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... 1 Scapular Dyskinesis and Physical Activity in Healthy College Students Contessa Brown, Kathryn Kittaka, Stefani Manchick, Kayla Olson, Jennifer Schepers, & Samantha Wallenberg December 13, 2019 A research project submitted in partial fulfillment for the requirements of the Doctor of Occupational Therapy degree from the University of Indianapolis, School of Occupational Therapy. Under the direction of the research advisor: Lucinda Dale, EdD, OTR, CHT, FAOTA 2 A Research Project Entitled Scapular Dyskinesis and Physical Activity in Healthy College Students Submitted to the School of Occupational Therapy at the University of Indianapolis in partial fulfillment for the requirements of the Doctor of Occupational Therapy degree. By: Contessa Brown, OTS, Kathryn Kittaka, OTS, Stefani Manchick, OTS, Kayla Olson, OTS, Jennifer Schepers, OTS, & Samantha Wallenberg, OTS Approved by: Research Advisor (1st Reader) Date 2nd Reader Date Accepted on this date by the Chair of the School of Occupational Therapy: Kate E. DeCleene Huber, OTR, MS, OTD Chair, School of Occupational Therapy Date 3 Abstract The primary purpose of this study was to quantify healthy college students scapula movement through the use of the Scapular Dyskinesis Test (SDT) and physical activity levels through the use of the International Physical Activity Questionnaire (IPAQ). The secondary purpose was to determine if there was a relationship between SDT and IPAQ scores. The investigators used a prospective, quantitative design and gathered data from 54 participants. Results showed that more than half of the participants had normal scapular ratings and high physical activity levels; however, more than 40% showed asymptomatic subtle or obvious dyskinesis in one or both of the scapula. Total hours of daily sitting exceeded hours that students were active. There were no significant relationships between the SDT and IPAQ. Sitting hours were similar among SDT and IPAQ scores. Participants were predominantly female graduate occupational therapy (OT) and physical therapy students; the majority of participants were employed. Participants could be at an increased risk for musculoskeletal disorders (MSD) and impaired occupational performance due to asymptomatic scapular dyskinesis. Participants with high IPAQ scores may misperceive that physical activity ensures normal scapulohumeral rhythm. Although the IPAQ can yield objective measures of physical activity, it is not a measurement of specific muscle function that impacts scapular dyskinesis. Clinicians and researchers can use the SDT as a screening tool to determine the presence of scapular dyskinesis in healthy college students. Keywords: scapulohumeral rhythm, International Physical Activity Questionnaire (IPAQ), fatigue, range of motion (ROM), sedentary lifestyle 4 Scapular Dyskinesis and Physical Activity in Healthy College Students The scapula is a stable base for glenohumeral (GH) joint mobility in a healthy shoulder (Kanik et al., 2017). The serratus anterior (SA), upper trapezius (UT), lower trapezius (LT), and middle trapezius (MT) are the most important muscles for positioning of the scapula and are the main contributors to scapular movement during scapulohumeral rhythm (Castelein, Cagnie, Parlevliet, & Cools, 2016a; Castelein, Cools, Parlevliet, & Cagnie, 2016; Fedorowich, Emery, Gervasi, & Ct, 2013). Scapulohumeral rhythm is the combination of GH motion and scapular upward rotation resulting from muscle contraction at the GH and scapulothoracic (ST) joints during shoulder elevation (Greene & Roberts, 2015, Chapter 8). Normal scapulohumeral rhythm occurs when the scapula remains stable during the first 30 to 60 of humerothoracic elevation, smoothly upwardly rotates during elevation, and downwardly rotates during humerothoracic lowering (McClure, Tate, Kareha, Irwin, & Zlupko, 2009). Shoulder kinematics related to GH abduction, GH rotation, and scapula upward rotation and anterior tipping contribute to participation in activities of daily living (ADLs), including feeding, combing hair, reaching overhead, and washing contralateral axilla and back (Rundquist, Obrecht, & Woodruff, 2009, p. 627). Scapular dyskinesis is the abnormal movement and positioning of the scapula in relation to the thorax and GH joint (Cools et al., 2014; Kibler & McMullen, 2003). McClure et al. (2009) defined scapular dyskinesis as winging, dysrhythmia, or both. Dysrhythmia was defined as the scapula [demonstrating] premature or excessive elevation or protraction, nonsmooth or stuttering motion during arm elevation or lowering, or rapid downward rotation during arm lowering and winging was defined as the medial border and/or inferior angle of the scapula [being] posteriorly displaced away from the posterior thorax (McClure et al., 2009, p. 162). Scapular 5 dyskinesis can result from a slouched posture, muscle strength imbalance, fatigue of the ST muscles, and stiffness of the soft tissue that surrounds the scapula (Andersen, Andersen, Zebis, & Sjgaard, 2014; Cools et al., 2014; Lee et al., 2016). Problems that result from scapular dyskinesis include shoulder and neck pain, predisposition to shoulder impingement syndrome, and disruption of shoulder and scapular movements, leading to greater risk of injury of the ST joint (Castelein et al., 2016a; Castelein et al., 2016; Cools et al., 2014; Escamilla, Hooks, & Wilk, 2014). As noted by Cooper (2014), dysfunction of scapulohumeral rhythm can result in significant impairment of the entire upper extremity (UE) and occupational performance limitations due to pain and reduced motor control (p. 219). For individuals whose occupational performance includes sustained overhead tasks, there is a greater risk of developing musculoskeletal pathologies when endurance of ST and GH muscle is impaired (Chopp-Hurley, ONeill, McDonald, Maciukiewicz, & Dickerson, 2016; Grassi, Rossiter, & Zoladz, 2015; Kozina, Repko, Ionova, Boychuk, & Korobeinik, 2016). Muscle endurance was defined as the time limit of work produced by a muscle at a given strength or speed of muscle contraction (Kozina et al., 2016; Manske, 2015). Fatigue occurs when there is reduced muscle power and strength (Grassi et al., 2015), and can result in impaired movements, reduced ability to maintain static postures, and compensation patterns (Lee et al., 2016; Sheard, Elliott, Cagnie, & OLeary, 2012). According to Healthy People 2020, more than 80% of adolescents do not meet the guidelines for aerobic physical activity and more than 80% of adults do not meet the recommended guidelines for aerobic and muscle strengthening activities (Office of Disease Prevention and Health Promotion [ODPHP], 2014). Melton, Bigham, Bland, Bird, and Fairman (2014) reported the average general technology usage of 578 college students to be 808.05 6 minutes per week. Lepp, Barkley, and Karpinski (2015) suggested that cell phone use alone distracts students from participating in physical activity, resulting in a more sedentary lifestyle (Smith, 2015). Sedentary behavior was defined as expending small amounts of energy and not meeting physical activity guidelines (Sedentary Behavior Research Network [SBRN], 2012). The increase in technology use and sedentary behavior in college students places them at risk for disorders and dysfunction of scapulohumeral rhythm and ST muscle function (Lepp et al., 2015; ODPHP, 2014; Smith, 2015). McClure et al. (2009) developed the SDT to identify abnormalities in scapular motion including winging, dysrhythmia, or both. The SDT requires individuals to repeatedly lift loads through shoulder flexion and shoulder abduction, reflecting loads lifted during ADLs (McClure et al., 2009). In addition to the SDT, researchers have used fatigue protocols to study scapula muscle endurance in healthy participants (Chopp-Hurley et al., 2016; Kanik et al., 2017). In a systematic review, Hickey, Solvig, Cavalheri, Harrold, and Mckenna (2018) found that asymptomatic athletes with scapular dyskinesis, as measured by visual dynamic assessments and physical landmarks, were 43% more likely to develop shoulder pain. Athletes time to fatigue and ST muscle endurance have been studied but scapular dyskinesis in a healthy college student population has not been described (Eraslan, Gelecek, & Genc, 2013; Zabihhosseinian, Holmes, Howarth, Ferguson, & Murphy, 2017). The purpose of this study was to quantify college students scapula movement using the SDT and physical activity using the IPAQ, and to determine if there was a relationship between the SDT and IPAQ scores. Literature Review Researchers have described multiple methods of assessing scapula movement, with no single method identified as superior. According to researchers reports, the testing procedures for 7 scapular movement can be categorized by their primary methodology: isometric exercises, shoulder flexion and abduction elevation exercises, fatigue protocols, and slouched posture positioning. Researchers have studied ST muscle activity using different static positions of the shoulder range of motion (ROM) arc with varied amounts of resistance applied and time sustained (Eraslan et al., 2013; Ha et al., 2012; Miyasaka et al., 2016; Peterson, Domino, & Cook, 2016). Ha et al. (2012) measured muscle activity during a series of shoulder elevation isometric exercises, including wall facing arm lift (WAL), prone arm lift (PAL), backward rocking arm lift (BRAL), and backward rocking diagonal arm lift (BRDAL) (Ha et al., 2012). Subjects maintained each position for 6 s with maximal effort against manual resistance (Ha et al., 2012). Ha et al. (2012) showed that during the BRAL exercise, the SA was significantly greater in maximal voluntary isometric contraction (MVIC) = 60.04 compared to PAL = 38.21, WAL = 43.33, and BRDAL = 43.48. Eraslan et al. (2013) similarly examined muscle endurance by instructing participants to flex their shoulders and elbows to 90, hold a digital dynamometer, and externally rotate their shoulders until 1-kg of resistance was attained. Muscle endurance was determined by the length of time the position and resistance were maintained (Eraslan et al., 2013). Eraslan et al. (2013) determined that decreased scapular endurance caused deviations in scapular mechanics and led to an increased risk of injury. In order to prescribe appropriate ST exercise for clients, researchers have measured ST muscle activity during shoulder elevation and abduction exercises (Castelein, Cagnie, Parlevliet, & Cools, 2016b; Nakamura, Tsuruike, & Ellenbecker, 2016). Castelein et al. (2016b) measured UT, MT, LT, and SA activity during elevation in the scapular plane, towel slide against a wall, and elevation with external rotation of a Thera-Band. Researchers concluded that elevation with 8 resisted external rotation enhanced MT and LT activity and elevation in the scapular plane produced increased UT, MT, LT, and SA muscle activity (Castelein et al., 2016b). Similarly, Nakamura et al., (2016) measured muscle activity of the UT, LT, and SA during 12 sets of five repetitions of the robbery exercise in two positions: 20 shoulder abduction and 90 shoulder abduction. Nakamura et al. (2016) found SA, UT, and LT activity increased during exercises conducted in a position of 90 abduction, which may have been due to the presence of scapular dyskinesis. This led researchers to conclude that posture and shoulder positions impacted muscle activity (Nakamura et al., 2016). During elevation exercises in the scapular plane, Castelein et al. (2016) determined that participants with neck pain and scapular dyskinesis showed lower MT activity compared to the control group. Fatigue protocols have been used by researchers with and without added resistance to assess ST muscle activity during shoulder elevation (Calvin, Keir, & McDonald, 2016; ChoppHurley et al., 2016; Kvist & Bang, 2016). Kvist and Bang (2016) and Chopp-Hurley et al. (2016) used resistance during repetitive shoulder elevation to study muscle fatigue. In both studies, researchers found altered positioning or movement of the scapula resulting from fatigue of ST muscles, which can impair scapulohumeral rhythm and induce pain (Chopp-Hurley et al., 2016; Kvist & Bang, 2016). Fedorowich et al. (2013) and Calvin et al. (2016) examined fatigue during repetitive pointing and work-related tasks without added resistance. Similar to studies in which researchers used resistance, fatigue caused by work-related tasks resulted in pain and substitution patterns of neighboring scapula muscles (Calvin et al., 2016). The results of these studies indicate that kinematic compensatory strategies emerge as muscles fatigue with repetitive tasks 9 (Chopp-Hurley et al., 2016). In contrast to others findings, the researchers determined there were gender differences with respect to fatigue of periscapular muscle. Researchers have studied ST muscle activity utilizing different postures during arm elevation (Lee et al., 2016; Malmstrm, Olsson, Baldetorp, & Fransson, 2015). Lee et al. (2016) measured the effects of slouched posture on LT, MT, and SA muscle activity. Participants abducted their shoulders to 90 in the scapular plane and held the position for 10 s (Lee et al., 2016). Participants then abducted their shoulders to 90 in a slouched posture to examine the effects of poor posture (Lee et al., 2016). Malmstrm et al. (2015) examined muscle activity of the UT, LT, and SA in an upright posture and slouched posture with an emphasized thoracic curve. In both postures, participants completed one arm elevation exercise with their arms and elbows extended (Malmstrm et al., 2015). The evidence from both studies indicated LT activity increased during slouched postures (Lee et al., 2016; Malmstrm et al., 2015). In addition, Lee et al. (2016) found increased activity of the MT and Malmstrm et al. (2015) found increased activity of the UT and SA in slouched postures. Authors of both studies concluded that slouched postures can lead to shoulder pain or injury as a result of increased muscle fatigue (Lee et al., 2016; Malmstrm et al., 2015). Calik, Yagci, Gursoy, and Zencir (2014) studied the effects of computer use on the UE of 871 students with pain and discomfort of the neck, shoulders, upper back, and lower back. The researchers determined that musculoskeletal system discomforts of the neck, shoulders, and upper back, were correlated with the time spent on computers (Calik et al., 2014). The findings of Calik et al. (2014), Lee et al. (2016), and Malmstrm et al. (2015) support the need for researchers to investigate the influence of sedentary behavior on the dynamics of shoulder function and mobility. 10 Hyperactivity of ST muscles affects scapular kinematics and contributes to conditions like subacromial impingement syndrome and scapular dyskinesis. Dysfunction associated with these conditions can result in increased pain in the neck and shoulder regions (Castelein et al., 2016a; Chopp-Hurley et al., 2016; Lee et al., 2016). Likewise, individuals with scapular dyskinesis or shoulder or neck pain have been shown to have abnormal UT, MT, LT, and SA activity (Casetlein et al., 2016a; Castelein et al., 2016b; Ersalan et al., 2013; Hanvold et al., 2013; Peterson et al., 2016). Proper functioning of the ST musculature decreases the risk of discomfort in MT and LT and/or the development of scapular dyskinesis (Lee et al., 2016). Researchers have analyzed ST muscle activity in healthy subjects and compared them to subjects with a history of shoulder disorders, shoulder pain, or neck pain (Castelein et al., 2016a; Castelein et al., 2016b; Ersalan et al., 2013; Hanvold et al., 2013; Peterson et al., 2016). However, scapular dyskinesis can be found in those who do not suffer from shoulder pain (Plummer, Sum, Pozzi, Varghese, & Michener, 2017). Additionally, researchers have analyzed scapular kinematics in a healthy population that included predominantly male subjects, providing a limited representation of abnormal scapular kinematics (Calvin et al., 2016; Chopp-Hurley et al., 2016; Lee et al., 2016; Malmstrm et al., 2015; Miyaska et al., 2016; Nakamura et al., 2016). Ha et al. (2012) and Kvist and Bang (2016) studied healthy male and female participants but sample sizes were too small to generalize results. Only one study was found in the reviewed literature that included healthy college students (Nakamura et al., 2016). However, the sample was limited to males and the sample was too small to generalize results (Nakamura et al., 2016). Although researchers have measured scapular dyskinesis in healthy persons, few have studied the healthy college student population or have taken into consideration students activity participation. Time spent sitting, exercising, and types of exercises should be taken into 11 consideration when measuring scapular dyskinesis. Researchers have inconsistently used a single outcome measure for scapular kinematic dysfunction. The SDT can serve as a dynamic method of assessment with sound psychometric properties and clinical utility, as it can be administered within a few minutes, using free-hand weights that are typically available in most clinics. Despite the sound psychometric properties of the IPAQ, investigators found that it is not often utilized to determine an individual's activity level. In this study, investigators used the SDT to determine the presence of scapular dyskinesis and the IPAQ to quantify physical activity. Method The investigators used a prospective, quantitative design with a single cohort for this study; two instruments, the SDT and IPAQ, were utilized to measure scapular dyskinesis and physical activity, respectively. Scapular Dyskinesis Test The SDT is a visual assessment used to determine if scapular dyskinesis is present. Scapular dyskinesis is identified by alterations in movement and positioning of the scapulae, which are visually distinguished as scapular winging or asymmetry (Tate, McClure, Kareha, Irwin, & Barbe, 2009). The SDT is performed by completing five repetitions each of resisted bilateral shoulder abduction and flexion. The pace of the motions is 5 s for elevation and 5 s for return to start position. The test motions are conducted with either three pound or five pound dumbbells depending on the individuals weight (McClure et al., 2009). McClure et al. (2009) rated scapular movement as normal, subtle, or obvious dyskinesis based on researchers observations. A normal rating was defined as no abnormal scapular movements (McClure et al., 2009). Inconsistency of scapular movement indicated a rating of subtle (McClure et al., 2009; Tate et al., 2009). Obvious scapular dyskinesis was defined as 12 scapular winging or asymmetry (Tate et al., 2009). A final unilateral rating was reported as normal if either both flexion and abduction motions were rated as normal or if one motion was rated as normal and the other motion was rated as subtle (McClure et al., 2009). A final unilateral rating of subtle was reported if both flexion and abduction motions were rated as subtle (McClure et al., 2009). A final unilateral rating of obvious was reported if either flexion or abduction motions were rated as obvious (McClure et al., 2009). Right and left scapulae were scored separately (McClure et al., 2009). There are no normative data for the SDT. To establish interrater reliability, McClure et al. (2009) conducted a study with 142 National Collegiate Athletic Association athletes who participated in sports that required overhead use of UEs, due to the higher incidence of shoulder injury in this population. The researchers focused on how the participants scapulae were positioned on the thorax during flexion and abduction (McClure et al., 2009). McClure et al. (2009) showed the SDT to have moderate interrater reliability for researchers who filmed (kw = 0.57) and rated scapular dyskinesis (kw = 0.54) (McClure et al., 2009). The SDT has also been established as a valid measure to identify scapular dyskinesis (Tate et al., 2009). Tate et al. (2009) conducted a study with 66 participants recruited from the McClure et al. (2009) study. Participants were instructed to refrain from any sport or demanding activity that could influence scapula/shoulder performance (McClure et al., 2009). Threedimensional kinematic testing via electromyographic (EMG) was used to measure muscle activity during humeral elevation to observe scapular motion (Tate et al., 2009). Analyses showed that individuals with less scapula upward rotation also had obvious dyskinesis (Tate et al., 2009). 13 In the current study, investigators selected the SDT due to established psychometric properties, training materials and procedures, and practical clinical use. The investigators had participants perform five repetitions of resisted bilateral shoulder flexion and abduction during the SDT (Tate et al., 2009). International Physical Activity Questionnaire The IPAQ is a questionnaire that measures physical activity or inactivity to obtain health related quantitative information (Craig et al., 2003). Craig et al. (2003) recommended using the long version of IPAQ for research purposes. The long version of the questionnaire includes four activity domains that are scored independently. The four domains include, leisure time physical activity, domestic and gardening (yard) activities, work-related physical activity, and transportrelated physical activity (International Physical Activity Questionnaire [IPAQ], 2005, p. 2). Participants rated their physical activity based on the previous seven days (Craig et al., 2003). The IPAQ scores can be reported as a continuous value or a categorical value. The continuous score represents the median metabolic equivalent of task (MET) minutes for walking, moderate intensity activity, and vigorous intensity activity per week for each domain (IPAQ, 2005). A MET minute represents energy expenditure and is calculated by multiplying the MET score by the time (in minutes) spent on each activity. A total physical activity score is calculated by summing the MET minutes from each domain (IPAQ, 2005). The categorical values represent low, moderate, or high levels of physical activity (IPAQ, 2005). The total time participants sit each day and week, per minute, is recorded and scored separately from the total weekly physical activity score (Craig et al., 2003; IPAQ, 2005). Craig et al. (2003) established test-retest reliability of the long IPAQ form by administering the form twice within seven to ten days. Nonparametric Spearman correlation 14 coefficients were calculated to measure the relationship of scores between the two administrations. Test-retest reliability ranged from 0.79-0.82 for the long form and 0.70 for the sitting recall portion. The categorical data were then used to calculate the percentage agreement and an overall high percentage agreement was calculated as 0.84 to 1.0 (Craig et al., 2003). Craig et al. (2003) established validity from the participants reported activity levels and monitor data, which were stored and summed in one-minute intervals. There were similar correlations when comparing the sitting data from the IPAQ and the sitting estimate from the accelerometer, indicating an agreement between objective and subjective sedentary behavior measures. The frequency, duration, and intensity of physical activity, along with the assessment of sedentary behavior showed the IPAQ to have a concurrent validity range between 0.42 to 1.0 and criterion validity range between 0.05 and 1.0 (Craig et al., 2003). Participants Inclusion criteria included enrollment as a student at the university and the ability to move both scapulae through normal movements during the SDT. Exclusion criteria included shoulder surgery within the past year, pain in shoulder or scapulae, and injury to the shoulders, arms, or back within the past month. Recruitment for this study was completed through electronic mail and flyers distributed campus wide at a private university in the Midwest. Investigators distributed the informed consent to each participant and answered questions before obtaining signed consent forms. Procedures The investigators submitted their study to the Human Research Protections Program and were approved as exempt. They completed the Collaborative Institutional Training Initiative program courses, Human Subjects Research and Healthy Related Research Course Learner 15 Group with a score of at least 80%. The investigators underwent standardized training via a selfinstructional slide presentation designed by McClure et al. (2009) to administer and score the SDT. They also completed a training session to learn how to use the video camera and how to save and remove the films of the SDT to a hard drive. Data Collection The investigators administered and scored the SDT according to McClure et al. (2009) three times with the first six participants, 48 hours in between sessions, in order to determine intra-rater and test-retest reliability. The SDT was completed one time for remaining participants. In addition to procedures established by McClure et al. (2009), investigators assured full viewing of the scapula by having participants wear a towel wrap and use a shower cap; shower caps also disguised participants identities. To remove potential bias, investigators gave participants assigned numbers for all data gathered; films of the SDT were saved and rated by two investigators not involved in the filming. Participants completed a questionnaire that included the IPAQ. Demographic information included their age, gender, height, weight, activity level (participation in sports or time spent exercising), and type of academic degree. Data Analysis Intra-rater, test-retest, and inter-rater reliability of the SDT were established from the first six participants using percent agreement (Portney & Watkins, 2009). SDT scores were analyzed using descriptive statistics to report frequencies of normal scapula movement, obvious dyskinesis, and subtle dyskinesis. SDT and IPAQ scores were analyzed using a chi-square test to determine the relationship between scapular dyskinesis and low, moderate, and vigorous physical activity level. To determine if there were differences in sitting and BMI among the SDT and IPAQ scores, a one-way ANOVA was used. Interrater reliability was calculated using the kappa 16 coefficient and percent agreement after the SDT data collection was completed. Body mass index (BMI) was calculated from participants' height and weight and was included in descriptive statistics (Centers for Disease Control and Prevention, 2017). Demographic data were analyzed using descriptive statistics. The SPSS version 25.0 software was used for statistical analysis and a significance level set at p < .05. To determine if the current sample of participants met the Centers for Disease Control (CDC) and American College of Sports Medicine (ACSM) guidelines of 150 minutes of physical activity per week, the total weekly physical activity in minutes was calculated for comparison (Craig et al., 2003; Pate et al., 1995; U.S. Department of Health and Human Services, 2018). Results After the first six participants were filmed, investigators observed inconsistencies in participants speed and ROM arc completion during the SDT. In order to standardize performance of the SDT, the investigators used a metronome to create a voice recording of an investigator counting out the pace for the five repetitions of shoulder flexion and abduction. This recording was played for all participants in this study to increase the consistency and accuracy of the SDT. The data of the original six participants of this study were removed from data analysis and another six participants were filmed to determine test-retest reliability. Following the adaptations, investigators gathered data from 58 participants; data from four participants were removed due to incomplete IPAQ information and/or lack of full ROM during the SDT. The final sample of 54 were predominantly female graduate OT and physical therapy students, who were employed and had a normal BMI as shown in Table 1. Percent agreement for the primary investigator (rater 1) and student rater (rater 2) were 100% and 69%, respectively, for intra-rater and test-retest reliability of the SDT for the first six 17 analyzed participants. When comparing ratings of the SDT of rater 1 and rater 2, percent agreement for the left scapula was 61% and for the right scapula was 72% (n = 54) for the entire sample. Correction for chance agreement using Cohens kappa for the left scapula was .323 (p = .001) and for the right scapula was .403 (p < .0005), showing fair agreement between the primary investigator and student rater for the sample (n = 54). Only scores of the SDT rated by the primary investigator were included in the data set for analyses of the entire sample. Scores from only the first session of the first six participants were included in the data set for analyses of the entire sample. More than half of the participants had normal scores for the SDT with more than 40% showing either subtle or obvious dyskinesis as shown in Table 2. The student investigator results are identified in Table 3. There were no significant relationships between the SDT and IPAQ, x (4, N = 54) = 6.151, p = .188, left, and x (4, N = 54) = 4.719, p = .317, right. There were no significant differences in BMI among the IPAQ categories, ANOVA F (2, 51) = .915, p = .407 or in sitting hours among the IPAQ categories, ANOVA F (2, 51) = 1.924, p = .156. There were no significant differences in BMI among the SDT ratings, ANOVA F (2, 51) = .769, p = .469, left, or ANOVA F (2, 51) = 1.813, p = .173, right. No significant differences were found in sitting hours among the SDT ratings, ANOVA F (2, 51) = .580, p = .564, left, or ANOVA F (2, 51) = 1.813, p = .173, right. As shown in Figure 1, participants sitting hours, on average, exceeded their activity hours. Students reported daily averages of 6.84 hours of sitting and 2.33 hours of physical activity, as defined by the IPAQ. Results of total sitting per week and total sitting per day are listed in Table 4. Participants more often scored in the high IPAQ category, shown in Table 4, with additional IPAQ results. According to the CDC-ACSM, 86.79% of the participants met either moderate or vigorous intensity guidelines for activity. 18 Discussion The investigators found that healthy college students more frequently had SDT scores classified as normal however, when the categories of subtle and obvious were combined, the sample showed more than 40% had either subtle or obvious scapular dyskinesis in one or both of the scapula. The SDT scores of normal may under represent participants who have subtle scapular dyskinesis because a unilateral rating of normal is assigned if flexion and abduction motions are rated as normal or if one motion is rated as normal and the other motion is rated as subtle. Likewise, the SDT scores of subtle may under represent participants who have obvious scapular dyskinesis. A unilateral rating of obvious is assigned if flexion and/or abduction are rated as obvious for three out of five ratings. In the presence of subtle or obvious dyskinesis, a clinician may decide to intervene regardless of the SDT rating (Tate et al., 2009). Obvious dyskinesis is a stronger reason for intervention, whereas the decision to intervene with subtle dyskinesis is more dependent on clinical judgement (Tate et al., 2009). The findings of this study contrast with those of Akodu, Akinbo, & Young (2018), who found that health science college students more frequently presented with abnormal scapular dyskinesis. Only indirect comparisons can be made to the results of Akodu et al. (2018) because the researchers used the SICK scapula static measurement that yielded presence or absence of scapular dyskinesis. Scapular dyskinesis was defined as asymmetry of the scapulae as participants stood in a static position (Akodu et al., 2018). In the current study, investigators rated unilateral scapula movement as normal, subtle dyskinesis, or obvious dyskinesis, as recommended by McClure et al. (2009). Investigators in the current study found no association between the IPAQ categories and scapular dyskinesis. Sedentary behavior can lead to generalized weakness, which has been 19 shown to place students at increased risk for dysfunction and disorders of ST muscle function (Lepp et al., 2015; ODPHP, 2014; Smith, 2015). Conversely, researchers have found that UE exercise training can improve kinematic function of the scapula and prevent the development of shoulder pathologies (Andersen et al., 2014; Cho, Lee, Kim, Hahn, & Lee, 2018). Only indirect comparisons from the literature can be made to the current study because participants did not report specific exercise routines. Although sedentary individuals can have risk for dysfunction and disorders of ST muscle function, active individuals who do not exercise ST muscles could also be at risk. High levels of activity as measured by the IPAQ do not necessarily involve exercises for the ST muscles. Participants in the current study were asymptomatic and could incorrectly assume that their physical activity will prevent scapular dyskinesis. Moreover, the inability to visualize their own scapulae presents another reason for a lack of awareness of scapular dyskinesis. Therefore, it is imperative to consider function of ST musculature during screenings and assessments by clinicians. Healthy college students in this study more frequently had IPAQ scores of high because the IPAQ classifies high physical activity as either a minimum of 1500 MET/minutes per week of vigorous-intensity activity or a minimum of 3000 MET/minutes per week of a combination of walking, moderate-intensity, or vigorous-intensity activity (IPAQ, 2005). Participants were meeting or exceeding these requirements, however, the IPAQ results showing high activity levels can be misleading because the total physical activity is not inclusive of how the rest of the time is spent, including time spent sitting. Although participants met the weekly physical activity guidelines, daily sitting exceeded daily active hours, comprising 28% of the students' day for the latter. The CDC and Prevention has indicated that increasing physical activity and decreasing time spent sitting can reduce overall health risks, however no recommendations for daily or 20 weekly maximum time spent sitting have been established (Pate et al., 1995; U.S. Department of Health and Human Services, 2018). A possible explanation for high IPAQ scores is that the majority of the participants were health-science majors. The findings of this study are consistent with Haddock and Gaines (2013) who found that kinesiology students reported healthier exercise behaviors and greater motivation to exercise than did non-kinesiology students. All participants in the current study had BMIs classified as normal. This may be explained by those with lower BMIs choosing to participate in the study due to having greater comfort in exposing their anatomy and reporting body weight on the questionnaire. These findings are consistent with those of Akodu et al. (2018); the healthy college aged sample with students in the physiotherapy department had a mean BMI score of 23.6, which is classified as normal. However, Osborn, Naquin, Gillan, and Bowers (2016), reported that 49% of college age sample had BMIs that were classified as overweight or obese. Sedentary lifestyle in a collegiate population may be related to the increased time spent completing academic requirements which could contribute to higher BMIs. In professional practice clinicians who use the SDT as a screening tool for shoulder pain or disorders should also utilize other methods of evaluations (Hickey et al., 2018; McClure et al., 2009). The prevalence of scapular dyskinesis is relatively equal between persons with and without pain (Kibler et al., 2013). Therefore, it is important that clinicians screen for scapular dyskinesis in both symptomatic and asymptomatic populations (Hickey et al., 2018; Kibler et al., 2013). Clinicians should consider the impact of scapular dyskinesis when working with clients that experience difficulty during ADLs (Rundquist et al., 2009). Scapulohumeral rhythm has a significant impact on the functional ability to bathe, comb hair, reach overhead, and bring utensils to the mouth while eating (Rundquist et al., 2009). Appropriate shoulder kinematic 21 function significantly impacts an individual's ability to perform ADLs that require the use of overhead UE movements (Rundquist et al., 2009). Because of the expertise of the primary investigator, only the ratings of the primary investigator were used in analyses of the SDT. Ratings of the SDT of the student rater and clinician rater showed only fair agreement which is in contrast to McClure et al. (2009). This finding can be explained by McClure et al. (2009) using raters that were athletic trainers and physical therapists to view and determine SDT in 1 or 2 viewings of videotaped participants. Completion of educational programs required for entry into professional practice and clinical experience of the athletic trainers and physical therapists could have contributed to better agreement in rating. The student rater in the current study had completed only two of five semesters of an entry-level OT curriculum that included fieldwork settings of outpatient pediatrics, acute care, and community-based at the time of rating the SDT. Student ratings in the current study may have shown better agreement with the clinician ratings if the data collection and analysis had occurred after additional course completion that focused on assessments or if fieldwork had included clients with shoulder conditions. Additionally, the students ratings may have shown better agreement with the primary investigator if training had been supplemented beyond those of McClure et al. (2009). Uhl, Kibler, Gecewich, and Tripp (2009) found that rating of the SDT was more accurate when raters used the yes/no method to indicate presence or absence of scapular dyskinesis, however a portion of those participants that were rated also had a shoulder injury. It could be that the SDT rating system that allows 3 ratings creates more variability among raters. It could also be that forced choice with limited viewings improves interrater reliability in contrast to researchers viewing unlimited times to rate scapula movement 22 in the current study. Moreover, it could be that accuracy is greater when rating symptomatic shoulders in contrast to asymptomatic shoulders in the current study. Limitations Data collection was conducted in a single building of health science programs on a Midwestern college campus, which contributed to a lack of diversity among participants. Therefore, the results are not applicable to the general college student population. Potential participants may have eliminated themselves from participation due to the discomfort of exposing their scapulae and identifying their body weight during dumbbell weight selection. Participants may not have used the appropriate dumbbell weight during the SDT due to not knowing or wanting to share their weight. Some participants were filmed more than once within the same session because of their unsuccessful attempts to complete full ROM during shoulder flexion and abduction. These participants completed more repetitions than other participants, potentially causing fatigue. A recording of a researcher counting from one to five throughout the performance of the SDT should be completed before data collection so that participants perform the SDT consistently. Providing a film of a researcher completing the SDT for participants to follow, would improve precision and accuracy in the performance of SDT. In order to ensure video quality is clear for viewing, researchers should make sure lighting is adequate and consistent throughout recordings. If multiple researchers perform the SDT, interrater reliability should be established prior to participants completing the SDT. If students are rating, it is suggested that students should receive additional training from an experienced clinician to ensure accuracy of ratings and the potential to achieve moderate or better interrater reliability. 23 Providing a scale for participants to weigh themselves privately prior to documenting weight and selecting a dumbbell, would verify accurate selection of weight for the SDT. Researchers who study healthy college students should recruit a more diverse sample. Conclusion Scapulohumeral rhythm has an important role in how one functions and participates in daily tasks and occupations. Shoulder kinematics are crucial to ADLs and instrumental activities of daily living that involve crossing midline to reach the opposite extremity or reaching overhead (Rundquist et al., 2009). The SDT can be a useful tool to identify healthy college students who exhibit scapular dyskinesis and would benefit from further assessment and intervention to restore normal scapular motion. Our study found that 40% of healthy college students had either subtle or obvious scapular dyskinesis in one or both of their scapulae, indicating the necessity to include the SDT in clinical screenings. The percentage may under represent those who have subtle or obvious scapular dyskinesis due to how the ratings are finalized. It is suggested that any abnormalities should be documented, even if the finalized SDT ratings are normal, as a part of the evaluation. Abnormalities in scapulohumeral rhythm can be asymptomatic, indirectly related to poor posture or sedentary lifestyle, and can result from muscle imbalance leading to development of MSD. Measurements of physical activity level and time spent sitting in college students are necessary to determine the influence of posture and sedentary lifestyle that could impact scapulohumeral rhythm. OT practitioners should consider the potential impact of scapular dyskinesis on occupational performance in asymptomatic student populations. 24 References Akodu, A. K., Akinbo, S. R., & Young, Q. O. (2018). Correlation among smartphone addiction, craniovertebral angle, scapular dyskinesis, and selected anthropometric variables in physiotherapy undergraduates. Journal of Taibah University Medical Sciences, 13(6), 528-534. doi:10.1016/j.jtumed.2018.09.001 Andersen, C. 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Retrieved from https://health.gov/paguidelines/second-edition/pdf/ 31 Zabihhosseinian, M., Holmes, M. W. R., Howarth, S., Ferguson, B., & Murphy, B. (2017). Neck muscle fatigue differentially alters scapular and humeral kinematics during humeral elevation in subclinical neck pain participants versus healthy controls. Journal of Electromyography and Kinesiology, 33, 73-82. doi:10.1016/j.jelekin.2017.02.002 32 Table 1 Participants Demographics Frequency (%) Gender Male Female n=54 n=4 (7%) n=50 (93%) College Major Occupational Therapy Physical Therapy Other n=54 36 (67%) 13 (24%) 5 (9%) College Year Graduate Undergraduate n=54 49 (91%) 5 (9%) Employed Yes No n=54 38 (70%) 16 (30%) Median Age n=53 23 Mean BMI n=53 23.531 SD: (+/- 2.698) Note. SD = standard deviation. 33 Table 2 Primary Investigator Scapular Dyskinesis Test Ratings Left SDT(%) Right SDT(%) Normal 29 (54%) 30 (56%) Subtle 13 (24%) 13 (24%) Obvious 12 (22%) 11 (20%) 54 54 Category: Total 34 Table 3 Student Investigator Scapular Dyskinesis Test Ratings Left SDT(%) Right SDT(%) Normal 36 (67%) 46 (85%) Subtle 10 (18%) 2 (4%) Obvious 8 (15%) 6 (11%) 54 54 Category: Total 35 Figure 1 36 Table 4 International Physical Activity Questionnaire Results Mean SD Range Weekly Sitting (minutes) Daily Sitting (minutes) 2926.67 410.16 +/-1005.39 +/-147.11 1080 - 46.20 137.14 - 651.43 IPAQ Categories (%) Low 4 (7%) Moderate 15 (28%) High 35 (65%) IPAQ Total MET Score Median Note. SD = standard deviation. 4329  ...

