with navigation for many reasons. Most commonly, lower field deficits make navigating different surfaces more challenging and lead to safety concerns. Children with CVI have also been documented to have challenges with mobility on stairs and uneven surfaces (Lam et al., 2010; Orbitus et al., 2011). Additionally, when in an unfamiliar environment, navigation is more challenging, as well as distance vision impacting ability to see signs or familiar landmarks (Lueck & Dutton, 2015). Functional mobility is often impacted in children with CVI with reports of them commonly falling over clearly visual objects and commonly running into things during mobility (Pilling, 2022). Another challenge is transferring most commonly in the bathroom. Children with CVI often run into things and struggle with depth perception making navigation increasingly challenging (Philip & Dutton, 2014). Another aspect of CVI is the inability to realize movement of an object. This is most likely relevant for safety during navigation especially when crossing the street or walking in public due to the inability to recognize moving structures such as a car (Philip & Dutton, 2014) Play The most important occupation for a child is play. Play is not only how children enjoy life and spend their leisure time but is also a huge element connected to cognitive development early on in life. For some children with CVI, play can be difficult. They have issues with structured play like games due to complications following directions (Salavati et al., 2015). Kids may also have challenges with sports due to the environmental factors (Lam et al., 2010). Similarly, children with CVI often struggle to discriminate between 2-D imagery and prefer 3-D items. This is a barrier in tasks such as puzzles, games, and matching activities, due to it being hard for them to process (Orbitus et al., 2011). Other activities that children often enjoy such as riding a bike or kicking a ball can also be hard due to decreased coordination and balance, and difficulty with safe navigation. Philip and Dutton (2014) list similar activities as challenging such as jumping into a swimming pool due to not being able to judge the height of the water and going down a slide from inability to see the slide when seated. Some children with CVI also have delayed/impacted reflexes which may impact tasks like throwing and catching a ball (Philip & Dutton, 2014). Numerous studies have also mentioned challenges of children when finding a toy in a complex environment such as toy box (Bennett et al., 2019; Philip & Dutton, 2014). Occupational Therapys Role A key role in OT intervention planning includes conducting a detailed occupational profile to help understand specifics to improve both visual and functional outcomes (Harpster, in press). Additionally, in order to better understand ways that occupational therapists can adapt environments to better meet the needs of the child and the occupation, they must be informed on appropriate modifications. Use of the CVI Range can be helpful when implementing interventions due to breakdown of phases in the tool (Roman-Lantzy, 2007). The basis for this functional vision assessment examines the 10 key characteristics of CVI including color preference, need for movement, visual latency, visual field preferences, challenges with complexity, need for light, difficulties with distance viewing, atypical visual reflexes, limited visual novelty, and absence of visual motor skills (Roman Lantzy, 2007). Based on assessment of these components, children are placed into a phase to better understand their current level. The three phases are grouped by scores from 0 (no functional vision use) to 10 (typical functional vision for age and no CVI) into five levels, further classified into three phases to target intervention methods (Roman-Lantzy, 2007). Phase I intervention aims to build consistent visual behavior, phase II targets integrating vision with function, and phase III works on refining CVI characteristics (Roman-Lantzy, 2007). Researchers from Salavati et al. (2015) emphasize that due to the high number of children with CP and CVI together, both occupational and physical therapists need assessment tools available that are adapted for children with CVI in order to gain accurate performance results to inform treatment. Similarly, an intervention study focused on telemedicine for children with CVI involved the Canadian Occupational Performance Measure (COPM) as a primary outcome measure (Schwartz et al., 2021). The results of this study indicate occupational therapy interventions via telemedicine can lead to functional improvements and an increase in satisfaction of goal performance through use of the COPM (Schwartz et al., 2021). As previously discussed, OT are skilled in adapting environments to better suit functioning through task and environment modification. Morse (1999) emphasizes how intervention should analyze the environment the child is in, the activities they participate in, the sensory-motor demands, and time pressure and other variables. Similarly, since OT are skilled to treat children with co-occurring diagnosis of CVI (Chang & Borchert, 2020), therefore, they need to know how to incorporate functional vision use during treatments in order to facilitate visual progress while working on other challenges. Another large element that could be beneficial in treatment of children with CVI is parent education. Parents are very important in teaching their challenge and need the knowledge to modify environments and materials correctly to better support the childs functional vision use and improve daily living (Pehere & Jacob, 2019). The engagement of caregivers/parents is essential, and OT can advocate and teach them how to better understand their child and help meet their needs. Discussion Many of these children experience impacts from CVI in all aspects of daily living, creating functional and developmental challenges. Because occupational therapy provides services exclusively for the persons tasks and occupations, the role of occupational therapist in caring for children with CVI is crucial. CVI affects children in a variety of ways and is a diagnosis that varies from person to person requiring client specific care to individualize treatment to best fit their skills and abilities. A key element important in relation to intervention is that visual functioning in CVI has been proven to improve if the child receives specialized care (Roman-Lantzy, 2010). This reiterates that children with CVI can make improvements overtime. Occupational therapy intervention may focus on specific occupations, context, and environments, and/or performance patterns and skills (AOTA, 2020). Common interventions in OT scope include therapeutic use of occupations and activities, interventions to support occupations, education, training, and advocacy (AOTA, 2020). However, OTs expect that due to the dynamic involvement of a person, environment, and the occupation the ability to adapt, change or develop in certain areas will impact other areas (AOTA, 2020). Because occupational therapy practitioners are taught to analyze the physical and environmental demands of an occupation, they can provide a unique insight into appropriate adaptations and modifications needed in children with CVI during engagement in occupations. Through the use of activity analysis, occupational therapy practitioners can assess the physical and contextual demands of an occupation, specific to the client and their abilities (AOTA, 2020). For children with CVI, their ability to engage in an occupation is variable depending on the context and environment they are in. Therefore, intervention for children with CVI cannot solely disassociate the person from the environment or occupation. Instead, intervention for this population must be inclusive of all three components and provide constant reassessment to determine optimal balance to gain occupational performance. However, modification and intervention can be implemented at the person, environment, and occupational level. The next three sections include general recommendations for OT to use at the person, environment, and occupation level, but do not fully capture all recommendations. For the person, some methods might include allowing extra time for visual processing, adequately address cooccurring challenges such as taking sensory breaks to help maintain focus, being aware of the impact of visual fatigue associated with CVI so planning harder activities earlier in sessions, practicing social participation situation with a child to help increase confidence, implementing emotional regulation strategies for the child to use when overwhelmed or frustrated, and provide the child with skills to advocate for themself and their needs, among many others (Baker-Nobles & Rutherford, 1995; Philip & Dutton, 2014; Swift et al., 2008). Environmental modifications can include but are not limited to adapting the light to be more or less stimulating with a light box, decreasing visual clutter by presenting items one at a time, use of contrasting colored backgrounds such as presenting toys in front of black sheet, adding shiny materials that can be eye catching such as holographic tape on the stairs, placing stimuli at close viewing distances, elevating material with slant board, and avoiding patterned tables or flooring (Baker-Nobles & Rutherford, 1995; Pehere & Jacob, 2019; Philip & Dutton, 2014). Occupational and task adaptation during intervention may involve choosing occupations/tasks meaningful to the child, implementing verbal guidance and cueing during activity, using visual attracting elements during activities, ensuring food on a plate is a contrasting color during eating, placing a mirror in front of the child for dressing to help with fastening buttons, giving verbal directions before games to ensure the child understands rules, and implementing consistent routines (Good et al., 2001; Pehere & Jacob, 2019; Swift et al., 2008). Other characteristics important for occupational therapists to consider when providing interventions is that treatment and intervention methods for children with low vision or other visual impairments will not suffice for children with CVI due to the impairments in CVI being at the brain level (Gorrie et al., 2019). Pehere and Jacob (2019) emphasize that whoever is leading intervention for these children should choose stimuli specific to the childs interests and continually make adjustments to facilitate ongoing engagement. They also suggest that intervention for children with CVI should be carried out through regular childhood development tasks including play, learning, communication, and movement. This specific suggestion further validates the role of OT in caring for this population due to centering all treatment around regular tasks and activities, known to them as occupations. OTs are skilled in environmental modification and task adaptation, which are evident as the forefront of CVI functioning. Because OT professionals are trained in adapt environments to better meet the needs of the individual and optimize their independence. Since children with CVI often exhibit many visual challenges, one of the most important intervention methods is environmental adaptation. Although limited evidence has been proven to examine the difference in how these environmental modifications help children with CVI, there are a few works of literature that have explored parent reports about caring for children with CVI. Many of the unique modifications can be recommended by therapists and applied in the childs natural environment. As a profession, occupational therapists pride themselves on implementing evidencebased care for all clients. However, the evidence and literature for tested intervention is minimal, causing the inability to implement evidence-based care for this population (Harpster, In press). Researchers in Williams' (2021) article mention the growing concern about unmet needs, failure to achieve potential, and avoidable mental health problems like anxiety and poor self-esteem that may be seen in children with CVI whose difficulties go unrecognized over time. Due to OT's broad scope of practice, occupational therapists could be the key to bridging these caps and maximizing care. In order for occupational therapy practitioners to obtain competence in caring for this unique population, they must first have evidence-based literature to guide them in care. Conclusion Due to OTs focus on daily activities (occupations), environmental and activity modification, and emphasis on client-specific care, occupational therapists can provide a unique skill set to help this population. The role of OT as part of the interdisciplinary care team for children with CVI is imperative. In order for healthcare providers to ensure children with CVI are receiving quality care, evidence-based interventions need to be explored in the literature. As the increase in CVI continues to rise, the need for research to support treatment for this population should follow. Occupational therapist can be vital assets in the interdisciplinary team that cares for children with CVI to help increase overall quality of life and independence during daily functioning. References Baethge, C., Goldbeck-Wood, S., & Mertens, S. (2019). SANRA-a scale for the quality assessment of narrative review articles. Research Integrity and Peer Review, 4, 5. https://doi.org/10.1186/s41073-019-0064-8 Baker-Nobles, L., & Rutherford, A. (1995). Understanding cortical visual impairment in children. The American Journal of Occupational Therapy: Official Publication of the American Occupational Therapy Association, 49(9), 899903. https://doi.org/10.5014/ajot.49.9.899 Bennett, C. R., Bex, P. J., Bauer, C. M., & Merabet, L. B. (2019). The assessment of visual function and functional vision. Seminars in Pediatric Neurology, 31, 3040. https://doi.org/10.1016/j.spen.2019.05.006 Blackstone, S. W., Luo, F., Canchola, J., Wilkinson, K. M., & Roman-Lantzy, C. (2021). Children with cortical visual impairment and complex communication needs: Identifying gaps between needs and current practice. Language, Speech, and Hearing Services in Schools, 52(2), 612629. https://doi.org/10.1044/2020_LSHSS-20-00088 Chang, M. Y., & Borchert, M. S. (2020). Advances in the evaluation and management of cortical/cerebral visual impairment in children. Survey of Ophthalmology, 65(6), 708724. https://doi.org/10.1016/j.survophthal.2020.03.001 Chokron, S., & Dutton, G. N. (2016). Impact of cerebral visual impairments on motor skills: Implications for developmental coordination disorders. Frontiers in Psychology, 7, 1471. https://doi.org/10.3389/fpsyg.2016.01471 Chokron, S., Kovarski, K., & Dutton, G. N. (2021). Cortical visual impairments and learning disabilities. Frontiers in Human Neuroscience, 15, 713316. https://doi.org/10.3389/fnhum.2021.713316 Chokron, S., Kovarski, K., Zalla, T., & Dutton, G. N. (2020). The inter-relationships between cerebral visual impairment, autism and intellectual disability. Neuroscience and Biobehavioral Reviews, 114, 201210. https://doi.org/10.1016/j.neubiorev.2020.04.008 Dutton, G. N., Chokron, S., Little, S., & McDowell, N. (2017). Posterior parietal visual dysfunction: An exploratory review. Vision Development and Rehabilitation, 3(1), 10-22. https://doi.org/10.3389/fnhum.2021.713316 Dutton, G. N., McKillop, E. C., & Saidkasimova, S. (2006). Visual problems as a result of brain damage in children. The British Journal of Ophthalmology, 90(8), 932933. https://doi.org/10.1136/bjo.2006.095349 Fazzi, E., Bova, S., Giovenzana, A., Signorini, S., Uggetti, C., & Bianchi, P. (2009). Cognitive visual dysfunctions in preterm children with periventricular leukomalacia. Developmental Medicine and Child Neurology, 51(12), 974981. https://doi.org/10.1111/j.14698749.2009.03272.x Fazzi, E., Molinaro, A., & Hartmann, E. (2015). The potential impact of visual impairment and CVI on development. In Lueck A. H., & Dutton, G. N. (Eds.), Vision and the brain: Understanding cerebral visual impairment in children (pp. 83-105). AFB Press. Ferrari, R. (2015). Writing narrative style literature reviews. Medical Writing, 24, 230-235. Good, W. V., Jan, J. E., Burden, S. K., Skoczenski, A., & Candy, R. (2001). Recent advances in cortical visual impairment. Developmental Medicine & Child Neurology, 43(1), 5660. https://doi.org/10.1017/s0012162201000093 Goodenough, T., Pease, A., & Williams, C. (2021). Bridging the gap: Parent and child perspectives of living with cerebral visual impairments. Frontiers in Human Neuroscience, 15, 689683. https://doi.org/10.3389/fnhum.2021.689683 Gorrie, F., Goodall, K., Rush, R., & Ravenscroft, J. (2019). Towards population screening for cerebral visual impairment: Validity of the five questions and the cvi questionnaire. PLoS One, 14(3), 0214290. https://doi.org/10.1371/journal.pone.0214290 Green, B. N., Johnson, C. D., & Adams, A. (2006). Writing narrative literature reviews for peerreviewed journals: Secrets of the trade. Journal of Chiropractic Medicine, 5(3), 101117. https://doi.org/10.1016/S0899-3467(07)60142-6 Guzzetta, A., Fazzi, B., Mercuri, E., Bertuccelli, B., Canapicchi, R., van Hof-van Duin, J., & Cioni, G. (2001). Visual function in children with hemiplegia in the first years of life. Developmental Medicine & Child Neurology, 43(5), 321329. https://doi.org/10.1017/s0012162201000603 Harpster, K. Lusk, K., Hamilton, S., Seastone, A., Fox, A., Rice, M., & Schwartz, T. (in press). Exploring the need for education on cortical visual impairment among occupational therapy professionals and teachers of students with visual impairment. The Journal of Visual Impairment and Blindness. Itzhak, B. N., Kooiker, M. J. G., van der Steen, J., Pel, J. J. M., Wagemans, J., & Ortibus, E. (2021). The relation between visual orienting functions, daily visual behavior and visuoperceptual performance in children with (suspected) cerebral visual impairment. Research in Developmental Disabilities, 119. https://doi.org/10.1016/j.ridd.2021.104092 Jackel, B. (2019). A survey of parents of children with cortical or cerebral visual impairment: 2018 Follow-up. Seminars in Pediatric Neurology, 31, 34. https://doi.org/10.1016/j.spen.2019.05.002 Jan, J. E., Groenveld, M., Sykanda, A. M., & Hoyt, C. S. (1987). Behavioral characteristics of children with permanent cortical visual impairment. Developmental Medicine and Child Neurology, 29(5), 571576. https://doi.org/10.1111/j.1469-8749.1987.tb08498.x Jayaraman, D., Jacob, N., & Swaminathan, M. (2021). Visual function assessment, ocular examination, and intervention in children with developmental delay: a systematic approach - part 2. Indian Journal of Ophthalmology, 69(8), 20122017. https://doi.org/10.4103/ijo.IJO_2396_20 Kran, B. S., Lawrence, L., Mayer, D. L., & Heidary, G. (2019). Cerebral/cortical visual impairment: A need to reassess current definitions of visual impairment and blindness. Seminars in Pediatric Neurology, 31, 2529. https://doi.org/10.1016/j.spen.2019.05.005 Lam, F. C., Lovett, F., & Dutton, G. N. (2010). Cerebral visual impairment in children: A longitudinal case study of functional outcomes beyond the visual acuities. Journal of Visual Impairment & Blindness, 104(10), 625635. https://doi.org/10.1177/0145482X1010401008 Law, M., Cooper, B., Strong, S., Stewart, D., Rigby, P., & Letts, L. (1996). The PersonEnvironment-Occupation Model: A transactive approach to Occupational Performance. Canadian Journal of Occupational Therapy, 63(1), 923. https://doi.org/10.1177/000841749606300103 Lueck, A. H., & Dutton, G. N. (2015). Vision and the brain: Understanding cerebral visual impairment in children. AFB Press, American Foundation for the Blind. https://ebookcentral.proquest.com/lib/uindy-ebooks/detail.action?docID=4727805. Lueck, A. H., Dutton, G. N., & Chokron, S. (2019). Profiling children with cerebral visual impairment using multiple methods of assessment to aid in differential diagnosis. Seminars in Pediatric Neurology, 31, 514. https://doi.org/10.1016/j.spen.2019.05.003 Martn, M. B., Santos-Lozano, A., Martn-Hernndez, J., Lpez-Miguel, A., Maldonado, M., Baladrn, C., Bauer, C. M., & Merabet, L. B. (2016). Cerebral versus ocular visual impairment: The impact on developmental neuroplasticity. Frontiers in Psychology, 7, 1958. https://doi.org/10.3389/fpsyg.2016.01958 Matsuba, C. A., & Jan, J. E. (2006). Long-term outcome of children with cortical visual impairment. Developmental Medicine and Child Neurology, 48(6), 50812. https://doi.org/10.1017/S0012162206001071 McConnell, E. L., Saunders, K. J., & Little, J. A. (2021). What assessments are currently used to investigate and diagnose cerebral visual impairment (CVI) in children? A systematic review. Ophthalmic & Physiological Optics: The Journal of the British College of Ophthalmic Opticians (Optometrists), 41(2), 224244. https://doi.org/10.1111/opo.12776 McKillop, E., & Dutton, G. N. (2008). Impairment of vision in children due to damage to the brain: a practical approach. British and Irish Orthoptic Journal, 5, 814. http://doi.org/10.22599/bioj.222 Merabet, L. B., Mayer, D. L., Bauer, C. M., Wright, D., & Kran, B. S. (2017). Disentangling how the brain is "wired" in cortical (cerebral) visual impairment. Seminars in Pediatric Neurology, 24(2), 8391. https://doi.org/10.1016/j.spen.2017.04.005 Morse, M. T. (1999). Cortical visual impairment: Some words of caution. RE: View, 31(1), 21. https://www.proquest.com/scholarly-journals/cortical-visual-impairment-some-wordscaution/docview/222982418/se-2?accountid=28917 Occupational Therapy Practice Framework: Domain and Process-Fourth Edition. (2020). The American Journal of Occupational Therapy: Official Publication of the American Occupational Therapy Association, 74(Supplement_2), 7412410010p17412410010p87. https://doi.org/10.5014/ajot.2020.74S2001 Ortibus, E., Laenen, A., Verhoeven, J., De Cock, P., Casteels, I., Schoolmeesters, B., Buyck, A., & Lagae, L. (2011). Screening for cerebral visual impairment: value of a CVI questionnaire. Neuropediatrics, 42(4), 138147. https://doi.org/10.1055/s-0031-1285908 Parajuli, R., Adhikari, S., & Shrestha, U. (2020). Profiles of cortical visual impairment (CVI) patients visiting pediatric outpatient department. Nepalese Journal of Ophthalmology, 12(1), 2531. https://doi.org/10.3126/nepjoph.v12i1.28385 Pehere, N., Chougule, P., & Dutton, G. N. (2018). Cerebral visual impairment in children: Causes and associated ophthalmological problems. Indian Journal of Ophthalmology, 66(6), 812815. https://doi.org/10.4103/ijo.IJO_1274_17 Pehere, N. K., & Jacob, N. (2019). Understanding low functioning cerebral visual impairment: An Indian context. Indian Journal of Ophthalmology, 67(10), 15361543. https://doi.org/10.4103/ijo.IJO_2089_18 Philip, S. S., & Dutton, G. N. (2014). Identifying and characterizing cerebral visual impairment in children: A review. Clinical & Experimental Optometry, 97(3), 196208. https://doi.org/10.1111/cxo.12155 Pilling R. F. (2022). Make it easier: 3-word strategies to help children with cerebral visual impairment use their vision more effectively. Eye (London, England), 10.1038/s41433021-01920-4. Advance online publication. https://doi.org/10.1038/s41433-021-01920-4 Roman-Lantzy, C. (2007). Cortical visual impairment: An approach to assessment and intervention. American Foundation for the Blind. Sakki, H., Bowman, R., Sargent, J., Kukadia, R., & Dale, N. (2021). Visual function subtyping in children with early-onset cerebral visual impairment. Developmental Medicine and Child Neurology, 63(3), 303312. https://doi.org/10.1111/dmcn.14710 Sakki, H., Dale, N. J., Mankad, K., Sargent, J., Talenti, G., & Bowman, R. (2022). Exploratory investigation of brain MRI lesions according to whole sample and visual function subtyping in children with cerebral visual impairment. Frontiers in Human Neuroscience, 15, 765371. https://doi.org/10.3389/fnhum.2021.765371 Salavati, M., Waninge, A., Rameckers, E. A. A., de Blcourt, A. C. E., Krijnen, W. P., Steenbergen, B., & van der Schans, C. P. (2015). Reliability of the modified Pediatric Evaluation of Disability Inventory, Dutch version (PEDI-NL) for children with cerebral palsy and cerebral visual impairment. Research in Developmental Disabilities, 37, 189 201. https://doi.org/10.1016/j.ridd.2014.11.018 Salavati, M., Waninge, A., Rameckers, E. A. A., van der Steen, J., Krijnen, W. P., van der Schans, C. P., & Steenbergen, B. (2017). Development and face validity of a cerebral visual impairment motor questionnaire for children with cerebral palsy. Child: Care, Health and Development, 43(1), 3747. https://doi.org/10.1111/cch.12377 Schwartz, T. L., Harpster, K., Long, J., & Gribben, P. (2021). Telemedicine-based approach in children with cerebral visual impairment (CVI). Journal of American Association for Pediatric Ophthalmology and Strabismus, 25(4), 47. https://doi.org/10.1016/j.jaapos.2021.08.179 Swift, S. H., Davidson, R. C., & Weems, L. J. (2008). Cortical visual impairment in children: presentation intervention, and prognosis in educational settings. Teaching Exceptional Children Plus, 4(5). http://escholarship.bc.edu/education/tecplus/vol4/iss5/art4. Tsirka, A., Liasis, A., Kuczynski, A., Vargha-Khadem, F., Kukadia, R., Dutton, G., & Bowman, R. (2020). Clinical use of the insight inventory in cerebral visual impairment and the effectiveness of tailored habilitational strategies. Developmental Medicine and Child Neurology, 62(11), 13241330. https://doi.org/10.1111/dmcn.14650 van Genderen, M., Dekker, M., Pilon, F., & Bals, I. (2012). Diagnosing cerebral visual impairment in children with good visual acuity. Strabismus, 20(2), 7883. https://doi.org/10.3109/09273972.2012.680232 Williams, C., Goodenough, T., Pease, A., Warnes, P., Harrison, S., Pilon, F., Hyvarinen, L., West, S., Self, J., Ferris, J., Watanabe, R., Clark, R., Evans, M., Osborne, D., Edwards, E., Billington, C., Hunn, R., Matharu, G., & CVI Prevalence Study Group. (2021). Cerebral visual impairment-related vision problems in primary school children: a crosssectional survey. Developmental Medicine and Child Neurology, 63(6), 683689. https://doi.org/10.1111/dmcn.14819  ...

... MENTAL HEALTH AT CASS HOUSING 1 An Occupation-Based Mental Health Program for Adults with Developmental and/or Intellectual Disabilities at CASS Housing Kenzie Salzbrenner, OTS May 2022 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. Beth Ann Walker, PhD, MS, OTR, FAOTA MENTAL HEALTH AT CASS HOUSING 2 Abstract In this capstone project, I addressed the mental health and overall wellness of Core Members, adults with developmental and/or intellectual disabilities, at CASS Housing using a variety of mindfulness, cognitive-behavioral, sensory modulation, and emotional regulation techniques. CASS Housing creates independent living solutions for these individuals, but Core Members face social and behavioral difficulties due to mental health disparities in this population. This need led to the development of my occupation-based, six-session mental health program called Promoting Healthy Minds which included sessions on emotional regulation, journaling, yoga and meditation, sensory modulation, and self-esteem. Following the program, participants indicated learning and increased confidence in areas of emotional regulation, mindfulness, strategies to improve self-esteem, and the sensory system. Future program developers can use this program as a guide for intervention strategies to address mental health disruptions and, therefore, improve overall occupational participation in this population. Introduction For this capstone project, I used an occupation-based approach to address the mental health and overall wellness of Core Members, adults with developmental and/or intellectual disabilities, at CASS Housing in Fort Wayne, Indiana. CASS is a privately funded non-profit organization whose goal is to create and maintain customizable, affordable, sustainable, and safe living arrangements for individuals with developmental and/or intellectual disabilities that promote independent living skills (CASS Housing, 2021). There are currently 14 Core Members who live at CASS. Along with living arrangements, CASS provides additional services to Core Members including living skills programs and vocational exploration. Each house also receives support from a Steward who lives in an apartment connected to each house and acts as a MENTAL HEALTH AT CASS HOUSING friendly neighbor by providing occasional support with daily living tasks, organizing monthly house outings, assisting to resolve Core Member conflicts, and meeting with the Core Members weekly to touch base on any issues or concerns. During the initial consultation and assessment to determine the needs of CASS, C. Stackhouse (personal communication, March 22, 2021), the Director of Residential Services, indicated that Core Members struggle with mental health issues leading to social and behavioral challenges in the CASS community. Researchers suggest that over 40% of people with developmental disabilities develop mental health difficulties including anxiety, depression, and psychosis compared to 25% of the general population (Currie et al., 2019). To address these mental health disparities, I developed a six-session program to promote the mental health and overall wellness of Core Members using approaches including mindfulness, emotional regulation, and sensory modulation (Currie et al., 2019; Vicker, n.d.; Wallis et al. 2017). I also addressed self-esteem among Core Members in this program. In this project scholarly report, I provide evidence and rationale for the development, theoretical justification, design and implementation, outcomes, and overall conclusions for this mental health program at CASS Housing. Background Through discussion with key stakeholders at CASS, a needs assessment, and a thorough literature review, I gathered relevant and necessary information to support the purpose and design of my mental health program for Core Members with development and/or intellectual disabilities. Developmental disability is an umbrella term for a group of conditions with impairment in physical, learning, language, or behavior areas resulting in developmental delay (Centers for Disease Control and Prevention, 2021). Intellectual disability is a form of 3 MENTAL HEALTH AT CASS HOUSING 4 developmental disability resulting in limited ability to learn at the expected level and function in daily life (Centers for Disease Control and Prevention, 2020). The Core Members have a range of diagnoses including autism spectrum disorder (ASD), Down syndrome, cerebral palsy, and epilepsy. The Founder, D. Buuck (personal communication, February 23, 2021), shared that the average age of Core Members is 32 with the youngest being 26 and the oldest 52. The model of the current homes is for Core Members who are already living independently or could be with minimal support (CASS Housing, 2022). Therefore, Core Members can cook, clean, manage medications, and complete self-care tasks independently. While Core Members demonstrate success with independent living skills, C. Stackhouse (personal communication, March 22, 2021) stated that residents are experiencing mental health challenges with anxiety, self-esteem, coping, and emotional regulation. He stated these challenges cause arguments, conflict, social isolation, and adverse behaviors among Core Members. These concerns, along with my interest in mental health, led to the development of a literature review and capstone project centered around the development and delivery of a mental health program for Core Members. Throughout various studies, researchers indicated the need for mental health programming among adults with developmental and/or intellectual disabilities. I used these current findings to mold my project design and desired outcomes. I addressed key topics of mindfulness, self-esteem, sensory modulation, and emotional regulation throughout my mental health program. McCauley et al. (2017) indicated that social and cognitive limitations associated with ASD and other developmental disorders prevent the development of meaningful selfconcept. For example, factors including loneliness, negative experiences with peers, lack of intimacy and companionship, and delays in the development of executive functioning limit selfesteem among those with developmental disabilities (McCauley et al., 2017; Ryan & Griffiths, MENTAL HEALTH AT CASS HOUSING 5 2015). Researchers also found that intellectual and developmental disabilities were associated with impairments in emotional development, and level of emotional dysregulation was correlated with severity of disability (Sappok et al., 2020). Per Melville et al. (2016), problem behaviors are the most common psychopathology among adults with intellectual disabilities. Researchers findings guided key topics to address in my mental health program and further emphasized the need for this program at CASS. Researchers explored intervention approaches including mindfulness, cognitivebehavioral, and sensory processing strategies to address anxiety, self-esteem, coping, and emotional regulation for those with developmental and/or intellectual disabilities. Mindfulness was defined as non-judgmental and non-reactive attention to experiences in the present moment including bodily sensations, cognitions, emotions, and urges (Cachia et al., 2016). Singh and Hwang (2020) found that both individual and group-based mindfulness practices are correlated with reduced aggression and destructive behaviors among people with intellectual and developmental disabilities. In addition to these findings, researchers identified that mindfulness and cognitive-behavioral techniques such as meditation, deep breathing, body scanning, and journaling decrease symptoms including anxiety, depression, and inadequacy in thinking among individuals with developmental and intellectual disabilities (Cachia et al., 2016; Currie et al., 2019). Along with mindfulness approaches, strategies of sensory processing and improved understanding of the sensory system guided my program. Wallis et al. (2017) explored sensory modulation interventions aimed at reducing anxiety and improving occupational participation for those with mental health difficulties. Sensory modulation activities for adolescents and adults MENTAL HEALTH AT CASS HOUSING 6 that can address mental health include yoga, art therapy/crafts, music therapy, aromatherapy, or sensory kits (Champagne, 2008). All in all, these various intervention approaches guided my mental health program development for Core Members at CASS. My project differed from current findings and programs as I combined a variety of mindfulness, emotional regulation, and sensory modulation interventions into one program. Target outcomes for the program were addressing, educating on, and improving emotional regulation, sensory modulation, mindfulness, and self-esteem among Core Members to improve mental health, wellness, and occupational participation. Guiding Theories The Person-Environment-Occupation-Performance (PEOP) model guided my doctoral capstone project. I selected this model as it uses a systems model to recognize the dynamic and reciprocal interaction between the person (intrinsic factors), environment (extrinsic factors), and occupational performance (Cole & Tufano, 2008). More importantly, this model considers the intrinsic factors of mental health and cognition. At CASS, I needed to consider both intrinsic factors like cognitive levels of Core Members and extrinsic factors like social support of other residents living in the house concerning mental health. Howlett et al. (2014) and McCauley et al. (2014) found that intrinsic factors of cognition, coping skills, and communication and extrinsic factors of companionship and negative experiences with peers can significantly impact individuals with developmental disabilities mental health. These findings validated the use of the PEOP model in the development of my mental health program. I also used the Cognitive Behavioral frame of reference (FOR) to develop my project. The Cognitive Behavioral FOR is important when psychological barriers limit activity MENTAL HEALTH AT CASS HOUSING 7 engagement (Cole & Tufano, 2008). Using this FOR, cognition and emotion are the two focuses of intervention approach (Cole & Tufano, 2008). Approaches that align with the Cognitive Behavioral FOR include mindfulness-based cognitive therapy including yoga, meditation, deepbreathing, and mindfulness (Cachia et al., 2016; Currie et al., 2019; Robertson, 2011). Function in this theory is viewed as one's ability to use cognitive processes to reason and develop accurate self-awareness and realistic perceptions of the environment and others around them; therefore, functional people can control behavior, thoughts, and feelings to promote occupational performance (Cole & Tufano, 2008). Using the PEOP model and Cognitive Behavioral FOR, I developed programming to address the overall mental health, wellness, and occupational performance of CASS core members. Project Design and Implementation I designed this project using a variety of methods including a needs assessment, thorough discussion with CASS directors, and a literature review of mental health approaches for this population as previously described. The overall purpose of this project was to address the mental health and overall wellness of the Core Members at CASS using a variety of mindfulness, cognitive-behavioral, and sensory modulation techniques (Cachia et al., 2016; Currie et al., 2019). The project consisted of six one-hour, in-person sessions with topics of Exploring Emotions, Journaling, Yoga/Meditation, Sensory Kits, Self-Esteem, and a review session. Each session, other than the final review session, consisted of an education portion via PowerPoint presentation, a supplemental video/picture to practice skills learned, and then a hands-on, occupation-based activity implementing strategies and techniques discussed in the session. In Exploring Emotions, we focused on using appropriate words/actions to describe emotions and the use of Zones of Regulation. I provided Core Members with social situations MENTAL HEALTH AT CASS HOUSING 8 that may elicit an emotional response, and they then used colored candies to match their Zone to their emotions about the situation. We then discussed strategies to move from the "bad" Zones of sadness, anger, and fear to the "good" Zone of happiness, contentment, and joy. Oakley et al. (2020) found that many adults with autism spectrum disorders or other social-communication issues struggle with alexithymia, which is difficulty identifying and describing emotions. Further, Romanowycz et al., (2021) indicated that the use of Zones of Regulation correlated with improvements in self-regulation and emotional behaviors among students. In the Journaling, Yoga/Meditation, and Sensory Kits sessions, we focused on intervention approaches of mindfulness-based therapy and sensory modulation that promoted emotional regulation, reduced destructive behaviors, and decreased anxiety in this population (Currie et al., 2019; Wallis et al., 2017). I used intervention approaches including yoga, journaling, deep breathing, meditation, and the creation of sensory kits in these sessions. We explored different graded and adapted mindfulness strategies including chair yoga, journaling phone apps, and using different sensory materials (ex. water beads, sand) for the sensory kits. The Self-Esteem session included activities of discussing core members strengths, completing an About Me journal entry regarding positive things about themselves, and creating a self-esteem vision board. Self-concept is a limitation for many adults with disabilities, so this session specifically targeted that need (McCauley et al., 2017). While the program sessions were successful overall, some various challenges and successes occurred during each session. Challenges of the program included the need to re-word statements to improve understanding, grade activities to meet the cognitive and developmental levels of each Core Member, and encourage Core Members to maintain attention to the task on hand. For example, some of the Core Members struggled to stay on-task and on-topic during the MENTAL HEALTH AT CASS HOUSING 9 program sessions. While it helped to incorporate different activities into the session to maintain interest, I often had to redirect Core Members back to the topic at hand. One of the greatest successes of the program was that the Core Members responded well to the different media I used throughout the sessions. By using a PowerPoint presentation with audio and visual stimuli and accompanying hands-on approaches, I felt that the Core Members demonstrated greater carry-over of learning than they would have if I had only selected one medium. Another success was that participation increased each session, as I only had 4 Core Members at the initial session but had 8 at the final session. For the outcome assessment to measure target goals throughout my program, I developed individual open-ended outcome measures called the Promoting Healthy Minds Questionnaire (PHMQ) specific to each session. I asked these short, open-ended outcome questions before and after each session. Finally, at the end of the program, I used my overall, open-ended questionnaire called the Promoting Healthy Minds Outcome (PHMO) that measured "satisfaction", feedback from participants, and the overall success of the program. In discussion with Dr. Beth Ann Walker (personal communication, 2022), we decided that open-ended questions specific for each session would best measure outcomes in this population due to question complexity, ease of use, and attendance. Ottmann and Crosbie (2013) indicated that open-ended exploratory questions produce adequate outcomes without forced and categorical responses in adults with intellectual disabilities. Further, Braveman and colleagues (2017) described that pretest/posttest use with a single group allows for ease of implementation and success in measuring change over time. MENTAL HEALTH AT CASS HOUSING 10 Outcomes In the first five sessions of the Promoting Healthy Minds program, Core Members indicated their understanding and knowledge of content for each session using a session-specific, open-ended pretest/posttest titled Promoting Healthy Minds Questionnaire (PHMQ). The participants received the session-specific intervention, and data collection occurred before and after each intervention session to measure target goals. Each PHMQ consisted of three to five questions to measure learning, application, and confidence with the topic(s) covered in class. Each PHMQ is outlined in Appendix A. The use of the open-ended PHMQ specific to each session was most appropriate to measure outcomes in this population due to question complexity, ease of use, and varying attendance (Bravemen 2017; Ottman & Crosbie, 2013). For session one, Exploring Emotions, I asked the four participants to describe healthy strategies to describe or show emotions, explain Zones of Regulation, and list ways to move from the Blue/Yellow/Red Zone to the Green Zone. Following the session, participants identified four new strategies to describe/show emotions, identified the color and emotions for each Zone of Regulation, and listed three new strategies to move to the Green Zone. The next day, one Core Member stated, I was able to use my Zones of Regulation paper last night to help me when I was mad and in the red zoneit helped me not act out on my bad feelings. For session two, "Journaling", I asked the seven participants to describe the benefits of journaling, different methods to journal, strategies to be successful with journaling, and confidence with journaling. Following the session, participants identified four new benefits of journaling, four alternative methods to journal, and three strategies for success with journaling. All participants stated they felt more confident about journaling after the session. MENTAL HEALTH AT CASS HOUSING 11 In session three, Yoga and Meditation, eight participants described the benefits of yoga, deep breathing, and meditation, strategies to use these techniques, and their confidence in using these techniques to regulate emotions. Following the intervention, participants indicated five new benefits of yoga, deep breathing, and meditation, five new strategies to use these techniques, and all participants indicated improved confidence in using these techniques to regulate emotions. In session four, Sensory Kits, six participants identified the senses, described the sensory system, and explored ways to calm or excite the sensory system. Following the intervention, participants listed all six senses, described the sensory system as "how my body feels or responds", and listed new ways to calm or excite the sensory system. In session five, Self-Esteem, eight participants were asked to describe self-esteem, why self-esteem is important, and strategies to improve self-esteem. In the pretest, participants could not identify or describe self-esteem. Following the session, participants described self-esteem as the good things about yourself, thinking positive, and setting good goals, indicated why selfesteem is important, and listed five new strategies to improve self-esteem. In the sixth session, participants responded to a final open-ended questionnaire, the Promoting Healthy Minds Outcome (PHMO), to assess overall learning, feedback, and satisfaction with the Promoting Healthy Minds program. The PHMO is outlined in Appendix B. The eight participants stated that the big ideas they learned in this class were handling emotions, yoga, journaling, mindfulness, and the sensory system. Participants identified mindfulness and emotional regulation strategies including yoga, journaling, deep breathing, listening to music, talking with a supportive person, and using Zones of Regulation. Participants indicated that they liked everything about the program and enjoyed spending time with me and my fellow MENTAL HEALTH AT CASS HOUSING 12 capstone student, Anna Slusser. Participants only critique of the class was that they wished there were more sessions. All participants agreed that they felt the Promoting Healthy Minds program improved their mental health and mindfulness skills. One participant shouted, This class helped me learn really important coping skills! Summary Through the development and implementation of my capstone project at CASS Housing, I addressed mental health disparities among the Core Members. CASS Housing creates a customizable, affordable, safe, and sustainable independent living environment for its Core Members. Throughout discussion with key stakeholders at CASS, a needs assessment, and a literature review, I identified that Core Members have mental health disparities in areas of emotional regulation, self-esteem, and anxiety (Hsieh et al., 2020; McCauley et al., 2017). These factors are impacted by disparities including lack of self-concept, poor sensory regulation, and alexithymia (McCauley et al., 2017; Oakley et al., 2020; Vicker, n.d.). As C. Stackhouse (personal communication, March 22, 2021), Director of Residential Services, indicated that Core Members' difficulties with coping and emotional regulation impact their independent living skills, and therefore occupational participation, my six-session Promoting Healthy Minds program included occupation-based mental health and mindfulness interventions to address these areas of need. Following the implementation of the occupation-based, six-session Promoting Healthy Minds program addressing areas of emotional regulation, mindfulness, sensory modulation, and self-esteem, Core Members demonstrated positive outcomes on the PHMQ and PHMO openended questionnaires. Important results included that Core Members identified new strategies to MENTAL HEALTH AT CASS HOUSING 13 describe and show emotions, emotional regulation techniques, strategies to improve self-esteem, and an improved understanding of the sensory system. Participants also indicated improved confidence with and understanding of yoga, meditation, deep breathing, and journaling to promote mindfulness. All in all, participants indicated that the Promoting Healthy Minds program improved their mental health and mindfulness skills. Conclusion Throughout my capstone experience at CASS Housing, I accomplished and learned new skills in program development, advocacy, and leadership. While the development of the Promoting Healthy Minds mental health and mindfulness program was the focus of my capstone experience, I also assisted in writing two grant applications, participated in a variety of CASS Housing life skills programs, organized and led social events for Core Members, completed Independent Living Scales assessments, set up a fundraiser for CASS, and created a mental health and mindfulness resource binder for the Stewards (see Appendix C). These new skills and increased knowledge of community resources for adults with disabilities will translate into my future occupational therapy interventions and education for adults with disabilities. The site benefited from the project through positive mental health and mindfulness outcomes for Core Members, the use of occupation-based approaches in programs, and the creation of the mental health and mindfulness resource binder for the Stewards. As Core Members indicated increased skill and confidence with emotional regulation, sensory modulation, self-esteem, and mindfulness strategies, they will have increased success managing mental health disparities in their independent living settings. The use of occupation-based strategies to engage Core Members in emotional regulation, sensory modulation, self-esteem, MENTAL HEALTH AT CASS HOUSING 14 and mindfulness activities increased engagement, interest, and motivation for Core Members participating in the Promoting Healthy Minds program. Further, the Steward resource binder acts as a supplement for Stewards to assist and support Core Members during times of mental health crises. This program was the first program to address mental health and mindfulness at CASS Housing; therefore, future program leaders at CASS and other supportive housing communities can use it as a guide to discuss and explore these topics among adults with developmental and/or intellectual disabilities. MENTAL HEALTH AT CASS HOUSING 15 References Braveman, B., Saurez-Balcazar, Y., Kielhofner, G., & Taylor, R.R. (2017). Program evaluation research. In R.R. Taylor (Ed.), Kielhofners research in occupational therapy: Methods of inquiry for enhancing practice (pp. 410-423). Philadelphia, PA: F.A. Davis. Cachia, R.L., Anderson, A., & Moore, D.W. (2016). Mindfulness in individuals with autism spectrum disorder: A systematic review and narrative analysis. Rev J Autism Dev Disord, 3(2). doi:10.1007/s40489-016-0074-0 CASS Housing. (2021). About. https://www.casshousing.org/about Centers for Disease Control and Prevention. (2020, November 10). Child development: Intellectual disability. https://www.cdc.gov/ncbddd/childdevelopment/facts-aboutintellectualdisability.html?