... Running head: EDUCATION, ADVOCACY, AND PROGRAM DEVELOPMENT 1 Education, Advocacy, and Program Development for Individuals with Disabilities Jordan Fiedler April 13, 2019 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 EDUCATION, ADVOCACY, AND PROGRAM DEVELOPMENT A Capstone Project Entitled Education, Advocacy, and Program Development for Individuals with Disabilities 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 Fiedler OTS Approved by: Faculty Capstone Advisor Date Doctoral Capstone Coordinator Date Accepted on this date by the Chair of the School of Occupational Therapy: Chair, School of Occupational Therapy Date 2 EDUCATION, ADVOCACY, AND PROGRAM DEVELOPMENT 3 Abstract Purpose: The purpose of this Doctoral Capstone Experience (DCE) project was to develop effective and inclusive safe transfer training for support staff at Garden Center Services (GCS), propose a plan to increase accessibility of the facility, and adjust wheelchairs and walkers to improve client positioning. Need: Through the use of the Americans with Disabilities Act (ADA) Checklist for Existing Facilities, many areas of inaccessibility in the buildings were identified. The majority of the consumers walkers were either too low or high, leading to improper ergonomics while using their walkers. The direct support staff (DSP) and day program director also identified a need to revamp the education on transfer training to staff. Implementation: From the accessibility assessment, a proposal plan was created including rankings of priority (low, medium, and high priority), cost, limitations due to inaccessibility, and recommendation of the changes needed. A new transfer training program was developed to be included within DSP training, including videos, hands-on practice, pre-/post-tests, competency forms, and handouts. Finally, each walker was adapted to the appropriate height for all individuals, and staff were trained in proper positioning for walkers and wheelchairs. Discontinuation: All training materials were provided to GCS for future use. The recommended accessibility changes will be completed in phases. The competency of staff for transferring consumers improved, and positioning and satisfaction from the consumers during functional mobility also increased. Keywords: accessibility, ergonomics, safe, competency EDUCATION, ADVOCACY, AND PROGRAM DEVELOPMENT 4 Background Information and Literature Review Background Information Garden Center Services (GCS) is an agency that provides housing and day programs for individuals with disabilities. GCS has two day programs between the State building and Kedzie building. The consumers of the agency range in abilities and disabilities including developmental delays, Down syndrome, hearing impairments, visual impairments, and more. The staff at GCS were not receiving adequate training from GCS on transfer training and mobility. The staff at GCS is comprised of direct support staff (DSP), day program managers, and nurses. The majority of the staff at GCS are DSPs whose qualifications are a high school degree without any previous experience needed. The purpose was to develop effective and inclusive safe transfer training for support staff at GCS. Guiding Model The model used to guide professional reasoning within the context of this doctoral capstone experience was the Ecology of Human Performance (EHP). The focus of the EHP is to look at the contexts of task performance, which include cultural, physical, and social environments. The person is made up of unique skills and abilities for cognitive, sensorimotor, and psychosocial domains (Cole & Tufano, 2008). Tasks are defined as the behaviors that are needed to complete an end goal (Cole & Tufano, 2008). Context is defined as the conditions that make up the persons surroundings and are put into two categories: temporal and environmental (Cole & Tufano, 2008). Personal-context-task transaction looks at the interaction between the person performing a task and their individual context(s), which leads to human performance (Cole & Tufano, 2008). When evaluating the staff and consumers, it was important to look at the transaction between the person-context-task to fully understand what was needed regarding EDUCATION, ADVOCACY, AND PROGRAM DEVELOPMENT 5 transfer training and staff education for the agency. By being an advocate and facilitator for the agency personnel, the focus was on gaining independence through needs and opinions to develop educational sessions and programs (Cole & Tufano, 2008). Motivation was increased by asking the person what they wanted and needed, so it was important to understand what the agencys motivation was to develop a program with the best fit. By adding the appropriate programming for the agency, this increased the performance range for the client, allowing them to be able to complete more tasks within their environment. Guiding Frame of Reference The focus of the biomechanical frame of reference (FOR) is on adaptation, compensation, and environmental modifications (Cole & Tufano, 2008). For the transfer training, it was important to understand all of the biomechanical principles to teach staff the best way to handle each consumers individual needs. The goal of the biomechanical FOR is to analyze the task demands when looking at occupation as a means of providing graded exercise or biomechanical interventions (Cole & Tufano, 2008). Within the biomechanical FOR, function can also be defined as using good body mechanics and ergonomics within daily life (Cole & Tufano, 2008). The goal of the program was to instill safe transferring and patient handling techniques among staff to prevent injuries among staff and consumers at GCS. Literature Review Factors inhibiting safety. A number of factors can affect safety while performing transfers (Aminzadeh, Edwards, Lockett, & Nair, 2000; King, Holliday, & Andrews, 2018). Inadequate space in bathrooms impacted the use of adaptive equipment and individuals from receiving ergonomic assistance due to care providers using awkward positioning, increasing risk of injury (King et al., 2018). Additional factors leading to fall risk included unsteady and EDUCATION, ADVOCACY, AND PROGRAM DEVELOPMENT 6 unpredictable clients along with non-secured throw rugs (Aminzadeh et al., 2000; King et al., 2018). Within bathrooms, use of inappropriate supports such as sinks, bath tubs, towel racks, doors, and curtain rods was another factor found to be hazardous due to the lack of grab bars (Aminzadeh et al., 2000). How to improve safety. Adaptive equipment (AE) was one way to increase the safety while performing a transfer (Kennedy, Arcelus, Guitard, Goubran, & Sveistrup, 2015; King & Novak, 2017; Kjellberg, Lagerstrom, & Hagberg, 2004; Stefanacci & Haimowitz, 2014). Showering and toileting transfers have been identified as some of the most hazardous activities among daily activities (Stefanacci & Haimowitz, 2014). Older adults and individuals with disabilities were reported to have greater instability than younger adults and individuals without disabilities, which increases the importance of transfer training for staff and individuals with disabilities (King & Novak, 2017). Transfer safety can be improved by ensuring the client is active in the transfer and with use of coordinated movements (Kjellberg et al., 2004). Results of Aminzadeh et al. (2000) indicated the importance and benefit of well-designed bathrooms to promote safety and independence of individuals in toileting, bathing, and grooming activities. Different aids that can increase safety include gait belts, draw sheets, bath mats, and grab bars (King et al., 2018; King & Novak, 2017; Kjellberg et al., 2004; Stefanacci & Haimowitz, 2014). When entering in and out of the bathtub, a loss of balance could occur, causing a person to take a lateral step, which is found to be difficult for older adults (King & Novak, 2017). By utilizing non-slip bath mats in and outside of the tub, postural control is increased, and lateral slip is reduced (Galeotafiore, 2019; King & Novak, 2017; Stefanacci & Haimowitz, 2014). Grab bars were indicated as another way to increase safety during transfers into the tub (King et al., 2018; Stefanacci & Haimowitz, 2014). Specifically, King and Novak (2017) recommended the EDUCATION, ADVOCACY, AND PROGRAM DEVELOPMENT 7 placement of vertical grab bars within tubs at entry-point and along the back to improve postural control when showering. Similarly, results indicated that vertical grab bar placement is preferred and increased safety for toileting (Kennedy et al., 2015). For older adults, elevation of a toilet by five-seven inches from standard toilet height of 15-17 inches increased leverage to stand (Stefanacci & Haimowitz, 2014). Transfer education. Proper transfer technique was important for professionals and the patient to ensure safety of all (Boninger, 2013; Kjellberg et al., 2004). Results indicated that higher scores for safety and comfort were reported if safe work techniques were used (Kjellberg et al., 2004). Effective transfer education included using videos, hands-on training, and assessment of competence of techniques learned (Claycomb, 2015). Communication of transfer education to staff and instructions to consumers during transfers with common language is important to maximize safety and cooperation. Another important factor in transfer training was knowing the limitations and barriers of each transfer, the client, and the equipment selected (Claycomb, 2015). In preparation for transfers, individuals should be educated on being close to transferring surface, locking of wheels on wheelchairs, and removing of obstacles (Boninger, 2013). Important ergonomic principles to teach during transfer training included keeping individuals being transferred as close to the transferrers body as possible and to transfer to level surface or to slightly downhill to increase safety of transfer (Boninger, 2013). Effects of training. Safe patient handling (SPH) is very important to protect the staff, protect consumers, and prevent lawsuits (Condie, 2015; Kjellberg et al., 2004; Ore, 2003). For nursing assistants, 44,100 days away from work were reported, and over half of those cases were due to overexertion (Condie, 2015). Patient falls were a leading cause of hospital injuries and were the most common adverse event reported in a hospital (Condie, 2015). The implementation EDUCATION, ADVOCACY, AND PROGRAM DEVELOPMENT 8 of safe patient handling programs led to significant reduction in falls and musculoskeletal disorders among caregivers and staff (Condie, 2015; Ore, 2003). These SPH programs led to a decrease in low-back injuries, decrease in lost work days, and a significant savings on workers compensation cost (Condie, 2015; Ore, 2003). While this project does not affect nurses or caregivers, this information is applicable to the staff at GCS because having adequate education regarding transferring clients could help reduce the likelihood of consumers and staff being injured or acquiring symptoms of musculoskeletal disorders. Through the use of EHP and biomechanical FOR as guidance, the purpose of this DCE was to develop effective and inclusive safe transfer training for support staff at GCS, propose a plan to increase accessibility of the facility, and adjust wheelchairs and walkers to improve client positioning. Multiple methods of education were used to educate staff and prove competency to increase effectiveness and safety of the current transfer training received by staff. Screening and Evaluation Results of Needs Assessment A needs assessment occurred that looked at accessibility of the facilities, wheelchairs/walkers of the clients, clinical observation of transfers of consumers, and occupational profiles with staff at GCS. The director of behavioral/day program services identified the initial need in regard to development of transfer training. The overall results of the needs assessment identified a need for changes to the environment to increase accessibility, education to the staff on transfer training to improve safety, and adjustments to wheelchairs/walkers to improve the overall quality of care of the consumers served at GCS. Accessibility assessment. GCS identified they were aware of changes that needed to be made in order to increase accessibility, but at the time of the DCE project, they did not have the EDUCATION, ADVOCACY, AND PROGRAM DEVELOPMENT 9 resources to make all of the changes identified. Through the use of the ADA Checklist for Existing Facilities, many areas of inaccessibility in the buildings were identified (Institute for Human Center Design [IHCD], 2016). The highest priority for change identified was the bathrooms. At the Kedzie building, there was one bathroom that was almost fully accessible with the exception of the height of the light switch, height of the towel dispenser, and the placement of the grab bars (IHCD, 2016). The majority of the other bathrooms at Kedzie had multiple areas that needed adjustment to be accessible including door width, grab bar placement, toilet height, towel dispenser height, and door weight (IHCD, 2016). At the State building, within the accessible stall the grab bars were too short and not properly positioned, the lock was unable to be opened with a closed fist, the toilet height was too low, the stall door was not wide enough, and the toilet paper dispenser was too far away from toilet (IHCD, 2016). Due to the nature of the consumers at GCS, my recommendation was to have more than one restroom that is accessible for the aging consumers they serve. Other inaccessible points identified within both buildings included clearance within rooms and the height of light switches (IHCD, 2016). Within rooms there should be 36 of clearance to allow for maneuvering of wheelchairs, but within five rooms at State and four rooms at Kedzie, adequate space was not available (IHCD, 2016). Due to these accessibility issues, the occupational performance of the consumers at GCS could be impacted. For example, due to inadequate clearance, an individual in a wheelchair would be unable to get to an area in a room to reach games or activities. Another way occupational performance could be affected is by paper towel dispensers and light switches being too high, making them unable to be reached by someone in a wheelchair. These areas of inaccessibility limit the independence of the individuals at GCS. EDUCATION, ADVOCACY, AND PROGRAM DEVELOPMENT 10 Wheelchair and walker assessment. Through assessment of positioning in wheelchairs and walkers, there was a need to make adjustments and educate the staff on appropriate positioning to improve occupational performance and prevent pressure sores (Pendleton & Schultz, 2017; Zhao, Shalem, Li, Master, & Liu, 2015). The majority of the consumers walkers were either too low or high, which led to improper ergonomics while using their walkers (Pendleton & Schultz, 2017; Zhao et al., 2015). According to Zhao et al. (2015), when a walker is too high, individuals grip too tightly, wrists become more ulnarly deviated, elbows more flexed, and shoulders more elevated and abducted (p. 129). When a walker is too low, individuals lean forward to grip, effectively putting strain on their lower back (Zhao et al., 2015). Improvements were needed to the walkers to promote proper body mechanics, improve functional mobility, and prevent falls for the consumers (Zhao et al., 2015). As Trefler and Taylor (1991) reported, proper positioning in a wheelchair is important to allow optimal performance for individuals with disabilities. Multiple consumers were observed with a mispositioned pelvis, which is without their hips against the back of their chair (Pendleton & Schultz, 2017; Trefler & Taylor, 1991). Improper head positioning was observed with some consumers heads not aligned with their head rests (Trefler & Taylor, 1991). It was also noted that straps were positioned inappropriately; for example, not being used, too loose, or too tight, leading to improper positioning (Pendleton & Schultz, 2017; Trefler & Taylor, 1991). Due to the preceding information, the staff needed to be educated on proper positioning of wheelchairs and walkers to allow for improved occupational performance for the consumers at GCS. Transfer training. From the occupational profile and clinical observation of the DSP and day program director at GCS, a need to revamp the education on transfer training with more detailed information was identified (Pendleton & Schultz, 2017). Staff indicated they would EDUCATION, ADVOCACY, AND PROGRAM DEVELOPMENT 11 benefit from the inclusion of hands-on experiences, which coincides with results of Claycombs recommendation of using videos, hands-on training, and assessments of competence of techniques learned (2015). Additionally, the staff reported there was no competence testing included after their DSP training. All of the staff identified receiving previous transfer training from prior work experience. When the DSP described transferring individuals, they described the appropriate techniques, but clinical observations showed evidence of need for transfer education, similar to Vijayakumar and Badlal (2017), who reported discrepancies of staff reports in knowledge from actual competency. Staff were observed transferring by bending at their hips, not being as close to the transfer surface as possible, and at times forgetting to lock wheels. Due to these clinical observations, it was evident that the staff needed further transfer training to improve transferring technique and competence (Boninger, 2013). Comparison and Contrast to Other Practice Areas There are similarities and differences between occupational therapy within a community setting such as GCS and between emerging and existing areas of occupational therapy. Similar to emerging practice areas such as primary care and lymphedema specialists, the role of an occupational therapist in a community-based setting needs to be advocated to co-workers and clients in the community-based setting. Ineffective transfer training can lead to injuries of consumers and staff, as occurs in existing practice areas including acute care and skilled nursing facilities. For example, in the acute care setting, transfer education to the individuals and family members is important to decrease fall risk and increase adherence with precautions (American Occupational Therapy Association [AOTA], 2017; Condie, 2015). Within the acute setting, transfer education to other staff members is not a typical role for occupational therapists but is an area that an occupational therapist would be qualified to address, similar to a community setting. EDUCATION, ADVOCACY, AND PROGRAM DEVELOPMENT 12 Another area occupational therapists are qualified to address within a variety of settings is wheelchair/walker positioning. Within schools, acute care, and skilled nursing facilities, clients and staff require education on proper positioning to increase occupational performance in daily activities, such as functional mobility and activities of daily living (Trefler & Taylor, 1991; Zhao et al., 2015). Within the acute care setting, oftentimes recommending the purchase of a walker is made, but within this community setting, a majority of the clients that need functional mobility devices already own them. Similar to the school setting, an occupational therapists role within the community setting is to support and adapt activities for their clients (AOTA, 2016). Contrary to a school occupational therapist, interventions within a community setting do not need to be related to school performance (AOTA, 2016). A similar role within this setting and the school setting is inclusion and accessibility (AOTA, 2016). While the role of inclusion and accessibility in a school is more focused on the inclusion in school activities, within the community setting, the focus is more on leisure and accessibility to the environment. Another similarity to the school setting is communication with the staff to promote success of the individuals (AOTA, 2016). Without the communication with the staff, follow-through of the interventions will not occur, and the clients occupational performance will be jeopardized. Implementation Phase Intervention Accessibility proposal plan. After completion of an assessment of accessibility, an accessibility proposal plan was developed with an itemized list of the changes that should be made to increase the accessibility at GCS. Included within the proposal plan was ranking of priority (low priority, medium priority, high priority), cost, limitations due to inaccessibility, and my best recommendation of the changes needed at GCS. The items identified as low priority EDUCATION, ADVOCACY, AND PROGRAM DEVELOPMENT 13 included height of light switches, coat rack, water fountain, and mirrors. Medium priority items included sink handles, height of towel dispensers, door width, and weight of bathroom doors. High priority items included toilet height, placement of grab bars, clearance throughout building, width of bathroom doors, placement of toilet paper dispenser, and safety of use of picnic tables. The accessibility proposal plan was presented to the director of behavioral/day program services, who shared the proposal plan with the director of operations. Transfer training. A new transfer training program was developed to be included within DSP training. The training is a PowerPoint presentation including videos and hands-on practice throughout the training. Supplemental materials created for the training program include pre/post-tests, competency forms, and handouts. The pre-/post-tests are ten questions to test the competency of the information learned throughout the training session (see Appendix A). The competency forms were created for each of the transfers used including: Hoyer lift transfer, twoperson lift transfer, squat pivot transfer, and stand pivot transfer. Each employee was required to get an 85 percent on each of the transfers to be considered competent. Handouts for each transfer were created include the steps of the transfer, competency points, and pictures of how to complete transfer (see Appendices B, C, D, and E). The format of the training session included a presentation of transfers. After explanation of each transfer, a video was played regarding the steps of the transfer. Then, a demonstration occurred, including practicing the transfers needed to ensure confidence before competency. The trainer walked around during the practicing in order to answer questions and provide feedback. After completion of the presentation, each individual was scheduled for competency and demonstrated each of the transfers. Handouts were provided to staff for future reference. For carryover of the transfer training, the director of behavioral/day program services was trained in EDUCATION, ADVOCACY, AND PROGRAM DEVELOPMENT 14 the implementation of the transfer training for future employees of GCS. All documents created were reviewed and provided to the director of behavioral/day program services, and she proved she was competent in teaching the information. Wheelchair and walker assessment. Through the needs assessment, I found the majority of individuals using walkers needed adjustments due to being too low or too high for the clients individual needs. Adjustment of walkers improved the clients biomechanics, increased stability, and improved independence in functional mobility. Each of the walkers were adapted to the appropriate height for all of the individuals at GCS. Also, wheelchair/walker positioning and importance was discussed with each of the DSPs. These training sessions were informal conversations that occurred over a few days; they included showing how to adjust the walkers appropriately. Handouts were developed for further reference regarding wheelchair and walker use, positioning, and the importance of positioning (see Appendices F and G). Leadership Leadership skills such as competence, confidence, flexibility, communication skills, and organization skills were essential to an effective implementation of this DCE project. Competence helped promote the implementation process at GCS. My competence was developed through past experiences including fieldwork experiences, classes, literature review, and interviews with the staff at GCS. Competence in this area has led to the confidence to provide education effectively to the staff. Another leadership skill that helped with the implementation phase was flexibility. Flexibility allowed me to be able to adapt to different situations and adjust my plan to the changing needs at GCS. Communication skills were necessary to be able to articulate and advocate for the needs of GCS. Lastly, my organizational skills were crucial for the implementation at GCS. Due to all the components of the project, I needed to have a EDUCATION, ADVOCACY, AND PROGRAM DEVELOPMENT 15 multitude of lists to ensure all aspects of the project were completed in time. Through the leadership skills mentioned above, the implementation phase at GCS was completed with greater ease. Staff Development Accessibility proposal plan. By presenting the accessibility proposal plan, staff development at GCS was improved. The assessment of accessibility and proposal plan provided the staff with the knowledge base to increase accessibility at GCS. Also, the plan shows the staff about the barriers within the environment at GCS that would not be noticeable unless they were someone with a disability. With the increased knowledge regarding accessibility, the staff gained increased knowledge about how they can adapt the environment and provide the consumers with increased independence through the environmental changes suggested. Because the proposal plan only focused on the day programs sites, the staff can apply the information presented to determine adaptations that may need to be made within the community integrated living arrangement (CILA) owned by GCS to better serve their consumers. Transfer training. The new transfer training will increase the effectiveness of the existing DSP training. Having hands-on experiences within the training will increase the staff competence before they start transferring consumers. Through the program developed, the staff will have increased evidence of the competence of the staff in the training of transfers. The new program will be able to be reused for all future employees, so all new employees will be on the same familiarity level about transfers when they begin work. Administration at GCS has made the transfer training a requirement for all future and existing staff. The director of behavioral/day program services was trained in the implementation of the training program. On a yearly basis, the director of behavioral/day program service will ensure all staff are competent and retrain EDUCATION, ADVOCACY, AND PROGRAM DEVELOPMENT 16 them if they are not. The materials for the program were provided to the director of behavioral/day program services and the director of behavioral/day program service for future use. The plan is for the training to be included with the training for all new DSPs before starting work. Due to all factors mentioned above, staffs knowledge of ergonomic transfers will be improved. Wheelchair and walker assessment. Before the completion of the implementation, staff did not have an understanding of the proper positioning for walkers and wheelchair use. The knowledge provided increased the staffs abilities and will allow them to be able to select and properly use walkers/wheelchairs with more confidence than before. Education on proper positioning and the importance of proper positioning is important knowledge for the staff to know for the safety and comfort of the consumers served at GCS. As for the transfer training program, the director of behavioral/day program service was trained in the information provided to the staff. The director of behavioral/day program service will be in charge of ensuring the positioning is appropriate for the walkers and wheelchairs. By following the guidelines, all current and future consumers will not be inhibited by improper walker/wheelchair positioning. Discontinuation & Outcome Phase Overall Discontinuation & Outcome Phase Accessibility proposal plan. In the beginning phases of the accessibility proposal plan, I was planning on completing an accessibility assessment and providing the areas that needed to be adjusted for accessibility. As the development of the plan occurred, it came to my attention that providing the information on the needed changes would be a daunting task due to the amount of changes found. Due to this, I decided to break down the accessibility issues into low, medium, and high priority. After breaking down the priority level, varying options and prices for EDUCATION, ADVOCACY, AND PROGRAM DEVELOPMENT 17 fixing the accessibility concerns were provided along with what my best recommendation was for adjustments. These additions to the plan decreased research needed by GCS and made the plan more feasible. The plan was provided to the director of behavioral/day program services, who shared the proposal plan with the director of operations. The outcome of the accessibility plan was that GCS plans to complete the recommended changes in phases to increase the accessibility for their consumers. Transfer training. Throughout the development of the training program, continuous changes were made to ensure the program was developed effectively for the staff. Discussions occurred with the director of behavioral/day program services and staff, partially through the development of the program, to ensure proper information was included within the program. From discussions, the information regarding adaptive equipment, wheelchair use, and walker use was added to the transfer presentation. One of the goals of GCS this year is to improve the training of their staff to provide quality care to their consumers. The addition of this transfer training program aligns with this goal, improving the competency of the staff and increasing the effectiveness of the training. The transfer training program was provided to the director of behavioral/day program service to allow for continuation of use of training at GCS. Competency forms and pre-/post-tests were provided to the staff to show effectiveness of training and competency of the DSPs. The transfer training proved to increase competency of the staff at GCS in transferring of individuals ergonomically based on the scores of competency forms and clinical observation. Wheelchair and walker assessment. From the needs assessment, it was identified that many of the walkers/wheelchairs needed adjustments. After completion of adjustments to the walkers/wheelchairs, I discussed the changes I made with the staff, who were unaware of the EDUCATION, ADVOCACY, AND PROGRAM DEVELOPMENT 18 correct adjustments needing to be made. The staff questioned how the heights of the walkers have gone unnoticed by all the other professionals who see the consumers at appointments. Due to this feedback, I made an adjustment to the plan of adjusting the walkers and added development of handouts for future reference, including proper positioning in wheelchair and proper walker use. Handouts were provided to staff and informed them they could ask me any further questions. Follow-up occurred with the staff a few weeks after to ensure they still had no questions regarding the material. The outcome of changes of the walkers/wheelchairs has led to improved positioning and satisfaction from the consumers during functional mobility. Response to Society Needs Accessibility proposal plan. The societal need being addressed at GCS was the accessibility of the building in order to increase the occupational performance of the consumers served. According to Nijs and Heylighen (2015), issues have been identified on multiple policy levels involving accessibility for individuals with disabilities. Through the use of the ADA Checklist for Existing Facilities, many areas of inaccessibility in the buildings were identified (IHCD, 2016). By providing GCS with information about accessibility, they will be able to increase the independence of the consumers served at their program. Transfer training. The societal need addressed was the safety of the staff and consumers at GCS during transfers. Proper transfer technique was important for professionals and the patient to ensure safety of all (Boninger, 2013; Kjellberg et al., 2004). Patient falls were a leading cause of hospital injuries and were the most common adverse event reported in a hospital (Condie, 2015). The implementation of safe patient handling programs led to significant reduction in falls and musculoskeletal disorders among caregivers and staff (Condie, 2015; Ore, 2003). According to Claycomb (2015), completion of an effective transfer education includes EDUCATION, ADVOCACY, AND PROGRAM DEVELOPMENT 19 using videos, hands-on training, and assessment of competence of techniques learned, which was the format of the transfer training program that was developed. Wheelchair and walker assessment. The societal need was adjustment of walkers and wheelchairs to prevent deformities and maintain proper positioning for the consumers at GCS. Through assessment of positioning in wheelchairs and walkers, it was determined there was a need to make adjustments and educate the staff on appropriate positioning to improve occupational performance and prevent pressure sores (Pendleton & Schultz, 2017; Zhao et al., 2015). Zhao et al. (2015) reported that having the walker too high or low can lead to strain, deformities, and discomfort of the consumers. By adapting the walkers and wheelchairs for positioning, the consumers have improved positioning for functional mobility and daily activities. Overall Learning Learning My experience at GCS has been a very valuable learning experience and has prepared me in multiple ways for my future practice as an occupational therapist. Flexibility has been something that I have struggled with due to my personality of being organized and attentive to details, but from this fieldwork experience, I have learned that flexibility is key. Within this setting, every day is different, and the needs are variable. This will be a valuable skill to be successful in future practice because clients and our settings are unpredictable, and adaptability will allow for successful treatment of clients. Another valuable skill learned was being selfsufficient in this setting. Because my site mentor is the director of behavioral/day program services, she was very busy the majority of the weeks; this has allowed me to be able to complete tasks without direction. Self-sufficiency is an important trait for any job; as a new graduate, EDUCATION, ADVOCACY, AND PROGRAM DEVELOPMENT 20 being self-sufficient can be hard, but this experience has allowed me to grow in this skill. At this experience, there was a lot of different staff members that I needed to communicate with on a daily basis. This has allowed me to work on my communication skills with other staff members in a way they understand. Effective communication is needed for every job because there are many people with varying backgrounds and adapting communication for their understanding is important. All these experiences helped increase my professional development and will further develop my skills as a future occupational therapist. Team members at GCS provided valuable insights to teach teamwork, leadership, and professionalism that I will utilize in future endeavors. One thing that was taught to me on the first day on the job by the behavior analyst was that building rapport is important to provide successful implementation, which will be helpful in future jobs no matter the setting. Another valuable lesson I learned was that teamwork is essential for follow-through on programs and plans. At one of the day programs, the behavior analyst had effective teamwork with the staff, which led to better success for the staff and consumers regarding programs. While at the other day program, the staff was not as effective, leading to more difficulty with follow-through. This experience has taught me to ensure that rapport and teamwork are established in any future job to have effective communication, collaboration, and respect amongst team members. Advocacy Advocacy skills were utilized throughout all aspects of the implementation phase at GCS, including advocating for occupational therapy, transfer training, accessibility, and proper positioning for walker/wheelchair use. At the start, advocacy about what occupational therapy is and the role of an occupational therapist in this environment was provided. Within this setting, there are many areas that could be addressed by an occupational therapist, but many would not EDUCATION, ADVOCACY, AND PROGRAM DEVELOPMENT 21 be considered traditional, which made explaining my role just as important. For the transfer training, advocacy was provided regarding what the importance of the training was for both the staff and consumers of GCS. Another area where advocacy for the clients was provided was with the accessibility proposal plan. Within the plan, I advocated for what would be best for the clients to promote optimal occupational performance and informed the director of behavioral/day program of the barriers at the day programs. Advocacy for proper positioning occurred through providing education to the staff and the consumers about positioning for walkers and wheelchairs. Several of the consumers questioned what I was doing because their walkers have been that height for many years. I had to explain to them what I was doing and the importance of the changes. After the explanation, all of the staff and consumers agreed to adjustments of their devices. Through the advocacy provided at GCS, the consumers benefited due to increased competency of the staff. Overall, my time at GCS was beneficial for all involved including staff, consumers, and myself. The implementation phase included development of an accessibility proposal plan, development of the transfer training program, and adjustments to wheelchairs and walkers. The outcome included plans for accessibility changes in phases to increase accessibility for consumers, increased competency of staff for transferring consumers, and improved positioning and satisfaction from the consumers during functional mobility. These initiatives will help improve accessibility for consumers and competency of staff at GCS. EDUCATION, ADVOCACY, AND PROGRAM DEVELOPMENT 22 References American Occupational Therapy Association. (2016). Fact sheet: Occupational therapy in school settings. Retrieved from https://www.aota.org/~/media/Corporate/Files/AboutOT/Professionals/WhatIsOT/CY/Fa ct-Sheets/School Settings fact sheet.pdf American Occupational Therapy Association. (2017). Fact sheet: Occupational therapy's role in acute care. Retrieved from https://www.aota.org/~/media/Corporate/Files/AboutOT/Professionals/WhatIsOT/RDP/F acts/Acute-Care.pdf Aminzadeh F, Edwards N, Lockett D, & Nair, R.C. (2000). Utilization of bathroom safety devices, patterns of bathing and toileting, and bathroom falls in a sample of community living older adults. Technology & Disability, 13(2), 95103. Boninger, M. L. (2013). Safe transfer technique. Archives of Physical Medicine and Rehabilitation, 94(12), 25792580. doi: 10.1016/j.apmr.2013.04.007 Claycomb, M. (2015). Guidelines to safe patient transfers. Rehab Management: The Interdisciplinary Journal of Rehabilitation, 28(1), 1417. Cole, M. B. & Tufano, R. (2008). Applied theories in occupational therapy: A practical approach. Thorofare, NJ: Slack Incorporated Condie, E. (2015). Safe patient handling. Interface, 1-5. Galeotafiore, J. (2019). 6 easy ways to prevent falls. Consumer Reports on Health, 31(3), 11. Institute for Human Centered Design. (2016). ADA Checklist for Existing Facilities. Retrieved from https://www.adachecklist.org/doc/fullchecklist/ada-checklist.pdf EDUCATION, ADVOCACY, AND PROGRAM DEVELOPMENT 23 Kennedy, M. J., Arcelus, A., Guitard, P., Goubran, R. A., & Sveistrup, H. (2015). Toilet grab-bar preference and center of pressure deviation during toilet transfers in healthy seniors, seniors with hip replacements, and seniors having suffered a stroke. Assistive Technology, 27(2), 7887. doi: 10.1080/10400435.2014.976799 King, E. C. 1., Holliday, P. J., & Andrews, G. J. (2018). Care challenges in the bathroom: The views of professional care providers working in clients homes. Journal of Applied Gerontology, 37(4), 493515. doi: 10.1177/0733464816649278 King, E. C., & Novak, A. C. (2017). Effect of bathroom aids and age on balance control during bathing transfers. American Journal of Occupational Therapy, 71(6), 1-9. doi: 10.5014/ajot.2017.027136 Kjellberg K, Lagerstrom M, & Hagberg M. (2004). Patient safety and comfort during transfers in relation to nurses work technique. Journal of Advanced Nursing, 47(3), 251259. doi: 10.1111/j.1365-2648.2004.03089.x Nijs, G., & Heylighen, A. (2015). Turning disability experience into expertise in assessing building accessibility: A contribution to articulating disability epistemology. Alter, 9(2), 144-156. Ore, T. (2003). Evaluation of safety training for manual handling of people with disabilities in specialized group homes in Australia. Australian & New Zealand Journal of Public Health, 27(1), 6469. doi: 10.1111/j.1467-842X.2003.tb00382.x Pendleton, H. M. & Schultz-Krohn, W. (Eds.). (2017). Pedrettis occupational therapy: Practice skills for physical dysfunction (8th ed.). St. Louis, MO: Elsevier Mosby. Stefanacci, R. G., & Haimowitz, D. (2014). Bathroom assistances. Geriatric Nursing, 35(2), 151153. doi: 10.1016/j.gerinurse.2014.02.006 EDUCATION, ADVOCACY, AND PROGRAM DEVELOPMENT 24 Trefler, E., & Taylor S. J. (1991). Prescription and positioning: Evaluating the physically disabled individual for wheelchair seating. Prosthetics and Orthotics International, 15(3), 217-224, doi: 10.3109/03093649109164291 Vijayakumar, M., & Badlal, P. (2017). Knowledge on safer patient lifting techniques among physiotherapists. International Journal of Health Sciences and Research, 7(5). Zhao, Y., Salem, Y., Li, M., Master, H., & Liu, H. (2015). Comparison of surface landmarks for measuring the individualized height of rolling walker. Physical & Occupational Therapy in Geriatrics, 33(2), 128138. doi: 10.3109/02703181.2015.1009228 EDUCATION, ADVOCACY, AND PROGRAM DEVELOPMENT 25 Appendix A Pre-/Post-Test for Transfers and Mobility Training Name: 1. If you have to turn while transferring a consumer: a. Turn feet slowly, while not twisting back b. Twist back towards surface transferring to c. Cross your legs over the other d. Turn body towards surface transferring to in a fast motion 2. Best positioning for your feet during a transfer is: a. Close together b. Wide apart c. With heels touching together 3. To safely transfer a consumer, what should you do before completing transfer? a. Know the consumers limitations and strengths b. Removal of environmental barriers c. Put arm and leg rests on d. All of the above e. A and B 4. The proper placement of gait belt is: a. Loosely over waist b. Loosely over chest c. Tightly over waist d. Tightly over chest 5. General positioning in wheelchair should include: a. Head positioned in neutral position b. Knees are bent to 100 degrees c. Toes are supported on the ground d. Back is partially against back of chair 6. Proper measurement for walker height includes: a. Measuring from crease of wrist to the floor b. When hands are on handles, elbow should be bent to 90 degrees c. When hands are on handles, elbow should be straight d. Measuring from hip crease to the floor 7. When transferring a consumer using a squat pivot transfer, the first thing you should do is tell the client what you are about to do. a. True b. False 8. Which of the following should be avoided when helping a consumer perform a transfer? a. Ensuring consumers feet are on the floor, under their knees, and hip width apart b. To lean forward before standing up c. Allowing the consumer to put their hands around your neck during the transfer d. Using an assistive device such as a walker or transfer belt 9. Positioning for two-person transfer includes: a. Both transferrers in front of consumer EDUCATION, ADVOCACY, AND PROGRAM DEVELOPMENT b. Both transferrers behind the consumer c. One person behind consumer, and one person in front of consumer 10. Hoyer lift should be used: a. When nobody can help with transfer b. When consumer is agitated c. Someone is unable to support weight d. A and C Answer Key 1- A 2- B 3- E 4- C 5- A 6- A 7- A 8- C 9- C 10- C 26 EDUCATION, ADVOCACY, AND PROGRAM DEVELOPMENT Appendix B Handout for Hoyer Lift Transfer 27 EDUCATION, ADVOCACY, AND PROGRAM DEVELOPMENT Appendix C Handout for Two-Person Transfer 28 EDUCATION, ADVOCACY, AND PROGRAM DEVELOPMENT Appendix D Handout for Squat Pivot Transfer 29 EDUCATION, ADVOCACY, AND PROGRAM DEVELOPMENT Appendix E Handout for Stand Pivot Transfer 30 EDUCATION, ADVOCACY, AND PROGRAM DEVELOPMENT Appendix F Handout for Walker Use 31 EDUCATION, ADVOCACY, AND PROGRAM DEVELOPMENT 32 EDUCATION, ADVOCACY, AND PROGRAM DEVELOPMENT Appendix G Handout for Wheelchair Use 33 EDUCATION, ADVOCACY, AND PROGRAM DEVELOPMENT 34  ...