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Fncbddd%2Fdeve lopmentaldisabilities%2Ffacts-about-intellectual-disability.html Centers for Disease Control and Prevention. (2021, February 26). Developmental disabilities: Key findings. https://www.cdc.gov/ncbddd/developmentaldisabilities/index.html Champagne, T. (2008). The sensory modulation program. OT Innovations. https://www.otinnovations.com/clinical-practice/sensory-modulation/the-sensory-modulation-programfor-adolescents-adults/ Cole, M., & Tufano, R. (2008). Applied theories in occupational therapy: A practical approach. Thorofare, N.J.: SLACK Inc. Currie, T.L., McKenzie, K., & Noone, S. (2019). The experience of people with an intellectual disability of a mindfulness-based program. Mindfulness, 10, 1304-1314. https://doi.org/10.1007/s12671-019-1095-4 MENTAL HEALTH AT CASS HOUSING 16 Howlett, S., Florio, T., Xu, H., & Troller, J. (2014). Ambulatory mental health data demonstrates the high needs of people with an intellectual disability: Results from the New South Wales intellectual disability and mental health linkage project. Australian & New Zealand Journal of Psychiatry, 49(2). doi:10.1177/0004867414536933 Hsieh, K., Scott, H.M., & Murthy, S. (2020). Associated risk factors for depression and anxiety in adults with intellectual and developmental disabilities: Five-year follow up. Am J Intellect Dev Disabil, 125(1), 49-63. doi:10.1352/1944-7558-125.1.49 McCauley, J.B., Harris, M.A., Zajic, M.C., Swain-Lerro, L.E., Oswald, T., McIntyre, N., Trzesniewski, K., Mundy, P., & Solomon, M. (2017). Self-esteem, internalizing symptoms, and theory of mind in youth with autism spectrum disorder. Journal of Clinical Child & Adolescent Psychology, 48(3), 400-411. https://doi.org/10.1080/15374416.2017.1381912 Melville, C.A., Johnson, P.C.D., Smiley, E., Simpson, N., Purves, D., McConnachie, A., & Cooper, S.A. (2016). Problem behaviours and symptom dimensions of psychiatric disorders in adults with intellectual disabilities: An exploratory and confirmatory factor analysis. Research in Developmental Disabilities, 55, 1-13. dx.doi.org/10.1016/j.ridd.2016.03.007 Oakley, B.F., Jones, E.J., Crawley, D., Charman, T., Buitelaar, J., Tillmann, J., Murphy, D.G., & Loth, E. (2020). Alexithymia in autism: Cross-sectional and longitudinal associations with social-communication difficulties, anxiety and depression symptoms. Psychological Medicine, 1-13. doi: 10.1017/S0033291720003244 Ottmann, G., & Crosbie, J. (2013). Mixed method approaches in open-ended, qualitative, exploratory research involving people with intellectual disabilities: A comparative MENTAL HEALTH AT CASS HOUSING 17 methods study. Journal of Intellectual Disabilities, 17(3), 182-197. doi: 10.1177/1744629513494927 Romanowycz, L., Azar, Z., Dang, H., & Fan, Y. (2021). The effectiveness of the Zones of Regulation curriculum in improving self-regulation and/or behaviour in students. The Allied Health Scholar, 2(2). https://ojs.unisa.edu.au/index.php/tahs/article/view/1595 Robertson, B. (2011). The adaption and application of mindfulness-based psychotherapeutic practices for individuals with intellectual disabilities. Advances in Mental Health and Intellectual Disabilities, 5(5), 46-52. doi:10.1108/20441281111180664 Ryan, T.G., & Griffiths, S. (2015). Self-advocacy and its impacts for adults with developmental disabilities. Australian Journal of Adult Learning, 55(1), 31-53. Retrieved March 25, 2021, from https://eric.ed.gov/?id=EJ1059141. Sappok, T., Heinrich, M., & Bohm, J. (2020). The impact of emotional development in people with autism spectrum disorder and intellectual developmental disability. Journal of Intellectual Disability Research, 64(12), 946-955. https://doi.org/10.1111/jir.12785 Singh, N.N., & Hwang, Y.S. (2020). Mindfulness-based programs and practices for people with intellectual and developmental disability. Current Opinion in Psychiatry, 33(2), 86-91. doi:10.1097/YCO.0000000000000570 Vicker, B. (n.d.). Behavioral issues and the use of social stories. Indiana Institute on Disability and Community. https://www.iidc.indiana.edu/irca/articles/behavioral-issues-and-theuse-of-social-stories.html Wallis, K., Sutton, D., & Bassett, S. (2017). Sensory modulation for people with anxiety in a community mental health setting. Occupational Therapy in Mental Health, 34(2), 122137. https://doi.org/10.1080/0164212X.2017.1363681 MENTAL HEALTH AT CASS HOUSING Appendix A Promoting Healthy Minds Questionnaire (PHMQ) for Sessions 1-5 Session 1: Exploring Emotions What is an emotion? What are strategies to describe or show emotions? What are Zones of Regulation? What are strategies to move from the Blue, Yellow, or Red Zone to the Green Zone? Session 2: Journaling What are benefits of journaling? Can you list some different ways/options to journal? What are some strategies you can use to be successful with journaling? Do you feel confident about being able to journal? Session 3: Yoga and Meditation What are benefits of yoga? What are benefits of deep breathing? What are benefits of meditation? What are some different ways to use yoga, deep breathing, or meditation? Do you feel confident about your ability to use yoga, deep breathing, or meditation to regulate emotions/stress/anxiety? Session 4: Sensory Kits Can you list all your senses? What is the sensory system? What are some ways to calm your sensory system? What are some ways to excite it? Session 5: Self-Esteem What is self-esteem? Why is self-esteem important? What are some strategies to improve self-esteem? 18 MENTAL HEALTH AT CASS HOUSING Appendix B Promoting Healthy Minds Outcome (PHMO) for Session 6 What are some big ideas you learned in this program? What is the most important thing you learned from this program? What are some mindfulness strategies you learned in this program? What are some emotional regulation strategies you learned in this program? What did you like about this program? What did you not like about this program? Do you think this program improved your mental health and mindfulness skills? 19 MENTAL HEALTH AT CASS HOUSING 20 Appendix C Mental Health and Mindfulness: Steward Resource Binder Mental Health and Mindfulness: Steward Resource Binder CASS Housing Created by Kenzie Salzbrenner, Occupational Therapy Student, University of Indianapolis MENTAL HEALTH AT CASS HOUSING 21 Emotional Regulation and Mental Health in Adults with Developmental and/or Intellectual Disabilities When addressing emotional regulation and mental health in adults with developmental and/or intellectual disabilities, these are main considerations: Mental Health o Over 40% of people with developmental disabilities develop mental health difficulties including anxiety, depression, and psychosis (lose touch with reality) compared to 25% of the general population (Currie et al., 2019) o Factors that influence the rate of mental illness in this population include lack of coping skills, poor communication, and physical health conditions Stress/Anxiety o Causes for the development of anxiety in this population are atypical sensory function leading to hyperresponsivity to stimuli (increased sensitivity and reactions), difficulty identifying and labeling emotions, and discomfort with unknown situations Emotional Regulation o Many adults with autism spectrum disorders or other social-communication issues struggle with alexithymia, which is difficulty identifying and describing emotions Symptoms of alexithymia include lack of emotional recognition, decreased empathy, and flat affect Self-Esteem o Social and cognitive limitations associated with autism spectrum disorder and other developmental disorders prevent development of meaningful self-concept o Factors including loneliness, negative experiences with peers, lack of intimacy and companionship, and delays in the development of executive functioning may limit self-esteem among those with developmental disabilities MENTAL HEALTH AT CASS HOUSING 22 Self-Advocacy o Self-advocacy can be hindered by lack of self-awareness, self-concept, and informed decision-making Productive Responses to Emotional Dysregulation When addressing emotional dysregulation, sensory outbursts, or behaviors in adults with developmental and/or intellectual disabilities, these are main considerations/techniques: View behavior as communication o There is a negative perception that adverse behaviors mean the individual is difficult, hard to manage, or aggressive o Do not take this viewpoint, rather consider that this population often has difficulty managing emotions, sensory input, and anxiety and ask yourself what are they trying to say with their behavior? Is there an unmet need, is the sensory environment too stimulating, are they having trouble describing how they are feeling? MENTAL HEALTH AT CASS HOUSING Ask them their thoughts and allow them to answer; do not put words into their mouth o Recognize they may have difficulty using appropriate words to describe emotions, see Zones of Regulation section of this binder o Give extended time to answer, this population often requires increased time to process or think of their response View them as your peers rather than talking down to or at them Encourage positive coping strategies o Journaling, yoga/meditation, deep breathing, and sensory kits are detailed throughout this binder Establish set rules/boundaries o Adults in this population do not like uncertainty/unknown or sudden changes Consider their sensory environment and its impact on their behavior or emotions o Is the sensory environment too stimulating or not stimulating enough? o Do they need space to resolve the issue? o See the Modifying the Sensory Environment section of this binder 23 MENTAL HEALTH AT CASS HOUSING 24 Zones of Regulation Zones of Regulation can provide vocabulary or a method to describe/explain emotions, as this population often has difficulty finding the words to describe how they are feeling o They can point to a Zone to show how they feel o They can use color words to describe how they feel I am in the Red Zone right now! You can use Zones of Regulation to discuss how to move from the Blue, Yellow, or Red Zone to the Green Zone o For example, I see that you are in the Red Zone, what can you do to get to the Green Zone? Go on a walk, spend time with friends, deep breathing, yoga/meditation, journaling, call a family member or friend, look at pictures of pets/things you like, find a quiet room MENTAL HEALTH AT CASS HOUSING Journaling Approaches Journaling can be used to reduce stress/anxiety, express emotions, gain selfconfidence, reflect on growth, boost mood, and clear the mind This population may need to use alternative journaling methods for ease of use: o o Artistic Options Pictures Coloring Stickers Phone App Options Speech to Text+ Cappuccino Audio recording journal Can create a group to journal your day and make cappuccino with coffee beans Can share audio stories, life updates, jokes Can use creative prompts to challenge friends Mahalo Video journal app Focus on gratitude Daily prompts, or can use your own prompts/journal ideas Happyfeed Journal Record images each day with a prompt/personal journal Makes a feed where you can see your images/posts from each day DailyBean Pick your daily beans with little bean emojis to show your mood/emotions from the day Puts beans in overall calendar so you can see how your month has been Can pick from a variety of bean categories including weather, social, friends, emotions/moods, food, exercise 25 MENTAL HEALTH AT CASS HOUSING Yoga and Meditation Approaches Benefits of yoga, deep breathing, and meditation: stress relief, reduces anxiety, improves energy, improves focus Yoga Techniques 26 MENTAL HEALTH AT CASS HOUSING 27 Deep breathing techniques o Belly breathing - focus on deep belly breaths, moving belly in and out o Lions breath - release a growl, snarl, loud sound with tongue out when exhaling o Shoulder roll breathing MENTAL HEALTH AT CASS HOUSING o 5-finger breathing o Body scanning How does each body part feel? Start at toes and move up, exploring if each body part is tense/relaxedrelax each body part Mindfulness- breathing Close eyes, find a quiet space, focus on deep breathing Loving kindness Positive affirmation to self and others For example, I hope that my roommate has a great day today o o 28 Meditation techniques Modifying the Sensory Environment Consider each sense when modifying the sensory environment in response to sensory dysregulation or emotional disturbances (sight, smell, taste, touch, hearing, movement) Each persons sensory system is DIFFERENT Ways to calm the sensory system: o Quiet space Sound machines, white noise o Dark space o Tactile Sensations Deep pressure/deep touch Example: weighted blankets, deep massage Warmth MENTAL HEALTH AT CASS HOUSING Fidgets Sensory boxes o Rock/swing forward and backwards o Calming, minimal tastes or smells Example: essential oil diffuser (lavender, eucalyptus) Ways to excite the sensory system: o Loud space o Bright space Colorful, changing, bright lights o Rock/swing side to side (left to right) o Light touch o Jumping o Strong tastes or smells Self-Esteem Methods to improve self-esteem: o Positive self-talk o Gratitude journal o Focus on positive rather than negative o Set achievable goals o Stay physically active o Surround yourself with positive people 29 MENTAL HEALTH AT CASS HOUSING 30 Appendix D DCE Weekly Planning Guide Week 1 DCE Stage (orientation, screening/evalua tion, implementation, discontinuation, dissemination) Orientation Weekly Goal Complete orientation to site/staff/core members Develop plan for project Objectives 2 Orientation Continued orientation with site Foster relationships with core members Finalize program plan/schedule Meet with site mentor, staff, and core members to introduce myself and educate them on my purpose Update MOU with site mentor Discuss possible outcome measures and needs assessment Shadow each director to understand roles Tasks Participate in programs with core members Assist core members with work in gardens Observe Independent Living Skills assessment Present program idea to board members Date complete 1/14/22 Set up additional meetings with key personnel Finalize and submit MOU Find 2 additional grant sources Edit presentation of capstone project plan for presentation to board members Observe house tour Introduction 1st Draft 1/21/22 Create weekly planning guide for project Create a talking point for meeting people Finalize MOU Ensure that paperwork for orientation is complete Research grant sources MENTAL HEALTH AT CASS HOUSING 3 Screening/Eval uation& Program Development 4 Program Development Complete search of literature for program evaluation/outco mes measures Complete pretest/screening Continue development of program plan Finalize program plans and schedule Review literature on mental health programs/interven tions for mental health and adults with developmental/int ellectual disabilities 31 Establish outcomes measures Establish key talking points/topics for first 3 sessions Needs Assessment Finalize calendar with site mentor and core members Finalize list of required items/supplies Develop plan for final 3 sessions for program 5 Implementation Implement session 1 6 Implementation Implement session 2 Practice program Finalize supplies for program Meet with core members to introduce program Meet with site mentor for final suggestions Practice program Finalize supplies for program Meet with core members to introduce program Review outcomes measures with site mentor and faculty mentor Plan first 3 sessions for program Background 1st Draft 1/28/22 Meet with core members, site mentor, and additional staff to finalize program calendar/schedule Discuss possible weaknesses/areas of improvement in project Meet with core members to introduce program plans Project Design 1st Draft Secure meeting time/space for program Finalize list of/gather supplies for program Present evidence for value of program Record observations during program Secure meeting time/space for program Finalize list of/gather supplies for program Present evidence for value of program 2/4/22 2/11/22 2/18/22 MENTAL HEALTH AT CASS HOUSING 32 7 Implementation Implement session 3 8 Implementation Implement session 4 9 Implementation Implement session 5 10 Implementation Implement session 6 Meet with site mentor for final suggestions Practice program Finalize supplies for program Meet with core members to introduce program Meet with site mentor for final suggestions Record observations during program Practice program Finalize supplies for program Meet with core members to introduce program Meet with site mentor for final suggestions Practice program Finalize supplies for program Meet with core members to introduce program Meet with site mentor for final suggestions Secure meeting time/space for program Finalize list of/gather supplies for program Present evidence for value of program Record observations during program Secure meeting time/space for program Finalize list of/gather supplies for program Present evidence for value of program Record observations during program Secure meeting time/space for program Finalize list of/gather supplies for program Present evidence for value of program Record observations during program Draft of outcomes Secure meeting time/space for program Finalize list of/gather supplies for program Present evidence for value of program Record observations during program Dissemination plan Practice program Finalize supplies for program Meet with core members to introduce program Meet with site mentor for final suggestions 2/25/22 3/4/22 3/11/22 3/18/22 MENTAL HEALTH AT CASS HOUSING 11 Discontinuation Complete posttest/screening 33 Gather data on post-test/screening measures Gather feedback on programs 12 Discontinuation Develop binder with program guides/additional resources Meet with core members to discuss end of program 13 14 Dissemination Dissemination Present program outcomes to staff, core members, site mentor Develop first draft of poster and VoiceThread for dissemination Meet with core members to determine layout of binder Meet with site mentor for assistance with literacy/format of binder Meet with core members to discuss findings of program Create presentation of program and findings Create PowerPoint of program and findings Create first draft of poster Create first draft of VoiceThread Meet with core members to implement posttest/screening for outcome measures Meet with staff for feedback on program Begin data analysis of findings Gather supplies for binder Meet with staff to determine additional needs to be met in binder Form binder Print supplies/materials Gather program feedback from core members 3/25/22 4/1/22 Schedule time to meet to disseminate program to board, staff, core members Finalize presentation and PowerPoint 4/8/22 Meet with site and faculty mentors for feedback on first draft of poster and VoiceThread 1st Draft of Abstract/Summary/ Conclusion 4/15/22  ...

... IMPLEMENTING A LIFE SKILLS CIRRICULUM 1 Implementing a Life Skills Curriculum to Young Adults and Teens Experiencing Homelessness Megan Rooks May 2022 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 IMPLEMENTING A LIFE SKILLS CIRRICULUM 2 Abstract Youth experiencing homelessness are faced with a multitude of challenges including finding safe shelter, obtaining income, and often trying to finish high school. (Marshall & Rosenberg, 2014). KIC-IT is a not-for-profit organization that provides coaching services and resources for young adults and teens experiencing homelessness. The purpose of this project was to fill a gap in services provided at KIC-IT by developing and implementing a life skills curriculum. Within the curriculum clients learned to prepare meals using the appliances available to them and foods available at a food pantry. Within the curriculum they also learned budgeting skills and were provided developmental handouts to aid in child rearing. After engaging in the curriculum, clients reported gaining skills in some area of cooking or budgeting. Along with gaining new skills, engaging in cooking classes was a way to build a rapport with staff to facilitate improved ability to work towards meeting goals. IMPLEMENTING A LIFE SKILLS CIRRICULUM 3 Implementing a Life Skills Curriculum to Young Adults and Teens Experiencing Homelessness In 2019, 35,038 youth in the United States ranging from ages 18-24 were considered homeless at some point throughout the year (National Alliance to End Homelessness, 2017). A person falls under the category of being homeless when they do not have access to safe shelter and are currently residing in a place not meant for human habitation (National Alliance to End Homelessness, 2017). Kids in Crisis Intervention Team (KIC-IT) is a not-for-profit organization based out of Johnson County Indiana, which provides services to help young adults and teens experiencing homelessness. KIC-IT has a mission to create a network of support and empowerment for youth to break the cycle of homelessness and promote independence (KIC-IT, 2020). KIC-IT offers case management services, immediate assistance through a drop-in center, and education through an outreach program for their clients. (KIC-IT, 2020). Once a client has started receiving coaching services from KIC-IT the three main goals they are working towards are gaining employment, safe shelter, and budgeting skills (K. Sparks, personal communication, February 12, 2021). Along with the drop-in center, KIC-IT also has transitional houses where their clients can stay up to a year to gain practice with managing bills and home maintenance before moving to a more permanent independent living situation. The purpose of this project was to develop a life skills curriculum for the clients of KICIT. The focus of the curriculum is meal preparation, grocery shopping, and child rearing. Cooking classes were held to teach meal preparation skills, and a cookbook was developed and utilized during these classes. The recipes focused on items that can be found at a food pantry and IMPLEMENTING A LIFE SKILLS CIRRICULUM 4 only require a microwave. Information about how to shop on a budget and ways to reduce their grocery bill were provided at the cooking nights. Childhood development handouts were also created for the clients of KIC-IT. Many of the clients have infants or young children but are lacking in education and resources about their childs developmental needs. These handouts will allow the clients to not only have an idea of what their child should be doing developmentally, but also included information on activities to help enrich their childs development. Background Homelessness in youth and young adults looks different than what is typically thought of when referring to someone who is homeless. Young adults and teens often couch surf between friends homes until their options run out (Schifalacqua et al., 2019). Experiencing homelessness, especially at such a young age, is a traumatic experience that has detrimental effects on an individuals life (Marshall & Rosenberg, 2014). Experiencing this type of living situation causes an individual to be placed under constant stress about meeting basic physiological needs such as a place to sleep at night or where their next meal will come from (Hopper et al., 2010; Levenson, 2017; Brothers et al., 2020). Along with a prevalent history of trauma, many young adults who are experiencing homelessness also have a much higher risk of having a meatal health diagnosis and externalizing behaviors such as substance abuse and high-risk sexual behaviors (Omery et al., 2020; Milburn et al., 2019). This is seen in the clients served at KIC-IT, as many of them have a diagnosis of depression, anxiety, or PTSD. When working with individuals who have a history of trauma, it is essential to approach the situation with care and compassion. Trauma-informed care (TIC) is a method of providing IMPLEMENTING A LIFE SKILLS CIRRICULUM 5 services that view an individuals current problem in the context of their past traumatic experience, which shifts the focus away from addressing and intervening on past trauma (Levenson, 2017). TIC focuses on creating an environment that fosters safety, trustworthiness, choice, collaboration, and empowerment (Fallot & Harris, 2009). When working with individuals who are experiencing homelessness, it is important to not only address the immediate physiological needs of the client but also consider the underlying psychological needs that come from a history of trauma (Hopper et al, 2010). Prestidge (2014) found that by incorporating the TIC approach into interventions for chronically homeless individuals, the recipients of the services can use services more effectively and move towards independence quicker. TIC is an essential part of this capstone project as it is the foundation for all interactions between the clients and capstone student. Many teens and young adults who are homeless are completely on their own without a strong support system. Even though these teens live alone, they often lack the necessary skills to successfully live independently (Thompson et. al, 2018). A person who is experiencing homelessness has little control over the occupations they are engaging in as a majority of their time is spent trying to secure housing, finding opportunities to make income, or functioning in a shelter (Marshall & Rosenberg, 2014). This lack of engagement in many occupations may lead to a decrease in skills needed to successfully live independently (Marshall & Rosenberg, 2014; Chan et al., 2007). This decrease in occupational engagement supported the need for this project to be completed. The clients at KIC-IT were already receiving coaching services on obtaining employment and budgeting skills, and one area staff felt was missing was teaching the clients skills that would be needed once they were able to secure more permeant housing. This capstone IMPLEMENTING A LIFE SKILLS CIRRICULUM 6 project provides the clients of KIC-IT with opportunities to learn new skills to be successful on their way to independence. Not only is one worried about meeting their own basic needs while being homeless, but many of these individuals are parents to multiple young children. Mothers with young children represent the fastest growing section of the homeless population (David et al., 2012). At KIC-IT a majority of the clients have children or are expecting a child. Mothers who are experiencing homelessness are often lacking in the proper resources and education (David et al., 2012). Children who are raised by mothers who are homeless are at a higher risk for developing problems such as developmental delays, poor school performance, and behavior problems (Haber & Toro, 2004). Through completion of the capstone project the clients of KIC-IT who are mothers of children now have access to materials about their childs developmental needs. Along with gaining education on their childrens developmental needs, parents are also gaining information on age-appropriate activities to help their child meet the developmental milestones. This capstone project meets needs that have not been met in previous studies by providing services that allow clients to gain education and obtain new skills along with resources to utilize in their own environment. This capstone project meets the needs of the clients by being flexible in service delivery as sessions were ran when most clients were coming into the youth drop-in center for their coaching meetings. Providing clients with educational materials and resources to take home allowed them to take information as needed to not become overwhelmed with the abundance of new information at once. Theory IMPLEMENTING A LIFE SKILLS CIRRICULUM 7 The Ecology of Human Performance (EHP) was used to guide the development of this doctoral capstone project. EHP is based on the idea that the interaction between a person and environment impacts performance in occupations, and that performance cannot be understood outside of context (Dunn et al., 1994). Within EHP, a person uses their skills and abilities to accomplish specific tasks or occupations, through their current context (Dunn et al., 1994). An individuals performance range is the current tasks they are able to complete which they derive meaning from (Dunn et al., 1994). Within EHP, intervention occurs as a collaborative process between the person and therapist with a main goal to facilitate occupational performance (Abiodun et al., 2021). EHP does not take the approach to fix the individual as some other theories do but considers a holistic view of their current situation (Dunn, 2017). When a person is experiencing homelessness, their context is severely limiting the ability of tasks they can complete. By being homeless they are not able to access many resources that allow for meaningful engagement in valued occupations. Interventions within EHP are in five categories: establish/restore, alter, adapt, prevent, and create (Abiodun et al., 2021; Dunn et al., 1994). For this DCE project the cooking classes and the developmental handouts that were created were developed within the establish/restore category of interventions. The goal of this type of intervention within the model is to restore function by improving abilities and skills within context (Abiodun et al., 2021; Dunn et al., 1994). By teaching these clients new skills they will be set up for more success while living independently. Project Clients at KIC-IT receive coaching from staff on how to manage the current crisis they are in, gain employment and learn the beginning stages of budgeting money. Through the coaching provided at KIC-IT clients talk through various skills needed to live independently but IMPLEMENTING A LIFE SKILLS CIRRICULUM 8 are never given direct instruction or practice in these skills. Along with coaching services, KICIT has a transitional housing program where clients live with two to three other clients in the same home. Many of these clients who live in these houses have never lived independently and have not had to complete home management tasks such as preparing meals. Through this capstone project cooking classes were developed to fill the gap in services provided to clients and to provide them with the skills necessary to be successful in living independently. The cooking classes were hosted once a month on nights that many clients had meetings at the youth center. Developing the project around the clients schedule allowed for a higher percentage of clients to be able to attend. Classes were hosted at the youth drop-in center and were an hour long each. A pre- and post-class survey was developed to assess the clients knowledge on cooking, staying within budget, and utilizing the food received from a pantry. Post-class survey questions assessed if clients had gained knowledge in the areas listed on the pre-class survey. Cooking nights were advertised at the youth center through flyers and by speaking with clients about the events. Recruitment of participants for these classes was difficult across the course. Many of the clients expressed interest in the classes, but on the night of the events they did not show up. Communication via text messages to remind clients about the event was another way to try to increase participation. Gift cards, raffle prizes, and a free meal were promoted at these events to try to overcome the challenge of increasing the clients engagement in the program. Another barrier that arose while hosting these cooking nights was the clients did not all show up at the same time. On some nights one client would show up at the start time, and then one would show up 15 or 20 minutes after, and some would even show up five minutes before IMPLEMENTING A LIFE SKILLS CIRRICULUM 9 the event ended. Trying to incorporate the clients who did not show up on time the activity was challenging. Clients who showed up with only a few minutes left of the activity were excluded from participating in an attempt to promote better time management skills and responsibility. Overall, talking to the clients about the cooking nights while they were already in the youth center was one of the most beneficial ways to recruit clients. Consistently promoting the gift cards and free dinner were the incentives that lead to increased engagement in the cooking nights across the capstone experience. Project Outcomes Before the cooking class started clients filled out a survey assessing their knowledge on a variety of cooking tasks. A 5-point Likert scale was used to assess clients in the areas of: ability to follow a recipe, ability to use appliances in their current living space, ability to cook a variety of meals at home, confidence in cooking, using ingredients at home to make a meal, and staying within budget while grocery shopping. After completing the session, clients answered questions on knowledge gained in the same areas they were asked about on the pre class assessment. The pre and post session surveys allowed an assessment to be completed at each session. This was vital to the project due to the inconsistencies in attendance with very few clients attending more than one session. The pre and post session surveys also allowed each client to be assessed at their current skill level since each client is coming to the cooking classes with different levels of skills. This method of assessment also allowed for cooking skills gained in the class as well as knowledge about budgeting while grocery shopping to be assessed. A total of five clients attended the cooking classes, with none of them attending more than one session. Before attending the cooking classes, all five clients reported agree or IMPLEMENTING A LIFE SKILLS CIRRICULUM 10 strongly agree on their ability to follow a recipe and to use the current appliances in their home. Areas where all five clients reported disagree or neutral were cooking a variety of meals at home and staying within budget while grocery shopping. After completing the cooking session, all clients increased in their knowledge on budgeting while grocery shopping as well as using ingredients they currently have to prepare a meal. A key observation throughout the course of the cooking nights was how the clients were able to have meaningful conversations with the staff during the events. Many of the clients found cooking to be relaxing and allowed them to open up to the staff to deepen their relationship. The relationships built through these conversations allowed the staff at KIC-IT to better serve the clients by knowing them on a more intimate level. Summary One in ten young adults ages 18 to 25 experience some form of homelessness throughout the year (Voices of Youth Count, 2017). Working with a vulnerable population such as young adults and teens who are experiencing homelessness comes with a myriad of challenges to ensure quality care is provided to them. These individuals often have either recent or past trauma that has led to their current state of homelessness (Schifalacqua et al., 2019). Understanding and addressing the underlying trauma is vital to developing rapport with these individuals (Hopper et al., 2010). Due to an unstable environment during vital developmental years, these individuals often lack the skills, education, and experience to overcome the barriers they are challenged with to break the cycle of homelessness on their own. KIC-IT provides coaching services to help these individuals gain safe and secure housing, employment/education, and develop budgeting skills. This capstone project developed a cooking curriculum along with developmental guidelines to IMPLEMENTING A LIFE SKILLS CIRRICULUM 11 fill a gap in service delivery. This curriculum also empowered these induvial with life skills needed to be successfully independent. Incentives of a free meal and a grocery gift card were used to increase client attendance at the cooking nights. The most successful way to recruit participants was through informal conversations at the youth center. Clients completed a pre- and post-class assessments to assess a variety of cooking and budgeting skills before and after each cooking session. Five clients attended at least one of the cooking skills nights, and each reported gaining life skills in these sessions. All participants of the cooking nights reported gaining skills in shopping within their budget and using ingredients they have at home to create a meal. Along with gaining practical life skills, clients were able to deepen their relationship with the staff at KIC-IT in a low-stress environment. This connection allows staff to better understand clients and help them make progress towards their goals which can lead to more positive client outcomes (Curry et al., 2021). Conclusion Positive outcomes look different when looking at results in an emerging practice area compared to a more traditional medical model for occupational therapy. The results of this capstone project display how impactful it is to help enable an individual to gain life skills necessary for independent living. Throughout the 14-week capstone experience a cooking curriculum and cookbook were developed and implemented to give clients at KIC-IT skills to successfully live independently. Along with this, clients were also given access to a developmental guide that also provides examples of developmentally appropriate activities to complete with their children. This curriculum filled a gap in service delivery for the current services that were being provided at IMPLEMENTING A LIFE SKILLS CIRRICULUM KIC-IT. Clients who engaged in the cooking curriculum reported learning skills to help them stay on budget by and increasing their cooking skills. Along with gaining hands on skills at the cooking nights, clients were able to connect with the staff at KIC-IT and deepen their relationship. By better understanding the clients, staff is able to provide more holistic and successful case management services for their clients. 12 IMPLEMENTING A LIFE SKILLS CIRRICULUM 13 References Abiodun, O. Y., Odunayo, A. C., Ayub, S., & Kumari, M. (2021). Disaster Management and Working with Displaced Persons (Methodological Paper). Open Journal of Therapy and Rehabilitation, 9(2), 29-41. Brothers, S., Lin, J., Schonberg, J., Drew, C., & Auerswald, C. (2020). Food insecurity among formerly homeless youth in supportive housing: A social-ecological analysis of a structural intervention. Social Science & Medicine, 245, 112724. Chan, K. P., Garland, K., Ratansi, K., & Yeres, B. (2007). Viewing youth homelessness through an occupational lens. Occupational Therapy Now, 9(4), 14. Curry, S. R., Baiocchi, A., Tully, B. A., Garst, N., Bielz, S., Kugley, S., & Morton, M. H. (2021). Improving program implementation and client engagement in interventions addressing youth homelessness: A meta-synthesis. Children and youth services review, 120, 105691. David, D. H., Gelberg, L., & Suchman, N. E. (2012). Implications of homelessness for parenting young children: A preliminary review from a developmental attachment perspective. Infant Mental Health Journal, 33(1), 1-9. Dunn, W. (2017). The ecological model of occupation. Perspectives on human occupation: Theories underlying practice, 207-235. Dunn, W., Brown, C., McGuigan, A., (1994). The ecology of human performance: A framework for considering the effect of context. The American Journal of Occupational Therapy. 48 (7), 595-607. IMPLEMENTING A LIFE SKILLS CIRRICULUM 14 Haber, M. G., & Toro, P. A. (2004). Homelessness among families, children, and adolescents: An ecologicaldevelopmental perspective. Clinical Child and Family Psychology Review, 7(3), 123-164. Hopper, E.K., Bassuk, E.L., & Olivet, J. (2010). Shelter from the storm: Trauma-informed care in homelessness services settings. The open health services and policy journal, 3(1). Levenson, J. (2017). Trauma-informed social work practice. Social Work, 62(2), 105-113. Marshall, C. A., & Rosenberg, M. W. (2014). Occupation and the process of transition from homelessness: Loccupation et le processus de transition de litinrance au logement. Canadian Journal of Occupational Therapy, 81(5), 330-338. Milburn, N. G., Stein, J. A., Lopez, S. A., Hilberg, A. M., Veprinsky, A., Arnold, E. M., ... & Comulada, W. S. (2019). Trauma, family factors and the mental health of homeless adolescents. Journal of Child & Adolescent Trauma, 12(1), 37-47. National Alliance to End Homelessness. (2017). Youth and Young Adults. https://endhomelessness.org/homelessness-in-america/who-experienceshomelessness/youth/ Omerov, P., Craftman, . G., Mattsson, E., & Klarare, A. (2020). Homeless persons' experiences of healthand social care: A systematic integrative review. Health & social care in the community, 28(1), 1-11. Prestidge, J. (2014). Using trauma-informed care to provide therapeutic support to homeless people with complex needs: a transatlantic search for an approach to engage the nonengaging. Housing, Care and Support, 17(4), 208214. https://doi.org/10.1108/HCS-092014-0024 IMPLEMENTING A LIFE SKILLS CIRRICULUM 15 Schifalacqua, M., Ghafoori, A., & Jacobowitz, M. (2019). A hidden healthcare crisis: Youth homelessness. Nurse Leader, 17(3), 193-196. Thompson, H. M., Wojciak, A. S., & Cooley, M. E. (2018). The experience with independent living services for youth in care and those formerly in care. Children and Youth Services Review, 84, 17-25. Voices of Youth Count (2017). Missed opportunities: Youth homelessness in America. https://voicesofyouthcount.org/wp-content/uploads/2017/11/ChapinHall_VoYC_1Pager_Final_111517.pdf IMPLEMENTING A LIFE SKILLS CIRRICULUM 16 Appendix A DCE Weekly Planning Guide Week DCE Stage Weekly Goal Objectives 1 Orientation Orientation to site Meet with site mentor and faculty to explain what I will do over the next 14 weeks Learn roles of each staff member Create plan for implementing life skills class 2 Evaluation 3 Evaluation 4 Review what is currently addressed through coaching program Understand process of becoming Kic-It client Implementation Create materials needed for cooking class Update MOU and literature review Tasks Set up meetings to finalize understand roles at KICIT Date complete 1/14 Research financial literacy and update MOU goals and objectives Finalize MOU Updated due 1/21 MOU and send to all mentors 1/21 Learn current materials provided to clients when starting program Create list of sponsors for programs and materials 1/28 Set up meetings with sponsors for materials 2/4 Create flyer for group cooking classes Create layout of cooking classes Create format for cookbook Set up time for Family Night IMPLEMENTING A LIFE SKILLS CIRRICULUM 5 Implementation Develop cookbook 6 Implementation Finalize plans and lessons for group cooking classes Develop child development handout 7 Implementation Lead group cooking classes 8 Implementation Create materials for group cooking class 9 10 11 Continue to develop cookbook and developmental guide Practice session of group cooking class 17 Add recipes to 2/11 cookbook Purchase materials needed For group session Create developmental guide for family night Create pre and Clean youth post center after assessments classes Continue to develop cookbook and developmental guide Implementation Organize Meeting with materials from mentor over classes and group cooking review group classes cooking classes with mentor 2/18 2/25 Continue to 3/4 add to cookbook developmental guide Set up 3/11 meetings with sponsors for materials Set up meeting with mentor Implementation Finalize group Practice Purchase 3/18 cooking session of materials classes group cooking needed class Add to developmental milestones Implementation Lead classes Administer Add recipes to 3/25 QoL survey cookbook Purchase materials for session IMPLEMENTING A LIFE SKILLS CIRRICULUM 12 Implementation Hand out developmental guides at youth center 13 Discontinuation Finalize materials created 14 Dissemination Present Provide information on developmental milestones to families and ageappropriate activities for their children Organize google drive with updated materials and content for clients Dissemination of project to site 18 Print materials 4/1 Print out 4/8 cookbook and developmental milestone handouts Practice presentation to site 4/15  ...

... Title: Development of a Social Participation and Community Integration Program for the Veteran Population Jordan Romero May 2022 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: Jenna Trost, OTR A Capstone Project Entitled Title: Development of a Social Participation and Community Integration Program for the Veteran Population Submitted to the School of Occupational Therapy at University of Indianapolis in partial fulfillment for the requirements of the Doctor of Occupational Therapy degree. By Jordan Romero OTD Student Approved by: Faculty Capstone Advisor Date Doctoral Capstone Coordinator Date Accepted on this date by the Chair of the School of Occupational Therapy: Chair, School of Occupational Therapy Date Abstract Introduction: This paper describes the process of the program development of Carving up the Ranks, a woodworking group aimed at improving social participation and community reintegration within the veteran population. Background: Occupational therapy is needed in veteran care to bridge the gaps areas of social participation and community reintegration. Methods: Interviews and research guided the development of the instructional manual for this woodworking group. Results: At the conclusion of the instructional manual development, the group session leaders were able to recite the programs objectives and deemed the manual to be readable, understandable, and replicable. Conclusions: The final rendition of the program manual was provided to all potential group session leaders. The researcher shared about the process of development and explained all contents. Recommendations/Implications: It is imperative that researchers work to broaden the variety of participants eligible to participate in future cohorts. Introduction According to the United States Department of Veteran Affairs, there are over 400,000 veterans in Indiana (U.S. Department of Veterans Affairs, 2017). Of this population, 7.61% are women and 46.43% are aged 65 or older (U.S. Department of Veterans Affairs, 2017). Of Indiana veterans, around 45% of them are enrolled in the Veteran Affair healthcare system and around 21% are receiving disability compensation (U.S. Department of Veterans Affairs, 2017). The Housing Assistance Council states that over 20% of veterans are living in homes with one or more major issues related to quality, crowding, or cost (2017). The Richard L. Roudebush Veterans Affairs Medical Center (RLRVAMC) is a part of Veteran Health Indiana (VHI) and has been serving veterans as an inpatient and outpatient care center in central Indiana since 1932 (Veterans Affairs, 2021). There are also several affiliated community clinics located across Indiana and partnerships with a veteran-centered YMCA wellness center (Veterans Affairs, 2021). At the RLRVAMC, the researcher will be developing an instructional manual for a woodworking program for veterans. The program will be centered around the creation of woodworking projects. The hospital has a partnership with a woodworking company that will allow the research team to use their resources and space. Researchers are planning to create several projects such as cornhole boards, cutting boards, Jenga blocks, etc. The program will support meaningful connections between veterans and promote occupational engagement in leisure, play, social participation, and community engagement. From the issues and barriers to social participation and community integration noted, the researcher is aiming the development of the program at reducing these barriers. By having the veterans participating in the program working towards meaningful occupational engagement, the researcher hypothesizes that there will be improvements in their social participation, perceived social supports, quality of life, and mental health outcomes. Background Literature shows that participation in programs that promote social participation and meaningful relationships leads to positive health outcomes. Gorman et al. conducted social peer support groups in a local coffee shop for veterans for nine months. Results from this study showed that veterans were more likely to take on social roles outside of these events (2018). The veterans also obtained practical and emotional support and empowered veterans to embrace a helper role to support other veterans. The participants demonstrated increased skills in occupational adaptation and engagement in community resources (Gorman et al., 2018). Additionally, authors Kirchen and Hersch studied personal and environmental factors that facilitate veteran adaptation to long-term care facilities (2015). They found that several themes began to emerge: importance of family, home, spirituality, military culture, leisure time use and food and music (Kirchen & Hersch, 2015). The creation of a leisure and social participation focused program would enhance themes related to military culture and leisure time use. According to Radomski and Brininger, many veterans return from deployment with traumatic brain injuries, stress disorders, amputations, burns, musculoskeletal disorders, and attendant occupational dysfunction (2014). Vaughan-Horrocks et al. states that a substantial number of veterans face diagnoses like post-traumatic stress disorder, depression, and anxiety (2021). The authors go on to report that even without a specific diagnosis, veterans are struggling with the role loss and the transition back to civilian life (Vaughan-Horrocks et al., 2021). Furthermore, todays veterans are experiencing increased survival rates from military injuries, multiple deployments, and recurrent exposure to traumatic events which has led to the increase in complexity and severity of challenges facing community integration (Vaughan-Horrocks et al., 2021). Veterans are facing challenges with the resumption to family life, work, and community engagement (Radomski & Brininger, 2014; Dillahunt-Aspillaga and Powell-Cope, 2018). Other occupational challenges that veterans face are associated with relationships, education, and physical health; The transition from a highly structures way of living to an unstructured civilian life is very difficult (Vaughan-Horrocks et al., 2021). It is vital that civilian occupational therapy practice focuses on veterans occupational performance and community integration. Occupational therapy can provide a profound impact on maintaining a healthy home life, improving sleep difficulties, and promoting community reintegration (Eakman & Radomski, 2017). Community Reintegration has been defined as the return to participation in life roles (Dillahunt-Aspillaga & Powell-Cope, 2018). The engagement in paid or volunteer work, engagement with family and friends, and participation in education are all key areas of community reintegration for veterans and service members. (Dillahunt-Aspillaga & Powell-Cope, 2018). It is recommended that a manualized recovery focused program is developed to support community integration and the development of a meaningful life (Clark et al., 1997). Eakman and Radomski also recommend that civilian occupational therapy practice focuses on veterans occupational performance and community integration (2017). In a recent study from authors Carra et al., researchers worked to determine which occupations veterans participated in with the aim of improving their health and well-being as well as determining if these occupations were associated with high self-reported health and outcomes (2021). They found that at least 25% of the veterans who participated in the study faced a difficult or extremely difficult transition back into civilian life (Carra et al., 2021). During the transition, veterans often need to work through trauma and losses related to culture, community, identity, and sense of purpose and meaning. The presence of service-related conditions like depression, anxiety, and PTSD can further worsen this transition. Veterans who participated in the study commonly reported occupations related to leisure and recreation, employment, household management, and social/community interaction (Carra et al., 2021). The participation in community interactions led to easier transitions and better physical health. The participation in leisure and recreational activities were more meaningful to many participants than employment activities as it allowed them to focus on the experience of participation rather than the outcome (Carra et al., 2021). Overall, the authors discovered that the participation in meaningful activities positively influenced the veterans overall health and adjustment to life following military service (Carra et al., 2021). In attempt to promote the participation in leisure and recreational activities among veterans and positively influence community reintegration, the Carve up the Ranks woodworking group was created. The purpose of this woodworking group is to promote independence, social participation, and community integration through the participation in the construction of various wooden projects. The group will take place on a weekly basis for approximately two hours, for eight weeks. The group sessions will include a warm-up activity to promote social participation and relationship building. Across the eight sessions, the veteran participants will complete three separate woodworking creations. Upon the completion of each session, the participants will engage in a wrap-up discussion to express what they have accomplished and how to effectively prepare for the next week. The participation in the woodworking program will hopefully lead to similar research results: increased independence, improved mental health outcomes, and a heightened sense of purpose and meaning in life. Theory/ Frame of Reference The model chosen to guide the researchers doctoral capstone experience (DCE) is the Canadian Model of Occupational Performance (CMOP). The researcher chose this model because of its highly client-centered nature and its focus on the interactions between the person, environment, and occupation itself (Cole & Tufano, 2008). Function and dysfunction are related to the balance between these three factors and changes in any area may cause issues with occupational performance (Cole & Tufano, 2008). Through the completion of the researchers needs assessment, the researcher learned that social participation and community engagement are occupations that are very meaningful and important to Veterans and contribute to their level of spirituality. By creating a program that focuses on engagement in desired occupations, the researcher can promote change and function through the lens of this model. While completing the DCE, the researcher intends to consider all these factors when designing a program to enhance participation in these preferred occupations. The researcher also chose to guide the DCE through the psychodynamic frame of reference. The psychodynamic frame has five focus areas including: social participation and relationships, emotional expression and motivation, self-awareness, defense mechanisms, and projective arts and activities (Cole & Tufano, 2008). Due to the concentration on social participation and relationship in this frame of reference, it matches well with the intentions of the program. The DCE will focus mostly on enhancing social participation and relationships through projective arts and activities. The researcher will be asking veterans to work together to complete constructive projects. The program is a great way to help them deal with their emotions, spark creativity, increase self-awareness, and become more in touch with their spirituality (Cole & Tufano, 2008). Project Design The creation of the woodworking group manual included the development of the group purpose, theoretical background, admission and exclusion criteria, reasons for group discharge, group goals, and content of individual sessions. To gather this information, the researcher met several times with her project mentors to gain a better understanding of their needs for this project. The researcher also met with other program leaders for the Veterans Affairs Hospital System to gain a better understanding of veteran programming. After several meetings with various program leaders, the researcher was able to determine the best format for the development of this manual. These meetings were vital for the development of the program manual as the researcher wanted to ensure that it aligned with the hospitals values and initiatives. The researcher also spent time researching the Whole Health initiative which values clients from a holistic perspective. This perspective guided the development of the individual session content to view the program participants from a holistic point of view. There were two specific goals that were developed to guide the creation of the instructional manual. First, the team members needed to be able to understand the program objectives after reading the manual. The second goal was for the team members to deem the manual as readable, understandable, and replicable. At the beginning of the project, the researcher conducted a short interview with the two main project supervisors to gain a better understanding of their needs and expectations from this project. They asked that the researcher define specific occupational therapy theoretical background to guide the project design, develop explicit goals for program participants, and create warm-up activities to promote social participation to start off each session that could be easily replicated by non-occupational therapy personnel. To assess the outcomes, the team members that will be guiding the programs implementation will be asked to read over the manual and verbalize the program purpose, participant goals, and individual session instructions. Throughout the implementation of this instructional manual, the researcher faced several challenges and successes. The researcher was tasked to complete this instructional manual remotely, which was a significant challenge. There were also three people that contributed to the creation of this instructional manual; two contributors were recreational therapists, and one was an art therapist. This was extremely beneficial as the researcher wanted to make sure that the manual was readable, understandable, and replicable across various professions. This was difficult at times when trying to set up meeting times with several people at once. The researcher was grateful to have such a wonderful team to work with that encouraged creativity and autonomy throughout this process. Project Outcomes Two goals were developed to guide the creation of the Carving up the Ranks instructional manual. Firstly, all team members must be able to understand the program objectives upon reading the manual. Secondly, all program leaders must deem the manual as readable, understandable, and replicable. At the conclusion of the instructional manual creation, all individuals involved in implementation were given a copy of the manual. After each leader was given the chance to look over the manual, they were asked to write down each of the program goals, in their own words. All three leaders were able to complete the task successfully. Next, each leader was asked to write the purpose of the program individually. This task was done successfully by all program leaders. Lastly, each leader was asked to verbally explain the materials needed, purposes for each individual sessions, and instructions to complete each session. Each potential session leader was able to describe these aspects successfully. The verbal portion of this evaluation was done in a one-on-one setting to avoid hearing each others answers. To conclude the evaluation, the three potential session leaders were asked to determine whether the program manual was readable, understandable, and replicable. Each of the three leaders deemed the program to meet the three criteria. It seemed as though the two recreational therapists had a better understanding of the instructional manual and the desired outcomes as they were more heavily involved in the manual creation. The art therapist joined the team towards the end of the manual creation. She seemed to take a bit longer in her verbal explanation of individual session instructions. Though she took longer than the other two leaders, she was able to complete the task successfully. In regard to the therapeutic conversations that were to take place during each session, the art therapist seemed to have a better understanding of the purpose. Overall, the leaders all completed the task successfully and deemed the instructional manual as readable, understandable, and replicable. The two recreational therapists and the art therapist were also able to successfully restate the overall program objectives without misconstruing the meaning. Summary Veterans are facing challenges with the resumption to family life, work, and community engagement (Radomski & Brininger, 2014; Dillahunt-Aspillaga and Powell-Cope, 2018). Other occupational challenges include relationships, education, and physical health; The transition from a highly structured lifestyle to an unstructured lifestyle can be extremely difficult (Vaughan-Horrocks et al., 2021). This transition has been described as community reintegration. Community Reintegration has been formally defined as the return to participation in life roles (Dillahunt-Aspillaga & Powell-Cope, 2018). It is recommended that a manualized recovery focused program is developed to support community integration and the development of a meaningful life (Clark et al., 1997). To address this recommendation, the researcher developed an instructional manual for a woodworking program for veterans. The program is centered around the creation of woodworking projects. A partnership with a local woodworking company allowed the researchers to host the program in their space and use their tools. The participants in the program will create several projects such as cornhole boards, cutting boards, Jenga blocks, etc. The program will support meaningful connections between veterans and promote occupational engagement in leisure, play, social participation, and community engagement. From the issues and barriers to social participation and community integration noted, the researcher is aiming the development of the program towards reducing these barriers. Through the participation and engagement in this program, the researcher hypothesizes that there will be improvements in veterans social participation, community integration, perceived social supports, quality of life, and mental health outcomes. The creation of the woodworking group manual included the development of the group purpose, theoretical background, admission and exclusion criteria, reasons for group discharge, group goals, and content of individual sessions. Two specific goals were developed to guide the creation of the instructional manual. The team members needed to be able to understand the program objectives after reading the manual. The manual also needed to be deemed readable, understandable, and replicable. Through an interview process, the potential session leaders were able to recite the program objectives. They also determined that the manual was readable, understandable, and replicable. Conclusion In conclusion, the researcher gathered ample information about veterans needs, interprofessional work, and program development through an occupational therapy lens. The manual was successfully labeled as readable, understandable, and replicable. The leaders were confident in their understanding of the program outcomes and implementation. The site will be able to run several trials of the program with the use of this manual. The researcher took time to go over each section of the instructional manual with each of the program leaders to describe the layout and purpose of the manual. The researcher was available for discussion and feedback to ensure that the manual was readable, understandable, and replicable. Future research needs to be completed to broaden the variety of participants eligible to participate in this program. Currently, the program can only support able-bodied, participants with no thoughts of suicide or self-harm. References Carra, K., Curtin, M., Fortune, T., & Gordon, B. (2021). Participation in occupations, health, and adjustment during the transition from military service: A cross-sectional study. Military Psychology, 33(5), 320-331. ISSN: 1532-7876 Clark, F., Azen, S. P., Zemke, R., Jackson, J., Carlson, M., Mandel, D., Hay, J., Josephson, K., Cherry, B., Hessel, C., Palmer, J., & Lipson, L. (1997). Occupational therapy for independent-living older adults: A randomized controlled trial. Journal of the American Medical Association, 278(16), 1321-1326. PMID: 9486748 Cole, M. & Tufano, R. (2008). Applied theories in occupational therapy: A practical approach. Thorofare, N.J.: SLACK Inc. Dillahunt-Aspillaga, C., & Powell-Cope, G. (2018, February). Community reintegration, participation, and employment issues in veterans and service members with traumatic brain injury. Physical Medicine and Rehabilitation, 99(2S), S1-S3. ISSN: 1532-821X Eakman, A. M., & Radomski, M. V. (2017, December). Occupational therapy past and present: Responding to physical, cognitive, and emotional consequences of war. British Journal of Occupational Therapy, 80(12), 697-698. ISSN: 1477-6006 Gorman, J. A., Scoglio, A. A., Smolinsky, J., Russo, A., & Drebing, C. E. (2018, June 13). Veteran coffee socials: A community-building strategy for enhancing community reintegration of veterans. Community Mental Health Journal, 54, 1189-1197. https://doi.org/10.1007/s10597-018-0288-y Kirchen, T. M., & Hersch, G. (2015). Understanding person and environment factors that facilitate veteran adaptation to long-term care. Physical and Occupational Therapy in Geriatrics, 33(3), 204-219. doi: 10.3109/02703181.2015.1037979 Radomski, M. V., & Brininger, T. L. (2014). Occupational therapy for servicemember and veteran recovery, resilience, and reintegration: Opportunities for societal contribution and professional transformation. American Journal of Occupational Therapy, 68(4), 379-380. ISSN: 1943-7676 U. S. Department of Veterans Affairs. (2017). Indiana. U. S. Department of Veterans Affairs. https://www.va.gov/vetdata/docs/SpecialReports/State_Summaries_Indiana.pdf Vaughan-Horrocks, H., Reagon, C., & Seymour, A. (2021, September). The experiences of veterans with mental health problems participating in an occupational therapy and resilience workshop intervention: an exploratory study. British Journal of Occupational Therapy, 84(9), 531-540. doi: 10.1177/0308022620977818 Veterans Affairs. (2021). Richard L. Roudebush VAMC. Veterans Affairs. https://www.va.gov/directory/guide/facility.asp?id=62  ...

... VISION LOSS TRAINING MANUAL Developing an Evidence-Based Training Manual on Vision Loss for Healthcare Providers and Caregivers Courtney Romatz May, 2022 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: Name, title VISION LOSS TRAINING MANUAL A Capstone Project Entitled Developing an Evidence-Based Training Manual on Vision Loss for Healthcare Providers and Caregivers Submitted to the School of Occupational Therapy at University of Indianapolis in partial fulfillment for the requirements of the Doctor of Occupational Therapy degree. By Courtney Romatz OTS Approved by: Faculty Capstone Advisor Date Doctoral Capstone Coordinator Date 5/2/2022 Accepted on this date by the Chair of the School of Occupational Therapy: Chair, School of Occupational Therapy Date Vision Loss Training Manual 3 ABSTRACT Vision loss is a common condition found in the aging population; however, it can often be dismissed. The purpose of this doctoral capstone experience was to develop an educational resource on vision loss to enhance the knowledge and confidence of healthcare providers and caregivers working with individuals with low vision or who are blind, specifically in seniorbased living facilities. In order to determine project specifics and needs, a low vision survey was created. The results of the survey provided areas to focus on within educational materials to enhance overall vision loss knowledge. Following creation and implementation of the vision loss training manual, a post-satisfaction survey was provided to staff. Results showed an overall increase in vision loss knowledge in the areas of eye conditions, adaptations, and technology. Additionally, staff were very likely to use this training manual in practice, or to provide it to another healthcare provider or caregiver. Vision Loss Training Manual 4 INTRODUCTION Bosma Enterprises is one of the Midwests largest nonprofit organizations and has been providing employment and training for individuals who are blind or visually impaired for over 100 years. They operate three individualized, mission-driven brands including: Bosma Enterprises, Bosma Center for Visionary Solutions and Bosma Visionary Opportunities Foundation. Bosmas mission is to create opportunities for individuals who are blind or visually impaired and their vision is equality for people who are blind or visually impaired (Bosma Enterprises, 2021). Bosma Enterprises is their business entity that partners with socially responsible companies that focus on supplier diversity. These partnerships create jobs for individuals with vision loss and help to expand sourcing options to companies with high-quality goods and services. Additionally, Bosma Center for Visionary Solutions serves many clients throughout the state of Indiana through personalized programs that can include counseling, job placement, and training for daily living skills to help adults gain life skills they need to remain independent (Bosma Enterprises, 2021). There is hope that with increased advocacy of the services and education that Bosma Enterprises provides on low vision and blindness, that more individuals and local facilities will become aware of such services and the need to address visual deficits. Low vision is a prevalent condition within the aging population; however, due to a lack of education, training, and confidence it is often dismissed by caregivers. Therefore, the purpose of this doctoral capstone project was to develop a low vision training manual and provide education based on this manual. Such resources could be provided to local long-term care facilities or community members to also increase the awareness of Bosma Enterprises and advocate for low vision and blindness needs. With the use of educational resources and Bosma Vision Loss Training Manual 5 Enterprises staff, I hope to have increased the awareness of Bosma Enterprises services and education on low vison and blindness to improve many individuals overall quality of life. BACKGROUND With the increasing age of the global population, the rates of visual disabilities and vision loss are increasing (Sahli & Idil, 2019). Ranking in behind arthritis and heart disease, low vision is the most common chronic condition that is prevalent in older adults (Reed-Jones et. Al, 2013). Additionally, the prevalence of low vision increases with age, from 1% of individuals in their late 60s to 17% of individuals aged 80 and older (National Eye Institute [NEI], 2019). Kaldenberg & Smallfield (2020) share that typical aging does not cause vision loss, however there are four main causes of low vision that can be directly related to the aging process. These include age-related macular degeneration, diabetic retinopathy, glaucoma, and cataracts (Kaldenberg & Smallfield, 2020). Therefore, it is essential that not only occupational therapy practitioners, but all healthcare workers and caregivers have the skillsets to address low vision needs. It is estimated that 2.2 billion people are visually impaired worldwide and because agerelated vision loss is a primary cause of vision impairment, that number is only projected to rise with increases in the average lifespan (Demmin & Silverstein, 2020). They share that vision loss often results in significant disability and can be associated with a great economic burden, decreased quality of life, concurrent medical issues, and mental health problems. There is data that shows the rates of depression and anxiety are elevated among people with visual impairments. The CDC (2021) shares that one in four adults with vision loss reports anxiety or depression. Furthermore, Demmin & Silverstein (2020) found that in order to improve outcomes and to have a better understanding of the mechanisms associating visual impairments and poor Vision Loss Training Manual 6 mental health, more education on low vision and blindness resources and adaptations is needed. An essential aspect of this is to develop more effective educational interventions and to expand access to services to improve the treatment of mental health problems in this population. Elliott et al. (2013) examined rates of visual impairments of older adults in assisted living facilities, which was the first study of its kind to provide information for understanding the scope of vision impairment problems in this population. Assessments included those of visual acuity, cognitive status, and presence of eye conditions. Through the vision screening program, it was identified that 70% of assisted living facility residents have vision impairments either for distance or near visual acuity, and 90% have contrast sensitivity. They found that prior research has documented the rate of vision impairments among nursing home residents to be greatly accentuated when compared to older adults who are living independently in the community. A cross-sectional study looked at the statistical analysis of comprehensive eye examination records of nursing home residents (Anderson et al., 2020). Findings showed that the overall prevalence rates of moderate-to-severe vision impairments and blindness were 47%. It was found that the high prevalence of vision loss among nursing home residents indicates a demand for further data collection on evidence about vision loss among nursing home residents at a national level (Anderson et al., 2020). Meehan & Shura (n.d.) explored a qualitative study to better understand the impacts of care and overall quality of life in long-term care settings from visual health. It was found through semi-structured interviews with residents of long-term facilities that vision impairments are often unseen and overlooked. Vision impairments are a critical aspect of health that requires appropriate care for improving quality of life. Many of the facilities residents reported an impact of their vision on their daily life and that coping strategies were rarely discussed causing Vision Loss Training Manual 7 implications for a lack of adaptations for individuals provided by caregivers and long-term care facility staff (Meehan & Shura, n.d.). Occupational therapy practitioners can help individuals with low vision to function at their highest level of independence by teaching new skills and modifying the task or environment. Kaldenberg and Smallfield (2020) share that the aging population is generating an increased demand for occupational therapists to address occupational performance with those who are experiencing low vision or blindness deficits. Older adults with visual impairments are three to four times more likely than adults with normal vision to experience difficulties completing instrumental activities of daily living (American Occupational Therapy Association, n.d.). Kaldenberg and Smallfield (2020) found strong evidence that supports the role of occupational therapy for adults with low vision to participate in low vision rehabilitation for ADL and IADL impairments through client-centered problem-solving training. This works to enhance an individuals overall ADL and IADL performance. Additionally, a systematic review was completed on interventions for older adults with low vision that can serve as a reference for occupational therapy practitioners to guide best practice and justify occupational therapy services to external stakeholders. Such interventions included performance of activities of daily living and instrumental activities of daily living, reading, and leisure or social participation. Campion et al., 2010 share that while response rates to online surveys can be variable, they were able to determine that there are low confidence levels among therapists assessing and giving advice to those with vison loss. This study showed the need for the development of appropriate vision loss education and training for those working with individuals with vision loss. Through an in-depth needs assessment, it was determined that Bosma Enterprises will benefit from an educational training manual to provide to providers at long-term care facilities or Vision Loss Training Manual 8 community members. Through a semi-structured survey provided to staff at Bosma Enterprises, and review of literature, a training manual was created. A post survey was then provided to provide outcome measures and satisfaction results. Such resources will increase the awareness of Bosma Enterprises and continue to advocate for vision loss needs to improve awareness and quality of life for those with vision loss while also providing Bosma with a tangible resource. Addressing this gap in knowledge and services for low vision leads to the purpose of this capstone project, which was to develop a vision loss training manual to increase awareness of care for individuals with low vision or who are blind. Model The theoretical model that I chose to guide my doctoral capstone experience (DCE) is the Person-Environment-Occupational-Performance Model (PEOP). I chose this model because it places a focus on occupations and occupational engagement. Furthermore, this model considers the many dimensions that make up an occupation and the factors that are currently influencing an individuals performance of this occupation (Baum & Christiansen, 2015). Vision loss is a common condition found in the aging population, and these rates of visual disabilities and vision loss are only expected to increase (Sahli & Idil, 2019). This model helped to investigate internal and external factors affecting their ability to engage in occupations, due to vision loss, and work to increase performance ability through changes in the environment (Baum & Christiansen, 2015). Because this model is very client-centered, it will help to work through motivation of an individuals desire to perform an activity and allow increased engagement in occupations. This model assisted in planning and developing a successful and beneficial training manual that offers ideas to increase occupational engagement. Vision Loss Training Manual 9 Theory The theory that I chose to guide my doctoral capstone experience (DCE) is the Activity Theory of Aging which is a part of the Lifespan (Developmental) frame of reference. This theory uses a holistic approach to allow for greater continued engagement that leads to greater life satisfaction (Cole & Tufano, 2008). The training manual that was created offers adaptations and adaptive equipment to assist with engagement in ADL and IADL tasks. The Activity Theory of Aging guided development my training manual based on client based, age-appropriate, and adaptive engagement opportunities. PROJECT Following discussion with the site mentor, a review of literature, and the implementation of a low vision survey, it was evident that there was a need for a low vision training manual and educational opportunities that could be provided by Bosma Enterprises. The goal of this project was for Bosma to have a tangible resource that helps to increase healthcare providers and caregiver knowledge and confidence in providing care for those with low vision. The project suggestion was created based on overall site need and both my site mentor and I agreed with project ideas. Development of the project took place over several weeks. During this time, an in-depth needs assessment with the site mentor was completed that allowed for identification of a greater sense of direction with the project. The next step was identifying gaps in my knowledge of vision loss and care for those with low vision. My site mentor provided me with various evidence-based practice resources, and I spent time doing personal education through continuing education courses. Vision Loss Training Manual 10 The project development began with the creation of a pre- and post-survey, based on a 5point Likert scale, that was given to staff at Bosma Enterprises. Campion et al., 2010 implemented a similar survey regarding confidence and knowledge when working with individuals with vision loss, which I used as a guide when creating my survey. The pre-survey addressed perception of knowledge and confidence with various aspects of vision loss and any topics that the respondent felt would be beneficial to include in a training manual. Similarly, the post-survey addressed confidence with various aspects of vision loss, following reading through the training manual, and addressed satisfaction of the overall results of the manual. Based on previous literature and educational resources that I found; I then created a training manual for vision loss. The goal of creating this training manual was to provide Bosma Enterprises with a tangible resource, that they can then use for educational training purposes in the community and to advocate for those with vision loss. The training manual includes an overview of vision loss, conditions that can cause loss of vision or blindness, types of vison loss, safety, tips for working with those who have vision loss, adaptations/adaptive equipment, leisure activities, technology, and extra resources and services provided to those with vision loss. Information included in the training manual was based on results of the pre-survey and Kaldenberg and Smallfields (2020) findings that professional development in the area of low vision practice should include the following topics: knowledge on health conditions and changes that influence visual function, information on the visual system, influences on occupation and the environment, exposure to potential members of a vision rehabilitation team, information on assessment tools, and knowledge about the influence of low vision diagnoses and outcomes. Limitations of the study included the small sample size for both the pre- and post-survey responses. The pre- and post-survey questions could also have interpretation bias of the Vision Loss Training Manual 11 questions. In the beginning implementation phases, the goal of the DCE project was to provide the pre- and post-survey to healthcare providers and caregivers at community based senior living facilities. The goal of the project was to create a training manual and educational presentation that was feasible for Bosma to provide to local facilities, that would in turn increase knowledge on Bosma Enterprises and knowledge on caring for those with vision loss. Due to many of the senior based facilities having COVID-19 restrictions and a lack of interest or willingness to participate, this was unable to be completed; however, it is a goal for future implementation that Bosma will be able to provide the training manual and educational resources to such facilities in order to increase awareness. PROJECT OUTCOMES In order to determine the results and success of the capstone project and training manual that was created, a pre-post descriptive survey was created through Qualtrics and sent to staff via email. The pre-survey was implemented prior to creation of the training manual and assessed overall understanding of confidence ratings on various aspects of low vision. Additionally, the survey offered the opportunity to include any other topics that was seen as beneficial to include in a training manual. Results of the pre-survey guided creation of the training manual and topics that were included. The post survey was emailed to staff the same day they received the vision loss training manual. Instructions were provided to review the training manual prior to completing the survey. It should be noted that 9 staff members completed the initial survey, while only 6 completed the post survey. Each question asked the respondent to rate their agreement from strongly disagree to strongly agree, based on a 5-point Likert scale. Additionally, the post-survey asked the respondent to rate their satisfaction and likeliness to use the training manual on a 5-point scale. Vision Loss Training Manual 12 After analyzing results of the pre and post survey outcomes, the success of the training manual and capstone project was evident and can be seen in Table 1 and 2. Table 1. Statement 1. I am confident in my knowledge regarding low vision. 2. I am confident in my knowledge on low vision adaptive aids and adaptations that can be made. 3. I am confident in my knowledge on eye conditions/diseases and how they may affect vision. 4. I am confident in my knowledge on technology that is available to individuals with vision loss. Pre-Rating (n=9) 2.2 Post-Rating (n=6) 4.6 Change 2.2 3.6 4.8 1.2 2.2 4.6 2.4 3.0 4.0 1.0 Table 2. Post-Survey Statement 1. I am satisfied with the materials included in the training manual. 2. I am likely to use this training manual as a resource, or to provide it to someone. Rating (n=6) 4.8 4.8 Table 1 shows the increased ratings in confidence and knowledge levels with various topics of vision loss. Table 2 shows the reported satisfaction on the outcome of the training manual. Based on the findings of Table 1 and 2, there is a positive correlation between the creation and implementation of the vision loss training manual and confidence/knowledge levels of individuals working with those who have low vision or are blind. Long-term success of the implementation of the training manual was not measured during the 14-week doctoral capstone experience. Vision Loss Training Manual 13 SUMMARY Based on prior literature, it is evident that vision loss is a common condition, especially within the aging population. There is a gap in education and training provided to healthcare providers working in senior living facilities and caregivers providing care to individuals with vision loss, causing a dismissal of needs. Bosma Enterprises works to close this gap in care by providing low vision services to those in the community at no cost. However, once they have exhausted their services they can provide for an individual, there is no continuation of knowledge or services provided. The goal of this doctoral capstone experience was to create a tangible resource for Bosma that they can then provide to individuals facing vision loss, caregivers working with these individuals or even healthcare providers. A pre and post survey based on a 5-point Likert scale was provided to staff at Bosma. The pre survey addressed confidence on various aspects of low vision and what they felt would be beneficial to a training manual. Based on results of the survey, the capstone student gathered evidence-based materials to create the resource. This training manual works to address the gap between Bosmas services and what next steps an individual can take to continue care for their needs. Based on the results of this study it was shown to be beneficial in increasing the knowledge of Bosma staff, and all reported they were very likely to provide this resource to someone they are working with or presenting to in the future. Results of the pre-survey showed that staff ranked their confidence on overall knowledge of vision loss at a 2.2 out of 5, knowledge on eye conditions at a 3.4, use of adaptive aids at 3.6 and technology for vision loss at 3.0. Post-survey results, following reading the training manual that was created, showed an increase in overall confidence and knowledge with ratings of 4.6, 4.2, 4.8, and 4.0, respectively. Vision Loss Training Manual 14 CONCLUSION Vision loss is a common condition, especially within the aging population (Sahli & Idil, 2019). There is a gap in education and training provided to healthcare providers working in senior living facilities and caregivers providing care to individuals with vision loss, causing a dismissal of needs. Bosma Enterprises works to close this gap in care, by providing low vision services to those in the community at no cost. However, once they have exhausted their services they can provide for an individual, there is no continuation of knowledge or services provided. The goal of this doctoral capstone experience was to create a tangible resource for Bosma, that they can then provide to individuals facing vision loss, caregivers working with these individuals or even healthcare providers. This training manual works to address the gap between Bosmas services and what next steps an individual can take to continue care for their needs. Based on the results of this study it was shown to be beneficial in increasing the knowledge of Bosma staff, and all reported they were very likely to provide this resource to someone they are working with or presenting to in the future. Vision Loss Training Manual 15 References American Occupational Therapy Association. (2021). Productive Aging Low Vision. https://www.aota.org/practice/productive-aging/low-vision.aspx American Occupational Therapy Association. (n.d.). Occupational Therapy Services for Persons with Visual Impairments. https://www.aota.org/About-OccupationalTherapy/Professionals/PA/Facts/low-vision.aspx Andersson, R. B., Al-Namaeh, M., Monaco, W. A., & Meng, H. (2020). Vision loss among Delaware Nursing Home Residents. Gerontology and Geriatric Medicine, 6, 233372142093424. https://doi.org/10.1177/2333721420934245 Bosma Enterprises. (2021) Bosma Enterprises Navigating Blindness | Our Business Model. https://www.bosma.org/about-bosma Campion, C., Awang, D., & Ward, G. (2010). Broadening the vision: The education and training needs of occupational therapists working with people with sight loss. British Journal of Occupational Therapy, 73(9), 413-421. https://doi.org/10.4276/030802210x12839367526093 Centers for Disease Control and Prevention. (2021). Vision loss and Mental Health. Centers for Disease Control and Prevention. Retrieved December 23, 2021, from https://www.cdc.gov/visionhealth/resources/features/vision-loss-mental-health.html Demmin, D. L., & Silverstein, S. M. (2020). Visual Impairment and Mental Health: UNMET Needs and Treatment Options. Clinical Ophthalmology, Volume 14, 42294251. https://doi.org/10.2147/opth.s258783 Vision Loss Training Manual 16 Elliott, A. F., McGwin, G., & Owsley, C. (2013). Vision impairment among older adults residing in assisted living. Journal of Aging and Health, 25(2), 364378. https://doi.org/10.1177/0898264312472538 Kaldenberg, J., & Smallfield, S. (2020). Occupational therapy practice guidelines for older adults with low vision. https://doi.org/10.7139/2017.978-1-56900-456-2 Meehan, R., & Shura, R. (n.d.). Residents Perspectives on Living with Vision Impairment in Long Term Care: An Unseen Factor in Quality of Life and Appropriateness of Care. The Journal of Nursing Home Research. https://www.jnursinghomeresearch.com/646residents-perspectives-on-living-with-vision-impairment-in-long-term-care-an-unseenfactor-in-quality-of-life-and-appropriateness-of-care.html National Eye Institute [NEI]. (2019, July 17). Eye health data and statistics. National Eye Institute. https://www.nei.nih.gov/learn-about-eye- health/resources-for-healtheducators/eye-health-data-and-statistics Reed-Jones, R. J., Solis, G. R., Lawson, K. A., Loya, A. M., Cude-Islas, D., & Berger, C. S. (2013). Vision and falls: A multidisciplinary review of the contributions of visual impairment to falls among older adults. Maturitas, 75(1), 22-28. https://doi.org/10.1016/j.maturitas.2013.01.019 ahl, E., & dil, A. (2019). Common approach to low vision: Examination and rehabilitation of the patient with low vision. Turkish Journal of Ophthalmology, 49(2), 8998. https://doi.org/10.4274/tjo.galenos.2018.65928 Vision Loss Training Manual 17 Appendix A Training Manual PDF https://drive.google.com/file/d/1k1z04Q9H69GmWz17DjAQz6btvBmhD34c/view?usp=sharing Vision Loss Training Manual 18 Appendix B Doctoral Capstone Experience and Project Weekly Planning Guide Week 1 DCE Stage (orientation, screening/evaluation, implementation, discontinuation, dissemination) Orientation Remote Weekly Goal Objectives Become oriented to sites website and available materials Meet with site mentor and IRT staff Introduce project to staff during meetings Screening/Evaluation Create general plan for project Finalize MOU 2 Screening/Evaluation Complete Needs Assessment by end of week Complete literature search to update literature review and methods Develop pretest measure outcomes Identify needs for project Tasks Discuss project during IRT meeting and weekly Monday meetings with site mentor Date complete 1/10 1/13 1/101/14 Gain more resources from site (Teaching Plan, Order 1/13 Forms, IRT form, Training Manual) Develop and complete needs Obtain necessary assessment information for site and their needs with my project Update literature based on needs for project and project goals Research more specific literature on needs revolving low vision education 1/171/21 1/18 Determine format of outcome measurements, Research similar studies with pre/post test Vision Loss Training Manual 19 Create connections with outside facility for project participation 3 Screening/Evaluation Develop number of questions, specific language use outcome measures Look at textbooks to help determine Reach out to contacts provided Staff members that have connections with site will reach out to see if interested in participating in study met with staff members to discuss needs with this Research similar 1/24 studies with pre/post test outcome measures Look at textbooks to help determine Create survey on 1/24Qualtrics 1/28 Develop pre and posttest measure outcomes Determine format of outcome measurements, number of questions, specific language use Develop resources for training manual Determine content included in different parts of training manual based on current teaching plans and research on content Meeting with site mentor to review through teaching plans and ideas with each section Connect with outside facility on project Email Barb (Activity Director) Site mentor has connection with activities director at local ALF provided with 1/19 1/25 Vision Loss Training Manual 4 5 Screening/Evaluation Develop Develop 20 Develop resources for training manual Determine content included in different parts of training manual based on current teaching plans and research on content contact info and sent email about interest/potential for participating in study/other info Meeting with site mentor to review through more of the teaching plans and ideas with each section Created specific chapters for training manual Work to find site to participate in project Reach out to outside facilities on participation again different forms of communication Follow up with staff on connecting with outside facilities for participation in project had no success/responses so far trying different forms of communication Develop resources for training manual Determine content included in different parts of training manual based on current teaching plans and literature start layout of training manual Began researching literature, visuals and information to include in training manual based on each section being included Found layout for training manual online 1/31-2/4 2/1-2/2 2/7-2/11 2/9 Vision Loss Training Manual 21 Re-assess feasibility of project 6 Orientation/Shadowing Become In Person oriented to site in person and roles of staff Develop In person orientation Meet with staff Havent received responses back from any outside facilities willing to participate in project reassessing goals and plans to fit needs of project with similar purpose Completed in person orientation and met with all staff members working inperson. 2/14 2/14 2/152/16 Shadow with staff in inhome visits Completed in home IRT visits Shadow vision rehab program Shadow with staff and participants in vision rehab program Develop resources for training manual Determine content included in different parts of training manual based on current teaching plans Completed shadowing with participants that are part of the in vision rehab program Finalized plan for 2/21different sections 2/25 of training manual and information to include In home visits with IRT staff 7 Discuss with site mentor and develop new plan and goals Meet with new staff of Bosma Conversation about needs informal needs assessment and re-assessing goals 2/17 2/24 Discussion of new project direction and how to still meet needs of project and site 2/212/23 2/24 Vision Loss Training Manual 22 In home visits with IRT staff Shadow with staff in inhome visits Re-create presurvey 8 Develop Re-design presurvey to fit new needs of project and plan Send preSend link of survey to staff pre-survey to staff with explanation Rough draft of training manual Complete an informal draft of training have ideas for each section and further questions prepared Completed in home IRT visits Created new presurvey based on new project direction and goals Survey to staff will assess needs and wants with training manual opportunity to include any other ideas or info Information draft of training manual was created outline of all information also created Present rough draft to staff and receive feedback Presented rough draft of training manual to staff during empower meeting received feedback verbally and via email Presented rough draft of training manual and outline of info received feedback from staff on other info to include/things to change Empower and lead meeting Participated in all day empower and leadership meeting with IRT staff and site mentor Participated in an empowerment and leadership meeting with site mentor and IRT staff 2/28 3/2 3/3 3/3 Vision Loss Training Manual 9 Develop 10 Implementation 23 Develop resources for training manual Determine content included in different parts of training manual based on current teaching plans Meet with site mentor for review of training manual Determined all content, visuals, and charts that could be included in training manual Finished final rough draft Site mentor provided feedback with several minor changes to make to training manual Creating resources for side project Determine needs with sensory garden side project Final review with staff and presented materials to staff Meet with site mentor and IRT staff to review training manual presented final product and discussed various uses Found several additional grant opportunities for items needed with sensory garden Developed a needs list to complete beneficial sensory garden Site mentor and IRT staff provided final feedback for any minor changes Presented final product and facilitated conversation about potential uses with training manual Final review with site mentor Development Side Project 11 Implementation Development Side Project Creating resources for side project Determine needs with sensory garden side project Created educational resources on information with sensory gardens for low vision 3/7-3/11 3/143/18 3/143/18 3/213/25 3/213/25 Vision Loss Training Manual 12 Discontinuation 24 Develop posttest outcome measures Begin to analyze data 13 Discontinuation / Dissemination Dissemination Begin to determine and analyze outcome measures from survey results Prepare to Prepare disseminate to presentation facility Disseminate Project 14 Developed post-survey, reviewed questions and sent to staff with explanation Complete dissemination presentation with all staff and receive more feedback on project Review Review Dissemination through dissemination (what to include, adaptive techniques, ways to build/create garden, safety, etc.) Created postsurvey for satisfaction results and outcome measures Sent to staff with explanation 3/30 3/31 Began to review and analyze outcome measures and project satisfaction Prepared presentation for dissemination Created PowerPoint and VoiceThread for those who couldnt attend dissemination Completed dissemination to several staff members Facilitated conversation to receive more feedback and satisfaction on project Reviewed through final products and dissemination 4/6 4/7 4/12 Vision Loss Training Manual 25 Address any final needs with site mentor process with site mentor Review through any final needs and outcomes Facilitated conversation on any final needs, outcomes and requirements of DCE experience 4/14  ...