... Running head: OT ROLE IN VA DOMICILIARY 1 Occupational Therapists Role in Richard L. Roudebush VA Medical Center-Domiciliary Lexi Ferguson May 3, 2019 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: Jennifer Fogo, PhD, OTR OT ROLE IN VA DOMICILIARY 2 A Capstone Project Entitled Title: Occupational Therapists Role in Richard L. Roudebush VA Medical CenterDomiciliary 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 Lexi Ferguson 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 OT ROLE IN VA DOMICILIARY 3 Abstract Veterans experiencing homelessness secondary to behavioral health or mental health conditions require proper care to address the barriers to successful participation in occupations. Occupational therapists hold the skilled-services to address the behavioral and mental health needs of Veterans. Therefore, the purpose of the DCE was to develop a program that assists Veterans experiencing homelessness by improving independence in daily, meaningful occupations to sustain community living and, through the process, advocate for occupational therapy services at the Domiciliary. Through developing a weekly positive outlook intervention group based on the requests of the Veterans, the group reported increased satisfaction with physical health, mood, family relationships, leisure time activities, and sexual interests. Through advocacy in the community, local businesses indicated improved perceptions of addressing mental health in the workplace. Finally, advocating for an occupational therapy position at the Domiciliary showed improved interdisciplinary care. In conclusion, program development for group intervention, advocacy for Veterans in the community, and advocacy for an occupational therapy position resulted in providing services that enhanced the Veterans overall daily functioning of meaningful occupations. OT ROLE IN VA DOMICILIARY 4 Occupational Therapists Role in Richard L. Roudebush VA Medical Center-Domiciliary Most United States citizens are familiar with at least one individual who served or currently serves in the military; therefore, the impact of military service influences the lives of many (Haibach, et al., 2017). Military personnel are some of the most physically-fit individuals during their active duty due to the standards of military readiness (Haibach et al., 2017). However, many Veterans post-service show decreased health and increased disparities compared to the rest of the population (Haibach et al., 2017). Veterans, in particular, presented with decreased behavioral health outcomes that included tobacco use, physical inactivity, poor diet, and alcohol misuse (Haibach et al., 2017). Researchers also found poor mental health to be a rapidly growing problem (Swarbrick & Noyes, 2018). Currently many of the behavioral health factors and mental health conditions experienced by Veterans are not being addressed in the health care system, making it difficult for Veterans to appropriately function in typical society and often resulting in homelessness (Haibach et al., 2017; Lippert & Lee, 2015). Homelessness Homelessness is one of the most salient injustices, especially the instances related to Veterans that are experiencing homelessness (Roy et al., 2017). Many Veterans are not receiving the necessary medical and mental assistance required to combat the behavioral health and mental health factors leading to homelessness (Haibach et al., 2017; Lippert & Lee, 2015; Roy et al., 2017). Researchers screened the U.S. Department of Veteran Affairs database and found that 35,897 Veterans reported being homeless during 2012-2013 (Byrne, Montgomery, & Fargo, 2016). The most recent nationwide point-in-time (PIT) count of Veterans experiencing homelessness on one night in January 2018 counted just over 37,800 (US Department of Veteran Affairs, 2018). OT ROLE IN VA DOMICILIARY 5 Stigma Researchers reported that individuals with a mental health condition experience public stigma that leads to social isolation and discrimination, which negatively impacts available housing, employment, and educational opportunities (Harnish et al., 2016). Researchers have also found that substance abuse was more stigmatizing than a mental health condition, but both conditions make it difficult for Veterans to function independently in society (Harnish et al., 2016). This stigma creates societal barriers for Veterans resulting in further complications of engagement in the community. Educating the general population on mental health is necessary to fight the present stigmas and create opportunities for growth for all (Swarbrick & Noyes, 2018). Interdisciplinary Care Interdisciplinary care is required to develop programs to address the widespread needs of Veterans with behavioral health and mental health conditions impacting their daily functioning (Clark, Rouse, Spangler, & Moye, 2018). Occupational therapy practitioners possess the necessary clinical skills to provide appropriate care for individuals with mental health conditions to improve the consumers daily function (Gindi, Galili, Volovic-Shushan, & Adir-Pavis, 2016). Researchers presented the initiative for occupational therapists to evaluate and provide a plan of care to improve identified weaknesses and increase participation in meaningful occupations (Swarbrick & Noyes, 2018). Health care practitioners, particularly occupational therapists, can assist Veterans experiencing homelessness with improving quality of life while living in the community (Trivedi et al., 2015). Occupational Empowerment Fisher and Hotchkiss (2008) defined marginalized individuals as persons with poor financial resources, limited housing, and lack of work or education. Occupational therapists can OT ROLE IN VA DOMICILIARY 6 empower marginalized individuals to participate in occupations throughout the community (Fisher & Hotchkiss, 2008). Fisher and Hotchkiss (2008) discovered a need to empower individuals and provide the means to allow for successful participation in meaningful occupations with social support. Occupational therapists possess the skill set to provide opportunities for their clients that are marginalized through the concept of occupational change (Fisher & Hotchkiss, 2008). This concept is accomplished by providing experiences of autonomy and independent completion of tasks (Fisher & Hotchkiss, 2008). The Model of Occupational Empowerment, designed by Fisher and Hotchkiss, guides occupational therapists to provide the appropriate care that is needed for consumers to continue their meaningful occupations while living in the community (Fisher & Hotchkiss, 2008). In conjunction with the Model of Occupational Empowerment, the psychodynamic frame of reference (FOR) addresses the specific factors impacting occupational performance secondary to behavioral health and mental health conditions. The psychodynamic FOR focuses on individuals social relationships with self-awareness and emotional expression through projective arts and activities (Cole & Tufano, 2008). This FOR assists in guiding care for occupational interventions that are creative and allow individuals to discover self (Cole & Tufano, 2008). The Model of Occupational Empowerment allows the consumers to become empowered (Fisher & Hotchkiss, 2008) through various creative activities and discover the self through the process which follows the foundation principles of the psychodynamic FOR (Cole & Tufano, 2008). This Doctoral Capstone Experience (DCE) involves advocacy and program development for individuals, who experience mental health conditions and are re-integrating back into the community after experiencing homelessness. OT ROLE IN VA DOMICILIARY Occupational Therapists Call to Action Researchers discuss the current need for occupational therapists to implement programs and advocate for consumers to guide individuals to reach their full potential for quality of life (Wasmuth & Pritchard, 2016). Occupational therapists are skilled in providing services to improve Veterans social, vocational, and coping skills, as well as increasing participation in leisure and daily living activities (Gindi, Galili, Volovic-Shushan, & Adir-Pavis, 2016). Community engagement, executive functioning training, and establishing healthy routines are specific interventions that lead to improved occupational participation (Ikiugu, Nissen, Bellar, Maassen, & Van Peursem, 2017; Wasmuth & Pritchard, 2016). Program Development An extreme need of health care professionals is to provide proper care to Veterans experiencing homelessness secondary to behavioral health and mental health conditions. The Occupational Therapy Practice Framework (OTPF) specifically invites occupational therapists to address barriers to occupational engagement (American Occupational Therapy Association [AOTA], 2014). Many leading organizations, researchers, and consumers of health care call upon health care practitioners to address behavioral health and mental health needs, specifically regarding Veterans care. Wasmuth and Pritchard (2016) encourage occupational therapists to develop programs that will assist in Veterans community reintegration. This includes providing programs addressing social participation, work participation, financial management, and home management. Through the application of the Model of Occupational Empowerment, occupational therapists can provide empowering, occupational-based programs to achieve the client-centered interventions that focus on self-awareness (Fisher & Hotchkiss, 2008; Cole & Tufano, 2008). The purpose of the DCE was to develop a program that assists Veterans 7 OT ROLE IN VA DOMICILIARY 8 experiencing homelessness by improving independence in daily functioning of meaningful occupations to sustain community living and, through the process, advocate for occupational therapy services at the facility. Screening and Evaluation Needs Assessment Bonnel and Smith (2018) discuss various ways to conduct a needs assessment. To discover a need for improvement, practitioners can complete interviews, use standardized tools, review documents, or review literature (Bonnel & Smith, 2018). These methods allow researchers to gather valuable information about occupational deficits from the perception of the stakeholders. Therefore, literature review, interviews, and an assessment tool were used in the screening and evaluation process. Literature Review The literature review provided insight into the urgent need of assisting Veterans with behavioral health and mental health conditions (Haibach et al., 2017; Lippert & Lee, 2015). Researchers provided evidence for program development to address community reintegration and the need for advocacy in the community to decrease stigma related to mental health and substance use/abuse (Swarbrick & Noyes, 2018; Wasmuth & Pritchard, 2016). Interviews The areas of need identified in the literature review were further explored with one-onone interviews with staff at the Domiciliary, which included recreational therapists, social workers, a pharmacist, a nurse practitioner, and peer support. From the various interviews, a need for group opportunities and a need to decrease stigma in the community emerged. Five out OT ROLE IN VA DOMICILIARY 9 of the six (83%) staff members discussed the relevancy of eight common topics for improvement during the one-on-one needs assessment interviews. Table 1 outlines the eight topics. Table 1 Group Workshop Topics Title Description Medial Toolbox Workshop A group that allows the expression of self and past experiences through exploring various media (Charon et al., 2017). A group where Veterans receive education and practice implementing pain reduction strategies, proper body mechanics for work, and musculoskeletal disorder prevention tips. A group in which Veterans receive education and training in managing emotions and opportunities to discuss strategies for community reintegration. A group that provides education and practice to Veterans on maintaining a positive outlook through all current and future life experiences. A group that follows the Sexual Assessment Framework created by McBride and Rines (2000) to address the sexual health needs of the Veterans. A group that provides opportunities to practice ways to implement learned skills from Domiciliary into real life situations and also provides independent exploration of work and leisure activities to participate in once discharged from Domiciliary. A past University of Indianapolis, Doctor of Occupational Therapy Student created a preemployment workshop for Veterans. The workshop follows the students sequenced schedule and activities. A group that provides education and implementation of creating a daily and monthly planner while organizing documents for easier accessibility and less stress. Empowering Function through Education Workshop Chillin Out Workshop Positive Outlook Workshop Sexual Education Workshop Community Inclusion Workshop Pre-Employment Workshop Its All in the Details Workshop OT ROLE IN VA DOMICILIARY 10 The Veterans (n = 36) were provided with a survey related to the eight different group options (Appendix A). The survey was placed under each of their doors with instructions to place a check mark next to the groups they are most interested in attending and return the survey to the recreational therapy office by Sunday evening. They were encouraged to complete the survey to provide their feedback. This provided the Veterans with the autonomy to choose the group, allowing for occupational empowerment, which is necessary for occupational change that is stated in the Model of Occupational Empowerment (Fisher & Hotchkiss, 2008). A total of 12 Veterans returned completed surveys (33%, n = 12). The Sexual Education Workshop received no votes (0%, n =0). The Community Inclusion Workshop received two votes (0.06%). The Empowering Function Through Education Workshop received three votes (0.08%). The Media Toolbox Workshop received four votes (0.1%). The Pre-Employment Workshop and Its All in the Details Workshop received six votes each (17%). The Chillin Out Workshop received eight votes (20%). The Positive Outlook Workshop (25%, n = 10) was chosen most frequently by the Veterans, therefore, the group will be developed with a positive outlook focus to empower the Veterans for occupational change while living in the community. Assessment Tool The U.S. Department of Veterans Affairs (VA) encourages various mental health facilities to complete the Q-LES-Q-SF to assess each Veteran for perceptions of quality of life (Riendeau et al., 2018). Stevanovic (2011) stated that the Q-LES-Q-SF is widely used in many settings addressing mental health. Researchers found the Q-LES-Q-SF has strong validity (r= 0.65, p < 0.001) and found a correlation of the psychosocial scale (r = 0.28, p < 0.001) compared to the Mental Component Score (Riendeau et al., 2018; Stevanovic, 2011). Hope, Page, and Hooke (2009) found the value in considering quality of life through the comprehensive OT ROLE IN VA DOMICILIARY 11 assessment of mental health and re-integrating back into the community. The researchers found the Q-LES-Q predicted outcomes related to the client score pertaining to length of stay and clinical outcomes (Hope et al., 2009). Researchers found that Q-LES-Q-SF is effective in understanding individuals quality of life as it pertains to mental health conditions (Hope et al., 2009; Riendeau et al., 2018; Stevanovic, 2011). The researchers presented strong evidence to use the Q-LES-Q-SF to assess the quality of life perceptions of the participating Veterans; therefore, the Veterans completed the tool (Hope et al., 2009; Riendeau et al., 2018; Stevanovic, 2011). At the initial Positive Outlook Workshop group, ten (n = 10) Veterans attended and completed the Q-LES-Q-SF. The initial quality of life scores of the Veterans showed a majority responded with fair or good life satisfaction perceptions. At the discontinuation of the Positive Outlook Workshop, the Q-LES-Q-SF was administered to the initial participants and responses were compared. Table 2 shows the results of the Veterans initial responses to the preassessment Q-LES-Q-SF. The results indicated a need to focus on improvement of work, financial status, and living/housing for overall occupational engagement in the community. OT ROLE IN VA DOMICILIARY 12 Table 2 Q-LES-Q-SF Pre-Assessment Scores From the results of the group options survey and the Q-LES-Q-SF, the group program focused on educating the Veterans on positive thinking skills to enhance participation in work, financial management, and house management. Survey The need to address stigma in the community was completed during community presentations and open dialogue with local businesses. A pre- and post-survey was distributed during the presentation time to gain insight into the experiences and perceptions of community individuals related to mental health (Appendix B). The community presentations provided education intending to decrease stigma and advocate for Veterans experiencing homelessness secondary to mental health and behavioral health conditions. Community-Based Versus Acute Psychiatric Care Researchers showed that the Q-LES-Q-SF is appropriate to understand the clients perceptions of their quality of life with various occupations pertaining to living in the community OT ROLE IN VA DOMICILIARY 13 (Hope et al., 2009; Riendeau et al., 2018; Stevanovic, 2011). The tool allows practitioners to understand the clients perceptions of areas of weakness in life and create a plan of care with a focus on the identified occupations (Riendeau et al., 2018). The Q-LES-Q-SF is appropriate for transitional care into the community, whereas in the acute psychiatric setting the Q-LES-Q-SF may not provide the functional insight for individuals occupational performance. In the acute psychiatric unit, a main objective for health care practitioners is to stabilize the client and prepare the client for discharge to the next appropriate phase of care. Researchers found a need to focus on activities of daily living (ADLs) and functional mobility in the acute psychiatric setting to improve the clients functional participation in occupations (Aryes & John, 2015). Improvement in performance of functional tasks and cognition are essential for safe and stabilized discharge from an acute care unit (Lipskaya-Velikovsky, Kotler, & Krupa, 2016). The basic functional movements for occupations require attention in acute care (Lipskaya-Velikovsky et al., 2016) to ensure greater improvement in overall quality of life in next stages of care. DCE Application The results from the screening process concluded a need for advocacy and program development to improve the occupational performance of the Veterans to reintegrate back into the community. This DCE concentrated on advocating for Veterans in the workplace to fight stigma associated with mental health and substance use conditions, advocating for a full-time occupational therapy position at the Domiciliary, and developing a program that provides a weekly group meeting addressing positive thinking during daily routines. OT ROLE IN VA DOMICILIARY 14 Implementation Phase Advocacy Swarbricks and Noyes (2018) discussed the benefits of advocacy in the occupational therapy profession. Occupational therapists have the clinical skills to address mental health in the community setting to improve clients quality of life (Swarbricks & Noyes, 2018). Occupational therapys scope of practice includes advocating for clients in the community for successful reintegration. Advocacy for clients is necessary for improved outcomes (Harnish et al., 2016). Through the needs assessment, the staff at the Indianapolis VA Domiciliary reiterated the concern for advocacy in the community. Therefore, the DCE addressed both community advocacy and occupational therapy advocacy. Community Advocacy Stigma associated with mental health conditions leading to homelessness are prominent in the community and lead to limited employment and housing opportunities (Harnish et al., 2016). Through education and open discussion in the workplace, employees and employers can create environments conducive to all working styles. One part of my DCE focused on reaching out to local businesses and scheduling a visit. Two companies in the Indianapolis areas were of interest secondary to personal connections. The companies included a commercial real estate firm and public relations firm. During the visits, an open discussion followed a brief education on mental health. Each presentation followed a similar schedule, starting with an introduction of myself, my role as a doctoral occupational therapy student, and my DCE focus. Next, I administered a brief survey to gather the participants perceptions on mental health prior to the presentation and discussion (Appendix B). Cornwell Partnership (n.d.) created the survey based off the NHS OT ROLE IN VA DOMICILIARY 15 Mental Health annual attitude survey standards. Then, I presented a free infograph from National Alliance on Mental Health (n.d.) that was projected on a large screen. After reviewing the infograph with the attendees, I asked how they could address mental health in the workplace. Many individuals provided input. I observed attendees using personal examples to collaborate and create a plan for addressing mental health in the workplace. At the end of the discussion, I administered the same brief survey to measure changes in attendees perceptions of mental health. Participants perceptions generally improved in accepting and addressing mental health. Table 3, in the discontinuation section, provides the detailed results from pre- and post-survey. Occupational Therapy Position Advocacy A second part to my DCE included advocating for a full-time occupational therapy position at the Indianapolis VA Domiciliary. Through my needs assessment, I found a need for the establishment of an occupational therapy position at the Domiciliary. The occupational therapist would address the barriers preventing Veterans from successfully engaging in meaningful occupations in the community. The first step to advocate for the position started with a schedule meeting with the Domiciliary Acting Director. During the conversation, she stated that an occupational therapy position would greatly enhance the holistic care of the Veterans at the facility. She advised me to contact the Business Manager to assess the plausibility of establishing a position. I emailed the Business Manager regarding the logistics of the occupational therapy position and she responded that this fiscal year (October 1-September 30) has no available funds. She recommended I contact the VA Occupational Therapy Manager. An email was sent to the VA Occupational Therapy Manager inquiring about the plausibility of an occupational therapy position at the Domiciliary. The Occupational Therapy Manager replied stating that she sees a great need for occupational therapy services at the Domiciliary. She OT ROLE IN VA DOMICILIARY 16 encouraged further advocacy and education on occupational therapys role at the Domiciliary with the current staff so they could advocate for the position in their respected fields. Through the process of meeting with the Domiciliary staff and communicating with the business manager, I was able to advocate and educate others on the role of occupational therapy at the Domiciliary in addressing the occupational needs of the Veterans. Through the process I continued to develop my leadership skills by practicing and learning clear and effective communication, identifying needs of clients, and advocating for the field of occupational therapy. The opportunities for growth allowed for enhanced care. This project promoted development of Veterans and staff through improved knowledge of an occupational therapists role. Not only did individuals at the local facility learn about the importance of occupational therapy, but also individuals in higher levels of management became more aware of the current needs of the Veterans. Program Development The focus of program development allowed for planning, developing, organizing, and marketing a weekly group to the Veterans at the Domiciliary. Program development focused on occupational empowerment following the established model for the DCE. The Veterans identified a desire for a Positive Outlook Workshop. Intensive research in positive psychology was completed and applied to group interventions. Part of the group goals was to create a positive attitude during daily occupations. Resources that guided the group interventions are included in Appendix C with the five-week group schedule. My leadership skills of empathetic communication, responsibility, organization, and group cohesiveness led to a positive experience for all Veterans that attended the group. The first week, the Q-LES-Q-SF was administered to gather pre-group intervention data on the Veterans quality of life (see Table 2). Then, the Veterans received education on positive outlook and the physiological and psychological impact OT ROLE IN VA DOMICILIARY 17 a positive attitude can have on the successful completion of daily occupations. Next, the Veterans established group goals and expectations for the following four weeks. The suggestions for the group were implemented into the group schedule and can be found in Appendix C. Weeks two through five included positive outlook interventions that the Veterans could implement into their daily lives. The group focused on individual strengths and positive occurrences through the week. Each week the Veterans participated in meaningful discussions and practiced activities that elicited positive thinking. To view all the completed interventions, see Appendix C. During the group sessions, most of the Veterans provided positive feedback on the nature walk exercise and the gratitude TED Talk video. The nature walk exercise is based off an exercise in Coveys (2004) book, The 7 Habits of Highly Effective People. The nature walk included imagining a nature scene that creates the sense of comfort. Then the Veterans were asked to notice the sounds of the nature scene. Then they were instructed to reach back. The Veterans interpreted this statement independently. Next, the Veterans were asked to examine their motives. Finally, the Veterans were instructed to imagine their worries and to leave the worries at the nature scene and return to the present environment. The gratitude video involved a TED Talk by Hailey Bartholomew called 635 Grateful Project. She discussed the benefits of finding gratitude in daily moments. She stated that many individuals take for granted the miniscule experiences in life (Bartholomew, 2014). In the group session, the Veterans expressed appreciation for the speakers perspectives regarding the change in perspective. The group discussed how the speakers environment and living circumstances remained the same, but her perspective on life changed resulting in improved quality of life. During the last group session, the Q-LES-Q-SF was administered to the individuals that completed the tool during the week one group prior to intervention (see Table 4 for results). Through successful leadership during the five-week group, OT ROLE IN VA DOMICILIARY 18 many Veterans expressed appreciation for the daily skills that could be implemented in their lives to create a positive occupational change. I created change in my professional skills as well. Through the practice of empathetic communication, leading by example, advocacy, and being authentic, I developed leadership skills that will continue to assist in future practice. Discontinuation and Outcome Phase Advocacy Researchers investigated the stigma related to individuals with a mental health condition and found that the stigma results in decreased housing, employment, and educational options (Harnish et al., 2016). Therefore, educating the community on mental health and various ways to address mental health will assist in improving community opportunities for individuals experiencing mental health conditions (Swarbrick & Noyes, 2018). One of the focuses for this DCE was to educate personnel from local businesses on how they can address issues related to mental health in the workplace. The employees of local businesses collaborated and planned to implement plans that will address mental health in the workplace. During the presentation, the employees also completed a pre- and post-survey on their perceptions of mental health. The employees noted changes in perceptions regarding embarrassment to tell someone of their own mental health condition. Premier Commercial Real Estate Services Stop Stigma pre-survey results indicated five employees (n = 5, 63%) reported disagreement or strong disagreement with sharing of personal mental health condition. After the open discussion, no participants reported feelings of disagreement towards sharing information about their mental health conditions (n = 0, 0%). BlastMedia pre- and post-survey results indicated similar findings. Six participants reported disagreement with sharing information about mental health conditions (n = 6, 50%) in the presurvey and only one participant reported feeling disagreement with the sharing of mental health OT ROLE IN VA DOMICILIARY 19 conditions (n = 1, 0.08%). Results showed that the employees perceptions of mental health in the workplace became more positive after the presentations and the employees experiencing mental health conditions were able to provide insight into best practices for addressing mental health from their personal experiences. The results of the pre- and post-stigma survey are located in Table 3. Table 3 Pre and Post-Assessment Stop Stigma Survey n = 20 Question Anyone can have a mental health problem I would be too embarrassed to tell anyone that I had a mental health problem I would be happy to have someone with a mental health problem at my school or place of work Mental health problems are not real illnesses in the same that physical illnesses are; people with mental health problems should just 'pull themselves together.' People with mental health problems are likely to be violent It's easy to spot someone with a Pre Post Strongly Agree Agree 19 1 Neither Disagree or Agree Strongly Disagree Strongly Agree Agree 18 2 9 6 3 2 3 4 11 2 10 7 10 1 2 3 9 Disagree 5 4 9 7 3 1 11 Neither Disagree or Agree Disagree Strongly Disagree 1 2 14 3 6 3 1 9 10 5 3 5 7 6 2 1 OT ROLE IN VA DOMICILIARY mental health problem Once you have a mental health problem you have it for life Medication is the only treatment for mental health problems Someone with a mental health problem should have the same right to do a job as anyone else I would not want to live next door to someone with a mental health problem 2 3 1 8 4 20 5 10 7 12 11 9 4 4 3 13 6 3 3 5 9 6 14 8 9 1 After discussion and completion of post-survey, employees were encouraged to write feedback on the presentation information, discussion, and overall organization. The participants provided positive feedback. One participant stated, Mental health is a topic that needs to be addressed. Thank you for initiating the conversation. Other feedback included providing more structure to the discussion with planned questions to initiate conversations. The feedback from the participants continued to guide the schedule and organization for future opportunities for community education on mental health. A primary way to ensure sustainability of the DCE is through advocacy for creating an occupational therapy position at the Domiciliary. Occupational therapists possess the clinical knowledge and experience to provide social, vocational, and coping skills, as well as leisure and daily living guidance to Veterans experiencing homelessness (Gindi, et al., 2016). Throughout the DCE, Domiciliary staff members were educated on occupational therapys scope of practice and how the position enhances care for the Veterans. The staff members were educated through presentations, conversations, and observations of the valuable skills occupational therapists OT ROLE IN VA DOMICILIARY 21 provide to Veterans. The staff now advocate for an occupational therapy position to be established at the Domiciliary for improved collaborative care. This DCE student will continue to collaborate with the occupational therapy manager to advocate for establishing an occupational therapy position at the Domiciliary. Researchers provided evidence that occupational therapists address the necessary client factors to improve the occupational performance of Veterans experiencing homelessness secondary to mental health and substance use conditions (Gindi, et al., 2016; Ikiugu, et al., 2017). The establishment of the occupational therapy position will create the opportunity to continue to address the Veterans occupational needs. The change will create enhanced interdisciplinary care at the Domiciliary to address current societal needs. Program Development Researchers have found the importance of implementing group therapy for individuals with mental health conditions (Wasmuth & Pritchard, 2016) and have created a model to address occupational change with individuals experiencing homelessness (Fisher & Hotchkiss, 2008). Researchers have also identified the need to empower Veterans to create occupational change through group therapy addressing issues such as community engagement, executive functioning training, and establishing healthy routines to improve successful community reintegration and occupational participation (Ikiugu, et al., 2017; Wasmuth & Pritchard, 2016). The Veterans residing at the Domiciliary were empowered to pick a group topic that was meaningful. During each group session the Veterans participated in empowering activities to create a positive outlook. The majority of participants reported increased or unchanged level of satisfaction with items on the post-assessment Q-LES-Q-SF compared to the pre-assessment Q-LES-Q-SF. The post-assessment scores of the Q-LES-Q-SF indicated the majority of participants reported good OT ROLE IN VA DOMICILIARY 22 or very good satisfaction with physical health (n = 5, 83%), mood (n = 5, 83%), family relationships (n = 5, 83%), and ability to get around physically (n = 5, 83%). Half of participants described very poor or poor satisfaction with work (n = 3, 50%) and the majority of participants reported very poor or poor satisfactions with living/housing situation (n = 5, 83%). Areas that decreased in Veteran satisfaction include living and housing situation, medication management, and overall well-being within the past week. Work satisfaction of Veterans remained low from pre- to post-assessment administration of Q-LES-Q-SF. Pre- and post-assessment results concluded that intervention groups focused on implementing a positive outlook improve Veteran satisfaction with physical health, mood, family relationships, leisure time activities; other improvements included sexual drive, interests, and/or performance. Table 4 display results of pre- and post-assessment Q-LES-Q-SF scores of six consistently attending Veterans. OT ROLE IN VA DOMICILIARY 23 Table 4 Q-LES-Q-SF Pre and Post-Assessment Scores n=6 Item Pre Very Poor Physical Health Mood Work Household Activities Social Relationships Family Relationships Leisure Time Activities Ability to Function in Daily Life Sexual Drive, Interest, and/or Performance Economic Status Living/Housing Situation Ability to get Around Physically Vision in Terms of Ability to do Work or Hobbies Overall Sense of Well Being Medication Overall Life Satisfaction this Past Week Total 2 Post Poor 2 1 1 1 1 1 3 2 Fair Good 2 3 1 3 4 1 1 1 4 3 1 2 1 1 4 1 2 1 1 10 Very Poor 20 Poor Fair Good Very Good 1 1 3 3 1 2 2 3 3 2 3 1 3 2 2 2 2 1 2 1 2 1 2 3 1 1 2 3 2 1 3 1 2 4 2 1 2 1 1 3 26 35 20 1 2 1 1 1 3 1 3 4 2 5 Very Good 1 2 2 4 3 3 2 2 2 3 4 2 1 1 34 27 8 3 1 7 1 2 2 2 Throughout the group sessions, Veterans were encouraged to share their thoughts and perceptions on various changes to enhance the group implementation. Veterans reported no modifications to enhance the group. Therefore, a continuous quality improvement assessment was completed after each group session. Suggested areas of improvement included flow of group schedule and increased time for open discussion concerning implementation of positive activities in daily life. The implementation of identified improvements allowed for smoother transitions between various activities and allowed the Veterans to learn from each others thoughts and perceptions on positive perspectives. Although the Greeting the Positive Life group will not continue, the Veterans were provided with a list of healthy activities to create a positive change OT ROLE IN VA DOMICILIARY 24 in their lives. Veterans also created schedules of daily routines integrating such activities to encourage successful implementation of healthy lifestyles. Overall Learning This experience provided many opportunities to enhance my skills as a future practitioner. Through the DCE, I advanced my skills in education, advocacy, documentation, group intervention skills, and mental health knowledge. The advancement of skills included selfreflection; gathering feedback through interaction with mentors, staff, Veterans, and local businesses; and researching evidence. Participating in clinical discussions with individuals from other disciplines including (a nurse practitioner, a psychiatrist, a vocational specialist, a nutritionist, a chaplain, peer supports, recreational therapists, and social workers) related to Veterans care brought insight into the importance of interdisciplinary collaboration to enhance the services provided to the Veterans. The two most impactful leadership skills I learned during my DCE included listening and educating by example. Through listening to others, I was able to identify needs of not only the Veterans in the group sessions but needs of the staff to assist in developing solutions to current barriers with Veteran care. The skill of educating by example was shown through the Positive Outlook group. In the group sessions and outside the group sessions, I participated in the various positive outlook activities. Veterans took notice of my participation in the activities. A Veteran stated, You truly live out what you preach Lexi. Eventually, the Veterans initiated change through integrating positive outlook activities into their daily routines. The feedback from the Veterans demonstrates the importance of providing examples of healthy living. I now listen more than speak and I continue to participate in the evidence-based interventions I provided during the group sessions. I developed leadership skills such as empathetic listening OT ROLE IN VA DOMICILIARY 25 and effective communication which allowed me to build rapport with Veterans and staff, which ultimately empowered the Veterans to create their own change through education of evidencebased interventions. I learned of the impact and insight Veterans possess if practitioners facilitate the development of greater self-efficacy. OT ROLE IN VA DOMICILIARY 26 References American Occupational Therapy Association. (2014). Occupational therapy practice framework: Domain and process (3rd ed.). American Journal of Occupational Therapy, 68(Suppl. 1), S1-S48. Aryes, H., & John, A. P. (2015). The assessment of motor process skills as a measure of ADL ability in schizophrenia. Scandinavian Journal of Occupational Therapy, 22, 470-477. doi:10.31109/11038128.2015.1061050 Bartholomew, H. (2014). 365 grateful project. Retrieved from https://positivepsychologyprogram.com/gratitude-ted-talks-videos/ Bonnel, W., & Smith, K. V. (2018). Proposal writing for clinical nursing and DNP projects (2nd ed.). New York: Springer Publishing Company. Byrne, T., Montgomery, A. E., & Fargo, J. D. (2016). Unsheltered homelessness among veterans: Correlates and profiles. Community Mental Health Journal, 52, 148-157. doi:10.1007/s10597-015-9922-0 Charon, R., DasGupta, S., Hermann, N., Irvine, C., Marcus, E. R., Rivera Coln, E., Spiegel, M. (2017). The principles and practice of narrative medicine. New York, NY: Oxford University Press. Clark, G., Rouse, S., Spangler, H., & Moye, J. (2018). Providing mental health care for the complex older veteran: Implications for social work practice. Health & Social Work, 43(1), 7-14. doi:10.1093/hsw/hlx046 Cole, M.B., & Tufano, R. (2008). Applied theories in occupational therapy: A practical approach. Thorofare, NJ: SLACK, Inc. OT ROLE IN VA DOMICILIARY 27 Cornwell Partnerships. (n.d.). The stop stigma survey. Retrieved from https://www.cornwallhealthyschools.org/mh-resources/ss-survey/ Covey, S. R. (2004). The 7 habits of highly effective people. New York, NY: Simon & Schuster Paperbacks. Fisher, G. S., & Hotchkiss, A. (2008). A model of occupational empowerment of marginalized populations in community environments. Occupational Therapy in Health Care, 22(1), 55-71. doi:10.1300/J003v22n01_05 Gindi, S., Galili, G., Volovic-Shushan, S., & Adir-Pavis, S. (2016). Integrating occupational therapy in treating combat stress reaction within a military unit: An intervention model. Work, 55, 737-745. doi:10.3233/WOR-162453 Haibach, J.P., Haibach, M. A., Hall, K. S., Masheb, R. M., Little, M. A., & Shepardson, R. L. (2017). Military and veteran health behavior research and practice: Challenges and opportunities. Journal of Behavioral Medicine, 40(1). doi:10.1007/s10865-016-9794-y Harnish, A., Corrigan, P., Byrne, T., Pinals, D. A., Rodrigues, S., & Smelson, D. (2016). Substance use and mental health stigma in veterans with co-occurring disorders. Journal of Dual Diagnosis, 12(3-4), 238-243. doi:10.1080/15504263.2016.1245066 Hope, M. L., Page, A. C., & Hooke, G. R. (2009). The value of adding the Quality of Life Enjoyment and Satisfaction Questionnaire to outcomes assessments of psychiatric inpatients with mood and affective disorders. Quality of Life Research, 18(5), 647-655. Ikiugu, M. N., Nissen, R. M., Bellar, C., Maassen, A., & Van Peursem, K. (2017). Centennial topicsclinical effectiveness of occupational therapy in mental health: A meta-analysis. American Journal of Occupational Therapy, 71, 7105100020. doi:10.5014/ajot.2017.024588 OT ROLE IN VA DOMICILIARY 28 Lippert, A. M., & Lee, B. A. (2015). Stress, coping, and mental health differences among homeless people. Sociological Inquiry, 85(3), 343-374. doi:10.1111/soin.12080 McBride, K. E. & Rines, B. (2000). Sexuality and spinal cord injury: A road map for nurses. SCI Nursing, 17(1), 8-13. National Alliance of Mental Illness. (n.d.). Mental health facts in America. Retrieved from https://www.nami.org/NAMI/media/NAMI-Media/Infographics/GeneralMHFacts.pdf Riendeau, R. P., Sullivan, J. L., Meterko, M., Stolzmann, K., Wiliamson, A. K., Miller, C. J., Bauer, M. S. (2018). Factor structure of the Q-LES-Q short form in an enrolled mental health clinic population. Quality of Life Research, 27, 2953-2964. doi:10.1007/s11136018-1963-8 Roy, W., Vallee, C., Kirsh, B. H., Marshall, C. A., Marval, R., & Low A. (2017). Occupationbased practices and homelessness: A scoping review. Canadian Journal of Occupational Therapy, 84(2), 98-110. doi:10.1177/0008417416688709 Stevanovic, D. (2011). Quality of Life Enjoyment and Satisfaction Questionnaire - short form for quality of life assessments in clinical practice: A psychometric study. Journal of Psychiatric and Mental Health Nursing, 18(8), 744-750. doi:10.1111/j.13652850.2011.01735.x Swarbrick, M. & Noyes, S. (2018). Guest editorialeffectiveness of occupational therapy services in mental health practice. American Journal of Occupational Therapy, 72, 7205170010. doi:10.5014/ajot.2018.725001 Trivedi, R. B., Post, E. P., Sun, H., Pomerantz, A., Saxon, A. J., Piette, J. D., Nelson, K. (2015). Prevalence, comorbidity, and prognosis of mental health among US veterans. American Journal of Public Health, 105(12), 2564-2569. OT ROLE IN VA DOMICILIARY 29 US Department of Veteran Affairs. (2018). Homeless veterans. Retrieved from https://www.va.gov/HOMELESS/pit_count.asp Wasmuth, S., & Pritchard, K. (2016). Theatre-based community engagement project for veterans recovering from substance use disorder. American Journal of Occupational Therapy, 70, 7004250020. doi:10.5014/ajot.2016.018333 OT ROLE IN VA DOMICILIARY 30 Appendix A Group Options Please place a check mark next to the groups you are most interested in. Once you complete the survey please give this sheet to Lexi Ferguson or place under the Recreational Therapy door on the garden level (023). ______Media Toolbox Workshop This group provides an opportunity to explore various pieces of art. The group will be provided a media (music, film, art piece, script to a play) that correlates with an aspect of life. In the group we will discuss the media and how we perceive the piece of art. ______Empowering Function through Education Workshop This group provides education and practice in pain management skills, proper body mechanic skills, and musculoskeletal disorder (carpal tunnel syndrome, frozen shoulder, tennis elbow) prevention skills. These skills will assist in decreasing risks for future injuries. ______Chilin Out Workshop This group provides education and practice into anger management. We will learn various methods to manage anger and practice using the skills to carry over into life situations. ______Positive Outlook Workshop This group provides education and practice into thinking positively. We will learn various ways to change our way of thinking during life situations and apply the skills to create a positive outlook. ______Sexual Education Workshop This group will provide an opportunity to learn about sexual identity, sexual education, and respecting others. The group will have educational and open discussion components to increase our knowledge about sexuality. ______Community Inclusion Workshop This group will put all your learned skills into practice. We will use the coping skills, nutrition skills, spiritual skills, social skills and apply these to situations you will face in your daily routines once reintegrating back into community living. ______Pre-Employment Workshop This group will work on building your resume, basic computer skills, and providing opportunities for practicing interviewing skills for the job search process. We will break down each step in this process so learn the steps for a successful job search. ______Its All in the Details Workshop This group will focus on organization and planning for maintaining a schedule while living independently in the community. We will look at different means to maintain OT ROLE IN VA DOMICILIARY organization with creating daily routine schedules, proper organization of household items, and maintaining a schedule for appoints and medication administration. 31 OT ROLE IN VA DOMICILIARY 32 Appendix B OT ROLE IN VA DOMICILIARY 33 Appendix C Group Title: Positive Outlook Workshop Author: Lexi Ferguson, OTS Frame of reference (FOR): Model of Occupational Empowerment and psychodynamic FOR Group membership: veterans residing at the Domiciliary Group goals and rationale: - Create a positive outlook - Hold self-accountable for implementing a positive outlook to life - Be a more caring individual - Spend more time with others - Create an inner peace - Obtain employment and housing Outcome criteria: Quality of Life, Enjoyment, and Satisfaction Questionnaire- Short Form (QLES-Q-SF) and Meaning of Life Questionnaire (authentichappiness.org, 2019) Method: - Review Schedule - Warm-Up - Introductions - Instructions for activity - Activity - Sharing - Discussion - Summary Time and place of meeting: Mondays at 9:00 AM in RM 031/032 Supplies and cost: - Binder: $4.99 References Cole, M. B. (2012). Group dynamics in occupational therapy The theoretical basis and practice application of group intervention (4th ed.). Thorofare, NJ: SLACK Incorporated. Suzuki, W. (2014). Health brain, happy life A personal program to activate your brain & do everything better. New York, NY: HarperCollins. Authentic Happiness. (2019). University of Pennsylvania. Retrieved from https://www.authentichappiness.sas.upenn.edu/home Covey, S. R. (2004). The 7 habits of highly effective people. New York, NY: Simon & Schuster Paperbacks. Week 1 (2/25/2019) - Session Title: The Start of Positivity o 10 participants - Format: o Veterans sign in o Provide information on my role as OT student at Domiciliary and as group leader Define OT scope of practice Define DCE OT ROLE IN VA DOMICILIARY o o o o o o 34 Define focus of DCE Enhance experience to improve re-integration back into the community Model of Occupational Empowerment Psychodynamic FOR Provide Q-LES-Q-SF Review schedule Warm-Up: 5 minutes Mindfulness exercise: Alternating nostril breathing (Suzuki, 2014) Introductions: 5 minutes Name One thing you are proud of Instructions: 5 minutes Provide education on positive psychology (Authentic Happiness, 2019) Strength-focused Focus on positive areas of life Neurochemical changes that happen in brain (literature to back up positive psychology) Activity: 10 minutes Review expectations in the group schedule; Have group members set up expectations for me (What do you expect from me the next five weeks?); Create group goals (Covey, 2004): Leader expectations: Provide research, educate, use visuals (movies, PowerPoints), invite guest speaker or motivational speaker, remind each other of positive things in life at beginning of week, provide morning meditation, good news check-in Desired results Positive outlook, discover the silver lining, find out how to see things more positive, share positive experiences with each other Identified resources films, do not provide handouts because too many papers, positive quote of the week (someone brings in positive quote) Accountability hold selves accountable (independent positivity check), positive challenges for the week Consequences: financial, psychic (respect, credibility, approval), opportunities, responsibilities Be kinder individuals, spend more time with others, inner peace, employment and housing Educated on using strengths in daily situations (Authentic Happiness, 2019) Provided written instructions on how to complete brief strengths questionnaire on authentichappiness.org Asked to complete questionnaire and bring results to next group meeting OR reflect on life and identify 4 strengths Sharing: 10 minutes How feel about goals? OT ROLE IN VA DOMICILIARY 35 What is one strength? How did you use that strength in a proud experience? o Discussion: 10 minutes How do you feel about the group? Any other thoughts? o Action Plan for week: 2 minutes Take strength-based assessment on authentichappiness.org Implement top strength in at least one situation Will be asked next week how implemented strength o Summary: 2 minutes Can someone please summarize what we did today? - Supplies o 5-minute positive brain wave music o Paper o Pen o Q-LES-Q-SF o Satisfaction Life Questionnaire o Registering account instructions o Table o Chairs Week 2 (3/4/2019) - Session Title: Present Time Travel o 13 participants - Format: o Review schedule o Good in the World News Cancer deaths have dropped by 25% in United States since 1991, saving more than 2 million lives. o Warm-Up: 10 minutes What did we review last week? Take away? Positive quote of the week: V.T. Write on whiteboard Creativity (Suzuki, 2014) Draw 4-5 random lines on the piece of paper Pass your paper to the left Draw something with the random lines Share drawings Creating something stimulates neurons and allows for positive changes to occur leading to a positive outlook when engage mind in different manners. Share Animal Strengths story from Covey (2004): p. 290-291 o Introductions: 5 minutes Name What is a top strength? How did you implement a strength this past week? Good news check in: What is one positive thing that happened last week? o Activity: 15 minutes OT ROLE IN VA DOMICILIARY - 36 J.H. share experience with implementing daily tasks for positivity Outside Walk (Visual imagery exercise secondary to below freezing temperatures) Walk around Dom and experience nature through various senses o Follow Covey (2004): p. 305-306 Listen carefully Try reaching back Examine your motives Write your worries on the sand o Read The Turn of the Table from Covey (2004): p. 304306 o Sharing: 10 minutes Has anyone truly stopped to smell the roses? How did it feel during our walk? o Discussion: 5 minutes How do you think walking in nature relates to positivity? What do you see as the benefits of being present in nature? How could you implement this in your daily routine (cold, raining snowing)? o Action Plan for week: 2 minutes Implement a different strength in at least one situation Will be asked next week how implemented strength Take a walk and be present in nature o Summary: 2 minutes What is the take away from today? Who wants to bring a quote about positivity for next week? Supplies o Paper with random lines o Coloring utensils o List of tasks that can assist with living a life of positivity o Chairs o Table o Playlist o Whiteboard o Dry erase marker o The 7 Habits of Highly Effective People Week 3 (3/11/2019) - Session Title: Positives of Gratitude o 12 Participants - Format: o Review schedule o Good in the World News Kraft opened free grocery store for unpaid workers during government shut down. Today Show OT ROLE IN VA DOMICILIARY - 37 o Warm-Up: 10 minutes Take away from last week? Positive quote of the week: M.C. Write on whiteboard Share gratitude journal with Veterans Three things you are thankful for (Authentic Happiness, 2019; Suzuki, 2014) Can complete a journal and write down three things each evening that you are thankful for o Introductions: 5 minutes Name What is a top strengths? How did you implement a strength this past week? Good news check in: What is one positive thing that happened last week? o Activity: 20 minutes Watch TED Video https://positivepsychologyprogram.com/gratitude-ted-talks-videos/ o Hailey Bartholomew: 365 Grateful Project Detailed letter of gratitude (Authentic Happiness, 2019) Think of someone in your life that has made a positive influence on you. Write a detailed letter of gratitude to this person. o Thank them o State what they did o State why you are thankful o Sharing: 5 minutes How was this experience of writing a thank you letter? o Discussion: 5 minutes What about gratitude do you think creates positivity? How can you implement this in your daily life? o Action Plan for week: 3 minutes Implement a different strength in at least one situation Will be asked next week how implemented strength Start and maintain a gratitude journal If need a journal let me know o Summary: 2 minutes What is the take away from today? Who wants to bring a quote about positivity for next week? Supplies o My gratitude journal o Paper o Writing utensils o Computer to play TED talk o Playlist o Chairs o Table OT ROLE IN VA DOMICILIARY 38 o White board o Dry erase marker Week 4 (3/18/2019) - Session Title: Exploring You o 13 Participants - Format: o Review schedule o Take away from last week? Gratitude Journal Thank you letter o Good in the World News March 9th: A personal trainer with Autism opened new gym and provides accommodations for individuals with special needs o Warm-Up (10 minutes) Positive quote of the week: J.H. Learn a dance (Suzuki, 2014) https://www.youtube.com/watch?v=BQ9q4U2P3ig o Introductions (5 minutes) Name What is one of your strengths? How did you implement a strength this past week? Good news check in: What is one positive thing that happened last week? o Activity (25 minutes) Magazine Collage On the paper paste various words or pictures from the magazines that you feel are representful of you or items that you find inspiring Sharing: Anyone want to share their collage? Personal Mission Statement (Convey, 2004) Based off the items you pasted and your own reflection create a personal mission statement. These are words you will live by, who you want to become, what you want to accomplish in your life, things that inspire you Sharing o How did you feel creating your own personal mission statement? o Discussion (5 minutes) How can creating a personal mission statement/laid out principles assist in creating a positive outlook? How can you implement this into your daily life? o Action Plan for week: 3 minutes Implement a different strength in at least one situation Will be asked next week how implemented strength Finish your personal mission statement: Review, edit, reflect Can be an ongoing process o Summary: 2 minutes OT ROLE IN VA DOMICILIARY - 39 What is the take away from today? Who wants to bring in a quote for next week (last week)? Supplies o Paper o Magazines o Scissors o Glue o Writing utensils o Screen o Dance video o Chair o Table o Playlist o Whiteboard o Dry erase marker o Computer Week 5 (3/25/2019) - Session Title: Go Forth with Positivity o 19 Participants - Format: o Review schedule o Take away from last week? Personal Mission Statement o Good in the World News An individual with Parkinsons Disease walks again after being in a w/c for years Foxnews.com/category/good-news o Warm-Up (5 minutes) Positive quote of the week: P.A. Positive affirmations during exercise (Suzuki, 2014) Remember these small tasks can become habits into daily life that can assist in leading to a life of positive outlook o Introductions (5 minutes) Name What are your top strengths? How did you implement a strength this past week? Good news check in: What is one positive thing that happened last week? o Activity (23 minutes) Positivity Plan: daily routine with positive changes Sharing What does it feel like to try and schedule your time? Are there any healthy activities in your schedule? o Discussion (5 minutes) What are you hopes for life? OT ROLE IN VA DOMICILIARY - 40 Reflect on the various roles you established in your positivity plan (family member, friend, employee). How can your identified strengths help you with these roles? What did you get out of this experience? o Action Plan/Summary: 2 minutes Can someone please summarize what we did today? Implement positivity activities and strengths into your daily life. Follow your positive daily schedule. o Complete final Q-LES-Q-SF (10 minutes) Supplies o Schedules o Writing utensils o Playlist o Chairs o Table o White board o Dry erase marker o Q-LES-Q-SF forms  ...