... Health Literacy Intervention for Hand Therapy Patients to Address Compliance Ethan Roberts May, 2022 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, OT Abstract The doctoral capstone experience (DCE) examined the impact of a health literacy intervention on compliance with hand therapy protocols. The intervention took place at three Athletico locations in the Midwest. Therapists disseminated health literacy materials to patients along with a pretest and posttest to compare compliance with attendance, orthosis wear, and home exercise programs (HEPs). Patients were able to provide feedback on the intervention with a satisfaction survey. Overall, the participants were very compliant and results on compliance were mixed, with attendance decreasing by 5%, orthosis wear increasing by 10%, and HEPs remaining unchanged. All the participants found the handouts easy to read and helpful, recommending continued dissemination to patients. The high level of satisfaction is an important outcome, indicating value in a client-centered practice such as Athletico. Moving forward, a more robust study would be helpful to develop a correlation between health literacy, satisfaction, and compliance. 2 Introduction The purpose of this DCE was to obtain advanced clinical practice skills in hand therapy and examine the impact of health literacy materials on patient compliance with hand therapy protocols. The clinical skills portion of the DCE took place at Athletico Lincoln Park North in Chicago under site mentor Kimberly Pontarelli. The health literacy portion included three Athletico locations in the Midwest (Lincoln Park North, Garfield Ridge in Chicago, and Urbandale, Iowa) with input from Pontarelli and Athletico Hand Therapy Services Manager Gary Johnson. Patients seeking hand therapy at Athletico may experience barriers to adherence with therapy protocols, including attendance at therapy sessions, orthosis wear, and HEPs (K. Pontarelli, personal communication, January 28, 2021). This was a concern since patients who do not follow hand therapy protocols are at risk of poor functional outcomes, such as deformities, contractures, and recurrence (Cole et al., 2019). The DCE targeted health literacy based on research that patients with lower health literacy have lower therapy adherence (Roh et al., 2016) and health literacy interventions improve health literacy and have a significant impact on behavior, including self-care and adherence in cardiovascular patients (Walters et al., 2020). In addition, the impact of health literacy interventions on compliance with hand therapy protocols had not been thoroughly studied. The intervention included dissemination of condition-specific health literacy materials to hand therapy patients at Athletico and a pretest/posttest to examine the impact of these materials on compliance with appointments, orthosis wear, and HEPs. Patients provided feedback on their perceptions of the health literacy materials using a survey to gauge satisfaction with the intervention. This paper focuses primarily on the health literacy intervention, including background, applied theory, the project design and implementation, outcomes, and conclusions. 3 Background Hand therapists are experiencing patient barriers to compliance with therapy protocols, increasing the potential for diminished outcomes (Cole et al., 2019). Researchers have examined the relationship between increased compliance and positive outcomes for a variety of conditions seen in this setting, including distal radial fracture (DRF) (Lyngcoln et al., 2005), osteoarthritis (OA) (Hennig at al., 2015), cubital tunnel syndrome (Shah et al., 2013), carpal tunnel syndrome (CTS), trigger finger (Lunsford et al., 2019), lateral epicondylitis (tennis elbow) (Sadeghi-Demneh & Jafarian, 2013), mallet finger (Roh et al., 2016), and Dupuytrens contracture (DC) (Kitridis et al., 2019) (see Appendix A). This research supports the need for hand therapy patients to increase compliance with appointments, orthosis wear, and HEPs to decrease the risk of poor functional outcomes. Patient compliance is a complex and subjective construct that can be affected by numerous factors, such as the condition, the relationship with the healthcare provider, and the patient (Bollen et al, 2014). In addition, patient compliance may be difficult to measure, adding another layer of complexity. Self-report measures on unsupervised HEP compliance may overestimate or underestimate adherence due to the patients beliefs and behaviors (Bollen et al., 2014). In addition, wording on self-report measures can impact responses. For example, patients were more likely to reveal non-adherence when asked how often a dose of medication was missed rather than whether medication was taken as prescribed (Engel et al., 2017). Mahmood et al. (2020) found a positive correlation between attendance at appointments and medication adherence for patients with hypertension. This suggests that attendance at appointments may provide an additional measure of compliance with unsupervised therapy protocols. Due to the complexity of measuring compliance, researchers recommend using more than one measure of adherence, which could include attendance at appointments, in-clinic observations, and self-report measures (Lyngcoln et al., 2004; Kingston et al., 2014). In 4 addition, a mixed-methods design, combining qualitative and quantitative principles, may provide further insight into research on compliance (Schoonenboom & Johnson, 2017). Researchers have found a variety of barriers to compliance with hand therapy protocols. Studies have shown the primary reasons for noncompliance with HEPs are lack of time, forgetting to do the exercises, and pain/discomfort (Kirwan et al., 2002; Kingston et al., 2014). Noncompliance with orthosis wear is more complex and may be affected by several factors. Barriers to orthosis adherence included patients' perceptions of the orthosis, comfort, and appearance for thumb carpometacarpal OA (Grschke et al., 2019), pain for cubital tunnel syndrome (Shah et al., 2013), and comfort, smell, itchiness, and the desire to perform daily tasks for acute traumatic hand tendon repairs (Savas & Aydogan, 2020). Depression, low income, and lack of health insurance may also create barriers to compliance with orthosis wear (Savas & Aydogan, 2020). Researchers have found patient barriers to appointments in other areas of healthcare. Forgetting about the appointment, personal and work-related issues and/or conflicts, and transportation issues were the main barriers at primary care clinics (Ullah et al., 2018). Patients with diabetes missed appointments due to practical barriers (as noted by Ullah et al., 2018), a low perceived value of appointments, and limited concern with their condition (Eades & Alexander, 2019). The variety of subjective barriers that may lead to noncompliance adds a further layer of complexity when considering interventions to improve compliance for hand therapy patients. Cole et al. (2019) used a systematic review to examine hand therapy interventions to address compliance with HEPs and orthosis wear and found only eight articles that met their inclusion criteria, indicating further research is needed in this area. In addition, studies have shown it to be challenging to improve compliance. There was no significant improvement in HEP adherence when patients were provided an instructional DVD in addition to written directions (Kingston et al., 2014). Neither orthosis material nor wear schedule impacted orthosis compliance (Cole et al., 2019), and there was no significant difference in compliance between 5 dynamic and static orthoses (Savas and Aydogan, 2020). Although the effect of health literacy interventions on compliance with hand therapy protocols has not been thoroughly investigated, there is research to support the potential benefits of this intervention. Researchers have found a positive relationship between health literacy and compliance for acute and chronic conditions with a significantly higher level of compliance with nonmedication therapies, such as those typical of hand therapy (Miller, 2016). This is consistent with findings that patients with lower health literacy were less compliant with therapy for mallet finger (Roh et al., 2016). Researchers have postulated that patients with higher levels of health literacy are better equipped to understand their condition, the purpose of therapy, and the poor outcomes that may result from noncompliance. Cole et al. (2019) identified low to moderate support for behavioral modifications supporting self-efficacy in patients with rheumatoid arthritis and postulated that interventions to improve self-efficacy, such as patient education to increase health literacy, could improve hand therapy compliance. In addition, health literacy interventions have been found to improve health literacy (Miller, 2016; Walters et al., 2020) and have a notable impact on health behaviors of cardiovascular patients (Walters et al., 2020) and patients with axial and/or peripheral psoriatic arthritis (Candelas et al., 2016). Materials available for health literacy interventions in hand therapy are limited and may exceed the readability recommendations of health care agencies. Current guidelines for health literacy materials are a maximum readability of sixth to eighth grade (Hadden et al., 2016). Hadden et al. (2016) found many of the documents on the American Society for Surgery of the Hand website exceeded these recommendations. They postulated that if the readability of documents on the website improved, then patient understanding of their conditions and treatments would increase, decreasing the likelihood of poor outcomes. Creating materials that are effective and easy for patients to understand can be challenging. Best practices are provided by Hadden et al. (2016), and there is a tool in the toolkit created by Brega et al. (2015) for writing intelligible health literacy materials. 6 Applied Theory The Model of Human Occupation (MOHO) provided a lens through which to better understand the impact of the health literacy materials on compliance. This client-centered and holistic theory provides a unified view of occupation through consideration of volition, habituation, and performance capacity (Kielhofner, 2008). Previous research found MOHO was useful for examining diabetes self-management with self-management as the occupation (Youngston, 2019). As a result, compliance with hand therapy protocols was conceptualized as the occupation within MOHO. MOHO views the person as an open system with inputs, which can be influenced by feedback, as well as outputs, which provide feedback, creating a loop. The health literacy materials were viewed as a new input to the system that should increase understanding of the condition, the objectives of therapy, and the potential consequences of noncompliance. The output desired was increased motivation to incorporate routines and habits to improve compliance with the goal of returning to occupations of value, such as work, sports, or hobbies. The biomechanical frame of reference (FOR) provided focus for clinical practice skills and the health literacy intervention. Patients seeking hand therapy typically have musculoskeletal conditions, cumulative trauma, or hand injuries, and therapists commonly use this FOR for these types of issues (Cole & Tufano, 2008). For example, Wolff and Rosenweig (2017) used the biomechanical framework for the postoperative management and rehabilitation of shoulder arthroplasty, emphasizing that shoulder anatomy and biomechanics were linked to therapy protocols and factors that may impact patient outcomes. Interventions within this FOR are targeted towards reducing deficits related to range of motion (ROM), strength, endurance, and pain (Cole & Tufano, 2008). This FOR was useful for creating health literacy materials to improve understanding of conditions, the purpose of appointments, orthoses, and HEPs, and the potential consequences of nonadherence. 7 Design and Implementation The clinical skills portion of the DCE took place during week one through week 14 and was similar to level II fieldwork. With the goal of developing entry level competencies, site mentor Pontarelli provided opportunities to increase knowledge of best practices for various conditions in hand therapy. Clinical skills included planning, implementing, and documenting evaluations, assessments, interventions, and outcome measures. The clinical skills experience provided a deeper understanding of orthosis recommendations and wear schedules and HEPs based on patient conditions. At Athletico Lincoln Park North, there were numerous resources available and opportunities to gain experience working with patients of different age ranges in an urban environment. The health literacy portion of the DCE was mixed-methods design. Pontarelli identified the seven most common conditions treated at Athletico Lincoln Park North as OA, trigger finger, CTS, cubital tunnel syndrome, tennis elbow, De Quervains tenosynovitis, and fractures of the upper extremity, such as DRF. The project focused on compliance with hand therapy protocols for patients with these seven conditions. Hand Therapy Services Manager Johnson forwarded an email to hand therapists at Athletico for consideration to participate in the project (see Appendix B). Hand therapists from two additional Athletico sites in the Midwest region agreed to participate (Don Cepek at Garfield Ridge and Rose Heacock-Smith at Urbandale). The student researcher (SR) grouped patients into pretest/posttest groups rather than focusing on individual patients due to patient turnover during the study. The pretest group consisted of 20 patients, and the posttest group was comprised of 16 patients. The Institutional Review Board (IRB) at University of Indianapolis deemed this project was not human subjects research. The SR created a health literacy handout for each of the seven conditions identified by Pontarelli (see Appendix C through Appendix I). The handouts, which included input from Pontarelli and Johnson, have an overall maximum readability of eighth grade, which was evaluated using the Flesch Kincaid Grade Level tool in Microsoft Word. 8 A questionnaire on HEPs and orthosis wear (see Appendix J) and a record of attendance at appointments served as measures of compliance for the pretest/posttest. Pretest and posttest participants needed to have attended at least two weeks of appointments to ensure data were from patients who had developed habits related to compliance. During week six of the DCE, therapists and the SR collected pretest information, including the questionnaire and the record of attendance at appointments, and distributed appropriate health literacy materials to current patients with at least one of the seven conditions. From week six through week 14, new patients with at least one of the seven conditions received the appropriate health literacy materials. During week 11, therapists and the SR collected posttest information, including the questionnaire and the record of attendance at appointments, from patients who had received health literacy materials from week six through week nine. A comparison of pretest and posttest data indicated changes in compliance. Patients who received the health literacy materials from week six through week 12 received a survey to collect feedback on their perceptions of the health literacy materials (see Appendix K). The survey provided information on patient satisfaction with the intervention. The DCE Weekly Planning Guide is included in Appendix L. Outcomes The importance of compliance with attendance, orthosis wear, and HEPs was an emphasis in the health literacy handouts. As a result, outcome measures included attendance at appointments and pretest/posttest data from a self-report questionnaire on compliance with orthosis wear and HEPs (see Appendix J). In addition, attendance and the self-report measure provided two measures of compliance. A self-report questionnaire provided data for unsupervised protocols (orthosis wear and HEPs), whereas the electronic medical record furnished attendance data. In addition, patients completed a survey to provide feedback on their perceptions of the health literacy handouts (see Appendix K). This mixed-methods design provided further insight into the potential value of the health literacy intervention. 9 Pretest and posttest compliance data for participants at the three Athletico sites are provided in Table 1 with detailed participant data by site in Appendix M. The pretest group consisted of 20 patients, and the posttest group included 16 patients. Overall, pretest data indicate the participants were very compliant with attendance at 94% and orthosis wear and HEPs at 80%. The posttest data also indicate a high level of compliance with attendance at 89%, orthosis wear at 90%, and HEPs at 80%. Due to the high rate of compliance of the pretest and posttest participants, the distributions were skewed rather than normal, suggesting a larger sample size would be required for inferential statistical analysis (Florida State College at Jacksonville (FSCJ), 2022). Descriptively, attendance dropped 5%, orthosis wear increased 10%, and HEPs remained unchanged. Table 1 Pretest and Posttest Compliance Data ____________________________________________________________________________ Compliance Variables Pretest Posttest ____________________________________________________________________________ Attendance (%)a 94 89 Orthosis Wear (%)b 80 90 HEPs (%)b 80 80 ____________________________________________________________________________ Percent of appointments attended. a Percent compliance rounded to one significant figure (0-1 day = 90%, 2-3 days = 60%, 4-5 b days = 40%, and 6-7 days = 7%). There were 17 patients who provided feedback on the health literacy intervention. All these participants (100%) indicated the health literacy handouts explained their conditions in a way that was easy to understand, found the handouts explained the purpose of therapy in a way that was clear and helpful, and recommended Athletico continue to provide these handouts to other patients (detailed survey results by site are provided in Appendix M). These results indicate a high level of satisfaction with the health literacy intervention. Satisfaction is 10 considered an important outcome of occupational therapy because it indicates the value of interventions and their relevance to patients, reflecting an important measure of client-centered care (Custer et al., 2014). Summary The scope of the DCE was to learn advanced clinical skills in hand therapy and examine the impact of a health literacy intervention on patient compliance with hand therapy protocols. The DCE addressed compliance because research supports the relationship between increased compliance with hand therapy protocols and decreased risk of poor functional outcomes. A health literacy intervention was chosen for three reasons: patients with lower health literacy have lower therapy adherence (Roh et al., 2016), health literacy interventions have been shown to improve health literacy and have a significant impact on positive health-related behaviors (Walters et al., 2020), and there was limited research on the impact of health literacy interventions in hand therapy. The intervention included dissemination of condition-specific health literacy materials to patients at three Athletico sites and used a pretest/posttest to examine the impact of these materials on compliance with appointments, orthosis wear, and HEPs. Overall, the participants had a high rate of compliance, which skewed the results and prevented use of inferential statistics. The descriptive analysis showed mixed results with attendance dropping 5%, orthosis wear increasing 10%, and HEPs remaining unchanged. Limitations include the small sample size, the change in participants between the pretest and posttest due to turnover, and the limited time frame for the intervention. The intervention also included patient feedback on their perceptions of the health literacy materials, which provided information on satisfaction with the intervention. All the participants indicated the health literacy handouts explained their conditions in a way that was easy to understand and the purpose of therapy in a way that was clear and helpful. In addition, all the participants recommended Athletico continue to provide these 11 handouts to other patients, suggesting a high level of satisfaction with the health literacy intervention. Conclusions The DCE included the creation and dissemination of health literacy materials for seven common conditions treated by hand therapists at Athletico. Participants recommended continued dissemination of these materials to Athletico patients so the handouts will be provided to Athletico hand therapists for future use. In addition, the research compiled on the relationship between compliance with hand therapy protocols and positive outcomes will be provided to Athletico hand therapists (Appendix A). Moving forward, an additional study with a larger diverse population over a longer period and different geographical regions may help to assess the impact of a health literacy intervention on compliance with hand therapy protocols. The larger diverse population should enable inferential statistics and provide data on potential language barriers to compliance as well as socio-economic factors. A longer time frame would provide data on how attendance may be affected by seasonal effects, such as cold and flu season and severe weather. The DCE intervention did yield a high level of client satisfaction, which is valuable in client-centered care. In addition, satisfaction has been correlated with compliance in healthcare, specifically reducing barriers related to modifying or forgetting recommendations (Krot & Rudawska, 2019). This may suggest that a more robust study could find increased compliance related to two factors: improved health literacy and increased satisfaction. 12 Acknowledgements Kimberly Pontarelli, Site Mentor Gary Johnson, Athletico Hand Therapy Services Manager Don Cepek, Athletico Hand Therapist Rose Heacock-Smith, Athletico Hand Therapist Alissia Garabrant, Faculty Mentor Christine Kroll, University of Indianapolis Doctorate of Occupational Therapy Capstone Coordinator 13 References Bollen, J. C., Dean, S. G., Siegert, R. J., Howe, T. E., & Goodwin, V. A. (2014). A systematic review of measures of self-reported adherence to unsupervised home-based rehabilitation exercise programmes, and their psychometric properties. BMJ Open, 4(6). https://doi.org/10.1136/bmjopen-2014-005044 Brega, A.G., Barnard, J., Macachi, N. M., Weiss, B. D., DeWalt, D. A., Brach, C., Cifuentes, M., Albright, K., & West, D. R. (2015). AHRQ health literacy universal precautions toolkit (2nd ed.). Prepared for Agency for Healthcare Research and Quality, University of Colorado, U.S. Candelas, G., Villaverde, V., Garcia, S., Guerra, M. Len, M. J., & Caete, J. D. (2016). Benefit of health education by a training nurse in patients with axial and/or peripheral psoriatic arthritis: A systematic literature review. Rheumatology International, 36, 1493-1506. https://doi.org/10.1007/s00296-016-3549-5 Cole, M. B. & Tufano, R. (2008). Applied theories in occupational therapy: A practical approach. Slack Incorporated. Cole, T., Robinson, L., Romero, L., & OBrien, L. (2019). Effectiveness of interventions to improve therapy adherence in people with upper limb conditions: A systematic review. Journal of Hand Therapy, 32(2), 175-183. https://doi.org/10.1016/j.jht.2017.11.040 Custer, M. G., Huebner, R. A., & Howell, D. M. (2015). Factors predicting client satisfaction in occupational therapy and rehabilitation. The American Journal of Occupational Therapy, 69(1), 1-10. https://doi.org/10.5014/ajot.2015.013094. Eades, C. & Alexander, H. (2019). A mixed-methods exploration of non-attendance at diabetes appointments using peer researchers. Health Expectations, 22, 1260-1271. https://doi.org/10.1111/hex.12959 14 Engel, T., Ungar, B., Ben-Haim, G., Levhar, N., Eliakim, R., & Ben-Horin, S. (2017). Rephrasing the question: A simple tool for evaluation of adherence to therapy in patients with inflammatory bowel disease. United European Gastroenterol J., 5(6), 880-886. https://doi.org/10.1177/2050640616687838 Florida State College at Jacksonville (2022, February 14). STA 2023: Statistics: The Central Limit Theorem. https://guides.fscj.edu/Statistics/centrallimit Grschke, J. S., Reinders-Messelink, H. A., van der Vegt, A. E., van der Sluis, C. K. (2019). User perspectives on orthoses for thumb carpometacarpal osteoarthritis. Journal of Hand Therapy, 32(4), 435-443. https://doi.org/10.1016/j.jht.2018.04.006 Hadden, K., Prince, L. Y., Schnaekel, A., Couch, C. G., Stephenson, J. M., & Wyrick, T. O. (2016). Readability of patient education materials in hand surgery and health literacy best practices for improvement. The Journal of Hand Surgery, 41(8), 825-832. https://doi.org/10.1016/j.jhsa.2016.05.006 Hennig, T., Hhre, L., Hornburg, V. T., Mowinckel, P., Norli, E. S., & Kjeken, I. (2015). Effect of home-based hand exercises in women with hand osteoarthritis: a randomised controlled trial .Annals of the Rheumatic Diseases, 74(8), 1501-1508. https://doi.org/10.1136/annrheumdis-2013-204808 Kielhofner, G. (2008). Model of human occupation: Theory and application (4th ed.). Lippincott Williams & Wilkins. Kingston, G. A., Williams, G., Gray, M. A., & Judd, J. (2014). Does a DVD improve compliance with home exercise programs for people who have sustained traumatic hand injury? Results of a feasibility study. Disability and Rehabilitation: Assistive Technology, 9(3), 188-194. https://doi.org/10.3109/17483107.2013.806600 15 Kirwan, T., Tooth, L., & Harkin, C. (2002). Compliance with hand therapy programs: Therapists and patients perceptions. Journal of Hand Therapy, 15(1), 31-40. https://doi.org/10.1053/handthe.2002.v15.01531 Kitridis, D., Karamitsou, P., Giannaros, I., Papadakis, N., Sinopidis, C., & Givissis, P. (2019). Dupuytrens disease: Limited fasciectomy, night splinting, and hand exercises - long term results. European Journal of Orthopaedic Surgery & Traumatology, 29(2), 349-355. https://doi.org/10.1007/s00590-018-2340-6 Krot, K., & Rudawska, I. (2019). Is patient satisfaction the key to promote compliance in the health care sector? Economics and Sociology, 12(3), 291-300. https://doi.org/10.14254/2071-789X.2019/12-3/19 Lewis, K. J., Coppieters, M. W., Ross, L., Hughes, I., Vicenzino, B,, & Schmid, A. B. (2020). Group education, night splinting and home exercises reduce conversion to surgery for carpal tunnel syndrome: a multicentre randomized trial. Journal of Physiotherapy, 66(2), 97-104. https://doi.org/10.1016/j.jphys.2020.03.007 Lyngcoln, A., Taylor, N., Pizzari, T., & Baskus, K. (2005). The relationship between adherence to hand therapy and short-term outcome after distal radial fracture. Journal of Hand Therapy, 18(1), 2-8. https://doi.org/10.1197/j.jht.2004.10.008 Mahmood, S., Jalal, Z,, Hadi, M. A., & Shah, K. U. (2020). Association between attendance at outpatient follow-up appointments and blood pressure control among patients with hypertension. BMC Cardiovascular Disorders, 20. https://doi.org/10.1186/s12872-02001741-5 Miller, T. A. (2016). Health literacy and adherence to medical treatment in chronic and acute illness: A meta-analysis. Patient Education and Counseling, 99(7), 1079-1086. https://doi.org/10.1016/j.pec.2016.01.020 16 Roh, Y.H., Lee, B. K. Park, M. H., Noh, J. H., Gong, H. S., & Baek, G. H. (2016). Effects of health literacy on treatment outcome and satisfaction in patients with mallet finger injury. Journal of Hand Therapy, 29(4), 459-464. https://doi.org/10.1016/j.jht.2016.06.004 Sadeghi-Demneh, E. & Jafarian, F. (2013). The immediate effects of orthoses on pain in people with lateral epicondylalgia. Pain Research and Treatment. Article 2013: 353597. https://doi.org/10.1155/2013/353597 Savas, S. & Aydogan, . (2020). Factors affecting orthosis adherence after acute traumatic tendon repairs: A prospective cohort study. Journal of Hand Therapy. Advance online publication. https://doi.org/10.1016/j.jht.2020.10.005 Schoonenboom, J. & Johnson, R. B. (2017). How to construct a mixed methods research. KZfSS Klner Zeitschrift fr Soziologie und Sozialpsychologie, 69(2), 107-131. https://doi.org/10.1007/s11577-017-0454-1 Shah, C. M., Calfee, R.P., Gelberman, R. H., & Goldfarb, C. A. (2013). Outcomes of Rigid Night Splinting and Activity Modification in the Treatment of Cubital Tunnel Syndrome. Journal of Hand Therapy, 38(6), 1125-1130. https://doi.org/10.1016/j.jhsa.2013.02.039 Ullah, S., Rajan, S., Liu, T., Demagistris, E., Jahrstorfer, R., Anandan, S. Gentile, C., & Gill, A. (2018). Why do patients miss their appointments at primary care clinics? Journal of Primary Medicine and Disease Prevention, 4(3). https://doi.org/10.23937/24695793/1510090 Walters, R., Leslie, S. J., Polson, R., Cusack, T., & Gorely, T. (2020) Establishing the efficacy of interventions to improve health literacy and health behaviours: A systematic review. BMC Public Health, 20, 1040-1056. https://doi.org/10.1186/s12889-020-08991-0 17 Wolff, A. L., & Rosenzweig, L. (2017). Anatomical and biomechanical framework for shoulder arthroplasty rehabilitation. Journal of Hand Therapy, 30(2), 167-174. https://doi.org/10.1016/j.jht.2017.05.009 Wu, J. R., Reilly, C. M., Holland, J., Higgins, M., Clark, P. C., & Dunbar, S. B. (2017). Relationship of health literacy of heart failure patients and their family members on heart failure knowledge and self-care. Journal of Family Nursing, 23(1), 116-137. https://doi.org.ezproxy.uindy.edu/10.1177/1074840716684808 Youngston, B. (2019). Understanding diabetes self-management using the model of human occupation. British Journal of Occupational Therapy, 82(5), 296-305. https://doiorg.ezproxy.uindy.edu/10.1177/0308022618820010 18 Appendix A Research on Compliance and Positive Outcomes Research has shown that compliance is an important factor in achieving positive outcomes for hand therapy patients. This supports the value of increasing compliance with HEPs, orthosis wear, and appointments. Research for various conditions is summarized below and in Table A1. Distal Radial Fracture (DRF) Lyngcoln et al. (2005) examined the relationship between compliance with therapy protocols, including HEPs and appointments, and outcomes following DRF and found a strong relationship between adherence and positive outcomes (based on wrist extension, grip strength, pain, and changes in activity). Osteoarthritis (OA) Hennig at al. (2015) examined the impact of HEPs on women with hand OA by comparing outcome measures for an exercise group with a control group. They found HEPs improved activity performance, grip strength, pain, and fatigue. Cubital Tunnel Syndrome Shah et al. (2013) found compliance with orthosis wear and activity modification for patients with cubital tunnel syndrome impacted positive outcomes (based on Quick Disabilities of the Arm, Shoulder, and Hand and Short Form-12 scores) and decreased treatment failure (based on progression to surgical intervention). Carpal Tunnel Syndrome (CTS) Lewis et al. (2020) examined the impact of education, orthosis wear, and nerve and tendon gliding exercises for patients with CTS who were waitlisted for a surgical consult by comparing outcome measures for a therapy group with a control group. They found education, orthosis wear, and gliding exercises increased patient satisfaction and perceived improvements and decreased progression to surgical intervention. 19 Trigger Finger Lunsford et al. (2019) used a systematic review to examine conservative treatment of trigger finger and found trigger finger orthoses worn only at night resulted in a 53% success rate (based on resolution of triggering) compared with success rates of over 80% for continuous orthosis wear. Lunsford et al. (2019) recommended patients wear trigger finger orthoses continuously with removal only for hygiene. Tennis Elbow Sadeghi-Demneh, E. & Jafarian, F. (2013) compared the effects of three orthoses (the elbow band, elbow sleeve, and wrist splint) with each other and with a placebo orthosis (a 5-cm wide elastic neoprene band with a Velcro strap that was worn around the arm, above the elbow, and applied no pressure). They found the three orthoses decreased pain significantly compared with the placebo orthosis and the elbow band and elbow sleeve provided the greatest improvement in pain. Mallet Finger Roh et al. (2016) examined the relationship between health literacy, treatment outcome, and patient satisfaction for patients with mallet finger injury. They found that patients with reduced health literacy were less compliant with therapy, which led to poor outcomes (based on extensor lag and Quick Disabilities of the Arm, Shoulder, and Hand score) and low patient satisfaction. Dupuytrens contracture (DC) Kitridis et al. (2019) researched the effectiveness of a treatment protocol for 30 patients with a DC and found the two patients who do not follow the splinting protocol were the only patients who experience recurrence. 20 Table A1 Research on Compliance and Positive Outcomes ____________________________________________________________________________ Condition Protocols Positive Outcomes Comparison Reference ____________________________________________________________________________ DRF HEPs Activity Within group Lyngcoln et al. Appointments Wrist extension compliance (2005) Grip strength Pain OA HEPs Activity Grip strength Pain Fatigue Exercise with control group Hennig et al. (2015) Cubital Tunnel Syndrome Orthosis wear Activity modification Function Health status Grip strength Progression High within group compliance (88% did not progress to surgery) Shah et al. (2013) CTS Education Orthosis wear Gliding exercises Satisfaction Perceived function Progression Therapy with control group Lewis et al. (2020) Trigger Finger Orthosis Wear Resolution Continuous wear with night-only group Lunsford et al. (2019) Tennis Elbow Orthosis wear Pain Orthosis with placebo group SadeghiDemneh, E. & Jafarian, F. (2013) Mallet Finger Orthosis wear Function Extensor lag Satisfaction Within group compliance Roh et al. (2016) DC Orthosis wear Recurrence Within group compliance Kitridis et al. (2019) ____________________________________________________________________________ 21 Appendix B Email Request to Participate in Project Hello, My name is Ethan Roberts. I am an occupational therapy student at University of Indianapolis currently completing my doctoral capstone with Kimberly Pontarelli at Athletico Lincoln Park North. I am examining health literacy and its impact on compliance with hand therapy treatment plans. To do this, I have designed health literacy materials to explain 7 common conditions seen in this setting (fractures, trigger finger, osteoarthritis, De Quervains tenosynovitis, lateral epicondylitis, carpal tunnel syndrome, and cubital tunnel syndrome). I designed a pretest to gauge compliance with completing home exercise programs and wearing orthoses as instructed. I am also collecting attendance data from the electronic medical record to view compliance with appointments. I will compare this pretest data with similar posttest measures and conduct a short posttest survey to collect patient feedback on their perceptions of the health literacy materials. I am hoping for some additional help from you! If you would like to include your clients in this study, I will supply you with all the pretest, health literacy, and posttest materials. The timing for this project is as follows: the pretest and health literacy materials will be distributed the week of February 14 to any current patients who have at least 1 of the 7 diagnoses; new clients with at least 1 of the 7 conditions can receive health literacy materials from February 14 through March 7; and the posttest will be administered on the week of March 21. If you have any questions, please feel free to contact me at robertser@uindy.edu. Thank you for your consideration! Sincerely, Ethan Roberts 22 Appendix C Health Literacy Handout for Osteoarthritis Osteoarthritis What is Osteoarthritis? Osteoarthritis occurs when the cartilage between bones at a joint begins to break down due to overusing the joint during daily tasks. Cartilage is flexible connective tissue that provides smooth movement at the joint and padding if bones are pushed together. When cartilage breaks down, it can cause swelling, pain, stiffness, and decreased range of movement at the joint. There may be a crackling sensation or sound when moving the joint and bone spurs, bumps on the surface of bone, can form at the joint. Symptoms often start slowly, get worse with time, and can interfere with a person's ability to sleep through the night. These symptoms can be managed and the progression can be decreased, but joint damage cannot be fixed. Osteoarthritis is the most common form of arthritis and can impact any joint, however the most common are joints in the hands, knees, hips, and spine. Some risk factors are older age, sex (more common in women), previous joint injuries, sustained stress on the joint, and obesity. Activities that put stress on joints, such as gardening, cutting, and chopping, may increase symptoms. (https://www.closerlookatstemcells.org/stem-cells-medicine/osteoarthritis/) What can hand therapy do for me? Hand therapists address symptoms of osteoarthritis to keep the condition from progressing and prevent the potential need for surgery. Treatment may consist of heat, exercises, and orthoses. 23 Therapists can recommend ways to change daily tasks to manage symptoms. The therapy plan will be customized for you to achieve best results. What can you expect? Appointment(s) - to check progress, change the plan as needed, and provide treatments to decrease symptoms. Why? This is your time to discuss your needs, any new symptoms, your progress, and changes needed to the plan. The goal is to make sure symptoms are decreasing so you can return to your valued daily tasks. Exercise - to manage symptoms. How? There is fluid that coats cartilage and helps smooth movement of a joint. During exercise, flow of the fluid that coats cartilage to the joint is increased, which decreases swelling, pain, and stiffness at the joint. Strengthening muscles helps protect and give support to joints. Stretching improves range of movement at the joint. (https://myhealth.alberta.ca/Health/aftercareinformation/pages/conditions.aspx?hwid=bo1528) Begin by holding your hand out in front of you with all fingers pointing towards the ceiling. Try to touch each finger to your thumb in order from your index finger to your little finger. Repeat 8-12 times on each hand, even if only one thumb is affected. Orthosis - to help manage symptoms and the ability to complete daily tasks. How? An orthosis can place the joint in a position that relieves stress, decreases pain, and protects the joint from deformity. An orthosis can also be used to place the joint in a position where it can be used for tasks, providing support to decrease pain and stress on the joint during activities. 24 .(https://www.orfit.com/blog/short-thumb-opponens-orthosis/) References https://www.mayoclinic.org/diseases-conditions/osteoarthritis/diagnosis-treatment/drc-20351930 https://www.cdc.gov/arthritis/basics/osteoarthritis.htm https://www.health.harvard.edu/staying-healthy/exercise-rx-for-overcoming-osteoarthritis https://www.sciencedirect.com/science/article/pii/S1877065716305310 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4350574/ https://www.arthritis.org/health-wellness/healthy-living/physical-activity/getting-started/benefitsof-exercise-for-osteoarthritis 25 Appendix D Health Literacy Handout for Trigger Finger Stenosing Tenosynovitis (Trigger Finger) What is trigger finger? Trigger finger is caused by inflammation of the tendon sheath, which is the tissue that surrounds tendons for protection and anchoring. Tendons connect muscle to bone to allow for movement. When the tendon sheath becomes irritated, the tissue begins to swell, which restricts the gliding motion of the tendon through the sheath. Sustained irritation of the sheath can lead to the formation of scar tissue and nodules, which further restrict the tendons ability to glide through the sheath. Eventually, the finger may lock in a bent position. Trigger finger can cause pain, stiffness, and snapping or locking when moving the finger. Symptoms often start off slowly, get worse with time, and can interfere with a person's ability to sleep through the night. Trigger finger can occur in any finger or the thumb and can affect more than one finger at once. Some risk factors are sustained gripping, diabetes, rheumatoid arthritis, previous surgery for carpal tunnel, and sex (women have a higher risk). Activities that require sustained hand use and gripping, such as gardening, driving, writing, and cutting, may increase symptoms. (https://www.mayoclinic.org/diseases-conditions/trigger-finger/symptoms-causes/syc-20365100) 26 What can hand therapy do for me? Hand therapists address symptoms during recovery from trigger finger to keep the symptoms from progressing and prevent the potential need for surgery. Treatment may consist of heat, exercises, tendon glides, and orthoses. During treatment, you may need to rest and stop the activity that caused the symptoms. Therapists may also recommend ways to change daily tasks to decrease symptoms. The therapy plan will be customized for you to achieve best results. What can you expect? Appointment(s) - to check progress, change the plan as needed, and provide treatments to decrease symptoms. Why? This is your time to discuss your needs, any new symptoms, your progress, and changes needed to the plan. The goal is to make sure symptoms are decreasing so you can return to your valued daily tasks. Exercises - to help with symptoms and recovery. How? Stretching can decrease stiffness and increase range of movement in the finger. Exercises (when symptoms are better) - to prevent trigger finger from returning. How? Strengthening exercises are targeted to increase grip strength and decrease strain when moving the finger. Tendon gliding helps the tendon move more freely in the tendon sheath, which can promote smooth motion of the tendon and prevent stiffness. (https://www.pthealth.ca/conditions/trigger-finger/) Example stretch: hold your arm out in front of you and use your hand to put light pressure on the palm side of the hand and fingers. Hold for 5-10 seconds before relaxing. Repeat this stretch 34 times per day. Orthosis - to help with symptoms and recovery. How? An orthosis prevents the finger from moving in a way that provokes symptoms and places the finger in an extended position to 27 decrease pressure on the tendon. Wearing the orthosis at night decreases nighttime symptoms to help you sleep. (https://www.amazon.com/HANDFIX-Adjustable-Tendonitis-Stiffness-Relief-Left/dp/B00K1MQXKS) References https://orthoinfo.aaos.org/en/diseases--conditions/trigger-finger/ https://www.mayoclinic.org/diseases-conditions/trigger-finger/symptoms-causes/syc-20365100 https://www.healthdirect.gov.au/surgery/trigger-finger-release 28 Appendix E Health Literacy Handout for Carpal Tunnel Syndrome Carpal Tunnel Syndrome What is carpal tunnel syndrome? Carpal tunnel syndrome is caused by compression of the median nerve in the carpal tunnel, which is located on the palm side of the hand. The carpal tunnel is formed by bone and ligament, which is tissue that connects bone to bone. The median nerve passes through the tunnel on its way down the arm to the hand. The median nerve provides sensation on the palm side of the thumb and first three fingers. It also controls muscles at the base of the thumb. When the median nerve is compressed in the carpal tunnel, it can cause numbness, tingling, pain, and weakness in the arm, hand, and fingers. Symptoms often start slowly, get worse with time, and can interfere with a person's ability to sleep through the night. Some risk factors are sustained hand motions, the structure of the wrist, arthritis, pregnancy, and a former injury. Carpal tunnel syndrome is more common in women because the carpal tunnel is smaller. Activities that require sustained flexing of the wrist, such as writing and keyboard and mouse use, may increase symptoms. (https://www.hopkinsmedicine.org/health/treatment-tests-and-therapies/carpal-tunnel-release) 29 What can hand therapy do for me? Hand therapists address symptoms during recovery from carpal tunnel syndrome to keep the condition from progressing and prevent the potential need for surgery. This may include heat, exercises, nerve glides, and orthoses. During treatment, you may need to rest and stop the activity that caused the symptoms. Therapists may also recommend ways to change daily tasks to decrease symptoms. The therapy plan will be customized for you to achieve best results. What can you expect? Appointment(s) - to check progress, change the plan as needed, and provide treatments to decrease symptoms. Why? This is your time to discuss your needs, any new symptoms, your progress, and changes needed to the plan. The goal is to make sure symptoms are decreasing so you can return to your valued daily tasks. Exercises (when symptoms are better) - to prevent carpal tunnel from coming back. How? Stretching wrist muscles improves range of movement at the wrist. Nerve-gliding can help the median nerve move more freely in the carpal tunnel. Nerve-gliding or nerve stretching promotes smooth motion of the nerve in the tunnel and helps prevent stiffness. Nerve-gliding also increases blood flow to nerve tissues, which helps to keep tissues healthy and prevent symptoms from returning. 30 (https://www.schreibermd.com/carpal-tunnel-excercises) Begin by holding your hand in a fist out in front of your body with your palm facing you. Progress through the series in order and hold each position for 5 seconds. Make sure to use gentle pressure on the thumb when performing position 6. Orthosis - to help with symptoms and recovery. How? An orthosis prevents the wrist from moving in a way that provokes symptoms and places the wrist in a position that decreases pressure on the median nerve. Wearing an orthosis at night helps with nighttime symptoms to improve sleep. (https://www.ncmedical.com/products/thumb-hole-wrist-cock-up-precut-splint_1090.html) References https://www.mayoclinic.org/diseases-conditions/carpal-tunnel-syndrome/symptoms-causes/syc20355603 https://www.hopkinsmedicine.org/health/treatment-tests-and-therapies/carpal-tunnel-release https://www.hopkinsmedicine.org/orthopaedic-surgery/specialty-areas/hand/conditions-wetreat/carpal-tunnel-syndrome.html 31 Appendix F Health Literacy Handout for Cubital Tunnel Syndrome Cubital Tunnel Syndrome What is cubital tunnel syndrome? Cubital tunnel syndrome is caused by compression of the ulnar nerve in the cubital tunnel, which is located on the inside of the elbow. Due to its position at the elbow, the ulnar nerve is particularly vulnerable to compression and injury in the cubital tunnel. The cubital tunnel tunnel is formed by muscle, bone, and ligament (fascia), which is tissue that connects bone to bone. The ulnar nerve passes through the tunnel on its way down the arm to the hand. The ulnar nerve provides sensation on the palm side and back side of the little and ring fingers. It also controls muscles in the hand that help with fine motor tasks and muscles in the forearm that help with grip strength. When the ulnar nerve is compressed in the cubital tunnel, it can cause numbness, tingling, pain, and weakness in the arm, hand, and fingers. Symptoms often start slowly, get worse with time, and can interfere with a person's ability to sleep through the night. Some risk factors are sustained bending at the elbow, weight bearing through the elbow, an injury, bone spurs, and arthritis. Activities that place the elbow in a bent position, such as reading, driving, and talking on the phone, may increase symptoms. (https://www.cedars-sinai.org/health-library/diseases-and-conditions/c/cubital-tunnel-syndrome.html) What can hand therapy do for me? Hand therapists address symptoms during recovery from cubital tunnel syndrome to keep the condition from progressing and prevent the potential need for surgery. Treatment may consist of heat, exercises, nerve glides, and orthoses. During treatment, you may need to rest and stop the activity that caused the symptoms. Therapists may also recommend ways to change daily 32 tasks to decrease symptoms. The therapy plan will be customized for you to achieve best results. What can you expect? Appointment(s) - to check progress, change the plan as needed, and provide treatments. Why? This is your time to discuss your needs, any new symptoms, your progress, and changes needed to the plan. The goal is to make sure symptoms are decreasing so you can return to your valued daily tasks. Exercises - to help with symptoms and recovery. How? Nerve-gliding can help the ulnar nerve move more freely in the cubital tunnel. Nerve-gliding or nerve stretching promotes smooth motion of the nerve in the tunnel and helps prevent stiffness in the arm and wrist. Nerve-gliding also increases blood flow to nerve tissues, which helps to keep tissues healthy and prevent symptoms from returning. Once symptoms decrease, stretching forearm muscles increases range of movement at the arm and wrist. Strengthening proximal muscles, such as those of the shoulder, helps ease strain on the elbow. Example nerve glide: Begin by holding your arm in front of you with your elbow straight, then flex your wrist and fingers towards you, then extend your wrist and fingers away from you, and end by flexing your elbow and wrist. (https://ahc.aurorahealthcare.org/fywb/x25998.pdf) Orthosis - to help with symptoms and recovery. How? An orthosis prevents the elbow from moving in a way that provokes symptoms and places the elbow in a position that decreases pressure on the ulnar nerve. Wearing an orthosis at night decreases nighttime symptoms to help you sleep. You want to remember to avoid leaning on your elbow, which puts pressure on the ulnar nerve. An elbow pad can protect the elbow when placed on hard surfaces. (Home made with towel + tape) (Store bought) (https://www.assh.org/handcare/blog/advice-from-a-certified-hand-therapist-on-cubital-tunnel-syndrome) References https://www.hopkinsmedicine.org/health/conditions-and-diseases/cubital-tunnel-syndrome 33 https://orthoinfo.aaos.org/en/diseases--conditions/ulnar-nerve-entrapment-at-the-elbow-cubitaltunnel-syndrome/ https://www.cedars-sinai.org/health-library/diseases-and-conditions/c/cubital-tunnelsyndrome.html https://sportsmedicine.mayoclinic.org/condition/ulnar-nerve-cubital-tunnel/ 34 Appendix G Health Literacy Handout for Tennis Elbow Lateral Epicondylitis (Tennis Elbow) What is tennis elbow? Tennis elbow occurs when the tendons in your elbow get overworked due to overuse and muscle strain. Tendons connect muscle to bone to allow for movement, and this condition affects the tendons that attach muscles to the outside of the elbow. When these muscles are repeatedly used to move the wrist and arm, it can cause little tears in these tendons. Common symptoms include pain and weakness. Pain typically occurs in the area around the outside of the elbow but may also be felt in the forearm and wrist. Symptoms may make it difficult to grip or hold objects and can interfere with a person's ability to sleep through the night. Some risk factors for developing tennis elbow are playing racket sports and age (tennis elbow is most common in adults between the ages of 30 and 50). Activities that require sustained motions of the wrist and arm, such as playing racket sports, painting, and cutting with a knife, may increase symptoms. (https://www.bellefleurphysio.com/tennis-elbow/) What can hand therapy do for me? Hand therapists address symptoms during recovery from tennis elbow to keep the condition from progressing and prevent the potential need for surgery. Treatment may consist of heat, 35 exercises, and an orthosis. During treatment, you may need to rest and stop the activity that caused the symptoms. Therapists may also recommend ways to change daily tasks to decrease symptoms. The therapy plan will be customized for you to achieve best results. What can you expect? Appointment(s) - to check progress, change the plan as needed, and provide treatments. Why? This is your time to discuss your needs, any new symptoms, your progress, and changes needed to the plan. The goal is to make sure symptoms are decreasing so you can return to your valued daily tasks. Exercises (as symptoms decrease) - to prevent tennis elbow from coming back. How? Exercises are targeted to increase grip strength and decrease strain when moving the wrist and arm by strengthening proximal muscles, such as those of the shoulder. In addition, stretching forearm muscles can help increase range of movement at the wrist and elbow. (https://myhealth.alberta.ca/Health/pages/conditions.aspx?hwid=zm2386) Begin by attaching a TheraBand to a stable surface. Hold your arm in front of you at a 90degree angle while holding the TheraBand. Keep your upper arm in at your side and move your forearm across your body as pictured above. You can move farther away from the surface you attached the TheraBand to in order to increase resistance through the band. Orthosis - to help with symptoms and recovery. How? An orthosis can decrease strain on tendons and muscles and help muscles relax. This decreases pain and stress while allowing for movement. 36 (https://www.amazon.com/OTC-Band-Forearm-Compression-Strap/dp/B000JNRHFY) References https://www.mayoclinic.org/diseases-conditions/tennis-elbow/symptoms-causes/syc-20351987 https://www.hopkinsmedicine.org/health/conditions-and-diseases/lateral-epicondylitis-tenniselbow https://www.ncbi.nlm.nih.gov/books/NBK506995/ 37 Appendix H Health Literacy Handout for De Quervains Tenosynovitis De Quervains Tenosynovitis What is De Quervains tenosynovitis? De Quervains tenosynovitis is caused by inflammation of the tendon sheath, which is tissue that surrounds tendons for protection and anchoring. Tendons connect muscle to bone to allow for movement, and this condition affects the two tendons in your wrist and thumb. When the tendon sheath becomes irritated, the tissue begins to swell, which restricts the gliding motion of the tendon through the sheath and can lead to inflammation of the tendon. People with this condition may have a sticky feeling or creaking sound when moving their thumb. De Quervains tenosynovitis can cause pain at the base of the thumb and discomfort when using the wrist, gripping objects, pinching, or making a fist. Pain typically begins at the base of the thumb, but may increase with time, traveling up the thumb and forearm. Symptoms often start slowly, get worse with time, and can interfere with a person's ability to sleep through the night. Activities that require sustained hand or wrist movements, such as gardening, playing racket sports or golf, and lifting a baby, may increase symptoms. Some risk factors are sustained hand or wrist movements at the elbow, sex (women have a higher risk), pregnancy, and age. De Quervains tenosynovitis is most common in adults between the ages of 30 and 50. (https://www.mayoclinic.org/diseases-conditions/de-quervains-tenosynovitis/symptoms-causes/syc-20371332) 38 What can hand therapy do for me? Hand therapists address symptoms during recovery from De Quervains tenosynovitis to keep the condition from progressing and prevent the potential need for surgery. Treatment may consist of heat, exercises, and orthoses. During treatment, you may need to rest and stop the activity that caused the symptoms. Therapists may also recommend ways to change daily tasks to decrease symptoms. The therapy plan will be customized for you to achieve best results. What can you expect? Appointment(s) - to check progress, change the plan as needed, and provide treatments to decrease symptoms. Why? This is your time to discuss your needs, any new symptoms, your progress, and changes needed to the plan. The goal is to make sure symptoms are decreasing so you can return to your valued daily tasks. Exercises - to help with symptoms and recovery. How? Exercises can increase strength at the wrist, which decreases strain on the affected tendons. Stretching can also be used to preserve range of movement in the thumb and decrease stiffness. (https://www.saintlukeskc.org/health-library/wrist-extension-strength) Begin by resting your forearm on a table or other stable surface with your hand hanging over the edge as pictured above. Slowly bend at the wrist to raise your hand toward the ceiling. Continue until you have completed 3 sets of 10 repetitions. Start with a small weight and gradually increase the weight as symptoms decrease. Orthosis - to help with symptoms and recovery. How? An orthosis places the joint in a position that relieves stress. This decreases pain and protects the joint from deformity. 39 (Dale, 2020, slide 6) References https://www.mayoclinic.org/diseases-conditions/de-quervains-tenosynovitis/symptomscauses/syc-20371332#:~:text=De%20Quervain%27s%20tenosynovitis%20 https://familydoctor.org/condition/de-quervains-tenosynovitis/ https://www.uhcw.nhs.uk/download/clientfiles/files/DeQuervains%20therapy%20exercises.pdf 40 Appendix I Health Literacy Handout for Fractures Fracture What is a fracture? A fracture is a partial or complete break in the bone. A fracture occurs when the force applied to the bone is more than the bone can handle, which can happen with falls, trauma, or sports injuries. Fractures can be classified as displaced or nondisplaced. In a displaced fracture, the bone breaks, moves out of alignment, and may require surgery to realign the bone. In a nondisplaced fracture, the broken bone stays aligned and may be treated without surgery. Common symptoms during recovery include pain, swelling, and decreased range of motion and strength. These deficits can interfere with a persons ability to complete daily activities such as dressing, shaving, and bathing. Healing is typically viewed in 3 stages: the inflammatory stage, the restorative stage, and the remodeling stage. It may take 7 or more weeks for the bone to heal. Healing time depends on a variety of factors, such as the severity of your fracture and your age, diet, and use of tobacco or alcohol. Some risk factors for fractures are a diet low in vitamin D and calcium, tobacco use, contact sports, and age (more common for older adults). Activities that increase the risk of falling, such as using a ladder, skiing, or walking on unshoveled or icy surfaces, or increase the risk of trauma, such as playing contact sports or using a hammer, may increase the risk of a fracture. X-rays of two fractures of the fingers (https://orthoinfo.aaos.org/en/diseases--conditions/hand-fractures) What can hand therapy do for me? Hand therapists address symptoms during recovery from a fracture to avoid poor outcomes, such as permanent loss of range of motion, chronic pain, and deformity. Treatment may consist of heat, exercises, and orthoses. During treatment, you may need to stop activities that 41 aggravate symptoms. Therapists may also recommend ways to change daily tasks to decrease symptoms. This plan will be customized for you to achieve best results. What can you expect? Appointment(s) - to check progress, change the plan as needed, and provide treatments. Why? This is your time to discuss your needs, any new symptoms, your progress, and changes needed to the plan. The goal is to make sure symptoms are decreasing so you can return to your valued daily tasks. Exercises - How? Stretching can help decrease stiffness by loosening joins and lengthening tight muscles. Strengthening exercises will help build back strength in muscles at and around the fracture site. These muscles lose strength following the fracture due to immobilization. The therapist will design a home exercise plan with both stretching and strengthening exercises to increase function. (Peterson, 2020, slide 29) Orthosis - to help with symptoms and recovery. How? An orthosis is selected based on your symptoms, condition, and location of fracture. An orthosis can position the hand to minimize stiffness and swelling. In addition, if medically appropriate, a mobilization or gutter orthosis can provide passive stretching to help increase range of motion. A sample mobilization orthosis is shown below. 42 (Peterson, 2020, slide 25) References https://orthoinfo.aaos.org/en/diseases--conditions/hand-fractures https://www.hopkinsmedicine.org/health/conditions-and-diseases/fractures https://www.orthopedic-institute.org/fracture-care/types-of-fractures/ https://www.mayoclinic.org/diseases-conditions/broken-arm/diagnosis-treatment/drc-20353266 43 Appendix J Pretest/Posttest Questionnaire on Home Exercise and Orthosis Compliance 1. Athletico location: ___________________________ 2. Primary language: ___________________________ 3. Do you have a home exercise plan? a. Yes b. No 4. If yes, how many days per week are you NOT able to complete your home exercise plan for any reason? a. b. c. d. 0-1 2-3 4-5 6-7 5. Do you have an orthosis? a. Yes b. No 6. If yes, how many days per week are you NOT able to wear your orthosis as instructed for any reason? a. b. c. d. 0-1 2-3 4-5 6-7 44 Appendix K Survey: Patient Perceptions of the Health Literacy Materials 1. Athletico location: _______________________________ 2. Primary language: _______________________________ 3. Which condition(s) did you receive a handout for? a. Fracture b. Trigger finger c. Osteoarthritis d. De Quervains tenosynovitis e. Lateral epicondylitis (tennis elbow) f. Carpal tunnel syndrome g. Cubital tunnel syndrome 4. Did the handout explain your condition(s) in a way that was easy to understand? a. Yes, definitely b. Yes, somewhat c. No 5. Did the handout explain the purpose of therapy in a way that was helpful and clear? a. Yes, definitely b. Yes, somewhat c. No 6. Would you recommend providing these handouts to other clients? a. Yes, definitely b. Yes, somewhat c. No 7. Please feel free to provide any comments or suggestions for improving the handouts ______________________________________________________________________ 45 ______________________________________________________________________ ______________________________________________________________________ 46 Appendix L DCE Weekly Planning Guide The DCE weekly planning guide is provided in Table L1. Table L1 DCE Weekly Planning Guide Week - DCE Stage Weekly Goal Objectives Tasks Date Completed ____________________________________________________________________________ 1 - Orientation 1) Complete Develop understanding Work with 1/14/22 orientation of population conditions site mentor and interventions through daily tasks 2) Work on pre/posttest For implementation of DCE Draft for feedback 2 Implementation 1) Continue work with mentor Develop understanding of population conditions and interventions Work with 1/21/22 site mentor through daily tasks 3 Implementation 1) Continue work with mentor Develop understanding of population conditions and interventions Work with 1/28/22 site mentor through daily tasks 2) Work on health literacy materials For feedback Written at grade 8 1/28/22 3) Draft of introduction Finalize draft Write introduction 1/28/22 4) Rough draft of final survey For feedback Write survey 1/28/22 1) Draft of background Finalize draft Write background 2/4/22 4 Implementation 1/14/22 47 ___________________________________________________________________________ Week - DCE Stage Weekly Goal Objectives Tasks Date Completed ____________________________________________________________________________ 2) Finalize For population Revise 2/4/22 final survey 5 Implementation 6 Implementation 3) Revise health literacy materials For additional feedback Written at grade 8 2/4/22 4) Continue work with mentor To gain experience Evaluations 2/4/22 and interventions 1) Finalize health literacy materials Implement feedback Written at grade 8 2/11/22 2) Finalize pre/posttest Implement feedback Revise 2/11/22 2) Draft of Finalize section project design Write section 2/11/22 3) Continue work with mentor Evaluations 2/11/22 and interventions To gain experience 1) Administer Collect pretest data pretest Administer and collect data 2/18/22a 2) Distribute health literacy materials To improve health literacy Distribute 2/18/22ahandouts 3/11/22 to population 3) Continue work with mentor To gain experience Evaluations 2/18/22 and interventions 48 ___________________________________________________________________________ Week - DCE Stage Weekly Goal Objectives Tasks Date Completed ____________________________________________________________________________ 7 Implementation 1) Continue To gain experience Evaluations 2/25/22 work with and mentor interventions 8 Implementation 1) Continue work with mentor To gain experience Evaluations 3/4/22 and interventions 9 Implementation 1) Finalize methods section Implement feedback Work on methods 2) Continue work with mentor To gain experience Evaluations 3/11/22 and interventions 10 Implementation 1) Continue work with mentor To gain experience Evaluations 3/18/22 and interventions Develop draft of outcomes Write outcomes To gain experience Evaluations 3/25/22 and interventions 2) Draft of outcomes 11 Implementation 1) Continue work with mentor 2/18/22 3/18/22 2) Administer Collect postttest data posttest Administer and collect data 3/25/22 3) Analyze data Data analysis 3/25/22 Write 3/25/22 Compare with pretest data 4) Work on For dissemination dissemination plan 49 ___________________________________________________________________________ Week - DCE Stage Weekly Goal Objectives Tasks Date Completed ____________________________________________________________________________ 12 Implementation 1) Continue To gain experience Evaluations 4/1/22 work with and mentor interventions 2) Work on outcomes 13 Implementation 1) Continue work with mentor 2) Finalize outcomes Develop understanding of outcomes Write/revise outcomes To gain experience Evaluations 4/8/22 and interventions Implement feedback Work on outcomes 4/8/22 Poster, paper, presentation 4/8/22 3) Work on Work on rough drafts dissemination materials 14 Discontinuation 1) Continue work with mentor 15 Dissemination 16 - Dissemination 4/1/22 To gain experience Evaluations 4/15/22 and interventions 2) Drafts abstract, summary, and conclusion Complete drafts Write drafts 4/15/22 1) Finalize paper Implement feedback Revise 4/22/22 2) Drafts of Dissemination dissemination materials Poster and presentation 4/22/22 3) Draft of Work on draft Final Summary Write draft 4/22/22 1) Finalize materials Poster and presentation 4/29/22 Implement feedback 50 ___________________________________________________________________________ Week - DCE Stage Weekly Goal Objectives Tasks Date Completed ____________________________________________________________________________ 2) Finalize Implement feedback Revise 4/29/22 final summary ____________________________________________________________________________ Moved to week 6 to provide the opportunity for additional sites to participate in the study. a 51 Appendix M Participant Data by Site Pretest and posttest participant information is provided in Table M1 and M2, respectively. Survey participant information is shown in Table M3. Table M1 Pretest Participant Information ____________________________________________________________________________ Pretest Participants Lincoln Park Garfield North Ridge Urbandale Total ____________________________________________________________________________ Number of participants 10 4 6 20 Primary language: English 9 3 6 18 Primary language: Spanish 1 1 0 2 153 23 53 229 7 7 0 14 95 70 100 94 Protocol includes orthosis 8 2 3 13 Orthosis 0-1 days missed/week 8 2 2 12 Orthosis 2-3 days missed/week 0 0 0 0 Orthosis 4-5 days missed/week 0 0 0 0 Orthosis 6-7 days missed/week 0 0 1 1 Orthosis wear (%)b 90 90 60 80 HEP provided 10 4 4 18 HEP 0-1 days missed/week 8 4 2 14 HEP 2-3 days missed/week 2 0 2 4 HEP 4-5 days missed/week 0 0 0 0 HEP 6-7 days missed/week 0 0 0 0 80 90 80 80 Appointments scheduled Appointments missed Attendance (%)a HEP (%)b ____________________________________________________________________________ Percent of appointments attended. a Percent compliance rounded to one significant figure (0-1 day = 90%, 2-3 days = 60%, 4-5 b days = 40%, and 6-7 days = 7%). 52 Table M2 Posttest Participant Information ____________________________________________________________________________ Posttest Participants Lincoln Park Garfield Urbandale Total North Ridge ____________________________________________________________________________ Number of participants 7 4 5 16 Primary language: English 5 3 5 13 Primary language: Spanish 1 1 0 2 Primary language: German 1 0 0 1 123 65 47 235 8 12 5 25 94 82 89 89 Protocol includes orthosis 5 1 2 8 Orthosis 0-1 days missed/week 5 1 2 8 Orthosis 2-3 days missed/week 0 0 0 0 Orthosis 4-5 days missed/week 0 0 0 0 Orthosis 6-7 days missed/week 0 0 0 0 90 90 90 90 Appointments scheduled Appointments missed Attendance (%)a Orthosis wear (%) b HEP provided 7 4 5 16 HEP 0-1 days missed/week 5 3 5 13 HEP 2-3 days missed/week 2 1 0 3 HEP 4-5 days missed/week 0 0 0 0 HEP 6-7 days missed/week 0 0 0 0 HEP (%)b 80 80 90 80 ____________________________________________________________________________ Percent of appointments attended. a Percent compliance rounded to one significant figure (0-1 day = 90%, 2-3 days = 60%, 4-5 b days = 40%, and 6-7 days = 7%). 53 Table M3 Survey Participants Information ____________________________________________________________________________ Participants Lincoln Park Garfield Urbandale Total North Ridge ____________________________________________________________________________ Number of participants 9 4 4 17 Primary language: English 7 3 4 14 Primary language: Spanish 1 1 0 2 Primary language: German 1 0 0 1 Fracture 3 2 4 9 Trigger finger 1 0 0 1 OA 0 1 0 1 De Quervains tenosynovitis 0 0 1 Tennis elbow 3 0 0 3 CTS 1 0 0 1 Cubital tunnel syndrome 1 0 0 1 Easy to understand definitely 9 4 4 17 Easy to understand somewhat 0 0 0 0 Easy to understand no 0 0 0 0 Helpful and clear definitely 9 4 4 17 Helpful and clear somewhat 0 0 0 0 Helpful and clear no 0 0 0 0 Recommend definitely 9 4 4 17 Recommend somewhat 0 0 0 0 Recommend - no 0 0 0 0 1 ____________________________________________________________________________  ...