... Creation of a Caregiver Resource Manual: For Caregivers of Participants Attending Adult Day Services Samantha Farmer May, 2019 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: Julie Bednarski, OTD, MHS, OTR A Capstone Project Entitled Title: Creation of a Caregiver Resource Manual: For Caregivers of Participants Attending Adult Day Services Submitted to the School of Occupational Therapy at University of Indianapolis in partial fulfillment for the requirements of the Doctor of Occupational Therapy degree. By: Samantha Farmer, OTS Approved by: Faculty Capstone Advisor Date Doctoral Capstone Coordinator Date Accepted on this date by the Chair of the School of Occupational Therapy: Chair, School of Occupational Therapy Date Running head: CREATION OF A CAREGIVER RESOURCE MANUAL Creation of a Caregiver Resource Manual: For Caregivers of Participants Attending Adult Day Services Samantha Farmer, OTS University of Indianapolis 1 CREATION OF A CAREGIVER RESOURCE MANUAL 2 Abstract Due to high residential care costs, individuals with dementia are remaining in their community and relying on informal caregivers (Vreugdenhil, 2014). Providing unpaid care for individuals with dementia can negatively impact the caregiver physically and psychologically resulting in caregiver burden (Thompson, Bridier, Leonard, & Morse, 2018). In previous literature, caregivers reported they lacked education on the physical, psychosocial, and environmental characteristics related to the caregiving process (Kort & van Hoof, 2014; Lestari et al., 2018; Wawrziczny et al., 2017; Weisman de Mamani et al., 2018). In attempt to decrease caregiver burden, the purpose of this doctoral capstone experience was to develop an educational resource for caregivers to increase their knowledge in relevant topic areas. The doctoral capstone experience was completed at an adult day center serving 20 participants with physical and cognitive impairments. After completing the needs assessment, caregivers were sent a survey to gather further sociodemographic and educational need information. A Caregiver Resource Manual was created during the initial 12 weeks of doctoral capstone experience and forty-eight copies were made. The Caregiver Resource Manuals were presented to caregivers in a caregiver in-service with a pre/post-test to measure knowledge gained during the in-service. Results of pre/post- test indicated an increase in knowledge of common terms and definitions relating to dementia care. Manuals were distributed to the caregivers who were unable to attend the inservice. After completion of the doctoral capstone experience, manuals will continue to be given to all caregivers upon their loved ones admission to the program. CREATION OF A CAREGIVER RESOURCE MANUAL 3 Literature Review Dementia, one of the most common progressive neurodegenerative conditions, is characterized by a decrease in cognitive function, language, recognition, memory, and movement (Lestari, Hamu, Rachmawati, Singkali, & Yusuf, 2018). Common types of dementia include Alzheimers Disease, frontotemporal dementia, mixed dementia, Lewy Body dementia, vascular dementia, and multi-infarct dementia (National Institutes of Health, 2013) Forty-seven million individuals live with some form of dementia across the world (Prince, Comas-Herrera, Knapp, Guerchet, & Karagiannidou, 2016). By 2050, 131 million individuals worldwide are expected to be living with dementia (Prince, 2016). Symptoms of dementia include aphasia (language disorder), agnosia (difficulty with object recognition), apraxia (disturbance in motor function), impairments in executive function (planning, problem solving, and sequencing), mood and personality changes, decreased social ability and decreased performance of activities of daily living (ADLs) and instrumental activities of daily living (IADLs) (Gulin et al., 2018; Lestari et al., 2018). As dementia symptoms progress, the affected individual will lose the functional capacity required to live independently requiring them to move to a residential care facility or be cared for by a family caregiver (Vreugdenhil, 2014; Zuria Idura, Noorliaili, Rosdinom, Azlin, & Tuti Iryani, 2018). Due to high costs of residential care and preference to remain in their own home, more individuals are now being cared for at home by their spouse or adult children (Vreugdenhil, 2014). According to the Alzheimers Association (2015), in 2014 nearly 16 million caregivers were providing unpaid care to individuals with dementia amounting to 18 billion hours. Demands of caring for an individual with dementia can include assistance with ADL tasks including bathing, dressing, and grooming and IADL tasks including shopping, laundry, home CREATION OF A CAREGIVER RESOURCE MANUAL 4 maintenance, financial management, driving (Weismande Mamani, Weintraub, Maura, Martinex, & Brown, 2018). Aside from the physical demands of caregiving, caregivers also are affected by their loved ones inappropriate, rude, and bizarre behavior symptoms (Weismande Mammani, et al., 2018). Negative outcomes such depression, social isolation, physical and emotional strain, and decreased physical health can result when caring for an individual with dementia, which leads to decreased quality of life for both the caregiver and the individual with dementia (Zuria Idura, 2018). When caring for an individual with dementia begins to negatively affect the caregiver, both physically and psychologically, it leads to the commonly known term caregiver burden (Thompson, Bridier, Leonard, & Morse, 2018). Thompson et al. (2018) defines caregiver burden as a period when a caregivers work, health, finances, social life, and other life roles are negatively impacted by caregiving producing caregiving stressors. In a study aiming to determine needs of caregivers, it was found that caregivers felt they needed assistance with home help, finances, social support, and leisure exploration and participation (Wawrziczny, Pasquier, Ducharme, Kergoat, & Antoine, 2017). Caregivers expressed a need for information regarding the disease progression and ways to manage difficult behavioral situations such as night problems and aggressive behaviors (Wawrziczny et al., 2017). Caregivers reported they often do not feel prepared for their caregiver role and lack of awareness and knowledge regarding resources for personal wellbeing. Caregivers across various studies reported they feel they needed education on diagnosis (Wawrziczny et al., 2017; Weisman de Mamani et al., 2018; Zuria Idura, 2018), behaviors (Wawrziczny et al., 2017; Weisman de Mamani et al., 2018), social support (Van Knippenberg et al., 2018; Wawrziczny et al., 2017; Zuria Idura, 2018), benefits of physical activity (Lestari et al., 2018), driving cessation (Byszewski, Power, Lee, Rhee, Parson, & Molnar, 2017; Pyun, Kang, Kim, Baek, Wang & Kim, CREATION OF A CAREGIVER RESOURCE MANUAL 5 2018), home modifications (Kort & van Hoof, 2014), and advanced directives (Bosisio, Jox, Jones, & Truchard, 2018; Lendon et al., 2018;). Education in these areas could decrease caregiver burden by increasing positive aspects of caregiving including feelings of accomplishment, self-efficacy, satisfaction, sense of meaning, personal growth, self-respect, and improved relationships (Grover, Nehra, Malhotra & Kate, 2017; Zuria Idura, 2018). Results of a study that aimed to examine emotional stress reactivity in dementia caregivers revealed that caregiver resources aimed to increase a caregivers competence, mastery, and coping skills would be beneficial to reduce daily stress for caregivers (Van Knippenberg et al., 2018). The purpose of this doctoral capstone experience (DCE) was to develop an educational resource for caregivers of individuals with dementia to increase their knowledge in attempt to decrease caregiver burden. Overview of Site and Project Adult day services strive to improve the quality of life for community-dwelling individuals with dementia and their family caregivers by providing respite services (Rokstad, Engedal, Kirkevold, Benth, and Selbl, 2018). Adult day services provide participation in meaningful structured activities, a safe environment, socialization, health monitoring, and ADL assistance (Rokstad et al., 2018; Lendon, Caffrey & Lau, 2016). By providing daytime medical care and socialization, adult day services aim to improve the quality of life of individuals with dementia and their caregivers and delay institutionalization or nursing home placement (Lendon et al., 2016). This DCE was completed at A Caring Place Adult Day Services (ACP). ACP offers Person-Centered Care for individuals with cognitive and physical impairments aged 50 years and older (Catholic Charities Indianapolis, 2018). ACP provides socialization, programming, fall prevention and walking programs, medication administration and health monitoring through CREATION OF A CAREGIVER RESOURCE MANUAL 6 Person-Centered Care, which promotes the personal worth, independence, hope and selfconfidence for each unique individual (A Caring Place Adult Day Services). Service Provision Model ACP follows the community-based service delivery model approach by serving the older adult community under a nonprofit organization. The community-based service delivery model approach was used to guide this DCE by providing education to the caregivers of the individuals attending ACP who are suffering from progression of dementia and other age-related illnesses. This project aimed to educate caregivers on aspects of caregiving that they may experience in order to increase the quality of life of and maintain occupational performance at home and within their community for the caregiver and their loved one. Within this project it was crucial to consider the background, socioeconomic status and education level of all individuals in the community in order to make the educational resource useable to all caregivers upon admission at ACP. Theory The model that guided this DCE was the Person-Environment-Occupation (PEO) model. The PEO focuses on the fit between the person, occupation and environment (Cole & Tufano, 2008). The better the fit there is between the person, environment and occupation the better the occupational performance (Cole & Tufano, 2008). Within this model, change is always happening, and any change causes the whole model to shift (Cole & Tufano, 2008). This model was important to this DCE because change in both the caregiver and care recipient physically or mentally affects the fit between their person, environment and occupation. Dementia is a progressive disease meaning change can happen at any point in the course of the disease and the individual and their caregiver will have to adapt their occupation and environment in order to CREATION OF A CAREGIVER RESOURCE MANUAL 7 safely remain at home (Lestari, 2018). The overall goal of this educational resource guided by the PEO model was to decrease caregiver burden by increasing the fit between their person, environment, and occupation. Using the community-based service delivery model and the (PEO) model, the goal of this DCE was to create an educational caregiver resource manual to be distributed to the caregivers of ACP. This Caregiver Resource Manual was intended to increase education for the caregivers of ACP in attempt to decrease caregiver burden and increase overall quality of life for the individuals with dementia and their caregivers at ACP. Screening and Evaluation Initial needs assessment began at initial interview with the program director at ACP. Possible project topics consisted of program development opportunities to assist staff members, participants attending ACP, and/or caregivers. After further discussion, email contact, and one more in person meeting, it was concluded that ACP could benefit most from an educational caregiver resource. The program director explained that she had collected much research relating to potential topic areas over her past 30 years in geriatrics. She had been wanting to create a resource for ACP but never had the time. Although much of the research and materials she had collected were outdated, her collection of research was a great starting point to gain topic ideas. Next, a SWOT analysis of the current caregiver interaction/programming was completed. The results of the SWOT analysis were used in the intervention plan to determine strengths, weaknesses, opportunities and threats (Aguilar, 2017). Aguilar (2017) found that the SWOT analysis along with other analysis evaluated her interventions effectiveness. CREATION OF A CAREGIVER RESOURCE MANUAL 8 Findings from SWOT analysis: S- Catholic Charities and ACP held a caregiver support group once a month at a south and north location, which was a strength of the caregiver programming at ACP. Another strength was that ACP provided transportation to and from the facility, which took the stress of transportation off the caregiver. W- Providing transportation was also weakness because it decreased staff and caregiver interaction. Instead, the majority of staff and caregiver interaction consisted of discussing details over the phone. The greatest weakness was that there were not a specific set of resources to be given to caregivers of participants upon admission or anytime throughout the experience. O-By creating a universal educational caregiver resource, caregivers will have the opportunity to receive education without increasing time or communication demands of the staff and caregivers. T- Threats to this educational resource include lack of understanding of materials due to low education level. This emphasized the importance of considering health literacy throughout this DCE. Another threat to this program was that not all participants at ACP had the same diagnosis, requiring different education for each caregiver. After completing the SWOT analysis, it was determined that an educational resource that was understandable by all educational levels and for all types of caregiver was needed. This educational resource would be given to all current caregivers as well as new caregivers upon enrolling their loved one at ACP. After initial research, it became apparent that sociodemographic data including gender, age, and primary diagnosis for the individuals attending ACP, as well as, each caregivers age, gender, living situation, level of education and current work status, would be needed to develop an appropriate caregiver resource specific for the caregivers of ACP participants (van CREATION OF A CAREGIVER RESOURCE MANUAL 9 Knippenberg, de Vugt, Ponds, Verhey, & Myin-Germeys, 2018; Wawrziczny, Pasquier, Ducharme, Kergoat, & Antoine, 2017). Surverys containing questions regarding sociodemographic information for the participant and their caregiver were sent home with 20 participants. Prior to the 20 questions, a short paragraph was included introducing the DCE student and explaining the purpose of the project. After two weeks, eight of the surveys were returned. In order to increase participation for the sociodemographic survey, it may have been beneficial to follow-up with a phone call in effort to obtain the requested information. Appendix A includes the sociodemographic survey used for this DCE. Results of the surveys concluded that the participants mean age were 74.9 with a range of 67-89. Seventy-five percent of the participants were male and 25% were female. Half of participants primary diagnoses were dementia while the other four were recorded as schizophrenia paranoid type, traumatic brain injury (TBI), stroke or brain trauma, and inability to live alone due to assistance needed with basic needs. The length of time that the participants had been attending ACP ranged from four months-to- five years. Table 1A details sociodemographic survey results for participants The survey of the eight respondents concluded that caregivers ages ranged from 45-75 with a mean age of 59. Seventy-five percent of the caregivers were female and 25% were male. Of the eight caregivers that responded to the survey, four were the spouse of the participant, three were children of the participant, and one was a sibling of the participant. All of the caregivers lived full time with the participant. Three of the caregivers reported having one or two other adults living in the home that are able to assist with caregiving. One of the caregivers had a 14-year-old child living at home who assisted in care of the participant. All other caregivers lived alone with the participant. Caregiver education levels ranged from 11th grade to a masters CREATION OF A CAREGIVER RESOURCE MANUAL 10 degree. Fifty percent of the caregivers were retired, while 25% of caregivers worked full time and 25% worked part time, five-to-20 hours per week. Table 2A includes sociodemographic survey results for the caregivers. While waiting for responses for the demographic survey, a literature review of scholarly research along with communication with the program director was completed to determine the topic areas most appropriate for the caregivers at ACP. The program director had more than 30 years of geriatric specific experience working as a licensed social worker (LCSW). A social worker is trained to be equipped with skills in counseling, education, case management and dementia care all used in caregiver support services, making this feedback reliable for this educational resource (Anderson, Dabelko-Schoeny, Fields, & Carter, 2015). Screening and Evaluation for the most appropriate way to implement caregiver education has similarities and differences based on setting. When comparing the adult day setting to a home health setting the individuals treated could be very similar regarding age, diagnoses, living situations etc. Different from the Caregiver Resource Manual created during this DCE, that is targeting the dementia population as a whole, caregiver education in the home health setting is given based on each individuals specific needs (Lannin, 2003). Topic areas addressed in home based rehabilitation could include physical, psychosocial and cognitive issues as well as home management and community integration (Lannin, 2003). The individual and their caregiver are screened and evaluated in those areas and the education is focused on each individuals specific strengths and weaknesses at the time (Lannin, 2003). After reviewing the sociodemographic survey, it was apparent that ACP had a diverse participant and caregiver population, therefore in order to ensure sustainability of this Caregiver Resource Manual it was important to make it broad and universal in order to be useful to as many caregivers as possible. CREATION OF A CAREGIVER RESOURCE MANUAL 11 In summary, screening and evaluation for this DCE consisted of interviews with the program director at ACP, SWOT Analysis, and a sociodemographic survey. Limited sociodemographic responses resulted in a less accurate representation of the participant population at ACP. However, the responses were useful in representing the sociodemographic differences among the caregivers that will be receiving this Caregiver Resource Manual. Implementation Phase After extensive online literature review, review of site mentors materials collected during her 30+ years of geriatric work, and collaboration with the site mentor the following sections were determined to be included in the Caregiver Resource Manual: 1. Diagnoses (Wawrziczny et al., 2017; Weisman de Mamani et al., 2018; Zuria Idura, 2018) 2. Caregiver Burden (Thompson et al., 2018, Zuria Idura, 2018) 3. Preparing for Doctors Appointments 4. Advance Directives and Legal and Financial Worksheets (Bosisio, Jox, Jones, & Truchard, 2018; Lendon et al., 2018) 5. Understanding and Managing Behaviors (Wawrziczny et al., 2017; Weisman de Mamani et al., 2018) 6. Home Safety as you Age in Place (Kort & van Hoof, 2014; Vreugdenhill, 2014) 7. Home Programming Activities (Lestari et al., 2018) 8. Depression (Aguilar, 2017) 9. Guidance for Continued Driving (Byszewski, Power, Lee, Rhee, Parson, & Molnar, 2017; Pyun, Kang, Kim, Baek, Wang & Kim, 2018) 10. Support Groups Once topics were finalized more extensive research was conducted to gather relevant data for each section. The student visited the Alzheimers Association to gather information from a local representative on the included topics. Student referred to occupational therapy textbooks and CREATION OF A CAREGIVER RESOURCE MANUAL 12 researched websites from reputable organizations including the Hartford foundation, EasterSeals Crossroads, and the National Institute for Health to compile the most updated and accurate information for each topic area. For the readers ease, each section began with an overview introducing the importance of the section and detailing what was going to be included. Following the overview, topics were further explained as well as how they could be applicable to their role of caregiving. In order to ensure health literacy was addressed, all of the topics were described using language that could be understood by individuals of many educational levels (Matsuyama, Wilson-Genderson, Maghanaki, Vachhani, Paasche-Orlow, 2011). After reviewing the educational levels of the caregivers at ACP, obtained in sociodemographic surveys, it was determined that information should not surpass the high school education level. However, in some sections handouts from various associations were provided using more advanced language and increased detail for further topic knowledge if the caregiver chose. Once each section was in draft form, the site mentor reviewed the section and provided feedback. After consultation with the site mentor and staff social worker it was determined that the best way to disseminate the Caregiver Resource Manual would be to host a caregiver inservice for all interested caregivers. Twenty current caregivers were sent invitations to the inservice. In order to ensure all 20 caregivers, as well as future caregivers, could have a copy of the Caregiver Resource Manual, 48 copies were created. Binders and binder tabs were ordered online. Once the binder resource was completed and revised, student scanned the final copy to the Catholic Charities printing office for duplication. CREATION OF A CAREGIVER RESOURCE MANUAL 13 After assembling all 48 binders a final review was completed. It was concluded that it would be beneficial to include a section on humor at the end of the material to emphasize the importance of humor and laughter in the caregiver process. A miscellaneous section was also added for the caregiver to add any resources that they collect throughout their caregiving journey. Leadership During the implementation phase of this DCE many leadership skills were required. This project was self-directed and required leadership to ensure that everything was ordered on time, caregivers were informed, and site mentor had sections in a timely manner for critique. A weekly planning guide was completed during the first two weeks and adapted as needed to assist with project timeline. The secondary focus of this DCE was administration. Student assisted with completion and submission of major administrative documents including: Title VI Bus Grant Renewal, 2019-2020 Budget, Medicare Re-mediation, Medicare Re-validation, and Title III CICOA Grant Renewal. Student took leadership with navigating computer online system while program director and social worker located needed documents and statistics to be inputted into the computer. Student took leadership with inputting bills and invoices into online payment system as well as assisting with credit card reports each month during DCE. Staff Development During this DCE at ACP there were multiple staffing changes. During the first week onsite a physical therapist, driver and kitchen aide were beginning new positions and trained simultaneously with student. During remainder of the DCE a CNA was hired and a bus driver increased his hours to assist with the program assistant/kitchen aid position as another staff CREATION OF A CAREGIVER RESOURCE MANUAL 14 member had to significantly cut her hours. While new staff members were being trained it was important for all staff members to cover the empty positions. The student was able to assist with coverage of these positions while positions were advertised and other staffing positions were adjusted. With each new hire and change in position the individual had to complete appropriate paperwork as well as be trained in new position requirements. The student was able to assist program director with updating position description forms to be completed by employees. The student was also able to assist these staff members with their transition and help them as needed until they felt confident completing their roles independently. During this DCE two of the staff members were studying and being trained to obtain their Program Assistant Certification. After reviewing and becoming knowledgeable of the certification content, student was able to assist the staff members in their preparation for their certification exam. This consisted of three, 2-hour training sessions with the program director, student, and the two staff members. Over the course of this DCE student was able to utilize leadership and staff development in order obtain beyond entry-level occupational therapy practitioner skills in program development and administration. Self-directed leadership was utilized to construct and finalize the Caregiver Resource Manual timely, as well as to plan the caregiver in-service for the discontinuation phase. Leadership skills required time management, communication, and organization. Leadership was also utilized during administrative tasks as many major administrative documents were completed during the DCE that required extensive research, patience, and forward-thinking. Administrative tasks during this experience promoted staff development in administrative aspects including staff training and updates to position descriptions. Staff development was also vital to this DCE during the implementation of the CREATION OF A CAREGIVER RESOURCE MANUAL 15 Caregiver Resource Manual, as the social worker and program director will continue to distribute this Caregiver Resource Manual to all new participants after completion of this DCE. Discontinuation and Outcome The caregiver in-service was completed on Wednesday March 27, 2019. Twenty caregivers were sent an invitation one month before the in-service with a requested return annotating their attendance. Eight caregiver responses were received. Out of the eight received, three of them stated they would be out of town and would like to reschedule. On the afternoon prior to the in-service, 14 caregivers were called and reminded of the caregiver in-service. The three caregivers that noted that they would be out of town were not called until the week following the in-service in attempt to reschedule. Two of the participants lived alone and requested to receive the information themselves, therefore their primary contact was not notified. After making the calls six caregivers were scheduled to attend the caregiver in-service. If caregivers were unable to make it at the scheduled time they were asked to choose another date/time to come to ACP to receive their manual personally. Four of the six caregivers that noted they would be present attended the in-service presentation. The presentation was 50 minutes. The presentation began with a pre-test including 10 questions (see Appendix B for pre/post test questions). Caregivers scores ranged from 0-3 correct answers on the pre-test (see Table 1B for results of pre-test). Student presented material and caregivers were encouraged to ask questions throughout the presentation. Post-test was administered after presentation. All caregivers were able to answer 6-8 questions during allotted time. Due to length of presentation, only ~3-4 minutes was allotted for post-test and then answers were reviewed to ensure that all caregivers knew the correct answers. Post-tests were not collected, but caregivers reported their final score on the post-test after going over the CREATION OF A CAREGIVER RESOURCE MANUAL 16 answers as a group. The number of questions correctly answered increased by 5-7 points for each caregiver when comparing pre/post test results (see table 2B for scores on the post-test and increase in number of correct answers). During the remainder of students DCE, caregivers were contacted and encouraged to come to ACP to receive their manual with a one-on-one presentation from student. Five additional caregivers were able to come in to receive the Caregiver Resource Manual. The Caregiver Resource Manuals were presented individually to the five caregivers with a 15-minute overview. The caregivers were encouraged to ask questions. All caregivers unable to receive their manual during the students on-site presentation will receive their manual at a later date by program director or social worker. The program director was given a list of caregivers that have and have not received the Caregiver Resource Manual at the end of the DCE. The program director attended the caregiver in-service and received instruction from the student on how to present the manual and explain the sections appropriately. The social worker was unable to attend the in-service but was educated on how to present the Caregiver Resource Manual to caregivers. After completion of the students DCE the Caregiver Resource Manual will continue to be distributed to all new caregivers upon their loved ones enrollment. The social worker and program director expressed confidence that the Caregiver Resource Manual will be used for years to come. The program director received copy of the Caregiver Resource Manual to be used when additional copies of the resource are needed. Program director also received a digital copy of all resources included in the manual in the case that sections would need to be updated in the future. The program director plans to have future students examine the resource yearly to ensure that all materials are still applicable and appropriate. The program director also received a copy CREATION OF A CAREGIVER RESOURCE MANUAL 17 of the pre/posttest given during the in-service, and reported at a time of multiple new admissions she may hold another caregiver in-service in the future. Response to Society Needs All caregivers that received the Caregiver Resource Manual during students DCE were receptive to the information included. Overall caregivers were thankful for the information and reported that the resource would be used in their daily caregiving processes. Caregivers reported that the Advance Directives and Legal and Financial Worksheets Section and the Preparing for Doctors Appointments Section would be the most beneficial for organizing their loved ones information and wishes. Caregivers across many studies reported they needed education on diagnosis (Wawrziczny et al., 2017; Weisman de Mamani et al., 2018; Zuria Idura, 2018), behaviors (Wawrziczny et al., 2017; Weisman de Mamani et al., 2018), social support (Van Knippenberg et al., 2018; Wawrziczny et al., 2017; Zuria Idura, 2018), benefits of physical activity (Lestari et al., 2018), driving cessation (Byszewski, Power, Lee, Rhee, Parson, & Molnar, 2017; Pyun, Kang, Kim, Baek, Wang & Kim, 2018), home modifications (Kort & van Hoof, 2014), and advanced directives (Bosisio, Jox, Jones, & Truchard, 2018; Lendon et al., 2018). Therefore, these topics were the most important to address for the caregivers of ACP. Caregivers were informed during presentation of Caregiver Resource Manual that this manual contained the most up to date resources commonly requested by caregivers but was not all-inclusive. Caregivers were encouraged to continue to add to their knowledge and continue to reach out to collect information during their caregiving journey. The student explained that this Caregiver Resource Manual was created to give them structure, knowledge, and organization in order to assist with decreasing caregiver burden and enabling their loved ones to age-in place for as long as possible. CREATION OF A CAREGIVER RESOURCE MANUAL 18 Overall Learning Throughout DCE the student interacted with participants, caregivers and staff to develop a Caregiver Resource Manual that would be inclusive to all participants. The student began with observing and interacting with participants in order to learn their strengths as well as learn about the progression of their diagnoses. The student mailed out demographic surveys to initially gain some information about the caregivers of the participants (refer to Appendix A). The student worked with all staff members including the program director, social work, program supports, physical therapist and kitchen staff to learn their role at ACP and learn from their interactions with the participants. After completion of the Caregiver Resource Manual, the student increased interaction with caregivers through phone calls, caregiver in-service and one on one meetings to present Caregiver Resource Manual. In doing this, the student was able to learn about the participant from the caregivers perspective as well as advocate for each participant individually. The student felt confident that she knew participants from day to day interactions and was able to guide each caregiver presentation differently based on knowledge of their loved one. During this DCE, the student was able to participant in six complex administrative documents. Completion of these documents took a combination of verbal, written and oral communication with the program director, the executive director of Catholic Charities, the staff social worker and other Catholic Charities employees in order to ensure all of the correct information and documentation was collected prior to submission. Overall Learning- Leadership and Advocacy During this DCE the student advocated for the needs of the caregivers. Although ACP is intended to assist all caregivers by providing respite care and transportation, their program was lacking a specific set of resources to assist caregivers with their daily caregiving processes. The CREATION OF A CAREGIVER RESOURCE MANUAL 19 student advocated for the Caregiver Resource Manual project and took on leadership with developing the manual. The student advocated for the occupational therapy profession when presenting the manual to all caregivers. Among other administrative tasks completed during DCE, the student attended Catholic Charities 100th Anniversary two-day conference with the program director. At this conference, the student was introduced to program directors and executive directors of Catholic Charities across Indiana. Through discussions with various attendees, the student described and advocated for her project and experience at ACP. Through conversations with program directors of Catholic Charities refugee program, the adoption clinic, and the crisis center, the student advocated for the role of occupational therapy and how it would benefit the individuals served in their programs. During conference student demonstrated professionalism, confidence, and excellent communication skills in order to represent ACP and the University of Indianapolis School of Occupational Therapy. The student also assisted with the administrative task of the 2019-2020 budget with the program director of ACP and her direct supervisor. During budget planning, additional staffing that was currently advertised for was going to be cut for the 2019-2020 budget, including the part-time occupational therapist. The program directors supervisor felt cutting these staff members would assist ACP in meeting their budget for the following year. Student advocated for the need of a staff occupational therapist within the ACP facility and the benefits the position would have for the participants. The program director agreed with the need for a staff occupational therapist and made some adjustments to include hours for a part-time occupational therapist in the 2019-2020 budget. CREATION OF A CAREGIVER RESOURCE MANUAL 20 Overall the student gained many skills in leadership, advocacy, and communication while on site during this DCE. The knowledge gained relating to administration and program development have taught the student skills beyond entry-level occupational therapy practitioner that will be integrated into everyday practice as an occupational therapy practitioner. CREATION OF A CAREGIVER RESOURCE MANUAL 21 References Aguilar, A. (2017). Coping with Behavioral Symptoms of Dementia: Educating Caregivers to Lower Stress. Doctor of Nursing Practice (DNP) Projects. 101. Alzheimers Association. (2015). 2015 Alzhemiers disease facts and figures. Alzhemiers & Dementia: The Journal of the Alzhemiers Association, 11(3), 332-384. doi: 10.1016/j.jalz.2015.02.003 Anderson, K. A., Dabelko-Schoeny, H. I., Fields, N. L., & Carter, J. R. (2015). Beyond respite: the role of adult day services in supporting dementia caregivers. Home Health Care Services Quarterly, 34(2), 101-112. Atherton, N., Bridle, C., Brown, D., Collins, H., Dosanjh, S., Griffiths, F., ... & McShane, R. (2016). Dementia and Physical Activity (DAPA)-an exercise intervention to improve cognition in people with mild to moderate dementia: study protocol for a randomized controlled trial. Trials, 17(1), 165. Bosisio, F., Jox, R. J., Jones, L., & Truchard, E. R. (2018). Planning ahead with dementia: what role can advance care planning play? A review on opportunities and challenges. Swiss Medical Weekly, 148(5152). Byszewski, A., Power, B., Lee, L., Rhee, G. G., Parson, B., & Molnar, F. (2017). Driving and dementia: workshop module on communicating cessation to drive. Canadian Geriatrics Journal, 20(4), 241. Catholic Charities Indianapolis. (2018) A Caring Place Adult Day Services. Retrieved from http://www.archindy.org/cc/indianapolis/caringplace.html Cole, M. & Tufano, R. (2008). Applied theories in occupational therapy: A practical approach. Thorofare, NJ: SLACK Incorporated. CREATION OF A CAREGIVER RESOURCE MANUAL 22 Gulin, S. L., Perrin, P. B., Peralta, S. V., McDonald, S. D., Stolfi, M. E., Morelli, E., ... & Arango-Lasprilla, J. C. (2018). The Influence of Personal Strengths on Quality of Care in Dementia Caregivers from Latin America. Journal of Rehabilitation, 84(1). Grover, S., Nehra, R., Malhotra, R., & Kate, N. (2017). Positive aspects of caregiving experience among caregivers of patients with dementia. East Asian Archives of Psychiatry, 27(2), 71. Kort, H. S., & van Hoof, J. (2014). Design of a website for home modifications for older persons with dementia. Technology and Disability, 26(1), 1-10. Lannin, N. (2003). Goal attainment scaling allows program evaluation of a home-based occupational therapy program. Occupational Therapy in Health Care, 17(1), 43-54. Lestari, D. I., Hamu, A. H., Rachmawati, S., Singkali, D. P., & Yusuf, A. (2018). The Effect of Physical Activity to Decreased of Dementia (Mild, Moderate and Severe) in Elderly: A Systematic Review. Lendon, J. P., Caffrey, C., & Lau, D. T. (2018). Advance directive documentation among adult day services centers and use among participants, by region and center characteristics: National Study of Long-Term Care Providers, 2016. Matsuyama, R. K., Wilson-Genderson, M., Kuhn, L., Moghanaki, D., Vachhani, H., & PaascheOrlow, M. (2011). Education level, not health literacy, associated with information needs for patients with cancer. Patient education and counseling, 85(3), e229-e236. National Institutes of Health. (2013). The Dementias: Hope Through Research. NIH Publication No. 13-2252. Prince, M., Comas-Herrera, A., Knapp, M., Guerchet, M., & Karagiannidou, M. (2016). World Alzheimer report 2016: improving healthcare for people living with dementia: coverage, quality and costs now and in the future. CREATION OF A CAREGIVER RESOURCE MANUAL 23 Pyun, J. M., Kang, M., Kim, S., Baek, M., Wang, M., & Kim, S. (2018). Driving Cessation and Cognitive Dysfunction in Patients with Mild Cognitive Impairment. Journal of Clinical Medicine, 7(12), 545. Rokstad, A. M. M., Engedal, K., Kirkevold , ., Benth, J. ., & Selbk, G. (2018). The impact of attending day care designed for home-dwelling people with dementia on nursing home admission: a 24-month controlled study. BMC Health Services Research, 18(1), 864. Thompson, C. J., Bridier, N., Leonard, L., & Morse, S. (2018). Exploring stress, coping, and decision-making considerations of Alzheimers family caregivers. Dementia, 1471301218809865. van Knippenberg, R. J., de Vugt, M. E., Ponds, R. W., Verhey, F. R., & Myin-Germeys, I. (2018). Emotional reactivity to daily life stress in spousal caregivers of people with dementia: An experience sampling study. PloS One, 13(4), e0194118. Vreugdenhil, A. (2014). Ageing-in-place: Frontline experiences of intergenerational family carers of people with dementia. Health Sociology Review, 23(1), 43-52. Wawrziczny, E., Pasquier, F., Ducharme, F., Kergoat, M. J., & Antoine, P. (2017). Do spouse caregivers of young and older persons with dementia have different needs? A comparative study. Psychogeriatrics, 17(5), 282-291. Weisman de Mamani, A., Weintraub, M. J., Maura, J., Martinez de Andino, A., & Brown, C. A. (2018). Stigma, expressed emotion, and quality of life in caregivers of individuals with dementia. Family Process, 57(3), 694-706. Zuria Idura, A. M., Noorliaili, M. T., Rosdinom, R., Azlin, B., & Tuti Iryani, M. D. (2018). Caring for Moderate to Severe Dementia Patients-Malaysian Family Caregivers Experience. International Medical Journal Malaysia, 17(1). CREATION OF A CAREGIVER RESOURCE MANUAL 24 Appendix A Sociodemographic survey Hello, my name is Samantha Farmer. I am an occupational therapy student at the University of Indianapolis completing my Doctoral Capstone at A Caring Place Adult Day Services, Catholic Charities Indianapolis, Inc. The purpose of my project is to develop a caregiver resource guide to assist with the physical and psychological aspects of caregiving. In order to get a better idea of the population this resource guide will be serving I have developed a few demographic questions which are listed below. If you are interested in participating, please complete the questions below and return to A Caring Place ADS as soon as possible. Thank you in advance for your feedback! PARTICIPANT INFORMATION Age______________________________________________ Gender___________________________________________ Length of time attending A Caring Place_________________ Diagnosis__________________________________________ CAREGIVER INFORMATION Age______________________________________________ Gender___________________________________________ Relationship to participant____________________________ Living situation o Any other adults living in the house who assist with care of participant? ______________________________________________________ o Any children living in the house? If yes, please list their ages. ______________________________________________________ Highest level of education____________________________ Employment status__________________________________ o Hours per week______________________________ CREATION OF A CAREGIVER RESOURCE MANUAL 25 Table 1A Sociodemographic results for Participants Age Gender 84 Male Length of time attending ACP 6 months 76 75 70 Male Female Female 3+ years 4 months Over 1 year 79 59 Male Male 1 year 5 years 89 67 Male Male 1 year ~4 years Primary diagnosis Inability to live alone due to assistance needed with basic needs Dementia Dementia Schizophrenia paranoid type Dementia Traumatic Brain Injury Dementia Stroke/brain trauma CREATION OF A CAREGIVER RESOURCE MANUAL 26 Table 2A Sociodemographic results for caregivers Age Gender Relationship Other to adults Participant living in the home? 62 Female Wife No Any children living in the home? Ages? No 66 Male Husband 2 No 54 Female Daughter 1 Yes, 14 45 75 Female Female Daughter Wife 1 No No No 56 Female Sister No No 57 60 Male Female Son Wife No No No No Highest level of education Employment Hours status per week High School Masters degree Bachelors degree College High School 11th grade Retired 0 Retired 0 College Graduate degree Semi-retired None Full-time 40 employment Full-time 40+ Retired 0 Advantage senior care 5 hours per week 20 0 CREATION OF A CAREGIVER RESOURCE MANUAL 27 Appendix B Caregiver Resource Manual In-Service Pre/Post Test March 27, 2019 1. When caring for an individual begins to negatively affect the caregiver, both physically and psychologically, it leads to what commonly known term? ____Caregiver Burden_____________________________________________________ 2. A record of changes that your loved one has experienced since his/her last appointment that should be filled out daily and taken to each doctors appointment for reminders of recent changes and behaviors ____Care-Log___________________________________________________________ 3. Instructions on how you loved one wants their medical care to be handled in emergency situations when they are unable to verbalize their wishes. ____Advance Directives__________________________________________________ 4. Term that defines the trend of older adults preferring to live in their homes or apartments as they age verse moving to a new place with a higher level of care. ____Age-in- place________________________________________________________ 5. Has been found to assist with regulating appetite, aid with sleep, relieve restlessness and tension, and maintain strength and coordination. ____Exercise/Physical Activity______________________________________________ 6. Activities that help your loved one remember past joys, such as telling stores, looking through photos, re-reading letters and greeting cards from the past, baking special family recipes and creating scrapbooks. _____Reminiscence Therapy________________________________________________ CREATION OF A CAREGIVER RESOURCE MANUAL 28 7. Although common, can be hard to diagnosis due to overlapping symptoms including: social withdrawal, difficulty concentrating, impaired thinking, isolation, and loss of interest in hobbies and activities. _____Depression_________________________________________________________ 8. Requires several areas of the brain to receive and process sensory data to get you places; may need to be limited or discontinued. _____Driving____________________________________________________________ 9. Aim to help caregivers better deal with the physical and emotional challenges of caregiving through sharing and listening. _____Support Groups______________________________________________________ 10. Decreases anxiety, stimulates hormones, improves muscle tone and enhances metabolism. _____Laughing/Humor_____________________________________________________ CREATION OF A CAREGIVER RESOURCE MANUAL 29 Table 1B Results of Pre-Test Caregiver 1 Stress Daily MemoBehavior Notes Caregiver 2 Resentment Care Plan Caregiver 3 Blank Blank Caregiver 4 Burn Out True Log Pre-Care Living Will Assisted Living Living Will Yes Home-Health Blank Question 5 Question 6 Exercise Talking, Taking Part in these daily activities Exercise Dementia Blank Blank Directive or living will In home caregiving Blank Blank Question 7 Question 8 Question 9 Question 10 Score Blank Blank Blank Blank +3 Blank Blank Blank Blank +2 Blank Blank Blank Blank +0 Blank Blank Blank Blank +1 Question 1 Question 2 Question 3 Question 4 The table above displays the results of the caregiver pre-test. For question 2, Daily MemoBehavior Notes was accepted as a correct answer. For question 3, living will was accepted as a correct answer. CREATION OF A CAREGIVER RESOURCE MANUAL 30 Table 2B Results of Post-Test Caregiver 1 8 Number of correct answers in allotted time Increase in +5 number correct compared to pretest Caregiver 2 8 Caregiver 3 6 Caregiver 4 7 +6 +6 +6  ...