... 1 Eskenazi Health: Quality of Care Improvement for Recent Amputees Travis W. Rippe May 2022 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. Katie Polo, DHS, OTR, CLT-LANA - Associate Professor 2 Abstract The number of amputations occurring in the United States is rising, thus creating a growing need for healthcare professionals who effectively address the specific needs of recent amputees. This project focused on the needs of inpatient amputees at Eskenazi Health Hospital in Indianapolis, IN. I identified amputees needs from the input of Eskenazi staff, amputees, and current literature. The largest needs for recent amputees at Eskenazi included transportation to outpatient appointments, psychological barriers, upper extremity amputee education, and education regarding the role of occupational therapy in amputee rehabilitation. I created educational materials for the inpatient rehabilitation department and amputee population at Eskenazi Health to improve amputee quality of care based on the needs and barriers identified. The results indicated therapists increased knowledge of connecting amputees to resources for their basic needs (transportation) and addressing the mental health needs of amputees. 3 Eskenazi Health: Quality of Care Improvement for Recent Amputees Introduction Sidney & Lois Eskenazi Hospital is a level one trauma center. Eskenazi provides medical care for the most intense injuries and traumas, including the most severe amputations. Eskenazi administers inpatient and outpatient occupational therapy services to help patients participate in meaningful occupations. Eskenazi aims to advocate, care, teach, and serve with a special emphasis on the vulnerable populations of Marion County (Eskenazi Health, n.d., n.p.). Eskenazi Hospital accepts all people of all ages and operates as a not-for-profit corporation (Eskenazi Health, n.d.). There is a growing need for healthcare professionals that serve patients with amputations. The amount of Americans living with an amputation is predicted to increase from 1.6 million individuals in 2005 to 3.6 million by 2050 (Ziegler et al., 2008). The project goal was to improve recent amputees quality of care at Eskenazi Health by identifying and successfully addressing the common needs and barriers of recent amputees at Eskenazi Health Hospital. The target population was inpatient amputees and the inpatient rehabilitation department consisting of occupational therapy (OT) and physical therapy (PT) professionals who treat amputees. This report includes background information relevant to the development of this doctoral capstone project, the needs assessment, project implementation, and the program outcomes. Background African Americans are at a higher risk for receiving a lower extremity amputation (Esquenazi & Yoo, 2012). Additionally, patients who are on Medicaid have a greater risk for amputations (Barnes et al., 2020). Many of the amputees Eskenazi serves are undocumented, African American, diabetic, of low socioeconomic status, urban residents, or homeless. This 4 vulnerable population is at a high risk for lacking resources, such as transportation, education, or financial privileges. Limited resources impact their access to care and decrease the vulnerable populations overall health and quality of life. In 2014, 3,510 individuals received an amputation in Indiana hospitals. Of these amputations, 174 were upper extremity (UE) amputations and 3,336 were lower extremity (LE) amputations (Amputee Coalition, 2019). Eskenazi therapists treat more LE amputees than UE amputees; however, it is important for Eskenazi to have specific resources that are available for both levels of amputations since the needs of LE and UE amputees present differently. Needs Assessment Before beginning the Doctoral Capstone Experience (DCE), common needs and barriers for amputees were discovered in literature to better understand the possible barriers amputees at Eskenazi may experience. Once on site, stakeholder interviews were completed to inform the direction of the project. The stakeholders interviewed included: amputees (recent and longstanding), occupational therapists, physical therapists, a social worker, a rehabilitation manager, a prosthetist, and a Physical Medicine & Rehabilitation physician. This improved the knowledge of specific needs and barriers of amputees at Eskenazi and what to address in this project. Transportation Stakeholders identified transportation to outpatient medical appointments as a large need for recent amputees (R. Kiser, personal communication, January 11, 2022; C. Walters, personal communication, January 11, 2022; C. Hall, A. Palicki, C. Walters, K. Wells, personal communication, January 19, 2022; W. Hayden, personal communication, January 22, 2022). One 5 patient reported being unable to drive after their amputation and said that transportation to/from medical appointments would have been a significant need if they did not have social support. Mental Health Another area of concern were the psychosocial and mental health factors that decrease patients outcomes (C. Walters, personal communication, January 11, 2022). Poor volition to participate in therapy was reported by therapists to be a barrier to patient success (R. Kiser, personal communication, January 11, 2022; C. Kittridge, personal communication, January 22, 2022). Some amputees do not fully participate in therapy because they do not realize the potential to engage in meaningful activities again (R. Kiser, personal communication, January 11, 2022). One patient reported encouragement as a critical component to their success after their amputation. This is relevant since encouragement is a strategy to motivate patients to participate in therapy. Upper Extremity Amputee Education There were limited resources available for UE amputees at Eskenazi that educated patients on information specific to their level of amputation. Amputee rehabilitation should be client-centered and tailored to the specific amputee. The type of amputation is significant as each amputation presents different challenges and occupational barriers. Occupational Therapy Education Some LE amputees were not receiving OT orders despite their need for OT services (C. Walters, personal communication, January 11, 2022). These LE amputees have specific occupational needs that only OT practitioners can address through their unique scope of practice. The OT scope of practice in amputee rehabilitation must be established in the therapy department and amputee population to improve the impact OT can have on amputees. 6 Gaps in Care After pinpointing the needs and barriers from the literature search and stakeholder interviews, the resources available to recent amputees at Eskenazi were analyzed to discover any possible gaps in the education and resources provided to recent amputees. The current resources, programs, or curriculum for staff and amputees at Eskenazi was created by past therapy students and employees. The Eskenazi inpatient rehabilitation department had two LE amputee handouts (one above the knee [AKA] and one below the knee [BKA] handout). The creators failed to include education for possible mental health issues after an amputation, transportation options, and the role and benefits of OT in LE amputee rehabilitation. Upon further investigation, it was discovered that there was no education for newly hired therapists regarding the role of OT in LE and UE amputee care. There was no UE amputee education provided to the inpatient rehabilitation staff and UE amputees. Many inpatient OTs were unsure of how to treat and educate UE amputees (C. Kittridge, personal communication, January 22, 2022). The exclusion of the role of OT and education specific to UE amputee rehabilitation could be a contributing cause for the uncertainty of how to treat and educate UE amputees. Four significant factors that this project addressed that other authors did not are: transportation needs, mental health/psychosocial education, education specific for UE amputees, and advocacy for the role of OT in UE/LE amputee rehabilitation to improve amputees access to the unique benefits of OT services. Stakeholders supported the project purpose to address the transportation needs of recent amputees, add mental health education and the role of OT in UE/LE amputee rehabilitation in the current resources provided by Eskenazi, and create educational handouts for recent UE 7 (transhumeral, transradial, and digit) amputees (C. Hall, A. Palicki, C. Walters, K. Wells, personal communication, January 19, 2022; W. Hayden, personal communication, January 22, 2022; C. Kittridge, personal communication, January 22, 2022). The faculty mentor, Dr. Katie Polo, also confirmed the purpose, design, implementation, and dissemination of the capstone project (K. Polo, personal communication, January 27, 2022). Guiding Theory and Frame of Reference The Canadian Model of Occupational Performance (CMOP), a client-centered and holistic model, guided the capstone project and provided a beneficial lens to address the barriers and needs of recent amputees at Eskenazi (Howard, 2020b). This model evaluates the patients spirituality, emotions, attitudes, cognition and processing, and any of the patients physical attributes (Howard, 2020b). The CMOP helped discover recent amputees emotional wellness, which was useful since depression, anxiety, and difficulties with emotional well-being are common experiences for recent amputees (Bani Saberi, 2004). The holistic view of the CMOP also provided a means to identify the personal, occupational, environmental, and spiritual factors that impact recent amputees transition to outpatient therapy services. The Rehabilitative Frame of Reference (FOR) guided the capstone experience. This FOR focuses on adaption, compensation, and environmental modifications . . . for persons who may not be able to remediate/restore deficits (Howard, 2020a, slide 5). This was appropriate for recent amputees because they will need to compensate and adapt to their environment to successfully complete their meaningful occupations. Amputees can do this through the use of a prosthetic or adaptive equipment. The Rehabilitative FOR guided professional reasoning in the planning process to best address how the recent amputee will adapt or compensate to 8 successfully transition to outpatient therapy and complete meaningful occupations despite their barriers. Doctoral Capstone Project Project Design The doctoral capstone project contained three goals: identify recent amputees needs and barriers from the perspective of Eskenazi staff, identify recent amputees needs and barriers from the perspective of the patient, and provide at least three new resources for recent amputees that are not currently provided at Eskenazi based on the identified barriers and needs. Weekly objectives were created to ensure these goals were met (see Appendix A). It was important to identify the gaps in care for recent amputees at Eskenazi based on the barriers and needs reported from stakeholders and current literature. Project implementation included creation of various educational handouts and updates to current resources based on the use of credible resources. Project Implementation First, the role of OT in amputee rehabilitation was added to all the current and created Eskenazi resources. The aim was to advocate for the OT profession by educating therapists who provide the handouts and the amputees who receive them about the benefits and role of OT. The role of OT was summarized as helps amputees heal from their new amputation and complete everyday activities they want to do. OTs in the hospital help amputees learn how to dress, shower, move around with their new amputation, monitor wound healing, and improve strength and balance (American Occupational Therapy Association, 2013; American Occupational Therapy Association, 2020; Burke Rehabilitation Hospital, 2019; Smurr et al., 2009). 9 Secondly, I developed and added mental health education to all the Eskenazi resources. The education included coping strategies to address the mental health needs of amputees and to advocate for a holistic approach to treatment. A study completed by Couture et al. (2012) informed the mental health information that was added to the Eskenazi resources. Couture et al. (2012) studied how LE amputees coped with their new amputation and discovered that the most beneficial coping strategies used were social support, positive reappraisal, and problem solving. A few tips of encouragement included in the additions that were based on this study were finding people who can support and encourage, finding the specific problem and discovering solutions to solve it, and changing ones perspective by focusing on the positives of the situation (Couture et al., 2012; Desmond et al., 2002; Folkman et al., 2016; Mnger et al., 2020; Nielsen, 2020, Nowlan et al., 2015; Semel Institute for Neuroscience and Behavior UCLA, n.d.). See Appendix B for the mental health additions. To address the lack of transportation to outpatient medical appointments, a handout was developed to inform patients of their transportation options. An Eskenazai social worker provided the available transportation options for recent amputees after being discharged from the hospital. Since the options are specific to Eskenazi patients in Indianapolis (Eskenazi Health transportation service, Medicaid transportation, Uber/Lyft, or family/social support), the social worker informed the educational handout and not current literature (R. Smith, personal communication, January 25, 2022). Instructions were included on how to utilize each of these options (Kuadey, n.d.; Southeastrans, n.d.). See Appendix C for the transportation handout. Finally, the development of three UE educational handouts (transhumeral, transradial, and digital amputation) targeted the lack of inpatient resources for UE amputees with information specific to their amputation. These handouts benefit the inpatient rehabilitation 10 department and UE amputees treated at Eskenazi. See Appendix D for a table of contents for the UE educational handouts. A case study discussion was used to inform new therapy hires of the specific needs of amputees at Eskenazi, best practice for amputees, and the resources available for this population at Eskenazi. Topics in the discussion include amputees transportation options, mental health education for amputees, and advocacy for the role of OT in amputee rehabilitation. The case study guides new hires through discussion about the needs specific to amputees (e.g., prosthetics, wound healing, etc.) and overall care of amputees in evaluation, intervention, and discharge planning. See Appendix E for the case study slides included in the new hire amputee orientation. During the DCE, there were few amputees at Eskenazi, and because of this there was less patient data collected from amputee input. However, the needs assessment contained feedback from many healthcare professionals from different disciplines. The amount of input from staff and amputees helped to develop a broader, more comprehensive perspective of the needs and barriers of recent amputees at Eskenazi. Project Outcomes The initial and final outcome measures were specifically designed to meet the needs of Eskenazi. Because of this, no assessments existed that specifically addressed the four domains of the capstone project (education regarding transportation, UE amputations, OT education, and mental health). Since there were few amputees at Eskenazi during my DCE, my project focus was to increase therapists knowledge on how to access amputee resources and use them to address the common needs of amputees that were identified during the needs assessment. Both outcome measures included the same Likert scales that asked therapists to rate their knowledge regarding the role of OT in UE/LE amputee rehabilitation, addressing the mental health needs of 11 amputees, connecting amputees to resources for their basic needs (transportation), treating UE amputees (only OT respondents), and knowledge and ability to find resources for amputees. The final outcome measure was nearly identical to the initial outcome measure; however, it was slightly different due to the different purpose for its use. See Appendix F for the final outcome measure. The capstone educator emailed the initial outcome measure to the inpatient rehabilitation department during week four of the DCE to determine a baseline for the therapists knowledge in the four domains. The initial outcome measure received sixteen responses. I created a Voicethread presentation to educate the inpatient rehabilitation team of the needs of recent amputees at Eskenazi, the resources I created to address these needs, and how to access the amputee resources. Voicethread was used because it allowed the therapists to view a recording of me explaining each resource. My educator sent the Voicethread to the inpatient rehabilitation department during week eleven of the DCE. After giving the therapy department one week to review my created resources and Voicethread presentation, my educator sent the final outcome measure to the department during week twelve. The final outcome measure received nine responses and was used to identify whether therapists knowledge increased in the four domains. The central tendencies (mean and median) were calculated for the Likert scale responses on the initial and final outcome measure for all the survey participants. The difference in the mean and median between the initial and final outcome measure in each Likert scale was calculated. A positive difference in a domain indicated a successful project implementation and an increase in therapists knowledge in that particular domain. Additionally, therapists answered yes or no for whether they will use the project resources. 12 When viewing all the responses, there was an increase in the mean and median for the following domains: connecting amputees to resources for their basic needs (transportation) and addressing the mental health needs of amputees. The results are demonstrated in Table 1. Table 1 Outcome Measure Results Mean Median Connecting to Basic Need Resources +0.83 +1 Addressing Mental Health Needs +0.55 +1 One therapist reported very little knowledge on four out of the six domains on the final outcome measure. This therapist may have been confused with the Likert scale scoring system. Another explanation for reporting less knowledge on the final outcome measure is the education provided between the initial and final outcome measure enlightened the participants of the large amount of information included in these domain topics that they do not know. This may have resulted in therapists having a false confidence in their amputee knowledge on the initial outcome measure and reporting less knowledge on the final outcome measure. One hundred percent of the final survey participants reported they will use the resources developed in the project. This ensures therapists will provide these resources to amputees which will increase recent amputees knowledge of OT, mental health, and resources for their basic needs. Summary Since amputations are becoming more prevalent, there is a rising need for competent care for recent amputees. The project goal was to improve the quality of care for recent amputees at 13 Eskenazi Health. Since Eskenazi Health is a level one trauma center and serves the vulnerable population of Marion County, many of their patients have numerous barriers that decrease their quality of life. The most significant needs included transportation, mental health needs, knowledge of the role of OT in UE/LE amputee rehabilitation, and education for UE amputations. These domains were addressed through resource development for patients and therapist training. The results consisted of increased therapist knowledge of how to connect amputees to resources for their basic needs (transportation) and addressing the mental health needs of amputees. One hundred percent of the survey participants reported that they will use the educational materials created in this project. Conclusions The creation of these resources benefits patient outcomes and decreases the gap between inpatient and outpatient therapy services. This project connected therapists and recent amputees at Eskenazi with the necessary information to improve amputees overall quality of life. All the resources developed are accessible to therapists through the inpatient rehabilitation departments shared resource folder. The therapists also have access to a Voicethread presentation explaining the developed resources through a video recording presentation of each slide. The Voicethread allows therapists to access the presentation at any time. Therapists can quickly review the slides that interest them when they have an amputee that can benefit from the project. Additionally, new therapy hires will receive proper amputee education during their orientation through the use of the amputee case study discussion created in this project. 14 The project dissemination met the specific needs of the inpatient rehabilitation department. Therapists reported benefiting from the Voicethread because it allowed them to access the amputee education and explanation of amputee resources on their own time (C. Kittridge, personal communication, April 14, 2022). The case study discussion will be used starting in the summer of 2022 to educate new inpatient therapy hires during orientation (C. Kittridge, personal communication, April 14, 2022). Eskenazi Health Hospital will benefit from future advocacy for the OT profession in the outpatient setting. This project focused on inpatient advocacy for OT, but there still remains a need for education in the outpatient setting regarding how OT can benefit amputees in their recovery and improve their quality of life. There are many factors that influence amputee care. Inadequate education in one area diminishes not only the amputees mental health, but also physical functioning, occupational performance, and quality of life. The areas of care addressed in this project must be incorporated into amputee education and therapist training to ensure therapists are competent at addressing recent amputees needs. 15 References American Occupational Therapy Association. (2013). The role of occupational therapy in wound management. American Journal of Occupational Therapy, 67(6), S60-S68. https://doi.org/10.5014/ajot.2013.67S60 American Occupational Therapy Association. (2020). Occupational therapy practice framework: Domain and process - Fourth edition. American Journal of Occupational Therapy, 74(2), 1-87. https://doi.org/10.5014/ajot.2020.74S2001 Amputee Coalition. (2019, March). Indiana. https://www.amputee-coalition.org/ resources/indiana-2/ Bani Saberi, O. (2004). Dealing with grief and depression. Amputee coalition. https://www.amputee-coalition.org/resources/dealing-with-grief-and-depression/ Barnes, J. A., Eid, M. A., Creager, M. A., & Goodney, P. P. (2020). Epidemiology and risk of amputation in patients with diabetes mellitus and peripheral artery disease. Arteriosclerosis, Thrombosis, and Vascular Biology, 40(8), 1808-1817. https://doi.org/10.1161/ATVBAHA.120.314595 Burke Rehabilitation Hospital. (2019). What to expect from occupational therapy after an amputation.https://www.burke.org/media/news/2019/04/what-to-expect-from-occupation al-therapy-after-an/631 Couture, M., Desrosiers, J., & Caron, C. D. (2012). Coping with a lower limb amputation due to vascular disease in the hospital, rehabilitation, and home setting. ISRN Rehabilitation, 19. https://doi.org/10.5402/2012/179878 Desmond, D., & MacLachlan, M. (2002). Psychosocial issues in the field of prosthetics and orthotics. JPO: Journal of Prosthetics and Orthotics, 14(1), 19-22. 16 Eskenazi Health. (n.d.). About. https://www.eskenazihealth.edu/about Esquenazi, A., & Yoo, S.K. (2012). Lower limb amputations-Epidemiology and assessment. PM&R knowledge now. https://now.aapmr.org/lower-limb-amputations-epidemiology-and-assessment/ Folkman, S., & Lazarus, R. S. (2016). Ways of coping. University of California, San Francisco Prevention Science Department of Medicine. https://prevention.ucsf.edu/sites/prevention.ucsf.edu/files/uploads/tools/surveys/pdf/Ways %20of%20coping.pdf Howard, B. (2020a). Biomechanical and rehabilitative frames of reference [PowerPoint slides]. Howard, B. (2020b). CMOP and morning routine [PowerPoint slides]. Kuadey, K. (n.d.). Medicaid transportation services (state-by-state guide). Food Stamps EBT. https://foodstampsebt.com/medicaid-transportation/ Mnger, M., Pinto, C. B., Pacheco, B. K., Duarte, D., Enes Gunduz, M., Simis, M., Battistella, L. R., & Fregni, F. (2020). Protective and risk factors for phantom limb pain and residual limb pain severity. Pain Practice, 20(6), 578587. https://doi.org/10.1111/papr.12881 Nielsen, K. S. (2020). People with more self-control are less stressed out. Society for personality and social psychology. https://www.spsp.org/news-center/blog/steensen-nielsenself-control-stress Nowlan, J. S., Wuthrich, V. M., & Rapee, R. M. (2015). Positive reappraisal in older adults: A systematic literature review. Aging & Mental Health, 19(6), 475-484. doi: 10.1080/13607863.2014.954528 17 Semel Institute for Neuroscience and Behavior UCLA. (n.d.). How do you cope? https://www.semel.ucla.edu/dual-diagnosis-program/News_and_Resources/How_Do_Yo u_Cope Smurr, L. M., Yankcosek, K., Gulick, K., Ganz, O., Kulla, S., Jones, M., Ebner, C., & Esquenazi, A. (2009). Care of the combat amputee. Office of The Surgeon GeneralDepartment of the Army, United States of America and US Army Medical Department Center and School Fort Sam Houston, Texas. https://ckapfwstor001.blob.core.usgovcloudapi.net/pfw-images /borden/amputee/CCAchapter18.pdf Southeastrans. (n.d.). Indiana facilities: Indiana non-emergency medical transportation. https://www.southeastrans.com/indiana-facilities/#:~:text=NEMT%20is%20a%20service %20that,no%20other%20means%20of%20transportation. Ziegler-Graham, K., MacKenzie, E. J., Ephraim, P. L., & Travison, T. G. (2008). Estimating the prevalence of limb loss in the united states: 2005 to 2050. Archives of Physical Medicine and Rehabilitation, 89(3), 422-429. https://doi.org/10.1016/j.apmr.2007.11.005 18 Appendix A Doctoral Capstone Experience Weekly Planning Guide Week DCE Cycle Weekly Goal Objectives 1 1) Orientation 2) Needs Assessment 1) Complete orientation 2) Stakeholder interviews 1) Complete all required documents 2) Prepare interview questions 2 1) Needs Assessment 2) Outcome measure 3) Submit MOU 4) Transportation 1) Stakeholder interviews 2) Understand how to create outcome measure 2) Create outcome measure 3) Educator feedback 4) Learn transportation options 1) Identify amputee needs 1) Identify ideas for project 1) Identify Eskenazi resources 2) Establish goals and indicators 3) Update MOU from feedback 4) Meet with SW 3 1) Needs Assessment 2) Outcome measure 1) Stakeholder interviews 2) Meet with mentor/educators 1) Identify amputee needs 2) Receive feedback 4 1) Project Direction 2) Outcome measure 1) Create a list of my goals/objectives 1) Meet with mentor/educator 1) Make updates from feedback 1) Create a final list of goals and objectives 2) Meet with mentor/educators 2) Make updates from feedback 2) Send to IP rehab 1) Review the needs assessment 1) Receive feedback 1) Identify 3 resources to create 2) Receive feedback 5 1) OT Role 1) Understand role of OT 1) Create additions to IP handouts 1) Identify 3 research articles 6 1) OT Role 2) Transportation 3) Mental Health 1) Meet with educators 1) Updates from feedback 2) Create handout 2) Meet with educators 1) Receive feedback 2) Explore Uber, Eskenazi transport options, Medicaid cabs 2) Receive feedback 19 2) Updates from feedback 3) Coping strategies 3) Mental health additions 3) Meet with educators 3) Update from feedback 3) Discover 5 research articles about coping strategies 3) Identify 3 effective coping strategies 3) Receive feedback 7 1) UE Amputation Rehab 1) Understand UE amputations 1) Create UE handouts 1) Discover 5 research articles 8 1) UE Amputation Rehab Handout 1) Finalize handout 1) Meet with educators 1) Updates from feedback 1) Receive feedback 9 1) Dissemination plan 1) Create dissemination plan 1) Speak with educators 10 1) Dissemination plan 1) Create Voicethread 1) Publish Voicethread 11 1) Dissemination plan 2) OT Addition 3) Transportation Handout 4) Mental Health Addition 5) UE Amputation Handouts 1) Educator feedback about VT 1) Updates to VT from feedback 1) Send VT via email 2-5) Send to IP rehab 1-5) Provide resources to educators 12 1) Outcome measure 1) Create outcome measure 1) Meet with educators 1) Updates from feedback 1) Send to IP rehab 1) Goals/indicators of final outcome measure 1) Identify how to quantify success of project 1) Receive feedback 13 1) Outcome measure 1) Collect and assess data 1) Create a document to organize data received 1) Measure success of project 14 DCE Scholarly Report 20 Appendix B Mental Health Addition 21 Appendix C Transportation Handout 22 23 Appendix D Table of Contents for Upper Extremity Educational Handouts 24 Appendix E New Hire Amputee Orientation Case Study 25 26 27 28 Appendix F Final Outcome Measure 1 What is your position in the rehabilitation department? Multiple Choice: occupational therapist, physical therapist, occupational therapy assistant, physical therapy assistant, speech therapist, rehab tech, other 2 Rate your level of knowledge of Eskenazi Health resources for recent amputees and your ability to find these resources. Linear Scale: 1 [very little] to 5 [expert] 3 Rate your level of knowledge connecting recent amputees with resources for their basic needs (transportation to outpatient appointments, food, clothing, shelter, etc.). Linear Scale: 1 [very little] to 5 [expert] 4 Rate your level of knowledge regarding the role of occupational therapy in the rehabilitation process for recent upper and lower limb amputees Linear Scale: 1 [very little] to 5 [expert] 5 Rate your level of knowledge regarding the role of physical therapy in the rehabilitation process for recent lower limb amputees. Linear Scale: 1 [very little] to 5 [expert] 6 Rate your level of knowledge addressing the mental health needs (grief, depression, etc.) of recent amputees. Linear Scale: 1 [very little] to 5 [expert] 7 FOR OT ONLY: Rate your confidence treating upper extremity (transhumeral, transradial, or digital amputation) amputees. Linear Scale: 1 [very little] to 5 [expert] 8 Do you think you will use Travis Rippe's resources for patient education in the future? Multiple Choice: yes, no 9 How do you think Eskenazi Health can continue to improve its care of recent amputees? Short Answer - not required  ...

... 1 Swaddle Bathing in the NICU Madeleine Parrish April 29, 2022 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, OTR, OTD SWADDLE BATHING IN THE NICU 2 A Capstone Project Entitled Swaddle Bathing in the NICU Submitted to the School of Occupational Therapy at University of Indianapolis in partial fulfillment for the requirements of the Doctor of Occupational Therapy degree. By Madeleine Parrish, OTS Doctor of Occupational Therapy Student Approved by: Faculty Capstone Advisor Date Doctoral Capstone Coordinator Date Accepted on this date by the Chair of the School of Occupational Therapy: Chair, School of Occupational Therapy Date SWADDLE BATHING IN THE NICU 3 Abstract This study examined how swaddle bathing impacts stress and maintaining temperatures compared to traditional tub and sponge bathing in the NICU. Education on the benefits and how to swaddle bathe was provided to the nursing staff, and surveys were distributed before and after education for nurses to compare bath tolerance, stress, and body temperature. Survey results were analyzed, and findings suggest that swaddle bathing was beneficial in increasing tolerance and decreasing stress cues during and after the bath, which is supported by current evidence. Providing the staff with baths made to facilitate swaddle bathing and further education on how to properly swaddle bathe is suggested to improve bathing in the NICU. Limitations of this study included having an informal education, decreased survey participation post-education, and having limited bathing products supporting swaddle bathing. SWADDLE BATHING IN THE NICU 4 Introduction This doctoral capstone took place in a level 3 neonatal intensive care unit (NICU) at Franciscan Health Indianapolis with the aim to decrease stress within this population. The criteria for NICU admission include prematurity, early term birth, low birth weight, heart complications, infections, respiratory problems, birth defects, and infants of diabetic mothers (Franciscan Health, 2021). Bathing is a problematic occupation within the NICU due to the increased risk of hypothermia for the infant population (Fernandez & Antolin-Rodriguez, 2018). Bathing can also cause physiological responses of stress in infants that may have long-term negative impacts on body regulation (Bembich et al., 2017). Based on the inclusion criteria for Franciscan Health's NICU, this specific population has high-risk factors for stress and hypothermia and would benefit from swaddle-bathing guidelines to decrease negative long-term impacts (Bembich et al., 2017). Franciscan Healths NICU provided the opportunity for learning advanced clinical skills such as neuroprotective intervention and policy development through interdisciplinary education for the team working at the NICU, which included neonatologists, nurses, respiratory therapists, occupational therapists, and physical therapists with advanced training specific to the NICU (Franciscan Health, 2021). Education for all involved parties is imperative to ensure consistent, evidence-based guidelines for occupations, including bathing, in the NICU (Santos et al., 2020). For this capstone, I utilized an interdisciplinary educator role for the medical team to introduce a developmentally appropriate, sensory-based bathing guideline as standard practice to decrease stress levels, which has negative impacts on growth in this population (Bembich et al., 2017). SWADDLE BATHING IN THE NICU 5 Background In a quasi-experimental study that has since been replicated many times, Peters (1998) found that bathing is a stressful occupation for infants in the NICU, especially due to this populations medical complications. Additionally, these infants are often not developmentally ready for an environment outside of the womb. The NICU is a stressful environment for infants due to sensory overload resulting from loud machines and other crying infants (Pineda et al., 2017). Stressful environments can negatively impact infant development, making it imperative that measures are taken to decrease as many stress factors as possible and provide as positive a sensory environment as possible (Pineda et al., 2017). These stress factors include auditory, visual, and tactile sensory overload, which cause physiological stress (Fernandez & AntolinRodriguez, 2018). Since bathing is an especially stressful occupation for newborns, this is an important area to modify as needed to make this occupation a positive and developmentally appropriate experience (McKim, 2020). Researchers discovered that tub bathing without swaddling can reduce moderate to mild pain for full-term newborns when compared to not bathing based on pain behaviors, oxygen saturation levels, and vital signs (Gunay & Coskun, 2018). This studys findings show that bathing can be a positive experience for infants (Gunay & Coskun, 2018). However, full term infants' sensory and motor systems are better developed and integrated than premature infants and infants in the NICU, making tub bathing without swaddling developmentally inappropriate method for the NICU population (Peters, 1998). Additionally, while tub bathing can reduce pain in newborns, researchers found that swaddle bathing newborns is a safer way to bathe in terms of preventing hypothermia and decreasing stress (Caka & Gozen, 2018). Therefore, swaddle bathing has clear advantages over tub bathing, even in fully developed infants (Caka & Gozen, SWADDLE BATHING IN THE NICU 6 2018). Overall, the literature has found overwhelming evidence that swaddled bathing decreases pain and stress in premature infants when compared to sponge bathing and other various types of traditional bathing of infants (Fernandez & Antolin-Rodriguez, 2018). In these studies, stress in infants while bathing was measured through the frequency of behavioral responses, such as grimacing, yawing, tongue extension, and fussing or crying (Paran et al., 2016). Researchers also used physiological measures, such as respiratory rates, heart rates, and oxygen saturation levels (Ceylan & Bolsk, 2018). Many researchers measured pain using scales such as the Newborn Infant Pain Scale (Caka & Gozen, 2018). In programs that replaced traditional bathing with swaddled bathing for premature infants, the infants showed decreased respiratory and heart rates, increased oxygen saturation levels, and decreased stress scores (Ceylan & Bolsk, 2018). Using the Newborn Infant Pain Scale, researchers found that swaddle bathing correlated with significantly lower pain levels (Caka & Gozen, 2018). Researchers also found that swaddled bathing helps maintain body temperature, which is important as infants lose heat and can reach unsafe levels of hypothermia during bathing (Quraishy et al., 2012). The model guiding my capstone project was the Person-Environment-OccupationPerformance (PEOP) model. This model views occupational performance as an outcome of transactions between the person, occupation, and environment (Cole & Tufano, 2008). This viewpoint is important for this project in the NICU because it concentrates on how an infant interacts with his or her environment in the NICU while bathing. Infants in the NICU are often underdeveloped, resulting in poor thermoregulation and sensory disintegration, which can negatively impact the bathing occupation (Fernandez & Antolin-Rodriguez, 2018). Additionally, the NICU environment can overload an infant's senses (Fernandez & Antolin-Rodriguez, 2018). SWADDLE BATHING IN THE NICU 7 When an infant and environment interact while bathing in the NICU, this population is more likely to exhibit signs of hypothermia, sensory overload, pain, and stress (Fernandez & AntolinRodriguez, 2018). These findings suggest that there is an incongruency within this transaction. By using the PEOP model, I identified ways to improve this transaction in the development of the capstone and make bathing a more comfortable and developmentally appropriate occupation for this population. When assessing the efficacy of this protocol, I used the PEOP model to ensure that all domains, such as the person, environment, and occupation, are modified to fit the NICU population's unique needs. If discrepancies became evident within this transaction, it was important that my project adapted to remain client centered. The frame of reference that guided my capstone project was Sensory Integration. According to this frame of reference, disability includes sensory integrative dysfunction (Cole & Tufano, 2008). Sensory disintegration is more common in this population due to the sensory and motor systems not fully developed yet (Gunay & Coskun, 2018). Therefore, it was imperative that my capstone utilized creative methods to aid in sensory integration while bathing and preventing as much pain and stress in the infants as possible. The Sensory Integration frame of reference helped guide the project towards developmentally appropriate methods of bathing in the NICU to enhance sensory integration and create a more relaxing bathing environment. Quraishy et al. (2012) created a specific protocol that was used as an excellent example for my capstone project, which included step-by-step instructions for safe, less stressful swaddle bathing. It uses a sensory-based approach to decrease stressors and increase positive sensory experiences, which fits into the Sensory Integration frame of reference very well (Quraishy et al., 2012). Overall, my goal was to utilize the PEOP model and Sensory Integration frame of reference to guide the creation of a developmentally appropriate bathing protocol for infants in SWADDLE BATHING IN THE NICU 8 the NICU, as well as educate the NICU interdisciplinary medical team to ensure a holistic approach for supporting development in this population. Occupational therapy is beneficial in the NICU because it provides a holistic approach and examines the biological, developmental, and social-emotional factors of this population (Vergara et al., 2006). Occupational therapists have advanced skills in interdisciplinary education and providing complex interventions to infants in the NICU using an occupational-based approach as opposed to a medical model approach (Vergara et al., 2006). These skills are beneficial to promoting developmentally appropriate care in the NICU for all occupations. While NICU nurses have the most interaction with their patients and families, they are often overworked with medical aspects of care and do not have the time, energy, or resources to create an evidence-based bathing protocol (Santos et al., 2020). Therefore, providing the NICU staff with education on developmentally appropriate, evidence-based bathing guidelines for infants in the NICU is well within the scope of practice and advanced knowledge and skills of occupational therapists within this setting (Vergara et al., 2006). My capstone goal was to provide education on swaddle bathing to the NICU staff and introduce evidence-based, developmentally appropriate guidelines for bathing infants at Franciscan Health's NICU to improve patient care. Project Design and Implementation This project was designed to measure how swaddle bathing can impact infants bathing experiences compared to traditional tub or sponge bathing. Bathing is a stressful occupation for infants in the NICU, which may cause long-term negative impacts on body regulation (Bembich et al., 2017). This population is also at a higher risk of hypothermia during bathing (Fernandez & Antolin-Rodriguez, 2018). Current evidence supports the utilization of swaddle bathing in the NICU to decrease stress and the risk of hypothermia (Fernandez & Antolin-Rodriguez, 2018). To SWADDLE BATHING IN THE NICU 9 measure how swaddle bathing can impact bathing in the NICU, nurses were provided a survey to fill out for 2 weeks (see Appendix A). This survey showed the types of baths given, stress responses, and body temperature differences before and after bathing. Following the survey, a poster was presented in the NICU to educate staff on how bathing impacts the infants, what swaddle bathing is, and how swaddle bathing can be utilized in the NICU to improve the bathing occupation for the population (see Appendix B). After 1.5 weeks of allowing the NICU staff to learn about swaddle bathing and the evidence supporting its benefits, the same survey was redistributed for 2 weeks to continue data collection and determine if education caused any changes in the type of bathing used. To assess the differences in infant response to different types of baths, the researcher determined percentage of types of bathing used, the number of stress signs observed in bathing, and the amount of heat loss in each bathing type. This information was collected to help determine the efficacy of education and any differences of heat loss and stress cues in infants during different types of baths. Project Outcomes To determine differences between swaddle, sponge, and traditional tub bathing of infants in the NICU, survey responses were analyzed to understand the bathing experiences. These surveys were distributed for 2 weeks prior to providing education and 2 weeks after education to record any differences in temperature loss during bathing and the amount of stress signs demonstrated during and after the bath. Out of 43 baths recorded by nursing staff, 13 were swaddle baths, 8 were tub baths, 19 were sponge baths, and 3 were not specified and therefore not included in further analysis (see Figure 1). There were no significant differences before and after education, so all data was consolidated for these findings. Figure 1. Bath Types Used in NICU SWADDLE BATHING IN THE NICU 10 Bath Type Swaddle Tub Sponge Not Specified Data from the surveys submitted show that infants demonstrated better tolerance of baths with swaddle bathing (see Figure 2). Options included poor, acceptable, good, and great overall tolerance of bath, with 46.15% of swaddle baths perceived as great, 38.46 good, and 15.38% acceptable. Traditional tub bath tolerance had 12.5% great, 62.5% good, with no great tolerances, and 25% acceptable. Sponge bathing was the most common bath type, with 20% great, 46.67% good, and 33.33% acceptable tolerance. Figure 2. Tolerance of Different Bath Types Swaddle Bath Tolerance Great Good Acceptable Tub Bath Tolerance Great Good Acceptable Sponge Bath Tolerance Great Good Acceptable SWADDLE BATHING IN THE NICU 11 Overall, stress signs were noted most often with sponge bathing. To compare stress signs, the average number of stress signs for each bath type was calculated (See Figure 3). Findings showed an average of 2.11 stress cues during bathing and 0.17 post-bath. Tub bathing had an average of 1.63 stress cues during bathing and 1.13 post-bath. Swaddle bathing had the least stress signs, with an average of 0.69 during bath and 0.08 post-bath. Figure 3. Observed Stress Signs During and After Bathing Stress Signs During and After Bathing Overall Stress Signs During Bathing Occupation 2.5 3 2 2.5 2 1.5 1.5 1 1 0.5 0 0.5 Swaddle Tub Sponge 0 Swaddle Tub Sponge Average # of Bath Stress Signs Average # of Post-Bath Stress Signs Average # of Post-Bath Stress Signs Average # of Bath Stress Signs On each survey, nurses recorded the infants temperature before and after the bath. There was not significant heat loss with any type of bath. However, Figure 4 shows that swaddle bathed infants lost the most heat out of the bath types with an average of -0.32 degrees Fahrenheit. Comparatively, sponge bathed infants lost an average of -0.23 degrees Fahrenheit, and tub bathed infants gained an average of 0.01 degrees. SWADDLE BATHING IN THE NICU 12 Figure 4. Average Temperature Changes After Bathing Average Temp Change (Fahrenheit) 0.1 0 Swaddle Tub Sponge -0.1 -0.2 -0.3 -0.4 Summary The stress sign findings of this project were in line with current research. Capstone data showed that swaddle bathing elicited the fewest stress signs both during and post-bath when compared to tub and sponge baths (Figure 3). In a systemic review, Fernandez and AntolinRodriguez (2018) found significant evidence that swaddle bathing helps decrease stress in premature infants, which is supported by the survey results of this project. After swaddle bathing during this project, many nurses and parents also reported increased relaxation. One large difference in this project compared to current research was temperature changes in bathing. Evidence suggests that swaddle bathing decreases heat loss due to providing additional insulation (Quraishy et al., 2012). However, the nurses in the NICU reported more heat loss with swaddle bathing, losing an average of 0.32 degrees Fahrenheit with swaddle bathing. While this heat loss was not significant compared to sponge or tub bathing and did not reach levels close to hypothermia, it may suggest that swaddle bathing was not provided correctly for many infants. One limitation of this study was that the education was informal. Education was provided to the nursing staff halfway through the capstone experience focusing on the benefits of swaddle SWADDLE BATHING IN THE NICU 13 bathing and providing instructions and a QR code for a video example of swaddle bathing in the NICUs break room. Since education was informal and staff had the option to partake or not, swaddle baths may have been given improperly. A mandatory, comprehensive education on swaddle bathing in the future would be beneficial in improving bathing experiences in patients and providing neuroprotection. Another limitation was the baths available at the hospital. The education included instructions for using the Dandy Tub, which is a tub specifically made to facilitate swaddle bathing. The Dandy Tubs made swaddle bathing more practical in the NICU, but the hospital had only three Dandy Tubs. Therefore, only three patients were able to use the Dandy Tubs, and most swaddle baths that occurred were not in baths made for swaddle baths, making the process more difficult for nurses. Based on this, I suggest the hospital invests in more developmentally appropriate bath products to ensure developmentally appropriate care of their patients. Despite these limitations, nurses that took part in the surveys shared positive perceptions of swaddle bathing, with feedback suggesting infants were more relaxed and had increased tolerances of swaddle baths compared to traditional tub baths and sponge baths. Overall, the project supported evidence that swaddle bathing decreases stress, which can have negative impacts on infant brain development (Bembich et al., 2017). Conclusion During this capstone experience, I learned about the importance of providing and advocating for neuroprotection in all occupations for patients in the NICU. I learned about the Synactive Theory of Development, which shows the need to support neurodevelopment to allow the infant to learn to self-regulate arousal and behavioral levels (VandenBerg, 2007). By providing baths that decrease stress, infant brains can create synaptic connections to associate SWADDLE BATHING IN THE NICU 14 touch with positive experiences, as opposed to the pain and discomfort generally associated with touch during routine care and necessary medical procedures. This can help decrease disability and neurodevelopmental problems often seen in NICU grads (VandenBerg, 2007). Through this project at Franciscan Health Indianapolis NICU, the staff learned valuable methods to provide neuroprotection during the bi-weekly occupation of bathing. By utilizing swaddle bathing as evidence-based practice, the brain development of patients in the NICU will be better supported for improved long-term outcomes (Bembich et al., 2017). Research suggests that providing developmentally appropriate care for preterm infants and infants with complex medical needs may decrease the risk of sensory disorders or neurodevelopment disorders seen later in life (VandenBerg, 2007). After these findings were disseminated, Franciscan Indianapolis began comparing different swaddle bathing products to standardize bathing in their NICU in order provide their patients with best practice. This capstone provided Franciscan Health with evidence and suggestions on how to improve patient care within the NICU. SWADDLE BATHING IN THE NICU 15 References Bembich, S., Fiani, G., Strajn, T., Sanesi, C., Demarini, S., & Sanson, G. (2017). Longitudinal responses to weighing and bathing procedures in preterm infants. Journal of Perinatal & Neonatal Nursing, 31(1), 67-74. doi: 10.1097/JPN.0000000000000228 Caka, S. Y. & Gozen, D. (2018). Effects of swaddled and traditional tub bathing methods on crying and physiological responses of newborns. Journal for Specialists in Pediatric Nursing, 23(1), 1-9. doi: 10.1111/jspn.12202 Ceylan, S. S. & Bolsk, B. (2018). Effects of swaddled and sponge bathing methods on signs of stress and pain in premature newborns: Implications for evidence-based practice. Worldviews of Evidence-Based Nursing, 15(4), 296-303. doi: 10.1111/wvn.12299 Cole, M. & Tufano, R. (2008). Applied theories in occupational therapy: A practical approach. SLACK Incorporated. Fernandez, D. & Antolin-Rodriguez, R. (2018). Bathing a premature infant in the intensive care unit: A systemic review. Journal of Pediatric Nursing, 42, 52-57. doi: 10.1016/j.pedn.2018.05.002 Franciscan Health. (2021). Neonatal intensive care (NICU). https://www.franciscanhealth.org/conditions-and-services/obstetrics-and-gynecologyobgyn/pregnancy-delivery/neonatal-intensive-care-nicu Gunay, U. & Coskun, D. (2018). The effect of tub bathing on the newborns pain: A randomized clinical trial. International Journal of Caring Sciences, 11(2), 1132-1140. MacDowell, C. (2021). The effect of a swaddle bathing policy in the NICU on the prevention of hypothermia and stress in the premature neonate [Unpublished manuscript]. College of Nursing, Creighton University. SWADDLE BATHING IN THE NICU 16 McKim, M. (2020). Swaddle bathing in the NICU. Journal of Obstetric, Gynecologic, & Neonatal Nursing, 49, 71-81. doi: 10.1016/j.jogn.2020.09.123 Paran M., Edraki, M., Montaseri, S., & Razavi Nejad, M. (2016). Comparing the effects of swaddle and conventional bathing methods on behavioral responses in preterm neonates. Iranian Journal of Neonatology, 7(4). doi: 10.22038/ijn.2016.7778 Peters, K. L. (1998). Bathing premature infants: Physiological and behavioral consequences. American Journal of Critical Care, 7(2), 90-100. Pineda, R., Durant, P., Mathur, A., Inder, T., Wallendorf, M., & Schlaggar, B. (2017). Auditory exposure in the neonatal intensive care unit: Room type and other predictors. The Journal of Pediatrics, 183, 56-66. doi: 10.1016/j.jpeds.2016.12.072 Quraishy, K., Bowles, S., & Moore, J. (2012). A protocol for swaddled bathing in the neonatal intensive care unit. Newborn & Infant Nursing Reviews, 1-3. Santos, H. M., Silva L. J., Goes, F. G. B., Santos, A. C. N., Araujo B. B. M., & Santos, I. M. M. (2020). Swaddle bathing in premature babies in a neonatal unit: The practice from the perspective of nurses. Rev Rene, 21(1), 1-9. doi: 10.15253/2175-6783.20202142454 VandenBerg, K. (2007). Individualized developmental care for high risk newborns in the NICU: A practice guideline. Early Human Development, 83(7), 433-442. doi: 10.1016/j.earlhumdev.2007.03.008 Vergara, E., Anzalone, M., Bigsby, R., & Gorga, D. (2006). Specialized knowledge and skills for occupational therapy practice in the neonatal intensive care unit. American Journal of Occupational Therapy, 60(6), 659-668. doi: 10.5014/ajot.60.6.659 SWADDLE BATHING IN THE NICU 17 Appendix A Bathing Survey Note. Adapted from The Effect of a Swaddle Bathing Policy in the NICU on the Prevention of Hypothermia and Stress in the Premature Neonate by C. MacDowell, 2021. College of Nursing, Creighton University. SWADDLE BATHING IN THE NICU 18 Appendix B Swaddle Bathing Education Resources SWADDLE BATHING IN THE NICU 19 SWADDLE BATHING IN THE NICU 20 Appendix C Project Timeline Week DCE Stage 1 Weekly Goal Objectives Tasks 1)Complete orientation by Screening/Evaluation end of week -Complete site orientation -Complete Learning Compass modules Orientation 2)Begin needs -Update assessment by MOU with end of week site mentor -Observe clinical work in the NICU Date Completed 1/14/22 -Finalize MOU -Begin lit review for any new research regarding swaddle bathing -Review site guideline examples and current bathing guidelines and equipment used 2 3 Screening/Evaluation 2)Complete literature search for gestational age bathing and sensory needs by end of week -Complete research Screening/Evaluation 1)Complete bathing literature search by end of week -Determine guideline requirements in swaddle bathing -Distribute surveys 1/21/22 -Meet with Taylor -List specific guideline requirements needed -Write intro 1/28/22 SWADDLE BATHING IN THE NICU 21 -Begin distributing surveys 4 Screening/Evaluation 1)Complete rough draft of bathing guidelines by end of week -Contact -Write manufacturers background for bathing draft products 2/4/22 -Continue distributing surveys -Background draft due 2/4 5 6 7 8 Screening/Evaluation 1)Complete final draft of bathing guidelines by end of week -Send final draft to site and faculty mentors Screening/Evaluation 2)Begin creating swaddle bathing education presentation by end of week Implementation 1)Create final swaddle bathing presentation for staff education by end of week Implementation -AOTA conference 3/31-4/2 1)Present education & increase -Write project design draft 2/11/22 -Send final draft to site and faculty mentors -Create education presentation 2/18/22 -Revise presentation as needed -Work with site 2/25/22 mentor throughout implementation process -Continue surveys -Send presentation to mentors -Place education in NICU and 3/4/22 SWADDLE BATHING IN THE NICU 22 awareness of poster/ppt 9 Implementation 10 Implementation 11 Implementation 12 Implementation 13 Discontinuation 14 Dissemination 1)Utilize swaddle bathing protocol at least once by end of week 1)Complete swaddle bathing education with nursing staff by end of week 1)Distribute posteducation surveys advocate to staff -Email Stephanie Lee PowerPoint if appropriate for Learning Compass -Finalize methods section with Taylor 3/11/22 Post-surveys -Write outcome draft 3/18/22 Post-surveys -Write dissemination plan 3/25/22 Final week of post-surveys 4/1/22 1)Analyze survey results by end of week -Determine any differences of stress cues/temps in bathing types -Create site presentation of findings 1)Disseminate survey findings to site by end of week -Abstract, Summary, Conclusion draft due 4/15 -Write abstract, 4/15/22 summary, and conclusion draft -Final site mentor evaluation 4/8/22 -Finalize outcomes section  ...

... Integrating Rehab Principles for the Geriatric Population in the Acute Care Setting Haylee Ottinger May 7, 2022 A capstone project submitted in partial fulfillment for the requirements of the Doctor of Occupational Therapy degree from the University of Indianapolis, School of Occupational Therapy. Under the direction of the faculty capstone advisor: Alison Nichols, OTR, OTD 2 Abstract Hospitalization is a significant event that frequently leads to disability for the geriatric population. Eskenazi Health has indicated that their therapists are not equipped with the means to fully treat this population to the best of their ability. The purpose of this capstone project was to identify and define opportunities within the therapeutic process in which inpatient therapists at Eskenazi Health could improve quality of care for this population. Therapists confidence in addressing the many needs of this population was measured before and after an education and training session on resources created to improve therapy services for geriatric patients. Results indicated improved confidence in all steps of the therapeutic process for the inpatient therapy team. Acute care therapists may benefit from the results of this project through continued education and understanding of the risk factors of debility and implications of care for the geriatric population. 3 Integrating Rehab Principles for the Geriatric Population in the Acute Care Setting Eskenazi Hospital has a long-standing history as the Marion County Hospital, dating back to the 1800s. As the first Level I Trauma Center and burn center in the state of Indiana, Eskenazi continues to be a leading provider of healthcare services for not only Marion County residents but all of Indiana. As one of Americas largest essential health care systems, Eskenazi Health provides treatment and services through more than one million outpatient visits each year (Eskenazi Health, n.d.-a). For more than 160 years, Eskenazi Health has served the residents of Marion County and Central Indiana with the goal of offering high-quality, cost-effective, and patient-focused health care. Currently, Eskenazi Health continues to treat patients with the mission to advocate, care, teach, and serve with special emphasis on the vulnerable populations of Marion County and the vision to continuously strive to enhance the ability to meet the needs of the underserved and all people of Marion County, will be sound economically and will lead innovatively in clinical care, research, education and service excellence (Eskenazi Health, n.d.-b). Eskenazi Health is home to more than 50 physical, occupational, and speech therapists who work in a variety of settings including outpatient, inpatient, neonatal intensive care unit, mental health, burn, wound, and emergency department areas. These therapists are highly skilled and work with a variety of patients from Marion County and surrounding areas. Specifically, therapists that are working in the inpatient setting are treating patients with acute illnesses or injuries who are no longer able to perform their daily tasks at their previous level of function (University of St. Augustine for Health Sciences, 2020). There are substantial risks connected to hospital-associated disability for the geriatric population (Boyd et al., 2008; Kosse et al., 2013; McCusker et al., 2002). Because Eskenazi Health is a Level I Trauma Center, there are many demanding needs of the therapists on the 4 inpatient team including large caseloads with a variety of patients, such as those with complex cases that may take priority over most geriatric patients at risk of further debility. Because of this, there is a significant need for support for this population of patients at Eskenazi Health. This led to the primary aim of this capstone project being to provide support for the team members of the inpatient physical and occupational therapy teams by acting as a resource to assist in better achieving the Eskenazi mission for this vulnerable population. To do this, resources were created that cover a variety of topics that have been identified in recent literature as areas of functional and occupational deficits for individuals 65 years of age and older. The purpose of this paper is to outline the details of the project, including the guiding theories and frame of reference, project design and implementation, and project outcomes. Background Literature has shown that older adults are at severe risk of functional loss during hospitalization (Boyd et al., 2008; Kosse et al., 2013; McCusker et al., 2002). As cited in Covinsky et al. (2011), acute medical illness that requires hospitalization is a critical event that often leads to disability for older adults. This hospital-associated disability occurs in approximately one-third of patients older than 70 years of age and can occur even when the illness that necessitated the hospitalization is successfully treated (Covinsky et al., 2003; Covinsky et al., 2011; Kosse et al., 2013). For example, Covinsky et al. (2003) found that 35% of patients aged 70 and older presented with declines in activities of daily living (ADL) function while hospitalized between baseline and admission with 23% of those patients failing to ever recover to baseline function between admission and discharge. For the patients who do not experience decline between baseline and admission, 12% show functional decline between admission and discharge. Another study found that 52.2% of all older adults presented worse 5 functional capacity at discharge than at baseline (Menezes et al., 2021). Many of these older adults, aged 65 or older, are discharged with new or additional disability, specifically causing difficulties performing ADL which puts them at greater risk for poor prognosis for functional recovery (Boyd et al., 2008; Covinsky et al., 2003; Menezes et al., 2021). The results of hospital-associated disability results in the subsequent inability to live independently and complete basic ADL (Covinsky et al., 2011). Both disability and functional decline are associated with increased risk of mortality, institutionalization, and service utilization resulting in higher societal costs. Because of this, the predictors of functional decline are of interest not only to clinicians, but to the patients and their family members, healthcare administrators, and health policy makers (McCusker et al., 2002). The most frequent predictors of functional decline in community-dwelling older adults are changes in cognition, affect, comorbidities, health behaviors, and other specific impairments (McCusker et al., 2002). Dependency for ADL, symptoms of depression, low levels of cognition, and in-hospital mobility have also been identified as risk factors for greater loss in functional capacity during hospitalization (Menezes et al., 2021). Increased age is another factor that puts these patients at a particularly high risk of poor functional outcomes because they are less likely to recover ADL function lost before admission and more likely to develop new functional deficits during hospitalization (Covinsky et al., 2003). Because of this, functional, cognitive, and emotional status, as well as in-hospital mobility must be carefully assessed at hospital admission and monitored during hospitalization. Menezes et al. (2021) calls for improved effective strategies for preventing loss in functional capacity in older adults. Due to the substantial risks connected to hospital-associated disability for the geriatric population, there is a significant need for support for this population of patients at Eskenazi 6 Health. Through the needs assessment and discussion with members of the inpatient therapy team at the capstone site, it has become apparent that there are many demanding needs of the therapists on the inpatient team. One of these challenges includes large caseloads with a variety of patients, such as those with complex cases that may take priority over most geriatric patients at risk of further debility. The inpatient therapy teams geriatric committee identified problems with: the amount of therapy time that is being dedicated to the geriatric patients, the ability to justify treatment sessions focused on maintaining prior level of function, creating effective and cost-efficient interventions, and lack of education and resources directed towards creating success for geriatric individuals at home and in the community. The findings of the needs assessment directed the development of the project, and in collaboration with the inpatient therapy team, a project was developed with the purpose being to focus on providing support for these team members by acting as a resource to assist in improving the efficiency and efficacy of the therapeutic process for geriatric patients. To do this, project goals were delineated that are aimed to create a golden standard of care for the geriatric population. These goals include: creating resources regarding a variety of health topics, creating a comprehensive list of interventions, outcome measures, and goals that are appropriate for use with these patients, and educating and training therapy staff members on the benefits and use of the materials created. Each of these objectives were created based on evidence-based practice guidelines that have been shown to improve physical and emotional well-being as well as functional outcomes for geriatric populations. Other early in-hospital physical rehabilitation programs appear to prevent functional loss in geriatric patients. According to Kosse et al. (2013), at time of discharge, patients who had participated in a multidisciplinary program or exercise program improved more on physical 7 functional tests and were less likely to be discharged to a nursing home compared to patients receiving only usual care models. Multidisciplinary programs reduced the length of hospital stay significantly. Follow-up interventions improved physical functioning after discharge. Early physical rehabilitation care for acutely hospitalized older adults leads to functional benefits (Kosse et al., 2013). As cited in Fox et al. (2012), geriatric care in the acute care setting was found to be associated with fewer falls, less delirium, less functional decline at discharge, shorter length of hospital stays, fewer discharged to nursing homes, lower costs, and more discharges home. Different from previous geriatric-based rehabilitation programs, this project will focus on completing and creating a variety of interventions, outcome measures, resources, and tools to further improve functional outcome measures of the geriatric population rather than using only one intervention/series of interventions and one outcome measure. The goal of using a variety of tools is to employ a more holistic approach for treating these patients. Like all individuals, the geriatric population has a varying number of needs, challenges, and physical capabilities. Through this project, the goal was to create an interdisciplinary program that allows the individuality of each older adult to be addressed and honored, in hopes of seeing greater success through functional outcomes. Through the screening process, a basic understanding of each patients physical being will be obtained. With the resources that have been created, the therapists at Eskenazi will be able to meet these older adults where they are physically to make a client-centered and effective plan of care. Furthermore, the project focused on creating resources aimed to educate the patients and their families on how to best address their needs and close the gaps in all areas of wellness that are crucial in allowing these individuals the best chance for success. 8 Guiding Model & Frame of Reference The creation of this project was guided by a model and frame of reference from the occupational therapy profession. The Canadian Model of Occupational Performance (CMOP) was selected as one of the guiding theories as this model allows for the therapeutic process to be holistic in nature, as the CMOP is based on the use of client-centered practice. This is important as it honors the vast diversity of the geriatric population treated at Eskenazi Health. CMOP focuses on the influence that the person, the occupation, and the environment have on the occupational performance of the patient. Using this model, the therapeutic process is focused on the person and how their individual human spirit creates a drive to perform their occupations. Within the CMOP, the human spirit is influenced by the physical, affective, and cognitive characteristics of the person. Because of this, it is important that these areas be addressed while in the acute care setting as it directly relates to occupational performance (Cole & Tufano, 2008). Using the theoretical basis of the CMOP and information found in the literature, efforts to improve the frequency and efficacy of patient care for each geriatric patient must address the human spirit, physical, affective, and cognitive skills of each of these individuals. The literature has acknowledged that addressing spirituality is associated with greater health outcomes including coping with illness and improved will to live (Finkelstein et al., 2007; Puchalski, 2004). This is especially important when working with the geriatric population, as the prevalence of depression in the geriatric population is high and is considered a leading cause of disability in older adults (Beyer, 2007). Based on discussion with inpatient therapists at Eskenazi Health, there was a lack of confidence on how to approach and/or treat the affective and spirituality components of the CMOP model in the acute care setting. To address this need, this project made efforts to suggest improved rapport building strategies with patients through subjective 9 interviewing skills and continued conversation throughout treatment sessions as well as making connections with music and pet therapy programs at Eskenazi Health. These three components, rapport building, pet therapy, and music therapy, among other intervention suggestions have been shown to improve patient affect by addressing the spirituality of the person, which in turn leads to improved patient outcomes (Aalbers et al., 2017; Bulette Coakley & Mahoney, 2009; Leach, 2005). Another theory that helped to lay the groundwork of this project is the Activity Theory, which falls into the Lifespan Development frame of reference. The Activity Theory proposes that greater continued engagement in activities leads to greater life satisfaction in the later years of life (Cole & Tufano, 2008). This is especially important when working with patients who are hospitalized as they are not in their normal environment, meaning they do not have access to engage in their normal activities. Using this theory as a guiding model, this project focused on developing interventions that simulate participation in normal daily events that go beyond the confines of a hospital room. Project Design In order to create an evidence-based, effective, quality-improvement standard of care for the geriatric population treated at Eskenazi, the development of this project necessitated a full breakdown of care through the entirety of the therapeutic process. This includes everything from screening and evaluation, all the way to outcomes and discontinuation of services (AOTA, 2020). This portion of the paper has been broken into the separate sections to follow the areas of the project by the appropriate stage of the therapeutic process. Unrelated to the therapeutic process, development of this project included meetings with several interdisciplinary teams including the inpatient therapy geriatrics committee, transitions of 10 care, a trauma surgeon, and pet and music therapy providers. The information gathered from these meetings were used to either supplement the needs assessment or used to create intervention and discharge ideas and are reflected in the resources provided in the appendices. Other aspects of the project included collection of data and analysis (see Project Outcomes section) and dissemination of project findings, materials, and further implications to the inpatient therapy team. Screening Due to the nature of the acute care setting and the purposes of this project, screening patients was equated to completing chart reviews on patients with therapy orders prior to evaluation. This aspect of the therapeutic process is important as it helps to develop a picture of the patient prior to evaluation. Because of this, it aids in getting an early start to evaluation for the geriatric population. For individuals who are 65 years of age and older, there are a lot of factors that play a role in their risk for debility, whether it be before, during, or following hospitalization. These risk factors include, but are not limited to: age, living environment, level of daily activity, independence with ADL, medication adherence, quality and quantity of sleep, nutrition, weight, depression, and social interaction and support (Axiom Home Care, 2017; Johns Hopkins Medicine, n,d.; Komiya et al., 2013; Kosse et al., 2013; Willacy & Tidy, 2021). Using a thorough chart review, many of these factors can be identified, prior to even interacting with the patient. This is helpful in allowing the therapist to be prepared for what to expect during the evaluation, which areas of the patients life may require more attention than others, and which assessment tools may be beneficial to use in evaluation. The aim of emphasizing this portion of the therapeutic process during dissemination was to help set a solid base for a successful therapeutic experience for both the patient and the therapist. 11 Evaluation Traditionally, the evaluation portion of the therapeutic process consists of a subjective interview to gather information about the patient, their history, and the environment they perform their daily tasks in as well as a formal assessment of their functional performance (AOTA, 2020). This is consistent with how therapists at Eskenazi Health typically perform their evaluations in the acute care setting. Following the purposes of this project and the needs assessment, it was decided that evaluations for the geriatric population would be improved by focusing on identifying the presence of the earlier identified risk factors for debility. To do this, a combination of subjective and functional outcome measures must be used. Emphasizing what has been found in the literature, a guide of probing questions was created to assist in identifying the earlier identified risk factors of debility to be used during the subjective interviewing portion of the evaluation. The goal of asking these questions was to assist in helping to discover if and/or what aspect of their lifestyle the patient is lacking resources for continued success during and following hospitalization. See Appendix A. Functional outcome measures are used to assess patients specific performance in different areas, whether it be physical skills, cognitive skills, and/or occupational performance skills (APTA, n.d.). Because of the large individuality within the geriatric population, there are a multitude of outcome measures that can be used during evaluation within this population. To assist in making it easier to delineate and differentiate which outcome measure might be best used for each client, a comprehensive list of these outcome measures organized by the skill that each tool measures was created. See Appendix B. Goal Writing and Interventions 12 Following evaluation, the next step in the therapeutic process includes creating a plan of care and goal writing (AOTA, 2020). Through the needs assessment, it was identified that the geriatric patients treated inpatient at Eskenazi Health are not being seen as frequently as they should be. Though there are a variety of systems-related reasons that go beyond the abilities of this project that play a role in this issue, it was identified through the needs assessment that some of the reasons this is happening include: patients being considered to be at their baseline and therapists feeling at a loss of intervention ideas for these patients. In hopes of helping to aid these issues, this project included a comprehensive list of maintenance goals for both professions and intervention ideas that can be used to create justifiable interventions to help improve functional outcomes for these patients. See Appendix C. Outcomes and Discharge from Services Following patient outcomes in this setting is slightly different than in other settings as the patient can be discharged from the hospital and, therefore, therapy services at any time following the creation of the plan of care. To track patient outcomes in this setting, the patients performance can be tracked through the therapists documentation over the therapy sessions. Because of the quick turnover of patient care, it is essential that the patients performance and debility risk factors are identified at evaluation, which further supports the necessity of the previously outlined resources created in this project. The quick turnover also necessitates the adherence for patient advocacy for this population. During the needs assessment, it was identified that there is a need for further resources to support health literacy for this population, as well as improvements in bridging the gap between inpatient to outpatient care in order to address the variety of needs that the geriatric population is predisposed to. To address these needs, a library of resources has been created. These resources 13 include handouts addressing several occupations listed in the Occupational Therapy Practice Framework: Domain and Practice, 4th ed. (AOTA, 2020), including but not limited to disease and health management, socialization, functional mobility, and sleep participation. See Appendix D. Project Outcomes In order to fully communicate all aspects of the project, how it impacts therapy practice, and the evidence that supports the project development, dissemination using a PowerPoint presentation and lunch-and-learn presentation of project findings, materials, and further implications to the inpatient therapy was completed. Because the aim of this project was focused on improving the quality of care for the geriatric population provided by the inpatient physical and occupational therapy teams, therapists confidence in addressing the multitude of needs of the geriatric population throughout the therapeutic process was measured before and after the project dissemination. To do this, a Google Forms survey was sent out to the physical therapists, physical therapy assistants, and occupational therapists who work on the inpatient team at Eskenazi Health. Survey responses were collected anonymously, and descriptive statistics were used to analysis survey responses. The therapists were asked to identify their respective profession with auto populated survey questions tailored specifically to each professions scope of practice. To get a better understanding of the therapists confidence in each survey item, responses were collected on the level of confidence in addressing debility for the geriatric population through different aspects of the therapeutic process. Specific areas of concentration were indicated as level of confidence in the following areas: identifying risk factors of debility, subjective interviewing, assessment tools, intervention planning, goal writing, and resources. 14 Occupational therapists were asked additional items regarding their confidence in addressing medication management and depression in practice with the geriatric population. Item responses indicated a Likert Scale of one through five, with one being I do not feel confident and five being I feel confident.... The post-survey included an additional short answer item asking survey respondents to identify an area of value for ongoing practice that the presentation provided. For a full list of survey items, see Appendix E. The scores of each survey item were collected from 21 therapists before the project dissemination and 9 therapists following the project dissemination. This data was used to descriptively compare the pre- and post-confidence of the inpatient therapists comfort level in treating debility risk factors of geriatric patients throughout the different aspects of the therapeutic process. The results indicated that the therapists confidence collectively improved for both physical therapy practitioners and occupational therapists on all survey items. The results indicated that all therapists gained confidence in addressing debility risk factors for the geriatric population throughout all steps of the therapeutic process following the project dissemination. For full results, see Appendix F. The largest improvements in therapists confidence was in accessing resources specific to the geriatric population. When the physical therapy practitioners were asked to rank their confidence on this item prior to the project dissemination, the majority of respondents (45.5%) responded they felt neutral in their ability. When compared to the responses post project dissemination, all physical therapy practitioners (100%) indicated improvement to feeling confident. Occupational therapists indicated a majority response (50%) of feeling somewhat confident in accessing resources specific to the geriatric population prior to project dissemination. Post project dissemination, the occupational therapists confidence improved with 15 majority of respondents (60%) indicating being somewhat confident and the remaining 40% indicating feeling confident. See Appendix F, Figure F11 F12. The therapists also showed improvement in confidence in selecting, accessing, and utilizing appropriate assessment tools. When the physical therapy practitioners were asked to rank their confidence on this item prior to the project dissemination, the majority of respondents (54.5%) responded they felt somewhat confident. When compared to the responses post project dissemination, the majority of physical therapy practitioners (75%) indicated improvement to feeling confident. Occupational therapists indicated a split response to on the same survey item with the majority of respondents (40%) indicated feeling less confident and a tie of 30% of respondents indicated they felt neutral about their ability and 30% indicated they did not feel confident. Post project dissemination, the occupational therapists confidence improved with majority of respondents (80%) indicated being somewhat confident in using outcome measures specific to the geriatric population. See Appendix F, Figure F5 F6. Occupational therapists showed improvement in confidence in addressing depression throughout the therapeutic process. Prior to the project dissemination, respondents indicated a majority of respondents (40%) indicated somewhat confident. This was followed closely by 30% of respondents indicating they felt less than confident. When compared to the responses post project dissemination, the majority of respondents (80%) indicated improvement to feeling confident. See Appendix F, Figure F14. Finally, all respondents were asked to describe one area in which the project dissemination provided value for their ongoing practice with the geriatric population. Thematic analysis of qualitative responses indicated all respondents provided positive responses. Responses were coded to identify areas of the therapeutic process that were indicated as having 16 improvements to personal practice. Results indicated improved: subjective interviewing, goals, resources to give patients and their families, continuation of care/follow-up, goals, and understanding of impact of depression. For a complete list of write-in responses, see Appendix F, Figure F15. Conclusion Geriatric patients are at risk for debility while hospitalized, but there is little discussion about this within the inpatient physical and occupational therapy teams at Eskenazi Health. This project advances the understanding of the risk factors of debility that are commonly identified in the geriatric population and defines opportunities within the therapeutic process that can be used to provide value for this population. These advances were presented to the inpatient rehabilitation team through a lunch-and-learn lecture with a PowerPoint presentation discussing the development of, research, and resources created through this project. Dissemination included staff training on how to utilize and access the materials created to promote translation of project content into therapist practice. Results indicated that the inpatient therapy staff benefitted from the project by indicating higher confidence in identifying debility risk factors; using probing subjective interview skills to identify performance deficits, areas to provide value; selecting, accessing, and utilizing appropriate standardized outcome measures; intervention planning; goal writing; and accessing resources aimed to improve overall wellness and quality of life. Additionally, occupational therapists indicated higher confidence in address medication management and depression. This project highlight implication of care regarding the geriatric population, as well as emphasizing the importance of advocacy for this vulnerable population through therapy practice. 17 References Aalbers, S., Fusar-Poli, L., Freeman, R., Spreen, M., Ket, J., Vink, A., Maratos, A., Crawford, M., Chen, X., & Gold, C. (2017, November). Music therapy for depression. Cochrane Database of Systematic Reviews. doi: https://doi.org/10.1002.14651858.CD004517.pub3 American Occupational Therapy Association. (2020). Occupational therapy practice framework: Domain and process (4th ed.). American Journal of Occupational Therapy, 74(Suppl. 2), 1-87 American Physical Therapy Association. (n.d.). Outcome measurement. https://www.apta.org/your-practice/outcomes-measurement Axiom Home Care. (2017). General Debility. http://axiomhomecare.com/department/generaldebility/ Beyer, J. (2007). Managing depression in geriatric populations. Annals of Clinical Psychiatry, 19(4), 221-238. doi: 10.1080/10401230701653245 Boyd, C., Landefeld, C., Counsell, S., et al. (2008). Recovery of activities of daily living in older adults after hospitalization for acute medical illness. Journal of American Geriatrics Society, 56(12), 2171-2179. doi:10.1111/j.1532-5415.2008.02023.x Bulette Coakley, A. & Mahoney, E. (2009). Creating a therapeutic and healing environment with a pet therapy program. Complementary Therapies in Clinical Practice, 15(3), 141-146. doi: https://doi.org/10.1016/j.ctcp.2009.05.004 Cole, M.B., & Tufano, R. (2008). Applied theories in occupational therapy: A practical approach. Thorofare, NJ: SLACK, Inc. Covinsky, K., Palmer, R., Fortinsky, R., et al. (2003). Loss of independence in activities of daily living in older adults hospitalized with medical illnesses: Increased vulnerability with 18 age. Journal of American Geriatrics Society, 51(4), 451-458. doi:10.1046/j.15325415.2003.51152.x Covinsky, K., Pierluissi, E., & Johnston, C. (2011). Hospitalization-associated disability: She was probably able to ambulate, but Im not sure. Journal of the American Medical Association, 306(16), 1782-1793. doi:10.1001/jama.2011.1556 Eskenazi Health. (n.d.-a) History. https://www.eskenazihealth.edu/about/history Eskenazi Health. (n.d.-b). About. https://www.eskenazihealth.edu/about Finkelstein, F., West, W., Gobin, J., Finkelstein, S., & Wuerth, D. (2007). Spirituality, quality of life and the dialysis patient. Nephrology Dialysis Transplantation, 22(9), 2432-2434. doi: https://doi.org/10.1093/ndt/gfm215 Fox, M., Persaud, M., Maimets, I., OBrien, K., Brooks, D., Tregunno, D., & Schraa, E. (2012). Effectiveness of acute geriatric unit care using acute care for elder components: A systematic review and meta-analysis. Journal of the American Geriatrics Society, 60(12), 2237-2245. https://doi.org/10.1111/jgs.12028 Johns Hopkins Medicine. (n.d.). Stay strong: Four ways to beat the frailty risk. https://www.hopkinsmedicine.org/health/wellness-and-prevention/stay-strong-four-waysto-beat-the-frailty-risk Komiya, K., Ishii, H., & Kushima, H. (2013). Physicians attitudes toward the definition of death from age-related physical debility in deceased elderly with aspiration pneumonia. Geriatrics and Gerontology International, 13(3). doi: 10.111/j.1447-0594.2012.00941.x Kosse, N., Dutmer, A., Dasenbrock, L., Bauer, J., & Lamoth, C. (2013). Effectiveness and feasibility of early physical rehabilitation programs for geriatric hospitalized patients: A systematic review. BMC Geriatrics, 13(107). doi:10.1186/1471-2318-13-107 19 Leach, M. (2005). Rapport: A key to treatment success. Complementary Therapies in Clinical Practice, 11, 262-265. doi: 10.1016/j.ctcp.2005.05.005 McCusker, J., Kakuma, R., & Abrahamowicz, M. (2002). Predictors of functional decline in hospitalized elderly patients: A systematic review. Journals of Gerontology, Series A, Biological Sciences, 57(9), M569-M577. doi:10.1093/gerona/57.9.m569 Menezes, K., Auger, C., Barbosa, J., Gomes, C., Menezes, W., & Guerra, R. (2021). Trajectories and predictors of functional capacity decline in older adults from a Brazilian northeastern hospital. Journal of Geriatric Physical Therapy, 44(2), 82-87. doi:10.1519/JPT.0000000000000255 Orange, S., Marshall, P., Madden, L., & Vince, R. (2019). Can sit-to-stand muscle power explain the ability to perform functional tasks in adults with severe obesity? Journal of Sports Sciences, 37(11), 1227-1234. doi: 10.1080/02640414.2018.1553500 Puchalski, C. (2004). Spirituality in health: The role of spirituality in critical care. Critical Care Clinics, 20(3), 487-504. doi: https://doi.org/10.1016/j.ccc.2004.03.007 University of St. Augustine for Health Sciences. (2020). What is occupational therapys role in acute care? https://www.usa.edu/blog/occupational-therapy-in-acute-care/ Willacy, H. & Tidy, C. (2021). Muscle weakness. Patient. https://patient.info/signssymptoms/tiredness-fatigue/muscle-weakness 20 Appendix A Subjective Interview Questions 21 Appendix B Outcome Measures by Skill Figure B1 Outcome Measures for Balance Figure B2 Outcome Measures for Mobility 22 Figure B3 Outcome Measures for Mobility Figure B4 Outcome Measures for Reach 23 Figure B5 Outcome Measures for Daily Routines/Physical Activity Levels Figure B6 Outcome Measures for Quality of Life/Depression 24 Figure B7 Outcome Measures for Cognition Figure B8 Outcome Measures for Frality 25 Figure B4 Outcome Measures for Miscellaneous 26 Appendix C Goals and Interventions Figure C1 Goals for Occupational Therapy 27 Figure C2 Goals for Physical Therapy Figure C3 Interventions for Mobility/Balance/Endurance 28 Figure C4 Interventions for Cognition Figure C5 Interventions including Pet Therapy and Music Therapy 29 Appendix D Educational Handouts and Resources Figure D1 Educational Handout on Weakness and Debility 30 Figure D2 Home Exercise Plan: Standing 31 Figure D3 Home Exercise Plan: Sitting 32 Figure D4 Home Exercise Plan: Supine 33 Figure D5 Educational Handout on Fall Prevention 34 Figure D6 Home Exercise Plan for Fall Prevention 35 Figure D7 Home Safety Checklist Handout 36 Figure D8 Educational Handout on Starting a Walking Program: Part 1 37 Figure D9 Educational Handout on Starting a Walking Program: Part 2 38 Figure D10 Educational Handout on Starting a Walking Program: Part 3 39 Figure D11 Educational Handout on Starting a Walking Program: Part 4 40 Figure D12 Educational Handout on Medication Management 41 Figure D13 Educational Handout on Sleep Hygiene 42 Figure D14 Educational Handout on Depression 43 Figure D15 Educational Handout on Ways to Improve Mental Health 44 Figure D15 Educational Handout on Outpatient Services for Geriatric Patients 45 Appendix E Pre- and Post-Survey Items Table E1 Pre/Post Survey: Physical Therapists/Physical Therapy Assistants Geriatrics Capstone Presentation Survey Thank you for agreeing to complete this survey. This survey is intended to provide pre/post feedback on the geriatrics capstone presentation. Are you a PT/PTA or OT? o PT/PTA o OT PT/PTA Survey Sections Debility: Consider the degree of confidence you have in identifying risk factors of debility throughout the therapeutic process. o 5. I can easily and regularly identify 5+ risk factors of debility. o 4. I can identify 4-5 risk factors of debility. o 3. I can identify some risk factors of debility, but probably not more than 3. o 2. I can identify 1-2 risk factors of debility. o 1. I cannot identify any risk factors of debility. Subjective Interviewing: Consider the degree of confidence you have in using probing interview skills to identify performance deficits, areas to provide value. o 5. I feel confident in my ability to use open-ended subjective questions that further my understanding of the patients lifestyle choices that reflect their risk for debility. o 4. I feel somewhat confident in my ability to use open-ended subjective questions that further my understanding of the patients lifestyle choices that reflect their risk for debility. o 3. I feel neutral about my ability to use open-ended subjective questions that further my understanding of the patients lifestyle choices that reflect their risk for debility. o 2. I feel less confident in my ability to use open-ended subjective questions that further my understanding of the patients lifestyle choices that reflect their risk for debility. o 1. I do not feel confident in my ability to use open-ended subjective questions that further my understanding of the patients lifestyle choices that reflect their risk for debility. Assessment Tools: Consider the degree of confidence you have in selecting, accessing, and utilizing appropriate standardized outcome measures specific to the geriatric population. o 5. I feel confident in my ability to know which assessment tools are best, how to access them, and how to utilize them in evaluation of the geriatric population. o 4. I feel somewhat confident in my ability to know which assessment tools are best, how to access them, and how to utilize them in evaluation of the geriatric population. o 3. I feel neutral about my ability to know which assessment tools are best, how to access them, and how to utilize them in evaluation of the geriatric population. o 2. I feel less confident in my ability to know which assessment tools are best, how to access them, and how to utilize them in evaluation of the geriatric population. 46 o 1. I do not feel confident in my ability to know which assessment tools are best, how to access them, and how to utilize them in evaluation of the geriatric population. Intervention Planning: Consider the degree of confidence you have in planning patient centered interventions that increase and/or maintain the functional capacities of the geriatric population within the confines of the acute care setting. o 5. I feel confident in my ability to plan and implement creative interventions for the geriatric population. o 4. I feel somewhat confident in my ability to plan and implement creative interventions for the geriatric population. o 3. I feel neutral about my ability to plan and implement creative interventions for the geriatric population. o 2. I feel less confident in my ability to plan and implement creative interventions for the geriatric population. o 1. I do not feel confident in my ability to plan and implement creative interventions for the geriatric population. Goal Writing: Consider the degree of confidence you have in developing goals focused on maintaining functional status for patients who are at risk for debility during their admission. o 5. I feel confident in my ability to develop non-traditional goals specific to interventions focused on maintains/increasing functional outcomes specific to the geriatric population. o 4. I feel somewhat confident in my ability to plan and implement creative interventions for the geriatric population. o 3. I feel neutral about my ability to plan and implement creative interventions for the geriatric population. o 2. I feel less confident in my ability to plan and implement creative interventions for the geriatric population. o 1. I do not feel confident in my ability to plan and implement creative interventions for the geriatric population. Resources: Consider the degree of confidence you have in accessing resources aimed to improve overall wellness and quality of life for the geriatric population. o 5. I feel confident in my ability to know what resources and how to access them throughout treatment with the geriatric population. o 4. I feel somewhat confident in my ability to know what resources and how to access them throughout treatment with the geriatric population. o 3. I feel neutral about my ability to know what resources and how to access them throughout treatment with the geriatric population. o 2. I feel less confident in my ability to know what resources and how to access them throughout treatment with the geriatric population. o 1. I do not feel confident in my ability to know what resources and how to access them throughout treatment with the geriatric population. Please describe one area where this presentation has provided value for your on-going practice with the geriatric population. 47 Table E2 Pre/Post Survey: Occupational Therapists Geriatrics Capstone Presentation Survey Thank you for agreeing to complete this survey. This survey is intended to provide pre/post feedback on the geriatrics capstone presentation. Are you a PT/PTA or OT? o PT/PTA o OT OT Survey Sections Debility: Consider the degree of confidence you have in identifying risk factors of debility throughout the therapeutic process. o 5. I can easily and regularly identify 5+ risk factors of debility. o 4. I can identify 4-5 risk factors of debility. o 3. I can identify some risk factors of debility, but probably not more than 3. o 2. I can identify 1-2 risk factors of debility. o 1. I cannot identify any risk factors of debility. Subjective Interviewing: Consider the degree of confidence you have in using probing interview skills to identify performance deficits, areas to provide value. o 5. I feel confident in my ability to use open-ended subjective questions that further my understanding of the patients lifestyle choices that reflect their risk for debility. o 4. I feel somewhat confident in my ability to use open-ended subjective questions that further my understanding of the patients lifestyle choices that reflect their risk for debility. o 3. I feel neutral about my ability to use open-ended subjective questions that further my understanding of the patients lifestyle choices that reflect their risk for debility. o 2. I feel less confident in my ability to use open-ended subjective questions that further my understanding of the patients lifestyle choices that reflect their risk for debility. o 1. I do not feel confident in my ability to use open-ended subjective questions that further my understanding of the patients lifestyle choices that reflect their risk for debility. Assessment Tools: Consider the degree of confidence you have in selecting, accessing, and utilizing appropriate standardized outcome measures specific to the geriatric population. o 5. I feel confident in my ability to know which assessment tools are best, how to access them, and how to utilize them in evaluation of the geriatric population. o 4. I feel somewhat confident in my ability to know which assessment tools are best, how to access them, and how to utilize them in evaluation of the geriatric population. o 3. I feel neutral about my ability to know which assessment tools are best, how to access them, and how to utilize them in evaluation of the geriatric population. o 2. I feel less confident in my ability to know which assessment tools are best, how to access them, and how to utilize them in evaluation of the geriatric population. o 1. I do not feel confident in my ability to know which assessment tools are best, how to access them, and how to utilize them in evaluation of the geriatric population. 48 Intervention Planning: Consider the degree of confidence you have in planning patient centered interventions that increase and/or maintain the functional capacities of the geriatric population within the confines of the acute care setting. o 5. I feel confident in my ability to plan and implement creative interventions for the geriatric population. o 4. I feel somewhat confident in my ability to plan and implement creative interventions for the geriatric population. o 3. I feel neutral about my ability to plan and implement creative interventions for the geriatric population. o 2. I feel less confident in my ability to plan and implement creative interventions for the geriatric population. o 1. I do not feel confident in my ability to plan and implement creative interventions for the geriatric population. Goal Writing: Consider the degree of confidence you have in developing goals focused on maintaining functional status for patients who are at risk for debility during their admission. o 5. I feel confident in my ability to develop non-traditional goals specific to interventions focused on maintains/increasing functional outcomes specific to the geriatric population. o 4. I feel somewhat confident in my ability to plan and implement creative interventions for the geriatric population. o 3. I feel neutral about my ability to plan and implement creative interventions for the geriatric population. o 2. I feel less confident in my ability to plan and implement creative interventions for the geriatric population. o 1. I do not feel confident in my ability to plan and implement creative interventions for the geriatric population. Resources: Consider the degree of confidence you have in accessing resources aimed to improve overall wellness and quality of life for the geriatric population. o 5. I feel confident in my ability to know what resources and how to access them throughout treatment with the geriatric population. o 4. I feel somewhat confident in my ability to know what resources and how to access them throughout treatment with the geriatric population. o 3. I feel neutral about my ability to know what resources and how to access them throughout treatment with the geriatric population. o 2. I feel less confident in my ability to know what resources and how to access them throughout treatment with the geriatric population. o 1. I do not feel confident in my ability to know what resources and how to access them throughout treatment with the geriatric population. Medication Management: Consider the degree of confidence you have in assessing, creating goals, and planning/implementing interventions focused on patient performance with medication management. o 5. I feel confident in my ability to address medication management across all stages of the therapeutic process. o 4. I feel somewhat confident in my ability to address medication management across all stages of the therapeutic process. 49 o 3. I feel neutral about my ability to address medication management across all stages of the therapeutic process. o 2. I feel less confident in my ability to address medication management across all stages of the therapeutic process. o 1. I do not feel confident in my ability to address medication management across all stages of the therapeutic process. Depression: Consider the degree of confidence you have in assessing, creating goals, and planning/implementing interventions focused on decreasing risk factors of depression for the geriatric population. o 5. I feel confident in my ability to address depression across all stages of the therapeutic process. o 4. I feel somewhat confident in my ability to address depression across all stages of the therapeutic process. o 3. I feel neutral about my ability to address depression across all stages of the therapeutic process. o 2. I feel less confident in my ability to address depression across all stages of the therapeutic process. o 1. I do not feel confident in my ability to address depression across all stages of the therapeutic process. Please describe one area where this presentation has provided value for your on-going practice with the geriatric population. 50 Appendix F Project Outcome Results Figure F1 Survey Item 1: PT Practitioners Pre-/Post- Response Figure F2 Survey Item 1: OT Practitioners Pre-/Post- Response 51 Figure F3 Survey Item 2: PT Practitioners Pre-/Post- Response Figure F4 Survey Item 2: OT Practitioners Pre-/Post- Response 52 Figure F5 Survey Item 3: PT Practitioners Pre-/Post- Response Figure F6 Survey Item 3: OT Practitioners Pre-/Post- Response 53 Figure F7 Survey Item 4: PT Practitioners Pre-/Post- Response Figure F8 Survey Item 4: OT Practitioners Pre-/Post- Response 54 Figure F9 Survey Item 5: PT Practitioners Pre-/Post- Response Figure F10 Survey Item 5: OT Practitioners Pre-/Post- Response 55 Figure F11 Survey Item 6: PT Practitioners Pre-/Post- Response Figure F12 Survey Item 6: OT Practitioners Pre-/Post- Response 56 Figure F13 Survey Item 7: OT Practitioners Pre-/Post- Response Figure F14 Survey Item 8: OT Practitioners Pre-/Post- Response 57 Figure F15 Survey Item 9: Post Survey Short-Answer Responses 58 Appendix G Weekly Objectives Chart Wee k 1 DCE Stage (orientation, screening/evaluation , implementation, discontinuation, dissemination) Orientation Weekly Goal 1) Meet with Rachel 2) Meet with Geriatrics Committee 2 3 Orientation Screening/Evaluati on 1) Watch Brainy Health Lecture 2) Update literature on debility risk factors Objectives Tasks 1) Discuss plan for project completion, what day-today will look like 2) Discuss purpose of project, project goals, brainstorm ideas, thoughts from committee members Update project goals 1) Learn about cognitive changes in aging 2) Use up-todate literature 1) Meet with 1) Learn about music therapy the benefits 2) Meet with pet of music therapy therapy, 3) Attend what it looks surgical like, how to symposium order music lecture on therapy for patients Date complet e 01/14 Schedule and prepare for geriatrics committee meeting Consider progression of project Identify what is available/wh at needs improvement s Watch 01/21 lecture Review literature Document new findings in paper Set up meetings Prepare for meetings Go to meetings 01/28 59 Geriatrics Care 4 Screening/Evaluati on 2) Learn about the benefits of pet therapy, what it looks like, how to order pet therapy for patients 3) Learn about consideratio ns of geriatrics care form trauma surgeon at Eskenazi 1) Meet with Dr. 1) Discuss Carr implications 2) Meet with of project case with trauma management team, learn 3) Meet with about the geriatrics consideratio committee ns of rehab from perspective of the trauma team 2) Learn about resources available for geriatric patients of variety of SES specific to the focus of debility risk factors 3) Discuss progress with project, results of meetings with other disciplines, Write-out findings of meetings Sign up to attend lecture Watch lecture about geriatrics care Set up meetings Prepare for meetings Go to meetings Write-out findings of meetings 02/04 60 5 Implementation 1) Comprehensi ve list of appropriate assessment tools 2) Trial assessment tools 3) Clinical Practice 1) 6 Implementation 1) Comprehensi ve list of subjective interview questions 2) Trail interview questions in practice 3) Clinical practice and continued directions of projects 1) Create a place where all assessment tools are available to all the therapists 2) Consider which assessments tools work well within confines of setting, patient population, and resources available 3) Continued advancemen t of clinical practice skills 1) List of example subjective interview questions 2) Consider which interview questions work well within confines of setting, patient population, and Research and 02/11 identify assessment tools for geriatric patients Put all the assessment tools in one place with relevant information Identify which assessment tools to trial & then trial them Research and 02/18 identify questions for geriatric patients Put all the interview question in one place with relevant information Identify which patients to 61 3) 7 Implementation 1) Comprehensi ve list of goals 2) Clinical Practice 3) Goals smart phrase in EPIC 4) Midterm 1) 2) 3) 4) 8 Implementation 1) Comprehensi ve list of interventions 2) Trial Interventions in practice 3) Meet with geriatrics committee 4) Clinical Practice 1) 2) resources available Continued advancemen t of clinical practice skills Create a resource of example intervention s to be used in this setting Consider which goals work well within confines of setting, patient population, and resources available Easy to access goals Complete midterm Create a place where all intervention ideas are available to all the therapists Consider which intervention s work well within confines of setting, patient population, trial questions on and then do it Identify which areas goals need to be made for Write goals 02/25 Put all goals in one place with relevant information Use goals in practice Make smart phrase with goals Complete midterm and go over it Identify which areas need intervention ideas Come up with intervention ideas Put all interventions in one place with relevant information 03/04 62 9 Implementation 1) 2) 3) 4) and resources available 3) Continued advancemen t of clinical practice skills Edit 1) Create a place resources where all Create new resources are resources available to all Place the therapists resources on 2) Make the learning resources home page in easily EPIC accessible Clinical 3) Continued Practice advancement of clinical practice skills Use interventions in practice Identify which areas patients could benefit from education 03/11 Create resources Put in ticket to request resources be placed on EPIC systems Use resources in practice 10 11 Discontinuation Discontinuation 1) Combine all resources 2) Put resources in shared drive 3) Paper 1) Work on presentation 2) Send our pre-survey 1) Begin wrapping up project 2) Make sure all materials are available to the therapists 3) Work on paper 1) Start preparing for disseminatio n Collect all the resources together 03/18 Place all resources in the shared drive Work on paper Create PowerPoint Start organizing information 03/25 63 2) Get presurvey responses to place on PowerPoint Create presentation outline Create survey Email survey out to therapists 12 13 Dissemination Dissemination 1) Prepare for presentation 1) Prepare for dissemination 2) Give presentation 3) Send out post survey 1) Continue getting prepared for disseminatio n 1) Practice presentation 2) Complete disseminatio n 3) Send out survey for data collection Finish slides 04/01 Create additional presentation material Practice 04/08 presenting presentation materials and accessing technology Give presentation Create postsurvey items 14 Dissemination 1) Collect project outcomes 2) Translate all materials to site 3) Final 1) Reflect on survey responses 2) Provide all materials to capstone mentor for further use 3) Complete final Send out post-survey Work on project outcomes section of paper Wrap up all materials to be provided to site 04/15 64 Complete final and go over it Doctoral Capstone Experience and Project Weekly Planning Guide  ...