... Supporting Parent and Infant Transition from the Neonatal Intensive Care Unit to Infant Clinic Follow-Up Haley Danhof May, 2019 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: Kate DeCleene Huber, Dean of the Occupational Therapy Department Running head: SUPPORTING PARENT AND INFANT TRANSITION FROM THE NEONATAL INTENSIVE CARE UNIT TO INFANT CLINIC FOLLOW-UP A Capstone Project Entitled Supporting Parent and Infant Transition from the Neonatal Intensive Care Unit to Infant Clinic Follow-Up 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 Haley Danhof 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 2 SUPPORTING PARENT AND INFANT TRANSITION FROM NEONATAL INTENSIVE CARE UNIT TO INFANT CLINIC FOLLOW-UP Supporting Parent and Infant Transition from Neonatal Intensive Care Unit to Infant Clinic Follow-Up Haley Danhof University of Indianapolis 3 SUPPORTING PARENT AND INFANT TRANSITION FROM NEONATAL INTENSIVE CARE UNIT TO INFANT CLINIC FOLLOW-UP 4 Section I: Abstract Follow-up care for infants after discharge from the Neonatal Intensive Care Unit (NICU) is essential as infants who have had a stay in the NICU are at an increased risk of having developmental delays. Infants have improved long-term outcomes if early intervention services are provided in the first year of life. A common problem in NICU follow-up clinics is high noshow rates, resulting in a gap in developmental care for infants with serious medical needs. The occupational therapy doctoral capstone student identified barriers that parents living in a metropolitan area, with diverse cultural backgrounds, faced in accessing and receiving developmental care for their infants. Common barriers included: limited understanding of the details of the Infant Clinic appointment, complete lack of knowledge about the existence of the Infant Clinic appointment and confusing the Infant Clinic appointment, with the well-child primary care visit after NICU discharge. In order to reduce these barriers and to streamline the process from NICU discharge to outpatient occupational and speech therapy follow-up at the Infant Clinic, several strategies were put into place. These strategies included: increased education and reiteration of importance of attending the Infant Clinic appointment by NICU staff, development of educational materials about the Infant Clinic written at appropriate reading levels in order to comply with health literacy guidelines, development of incentives to increase parent motivation to attend the appointment, and increased interdisciplinary collaboration between NICU staff and Infant Clinic staff in order to improve continuity of care across the two settings. SUPPORTING PARENT AND INFANT TRANSITION FROM NEONATAL INTENSIVE CARE UNIT TO INFANT CLINIC FOLLOW-UP 5 Supporting Parent and Infant Transition from Neonatal Intensive Care Unit to Infant Clinic Follow-Up Survival rates for infants of young gestational age and low birth weight have increased in recent years, while the length of stay in the Neonatal Intensive Care Unit (NICU) has decreased (Brachio et al., 2018; Bockli, Andrews, Pellerite, & Meadow, 2014; Santos, Pearce, & Stroustrup, 2015). Due to these trends, infants being discharged from the NICU are more likely to have unresolved medical issues continuing at home, making access to follow-up care after NICU discharge a necessity (Bockli et al., 2014; Santos et al., 2015). Some of the common medical complications after NICU discharge include: feeding problems, issues with growth, and neurodevelopmental disabilities (Bockli et al., 2014). NICU follow-up clinics serve to provide parents with access to practitioners who specialize in the care needed for their infants, and to provide support for parents (Bockli et al., 2014). Multidisciplinary medical care after NICU discharge from professionals who specialize in premature infants is essential (Bockli et al., 2014). A study on follow-up clinics showed that pediatricians are concerned that they do not have the training needed to provide such specialized care and rely on specialists who are trained in infant care (Brachio et al., 2018; Bockli et al., 2014). Another important function of follow-up clinics is to establish ongoing specialized care for the infant if necessary (Bockli et al., 2014; Greene & Patra, 2014). Infants who are discharged from the NICU are at increased risk for long-term neurodevelopmental impairment, which necessitates evaluation by occupational therapy (OT), speech therapy (ST), and physical therapy (PT) (Orton et al., 2018). Evaluation by these disciplines in the first year of the infants life is needed in order to identify developmental delays and to make referrals to early intervention services (Greene & Patra 2016; Orton et al., 2018). SUPPORTING PARENT AND INFANT TRANSITION FROM NEONATAL INTENSIVE CARE UNIT TO INFANT CLINIC FOLLOW-UP 6 Though the importance of follow-up after NICU discharge may be obvious to health care providers, there is often a disconnect in parents following through with referrals made for follow-up care (Bockli et al., 2014). A common struggle among various NICU follow-up clinics is a high no-show rate, with many patients not coming to these appointments (Bockli et al., 2014). In a study exploring the difficulties faced by NICU follow-up clinics, a majority of respondents stated the no-show rate for their clinic was as high as 20% (Bockli et al., 2014). The factors related to the high no-show rates were not discussed in the study (Bockli et al., 2014). However, other researchers have highlighted the importance of identifying barriers that patients face in accessing health care; factors that could be contributing to no-show rates (Betancourt, Green, Carrillo, & Ananeh-Firempong, 2016; Batterham et al., 2016). There are disparities in health care access especially among racial and ethnic minorities (Betancourt et al., 2016). These disparities include: differences in patient recognition of symptoms, ability to communicate symptoms with practitioners, ability to understand recommendations made by practitioners, and compliance with recommendations and medications (Betancourt et al., 2016). These factors can also be referred to as a persons health literacy level (Batterham et al., 2016). Health literacy is defined as: the personal and relational factors that affect a persons ability to acquire, understand and use information about health and health services (p. 3, Batterham et al., 2016). Individuals with lower health literacy levels have a lower utilization of health services and have poorer health outcomes as compared to individuals with high levels of health literacy (Batterham et al., 2016). It is the responsibility of health care providers to assess the health literacy of the patient population being served in order to provide better support to patients, to increase health care access, and to improve health outcomes (Batterham et al., 2016). SUPPORTING PARENT AND INFANT TRANSITION FROM NEONATAL INTENSIVE CARE UNIT TO INFANT CLINIC FOLLOW-UP 7 In addition to potential socioeconomic and health literacy barriers, parents who have sick infants in the NICU face many stressors on top of stressors already associated with having a newborn (Williams et al., 2018). Due to this increased level of stress, it is crucial that NICU staff become more aware of the needs that NICU parents have (Williams et al., 2018). After barriers and stressors specific to the patient population have been identified, health care providers must utilize their increased awareness by developing strategies to increase ease in service activation (Batterham et al., 2016). The Doctoral Capstone Experience & Project Introduction This purpose of the OT doctoral capstone experience (DCE) is to streamline inpatient therapy services in the NICU, which includes OT and ST, with the outpatient OT and ST services in the infant follow-up clinic at Eskenazi Hospital. There is a high no-show rate in the Infant Clinic, which results in a gap in follow-up care for infants with immediate developmental needs. The barriers that patients face in regard to accessing health care services and coming to the Infant Clinic need to be identified, and strategies must be developed to reduce these barriers in order to provide care appropriate to the health literacy level of Eskenazis patient population (Betancourt et al., 2016; Batterham et al., 2016). Additionally, there is a need for a written discharge guidelines that can be utilized by the IP and OP therapy teams to ensure consistency in the Infant Clinic referral process, and thorough, multidisciplinary education about details and importance of the appointment. Section II: Literature Review The role of OT in the NICU OT practice in the NICU is a specialized and emerging practice area and requires the occupational therapist to have additional training and skills beyond entry level in order to SUPPORTING PARENT AND INFANT TRANSITION FROM NEONATAL INTENSIVE CARE UNIT TO INFANT CLINIC FOLLOW-UP 8 provide services to infants and parents (Borges et al., 2018; Vergara et al., 2006). Knowledge of the varying medical diagnoses, conditions, developmental variability, and potential abnormalities that neonates experience is necessary in order to provide proficient care in this setting (Vergara et al., 2006). It is important as a NICU therapist to have an awareness of the fragility of the neonates as they are at risk for harm if exposed to inappropriate environments (Aita et al., 2017; Altimier & Phillips, 2016; Santos et al., 2015; Vergara et al., 2006). The occupational therapist often focuses intervention priority on protecting the infant from being exposed to inappropriate environmental conditions by modifying sensory aspects of the environment such as lighting, noise, and temperature of the nursery (Aita et al., 2017; Altimier & Phillips, 2016; Santos et al., 2015; Vergara et al., 2006). Besides sensory integration and modulation, other areas of intervention may include addressing neurodevelopment and feeding skills (Borges et al., 2018; Vergara et al., 2006). Establishing relationships with families. Aside from providing direct care to neonates, occupational therapists are expected to establish therapeutic relationships with the families of the neonates as many families are under high amounts of stress and facing uncertainty regarding their infants outcomes (Vergara et al., 2006; Dudek-Shriber, 2004). These relationships serve to equip and empower the family members to contribute to the infants optimal development (Vergara et al., 2006). Occupational therapists are also viewed by other NICU professionals as being primary providers of parent education, which occurs through these established relationships (Caretto, 2000). Facilitate transfer to follow-up care. Though discharge planning begins upon admission to the NICU, the role of OT with neonates does not end at NICU discharge (Caretto, 2000; Hall, Phillips, & Hynan, 2016). Occupational therapists are not only also responsible for SUPPORTING PARENT AND INFANT TRANSITION FROM NEONATAL INTENSIVE CARE UNIT TO INFANT CLINIC FOLLOW-UP 9 preparing parents to take their infant home, but also for directing parents to appropriate followup care. These infants often have developmental delays that impact their long-term cognitive, social/behavioral, physical, and emotional development and require outpatient OT or early intervention after discharge (Bockli et al., 2014; Hall et al., 2016; Santos et al., 2015). However, there are barriers that impact parents abilities to access the developmental care that their infants need after discharge (Betancourt et al., 2016; Batterham et al., 2016; Purdy et al., 2015). Parental Barriers to Providing Care after Discharge Parent anxiety. Researchers have studied parents experiences after NICU discharge, and have found themes relating to parent fear and anxiety of leaving the safe environment of the NICU and having to care for the infant independently at home (Aloysius et al., 2017; Caretto, 2000; Forsythe & Willis, 2008; Hummel, 2003; Williams et al., 2018). Anxiety is increased in parents of infants in the NICU as compared to parents of typically developing infants (Hummel, 2003). Some research has shown that these concerns persist even up to 18 months after NICU discharge (Aloysius et al., 2017). Limited access. Aside from stress and anxiety, parents face additional barriers to accessing and receiving services after discharge (Purdy et al., 2015). Some of these barriers include: limited access to health insurance, insufficient administrative procedures for transferring care to outpatient or community resources, difficulty obtaining specialized equipment needed to care for their infant, limited access to medications, lack of access to specialized or emergency services in isolated areas, and poor discharge follow-up guidelines for families (Betancourt et al., 2016; Batterham et al., 2016; Purdy et al., 2015). Resources to reduce these barriers specific to discharge guidelines include: pre-established discharge plans, parent training check lists, and NICU follow-up programs (Purdy et al., 2015). SUPPORTING PARENT AND INFANT TRANSITION FROM NEONATAL INTENSIVE 10 CARE UNIT TO INFANT CLINIC FOLLOW-UP Cultural barriers. Cultural barriers can also make it more difficult for patients to access and receive necessary and appropriate health care services (Betancourt et al., 2016). Individuals who are part of a minority ethnic population tend to be more socioeconomically disadvantaged, and have lower education levels compared to their majority population counterparts (Betancourt et al., 2016). Due to these disadvantages, those in the minority group tend to have difficulty communicating with their health care providers about symptoms, understanding the prescribed instructions for health management, and adhering to recommendations (Betancourt et al., 2016). According to researchers who studied this topic, it is important for health care providers to identify the sociocultural barriers specific to various minority groups and to identify which ways these sociocultural barriers have not been addressed by the health care organization (Betancourt et al., 2016). Importance of addressing barriers. There are risks involved in leaving the socioeconomic and cultural barriers unaddressed, specifically related to the long-term outcomes for infants (Nwabara et al., 2017). It is crucial for many of the infants discharged from the NICU, to be evaluated by therapy services in the first year of their life to test for potential developmental delays, and so they can be referred to the appropriate discipline if needed for ongoing services (Orton et al., 2018; Greene & Patra 2016). Early intervention for infants who spent time in the NICU is also related to better long-term outcomes for the child (Benzies, Magill-Evans, Hayden, & Ballantyne, 2013; Landsem et al., 2015; Ma et al., 2015). In addition to the issue of high no-show rates seen in NICU follow-up clinics, there is also a delay in the activation of therapy services post NICU discharge, and some infants who need follow-up services are not receiving them altogether (Bockli et al., 2014; Nwabara et al., 2017). Identification of the barriers that contribute to high no-show rates and delayed activation of SUPPORTING PARENT AND INFANT TRANSITION FROM NEONATAL INTENSIVE 11 CARE UNIT TO INFANT CLINIC FOLLOW-UP services, is the first step in providing more accessible health care for patients of diverse socioeconomic and cultural backgrounds (Betancourt et al., 2016; Batterham et al., 2016). Experience of NICU Parents The fears that parents had about taking their infant home, were found to be manageable if parents were given support from NICU professionals during the NICU stay and after discharge (Aloysius et al., 2017; Caretto, 2000). Other factors that influence the degree of parent anxiety include: degree of parent involvement in the NICU and parents staying with their infant in the NICU (Aloysius et al., 2017; Davidson et al., 2017). One study found that mothers who were present and involved during their infants stay in the NICU, had increased maternal satisfaction as compared to those who were not (Davidson et al., 2017). Other researchers have found that parents who participate in the care of their newborn, are better prepared to transition home (Aloysius et al., 2017; Larsson et al., 2015; Osorio et al., 2017). Mothers who were provided with information about their infants condition, taught how to look for signs of pain or discomfort, and taught how to respond by providing learned soothing strategies for their infant had increased maternal satisfaction (Davidson., et al, 2017). Some other contributors to parent stress and frustration were related to rules and regulations present in the NICU (Williams et al., 2018). Researchers suggest that having clear and empathetic communication with parents regarding reasoning and significance behind rules may also decrease parent anxiety (Williams et al., 2018). Strategies to Decrease Parental Barriers Education. Though some sort of parent education is common across NICUs, there is variation in how parent education is provided by occupational therapists in the NICU (Caretto, 2000). Researchers found that the majority of therapists scheduled education sessions with SUPPORTING PARENT AND INFANT TRANSITION FROM NEONATAL INTENSIVE 12 CARE UNIT TO INFANT CLINIC FOLLOW-UP families at the times the family was present in the NICU (Caretto, 2000). Additionally, there was a variety of teaching methods reported, including: demonstration, discussion, handouts, and hands-on practice (Caretto, 2000). Some even reported that parents rooming-in, or staying the night in the hospital to practice providing all necessary care for their infant, was a standard parents needed to meet prior to discharge (Caretto, 2000). However, not all parents were provided with resources at discharge (Caretto, 2000). Out of all the participants in the study, 86% reported that written discharge plans were provided at discharge, and 81% reported that some type of follow-up with parents was required after discharge (Caretto, 2000). According to researchers, there is still a need for continued research on parent education and discharge criteria in order for occupational therapists to provide more effective parent education programs (Caretto, 2000). Strategies to Decrease Parental Barriers Sensitivity to patients diverse cultural backgrounds. When working with patients of diverse cultural backgrounds, researchers emphasize the importance of developing cultural competence (Betancourt et al., 2016). Cultural competence has been defined by researchers as understanding the importance of social and cultural influences on patients health beliefs and behaviors; considering how these factors interact at multiple levels of the health care delivery system; and, finally, devising interventions that take these issues into account to assure quality health care delivery to diverse patient populations (p. 297, Betancourt et al., 2016). Some of the interventions identified by researchers included: developing interpreter services, languageappropriate education resources, and providing education to health care professionals on crosscultural barriers (Betancourt et al., 2016). Interdisciplinary collaboration. It is the responsibility of NICU professionals to work SUPPORTING PARENT AND INFANT TRANSITION FROM NEONATAL INTENSIVE 13 CARE UNIT TO INFANT CLINIC FOLLOW-UP together to develop patient-specific and realistic, discharge plans in order for parents and infants to have a smooth, supported, and healthy transition to home (Hall et al., 2016; Hummel, 2003; Purdy et al., 2015). Additionally, NICU professionals who are responsible for referring parents to community and outpatient resources, need to be up-to-date on guidelines for recognizing potential barriers and strategies to overcome those barriers in order to properly care for NICU families (Purdy et al., 2015). A strategy for further providing a seamless discharge to follow-up services, is to integrate interdisciplinary collaboration into the process for follow-up referrals (Welch, Check, & OShea, 2017). Difference between multidisciplinary and interdisciplinary teams. There is a significant difference between multidisciplinary and interdisciplinary teams (Choi & Pak, 2006). A multidisciplinary team uses each professionals expertise to accomplish individual goals, staying within their own boundaries (Choi & Pak, 2006). An interdisciplinary team searches for opportunities to link various processionals skills to work coherently towards a group goal (Choi & Pak, 2006). Interdisciplinary collaboration has also been defined as: an effective interpersonal process that facilitates the achievement of goals that cannot be achieved when individual professionals act on their own (p. 299, Bronstein, 2003). A study comparing multidisciplinary and interdisciplinary teams, found that interdisciplinary teams had significantly better teamwork and team effectiveness than multidisciplinary teams (Korner 2010). One study found that having scheduled multidisciplinary meetings regarding patient care in the NICU resulted in improved team collaboration, continuity of care for patients, and improved patient outcomes (Welch et al., 2017). Those in attendance included: neonatologists, pediatric surgeons, a physical therapist, an occupational therapist, a speech therapist, social worker, family support coordinator, the NICU Nurse Manager, and others (Welch et al., 2017). SUPPORTING PARENT AND INFANT TRANSITION FROM NEONATAL INTENSIVE 14 CARE UNIT TO INFANT CLINIC FOLLOW-UP After one year of implementing weekly multidisciplinary team meetings, the average hospitalization duration decreased by 6.5 days, showing a significant improvement in patient outcomes, thus, highlighting the effectiveness of implementing interdisciplinary collaboration into existing multidisciplinary teams (Welch et al., 2017). Another study highlighted the importance of interdisciplinary collaboration in providing psychosocial support and continuity of care to NICU parents (Chorna et al., 2016; Hynan & Hall, 2015). This study also emphasized that psychosocial support should begin in the antepartum phase, continue during the NICU admittance, and into the post-NICU discharge phase (Hynan & Hall, 2015). An important aspect of collaboration among practitioners is providing communication to parents with a focus on clarity and continuity especially during transitions in care and handoffs to new providers, such as NICU to NICU follow-up (Chorna et al., 2016; Hynan & Hall, 2015). Other research has specifically discussed the necessity of collaboration between developmental pediatricians and rehabilitation services, like OT, PT, and ST, in NICU follow-up clinics (Brachio et al., 2018; Smyser, et al., 2016). NICU follow-up clinics serve a crucial role in providing multidisciplinary care to infants and parental support after discharge in many ways: acting as a connection between primary care physicians and specialists, early identification of developmental delays and disabilities, and referral to other appropriate services (Brachio et al., 2018). However, in order for these followup clinics to be successful there not only needs to be interdisciplinary collaboration within settings, but also between the professionals in the NICU and those in the NICU follow-up clinics (Chorna et al., 2016; Hynan & Hall, 2015). Theoretical Basis Theoretical Framework: Model SUPPORTING PARENT AND INFANT TRANSITION FROM NEONATAL INTENSIVE 15 CARE UNIT TO INFANT CLINIC FOLLOW-UP The NICU Developmental Care model will guide this DCE (Altmier & Phillips, 2016). This model consists of seven neuroprotective family-centered developmental core measures and is commonly used to guide practice within NICUs (Altimier & Phillips, 2016). Though the NICU Developmental Care model is not a traditional occupational therapy practice model, it is highly specific to providing care within the NICU and has a focus on providing family support, which is a focus of this DCE. All seven of the core measures outlined in this model can be applicable to OT, however, some of the most applicable for this project are: healing environment, partnering with families, positioning and handling, safeguarding sleep, and minimizing stress and pain (Altimier & Phillips, 2016). This model also has guidelines that serve both the infant and the parent as clients, which is important for this setting as intervention often involves parent education to increase self-efficacy in the ability to care for their newborn (Altimier & Phillips, 2016; Davidson et al., 2017). Neuroprotective family-centered developmental care includes ensuring the whole family is involved in the infants care. Several researchers have identified the importance of involving family in patient care (Altimier & Phillips, 2016; Davidson et al., 2017). The effect that the environment has on infant stress and development is emphasized in the NICU Developmental Care Model (Altimier & Phillips, 2016; Painter, Lewis, & Hamilton, 2019). This aspect of the model is highly applicable to the role of OT for providing intervention in the NICU (Altimier & Phillips, 2016; Vergara et al., 2006). Many OT interventions in this setting are prioritized on modifying the environment especially as related to sensory modulation (Altimier & Phillips, 2016; Vergara et al., 2006). Though this model primarily serves to provide policies and guidelines for infant care during time at the NICU, its core guidelines are also applicable after NICU discharge and align with the intervention areas for OTs working with infants after NICU discharge (Vergara et al., SUPPORTING PARENT AND INFANT TRANSITION FROM NEONATAL INTENSIVE 16 CARE UNIT TO INFANT CLINIC FOLLOW-UP 2006; Aloysius, Kharusi, Winter, Platonos, Banerjee, & Deierl, 2017). According to researchers, discharge planning and preparation should begin upon an infants admission to the NICU in order to adequately prepare parents to be their infants primary caregiver (Aloysius et al., 2017). Due to the focus of the DCE being on providing parental support before NICU discharge, in order to improve consistency with therapy post-discharge, a model that focuses on family support with discharge in mind will be an excellent framework for this project. Theoretical Framework: Frame of Reference The frame of reference that will guide this project is the Sensory Integration and Processing frame (Cole & Tufano, 2008). Not only is sensory integration a standard approach for OT in the pediatric setting, but this frame can be also applied to clients with a variety of occupational difficulties including difficulties with: hypersensitivity and hyposensitivity to sensory stimuli, postural control, motor control, and cognition (Cole & Tufano, 2008; Mohapatra & Rani, 2016; Smith, Mruzek, & Mozingo, 2015). These difficulties are commonly addressed by OT in the NICU and NICU follow-up settings as premature infants are at an increased risk of having developmental challenges identical to those listed above (Vergara et al., 2006; Aloysius et al., 2017). This frame views therapeutic changes as occurring as a result of sensory interaction within the infants environment (Cole & Tufano, 2008; Mohapatra & Rani, 2016). These sensory interactions are adjusted based on the infants ever-changing needs; the adjustments are made by the occupational therapist who makes decisions based off of the infants cues (Cole & Tufano, 2008). Controlling and modifying these environmental interactions are again, a priority for OT intervention in the NICU, and there has been research that highlights the major impact that the NICU environment has on neurodevelopmental outcomes of infants in the NICU (Aita et al., 2017; Altimier & Phillips, 2016; Santos et al., 2015). According to this frame, the client is the SUPPORTING PARENT AND INFANT TRANSITION FROM NEONATAL INTENSIVE 17 CARE UNIT TO INFANT CLINIC FOLLOW-UP one who knows what kind and how much sensory input they need (Cole & Tufano, 2008; Mohapatra & Rani, 2016). How these adjustments are made by the occupational therapist, will be further discussed in the following section. This frame will not only be helpful with guiding program development and the creation of educational parent resources for NICU discharge, but it will also guide the secondary DCE focus, which is clinical practice skills. These interventions and interactions with direct patient care include sensory integration principles with all clients especially those who come to the clinic for feeding groups. Section III: Screening and Evaluation Needs Assessment Needs assessment for the site. The needs assessment was completed through several informal meetings with the site mentor prior to, and in the first week of the DCE. After these meetings, the project focus was identified as: developing discharge guidelines for NICU and Infant Clinic staff in order to provide increased parent support during and after NICU discharge. The questions that guided the needs assessment were related to what was going well with existing NICU discharge processes, and what needs to be improved with those discharge processes (Appendix A). A theme that emerged from the discussion was the high incidence of no-shows at the clinic. The site mentor explained that not only are no-shows detrimental to productivity rates, but parents failing to bring their infants to the Infant Clinic, often leads to lack of developmental care for these babies as they fall through the cracks, and are at risk for not receiving the developmental care they desperately need. The Infant Clinic is run by the site mentor, who is an occupational therapist, and a speech therapist who specializes in infant feeding. The majority of infants who come to the follow-up clinic are referred by NICU doctors and residents, and many of the infants had either an extended stay in the NICU, a diagnosis of SUPPORTING PARENT AND INFANT TRANSITION FROM NEONATAL INTENSIVE 18 CARE UNIT TO INFANT CLINIC FOLLOW-UP Neonatal Abstinence Syndrome (NAS), or premature birth that resulted in developmental delays related to feeding, reflexes, and emotion regulation. Infants can also be referred to the Infant Clinic through community referrals such as primary care physicians, though these referrals are not as common. The occupational therapist and speech therapist complete an evaluation which assesses: infant reflexes, emotion regulation, and feeding and eating skills. Based on the assessment, the therapists work together to determine whether the infant should continue to receive care at the Infant Clinic, receive a home-based early intervention referral, or be discharged from care. Therefore, if the parents do not bring their infant to the appointment, they are at risk for not receiving home-based early intervention services either. The site mentor identified several factors she believed contributed to barriers for parents in understanding the purpose and importance of following through with NICU follow-up care. Some barriers included: patient demographics, limited education and/or emphasis on the importance of the Infant Clinic appointment at the time of referral, limited patient motivation to go to the appointment, health literacy, and other parent-specific factors that might make it difficult for parents to come to the appointment (e.g. other kids, lack of transportation, foster care, etc.). She also acknowledged her efforts to provide patient information at the appropriate health literacy level at the Infant Clinic but was unsure if health literacy level was addressed by inpatient staff. In addition to naming potential barriers that parents face in accessing the Infant Clinic, the site mentor also described the impact that the no-show rate has on the therapists. When there are several no-shows to the Infant Clinic, the occupational therapist and speech therapist fall behind productivity standards as they are obviously unable to complete evaluations if there are no babies present. Also, the waitlist for infants to be scheduled in the Infant Clinic continuously SUPPORTING PARENT AND INFANT TRANSITION FROM NEONATAL INTENSIVE 19 CARE UNIT TO INFANT CLINIC FOLLOW-UP grows as the parents who no-show their evaluations are often tacked back onto the waitlist at the next available date. Not only would increasing the show-rate benefit the infants ongoing development, but it would also help to increase the productivity rates for the therapists and shorten the waitlist for the Infant Clinic. Needs assessment for the parent. In pediatric settings, the parents are also considered the client, especially when the patient is an infant and unable to voice his or her opinions, concerns, and goals. (Stoffel et al., 2017). In an effort to understand the experiences of parents who have had infants in the NICU, one-on-one interviews were conducted with two mothers of current pediatric clients at the outpatient clinic, whose children spent time in the NICU or hospital after birth. Questions were focused on the NICU experience specifically related to what aspects contributed to increased parent support and confidence at discharge, and what areas needed to be improved (Appendix B). Some common themes arose from the two interviews, including: education and training on providing medical and developmental care for the infant at home, need for psychological and emotional support, a desire for communication with other parents with similar experiences, and feeling overwhelmed about what to expect with their infants future. The mothers that were interviewed both spoke English and were of a higher socioeconomic status as compared to the typical patient population at Eskenazi. The reason they were chosen to be interviewed, was because the site mentor identified them as willing participants who were far enough removed from the NICU experience, that it would not be upsetting for them to share about the hardships they endured during that time. However, due to the difference in these mothers socioeconomic status as compared to the typical Eskenazi patient demographic, there will still be a patient questionnaire given to parents at Infant Clinic appointments to understand the experiences of the patients who represent the majority of the SUPPORTING PARENT AND INFANT TRANSITION FROM NEONATAL INTENSIVE 20 CARE UNIT TO INFANT CLINIC FOLLOW-UP patient population at the hospital. See tables 1-4 for Infant Clinic patient demographics, the data represents patients from February 2017 to February 2019. The patient questionnaire will be developed utilizing the feedback from the one-on-one interviews with past NICU mothers. These questionnaires be given during the implementation phase of the project, as the goal of this project is to identify the barriers that parents face in the transition from NICU discharge to outpatient developmental care services, and then to develop strategies to increase the show-rate to Infant Clinic appointment. Table 1 Payor Mix (n = 200) Payor Source Medicaid n 176 % 88.0 Health Advantage 1 0.5 Commercial 12 6.0 Uninsured 11 5.5 Hispanic or Latino n 68 % 34.0 Not Hispanic, Latino/a, or Spanish origin 125 62.5 Unreported 7 3.5 Table 2 Ethnicity (n = 200) Ethnicity Table 3 SUPPORTING PARENT AND INFANT TRANSITION FROM NEONATAL INTENSIVE 21 CARE UNIT TO INFANT CLINIC FOLLOW-UP Race (n = 200) Race White n 61 % 30.5 Black or African American 66 33.0 Unreported 58 29.0 Asian 5 2.5 More than one race 9 4.5 Other Pacific Islander 1 0.5 English n 142 % 71.0 Spanish 49 24.5 Other 9 4.5 Table 4 Preferred Language (n = 200) Language Parental Barriers to Follow-up Care Health literacy level. One of the primary barriers identified by the site mentor was the level of health literacy of the patient population. According to researchers, it is important to diagnose health literacy strengths and weaknesses of the patient population being served and to develop specific strategies for responding to the common health literacy limitations relevant to the target population (Batterham et al., 2016; (Betancourt, Green, Carrillo, & AnanehFirempong, 2016). The site mentor further identified the need for the educational resources that are distributed at discharge or distributed upon referral to the Infant Clinic to be adjusted to a SUPPORTING PARENT AND INFANT TRANSITION FROM NEONATAL INTENSIVE 22 CARE UNIT TO INFANT CLINIC FOLLOW-UP Flesch-Kincaid 6th grade reading level (Badarudeen & Sabharwal, 2010; Betancourt et al., 2016). Researchers have also described health literacy to include a persons level of motivation to understand and use information in ways that contribute to good health (World Health Organization, 1998). According to the site mentor, it seems that a lack of patient motivation to attend follow-up appointments contributes to the no-show rate. For this reason, it may be useful to advertise and offer incentives for attending the follow-up appointment. Lack of NICU parent support. Additionally, both the mothers with NICU experience who were interviewed during the needs assessment phase, and researchers, have described the impact having an infant in the NICU has on overall levels of stress and anxiety and the need for support for NICU parents (Aloysius et al., 2017; Caretto, 2000; Forsythe & Willis, 2008; Hummel, 2003; Williams et al., 2018). One mother from the needs assessment specifically identified a desire for emotional support during her time in the NICU. Research has shown that support from NICU professionals during and after time spent in the NICU, decreased parent anxiety (Aloysius et al., 2017). Therefore, there is a need for emotional support for parents during and after time spent in the NICU, and presence of this type of support could lead to better long-term outcomes for both parents and infants (Aloysius et al., 2017; Caretto, 2000; Forsythe & Willis, 2008; Hummel, 2003; Williams et al., 2018). The type of support that would be most utilized by Eskenazis patient population will be identified during the implementation phase. Application to Current and Existing Practice Areas The settings of the infant follow-up clinic and the NICU are both emerging practice areas for OT (Borges et al., 2017; Lammers, 2018; Vergara et al., 2006). However, the value of identifying the barriers that an organizations patients face in accessing health care, is highly applicable to both existing and emerging practice areas. In order to provide patient-centered care SUPPORTING PARENT AND INFANT TRANSITION FROM NEONATAL INTENSIVE 23 CARE UNIT TO INFANT CLINIC FOLLOW-UP in any setting, an understanding of patient demographics and barriers patients face must be achieved (Badarudeen & Sabharwal, 2010; Betancourt et al., 2016). However, depending on patient demographics in a particular setting, the barriers that patients face to showing up for appointments may differ. For example, if the patient demographic consists of patients with higher education levels, higher socioeconomic status, and higher levels of health literacy, there may not be as much of a focus on providing patient incentives due to higher patient motivation levels (World Health Organization, 1998). If the patient population has a higher employment rate and patients have less availability to attend appointments during the work day, a strategy for increasing patient access may be scheduling appointments during evening hours, for example. On the other end of the spectrum, for Eskenazis patient population, transportation to and from appointments is a barrier many patients face in attending appointments at the Infant Clinic. Therefore, a strategy specific to this patient population could be to provide transportation vouchers for patients. Overall, the concepts of this project are clearly applicable to any OT practice setting due to OTs emphasis on providing patient-centered care (Stoffel et al., 2017). The varying factors among practice settings are simply the actual patient demographic characteristics. According to researchers, it is the role of all health care organizations to identify how demographic and cultural factors impact patients access to health care, and to respond by developing strategies to reduce those barriers (Badarudeen & Sabharwal, 2010; Betancourt et al., 2016). Section IV: Implementation Data Collection and Identification of Barriers The implementation phase of this DCE project includes two major foci: identifying the barriers that parents face in coming to their Infant Clinic appointments and developing strategies SUPPORTING PARENT AND INFANT TRANSITION FROM NEONATAL INTENSIVE 24 CARE UNIT TO INFANT CLINIC FOLLOW-UP to reduce those barriers. The barriers were identified through a parent questionnaire related to the NICU stay, NICU discharge experience, and Infant Clinic appointment (Appendix C). The surveys were written at a 6th grade reading level per the Flesch Kincaid readability standard for medical information (Badarudeen & Sabharwal, 2010). Surveys were completed at Infant Clinic appointments with parents who met the following criteria: parents of infants who had a NICU stay, parents who were present and involved during the infants NICU stay, and parents who had custody of their infant. Foster parents and parents of infants who came from community referrals (i.e. primary care clinics) were not surveyed due to lack of NICU experience. Due to the high noshow rates and the high number foster parents who come to the Infant Clinic, not many surveys were able to be administered in-person, and those parents who did complete surveys did not answer all of the questions. In order to gather more data, and to gather data from the perspectives of parents who did not come to the Infant Clinic, the survey was also administered over the phone to parents who no-showed their Infant Clinic appointments over an eight-month time period. The reasons parents gave for missing the Infant Clinic appointments had moderate variability. Some common responses included: not ever knowing they had an appointment, going to the well-baby visit after NICU discharge thinking it was interchangeable with the Infant Clinic appointment, loosing appointment information, and forgetting about the appointment altogether. Infant Clinic data collection. In addition to completing the parent surveys, Infant Clinic appointment data from a year-long period was analyzed for number of no-shows. Over a yearlong period, ninety-three referrals were made to the Infant Clinic from the NICU. Of those ninety-three, thirty-six no-showed their Infant Clinic appointments, without ever re-scheduling or coming to the clinic for evaluation, resulting in a 38% no-show rate for the Infant Clinic. Fortyfive came to their Infant Clinic appointments, with thirteen of those no-showing at least one SUPPORTING PARENT AND INFANT TRANSITION FROM NEONATAL INTENSIVE 25 CARE UNIT TO INFANT CLINIC FOLLOW-UP time, but often more than one-time. Of the twelve remaining referrals, a few called and cancelled their appointments without rescheduling, and some had upcoming appointments scheduled for evaluation (Appendix D). Data was also collected to track how many infants were actively receiving in-home early intervention services by the time of the Infant Clinic appointment in order to assess for possible gaps in developmental care. Of the forty-five infants who were seen in the Infant Clinic, only nine had activated First Steps services by the time of the Infant Clinic Evaluation. Minor Process Adjustments Aside from the focus on data collection, strategies were also developed with the goal of improving the show-rate to the Infant Clinic by increasing communication and continuity of care between the inpatient NICU staff and the outpatient Infant Clinic staff. In order to understand the roles of various NICU staff related to Infant Clinic referrals, several meetings were held with the following NICU team members: social worker, family care coordinator, OTs, STs, nursing manager, and other lead nursing staff. Some small changes that were made based off of those discussions included: updating discharge letters in EPIC (electronic medical documentation system) to use consistent terminology of Infant Clinic as the title of the clinic varied among various documentation between NICU staff, causing confusion. A few of the other minor changes made to the existing referral process included: education about the purpose of the Infant Clinic and importance of attending the appointment, included in the Baby Boot Camp class content. Baby Boot Camp is a class that covers basic newborn care, safety, and information about follow-up appointments. This class is available and encouraged for all parents who deliver their babies at Eskenazi, but it is often mandatory for high-risk parents such as young parents, first time parents, parents lacking social support, or SUPPORTING PARENT AND INFANT TRANSITION FROM NEONATAL INTENSIVE 26 CARE UNIT TO INFANT CLINIC FOLLOW-UP parents who abused substances or engaged in other risk-taking behaviors throughout their pregnancy. The nursing team will also begin showing parents the location of the Infant Clinic when they walk families out at discharge, in order to increase accessibility of the clinic. Creation of Resources Infant Clinic handout. An Infant Clinic handout was created which included details about the appointment, importance of the appointment, what to expect at the appointment, photos of the OT and ST who staff the clinic, and how to prepare for the appointment. This handout will be given to parents at the time of referral to the Infant Clinic by the inpatient NICU therapist who makes the referral. The handout will available for other NICU staff to give to families as necessary (e.g. if parents lose their copy, if nursing thinks a family might benefit from having information about the appointment if a future referral might be needed, etc.). In addition to the NICU, the handouts will be distributed in the newborn unit, where Infant Clinic referrals are occasionally made, and at primary care clinics that often refer to the clinic. These handouts were also sent to the marketing department at Eskenazi for approval and branding prior to distribution (Appendix E). A change that occurred with all resources created, including ensuring that all information given about the Infant Clinic is written at a 6th grade reading level or below in order to meet appropriate health literacy standards for medical information (Badarudeen & Sabharwal, 2010). Therapy team posters. Due to the feedback received from parent surveysthat parents did not know what the Infant Clinic was, or often could not recall their infant having therapy in the NICUposters were also created for all NICU baby rooms. The posters provided education on the role of the inpatient therapy team and the outpatient therapy team in the Infant Clinic. These posters were created in collaboration with the family care coordinator in the NICU SUPPORTING PARENT AND INFANT TRANSITION FROM NEONATAL INTENSIVE 27 CARE UNIT TO INFANT CLINIC FOLLOW-UP (Appendix F). NICU journal pages. The family care coordinator was in the process of creating a NICU Journal to be given to all families with infants in the NICU to be used as a method for tracking their infants successes, discharge checklists, and notes from the treatment team. As a strategy to increase continuity of care and interdisciplinary collaboration, a few additional journal pages were created in collaboration with the family care coordinator that were focused on a checklist for after discharge (Appendix G). The checklist included various activities such as: attending the well-baby visit, attending the Infant Clinic appointment, completing tummy time, and baby-proofing the home, in order to reinforce the importance of follow-up after discharge. There were also educational pages created in collaboration with the both therapy teams for skills that parents can work on with their infant after discharge. The third page included an interactive feeding worksheet where parents could fill out their infants feeding plan at discharge, with help from the speech therapist, in order to ensure parents were on the same page as NICU staff at discharge, and to hopefully prepare parents for the Infant Clinic appointment, where a feeding evaluation takes place and parents are expected to know the details of their infants feeds (i.e. bottle system, nipple size, type of formula, volume per feed, frequency of feeds, etc.). Establishment of Incentives for the Infant Clinic Evaluation Due to the aspect of health literacy that is related to level of patient motivation to access appropriate health care, incentives were also developed in an effort to increase parent motivation to attend the Infant Clinic evaluations, as Eskenazis patient population has on average, low health literacy levels (World Health Organization, 1998). The Marion County Health Department has a program titled the B.A.B.E. coupon program. This program allows low-income parents who live in Marion County to receive B.A.B.E. coupons for attending their prenatal, post- SUPPORTING PARENT AND INFANT TRANSITION FROM NEONATAL INTENSIVE 28 CARE UNIT TO INFANT CLINIC FOLLOW-UP partum, and primary care appointments for their infant. B.A.B.E. coupons can be cashed-in at the B.A.B.E. store for various essential and non-essential baby items. These coupons were not previously being distributed in the Infant Clinic, and Infant Clinic staff were not aware the program existed, so the application process was completed and the Infant Clinic was approved for B.A.B.E. coupon distribution. Several local charities and other baby companies were also contacted in search of donations for the Infant Clinic. Project Linus, a charity organization that donates baby blankets to sick children, agreed to provide ongoing baby blanket donations to the Infant Clinic. Aside from the two ongoing donations, several one-time donations were received from baby companies and staff members who had unwanted baby items. These gifts, along with one B.A.B.E. coupon, will be given to parents by the therapists at the initial evaluation, with a note that reinforces the importance of attending these appointments. Moving forward, NICU staff will be telling parents that they will receive a free gift and B.A.B.E. coupon at the Infant Clinic evaluation, in order to increase parent motivation to show-up for the appointment. Leadership There were many opportunities for leadership skills development throughout the DCE. Making changes to an existing program is a very sensitive and complex project to take on as the student must gain a comprehensive understanding of how the existing program was run prior to attempting any change. Also, managing communication between therapy teams in two different settings is complicated. In order to build positive working relationships with all staff members, the student spent a lot of time meeting with the team members involved in NICU discharge and Infant Clinic referrals to gain their feedback on areas of strength and weakness with the existing process. Additionally, the student made effort to incorporate every related staff members SUPPORTING PARENT AND INFANT TRANSITION FROM NEONATAL INTENSIVE 29 CARE UNIT TO INFANT CLINIC FOLLOW-UP feedback into all aspects of the project. At times there were miscommunications or need for clarification, and the student took additional time to meet with those individuals in order to make sure everyone was on the same page and agreed with any potential changes. All of these experiences provided the opportunity for the development of flexibility, openness, and patience when leading this type of project. Also, due to some tension between the teams, the student was served as a liaison between the two teams and facilitate positive conversations in order to initiate change. Additionally, these experiences required that the student take initiative to contact and collaborate with professionals outside of the therapy team in order to develop a program that had a holistic approach. This resulted in an increased comfort level with meeting with and presenting in front of various staff members about process changes. It also allowed for change in the referral process in areas that would not have been reached if the project was kept within the therapy department, which will make the program more effective in the long run (Bronstein, 2003). Staff Development Due to the extremely busy schedules that both the inpatient therapy team and outpatient therapy team have, there was not time for any one staff member to make quality improvement adjustments to the Infant Clinic referral process. This project involved a lot of time spent in meetings and required being present at both the outpatient campus and the main hospital downtown. Prior to this project, there was limited communication between the inpatient and outpatient therapists, and throughout this project, the student was able to meet with several staff members on both teams in order to gain insight and make changes. This facilitated increased communication and clarity between the teams which will improve continuity of care related to NICU discharge and follow-up in the Infant Clinic. This project also allowed for more SUPPORTING PARENT AND INFANT TRANSITION FROM NEONATAL INTENSIVE 30 CARE UNIT TO INFANT CLINIC FOLLOW-UP interdisciplinary collaboration as the student involved staff in the NICU in the Infant Clinic referral process, who were not previously involved. Some of these staff members included: Baby Boot Camp leaders, nursing, and the family care coordinator. There was a lack of understanding of the roles that each member played in the NICU and in the Infant Clinic, so the student created a discharge guidelines resource that summarized every team members role in making Infant Clinic referrals or other roles related to NICU discharge (Appendix H). This resource will be used to further staff development after the DCE ends, as NICU and Infant Clinic staff may refer to it in order to know who to reach out to when needed regarding specific aspects of the discharge process. There was also a statement released in the Eskenazi staff newsletter over a span of several days, in order to inform all staff about the Infant Clinic and how referrals are made as many staff members did not even know it existed. Specific information about the changes to the process will also be presented to the NICU staff that is involved in making referrals to the Infant Clinic during a lunch and learn. The goal is that this project will impact staff development long-term, not only related to the Infant Clinic, but also by increasing interdisciplinary collaboration moving forward. Section V: Discontinuation & Outcomes Project Outcomes A goal attainment scale (GAS) was created by the student in order to measure project outcomes (Case-Smith & OBrien, 2014). The GAS was focused on goals specific to the program development and was scored by the site mentor. All four project goals met at least more than the expected outcome, with three of the four goals meeting much more than expected outcome (Appendix I). Discontinuation SUPPORTING PARENT AND INFANT TRANSITION FROM NEONATAL INTENSIVE 31 CARE UNIT TO INFANT CLINIC FOLLOW-UP There are several strategies in place for ensuring this project can be sustained after the student completes the DCE rotation. The identification of barriers to the Infant Clinic show-rate and the development of strategies to reduce barriers, can be easily sustained by NICU and Infant Clinic staff. For example, the survey given to parents to identify barriers faced in accessing developmental care during and after NICU discharge, will be left with the site mentor for distribution in the future as desired. The initial survey that was developed for identification of parental barriers was rather lengthy and would not be easily utilized by the site mentor due to time constraints during Infant Clinic appointments. To address this problem, a simplified version was created that will be more realistic for the site mentor to administer during Infant Clinic appointments. The data collected from these surveys was provided to the site mentor on a shared computer folder so that she may complete further data analysis if desired in the future. The appointment data that was gathered by the student including: number of Infant Clinic referrals from the NICU versus Newborn Unit or community referrals, no-show rate, cancellation rate, and First Steps referral rate versus infants receiving First Steps services at time of the Infant Clinic evaluation, will also be available for the site mentor to access as desired on the shared computer folder. The student focused data analysis on no-show rate, but also tracked other data that the site mentor may utilize for future program development. In order to guarantee continued utilization of the strategies that were developed by the student, the student held a Lunch and Learn presentation for related staff that will be responsible for maintenance of these strategies. The Lunch and Learn included presentation of the data that was gathered during the implementation phase, as well as the many strategies that were put into place to hopefully reduce barriers. The student developed a written discharge protocol resource that outlines each related NICU and Infant Clinic staff members specific roles SUPPORTING PARENT AND INFANT TRANSITION FROM NEONATAL INTENSIVE 32 CARE UNIT TO INFANT CLINIC FOLLOW-UP related to the discharge and Infant Clinic referral process. The staff members included in the discharge guidelines included: the NICU social worker and case manager, the family care coordinator, NICU speech and occupational therapists, NICU nursing staff, Infant clinic speech and occupational therapist, outpatient therapy managers, and registrars responsible for scheduling Infant Clinic appointments. In addition to the clarification of staff roles related to discharge, each staff member description also included roles related to the new Infant Clinic referral process. The resource was originally titled NICU Discharge and Infant Clinic Referral Protocol/Staff Roles, however, at the lunch and learn, the therapy manager clarified that the term protocol cannot be used unless the guidelines are mandated by the hospital managers, so the term guidelines was used instead. Another important aspect of the Lunch and Learn was the emphasis on addressing health literacy level of the patient population (Badarudeen & Sabharwal, 2010). Staff were shown how to assess the readability of educational resources and handouts given to families and given resources to utilize for identifying words related to higher reading levels in order to empower staff to address this independently moving forward. All resources that were created by the student were created at the appropriate reading level and will be available on a shared computer folder in order to staff to reprint as needed. The educational material published through the marketing department will be printed as needed through Eskenazis printing department, Ricoh. The site mentor will be responsible for placing new orders. In order to sustain the ongoing donations that were secured as incentives for parents to come to the Infant Clinic, the student trained the site mentor on the process for requesting more inventory when the supply in the Infant Clinic runs low. Further, the student transferred the necessary contact information for the charity organizations to the site mentor and left detailed SUPPORTING PARENT AND INFANT TRANSITION FROM NEONATAL INTENSIVE 33 CARE UNIT TO INFANT CLINIC FOLLOW-UP instructions in the shared computer folder for the site mentors reference. The student also organized the donations and ensured they would be easily accessible by the site mentor for distribution (i.e. wrapped onesies and blankets together, ensured the site had needed stamps to authorize coupons, etc.). An important emphasis of the project was on interdisciplinary collaboration, which was essential in the completion of this project and is required moving forward in order to sustain the strategies (Bronstein, 2003; Welch et al., 2017). The written discharge guidelines highlight the reliance that NICU and Infant Clinic staff have on one another in order for the new process to be successful. The strategies that were implemented would not have been possible without communication between all related NICU and Infant Clinic staff, which is why continued communication between inpatient and outpatient services is so important in order for the program to keep progressing. The collaboration between various disciplines allowed Infant Clinic education to be shared with patients and staff through avenues that would not have been identified or utilized without such interdisciplinary collaboration (Bronstein, 2003). Response to Societal Needs It is essential for infants discharged from the NICU to have access to developmental care as they are at a high risk for having a developmental delay and experience improved outcomes with early intervention services (Bockli et al., 2014; Santos et al., 2015). It is the responsibility of health care providers to assess the barriers that patients face in receiving these services and to develop a plan to minimize or eliminate these barriers (Betancourt et al., 2016). This project addressed the barriers that Eskenazis patients experience in accessing developmental care through parent-centered interviewing and development of strategies that met health literacy guidelines (Batterham et al., 2016). All resources given to parents about the Infant Clinic moving SUPPORTING PARENT AND INFANT TRANSITION FROM NEONATAL INTENSIVE 34 CARE UNIT TO INFANT CLINIC FOLLOW-UP forward, will meet the reading level requirement for medical information, and education about the Infant Clinic will be given consistently throughout the NICU stay through a variety of sources, including: NICU staff, Baby Boot Camp classes, NICU journal, posters in baby rooms, and Infant Clinic appointment materials given at time of referral (Batterham et al., 2016). Strategies will be continued on the outpatient side of services at the Infant Clinic through parent reinforcement of the importance of providing early developmental care to their infants (Greene & Patra 2016; Orton et al., 2018). In addition to targeting the low education levels commonly held by patients with low health literacy levels, the strategies also targeted patient motivation by offering incentives for coming to the Infant Clinic evaluation. Not only does this encourage parents to come to the appointment, but it also reduces the financial burden that many patients have, by providing free baby supplies to parents. These strategies will help the Infant Clinic therapists to provide necessary developmental care to a greater number of fragile NICU graduates, reducing the length of the wait list by increasing the first-time show-rate to evaluations. Most importantly, the increased ease in accessing the Infant Clinic will provide better long-term outcomes for infants (Nwabara et al., 2017; Greene & Patra 2016; Orton et al., 2018). Section VI: Overall Learning Communication Skills Communication with parents. Communication was a fundamental part of this DCE project as the student served in a consultative role during a majority of the experience. One aspect of patient communication that has been thoroughly discussed, is the communication of important Infant Clinic information at the appropriate health literacy level of the patient population (Batterham et al., 2016). This included using terms that were simple and easy to SUPPORTING PARENT AND INFANT TRANSITION FROM NEONATAL INTENSIVE 35 CARE UNIT TO INFANT CLINIC FOLLOW-UP understand when providing verbal education to families and writing all printed information at a 6th grade reading level or below (Batterham et al., 2016). Due to the history of substance abuse during pregnancy that many of the parents coming to the Infant Clinic had, it was also important to approach all parent interactions without making assumptions or judgments about the parents desires to love and care for their infant despite making unfavorable choices. It was also essential to show empathy while communicating with parents and acknowledge the difficult experiences they have endured having had an infant in the NICU. When the student made phone calls to parents who no-showed their Infant Clinic appointments, it was especially important to be sensitive to parent experiences, as being questioned about the reasoning behind not attending their infants appointment, could be perceived as an attack. The student made increased effort to acknowledge the busy schedules and difficult experiences that parents had as well as thank parents for feedback while reinforcing the importance of their input in improving Eskenazis services, with every parent interaction. The student also gained experience with working with patients of diverse cultural backgrounds as many of the patients were Spanish-speakers. In order to facilitate communication, the student often used an interpreter, both live and over-the phone. However, there were times when interpreters were not available and the student was flexible in finding alternative means for communication. In order to provide client-centered care with use of an interpreter, it was crucial that the student maintained eye contact and receptive body language with the parent and/or patient while the interpreter was talking, and took additional time to confirm that the patient understood all aspects of education and recommendations. Communication with staff. Communication with colleagues and staff was also completed with sensitivity as the student served as a liaison between the inpatient therapy team SUPPORTING PARENT AND INFANT TRANSITION FROM NEONATAL INTENSIVE 36 CARE UNIT TO INFANT CLINIC FOLLOW-UP and outpatient therapy team and was often communicating about changes to existing processes which can be difficult to do, not only as a student, but also as a person who is new to the organization. In order to make sure important information about changes to the existing processes were communicated correctly and carefully, the student planned time to be at the hospital in the NICU to have in-person meetings, as messages can often be misconstrued over email. Also, any time a new resource was created that involved information about various staff roles or collaboration with other professionals, the student asked for feedback from the involved staff members so that everyone was on the same page, and there were not any surprises with the new guidelines. All data regarding the Infant Clinic and additions to the existing processes were approved by NICU staff, then presented in-person to staff so that any needed clarifications could be provided immediately. Also, it was important for the student to keep an open, flexible mindset throughout all of these meetings so that staff felt free to offer concerns, opinions, and ideas. The student took time to develop relationships with staff members who were not previously involved in the Infant Clinic referral process but were perceived by the student to be a good fit for delivering parent education about the importance of follow-up care after NICU discharge. These relationships resulted in collaboration on several different projects and allowed the Infant Clinic education to infiltrate more aspects of the NICU stay than previously anticipated (i.e. Baby Boot Camp in Newborn Unit, nursing staff showing parents the location of the clinic at discharge, etc.). Other strategies were used in order to disseminate information about the Infant Clinic to a large group of people. A statement was released in the Eskenazi employee newsletter informing staff about the purpose, location, and schedule for the Infant Clinic, and publishing of informational materials about the Infant Clinic to be distributed to patients at all referral source SUPPORTING PARENT AND INFANT TRANSITION FROM NEONATAL INTENSIVE 37 CARE UNIT TO INFANT CLINIC FOLLOW-UP locations. Nursing staff was educated through an informational email about the purpose of the Infant Clinic and their roles in assisting with the referral process. Communication with the public. Communication with the public and community took place in order to ask for and coordinate ongoing donations for the Infant Clinic. The student contacted dozens of companies and charities and shared the project purpose, while also sharing the plan for using any donated supplies to motivate parents to attend the Infant Clinic. The student also used strategic communication of researching the charities mission and specifically detailing how their mission aligned with that of the Infant Clinics. All interactions were positive and the student followed up with every organization after receiving donations to express gratitude and to give specific examples of how the donation will positively impact patients lives. Leadership and Advocacy Skills Leadership. The student utilized leadership skills by taking initiative at every phase of the project. The site mentor was occupied with a full caseload and also served in a leadership position at the outpatient clinic, working on program development of her own in other areas. Due to the site mentors varied availability, it was important for the student to take initiative to contact other staff members in order to make connections and develop relationships with staff at all sites (i.e. outpatient clinic, Infant Clinic, NICU). Creating change in existing processes is difficult to do, so much of the students initiative was demonstrated in forming positive working relationships across various inpatient and outpatient disciplines and spending extensive time observing other disciplines in order to learn about their roles and potential areas for collaboration. This allowed the student to inform other therapy staff about the roles that nontherapy staff play related to follow-up after NICU discharge and implement changes in areas that would have not otherwise been reached. This initiative also set an example for other staff about SUPPORTING PARENT AND INFANT TRANSITION FROM NEONATAL INTENSIVE 38 CARE UNIT TO INFANT CLINIC FOLLOW-UP the positive outcomes that occur with interdisciplinary collaboration. The multidisciplinary staff was already very collaborative with patient care during the NICU stay, however, the potential collaboration opportunities related to follow-up care post NICU discharge had not been addressed. Advocacy. There were many opportunities for advocacy throughout the DCE. The student utilized advocacy skills through identification of barriers that patients face in accessing health care and by acting to reduce such barriers. Though the surveys questioned parents on the reasoning for no-showing the Infant Clinic appointments, questions were also included to gain feedback from parents on what would have made the NICU stay and discharge experience more successful. These questions were asked so that continued quality improvement takes place using feedback provided directly from past NICU families, ensuring the specific needs of patients are being addressed. Acknowledgement that Eskenazis patient population consists of individuals with diverse cultural backgrounds, who require strategies designed specifically for them, is another form of patient advocacy (Betancourt et al., 2016). An example of strategies designed specifically for this patient population include the time that appointment reminders are sent to families. The registrars send families appointment reminders the day before their appointments, which may seem like late notice for individuals who come from a higher socioeconomic status and are working, requiring scheduling in advance, however, according to feedback given by parents, these appointment reminders come at a good time for them. Some parents commented that they would like reminders even closer to the appointments, such as day of the appointment. Also, the education that was provided to staff on the importance of creating resources that are at the appropriate reading level for the patient population being served, is another example of utilization of advocacy skills (Betancourt et al., 2016; Batterham et al., 2016). SUPPORTING PARENT AND INFANT TRANSITION FROM NEONATAL INTENSIVE 39 CARE UNIT TO INFANT CLINIC FOLLOW-UP In regard to the patient care aspect of this DCE, patient advocacy took place through documentation. Many of the parents from this patient population have had custody battles to keep their infants, either due to domestic violence, substance abuse, or other factors. When parents come to the Infant Clinic and it is obvious that they are playing an active role in providing appropriate care for their infant and are committed to making changes, it is always documented so that the parents have support from health care providers who have witnessed parents provide proper care to their infants. Conclusion The student met all goals set for the DCE as well as developed strong leadership and program development skills. With the newly implemented strategies in place, patient barriers to accessing the Infant Clinic will be reduced. More importantly, the strategies have facilitated increased staff sensitivity to health literacy levels and the strategies implemented have proven the effectiveness of an interdisciplinary team. The new guidelines will ensure that the Infant Clinic referral process consists of interdisciplinary collaboration, resulting in increased continuity of care and better long-term outcomes for infants and their families. SUPPORTING PARENT AND INFANT TRANSITION FROM NEONATAL INTENSIVE 40 CARE UNIT TO INFANT CLINIC FOLLOW-UP References Aita, M., Stremler, R., Feeley, N., Lavalle, A., & De Clifford-Faugre, G. (2017). Effectiveness of interventions during NICU hospitalization on the neurodevelopment of preterm infants: a systematic review protocol. 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Cole, M. B., & Tufano, R. (2008). Applied theories in occupational therapy: A practical approach. Slack Incorporated. Davidson, J. E., Aslakson, R. A., Long, A. C., Puntillo, K. A., Kross, E. K., Hart, J., ... & Netzer, G. (2017). Guidelines for family-centered care in the neonatal, pediatric, and adult SUPPORTING PARENT AND INFANT TRANSITION FROM NEONATAL INTENSIVE 42 CARE UNIT TO INFANT CLINIC FOLLOW-UP ICU. Critical care medicine, 45(1), 103-128. Dudek-Shriber, L. (2004). Parent stress in the neonatal intensive care unit and the influence of parent and infant character- istics. American Journal of Occupational Therapy, 58, 509 520. Forsythe, P. L., & Willis, V. (2008). Parenting preemies: A unique program for family support and education after NICU discharge. Advances in Neonatal Care, 8(4), 221-230. Greene, M., & Patra, K. (2016). Part C early intervention utilization in preterm infants: Opportunity for referral from a NICU follow-up clinic. Research in developmental disabilities, 53, 287-295. Hall, S. L., Phillips, R., & Hynan, M. T. (2016). Transforming NICU care to provide comprehensive family support. Newborn and Infant Nursing Reviews, 16(2), 69-73. Hummel, P. (2003). Parenting the high-risk infant. Newborn and Infant Nursing Reviews, 3(3), 88-92. Hynan, M. T., & Hall, S. L. (2015). Psychosocial program standards for NICU parents. Journal of Perinatology, 35(S1), S1. Krner, M. (2010). Interprofessional teamwork in medical rehabilitation: a comparison of multidisciplinary and interdisciplinary team approach. Clinical rehabilitation, 24(8), 745755. Lammers, J. (2018). Physical Therapists' Beliefs about Preparation to Work in Special Care Nurseries and Neonatal Intensive Care Units (Doctoral dissertation, Nova Southeastern University). Landsem, I. P., Handegrd, B. H., Ulvund, S. E., Kaaresen, P. I., & Rnning, J. A. (2015). Early intervention influences positively quality of life as reported by prematurely born children SUPPORTING PARENT AND INFANT TRANSITION FROM NEONATAL INTENSIVE 43 CARE UNIT TO INFANT CLINIC FOLLOW-UP at age nine and their parents; a randomized clinical trial. Health and quality of life outcomes, 13(1), 25. Larsson, C., Wagstrom, U., Normann, Blomqvist Y.T. (2015). Parents Experience of Discharge Readiness from a Swedish NICU Nursing Open, vol. 4, pp. 90-95. Ma, L., Yang, B., Meng, L., Wang, B., Zheng, C., & Cao, A. (2015). Effect of early intervention on premature infants general movements. Brain and Development, 37(4), 387-393. Mohapatra, J., & Rani, P. (2016). Sensory Frame Work of Reference for the Development of Communication Skills in Children with Autism Spectrum Disorders an Occupational Therapy Perspective. J Pediatr Neonatal Care, 5(3), 00183. Nwabara, O., Rogers, C., Inder, T., & Pineda, R. (2017). Early therapy services following neonatal intensive care unit discharge. Physical & occupational therapy in pediatrics, 37(4), 414-424. Orton, J. L., Olsen, J. E., Ong, K., Lester, R., & Spittle, A. J. (2018). NICU Graduates: The role of the allied health team in follow-up. Pediatric annals, 47(4), e165-e171. Osorio, S.P., Ochoa Marin, S.C., Semenic, S. (2017). Preparing for post discharge care of premature infants: experiences of parents. Invest. Educ. Enferm. 35 (1), 100-108. Painter, L., Lewis, S., & Hamilton, B. K. (2019). Improving Neurodevelopmental Outcomes in NICU Patients. Advances in neonatal care: official journal of the National Association of Neonatal Nurses. Purdy, I. B., Craig, J. W., & Zeanah, P. (2015). NICU discharge planning and beyond: recommendations for parent psychosocial support. Journal of Perinatology, 35(S1), S24. Santos, J., Pearce, S. E., & Stroustrup, A. (2015). Impact of hospital-based environmental exposures on neurodevelopmental outcomes of preterm infants. Current opinion in SUPPORTING PARENT AND INFANT TRANSITION FROM NEONATAL INTENSIVE 44 CARE UNIT TO INFANT CLINIC FOLLOW-UP pediatrics, 27(2), 254. Smith, T., Mruzek, D. W., & Mozingo, D. (2015). Sensory integration therapy. Controversial therapies for autism and intellectual disabilities: Fad, fashion, and science in professional practice, 247-269. Smyser, C. D., Tam, E. W., Chang, T., Soul, J. S., Miller, S. P., & Glass, H. C. (2016). Fellowship training in the emerging fields of fetal-neonatal neurology and neonatal neurocritical care. Pediatric neurology, 63, 39-44. Stoffel, A., Rhein, J., Khetani, M. A., Pizur-Barnekow, K., James, L. W., & Schefkind, S. (2017). Family centered: Occupational therapys role in promoting meaningful family engagement in early intervention. OT Practice, 22(18), 813. Vergara, E., Anzalone, M., Bigsby, R., & Gorga, D. (2006). Specialized knowledge and skills for occupational therapy practice in the neonatal intensive care unit. The American Journal of Occupational Therapy, 60(6), 659. Welch, C. D., Check, J., & OShea, T. M. (2017). Improving care collaboration for NICU patients to decrease length of stay and readmission rate. BMJ Open Qual, 6(2), e000130. Williams, K. G., Patel, K. T., Stausmire, J. M., Bridges, C., Mathis, M. W., & Barkin, J. L. (2018). The Neonatal Intensive Care Unit: Environmental Stressors and Supports. International journal of environmental research and public health, 15(1), 60. World Health Organization. (1998). Health promotion glossary. SUPPORTING PARENT AND INFANT TRANSITION FROM NEONATAL INTENSIVE 45 CARE UNIT TO INFANT CLINIC FOLLOW-UP Appendix A Needs Assessment Questions for Site Mentor 1. What is currently going well for the Infant Clinic? 2. What is currently not going well for the Infant Clinic? 3. What factors do you think contribute to the no show rate? 4. What do you think is going well at NICU discharge that contributes to parents showing up for their appointments? 5. What do you think is not going well at NICU discharge that contributes to parents not showing up for their appointments? 6. How do you think cultural background impacts the follow through/show-rate with the Infant Clinic? 7. If you could make one change to the discharge process, what would it be? 8. Do you have any ideas for incentives that could be offered to parents when they arrive to the Infant Clinic for their first appointment? SUPPORTING PARENT AND INFANT TRANSITION FROM NEONATAL INTENSIVE 46 CARE UNIT TO INFANT CLINIC FOLLOW-UP Appendix B Needs Assessment Questions for One-on-One Parent Interview Reason for child stay in the NICU/hospital: Length of stay in hospital: 1. What factors were helpful for you during time spent in the NICU? 2. What was most difficult about having your infant in the NICU? 3. Did you feel involved in the care of your infant while he/she was in the NICU? 4. Did you understand the medical needs of your infant while he/she was in the NICU? 5. What made you feel most supported when your infant was in the NICU? 6. Did you have contact with any other parents who had their baby in the hospital? 7. When/Where you contacted by First Steps after discharge from the NICU? 8. How long did it take for a First Steps therapist to get to your house after discharge from NICU? 9. Did your infant receive services at a NICU follow up clinic with OT/ST? 10. What was difficult about keeping track of appointments? What would make it easier to keep track of your babys appointments? 11. How did you manage your schedule with doctors appointments after discharge? 12. Did you feel equipped to participate in your childs development at home? (working on strategies taught by therapy?) 13. What would make you feel more supported/at ease when taking your child home from the NICU? 14. Would you be interested in a home program to fill the gap between discharge from NICU to waiting for either First Steps or outpatient services? 15. What information were you given in the NICU about how to support your childs development/available services? 16. Did you understand the purpose of the NICU follow-up appointment? SUPPORTING PARENT AND INFANT TRANSITION FROM NEONATAL INTENSIVE 47 CARE UNIT TO INFANT CLINIC FOLLOW-UP Appendix C NICU Discharge Parent Survey (Implementation Phase) 1. What is your relationship to your baby? a. Birth mom b. Birth dad c. Foster mom d. Foster dad e. Other (Explain): __________________________________ 2. Why was your baby in the NICU? a. My baby was too small b. My baby came too early c. My baby was not eating enough d. My baby needed help breathing e. My baby needed medicine f. Other (Explain): __________________________________ 3. What/Who was helpful for you during time spent in the NICU? a. Employees in the NICU b. Educational papers given to me in the NICU c. Support from my family and friends d. Practicing with a therapist or nurse before I left e. I looked up things about the NICU online so that I could understand what was going on f. Other (Explain): __________________________________ 4. What was most difficult about having your baby in the NICU? a. Not understanding what was happening with my baby b. Having to see my baby upset or in pain c. Finding time to visit my baby because of work, or my other kids d. Trying to keep track of meetings about my babys care e. Not being there to talk to my babys doctors or nurses f. Not having an interpreter there to help me talk to my babys doctors or nurses g. Other (Explain): __________________________________ 5. Did you feel involved in helping take care of your baby while he/she was in the NICU? (For example, involved in diaper changes, feeding, holding, comforting, etc.) a. Yes b. No 6. During your babys time in the NICU, did you have contact with any other parents who currently or previously had a baby in the NICU? a. Yes b. No SUPPORTING PARENT AND INFANT TRANSITION FROM NEONATAL INTENSIVE 48 CARE UNIT TO INFANT CLINIC FOLLOW-UP 7. Would you have used any of the following (circle if you would have): a. In-person parent support groups while your baby was in the NICU b. Online support group for parents of babies in the NICU c. Opportunity to talk to parents who have had babies in the NICU in the past 8. First Steps in a company that provides therapists to come to your house to help your baby get stronger and continue to grow. Before today, did you know what First Steps was? a. Yes b. No 9. Did First Steps call you? a. Yes b. No 10. When were you contacted by First Steps after discharge from the NICU? a. 1st week after discharge b. 1st month after discharge c. More than one month after discharge d. Other (Explain): __________________________________ 11. Was it hard to keep track of your babys appointments? a. Yes b. No 12. Why was it hard to keep track of your babys appointments? a. Too many other appointments b. My schedule is too busy c. No way to organize appointments d. Did not know when appointments were e. Did not know where appointments were f. Other (Explain): __________________________________ 13. What would make it easier to keep track of your babys appointments? a. Reminder calls or texts b. Having a place to write it down c. Having support from a friend or family member d. Transportation to help me get there e. Other (Explain): __________________________________ 14. When it was time for your baby to be discharged from the NICU, how comfortable were you with changing his/her diaper? a. Completely uncomfortable b. A little bit uncomfortable c. I felt I could do it, but I was a little nervous d. Fairly comfortable SUPPORTING PARENT AND INFANT TRANSITION FROM NEONATAL INTENSIVE 49 CARE UNIT TO INFANT CLINIC FOLLOW-UP e. Completely comfortable f. Other (Explain): __________________________________ 15. When it was time for your baby to be discharged from the NICU, how comfortable were you with feeding your baby? a. Completely uncomfortable b. A little bit uncomfortable c. I felt I could do it, but I was a little nervous d. Fairly comfortable e. Completely comfortable f. Other (Explain): __________________________________ 16. When it was time for your baby to be discharged from the NICU, how comfortable were you with holding and moving your baby? a. Completely uncomfortable b. A little bit uncomfortable c. I felt I could do it, but I was a little nervous d. Fairly comfortable e. Completely comfortable f. Other (Explain): __________________________________ 17. What would make you feel better about taking your baby home from the NICU? a. Having a phone number I can call to talk to someone from the NICU after discharge b. More training on (Check all that apply): i. NG tube __________________ ii. G tube ___________________ iii. Feeding my baby ___________ c. Papers that remind me how to do exercises for my baby d. Papers that remind me about medicines for my baby e. Practicing feeding, diaper changes, and handling my baby before I go home with my baby f. Other (Explain): __________________________________ 18. Before your baby went home, did the occupational therapist meet with you to practice exercises with your baby? a. Yes b. No 19. Before your baby went home, did the speech therapist meet with you to practice feeding your baby? a. Yes b. No 20. Did you understand why you were scheduled for the NICU follow-up appointment you attended today? SUPPORTING PARENT AND INFANT TRANSITION FROM NEONATAL INTENSIVE 50 CARE UNIT TO INFANT CLINIC FOLLOW-UP a. Yes b. No 21. Was it hard to make it to the NICU follow-up appointment today? a. Yes b. No 22. What was hard about coming to your appointment today? a. I have other kids I have to take places b. My baby has a lot of other appointments c. I do not have a car and I have to plan my transportation d. The time of the appointment e. I did not know where the was f. Other (Explain): __________________________________ 23. Did you ever use the handouts given to you at discharge? a. Yes b. No 24. If no, why? a. Too many forms b. They were hard to read c. Did not understand what to do d. Not relevant to my baby e. Other (Explain): __________________________________ Additional Comments: SUPPORTING PARENT AND INFANT TRANSITION FROM NEONATAL INTENSIVE 51 CARE UNIT TO INFANT CLINIC FOLLOW-UP Appendix D Infant Clinic Data Infant Clinic Show-Rate No-shows Shows Cancelled Not Scheduled Upcoming Appointment First Steps Services Started Yes No SUPPORTING PARENT AND INFANT TRANSITION FROM NEONATAL INTENSIVE 52 CARE UNIT TO INFANT CLINIC FOLLOW-UP Appendix E Infant Clinic Resource Your Infant Clinic Appointment What will happen at the appointment? x The therapists will ask you questions about your babys birth and time in the hospital. They will also ask you how things are going at home. x The therapists will hold and play with your baby to check his or her body, head and eye movement. x The therapists will watch you feed your baby to make sure he or she is eating safely and comfortably. x The therapists will tell you how your baby is doing and give ideas for helping him or her grow and learn at home. They will also answer any questions you have. x The therapists may want to see your baby again to make sure he or she continues to grow normally and to support you. x Bonuses: You will find out your babys weight and receive a B.A.B.E. coupon and a small gift for you and your family. What should I bring to the appointment? Any bottles and nipples you have been using or plan to use at home Formula or breast milk to use during the evaluation Breastfeeding supplies that have been recommended Pacifiers or special blankets that might help make your baby more comfortable Any paperwork you have been given after special tests or appointments At least one dry diaper Baby foods and spoons if your baby is eating these Where is the appointment? Your appointment will take place in the Outpatient Rehabilitation Center, located on the first floor of the Sidney & Lois Eskenazi Hospital, 720 Eskenazi Ave., Indianapolis, IN 46202. The center is located next to the Frank & Katrina Basile Gift Shop. When you arrive, please check in at the front desk. The center can be reached at 317.880.0280 should you have any questions. SUPPORTING PARENT AND INFANT TRANSITION FROM NEONATAL INTENSIVE 53 CARE UNIT TO INFANT CLINIC FOLLOW-UP SUPPORTING PARENT AND INFANT TRANSITION FROM NEONATAL INTENSIVE 54 CARE UNIT TO INFANT CLINIC FOLLOW-UP Appendix F Therapy Team Posters for Infant Rooms in NICU SUPPORTING PARENT AND INFANT TRANSITION FROM NEONATAL INTENSIVE 55 CARE UNIT TO INFANT CLINIC FOLLOW-UP Appendix G NICU Journal Therapy Related Pages *Photos were removed to preserve patient privacy. Patients gave consent to Eskenazi. SUPPORTING PARENT AND INFANT TRANSITION FROM NEONATAL INTENSIVE 56 CARE UNIT TO INFANT CLINIC FOLLOW-UP SUPPORTING PARENT AND INFANT TRANSITION FROM NEONATAL INTENSIVE 57 CARE UNIT TO INFANT CLINIC FOLLOW-UP SUPPORTING PARENT AND INFANT TRANSITION FROM NEONATAL INTENSIVE 58 CARE UNIT TO INFANT CLINIC FOLLOW-UP SUPPORTING PARENT AND INFANT TRANSITION FROM NEONATAL INTENSIVE 59 CARE UNIT TO INFANT CLINIC FOLLOW-UP SUPPORTING PARENT AND INFANT TRANSITION FROM NEONATAL INTENSIVE 60 CARE UNIT TO INFANT CLINIC FOLLOW-UP Appendix H Infant Clinic Referral Guidelines and Staff Roles Multidisciplinary Roles Related to NICU Discharge and Infant Clinic Follow-Up *All Staff use the terminology: Infant Clinic when referring to this appointment Sabrina Quigley- NICU Social Worker & Case Manager Collaborates with the multidisciplinary team to determine what type of follow-up may be needed for each infant after discharge such as: home nursing, enteral feedings, outpatient case management, and/or First Steps. Discusses follow-up recommendations with team and families and facilitates needed referrals to those agencies/providers as agreed upon by family. Makes community referrals for families based on individual case-by-case needs (e.g. Healthy Families, Healthy Start, referrals for baby supplies, WIC, counseling, employment, education, child care, peer-parent support, financial resources, or social security referrals for babies with qualifying medical needs). Coordinates with DCS when indicated to ensure safe and timely discharge of infants to their identified caregivers o Ensure the caregivers have access to appropriate services for baby after discharge Points out/reinforces importance of follow-up appointments to parents (including Infant Clinic) Infant Clinic Specific Changes o Name of Infant Clinic appointment changed in family Discharge Lists from Outpatient Rehabilitation to Infant Clinic Angela Meyers- Family Support Coordinator, (NICU Nest) Provides support to new parents in the NICU through promoting parent-provider partnerships, helping parents navigate newborn Medicaid, selecting a primary medical provider for their infants, and teaching families how to use Medicaid cabs Hosts family support activities on the unit Assists with accessing community resources Offers free baby pictures to parents Promotes parent self-care (e.g. reminds parents to stay hydrated, eat regular meals, ensures breastfeeding moms know how to use their meal cards, share strategies for stress management, helps to facilitate needed referrals/services if parents express depression or anxiety, etc.) Collaborates with other members of the care team to develop resources that support education for families SUPPORTING PARENT AND INFANT TRANSITION FROM NEONATAL INTENSIVE 61 CARE UNIT TO INFANT CLINIC FOLLOW-UP Created and manages NICU journal Provides education to parents during Baby Boot Camp (Mondays for Spanish speakers) Infant Clinic Specific Changes o NICU journal pages include parent education from a therapy perspective: o Eat, Play, Sleep page (ways to facilitate developmental after discharge) o Interactive feeding plan page (to promote parent understanding of their infants feeding plan at discharge and to help prepare for potential Infant Clinic appointment) o Page for tracking progress after discharge home (writing appointments in calendar, attending Infant Clinic appointment, attending well-child visit, etc.) o Collaboration for poster in NICU baby rooms which explains the purpose of Inpatient and Outpatient therapies (NICU and Infant Clinic) o Notify Emily if posters need to be replaced or updated o Inclusion of Infant Clinic education in Baby Boot Camp classes Nursing Staff Ensure all discharge criteria have been completed (e.g. car seat study, pre/post O2 sats, NBN screen, etc.) Provide discharge education specific to patient (e.g. tube feeding, nutrition preparation, medication administration, newborn care, circumcision care, etc.) Lead Baby Boot Camp classes (only specific to some nursing staff, not all) Review of all follow-up appointments Review final discharge summary Observe car seat installation and infant positioning in car seat and provide education when needed Escort patient to discharge location Infant Clinic Specific Changes o Re-iterate importance of attending Infant Clinic appointment at discharge during family appointment review o Show ALL parents/families the location of the Infant Clinic at discharge while walking them out Inpatient NICU Occupational & Speech Therapists Occupational Therapy Specific: Meet with caregivers during NICU stay to provide training on infant positioning and/or infant massage (as able) Provide parent education regarding infant progress o Developmental home program and or individualized home exercise programs Answer any questions parents have regarding recommendations Speech Therapy Specific SUPPORTING PARENT AND INFANT TRANSITION FROM NEONATAL INTENSIVE 62 CARE UNIT TO INFANT CLINIC FOLLOW-UP Meet with caregivers during NICU stay to provide coaching during a feeding, education, support about specific interventions and recommendations (as able) Establish a home feeding plan that is safe, promotes infants growth, and is collaborative with the familys needs and culture (verbally or in writing) as appropriate Offer recommendations based on the infants current skills and cues Answer any questions parents have regarding home feeding plan/recommendations Both Therapies: Attend weekly discharge planning rounds for multidisciplinary collaboration in preparing for infants discharge home Make recommendations or referrals for follow-up services or therapy as indicated (e.g. First Steps, Infant Clinic, outpatient video fluoroscopy swallow study, etc.) Assist infants and their families with smooth transition from NICU to home If an Infant Clinic referral is made: o Communicate with registrar to schedule appointment o Provide appointment reminder Infant Clinic Specific Changes o Provide parents with new Infant Clinic informational materials when providing appointment reminder and reinforce importance of appointment o Notify Emily when stock of Infant Clinic informational materials needs to be replenished Outpatient Infant Clinic Occupational & Speech Therapists Evaluate infant development and parent feeding infant Provide recommendations for exercises, positioning, feeding program, etc., at home Answer any questions parents have regarding home exercise plans/recommendations Determine need for further services and initiate First Steps referral, if needed Schedule needed return visits and provide family with an appointment reminder Infant Clinic Specific Changes o Maintain stock of Infant Clinic informational resources (reprint for NICU staff when notified) o Provide parents with ongoing donations at time of 1st eval (Project Linus & B.A.B.E. coupons) o Maintain stock of ongoing donations o Administer parent survey as needed/desired Registrars Schedule Infant Clinic evaluation after receiving order from NICU team Inform inpatient therapists via in-basket when appointment has been scheduled SUPPORTING PARENT AND INFANT TRANSITION FROM NEONATAL INTENSIVE 63 CARE UNIT TO INFANT CLINIC FOLLOW-UP Call parents to confirm details of Infant Clinic appointment within 1 week of appointment If parents do not answer, leave a detailed message telling parents to call back to confirm Make at least one more attempt for contact with parents Infant Clinic Specific Changes o Read script for Infant Clinic appointment confirmation calls (includes updated info needed for Infant Clinic appointments, similar to information included on new Infant Clinic resource) SUPPORTING PARENT AND INFANT TRANSITION FROM NEONATAL INTENSIVE 64 CARE UNIT TO INFANT CLINIC FOLLOW-UP Appendix I Goal Attainment Scale (Outcome Measure) *Items in bold are the score given by the site mentor. Goal 1: Identify the barriers that parents face in understanding information about their Infant Clinic appointment and barriers to coming to the Infant Clinic. Much less than expected outcome -2 Receive feedback from less than 5 parents on barriers faced in understanding and accessing the Infant Clinic and the feedback is unclear/parent does not identify any external barriers that can be impacted by project Less than expected outcome -1 Receive feedback from less than 5 parents on barriers faced in understanding and accessing the Infant Clinic Expected outcome More than expected outcome 0 +1 Receive Receive feedback from at feedback from least 5 parents 10 or more about barriers parents on faced in barriers faced understanding when and accessing understanding the Infant Clinic and accessing the infant clinic (and feedback comes from parents who come to the clinic and parents who noshowed) Much more than expected outcome +2 Receive feedback from 20 or more parents on barriers faced when understanding and accessing the infant clinic (and feedback comes from parents who come to the clinic and parents who noshowed) Goal 2: Complete data analysis in order to understand number of no-shows (NS) and number of patients receiving First Steps (FS) services by time of initial Infant Clinic Evaluation. Much less than expected outcome -2 Complete data analysis for NS rate and FS rate for at least 5 weeks of Infant Clinic Appointments Less than expected outcome -1 Complete data analysis for NS rate and FS rate for at least 5 weeks of Infant Clinic Appointments Expected outcome 0 Complete data analysis for NS rate and FS rate for at least 10 weeks of Infant Clinic Appointments More than expected outcome +1 Complete data analysis for NS rate and FS rate for at least 14 weeks of Infant Clinic Appointments Much more than expected outcome +2 Complete data analysis for NS rate and FS rate for 15+ weeks of Infant Clinic Appointments SUPPORTING PARENT AND INFANT TRANSITION FROM NEONATAL INTENSIVE 65 CARE UNIT TO INFANT CLINIC FOLLOW-UP (during timeline of DCE) BUT there is some missing data (during timeline of DCE) (during timeline of DCE) (during timeline of DCE) (including timeline of DCE) and complete additional data analysis relevant to project Goal 3: Meet with NICU staff to gain feedback about existing Infant Clinic referral process Much less than expected outcome -2 Meet with at least 1 OT and 1 ST from the NICU to gain insight on Infant Clinic referral process (successes and barriers), but contact takes place 25% or less during DCE timeline Less than expected outcome -1 Meet with at least 1 OT and 1 ST from the NICU to gain insight on Infant Clinic referral process (successes and barriers), but do not maintain ongoing communication throughout DCE (contact takes place less than 50% but more than 25% of total weeks) Expected outcome 0 Meet with at least 1 OT and 1 ST from the NICU to gain insight on Infant Clinic referral process (successes and barriers) and contact takes place at least 50% of DCE timeline (7/14 weeks) More than Much more expected than expected outcome outcome +1 +2 Meet with at Meet with at least 1 OT and 1 least 1 OT and ST from the 1 ST from the NICU to gain NICU and 2 or insight on Infant more other Clinic referral NICU process professionals, to (successes and gain insight on barriers) AND at Infant Clinic least 1 other referral process professional in (successes and the NICU related barriers) AND to the discharge maintain process communication on regular basis (~75% of DCE) Goal 4: Identify and implement strategies to increase parent/patient access to infant followup clinic. Much less than expected outcome -2 Identify strategies to reduce barriers Less than expected outcome -1 Identify strategies to reduce barriers Expected outcome 0 Identify strategies to reduce barriers More than expected outcome +1 Identify strategies to reduce barriers Much more than expected outcome +2 Identify strategies to reduce barriers SUPPORTING PARENT AND INFANT TRANSITION FROM NEONATAL INTENSIVE 66 CARE UNIT TO INFANT CLINIC FOLLOW-UP related to infant clinic access, but implement less than 2 and do not involve multidisciplinary solutions (strategies impact therapy department only) related to infant clinic access, but implement less than two during DCE timeline related to infant clinic access (high no-show rate) and implement at least 2 strategies related to infant clinic access and implement at least 2 strategies, involving interdisciplinary collaboration (NICU professionals outside of therapy team) related to infant clinic access and implement more than 2 strategies, involving interdisciplinary collaboration on an ongoing basis, and making strategies sustainability in a way that puts a minimal increase on staff workload after DCE  ...