... 1 CARDIAC PRE-OPERATIVE SCREENING TOOL Rehabilitative Pre-Operative Screening Tool for Cardio-pulmonary Surgery Patients Anna Morrisey April 29, 2022 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. Alison Nichols, OTR 2 CARDIAC PRE-OPERATIVE SCREENING TOOL Abstract Cardiac physicians commonly see their patients pre-operatively to address risk factors. occupational therapy (OT) and physical therapy (PT) practitioners are often involved in a patient's care post-operatively, yet they do not typically screen their patients pre-operatively. The purpose of this project was to develop a screening tool to assess functional factors preoperatively and to advocate for OT and PT practitioners' involvement in patient care postsurgery. Using a two-round Delphi survey technique, the therapy team received an 8-question survey to write questions they wanted patients to answer pre-operatively. Then, a 30-question screening tool was created to address a patients physical functioning, cognition, home set-up, support system, and goals pre-operatively. In addition to the screening tool development, the role of the therapy team was further defined to the patient and cardiovascular surgery physicians. Future research is needed to evaluate the correlation between length of stay and using the Cardiac Pre-Operative Screening Tool. 3 CARDIAC PRE-OPERATIVE SCREENING TOOL Rehabilitative Pre-Operative Screening Tool for Cardio-pulmonary Surgery Patients Introduction This Doctoral Capstone Experience (DCE) took place at Indiana University (IU) Health Methodist Hospital, in downtown Indianapolis, Indiana. IU Health is the largest healthcare organization in Indiana (IU Health, 2020a). IU Health has an overall mission to improve the health of our patients and community through innovation, and excellence in care, education, research and service (IU Health, 2020a). Their vision is to be a preeminent leader in clinical care, education, research and service, which is achieved through objective evidence and established best practices (IU Health, 2020a). This hospital is one of Indianas largest Level 1 Adult Trauma Centers, so it is well-equipped to handle significant traumas, such as motor vehicle accidents, gunshot wounds, burns, etc. (IU Health, 2020c). This DCE was primarily focused in the cardio-pulmonary intensive care unit (ICU). It is common practice for physicians to complete a pre-operative screening with their patients to identify any risk factors prior to surgery (Kumar et al., 2018). There is a gap in the literature regarding the use of a rehabilitation-specific pre-operative screening for patients undergoing cardiac surgery, so the purpose of this project was to develop a screening tool to assess a patient's prior level of physical functioning, cognition, home set-up, support system, and goals prior to their cardiac surgery, as well as to advocate for both occupational therapy (OT) and physical therapy (PT) practitioners (therapy team) to be involved in a patients care after their surgery. I gathered qualitative information from the therapy team at my site to determine screening questions that were included in the screening tool that patients fill out prior to their cardiac surgery. I obtained the data from the therapy team through an online survey. Information 4 CARDIAC PRE-OPERATIVE SCREENING TOOL gathered from the therapists regarding their degree, credentials, and years of experience helped to determine the validity of the screening tool. Background Population Served IU Health Methodist Hospital cares for patients with diverse backgrounds, medical needs, values, races, and ethnicities throughout central Indiana. Patients from various counties within the state receive services from this hospital (IU Health, 2020b). With this DCE being focused in the cardio-pulmonary ICU, common conditions and diagnoses treated by OT practitioners in this particular ICU include patients on extracorporeal membrane oxygenation (ECMO), who need coronary artery bypass graft surgery (CABG), heart/lung transplants, valve replacement, open-heart surgery, and stent placements, and who have coronary artery disease (CAD), chronic obstructive pulmonary disease (COPD), and heart failure (Edwards, S., personal communication, February 24, 2021). Common health and occupational risk factors include impaired cognition, smoking, diabetes, COVID-19, and obesity (Edwards, S., personal communication, February 24, 2021). Needs Assessment During the initial interview, the therapy team discussed the setbacks some patients experience with ICU delirium and the lack of knowledge of the role of the therapy practitioners in the ICU. Delirium involves a change in perception or cognition, which impacts an individual's ability to receive, process, store and recall information (Kotfis et al., 2018, p. 129). Its impact ranges from 11.4% to 55% of patients receiving care in the ICU (Pagad et al., 2020). Symptoms of ICU delirium are often reversible, although some literature indicates individuals 5 CARDIAC PRE-OPERATIVE SCREENING TOOL who experience ICU delirium have longer hospital stays, prolonged mechanical ventilation, and higher mortality (Ibrahim et al., 2018, p. 1; Pauley et al., 2017). There is no known cause of delirium, and it is often a mixture of predisposing risk factors that cause severe confusion (Ibrahim et al., 2018). Some risk factors can include age, anxiety, depression, and cognitive impairments (Jackson et al., 2016; Matter et al., 2013). Antipsychotics are often a medication used to prevent the deliriums side effects, but there is no relevant evidence that the medication works efficiently (Ibrahim et al., 2018). Non-pharmaceutical interventions to help patients who are experiencing ICU delirium can include the use of calendars, clocks, early mobilization, sleep preservation techniques, ICU diaries, music therapy, and family education (Ibrahim et al., 2018; Laxton & Morrow, 2018). Early rehabilitation is vital to cardiac patients who are experiencing ICU delirium. The research indicates that patients who did not receive therapy and were sedated had an average of four days with delirium, while patients who received therapy had an average of two days with severe confusion (Ibrahim et al., 2018). As a result of the decreased delirium, a patient's stay in the hospital was reduced by 3.1 days (Ibrahim et al., 2018). In a different study, 104 patients, who were previously mechanically vented in the ICU after having long-term complications of critical illness, were assessed to determine if OT and PT improved functional outcomes (Schweickert et al., 2009). Forty-nine patients participated in therapy during periods of daily interruption in their sedation, while 55 patients had therapy as needed ordered by the primary care team (Schweickert et al., 2009). Overall, the patients receiving consistent therapy were discharged faster, had a shorter duration of delirium, and had more ventilator-free days (Schweickert et al., 2009). 6 CARDIAC PRE-OPERATIVE SCREENING TOOL At this site, the overall goal for OT practitioners is to evaluate and provide interventions that help patients who are critically ill begin to gain the independence and safety needed to move to acute care (Edwards, S., personal communication, February 24, 2021). OT practitioners also identify barriers that patients may face in the ICU (Edwards, S., personal communication, February 24, 2021). According to Affleck et al. (1986), there are three common problems that occur in the ICU: immobility and prolonged bed rest, sensory deprivation and stress, and prolonged mechanical ventilation (p. 324). For individuals who are awake and alert, OT practitioners have the ability to work on bed, room, and bathroom mobility with their patients in the ICU. The ICU setting can cause patients to have feelings of isolation (Affleck et al., 1986), which has been especially difficult throughout the COVID-19 pandemic when a patients support system is unable to visit. The decreased social support, along with the constant sound of the monitors going off, the lights turning on and off, and decreased independence can cause a patient to feel stressed (Affleck et al., 1986). These environmental factors can also put patients at risk for ICU delirium. OT practitioners can assess and provide interventions, such as improving sleep hygiene, cognitive retraining, and modifying the environment for individuals, including those with heart conditions (Laxton & Morrow, 2018). In an acute care setting, OT and PT practitioners often meet their patients for the first time after surgery. During the initial meeting or evaluation, the therapy team can gain a better picture of their patients overall health and wellbeing prior to surgery and their current level of function (AOTA, 2020). Literature indicates there is a screening tool for patients undergoing a total joint arthroplasty (Odum et al., 2020) that addresses pre-operative mobility, home safety, social/cognitive barriers, and patient health history in order to determine rehabilitation needs post-operatively (p. 144). At this site, the therapy team currently uses a pre-operative screening 7 CARDIAC PRE-OPERATIVE SCREENING TOOL tool for patients undergoing orthopedic surgery. Just as physicians are able to screen their patients and identify risk factors prior to major surgery, it is important that the therapy team can also screen their patients with different conditions (Kumar et al., 2018). Because of the prevalence of ICU delirium at this site and lack of knowledge of therapys role in the ICU, it was determined that a cardiac-specific pre-operative screening tool could allow the therapists to gain information about their patients prior to their surgery. With the information gathered prior to a scheduled surgery, the therapy team can gain a better picture of their patients current function, identify risk factors such as cognition, and make more appropriate goals during their hospital admission (Odum et al., 2020). Model and Frame of Reference (FOR) The model guiding this DCE is the Canadian Model of Occupational Performance (CMOP). The focus of CMOP is that occupational performance is the interaction between the person, the environment, and the occupation itself (Cole & Tufano, 2008). The person would include the patients physical, cognitive, and affective components (Cole & Tufano, 2008). At the center of CMOP is the human spirit which is a persons source of will and selfdetermination, and a sense of meaning, purpose, and connectedness that people experience in the context of their environment (Cole & Tufano, 2008, p. 28). Understanding the physical and cognitive aspects of a patient, in addition to their human spirit, allowed the screening tool to be more informative and holistic of the patients function prior to surgery. This helped to predict any dysfunction, defined as any disruption between the person-environment-occupation interaction, a patient may have after their surgery and allowed the therapy team to better address these complications (Cole & Tufano, 2008). 8 CARDIAC PRE-OPERATIVE SCREENING TOOL The Cognitive Behavioral FOR is often used when a patient experiences a psychological barrier that affects their engagement in meaningful activities, such as ICU delirium (Cole & Tufano, 2008). When a patient experiences ICU delirium, they are unable to balance their life roles and occupations. Assessing a patient through interviews, questionnaires, and clinical observations is vital to this FOR (Cole & Tufano, 2008). This FOR guided the questions included in the screening tool so cognition, which can be related to ICU delirium, could be addressed prior to a patients cardiac surgery. In addition to the Cognitive Behavioral FOR, the Rehabilitative FOR was also addressed. This FOR is occupation-based and focuses on a patients functioning so that they can achieve their highest level of occupational performance (Cole & Tufano, 2008). It also guided the questions included on the screening tool, so the therapy team could gain a better insight into their patients overall function prior to surgery. Project Design The plan and goals for this project were designed by combining the needs assessment, literature review, University of Indianapolis School of Occupational Therapy curricular threads, and collaborating with the site. This project was completed using the Delphi survey technique. Through a two-round process, a screening tool was created. During this process, feedback from the OT and PT practitioners was obtained to ensure the screening tool was inclusive of both disciplines. Implementation During the first four weeks of this DCE, through the help of the site mentor, a list of all OT and PT practitioners who have rotated through the cardiac floors was created. A total of 31 therapists were included in the list. These therapists were the participants in this project and 9 CARDIAC PRE-OPERATIVE SCREENING TOOL helped to create the screening tool. During the first four weeks, a Google Form was created with eight questions including: 1. What are your credentials? 2. Where did you graduate from? What year did you graduate? 3. How many years of experience do you have working with cardiac patients? 4. Are you a member of any professional organizations? If so, please list. 5. If you could see a patient prior to their scheduled surgery, what home set up questions would you want answered? 6. If you could see a patient prior to their scheduled surgery, what about the patient's functional tasks would you want answered? 7. If you could see a patient prior to their scheduled surgery, what about the patient's support system would you want answered? 8. If you could see a patient prior to their scheduled surgery, what about the patient's values, beliefs, and spirituality would you want answered? These questions were reviewed by the site mentor and approved prior to sending them to the therapists. The first four questions listed increased the validity of the screening tool. The final four questions contributed to the creation of the screening tool. With this Delphi survey technique, 31 total OT and PT practitioners received the Google Form through email and had approximately four weeks to respond. Once the first round of comments was collected, a list of potential questions for the screening tool was created. During the second round, the therapy team reviewed the different questions and the wording of the questions to come to a consensus of questions that should be included in the pre-operative screening tool. From there, a final draft of the screening tool was created. 10 CARDIAC PRE-OPERATIVE SCREENING TOOL Originally, this project involved assessing a patients cognition, using the Mini-Mental State Examination, prior to their cardiac surgery. Results from the assessment were going to be used to assess the potential correlation between cognition and ICU delirium. Unfortunately, due to the cancellation of elective surgeries at this site because of the COVID-19 pandemic, not enough participants would be available to complete the assessment. Another barrier included the implementation of the screening tool. Currently, an orthopedic clinic at this site calls patients, rather than having them fill out a survey in person, prior to their surgery to ask a list of rehabilitation-related questions. There was the question on whether this screening tool would be administered over the phone or filled out by the patient in-person. During the dissemination process of this DCE, it was determined that the patient would fill out the screening tool in the cardiac clinic prior to their surgery. From there, a secretary at the clinic front desk would scan the screening tool along with the other questionnaires filled out by the patient, into the patients medical chart for the therapists and other medical providers to view. Outcomes During this DCE, I spent 20% of my overall experience communicating with the therapy team to create a pre-operative screening tool for the cardiac population as part of my project. This screening tool was created through a two-round Delphi survey technique. The participants consisted of the cardiac OT and PT practitioners, all licensed and certified, at IU Health Methodist Hospital. Participants had anywhere from three months to eleven years of experience working with cardiac patients. As mentioned above, participants were sent a Google Form explaining the purpose of the project and were asked for questions they felt would be important to include in a pre-operative screening tool for cardiac patients. Of the 31 surveys sent to the OT and PT practitioners, 23 (74%) completed the survey. After the first round, a consensus above 11 CARDIAC PRE-OPERATIVE SCREENING TOOL 50% was reached for a variety of different elements discussing type of home, steps into and inside home, bathroom set-up, independence with activities of daily living (ADL) and instrumental activities of daily living (IADL), assistive devices, support system, hobbies, and goals. Although falls, cognition, type of caregiver/therapist, and preferred learning style did not meet the 50% threshold, the questions were still addressed in round two, due to the site mentor stressing the importance of the categories. A list of questions was then formulated based on the responses. When going through this Delphi survey technique, the therapy team suggested addressing cognition on the screening tool. Robinson et al. (2009) suggest pre-existing cognitive impairments are one of the strongest risk factors for delirium after a surgery. Cognition and physical function can also be linked. Literature indicates that individuals with dementia or other cognitive impairments are likely to demonstrate physical decline when compared to individuals with normal cognition (Taylor et al., 2019). Due to the strong link between cognition, delirium, and physical decline, it is important to include questions regarding cognition in the screening tool. Challenges to this include that the screening tool is not an assessment and is meant to be filled out by the patient. After reviewing the literature, I discovered the Dementia Screening Interview (AD8), an informant interview used to assess the prevalence of dementia in patients, which is used by the Alzheimers Association (Alzheimers Association, n.d.; Galvin, 2006). According to Galvin et al. (2006), the AD8 demonstrates good validity and reliability in detecting cognitive impairment. This information was communicated to the therapy team and questions similar to the AD8 were written and reviewed by the therapy team in rounds one and two of this process. 12 CARDIAC PRE-OPERATIVE SCREENING TOOL In the second and final round, 8/23 (31%) participants reviewed the list of questions that met the consensus threshold in the first round. Respondents had the opportunity to comment on the different elements. Feedback regarding the wording of the questions and order of the questions was received. The participants agreed with 100% of the questions listed. Ultimately, after round two of this process, there was a consensus that led to including 30 elements in the screening tool (see Appendix A). Summary The overall purpose of this project, which was to develop a screening tool and to advocate for the therapy team to be involved in a patients care post-operatively, was met. The Cardiac Pre-Operative Screening Tool has 30 questions, which aids the therapy team in the evaluation process. The questions included allow the therapy team to assess a patient's prior level of physical functioning, cognition, home set-up, support system, and goals, prior to their cardiac surgery. In addition to addressing the factors listed, questions addressing cognition are also included. With literature suggesting a link between cognitive impairments and the likelihood of delirium in hospitalized older adults, these questions help to address any potential underlying cognitive impairments in patients undergoing a cardiac surgery (Jackson et al., 2016). If there are cognitive impairments, the therapy team can adapt their evaluation and treatment sessions to meet the needs of the patient, including modifying the environment to help decrease confusion and stress (Affleck et al., 1986). With both OT and PT practitioners providing consistent therapy to the patient, the literature indicates patients can have a shorter duration of delirium, more ventilator-free days, and decrease their hospital stay (Ibrahim et al., 2018; Schweickert et al., 2009). With the Cardiac Pre-Operative Screening Tool, the therapy team at this site can identify 13 CARDIAC PRE-OPERATIVE SCREENING TOOL risk factors and evaluate the patient undergoing a cardiac surgery pre-operatively, just as physicians and the orthopedic therapy team is able to do (Kumar et al., 2018; Odum et al., 2020). Conclusion During this DCE, I spent 80% of my time furthering my skills as a future OT practitioner in the cardio-pulmonary ICU. There, I gained a better understanding of the therapy process with a higher acuity of patients. Through this clinical experience, I gained more confidence and independence in communicating with family members, caregivers, physicians, nurses, the therapy team, and other medical professionals. I also gained a greater level of independence, knowledge, and awareness with line management, documentation, different conditions, disease processes, medications, precautions, and protocols in the cardio-pulmonary ICU. Through the completion of this project, I was able to further advocate for the OT profession. On the screening tool, a description of the tool is given, along with the role of OT and PT practitioners after a patients surgery. OT and PT have similarities, but they are also vastly different professions. Literature indicates there is a lack of understanding specifically for the role of OT in a large medical hospital setting (Bonsall et al., 2016). Bonsall et al. (2016) conducted a study to further assess the lack of understanding by sending a survey to medical professionals employed by the University of Missouri Healthcare system. 68 employees filled out the survey, and the data was analyzed using descriptive statistics. Results indicated that 100% of the respondents had heard of OT, yet less than half were able to identify areas outside of activities of daily living as domains OT can address. OT practitioners have the ability to address multiple areas outside of ADL, including education, sleep hygiene, IADL, cognition, the environment, etc. (AOTA, 2020; Laxton & Morrow, 2018). This screening tool helped and will continue to help advocate for the OT profession to patients and the medical team. During the 14 CARDIAC PRE-OPERATIVE SCREENING TOOL dissemination process of this DCE, the benefits of the screening tool, collaboratively created by OT and PT practitioners, were explained to the physician assistants on the cardiovascular surgery team. During this process, the benefit of patients being evaluated by both disciplines was expressed to further advocate for OT. Overall, through completing this project, I gained a better understanding of the impact cognition has on delirium and physical functioning and the benefits of the therapy team being a part of a patients care prior to their surgery. Future research should evaluate if there is a correlation between length of stay and using the Cardiac Pre-Operative Screening Tool. 15 CARDIAC PRE-OPERATIVE SCREENING TOOL References Affleck, A. T., Lieberman, S., Polon, J., & Rohrkemper, K. (1986). Providing occupational therapy in an intensive care unit. The American Journal of Occupational Therapy, 40(5), 323332. Alzheimers Association. (n.d.). Cognitive assessment toolkit: A guide to detect cognitive impairment quickly and efficiently during the medicare annual wellness visit. https://www.alz.org/getmedia/9687d51e-641a-43a1-a96b-b29eb00e72bb/cognitiveassessment-toolkit American Occupational Therapy Association. (2020). Occupational therapy practice framework: Domain and process (4th ed.). American Journal of Occupational Therapy, 74(Suppl. 2). https://doi.org/10.5014/ajot.2020.74S2001 Bonsall, A., Mosby, A., Walz, M., & Wintermute, K. (2016). Health care professionals' knowledge of occupational therapy. American Journal of Occupational Therapy, 70(Suppl. 1), 70115101891. https://doi.org/10.5014/ajot.2016.70S1-PO1060 Cole, M. & Tufano, R. (2008). Applied theories in occupational therapy: A practical approach. Thorofare, NJ: SLACK Incorporated. Galvin, J. E., Roe, C. M., Xiong, C., & Morris, J. C. (2006). Validity and reliability of the AD8 informant interview in dementia. Neurology, 67(11), 19421948. https://doi.org/10.1212/01.wnl.0000247042.15547.eb Ibrahim, K., McCarthy, C. P., McCarthy, K. J., Brown, C. H., Needham, D. M., Januzzi, J. L., Jr, & McEvoy, J. W. (2018). Delirium in the cardiac intensive care unit. Journal of the American Heart Association, 7(4), e008568. https://doi.org/10.1161/JAHA.118.008568 Indiana University Health. (2020a). About our system. https://iuhealth.org/about-our-system 16 CARDIAC PRE-OPERATIVE SCREENING TOOL Indiana University Health. (2020b). Diversity, equity, & inclusion. https://iuhealth.org/about-oursystem/diversity-equity-inclusion Indiana University Health. (2020c). Level I trauma center. https://iuhealth.org/find-medicalservices/level-1-trauma-center Jackson, T. A., MacLullich, A. M. J., Gladman, J. R. F., Lord, J. M., & Sheehan, B. (2016). Undiagnosed long-term cognitive impairment in acutely hospitalised older medical patients with delirium: A prospective cohort study. Age and Ageing, 45(4), 493499. https://doi.org/10.1093/ageing/afw064 Kotfis, K., Marra, A., & Ely, E. W. (2018). ICU delirium: A diagnostic and therapeutic challenge in the intensive care unit. Anaesthesiology Intensive Therapy, 50(2), 160167. https://doi.org/10.5603/AIT.a2018.0011 Kumar, C., Salzman, B., & Colburn, J. L. (2018). Preoperative assessment in older adults: A comprehensive approach. American Family Physician, 98(4), 214220. Laxton, L., & Morrow, M. (2018). Occupational therapys role in delirium assessment, prevention, & management within the intensive care unit [PDF]. https://www.occupationaltherapy.com/articles/occupational-therapy-s-role-in-4592-4592 Matter, I., Chan, M. F., & Childs, C. (2013). Risk factor for acute delirium in critically ill adult patients: A systematic review. International Scholarly Research Notice, 1-11. https://doi.org/10.5402/2013/910125 Odum, S. M., Sheets, S. L., Curtin, B. M., & OrthoCarolina Quality Improvement Committee. (2020). A risk assessment tool based on orthopedic psychosocial and health status factors is associated with post-acute resources. The Journal of Arthroplasty, 35(6s), 144-150. https://doi.org/10.1016/j.arth.2020.02.041 17 CARDIAC PRE-OPERATIVE SCREENING TOOL Pagad, S., Somagutta, M. R., May, V., Arnold, A. A., Nanthakumaran, S., Sridharan, S., & Malik, B. H. (2020). Delirium in cardiac intensive care unit. Cureus, 12(8), e10096. https://doi.org/10.7759/cureus.10096 Pauley, E., Lishmanov, A., Schumann, S., Gala, G. J., van Diepen, S., & Katz, J. N. (2015). Delirium is a robust predictor of morbidity and mortality among critically ill patients treated in the cardiac intensive care unit. The American Heart Journal, 170(1), 79-86. http://dx.doi.org.ezproxy.uindy.edu/10.1016/j.ahj.2015.04.013 Robinson, T. N., Raeburn, C. D., Tran, Z. V., Angles, E. M., Brenner, L. A., & Moss, M. (2009). Postoperative delirium in the elderly: Risk factors and outcomes. Annals of Surgery, 249(1), 173178. https://doi.org/10.1097/SLA.0b013e31818e4776 Schweickert, W. D., Pohlman, M. C., Pohlman, A. S., Nigos, C., Pawlik, A. J., Esbrook, C. L., Spears, L., Miller, M., Franczyk, M., Deprizio, D., Schmidt, G. A., Bowman, A., Barr, R., McCallister, K. E., Hall, J. B., & Kress, J. P. (2009). Early physical and occupational therapy in mechanically ventilated, critically ill patients: A randomised controlled trial. Lancet (London, England), 373(9678), 18741882. https://doi.org/10.1016/S01406736(09)60658-9 Taylor, M. E., Boripuntakul, S., Toson, B., Close, J., Lord, S. R., Kochan, N. A., Sachdev, P. S., Brodaty, H., & Delbaere, K. (2019). The role of cognitive function and physical activity in physical decline in older adults across the cognitive spectrum. Aging & Mental Health, 23(7), 863871. https://doi.org/10.1080/13607863.2018.1474446 18 CARDIAC PRE-OPERATIVE SCREENING TOOL Appendix A Cardiac Pre-Operative Screening Tool This screening tool is designed by Occupational and Physical Therapists at IU Health. After surgery, you will likely meet with the therapy team to address your mobility, strength, ability to do your self-care tasks, and other factors. Both therapies will work alongside your medical team to address your balance, activity tolerance, and functional mobility after surgery. Please take the time to fill this out, so we can best assist you after your surgery. Thank you! Name: Date of Birth: Date of Surgery: Home 1. What type of home do you live in? House Apartment Condo Other: _________________________ 2. How many steps are there to enter your home? 0 1-2 3-4 5+ 3. Are there any handrails when going up the stairs? Yes (circle one): right side/left side/both sides No 4. If you live in a home with stairs, will you need to use stairs to access a different floor (i.e. second floor and basement)? Yes No N/A 5. Is there a bathroom with a shower that can be accessed on the main level? Yes No 6. What type of shower do you have? Tub Walk-in 7. Do you have any adaptive equipment in the bathroom (check all that apply)? Shower chair 19 CARDIAC PRE-OPERATIVE SCREENING TOOL Tub bench Grab bars Hand-held shower head Other: _________________________ N/A 8. Is your toilet elevated or a regular height? Elevated Regular Support System 9. Do you live with anyone? Yes No 10. Is there someone (above the age of 18) who can physically assist you, if needed? Yes No 11. Are they able to assist you 24 hours/day? Yes No 12. Do you prefer a specific caregiver and/or therapist to assist you? Male Female No preference Prior Level of Function 13. Have you had any falls in the past three months? Yes No 14. Do you currently require assistance with mobility (walking, getting in/out of bed, getting into/out of the shower, getting on/off the toilet, etc.)? Yes No 15. Do you currently use any assistive mobility devices (check all that apply)? Walker Rollator (4 wheels and a seat) Cane Wheelchair Other: _________________________ N/A 16. Do you currently drive? 20 CARDIAC PRE-OPERATIVE SCREENING TOOL Yes No 17. Do you currently work? Yes No 18. Do you currently require assistance with toileting tasks (pulling pants up and down, wiping)? Yes No 19. Do you currently require assistance with bathing tasks? Yes No 20. Do you currently require assistance getting dressed (putting on socks/shoes, pulling up pants, threading arms through sleeves, etc.)? Yes No 21. Do you currently require assistance managing medication and/or finances? Yes No 22. Do you currently require assistance with cooking, cleaning, or laundry tasks? Yes No 23. Do you have difficulty recalling conversations a few days later? Yes No 24. Do you have trouble remembering things that have happened recently? Yes No 25. When speaking, do you have difficulty finding the right words to use or use the wrong words? Yes No Extra 26. What is your preferred learning style? Written Verbal Demonstration 27. Where do you expect to go after surgery? 21 CARDIAC PRE-OPERATIVE SCREENING TOOL Home Rehab 28. What goals do you have after surgery? 29. What do you like to do for fun? 30. Is there anything extra you would like for us to know about? ________________________________________________________________________ 22 CARDIAC PRE-OPERATIVE SCREENING TOOL Appendix B Timeline Week DCE Stage (orientation, screening/evalua tion, implementation, discontinuation, dissemination) 1 Orientation Weekly Goal Objectives Tasks Date complete -Complete orientation by end of the week -Address supervision when treating/evaluating -Understand site expectations -Meet with site mentor regarding project idea -Communicate with site mentor to determine cardiac dedicated therapists -Complete initial post with timeline -Submit MOU and IRB for review -Complete initial post -Complete 3 response posts -Finalize MOU -Create list of therapists with their emails -Complete initial post -Complete 3 response posts -Introduction draft -Create survey -Review OT Cardiac Reference Manual Anticipate completion by 1/16 2 Screening/Evalu ation -Gather list of therapists to send survey to 3 Screening/Evalu ation -Create survey (include information on therapists credentials to add to validity to project) -Independently explain at least three conditions/diagnos es in detail -Research and find sites to send survey with (Survey Monkey, etc.) -Review OT Cardiac Reference Manual provided by educator Anticipate completion by 1/23 Anticipate completion by 1/30 23 CARDIAC PRE-OPERATIVE SCREENING TOOL 4 Implementation -Begin to gather list of questions from therapists -Will manage medical lines with moderate assistance -Send survey to therapists -Practice managing medical lines daily throughout capstone to gain more experience -Combine questions addressed by therapists in Word document 5 Implementation -Gather results from therapists 6 Implementation -Gather results from therapists -Combine questions addressed by therapists in Word document 7 Implementation -Gather results from therapists -Independently explain at least six conditions/diagnos es in detail -Will independently write all notes in the ICU with minimal assistance -Combine questions addressed by therapists in Word document -Review OT Cardiac Reference Manual provided by educator -Write notes daily and ask for feedback from educator -Complete initial post -Complete 3 response posts -Background draft -Create Word document for questions -Complete initial post -Complete 3 response posts -Design and implementati on draft -Organize questions into categories -Complete initial post -Complete 3 response posts -Continue to organize questions into categories -Complete initial post -Complete 3 response posts -Continue to organize questions into categories -Review OT Cardiac Reference Manual Anticipate completion by 2/6 Anticipate completion by 2/13 Anticipate completion by 2/20 Anticipate completion by 2/27 24 CARDIAC PRE-OPERATIVE SCREENING TOOL 8 Implementation -Finalize gathering results from therapists 9 Implementation -Review results from survey -Develop template screening tool 10 Implementation -Work on screening tool -Independently explain at least ten conditions/diagnos es in detail -Will independently provide education to the patient and their family in the ICU 11 Implementation -Assess wording of questions -Ask for therapists feedback -Combine questions addressed by therapists in Word document -Send out email/ask therapists if survey still needs completed -Ensure all questions are in Word document -Create categories for similar questions -Review formatting of past screening tools -Review OT Cardiac Reference Manual provided by educator -Continue to practice daily educating patients on post-operative precautions, etc. -Complete initial post -Complete 3 response posts -Continue to organize questions into categories Anticipate completion by 3/6 -Complete initial post -Complete 3 response posts -Design screening tool Anticipate completion by 3/13 -Complete initial post -Complete 3 response posts -Outcomes draft -Input questions into screening tool template -Review OT Cardiac Reference Manual Anticipate completion by 3/20 -Use Grammarly to address spelling and grammar -Print out questions for -Complete initial post -Complete 3 response posts Anticipate completion by 3/27 25 CARDIAC PRE-OPERATIVE SCREENING TOOL therapists to review Disseminatio n plan -Print out questions for therapists to review -Complete initial post -Complete 3 response posts -Print out questions for therapists to review 12 Implementation -Finalize screening tool -Ask for therapists feedback regarding tool -Review formatting, spelling, and grammar -Print out screening tool for therapists to review 13 Discontinuation -Finalize screening tool -Review formatting, spelling, and grammar 14 Dissemination -Complete initial post -Complete 3 response posts -Present -Email -Complete assessment tool to screening tool initial post rehab department to therapists and -Complete 3 and surgeons surgeons office response -Treat full caseload posts with line-of-site Abstract, supervision summary, and conclusion draft -Email screening tool Anticipate completion by 4/3 Anticipate completion by 4/10 Anticipate completion by 4/17  ...