... Investigation of Risk Factors for Musculoskeletal Disorders in an Obstetrician-Gynecologist and Orthopedic Surgeon Alex Baird, Hailey Brown, Samantha Farmer, Jordan Fiedler, Morgan Rhodes, and Annette Zajac December 13, 2018 A research project submitted in partial fulfillment for the requirements of the Doctor of Occupational Therapy degree from the University of Indianapolis, School of Occupational Therapy. Under the direction of the research advisor: Lucinda Dale, EdD, OTR, CHT, FAOTA A Research Project Entitled Investigation of Risk Factors for Musculoskeletal Disorders in an Obstetrician-Gynecologist and Orthopedic Surgeon 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: Alex Baird, OTS, Hailey Brown, OTS, Samantha Farmer, OTS, Jordan Fiedler, OTS, Morgan Rhodes, OTS, and Annette Zajac, OTS Approved by: Research Advisor (1st Reader) Date 2nd Reader Date Accepted on this date by the Chair of the School of Occupational Therapy: Kate E. DeCleene Huber, OTD, MS, OTR Chair, School of Occupational Therapy Date Running head: RISK FACTORS FOR MSD IN TWO SURGEONS 1 Investigation of Risk Factors for Musculoskeletal Disorders in an Obstetrician-Gynecologist and Orthopedic Surgeon Alex Baird, Hailey Brown, Samantha Farmer, Jordan Fiedler, Morgan Rhodes, Annette Zajac, Lucinda Dale, EdD, OTR, CHT, FAOTA University of Indianapolis RISK FACTORS FOR MSD IN TWO SURGEONS 2 Abstract The purpose of the study was to determine risk factors for musculoskeletal disorders (MSD) in an obstetrician-gynecologist (OB/GYN) surgeon and an orthopedic surgeon. A prospective case series format and mixed method design was used to gather quantitative and qualitative data by using the Rapid Upper Limb Assessment (RULA) to measure MSD risk factors during surgery observation; the Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) to measure upper extremity symptoms and function, reflecting a typical work week for each surgeon; observation of surgeon office hours; and semi-structured interviews with each surgeon. Researchers compared the RULA scores to established exposure levels for MSD risk and interpreted the QuickDASH scores by comparing to normative data. Transcribed interview data were analyzed through open coding, member checking, and organizing data into smaller categories. Three themes emerged from the data: (a) both surgeons had risks for MSD during occupational performance outside of work, (b) both surgeons had risks for MSD during work inside and outside the operating room (OR), and (c) both surgeons had MSD symptoms exacerbated by work tasks. Surgeons had more opportunities to modify MSD risk outside the OR. Keywords: musculoskeletal disorders, obstetrician-gynecologist, occupational therapy, orthopedic, QuickDASH, Rapid Upper Limb Assessment, risk factors, surgeons RISK FACTORS FOR MSD IN TWO SURGEONS 3 Investigation of Risk Factors for Musculoskeletal Disorders in an Obstetrician-Gynecologist and Orthopedic Surgeon Musculoskeletal disorders (MSD), or repetitive strain injuries, are defined as injuries to the musculoskeletal and nervous system as a result of risk factors including overexertion, repetitive motion, awkward or sustained postures, localized pressure, and vibration (Occupational Safety and Health Administration [OSHA], 2017). Common conditions of MSD include carpal tunnel syndrome (CTS) and rotator cuff tears, among others (Roll, 2017). Risk factors address how the body is positioned in space relative to duration, effort, and frequency (OSHA, 2017). These risk factors are typically reduced by altering standing positions, modifying equipment design, and optimizing appropriate breaks (OSHA, 2017). In 2015, MSD accounted for 31% of the total cases of nonfatal occupational injuries requiring days off of work among all workers, making MSD one of the leading causes of absenteeism in the workplace (Bureau of Labor Statistics [BLS], 2016). The estimated annual cost of MSD conditions for medical care and lost wages was $213 billion in 2012 (Weinstein, Yelin, & Watkins-Castillo, 2014). This cost is projected to increase unless there is implementation of evidence-based practice with access to effective interventions and prevention education (Weinstein et al., 2014). Musculoskeletal disorders, caused by risk factors in the workplace, lead to loss of productivity, ultimately costing companies and the government valuable time and money (BLS, 2016). Employers spend approximately $3 billion per year on MSD injuries of the hand and wrist, shoulder, cervical spine, lumbar spine, and knee among state workers (Davis, Dunning, Jewell, & Lockey, 2014). In a systematic review, Long, Bogossian, and Johnston (2013) found prevalence rates of 45%, 40%, and 35%, respectively, for MSD of the neck, shoulder, and upper back among midwives, nurses, and doctors. Risk factors for MSD in surgeons, doctors, and dentists included RISK FACTORS FOR MSD IN TWO SURGEONS 4 prolonged static postures, repetition, awkward and cramped positions, inadequate training, and age (Zeb, Shah, Javed, Darain, & Rahman, 2016). Ruitenburg, Frings-Dresen, and Sluiter (2012) found hospital doctors were unaffected by postures that typically produced fatigue within their work environment, but surgeons that worked in sustained postures were affected by fatigue. Similarly, Cavanagh, Brake, Kearns, and Hong (2012) found dynamic and static postural stresses lead to fatigue and disability in surgical practice. Researchers reported laparoscopic surgeons lacked proper knowledge regarding how their techniques and postures may be contributing to their overuse injuries (Miller, Benden, Pickens, Shipp, & Zheng, 2012). Researchers have not described risk factors for MSD reflecting surgeons' work outside the operating room (OR) or surgeons' nonwork activities. The purpose of this study was to identify risk factors which could lead to MSD for an orthopedic surgeon and an obstetriciangynecologist (OB/GYN) surgeon. Orthopedic surgeons correct problems that arise in the skeleton, including the ligaments and tendons (American Academy of Orthopaedic Surgeons, 2016). OB/GYN surgeons perform surgical operations focusing on disorders associated with the female reproductive system (American College of Surgeons, 2016). Utilizing a prospective case series format, the primary investigator (PI) and occupational therapy student (OTS) researchers completed a comprehensive analysis of risk factors for MSD experienced by two surgeons. Demands of surgical procedures, surgical environment, work beyond operative procedures, and occupations outside of work were considered. Researchers used the Rapid Upper Limb Assessment (RULA) to measure MSD risk factors during surgery and the Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) to measure upper extremity symptoms and function in two surgeons. By identifying risk factors for MSD in surgeons, it is possible to provide a foundation for reducing risk for MSD during all occupational performance. RISK FACTORS FOR MSD IN TWO SURGEONS 5 Literature Review The client factors identified in the literature included gender, age, years of experience, and ergonomic training that contributed to MSD risk factors. Franasiak et al. (2012) and Sutton, Irvin, Zeigler, Lee, and Park (2014) studied differences in symptoms experienced and treatment sought by male surgeons compared to females. Males who had a glove size of 5.5-6.5 reported significantly less shoulder discomfort than females of the same glove size (Sutton et al., 2014). Females who had larger glove sizes of 7-8.5 received treatment for their wrist, thumb, or fingers more often than male surgeons of the same glove size (Sutton et al., 2014). Female gynecologic surgeons who performed minimally invasive surgery (MIS) wore smaller gloves, were shorter in stature, and reported more physical strain than their male counterparts (Franasiak et al., 2012). Researchers have found conflicting results when examining the relationship between age and frequency of MSD (Alzahrani, Alqahtani, Tanzer, & Hamdy, 2016; Batham & Yasobant, 2016; Eleftheriou et al., 2012). Among vaginal surgeons and dentists, those who were younger had a higher frequency of work-related MSD (Batham & Yasobant, 2016; Kim-Fine, Woolley, Weaver, Killian, & Gebhart, 2013). In contrast, results of a survey of 402 orthopedic surgeons showed that the rate of MSD increased as age increased (Alzahrani et al., 2016). Findings on the impact of years of experience on MSD occurrence have been varied (AlQahtani, Alzahrani, & Harvey, 2016; Alzahrani et al., 2016; Franasiak et al., 2012; Kim-Fine et al., 2013; Liang et al., 2013). Among orthopedic surgeons, the number of work-related injuries was significantly higher with those who had been in practice for more than 21 years (Alzahrani et al., 2016). AlQahtani et al. (2016) found that being in practice more than 10 years was associated with an increased number of body regions involved in MSD. Results from two studies indicated surgeons performing laparoendoscopic single-site surgery and urologic procedures via laparoscopy had fewer symptoms as they gained experience with performing the RISK FACTORS FOR MSD IN TWO SURGEONS 6 surgery (Liang et al., 2013; Morandeira-Rivas et al., 2012). Contrasting results were found with vaginal and gynecologic surgeons who performed MIS: those who had fewer years of experience were at higher risk for work-related MSD (Franasiak et al., 2012; Kim-Fine et al., 2013). Formal training in OR ergonomics has not been shown to have significant benefit in reducing occurrence of MSD (Franasiak et al., 2012; Quinn & Moohan, 2015; Vijendren, Yung, Sanchez, & Duffield, 2016). Eighty-three percent of laparoscopic trainees reported receiving training on body positioning and room layout during surgery; however, only 13% understood proper grasps for suturing (Quinn & Moohan, 2015). Although some of the laparoscopic trainees received instruction on proper ergonomics to prevent MSD, 85% still developed a MSD during training, including back, shoulder, and neck pain (Quinn & Moohan, 2015). Similarly, Franasiak et al. (2012) found that only 16% of gynecologic oncology surgeons who performed MIS had received formal training in ergonomics, yet a majority of the surgeons reported symptoms of physical strain. For these surgeons, ergonomic training was limited to body positioning in the OR or the physical environment of the OR (Franasiak et al., 2012). Similarly, Vijendren et al. (2016) found that despite interventions, such as completion of e-learning modules to increase surgeons understanding of ergonomic principles, the impact of ergonomic training on incidence of MSD was unclear. Occupational demands leading to MSD risk factors in the literature included physical environment, sequencing and timing, and surgical tools. Research indicates that older ORs, without the advantages of modernization, led to increased risk of staff injury (Cutner, Stavroulis, & Zolfaghari, 2013). Fixed equipment in older ORs caused staff to maintain awkward positions; cramped rooms restricted movement and led to safety hazards from cables and wires (Cutner et al., 2013). Researchers concluded that modernization of the workplace was crucial in order to prevent injury to surgeons and surgical staff (Cutner et al., 2013). RISK FACTORS FOR MSD IN TWO SURGEONS 7 The development of MSD can be influenced by duration of work and break sessions (Maciel, Millen, Xavier, Morrone, & Silva-Junior, 2012). In 2012, Maciel et al. used a crosssectional design to investigate workplace ergonomics and recommended improvements to reduce fatigue and muscle overuse among colonoscopist doctors. Results indicated a high potential for injury in body structures crucial to the colonoscopy evaluation process, including the wrists, hands, and fingers (Maciel et al., 2012). Results showed significantly dangerous biomechanical factors, that included force of the hand in the clamped position, static positioning of the upper extremity, and forced flexion and extension of the wrist (Maciel et al., 2012). Recommendations to reduce risk factors included placement of furniture, positioning of patients, and the adoption of regular breaks (Maciel et al., 2012). A risk factor shown to contribute to overuse injuries in surgeons is the tool design (Yu et al., 2016). In a study by Gonzalez, Salgado, and Moruno (2015), laparoscopic surgeons used tools with varying handle sizes and then rated the handles based on their ergonomic principles. The results from surgeon ratings indicated that four handle sizes were necessary to accommodate the surgeons hand sizes (Gonzalez et al., 2015). Similarly, Yu et al. (2016) found that wrist position associated with using tools created risk factors for surgeons. Researchers studied the wrist positions of eight surgeons while using four tools to complete tasks during laparoscopic surgeries (Yu et al., 2016). The participants completed specific tasks that simulated surgery and found that the tool requiring neutral wrist position was preferred due to the adjustable handle (Yu et al., 2016). Also, the researchers suggested that tool handles causing wrist flexion and extension more than 15 degrees from neutral increased risk for MSD (Yu et al., 2016). Lee et al. (2014) found that surgeons who used laparoscopic tools had greater cumulative muscle workload from the biceps and flexor carpi ulnaris during surgery as compared to those who used robotic instruments. Muscle activity from the trapezius was greater if surgeons were RISK FACTORS FOR MSD IN TWO SURGEONS 8 new to robotic surgery (Lee et al., 2014). Yu et al. (2016) found that tools impacted performance, but additionally identified experience as influencing physical demands. In a study of female surgeons who used laparoscopy, Sutton et al. (2014) found surgeons' physical symptoms were due to instrument design. In a study conducted by Kavalersky et al. (2015), a redesigned surgical hammer decreased the risk of injury to orthopedic surgeons, and improved surgical performance compared to a standard medical hammer (Kavalersky et al., 2015). Researchers have found that surgeons performance skills can contribute to MSD risk factors. Ruitenburg et al. (2012) recorded the duration and frequency of postures and tasks of general surgeons, internal medicine doctors, and medicine doctors. In comparison with hospital doctors, surgeons performed fine repetitive movements 26 times longer while standing 130% longer (Ruitenburg et al., 2012). The results also indicated surgeons spent 80 minutes using repetitive movements, and hospital doctors only spent three minutes using repetitive movements (Ruitenburg et al., 2012). Due to the longer duration of physically strenuous work, more surgeons reported neck and arm pain along with difficulties coping with job demands (Ruitenburg et al., 2012). High finger exertion associated with wrist postures during surgery has been shown to lead to MSD in surgeons (Maciel et al., 2012). Maciel et al. (2012) measured physical strain, posture, strength of hands, repetition of work, tools used, and job performance of doctors during colonoscopies. After analyzing six 30-minute exams, results indicated that the sustained pincer grip required during the entire colonoscopy was a risk for injury (Maciel et al., 2012). Craven, Franasiak, Mosaly, and Gehrig (2013) evaluated hand and wrist posture, task exposure per day, and exertion through intensity, duration, and speed in five gynecologists. Results indicated that surgeons spent 80% of their workday in the OR (Craven et al., 2013). Surgeons often rushed to RISK FACTORS FOR MSD IN TWO SURGEONS 9 complete their work by using near maximal intensity of exertion, which was potentially hazardous to the gynecologic surgeons (Craven et al., 2013). Researchers have found that the patients positioning often determines the surgeons placement in the OR (Youssef et al., 2011). Researchers compared standing positions and surgical techniques during four simulated laparoscopic colonoscopy procedures and found that the between-standing position and one-handed technique required less effort, frustration, and physical demand as measured by the RULA (Youssef et al., 2011). Another group of researchers found that the conventional positioning of the patient in retroperitoneoscopic upper urinary tract surgery was associated with poor surgical ergonomics because it forced the surgeon to use unbalanced posture and elevated muscular efforts (Fan et al., 2014). The height of the surgical table and positioning of the monitor were contributing factors to MSD risk (Liang et al., 2013; Maciel et al., 2012; Sutton et al., 2014). According to Sutton et al. (2014), 43% of surgeons who completed laparoscopic surgery indicated that their physical symptoms were due to the height of the OR table. Results from Liang et al. (2013) indicated that surgeons had fewer MSD symptoms when the table was at pubic height. Another study showed that surgeons adjusted the table, made accommodations, and positioned themselves in less awkward positions to prevent MSD symptoms (Maciel et al., 2012). Liang et al. (2013) found that neutral head position during surgery was established by controlling monitor height to avoid spinal axial rotation and neck extension. To maintain this position, Liang et al. (2013) recommended that the monitor should be positioned in front of the surgeon and 10-15 degrees below surgeon eye level. During vaginal surgery, the types of chairs used by the surgeons affected their musculoskeletal discomfort (Singh et al., 2016). The results indicated (a) significantly higher discomfort scores for two of the four chairs, (b) no difference in postural loads among the chairs, RISK FACTORS FOR MSD IN TWO SURGEONS 10 and (c) increased comfort when chairs dispersed pressure (Singh et al., 2016). Researchers have shown a positive relationship between body mass index (BMI) of patients and reports of physical strain by surgeons using MIS through laparoscopy (Franasiak et al., 2012). These correlations have not been reported by surgeons performing robotic surgery with MIS, even when patients are obese according to BMI (Franasiak et al., 2012). Researchers investigating MSD risk factors for surgeons have focused their assessments on the OR environment and surgeons' tasks during procedures, yet risks can also arise from work tasks out of the OR and nonwork tasks. Researchers of the current study expanded identification of risk factors for MSD in surgeons by using multiple sources of quantitative and qualitative data. Method Participants In a purposive sample, the PI and OTS researchers recruited one orthopedic surgeon and one OB/GYN surgeon to participate in the study. According to Portney and Watkins (2009, Chapter 14), purposive sampling can yield participants who are effective informants and who meet specific criteria for the study. The PI completed informed consent procedures with both surgeons and enrolled them in the study. Measures RULA. The RULA is an observation tool consisting of a single worksheet, containing diagrams of postures and scoring tables in which researchers and clinicians evaluate posture, force, and repetition for the upper arm, lower arm, wrist, neck, trunk, and leg regions (McAtamney & Corlett, 1993). The RULA is used to measure MSD risk levels on a four-point scale of exertion (McAtamney & Corlett, 1993). The four levels of scoring are defined as: (a) acceptable if not maintained or repeated for long periods (score of one or two); (b) requiring RISK FACTORS FOR MSD IN TWO SURGEONS 11 further investigation, possible changes required (score of three or four); (c) requiring change in the near future (score of five or six); and (d) requiring immediate change (score of seven). The body is divided into two sections in the RULA, and only one side of the body is evaluated at a time; Section A involves the arm and wrist, and Section B involves the neck and trunk (McAtamney & Corlett, 1993). The RULA is a free assessment that does not require a formal training protocol or advanced education in ergonomics; however, researchers or clinicians who plan to use the RULA should use training materials available from the authors to use and score the RULA (McAtamney & Corlett, 1993). Researchers found that occupational therapy students with no RULA training successfully used the RULA to measure risk factors in simulated observations; there were no difference in students scores when compared to those of clinicians (Chen, Falkmer, Parsons, Buzzard, & Ciccarelli, 2014). This finding made the RULA an appropriate choice for the current study as the PI and OTS researchers measured MSD risk factors in surgeons. Although there are no normative data available, researchers have established construct validity and interrater reliability for the RULA (McAtamney & Corlett, 1993). The RULA has yielded valid and reliable results for measurement of MSD risks in hospital-based settings. For example, researchers used the RULA to evaluate posture, force, and frequency, which were variables identified as risk factors for MSD in surgeons during robotic gynecologic oncology procedures (Craven et al., 2013). Similarly, researchers used the RULA to measure standing position (between-standing or side-standing) and hand technique (twohanded or one-handed) during four simulated laparoscopic colonoscopy procedures (Youssef et al., 2011). The results of these studies support the use of the RULA to measure similar risk factors for MSD in the current study. RISK FACTORS FOR MSD IN TWO SURGEONS 12 QuickDASH. The QuickDASH measures the physical function and symptoms in persons with any or multiple MSD of the upper limb through self-rating of items (Beaton, Wright, Katz, & the Upper Extremity Collaborative Group, 2005, p. 1038). The QuickDASH has a Disability/Symptom section and two optional modules, Sports/Performing Arts and Work (Beaton et al., 2005). Each item is self-rated through a Likert scale with scores ranging from one to five. Within the Disability/Symptom section, a score of one means the participant reported none, not at all, not limited at all, or no difficulty as answers (Kennedy, 2011, p. 259). A score of five in the Disability/Symptom section means the client reported unable, extreme, extremely, or so much difficulty that I cant sleep as answers (Kennedy, 2011, p. 259). For the optional modules, a one means the participants reported no difficulty and a five means the participants reported unable (Kennedy, 2011, p. 260). For the Disability/Symptom section, 10 or 11 items need to be answered to be scored (Beaton et al., 2005). The score is found by summing the values for each item and dividing it by the number of responses (Beaton et al., 2005). The value is then subtracted by one and multiplied by 25 to get a score on a scale 0-100 (Beaton et al., 2005). For the optional modules, all items must be rated to calculate a score (Beaton et al., 2005). The value for the optional modules is found by adding the values of the items and dividing the sum by four (Beaton et al., 2005). One is then subtracted from the average of the value and multiplied by 25 to get a score on a scale from 0-100. Lower scores indicate higher function, and higher scores indicate lower function. Researchers and clinicians who use the QuickDASH can use the published guidelines to learn administration and scoring. In the development of the QuickDASH, a Cronbachs alpha of .94 was found, indicating high test-retest reliability (Beaton et al., 2005). Gabel, Michener, Melloh, and Burkett (2010) found high internal consistency with a Cronbachs alpha of .92 for the QuickDASH for individuals with upper extremity MSD. High test-retest reliability was found within three studies RISK FACTORS FOR MSD IN TWO SURGEONS 13 (Gabel et al. 2010; Mintken, Glynn, & Cleland, 2009; Wu, Edgar, & Wood, 2007). Intraclass correlation coefficient (ICC) for the QuickDASH was calculated as .90 (Mintken et al., 2009) and .91 (Gabel et al., 2010). Convergent construct validity for overall problem, overall pain, ability to function, and ability to work was found to be r = .70, r = .73, r = .80, and r = .76, respectively (Beaton et al., 2005). For criterion validity, the QuickDASH had a moderate correlation (r = -.44) with the Short-Form Health Survey (SF-12) for neck and upper extremity MSD (Fan, Smith, & Silverstein, 2008). Also, the QuickDASH had a high correlation with the Disabilities of the Arm, Shoulder and Hand (DASH) (r = .98) for shoulder pain and with the DASH (r = .97) for neck pain (Mehta, MacDermid, Carlesso, & McPhee, 2010; Mintken et al., 2009). Several studies have shown the QuickDASH to be an effective measure of clinical change. According to Beaton et al. (2005), the responsiveness for change in a group of patients undergoing treatment/expected to improve was found to be a standardized response mean (SRM) = 0.79 (p. 1038-1046). Responsiveness for change in those rating their problem as better was found to be SRM = 1.03 (Beaton et al., 2005, p. 1038-1046). Franchignoni et al. (2013) reported 10.83 and 15.91 points as the minimal clinically important difference (MCID) for the DASH and QuickDASH, respectively for patients undergoing physical therapy. Normative data for the DASH can be applied to the QuickDASH due to the similarity of construct validity and responsiveness of the two tools (Hunsaker, Cioffi, Amadio, Wright, & Caughlin, 2002). Normative data for the general US population for DASH Function/Symptom, DASH Optional Sports/Performing Arts Module, and DASH Optional Work Module have been established as 10.1, 9.75, and 8.81, respectively (Hunsaker et al., 2002). QuickDASH was selected to measure physical function and symptoms of upper extremity MSD of the participants RISK FACTORS FOR MSD IN TWO SURGEONS 14 in the study. Information gathered through the QuickDASH provided insight as to which work and nonwork tasks and activities were difficult for the surgeons. Interview. The interview questions for the surgeons were designed by the OTS researchers to gain an understanding of MSD risks during nonwork and work activities not measured by the RULA and upper extremity function and symptoms as measured by the QuickDASH (American Occupational Therapy Association, 2017; Eleftheriou et al., 2012; Epstein, Colford, Epstein, Loye, & Walsh, 2012; Sharan & Ajeesh, 2012; Yoon & Yoon, 2013). The interview consisted of 13 standard questions that were refined based on feedback from an expert panel of occupational therapy faculty at an accredited university, to increase the validity of the interview. Categories of questions included contrast, descriptive, and structural (Stein, Rice, & Cutler, 2013, Chapter 4). (See Appendix). Procedures This study took place in a community hospital for general care. The OTS researchers and the PI, a registered occupational therapist, studied one orthopedic surgeon and one OB/GYN surgeon using a prospective case series format. A mixed method design was used to gather qualitative and quantitative data (Stein et al., 2013, Chapter 4). Researchers observed (a) a right total knee arthroplasty (TKA), (b) revision of a right TKA, and (c) a laparoscopic assisted vaginal hysterectomy with salpingectomy with assistance from a second surgeon. The PI and OTS researchers, who completed seven research-oriented courses, were from an accredited Occupational Therapy Doctorate program. Students were trained to understand The Health Insurance Portability and Accountability Act as part of their coursework. The PI and OTS researchers completed the Collaborative Institutional Training Initiative as required by the Institutional Review Board to protect human subjects. Before data gathering began, the study was approved as exempt by the Institutional Review Board of the University of Indianapolis, as RISK FACTORS FOR MSD IN TWO SURGEONS 15 well as, the Institutional Review Board for the community hospital in which the surgeons were observed. OTS researchers prepared for the interviews of the surgeons by completing a mock interview with the PI. For the RULA, the PI and OTS researchers individually viewed a YouTube video of a total hip arthroplasty with anterior approach to practice administering and scoring. After scoring, the PI and OTS researchers discussed and came to a consensus on scoring to improve interrater reliability. The OTS researchers also reviewed the QuickDASH scoring and normative data individually and collectively. The PI educated the OTS researchers in OR procedures for observers including proper attire, appropriate area to observe, avoidance of intrusion into the sterile field, items allowed in the OR, and communication allowed during procedures. Data Collection The PI confirmed case, time, date, and received each surgeons approval two days prior to the procedure. The PI accompanied one student in the OR, where they each used the RULA to score the right and left upper extremity in one or two observations of each surgeon and recorded observations with field notes. Following the scoring, the PI and OTS researcher compared scores with the remaining OTS researchers to ensure correct scoring. Aside from the risk factors identified using the RULA, researchers recorded frequency, duration, and type of repetitive and sustained gripping and pinching, lateral and tripod pinch, vibratory tools, and air temperature in the OR. Observation of the orthopedic surgeon's office hours occurred to observe risk factors when not performing surgery in the OR. A semi-structured interview for each surgeon took place at the surgeons convenience. Due to unique answers to standard questions from the participants, researchers added questions throughout the interview to gather more information. As an expert in the field, the PI was RISK FACTORS FOR MSD IN TWO SURGEONS 16 present during the interview to ensure clinically relevant data were being gathered. Interviews were completed over the phone with the phone on speaker. Two OTS researchers and the PI were present to conduct the interview for the first interview with the orthopedic surgeon, and one OTS researcher and the PI were present for the second interview with the OB/GYN surgeon. These interviews were recorded using an audiotape, which was later transcribed. OTS researchers recorded handwritten notes during the interview. The QuickDASH was completed by the surgeons at the end of a typical work week because of the instructions to rate items based on symptoms and function during the past week. Surgeons completed the QuickDASH and optional modules and mailed the document to the PI and OTS researchers. To support the validity of findings and document the thought process of all decisions in the data interpretation process, researchers completed an audit trail (Portney & Watkins, 2009, Chapter 14). Data Analysis After configuration of individual Group A and B scoring, the total RULA score was found using Table C; based on an algorithm, the total score was interpreted to determine exposure level to risk factors of MSD. The PI and OTS researchers interpreted the transcribed data through open coding and received approval of accuracy and clarifications from the interviewees. The goal of coding was to dissect the data and rearrange it into categories that facilitated comparison between items in the same category and between categories (Stein et al., 2013, Chapter 4). To enhance interpretive validity, member checking was performed, which involved transcribing the notes following the interview and bringing them back to the interviewee for approval of accuracy (Guba, 1981; Johnson, 1997). OTS researchers and PI classified and categorized data into RISK FACTORS FOR MSD IN TWO SURGEONS 17 similar groups through content analysis; researchers compared and interpreted the data related to other data to provide meaning (Johnson & Christensen, 2014). The data were scored using standardized instructions from the QuickDASH manual. The data scores were then compared to normative data for the QuickDASH and optional modules. OTS researchers made note of items with extreme scores. While completing the two case studies, OTS researchers implemented the process of triangulation, in which multiple methods were used to tabulate and analyze risk factors for MSD for the surgeons (Stein et al., 2013, Chapter 4). These multiple methods, including the use of quantitative tools such as the RULA and QuickDASH, as well as, qualitative methods such as an interview and field notes, allowed for a multiple method analysis of MSD risk factors. Triangulation allowed for the same information to be documented and understood in multiple ways, which increased the validity and trustworthiness of the data analysis (Stein et al., 2013, Chapter 4). The goal of the mixed methods design was to reach data saturation, where all relevant data were retrieved (Stein et al., 2013, Chapter 4). Results Three themes emerged from the data: (a) both surgeons had risks for MSD during occupational performance outside of work, (b) both surgeons had risks for MSD during work in and outside the OR, and (c) both surgeons had MSD symptoms exacerbated by work tasks. Theme A Both surgeons had risks for MSD during occupational performance outside of work. Surgeons described occupations related to instrumental activities of daily living (IADL), work, social participation and leisure that involved child rearing, care of pets, driving and community mobility, home management, meal preparation, volunteer participation, and leisure participation. Both surgeons had spouses and two school-aged children. Child rearing involved transporting RISK FACTORS FOR MSD IN TWO SURGEONS 18 children, participating in childrens sports, and spending time with children. (See Table 1.1 and Table 1.2). Home management and care of pets included lifting and carrying loads by both surgeons: I . . . fed the chickens last night, and so I carried a 40 pound bag of chicken feed 250 feet . . . up and down a hill . . . [I had to] fill buckets [with chicken feed] (Surgeon 1, Lines 46-48). One surgeon cleaned and kept track of pets: I have two dogs and a rabbit that need corralled or cleaned up after. [I least enjoy] real dirty stuff like cleaning out the rabbit cage (Surgeon 2, Lines 36, 38, 62-63). Additional occupations outside of work included volunteer and leisure participation that included repetitive movements of the upper extremity: I coach baseball and soccer, always, sometimes softball . . . I throw at least an hour solid of batting practice about once or twice a week . . . I probably throw on average 200-400 pitches with those kids (Surgeon 1, Line 28-33). The orthopedic surgeon reported spending less time in leisure participation of woodworking compared to the past. Nonetheless, he recognized that the risk factor of vibration through use of tools during this activity was similar to that experienced in his job as an orthopedic surgeon: I do woodworking on the side as well and I may spend four to five hours probably per week, doing things of that nature, which includes use of similar vibratory tools . . . two years ago I would get up around four and . . . work in my woodshop until 6 a.m. and then go into work and then probably come home and . . . if I had the time do some more stuff at night. (Surgeon 1, Lines 99-102) The OB/GYN described child rearing, meal preparation, and gardening as her leisure participation. I most enjoy spending leisure time with my kids . . . cooking when I have the opportunity . . . and outside work like gardening types of activity (Surgeon 2, Line 58-60). She RISK FACTORS FOR MSD IN TWO SURGEONS 19 indicated that she spent 3 hours in the evening and an hour in the mornings so . . . during the week and on weekends it could be around 8 hours a day (Surgeon 2, Line 52-54) doing leisure activities. The OB/GYN surgeon described that yard work and. . . deeper cleaning activities [at home] where Im . . .bending and squatting down and lifting . . .probably affect me in similar areas to where my work does (Surgeon 2, Lines 247; 248). Additionally, she described prolonged standing at home, which combined with work demands to increase her symptoms: I can stand and clean and do laundry and [do tasks] in the kitchen . . .and especially if Ive been at work all day . . .by 10:00 at night Im really feeling pretty old (Surgeon 2; Lines 109-111). The orthopedic surgeons primary concern was his lower back pain that he believed could be from inadequate rest and sleep. However, the surgeon was also frequently involved in other IADLs around the home that may contribute to symptoms. The orthopedic surgeon described meal preparation as enjoyable leisure participation. Lawn care, as part of home management, was considered a leisure activity; however, he explained he no longer completed this task. I actually enjoy mowing the grass . . . when I get the chance to, but its a three and a half hour process, so I dont do it any longer (Surgeon 1, Lines 70-71). He stated that he experienced MSD symptoms in multiple activities, such as CTS symptoms of numbness and tingling while mowing the grass and arthritis in his right hand. He reported monitoring his arthritis symptoms and believed they resulted from pinching and other IADL. In addition, he stated, if I put my shoulder back [and] lean my head far back my arms go to sleep (Surgeon 1, Lines 185-186). In reference to woodworking, the surgeon described being pretty good about being ergonomic (Surgeon 1, Line 92). He was aware that his woodworking resulted in muscular fatigue, reporting that his hands got tired when carving wood. On the QuickDASH, both surgeons reported mild difficulty with heavy household chores, recreational activities, and sleep. The OB/GYN surgeon also reported mild difficulty with RISK FACTORS FOR MSD IN TWO SURGEONS 20 opening a tight or new jar and slight limitation in performing daily activities outside of work. The orthopedic surgeon rated himself as having severe difficulty with bathing his back and rated his social participation as slightly limited. In contrast, the OB/GYN surgeon reported no limitation in social activities. The orthopedic surgeon identified baseball and woodworking as two activities on the Sports and Performing Arts modules of the QuickDASH with a score of 25, reflecting disability greater than the normative value of 9.25 (Figure 2.1). No sports or performing arts activities for the OB/GYN were reported. The orthopedic surgeon and OB/GYN surgeon scored 20.45 and 13.64 on the QuickDASH, respectively, with the normative value of 10.10 (Figure 2.2). Theme B Both surgeons had risks for MSD during work in and outside the OR. Surgeons varied in time spent performing scheduled OR procedures with the OB/GYN spending 8 hours a week and the orthopedic surgeon spending 15-20 hours per week (Figure 3.1 and Figure 3.2). Surgeries observed for the current study were 60-70 minutes with a temperature of 64F. The environment during all surgeries was relaxed, and casual conversation among professionals occurred with several instances of staff entering and exiting the OR. During one procedure, the lights were dimmed by the circulating nurse to visualize the monitor screen better. Both surgeons reported differences in surgical task demands based on their positioning relative to: (a) the type and location of surgical procedure for the patient, (b) surgeon hand dominance, and (c) characteristics of the patient. For example, the orthopedic surgeon preferred a right THA rather than a left THA due to hand dominance and having to move [himself into] position on a left hip more than a right hip (Surgeon 1, Lines 174-176). The OB/GYN surgeon preferred to be perpendicular to the patients left side due to hand dominance and directing surgical instruments. For the orthopedic surgeon, revision of total joints was described as more RISK FACTORS FOR MSD IN TWO SURGEONS 21 demanding because of awkward postures and longer duration of standing, whereas for the OB/GYN surgeon, vaginal surgeries were more demanding due to the required tugging and pulling (Surgeon 1, Lines 162-163; Surgeon 2, Line 205). Larger patients with more scar tissue required more muscle power and torque with surgical instruments. During the procedure, the orthopedic surgeon commented on surgeons disease in reference to sustained neck flexion during operative procedures (Surgeon 1, Line 187). Task demands during surgery for both surgeons were also influenced by: (a) types of instruments used, (b) types of hand use needed to use instruments, (c) scheduling of procedures, and (d) breaks during procedures. For example, the orthopedic surgeon, unlike the OB/GYN, frequently used vibratory tools. Gripping and manipulating were repetitive and sustained during the procedures and included composite grip, pistol grip, tip pinch, palmar pinch, hook grip, cylindrical grip, and lateral pinch. Resisted thumb extension also occurred to use dissection scissors and to perform suturing that required resistive finger flexion with end-range extremes of wrist and forearm positions. The orthopedic surgeon often used his left hand as a stabilizer and occasionally utilized his right hand as a hammer. The orthopedic surgeon was scheduled to complete several consecutive surgeries using neighboring ORs with no breaks between procedures. One unexpected delay for TKA procedure was observed because lab results were not available. Mixing of cement during TKA required a two minute pause during the procedure. Both surgeons rested upper extremities on patients with the orthopedic surgeon demonstrating fewer and shorter breaks in comparison to the OB/GYN. For the left and right sides of both surgeons, the RULA score was a seven during surgery, which is the highest possible score indicating a need to assess and implement a change (McAtamney & Corlett, 1993). Positions of highest MSD risk for both surgeons included lower arm, neck, and wrist twist, with an addition of neck position for the orthopedic surgeon and trunk RISK FACTORS FOR MSD IN TWO SURGEONS 22 position for the OB/GYN surgeon. For the leg score, both surgeons scored the lowest possible score. Both surgeons scored higher than the QuickDASH work module (optional) normative value of 8.81, with the orthopedic surgeon scoring 12.5 and the OB/GYN surgeon scoring a 25 (Figures 1.1 and 1.2). Scores indicated that both surgeons experienced decreased function related to use of their upper extremities during work. Both surgeons worked outside of the OR meeting with scheduled patients, documenting operative procedures and office visits, using the computer to review patient charts, and fulfilling scheduled on-call hours at the hospital. In a single week, the time worked in addition to surgery was 60-70 hours for the orthopedic surgeon and 40-50 hours for the OB/GYN surgeon (Figure 3.1 and Figure 3.2). The OB/GYN surgeon described her routine as being on-call one night a week and every sixth weekend. After working a full day, a typical on-call routine included staying in the hospital to either sleep, work, or chart, followed by another full day of work for the OB/GYN surgeon. The OB/GYN surgeon used a documentation template and dictated typical cases handsfree on the phone for 60-70% of her cases. She used tablets for documentation three days a week for 3 hours a day, and after work hours she used a desktop computer. She indicated she used an external mouse for comfort and had difficulties using her dominant hand and forearm during documentation. The orthopedic surgeon indicated that he spent 15-20 minutes of documentation per person, (Surgeon 1, Line 62; 64-65), which was mostly completed using a hands-free dictaphone. To complete all documentation, he completed 2 to 3 hours of computer work at home (Surgeon 1, Lines 55-56; 121-123) each work night, 6 hours on a tablet with keyboard attached at work, and another hour on his cell phone. The orthopedic surgeon reported his worst posture as occurring during office hours with examinations of scheduled patients. He explained that during exams, he placed his laptop on his RISK FACTORS FOR MSD IN TWO SURGEONS 23 thighs and used a rolling stool with no back support. He also reported lifting or palpating extremities from a seated position that caused neck flexion, hip flexion, and reversal of normal spinal curvatures. The surgeon explained that he recognized his postures were poor and resulted in lower back and neck pain, but he used them to create a more informal atmosphere for the patient. The PI observed sustained and awkward postures and positioning outside of examination rooms of the orthopedic surgeon. During office hour observation, the surgeons laptop was positioned on top of the counter about waist height, requiring 90 degree elbow flexion, sustained neck flexion of 20 to 40 degrees, sustained wrist extension of 20 to 40 degrees, and a neutral thoracic spine. He used a cell phone to make phone calls and to text while using both hands with sustained neck flexion. Theme C Both surgeons had MSD conditions and/or symptoms exacerbated during work tasks for which they received past or current treatment. The OB/GYN surgeon described seeking treatment for her diagnosis of right lateral epicondylitis by receiving site injections to alleviate pain. When asked what made her symptoms worse, she replied, I cant even say that its just surgery that aggravates it because I feel like the computer stuff can aggravate it just as much (Surgeon 2, Lines 189-190). She also described foot and leg pain, as well as, bunions that were definitely more painful after standing for prolonged periods of time (Surgeon 2, Lines 181182). The OB/GYN indicated she did not do a good job utilizing her nondominant hand and stated that her neck pain is almost always on the right (Surgeon 2, Lines 183-184). When asked what made her symptoms better she replied, rest makes it better. So if I have a prolonged RISK FACTORS FOR MSD IN TWO SURGEONS 24 period of time off . . . at least two-three days then when I go back on Monday its much better (Surgeon 2, Lines 188-189). The orthopedic surgeon experienced lower back and neck pain due to awkward and sustained postures during patient examinations. He described hip pain as more sacroiliac pain due to prolonged standing. The orthopedic surgeon also recognized improved posture while sitting at home with computer use: It is a big Mac . . . . [and has a] big screen so I am sitting back comfortably [when I use it] (Surgeon 1; Lines 126-127). Surgeons reduced demands on the body primarily for work related tasks. The OB/GYN surgeon stated that she had a limited modification ability in OR so it was important to make modifications outside the OR (Surgeon 2, Lines 257-258). Both surgeons indicated ergonomic changes that could be made to reduce their own risk factors; the OB/GYN surgeon had made ergonomic changes to her office work area including use of mobile tables, but she described these to be a little cumbersome and I havent really taken to using [those] (Surgeon 2, Lines 166-167). Both surgeons described their preferences for using desktop computers, as contrasted by laptops, cell phones, or tablets, because of reduced musculoskeletal discomfort during documentation or chart review. The orthopedic surgeon planned to purchase a new desk chair to improve posture while completing computer work tasks at home. One surgeon was selfmonitoring MSD in his arthritic right hand. Discussion Risks for MSD in the OR were similar to those reported by other researchers with most risks unable to be modified. Similar to the findings of Ruitenberg et al. (2012), the surgeons in this study had (a) abducted arms, (b) fixed and forward cervical spines that occasionally included rotation, (c) consistent static loads inflicted on shoulders and neck regions, and (d) long-term fixed lower back postures during surgery. In contrast to the findings of Ruitenberg et al. (2012), RISK FACTORS FOR MSD IN TWO SURGEONS 25 the surgeons in this study used asymmetric postures. Additionally, the orthopedic surgeon experienced sustained and awkward postures during work outside the OR, which researchers have not described. Other researchers have not shown highest scores on the RULA based on observation of TKA revision or laparoscopic assisted vaginal hysterectomy with salpingectomy surgery as was shown in the current study. Studies also have not shown the greatest risk of MSD resulting from upper body positioning during these procedures, as was observed in the current study. Similar to Craven et al. (2013), the researchers in the current study used the RULA that confirmed MSD risk during operative procedures. In contrast, Craven et al. (2013) measured risk factors during robotic surgery and did not report awkward postures observed and/or reported by surgeons while using technology and examining patients outside of the OR. The latter findings in the current study showed additional MSD risk related to posture for surgeons when completing work tasks outside of the OR. Similar to researchers reports, repetitive movements and exertion were observed as risk factors within the OR in the current study (Batham & Yasobant, 2016; Maciel et al., 2012). The identification of repetitive movement and exertion outside of the OR in this study provided additional depth to current MSD risk factor research for surgeons, and is similar to findings for other professions. In a study completed by Zeb et al. (2016), risk factors for MSD were found to be prevalent among surgeons, doctors, and dentists. Although the participants in the current study were surgeons, their work outside of the OR included prolonged static postures, repetition, and awkward and cramped positions that could lead to MSD, similar to other professionals (Zeb et al., 2016). During observation of surgeons in the current study, 1-2 minute spontaneous pauses during surgical procedures could have been used to regain neutral stance and correct head, neck, and trunk flexion. Although the researchers observed these brief pauses, there were no RISK FACTORS FOR MSD IN TWO SURGEONS 26 opportunities for prolonged rest breaks, a recommendation based on findings of Maciel et al. (2012). Lack of rest breaks during physically strenuous work could lead to neck and arm pain, symptoms that were reported by both surgeons and findings that were in accordance with Ruitenburg et al. (2012). Similarly, Maciel et al. (2012) found that short periods of rest were available between operative cases, however, surgeons did not use these periods for reduction of MSD risk. The OB/GYN surgeon in the current study stated that rest made her symptoms decrease, supporting the recommendation for regular rest breaks in the literature (Maciel et al., 2012). Although Gutierrez-Diez et al. (2018) recommended that breaks should be up to 5 minutes for every 2 hours of surgical intervention, it is unclear if the surgeons in the current study would be able to include these scheduled breaks as none were observed during data collection. Consistent with the literature, both surgeons in this study explained that a more strenuous day led to experiencing more MSD related symptoms (Ruitenburg et al., 2012). Likewise, surgeons identified patient size as one factor that increased task demands during operative procedures (Franasiak et al., 2012). In contrast to the literature, surgeons in this study also identified revisions of total joints and scar tissue as patient factors that increased task demands. Franasiak et al. (2012) found a positive relationship between BMI of the patient and physical strain reported by surgeons who performed laparoscopic procedures. The results indicated increased reports of strain when sustained and awkward positions were necessary (Franasiak et al., 2012). It is likely that the orthopedic surgeon in this study frequently operated on a patient who was overweight or obese during TKA and THA procedures, as Suleiman et al. (2012) found that 90% of TKA patients and 77% of THA patients were overweight or obese. The OB/GYN in the current study described that performing vaginal delivery led to the most musculoskeletal symptoms because the positioning required her to use her upper body in sustained postures with RISK FACTORS FOR MSD IN TWO SURGEONS 27 high exertion. Although researchers have reported MSD risk factors for OB/GYNs during laparoscopic procedures, risk factors for vaginal deliveries have not been reported (Craven et al., 2013). Gonzalez et al. (2015), Kavalersky et al. (2015), Sutton et al. (2014), and Yu et al. (2016) studied types, sizes, and handle angles of surgical instruments, and made recommendations for modifications or replacement with new instruments to reduce MSD risks. In contrast, researchers in the current study found that risk factors arose from the use of instruments which included sustained and awkward postures, and sustained and repetitive grip and pinch. Only some of these risks were measured by the RULA, confirming the value of additional detailed observations of task demands related to surgical instrument use to understand MSD risk more completely. Task demands of surgical procedures may make it difficult or impossible to consider alternate instruments or change in how current instruments are used to reduce MSD risk. Prior to this study, researchers have not used the QuickDASH to measure physical function and symptoms for MSD in surgeons (Beaton et al., 2005, p. 1038), yet both surgeons had disability greater than the normative value for the work module. It is possible that completion of the QuickDASH increased surgeon awareness of risk factors for MSD of the upper extremity, but this cannot be confirmed. Surgeons in the current study more often attributed MSD symptoms and decreased work performance to demands of work, however, roles and tasks outside of work may be part of the cause, as risk factors for development of MSD can occur during all tasks and in all contexts. It is also possible that surgeons rated items on the work module based on performance of work in the OR, not necessarily outside of the OR which could result in a more narrow view of work performance. RISK FACTORS FOR MSD IN TWO SURGEONS 28 In the current study, task demands during work outside the OR and during nonwork tasks demonstrated MSD risks. In contrast, researchers investigating MSD risk factors for surgeons have focused their assessments on the OR environment and surgeons' tasks in the OR (Ruitenberg et al., 2012; Zeb et al., 2016). In the current study, risk factors for MSD were found outside of the OR and outside of work tasks; both surgeons had diagnosis of MSD and disability greater than the normative data of the QuickDASH. A study by Sacouche, Morrone, & SilvaJnior (2012) indicated hospital workers whose occupation of work entails the IADL of home establishment (laundry) were affected by MSD. Although surgeons were not participants in the study, it showed the prevalence of MSD risk factors such as repetitive movements, awkward postures, and exertions in one IADL, which could occur in the surgeons roles as parent, spouse, home manager, and pet owner (Sacouche et al., 2012). The surgeons identified tasks within their occupations that had potential to make them symptomatic or already had caused symptoms, but were unable to determine risks in all occupations completed. Although researchers have not described risk factors for surgeons outside of work, risk factors for MSD were possible across contexts and roles. Data from the Centers for Disease Control indicated that among individuals with MSD conditions, activities of daily living (ADL) were self-reported as the most difficult to perform compared to other occupations (Weinstein et al., 2014). This finding was similar to surgeons reports in the current study, as the orthopedic surgeon reported that his most difficult task was washing his back, which he rated severely difficult. Moreover, ADL and IADL participation could contribute to MSD symptoms, but are often perceived to be work-related (Sacouche et al., 2012; Weinstein et al., 2014). Surgeons had more opportunities to modify MSD risk factors during work outside the OR, and during nonwork tasks because of greater control over decisions to use technology and RISK FACTORS FOR MSD IN TWO SURGEONS 29 perform tasks, with less reliance on others. Yet, the literature does not address surgeons opportunities to reduce risk factors across all contexts and roles. Opportunities for modifications outside of the OR included improving posture and reducing loads on upper extremities during patient examinations by standing and moving closer to patients for the orthopedic surgeon. In addition the orthopedic surgeon could use a more neutral stance with reduced head and neck flexion during use of the computer. It could have been that the OB/GYN surgeons use of mobile tables during patient examinations would reduce MSD risk, but this could not be confirmed. Sleep postures and documentation during on call work for the OB/GYN could have also produced MSD risk but these were not observed. Because surgeons had more control over, and more opportunities for modifications outside of the OR, these modifications are even more important for decreasing the cumulative impact of MSD risk factors (Alzahrani et al., 2016). Outside of work the orthopedic surgeon described occupations that had risks for MSD, including using vibratory tools for woodworking, lifting loads while caring for pets, and throwing a softball repetitively. Additionally, the orthopedic surgeon continued computer work at home to review patient charts and complete documentation. The OB/GYN lifted loads and used awkward and sustained postures during home management and care of pets outside of work. Reducing risks during these occupations would likely be more feasible and reduce the cumulative effect of MSD risk for both surgeons. It was less feasible to modify tasks in the OR due to positioning of equipment, time frames for completion of surgical procedures, location and task performance of other personnel, and location and maintenance of the sterile field. Altering position of the monitor to use a more symmetric head position may have been possible during one procedure, but this was only discussed with one surgeon, and was not attempted. Eliminating use of hand for hammering was discussed with one surgeon who agreed that using instruments instead would reduce stress. It is RISK FACTORS FOR MSD IN TWO SURGEONS 30 also possible that surgeons could use pauses more intentionally to rest upper extremities and regain neutral postures. Surgeons did not describe the value of reducing MSD risks across occupations that would improve occupational performance for all occupations. Instead, surgeons expressed awareness of what tasks exacerbated symptoms. Similar to results of Miller et al. (2012) it is possible the surgeons of this study lacked the knowledge to reduce the MSD risk factors during surgeries. In contrast to Miller et al. (2012), the researchers of this study found they also may have lacked knowledge in reduction of risk factors for occupations outside of work and work outside of the OR, however, this cannot be confirmed as researchers did not have opportunities to discuss these in detail. In the QuickDASH, the orthopedic surgeon reported more disability when compared to the OB/GYN surgeon. However, the OB/GYN surgeon reported more disability on the QuickDASH work module. Only indirect comparisons can be made to Franasiak et al. (2012) who found that female surgeons performing gynecologic surgery reported more physical strain than did males. Contrary to Franasiak et al. (2012), the OB/GYN surgeon also described deliveries, not necessarily surgery, as causing physical strain. The OB/GYN sought treatment for her symptoms, in alignment with reports from Sutton et al. (2104) who found that female surgeons more often received treatment compared to their male counterparts. The male surgeon in the current study opted to self-manage his symptoms. Different decisions on managing symptoms could be explained by surgeons unique expertise and knowledge of their conditions, but this was not confirmed. Surgeons rarely described modifications to reduce risk factors across occupations; modifications they described included work tasks, not nonwork tasks. Similar to researchers findings (Franasiak et al., 2012), the surgeons within the current study showed initiative to RISK FACTORS FOR MSD IN TWO SURGEONS 31 reduce some risk factors for MSD, but these were few and limited to work tasks. The surgeons did not describe the value of making modifications of nonwork tasks to reduce MSD risk. Although one surgeon described making modifications to reduce risk factors for continuing work on the computer at home, it is unclear if the surgeon recognized this modification as a method to reduce risk factors for nonwork tasks on the computer. This lack of recognition is consistent with the literature, where researchers have not described modifications to reduce MSD risk during nonwork tasks and tasks outside of the OR for surgeons. Limitations Both surgeons received the highest exposure level for MSD risk as measured by the RULA before the surgical procedures were completed; additional risk factors were observed after the highest score was obtained, demonstrating that a ceiling effect was reached on the RULA (Portney & Watkins, 2009, Chapter 14). Not all risk factors nor the number of those risk factors were measured by the RULA. Another limitation was that researchers did not observe on-call work for either surgeon and only observed office hours for the orthopedic surgeon, relying on self-reports of their actions. Additionally, researchers relied on surgeons descriptions of nonwork activities and work outside of the OR rather than observations of these activities. This could have produced inaccurate reports of MSD risk. Regarding the results of the QuickDASH, the surgeons could have rated themselves on one aspect of work rather than on all aspects of work. Therefore, the results given by the surgeons in the work module may be narrowed to more operative work rather than considering other aspects of their work occupation. Researchers conducted only one interview with each surgeon, limiting the opportunity to ask additional questions following analysis of the data and preventing data saturation. The prospective case series design used in this study yielded in depth and specific data for MSD risks for two surgeons, preventing generalization of the findings to other surgeons. RISK FACTORS FOR MSD IN TWO SURGEONS 32 Conclusions As a result of this study, researchers identified three themes related to two surgeons and risk factors for MSD across all occupations. Both surgeons had risks for MSD during occupational performance outside of work, had risks for MSD during work that included work inside and outside the OR, and had opportunities to reduce MSD risk, with greater opportunities outside the OR. These findings confirm that MSD risk factors for one orthopedic surgeon and one OB/GYN surgeon resulted from work in and outside of the OR, as well as, outside of work. Researchers who have studied risk factors for MSD among surgeons have limited their data collection and analyses to work in the OR or have concluded that work tasks can explain MSD risk. Likewise, researchers have attributed MSD exacerbation to surgeons lack of modifying work performance in the OR. The findings of this study indicate that MSD risks occur during all aspects of work for surgeons and during occupations outside of work, filling a gap in the literature. Moreover, there are more opportunities to reduce MSD risk outside of the OR, highlighting the importance of a more comprehensive understanding of MSD risk across roles and contexts. Considering risk factors across all occupations, especially nonwork related tasks, presents a greater opportunity to modify the environment and tasks to reduce and prevent MSD symptoms and increase surgeon performance. Recommendations Researchers should gather data in multiple roles, environments, and occupations to ensure risk factors of MSD are being analyzed comprehensively for orthopedic and OB/GYN surgeons. Due to the ceiling effect of the RULA in the current study, researchers should seek out alternative or additional assessment tools to identify MSD risks in the OR more thoroughly. Additionally, researchers should observe occupational performance outside of the OR and outside of work to identify MSD risk factors. RISK FACTORS FOR MSD IN TWO SURGEONS 33 Occupational therapists who provide services for orthopedic and OB/GYN surgeons should identify MSD risks across all occupations to prevent and/or reduce MSD risk and MSD conditions. Occupational therapists should also educate orthopedic and OB/GYN surgeons on the importance of recognizing and reducing MSD risk outside the OR and outside work occupations. Orthopedic and OB/GYN surgeons should recognize and use brief breaks during and in between surgical procedures to correct postures and reduce other MSD risks. If applicable, surgeons should collaborate with OR staff to modify scheduled procedures to achieve better distribution of demanding surgeries. 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P., Millen, R. A. M., Xavier, C. A., Morrone, L. C., & Silva-Junior, J. S. (2012). Musculoskeletal disorders related to the work of doctors who perform medical invasive evaluation. Work: A Journal of Prevention, Assessment, & Rehabilitation, 41(Supplement 1), 1860-1863. doi:10.3233/WOR-2012-0398-1860 McAtamney, L., & Corlett, E. N. (1993). RULA: A survey method for the investigation of work-related upper limb disorders. Applied Ergonomics, 24(2), 91-99. https://doi.org/10.1016/0003-6870(93)90080-S RISK FACTORS FOR MSD IN TWO SURGEONS 39 Mehta, S., MacDermid, J. C., Carlesso, L. C., & McPhee, C. (2010). Concurrent validation of the DASH and the QuickDASH in comparison to neck-specific scales in patients with neck pain. Spine, 35(24), 2150-2156. doi:10.1097/BRS.0b013e3181c85151 Miller, K., Benden, M., Pickens, A., Shipp, E., & Zheng, Q. (2012). Ergonomics principles associated with laparoscopic surgeon injury/illness. 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Does BMI affect perioperative complications following total knee and hip arthroplasty? Journal of Surgical Research, 174(1), 7-11. doi: 10.1016/j.jss.2011.05.057 Sutton, E., Irvin, M., Zeigler, C., Lee, G., & Park, A. (2014). The ergonomics of women in surgery. Surgical Endoscopy, 28(4), 1051-1055. doi:10.1007/s00464-013-3281-0 RISK FACTORS FOR MSD IN TWO SURGEONS 41 United States of America, U.S. Department of Labor, Occupational Safety and Health Administration. (2017). Ergonomics. Retrieved from https://www.osha.gov/SLTC/ergonomics/identifyprobs.html Vijendren, A., Yung, M., Sanchez, J., & Duffield, K. (2016). Occupational musculoskeletal pain amongst ENT surgeons- Are we looking at the tip of an iceberg? The Journal of Laryngology & Otology, 130, 490-496. doi.org/10.1017/S0022215116001006 Weinstein, S. I., Yelin, E. H., & Watkins-Castillo, S. I. (2014). Table 1.5.2: Self-reported limitations in activities of daily living for persons due to select medical conditions by age, United States 2012. In U.S. Bone and Joint Initiative, The burden of musculoskeletal diseases in the United States: Prevalence, societal and economic cost (3rd ed.). Rosemont, IL: American Academy of Orthopaedic Surgeons. Retrieved from http://www.boneandjointburden.org/ docs/T1.5.2.pdf Wu, A., Edgar, D. W., & Wood, F. M. (2007). The QuickDASH is an appropriate tool for measuring the quality of recovery after upper limb burn injury. Burns, 33(7), 843-849. http://dx.doi.org/10.1016/j.burns.2007.03.015 Yoon, T., & Yoon, J. (2013). Effect of working position on the perceived fatigue while drilling on the ceiling. Journal of the Ergonomics Society of Korea, 32(6), 549-555. http://dx.doi.org/10.5143/JESK.2013.32.6.549 Yu, D., Lowndes, B., Morrow, M., Kaufman, K., Bingener, J., & Hallbeck, S. (2016). Impact of novel shift handle laparoscopic tool on wrist ergonomics and task performance. Surgical Endoscopy, 30(8), 3480-3490. doi:10.1007/s00464-015-4634-7 Youssef, Y., Lee, G., Godinez, C., Sutton, E., Klein, R. M., George, I., Park, A. (2011). Laparoscopic cholecystectomy poses physical injury risks to surgeons: Analysis of hand RISK FACTORS FOR MSD IN TWO SURGEONS technique and standing position. Surgical Endoscopy, 25(7), 2168-2174. doi:10.1007/s00464-010-1517-9 Zeb, A., Shah, W., Javed, F., Darain, H., & Rahman, M. U. (2016). Prevalence of work related musculoskeletal disorders among physicians, surgeons and dentists at tertiary care hospitals of Peshawar. Annals of Allied Health Sciences, 2(1), 105-109. http://dx.doi.org/10.13075/mp.5893.00142 42 RISK FACTORS FOR MSD IN TWO SURGEONS 43 Table 1.1 Occupational Profile of the Orthopedic Surgeon Occupational Profile: Orthopedic Surgeon 40 Age 13 Years of Experience Right total knee arthroplasty (R TKA) and revision of R TKA Surgery Observed Home management, care of pets, child rearing, volunteer, Risk Factors in Occupations leisure participation, rest and sleep Parent, home manager, pet owner, spouse, coach, Roles woodworker, cook, surgeon Repetitive movement; awkward and sustained postures; Risk Factors Identified vibration; positioning; lack of rest; sustained and repetitive grip and pinch Table 1.2 Occupational Profile of the Obstetrician/Gynecologist Surgeon Occupational Profile: Obstetrician/Gynecologist Surgeon 43 Age 16 Years of Experience Laparoscopic assisted vaginal hysterectomy with salpingectomy Surgery Observed Risk Factors in Occupations Roles Child rearing, care of pets, home management, meal preparation, leisure participation Parent, home manager, pet owner, spouse, gardener, surgeon Risk Factors Identified Repetitive movement; sustained and awkward postures; positioning; patient size; lack of rest; sustained and repetitive grip and pinch RISK FACTORS FOR MSD IN TWO SURGEONS Figure 2.1 Comparison of Orthopedic Surgeon Scores of QuickDASH to Normative Data Figure 2.2 Comparison of Obstetrician/Gynecologist Surgeon Scores of QuickDASH to Normative Data 44 RISK FACTORS FOR MSD IN TWO SURGEONS Figure 3.1 Percentage Time Use in Single Week for Orthopedic Surgeon Figure 3.2 Percentage Time Use in Single Week for Obstetrician/Gynecologist Surgeon 45 RISK FACTORS FOR MSD IN TWO SURGEONS 46 Appendix Interview of Surgeons 1. Please describe the following: a. your age b. number of years working as a surgeon c. number of hours working weekly performing surgery d. number of hours working weekly beyond performing surgery 2. Describe your roles beyond the role of surgeon. (For example, parent, spouse, friend, colleague, caregiver). Describe the musculoskeletal demands, if any, that are associated with these roles. 3. Describe your activities during a typical non-work day. (For example, leisure, rest, sports, home maintenance). How much time do you spend on these activities? 4. Describe what you most and least enjoy doing when you arent at work, and why. 5. Do you perform non-work tasks that are similar to tasks performed during surgery? If yes, please describe. (For example, prolonged standing, fine motor, close visual work, awkward and/or sustained positions, use of tools) Do these tasks produce musculoskeletal symptoms? If yes, please describe. 6. Describe how non-work activities are different or the same now compared to 5 years ago. 7. Tell us how work activities are different or the same now compared to 5 years ago. 8. What kind of technology do you use at work when not completing surgical procedures? (For example, cell phone, laptop, tablet). How often and for how long do you use this technology? 9. What kind of technology do you use when not at work? (For example, cell phone, laptop, tablet). How often and for how long do you use this technology? 10. Do you currently have musculoskeletal symptoms? If yes, describe location and symptoms. What makes your symptoms better or worse? 11. Describe your surgery schedule. (For example, how many and what types of surgeries are scheduled weekly? How many and what types of surgeries do you perform when on call?) 12. Describe what you believe is most demanding on your body as a result of performing surgical procedures. Are there surgical procedures that are more or less demanding on your body than others? If yes, please describe. 13. Describe what you believe is most demanding on your body as a result of non-work activities.  ...

... 1 Scapular Dyskinesis and Physical Activity in Healthy College Students Contessa Brown, Kathryn Kittaka, Stefani Manchick, Kayla Olson, Jennifer Schepers, & Samantha Wallenberg December 13, 2019 A research project submitted in partial fulfillment for the requirements of the Doctor of Occupational Therapy degree from the University of Indianapolis, School of Occupational Therapy. Under the direction of the research advisor: Lucinda Dale, EdD, OTR, CHT, FAOTA 2 A Research Project Entitled Scapular Dyskinesis and Physical Activity in Healthy College Students Submitted to the School of Occupational Therapy at the University of Indianapolis in partial fulfillment for the requirements of the Doctor of Occupational Therapy degree. By: Contessa Brown, OTS, Kathryn Kittaka, OTS, Stefani Manchick, OTS, Kayla Olson, OTS, Jennifer Schepers, OTS, & Samantha Wallenberg, OTS Approved by: Research Advisor (1st Reader) Date 2nd Reader Date Accepted on this date by the Chair of the School of Occupational Therapy: Kate E. DeCleene Huber, OTR, MS, OTD Chair, School of Occupational Therapy Date 3 Abstract The primary purpose of this study was to quantify healthy college students scapula movement through the use of the Scapular Dyskinesis Test (SDT) and physical activity levels through the use of the International Physical Activity Questionnaire (IPAQ). The secondary purpose was to determine if there was a relationship between SDT and IPAQ scores. The investigators used a prospective, quantitative design and gathered data from 54 participants. Results showed that more than half of the participants had normal scapular ratings and high physical activity levels; however, more than 40% showed asymptomatic subtle or obvious dyskinesis in one or both of the scapula. Total hours of daily sitting exceeded hours that students were active. There were no significant relationships between the SDT and IPAQ. Sitting hours were similar among SDT and IPAQ scores. Participants were predominantly female graduate occupational therapy (OT) and physical therapy students; the majority of participants were employed. Participants could be at an increased risk for musculoskeletal disorders (MSD) and impaired occupational performance due to asymptomatic scapular dyskinesis. Participants with high IPAQ scores may misperceive that physical activity ensures normal scapulohumeral rhythm. Although the IPAQ can yield objective measures of physical activity, it is not a measurement of specific muscle function that impacts scapular dyskinesis. Clinicians and researchers can use the SDT as a screening tool to determine the presence of scapular dyskinesis in healthy college students. Keywords: scapulohumeral rhythm, International Physical Activity Questionnaire (IPAQ), fatigue, range of motion (ROM), sedentary lifestyle 4 Scapular Dyskinesis and Physical Activity in Healthy College Students The scapula is a stable base for glenohumeral (GH) joint mobility in a healthy shoulder (Kanik et al., 2017). The serratus anterior (SA), upper trapezius (UT), lower trapezius (LT), and middle trapezius (MT) are the most important muscles for positioning of the scapula and are the main contributors to scapular movement during scapulohumeral rhythm (Castelein, Cagnie, Parlevliet, & Cools, 2016a; Castelein, Cools, Parlevliet, & Cagnie, 2016; Fedorowich, Emery, Gervasi, & Ct, 2013). Scapulohumeral rhythm is the combination of GH motion and scapular upward rotation resulting from muscle contraction at the GH and scapulothoracic (ST) joints during shoulder elevation (Greene & Roberts, 2015, Chapter 8). Normal scapulohumeral rhythm occurs when the scapula remains stable during the first 30 to 60 of humerothoracic elevation, smoothly upwardly rotates during elevation, and downwardly rotates during humerothoracic lowering (McClure, Tate, Kareha, Irwin, & Zlupko, 2009). Shoulder kinematics related to GH abduction, GH rotation, and scapula upward rotation and anterior tipping contribute to participation in activities of daily living (ADLs), including feeding, combing hair, reaching overhead, and washing contralateral axilla and back (Rundquist, Obrecht, & Woodruff, 2009, p. 627). Scapular dyskinesis is the abnormal movement and positioning of the scapula in relation to the thorax and GH joint (Cools et al., 2014; Kibler & McMullen, 2003). McClure et al. (2009) defined scapular dyskinesis as winging, dysrhythmia, or both. Dysrhythmia was defined as the scapula [demonstrating] premature or excessive elevation or protraction, nonsmooth or stuttering motion during arm elevation or lowering, or rapid downward rotation during arm lowering and winging was defined as the medial border and/or inferior angle of the scapula [being] posteriorly displaced away from the posterior thorax (McClure et al., 2009, p. 162). Scapular 5 dyskinesis can result from a slouched posture, muscle strength imbalance, fatigue of the ST muscles, and stiffness of the soft tissue that surrounds the scapula (Andersen, Andersen, Zebis, & Sjgaard, 2014; Cools et al., 2014; Lee et al., 2016). Problems that result from scapular dyskinesis include shoulder and neck pain, predisposition to shoulder impingement syndrome, and disruption of shoulder and scapular movements, leading to greater risk of injury of the ST joint (Castelein et al., 2016a; Castelein et al., 2016; Cools et al., 2014; Escamilla, Hooks, & Wilk, 2014). As noted by Cooper (2014), dysfunction of scapulohumeral rhythm can result in significant impairment of the entire upper extremity (UE) and occupational performance limitations due to pain and reduced motor control (p. 219). For individuals whose occupational performance includes sustained overhead tasks, there is a greater risk of developing musculoskeletal pathologies when endurance of ST and GH muscle is impaired (Chopp-Hurley, ONeill, McDonald, Maciukiewicz, & Dickerson, 2016; Grassi, Rossiter, & Zoladz, 2015; Kozina, Repko, Ionova, Boychuk, & Korobeinik, 2016). Muscle endurance was defined as the time limit of work produced by a muscle at a given strength or speed of muscle contraction (Kozina et al., 2016; Manske, 2015). Fatigue occurs when there is reduced muscle power and strength (Grassi et al., 2015), and can result in impaired movements, reduced ability to maintain static postures, and compensation patterns (Lee et al., 2016; Sheard, Elliott, Cagnie, & OLeary, 2012). According to Healthy People 2020, more than 80% of adolescents do not meet the guidelines for aerobic physical activity and more than 80% of adults do not meet the recommended guidelines for aerobic and muscle strengthening activities (Office of Disease Prevention and Health Promotion [ODPHP], 2014). Melton, Bigham, Bland, Bird, and Fairman (2014) reported the average general technology usage of 578 college students to be 808.05 6 minutes per week. Lepp, Barkley, and Karpinski (2015) suggested that cell phone use alone distracts students from participating in physical activity, resulting in a more sedentary lifestyle (Smith, 2015). Sedentary behavior was defined as expending small amounts of energy and not meeting physical activity guidelines (Sedentary Behavior Research Network [SBRN], 2012). The increase in technology use and sedentary behavior in college students places them at risk for disorders and dysfunction of scapulohumeral rhythm and ST muscle function (Lepp et al., 2015; ODPHP, 2014; Smith, 2015). McClure et al. (2009) developed the SDT to identify abnormalities in scapular motion including winging, dysrhythmia, or both. The SDT requires individuals to repeatedly lift loads through shoulder flexion and shoulder abduction, reflecting loads lifted during ADLs (McClure et al., 2009). In addition to the SDT, researchers have used fatigue protocols to study scapula muscle endurance in healthy participants (Chopp-Hurley et al., 2016; Kanik et al., 2017). In a systematic review, Hickey, Solvig, Cavalheri, Harrold, and Mckenna (2018) found that asymptomatic athletes with scapular dyskinesis, as measured by visual dynamic assessments and physical landmarks, were 43% more likely to develop shoulder pain. Athletes time to fatigue and ST muscle endurance have been studied but scapular dyskinesis in a healthy college student population has not been described (Eraslan, Gelecek, & Genc, 2013; Zabihhosseinian, Holmes, Howarth, Ferguson, & Murphy, 2017). The purpose of this study was to quantify college students scapula movement using the SDT and physical activity using the IPAQ, and to determine if there was a relationship between the SDT and IPAQ scores. Literature Review Researchers have described multiple methods of assessing scapula movement, with no single method identified as superior. According to researchers reports, the testing procedures for 7 scapular movement can be categorized by their primary methodology: isometric exercises, shoulder flexion and abduction elevation exercises, fatigue protocols, and slouched posture positioning. Researchers have studied ST muscle activity using different static positions of the shoulder range of motion (ROM) arc with varied amounts of resistance applied and time sustained (Eraslan et al., 2013; Ha et al., 2012; Miyasaka et al., 2016; Peterson, Domino, & Cook, 2016). Ha et al. (2012) measured muscle activity during a series of shoulder elevation isometric exercises, including wall facing arm lift (WAL), prone arm lift (PAL), backward rocking arm lift (BRAL), and backward rocking diagonal arm lift (BRDAL) (Ha et al., 2012). Subjects maintained each position for 6 s with maximal effort against manual resistance (Ha et al., 2012). Ha et al. (2012) showed that during the BRAL exercise, the SA was significantly greater in maximal voluntary isometric contraction (MVIC) = 60.04 compared to PAL = 38.21, WAL = 43.33, and BRDAL = 43.48. Eraslan et al. (2013) similarly examined muscle endurance by instructing participants to flex their shoulders and elbows to 90, hold a digital dynamometer, and externally rotate their shoulders until 1-kg of resistance was attained. Muscle endurance was determined by the length of time the position and resistance were maintained (Eraslan et al., 2013). Eraslan et al. (2013) determined that decreased scapular endurance caused deviations in scapular mechanics and led to an increased risk of injury. In order to prescribe appropriate ST exercise for clients, researchers have measured ST muscle activity during shoulder elevation and abduction exercises (Castelein, Cagnie, Parlevliet, & Cools, 2016b; Nakamura, Tsuruike, & Ellenbecker, 2016). Castelein et al. (2016b) measured UT, MT, LT, and SA activity during elevation in the scapular plane, towel slide against a wall, and elevation with external rotation of a Thera-Band. Researchers concluded that elevation with 8 resisted external rotation enhanced MT and LT activity and elevation in the scapular plane produced increased UT, MT, LT, and SA muscle activity (Castelein et al., 2016b). Similarly, Nakamura et al., (2016) measured muscle activity of the UT, LT, and SA during 12 sets of five repetitions of the robbery exercise in two positions: 20 shoulder abduction and 90 shoulder abduction. Nakamura et al. (2016) found SA, UT, and LT activity increased during exercises conducted in a position of 90 abduction, which may have been due to the presence of scapular dyskinesis. This led researchers to conclude that posture and shoulder positions impacted muscle activity (Nakamura et al., 2016). During elevation exercises in the scapular plane, Castelein et al. (2016) determined that participants with neck pain and scapular dyskinesis showed lower MT activity compared to the control group. Fatigue protocols have been used by researchers with and without added resistance to assess ST muscle activity during shoulder elevation (Calvin, Keir, & McDonald, 2016; ChoppHurley et al., 2016; Kvist & Bang, 2016). Kvist and Bang (2016) and Chopp-Hurley et al. (2016) used resistance during repetitive shoulder elevation to study muscle fatigue. In both studies, researchers found altered positioning or movement of the scapula resulting from fatigue of ST muscles, which can impair scapulohumeral rhythm and induce pain (Chopp-Hurley et al., 2016; Kvist & Bang, 2016). Fedorowich et al. (2013) and Calvin et al. (2016) examined fatigue during repetitive pointing and work-related tasks without added resistance. Similar to studies in which researchers used resistance, fatigue caused by work-related tasks resulted in pain and substitution patterns of neighboring scapula muscles (Calvin et al., 2016). The results of these studies indicate that kinematic compensatory strategies emerge as muscles fatigue with repetitive tasks 9 (Chopp-Hurley et al., 2016). In contrast to others findings, the researchers determined there were gender differences with respect to fatigue of periscapular muscle. Researchers have studied ST muscle activity utilizing different postures during arm elevation (Lee et al., 2016; Malmstrm, Olsson, Baldetorp, & Fransson, 2015). Lee et al. (2016) measured the effects of slouched posture on LT, MT, and SA muscle activity. Participants abducted their shoulders to 90 in the scapular plane and held the position for 10 s (Lee et al., 2016). Participants then abducted their shoulders to 90 in a slouched posture to examine the effects of poor posture (Lee et al., 2016). Malmstrm et al. (2015) examined muscle activity of the UT, LT, and SA in an upright posture and slouched posture with an emphasized thoracic curve. In both postures, participants completed one arm elevation exercise with their arms and elbows extended (Malmstrm et al., 2015). The evidence from both studies indicated LT activity increased during slouched postures (Lee et al., 2016; Malmstrm et al., 2015). In addition, Lee et al. (2016) found increased activity of the MT and Malmstrm et al. (2015) found increased activity of the UT and SA in slouched postures. Authors of both studies concluded that slouched postures can lead to shoulder pain or injury as a result of increased muscle fatigue (Lee et al., 2016; Malmstrm et al., 2015). Calik, Yagci, Gursoy, and Zencir (2014) studied the effects of computer use on the UE of 871 students with pain and discomfort of the neck, shoulders, upper back, and lower back. The researchers determined that musculoskeletal system discomforts of the neck, shoulders, and upper back, were correlated with the time spent on computers (Calik et al., 2014). The findings of Calik et al. (2014), Lee et al. (2016), and Malmstrm et al. (2015) support the need for researchers to investigate the influence of sedentary behavior on the dynamics of shoulder function and mobility. 10 Hyperactivity of ST muscles affects scapular kinematics and contributes to conditions like subacromial impingement syndrome and scapular dyskinesis. Dysfunction associated with these conditions can result in increased pain in the neck and shoulder regions (Castelein et al., 2016a; Chopp-Hurley et al., 2016; Lee et al., 2016). Likewise, individuals with scapular dyskinesis or shoulder or neck pain have been shown to have abnormal UT, MT, LT, and SA activity (Casetlein et al., 2016a; Castelein et al., 2016b; Ersalan et al., 2013; Hanvold et al., 2013; Peterson et al., 2016). Proper functioning of the ST musculature decreases the risk of discomfort in MT and LT and/or the development of scapular dyskinesis (Lee et al., 2016). Researchers have analyzed ST muscle activity in healthy subjects and compared them to subjects with a history of shoulder disorders, shoulder pain, or neck pain (Castelein et al., 2016a; Castelein et al., 2016b; Ersalan et al., 2013; Hanvold et al., 2013; Peterson et al., 2016). However, scapular dyskinesis can be found in those who do not suffer from shoulder pain (Plummer, Sum, Pozzi, Varghese, & Michener, 2017). Additionally, researchers have analyzed scapular kinematics in a healthy population that included predominantly male subjects, providing a limited representation of abnormal scapular kinematics (Calvin et al., 2016; Chopp-Hurley et al., 2016; Lee et al., 2016; Malmstrm et al., 2015; Miyaska et al., 2016; Nakamura et al., 2016). Ha et al. (2012) and Kvist and Bang (2016) studied healthy male and female participants but sample sizes were too small to generalize results. Only one study was found in the reviewed literature that included healthy college students (Nakamura et al., 2016). However, the sample was limited to males and the sample was too small to generalize results (Nakamura et al., 2016). Although researchers have measured scapular dyskinesis in healthy persons, few have studied the healthy college student population or have taken into consideration students activity participation. Time spent sitting, exercising, and types of exercises should be taken into 11 consideration when measuring scapular dyskinesis. Researchers have inconsistently used a single outcome measure for scapular kinematic dysfunction. The SDT can serve as a dynamic method of assessment with sound psychometric properties and clinical utility, as it can be administered within a few minutes, using free-hand weights that are typically available in most clinics. Despite the sound psychometric properties of the IPAQ, investigators found that it is not often utilized to determine an individual's activity level. In this study, investigators used the SDT to determine the presence of scapular dyskinesis and the IPAQ to quantify physical activity. Method The investigators used a prospective, quantitative design with a single cohort for this study; two instruments, the SDT and IPAQ, were utilized to measure scapular dyskinesis and physical activity, respectively. Scapular Dyskinesis Test The SDT is a visual assessment used to determine if scapular dyskinesis is present. Scapular dyskinesis is identified by alterations in movement and positioning of the scapulae, which are visually distinguished as scapular winging or asymmetry (Tate, McClure, Kareha, Irwin, & Barbe, 2009). The SDT is performed by completing five repetitions each of resisted bilateral shoulder abduction and flexion. The pace of the motions is 5 s for elevation and 5 s for return to start position. The test motions are conducted with either three pound or five pound dumbbells depending on the individuals weight (McClure et al., 2009). McClure et al. (2009) rated scapular movement as normal, subtle, or obvious dyskinesis based on researchers observations. A normal rating was defined as no abnormal scapular movements (McClure et al., 2009). Inconsistency of scapular movement indicated a rating of subtle (McClure et al., 2009; Tate et al., 2009). Obvious scapular dyskinesis was defined as 12 scapular winging or asymmetry (Tate et al., 2009). A final unilateral rating was reported as normal if either both flexion and abduction motions were rated as normal or if one motion was rated as normal and the other motion was rated as subtle (McClure et al., 2009). A final unilateral rating of subtle was reported if both flexion and abduction motions were rated as subtle (McClure et al., 2009). A final unilateral rating of obvious was reported if either flexion or abduction motions were rated as obvious (McClure et al., 2009). Right and left scapulae were scored separately (McClure et al., 2009). There are no normative data for the SDT. To establish interrater reliability, McClure et al. (2009) conducted a study with 142 National Collegiate Athletic Association athletes who participated in sports that required overhead use of UEs, due to the higher incidence of shoulder injury in this population. The researchers focused on how the participants scapulae were positioned on the thorax during flexion and abduction (McClure et al., 2009). McClure et al. (2009) showed the SDT to have moderate interrater reliability for researchers who filmed (kw = 0.57) and rated scapular dyskinesis (kw = 0.54) (McClure et al., 2009). The SDT has also been established as a valid measure to identify scapular dyskinesis (Tate et al., 2009). Tate et al. (2009) conducted a study with 66 participants recruited from the McClure et al. (2009) study. Participants were instructed to refrain from any sport or demanding activity that could influence scapula/shoulder performance (McClure et al., 2009). Threedimensional kinematic testing via electromyographic (EMG) was used to measure muscle activity during humeral elevation to observe scapular motion (Tate et al., 2009). Analyses showed that individuals with less scapula upward rotation also had obvious dyskinesis (Tate et al., 2009). 13 In the current study, investigators selected the SDT due to established psychometric properties, training materials and procedures, and practical clinical use. The investigators had participants perform five repetitions of resisted bilateral shoulder flexion and abduction during the SDT (Tate et al., 2009). International Physical Activity Questionnaire The IPAQ is a questionnaire that measures physical activity or inactivity to obtain health related quantitative information (Craig et al., 2003). Craig et al. (2003) recommended using the long version of IPAQ for research purposes. The long version of the questionnaire includes four activity domains that are scored independently. The four domains include, leisure time physical activity, domestic and gardening (yard) activities, work-related physical activity, and transportrelated physical activity (International Physical Activity Questionnaire [IPAQ], 2005, p. 2). Participants rated their physical activity based on the previous seven days (Craig et al., 2003). The IPAQ scores can be reported as a continuous value or a categorical value. The continuous score represents the median metabolic equivalent of task (MET) minutes for walking, moderate intensity activity, and vigorous intensity activity per week for each domain (IPAQ, 2005). A MET minute represents energy expenditure and is calculated by multiplying the MET score by the time (in minutes) spent on each activity. A total physical activity score is calculated by summing the MET minutes from each domain (IPAQ, 2005). The categorical values represent low, moderate, or high levels of physical activity (IPAQ, 2005). The total time participants sit each day and week, per minute, is recorded and scored separately from the total weekly physical activity score (Craig et al., 2003; IPAQ, 2005). Craig et al. (2003) established test-retest reliability of the long IPAQ form by administering the form twice within seven to ten days. Nonparametric Spearman correlation 14 coefficients were calculated to measure the relationship of scores between the two administrations. Test-retest reliability ranged from 0.79-0.82 for the long form and 0.70 for the sitting recall portion. The categorical data were then used to calculate the percentage agreement and an overall high percentage agreement was calculated as 0.84 to 1.0 (Craig et al., 2003). Craig et al. (2003) established validity from the participants reported activity levels and monitor data, which were stored and summed in one-minute intervals. There were similar correlations when comparing the sitting data from the IPAQ and the sitting estimate from the accelerometer, indicating an agreement between objective and subjective sedentary behavior measures. The frequency, duration, and intensity of physical activity, along with the assessment of sedentary behavior showed the IPAQ to have a concurrent validity range between 0.42 to 1.0 and criterion validity range between 0.05 and 1.0 (Craig et al., 2003). Participants Inclusion criteria included enrollment as a student at the university and the ability to move both scapulae through normal movements during the SDT. Exclusion criteria included shoulder surgery within the past year, pain in shoulder or scapulae, and injury to the shoulders, arms, or back within the past month. Recruitment for this study was completed through electronic mail and flyers distributed campus wide at a private university in the Midwest. Investigators distributed the informed consent to each participant and answered questions before obtaining signed consent forms. Procedures The investigators submitted their study to the Human Research Protections Program and were approved as exempt. They completed the Collaborative Institutional Training Initiative program courses, Human Subjects Research and Healthy Related Research Course Learner 15 Group with a score of at least 80%. The investigators underwent standardized training via a selfinstructional slide presentation designed by McClure et al. (2009) to administer and score the SDT. They also completed a training session to learn how to use the video camera and how to save and remove the films of the SDT to a hard drive. Data Collection The investigators administered and scored the SDT according to McClure et al. (2009) three times with the first six participants, 48 hours in between sessions, in order to determine intra-rater and test-retest reliability. The SDT was completed one time for remaining participants. In addition to procedures established by McClure et al. (2009), investigators assured full viewing of the scapula by having participants wear a towel wrap and use a shower cap; shower caps also disguised participants identities. To remove potential bias, investigators gave participants assigned numbers for all data gathered; films of the SDT were saved and rated by two investigators not involved in the filming. Participants completed a questionnaire that included the IPAQ. Demographic information included their age, gender, height, weight, activity level (participation in sports or time spent exercising), and type of academic degree. Data Analysis Intra-rater, test-retest, and inter-rater reliability of the SDT were established from the first six participants using percent agreement (Portney & Watkins, 2009). SDT scores were analyzed using descriptive statistics to report frequencies of normal scapula movement, obvious dyskinesis, and subtle dyskinesis. SDT and IPAQ scores were analyzed using a chi-square test to determine the relationship between scapular dyskinesis and low, moderate, and vigorous physical activity level. To determine if there were differences in sitting and BMI among the SDT and IPAQ scores, a one-way ANOVA was used. Interrater reliability was calculated using the kappa 16 coefficient and percent agreement after the SDT data collection was completed. Body mass index (BMI) was calculated from participants' height and weight and was included in descriptive statistics (Centers for Disease Control and Prevention, 2017). Demographic data were analyzed using descriptive statistics. The SPSS version 25.0 software was used for statistical analysis and a significance level set at p < .05. To determine if the current sample of participants met the Centers for Disease Control (CDC) and American College of Sports Medicine (ACSM) guidelines of 150 minutes of physical activity per week, the total weekly physical activity in minutes was calculated for comparison (Craig et al., 2003; Pate et al., 1995; U.S. Department of Health and Human Services, 2018). Results After the first six participants were filmed, investigators observed inconsistencies in participants speed and ROM arc completion during the SDT. In order to standardize performance of the SDT, the investigators used a metronome to create a voice recording of an investigator counting out the pace for the five repetitions of shoulder flexion and abduction. This recording was played for all participants in this study to increase the consistency and accuracy of the SDT. The data of the original six participants of this study were removed from data analysis and another six participants were filmed to determine test-retest reliability. Following the adaptations, investigators gathered data from 58 participants; data from four participants were removed due to incomplete IPAQ information and/or lack of full ROM during the SDT. The final sample of 54 were predominantly female graduate OT and physical therapy students, who were employed and had a normal BMI as shown in Table 1. Percent agreement for the primary investigator (rater 1) and student rater (rater 2) were 100% and 69%, respectively, for intra-rater and test-retest reliability of the SDT for the first six 17 analyzed participants. When comparing ratings of the SDT of rater 1 and rater 2, percent agreement for the left scapula was 61% and for the right scapula was 72% (n = 54) for the entire sample. Correction for chance agreement using Cohens kappa for the left scapula was .323 (p = .001) and for the right scapula was .403 (p < .0005), showing fair agreement between the primary investigator and student rater for the sample (n = 54). Only scores of the SDT rated by the primary investigator were included in the data set for analyses of the entire sample. Scores from only the first session of the first six participants were included in the data set for analyses of the entire sample. More than half of the participants had normal scores for the SDT with more than 40% showing either subtle or obvious dyskinesis as shown in Table 2. The student investigator results are identified in Table 3. There were no significant relationships between the SDT and IPAQ, x (4, N = 54) = 6.151, p = .188, left, and x (4, N = 54) = 4.719, p = .317, right. There were no significant differences in BMI among the IPAQ categories, ANOVA F (2, 51) = .915, p = .407 or in sitting hours among the IPAQ categories, ANOVA F (2, 51) = 1.924, p = .156. There were no significant differences in BMI among the SDT ratings, ANOVA F (2, 51) = .769, p = .469, left, or ANOVA F (2, 51) = 1.813, p = .173, right. No significant differences were found in sitting hours among the SDT ratings, ANOVA F (2, 51) = .580, p = .564, left, or ANOVA F (2, 51) = 1.813, p = .173, right. As shown in Figure 1, participants sitting hours, on average, exceeded their activity hours. Students reported daily averages of 6.84 hours of sitting and 2.33 hours of physical activity, as defined by the IPAQ. Results of total sitting per week and total sitting per day are listed in Table 4. Participants more often scored in the high IPAQ category, shown in Table 4, with additional IPAQ results. According to the CDC-ACSM, 86.79% of the participants met either moderate or vigorous intensity guidelines for activity. 18 Discussion The investigators found that healthy college students more frequently had SDT scores classified as normal however, when the categories of subtle and obvious were combined, the sample showed more than 40% had either subtle or obvious scapular dyskinesis in one or both of the scapula. The SDT scores of normal may under represent participants who have subtle scapular dyskinesis because a unilateral rating of normal is assigned if flexion and abduction motions are rated as normal or if one motion is rated as normal and the other motion is rated as subtle. Likewise, the SDT scores of subtle may under represent participants who have obvious scapular dyskinesis. A unilateral rating of obvious is assigned if flexion and/or abduction are rated as obvious for three out of five ratings. In the presence of subtle or obvious dyskinesis, a clinician may decide to intervene regardless of the SDT rating (Tate et al., 2009). Obvious dyskinesis is a stronger reason for intervention, whereas the decision to intervene with subtle dyskinesis is more dependent on clinical judgement (Tate et al., 2009). The findings of this study contrast with those of Akodu, Akinbo, & Young (2018), who found that health science college students more frequently presented with abnormal scapular dyskinesis. Only indirect comparisons can be made to the results of Akodu et al. (2018) because the researchers used the SICK scapula static measurement that yielded presence or absence of scapular dyskinesis. Scapular dyskinesis was defined as asymmetry of the scapulae as participants stood in a static position (Akodu et al., 2018). In the current study, investigators rated unilateral scapula movement as normal, subtle dyskinesis, or obvious dyskinesis, as recommended by McClure et al. (2009). Investigators in the current study found no association between the IPAQ categories and scapular dyskinesis. Sedentary behavior can lead to generalized weakness, which has been 19 shown to place students at increased risk for dysfunction and disorders of ST muscle function (Lepp et al., 2015; ODPHP, 2014; Smith, 2015). Conversely, researchers have found that UE exercise training can improve kinematic function of the scapula and prevent the development of shoulder pathologies (Andersen et al., 2014; Cho, Lee, Kim, Hahn, & Lee, 2018). Only indirect comparisons from the literature can be made to the current study because participants did not report specific exercise routines. Although sedentary individuals can have risk for dysfunction and disorders of ST muscle function, active individuals who do not exercise ST muscles could also be at risk. High levels of activity as measured by the IPAQ do not necessarily involve exercises for the ST muscles. Participants in the current study were asymptomatic and could incorrectly assume that their physical activity will prevent scapular dyskinesis. Moreover, the inability to visualize their own scapulae presents another reason for a lack of awareness of scapular dyskinesis. Therefore, it is imperative to consider function of ST musculature during screenings and assessments by clinicians. Healthy college students in this study more frequently had IPAQ scores of high because the IPAQ classifies high physical activity as either a minimum of 1500 MET/minutes per week of vigorous-intensity activity or a minimum of 3000 MET/minutes per week of a combination of walking, moderate-intensity, or vigorous-intensity activity (IPAQ, 2005). Participants were meeting or exceeding these requirements, however, the IPAQ results showing high activity levels can be misleading because the total physical activity is not inclusive of how the rest of the time is spent, including time spent sitting. Although participants met the weekly physical activity guidelines, daily sitting exceeded daily active hours, comprising 28% of the students' day for the latter. The CDC and Prevention has indicated that increasing physical activity and decreasing time spent sitting can reduce overall health risks, however no recommendations for daily or 20 weekly maximum time spent sitting have been established (Pate et al., 1995; U.S. Department of Health and Human Services, 2018). A possible explanation for high IPAQ scores is that the majority of the participants were health-science majors. The findings of this study are consistent with Haddock and Gaines (2013) who found that kinesiology students reported healthier exercise behaviors and greater motivation to exercise than did non-kinesiology students. All participants in the current study had BMIs classified as normal. This may be explained by those with lower BMIs choosing to participate in the study due to having greater comfort in exposing their anatomy and reporting body weight on the questionnaire. These findings are consistent with those of Akodu et al. (2018); the healthy college aged sample with students in the physiotherapy department had a mean BMI score of 23.6, which is classified as normal. However, Osborn, Naquin, Gillan, and Bowers (2016), reported that 49% of college age sample had BMIs that were classified as overweight or obese. Sedentary lifestyle in a collegiate population may be related to the increased time spent completing academic requirements which could contribute to higher BMIs. In professional practice clinicians who use the SDT as a screening tool for shoulder pain or disorders should also utilize other methods of evaluations (Hickey et al., 2018; McClure et al., 2009). The prevalence of scapular dyskinesis is relatively equal between persons with and without pain (Kibler et al., 2013). Therefore, it is important that clinicians screen for scapular dyskinesis in both symptomatic and asymptomatic populations (Hickey et al., 2018; Kibler et al., 2013). Clinicians should consider the impact of scapular dyskinesis when working with clients that experience difficulty during ADLs (Rundquist et al., 2009). Scapulohumeral rhythm has a significant impact on the functional ability to bathe, comb hair, reach overhead, and bring utensils to the mouth while eating (Rundquist et al., 2009). Appropriate shoulder kinematic 21 function significantly impacts an individual's ability to perform ADLs that require the use of overhead UE movements (Rundquist et al., 2009). Because of the expertise of the primary investigator, only the ratings of the primary investigator were used in analyses of the SDT. Ratings of the SDT of the student rater and clinician rater showed only fair agreement which is in contrast to McClure et al. (2009). This finding can be explained by McClure et al. (2009) using raters that were athletic trainers and physical therapists to view and determine SDT in 1 or 2 viewings of videotaped participants. Completion of educational programs required for entry into professional practice and clinical experience of the athletic trainers and physical therapists could have contributed to better agreement in rating. The student rater in the current study had completed only two of five semesters of an entry-level OT curriculum that included fieldwork settings of outpatient pediatrics, acute care, and community-based at the time of rating the SDT. Student ratings in the current study may have shown better agreement with the clinician ratings if the data collection and analysis had occurred after additional course completion that focused on assessments or if fieldwork had included clients with shoulder conditions. Additionally, the students ratings may have shown better agreement with the primary investigator if training had been supplemented beyond those of McClure et al. (2009). Uhl, Kibler, Gecewich, and Tripp (2009) found that rating of the SDT was more accurate when raters used the yes/no method to indicate presence or absence of scapular dyskinesis, however a portion of those participants that were rated also had a shoulder injury. It could be that the SDT rating system that allows 3 ratings creates more variability among raters. It could also be that forced choice with limited viewings improves interrater reliability in contrast to researchers viewing unlimited times to rate scapula movement 22 in the current study. Moreover, it could be that accuracy is greater when rating symptomatic shoulders in contrast to asymptomatic shoulders in the current study. Limitations Data collection was conducted in a single building of health science programs on a Midwestern college campus, which contributed to a lack of diversity among participants. Therefore, the results are not applicable to the general college student population. Potential participants may have eliminated themselves from participation due to the discomfort of exposing their scapulae and identifying their body weight during dumbbell weight selection. Participants may not have used the appropriate dumbbell weight during the SDT due to not knowing or wanting to share their weight. Some participants were filmed more than once within the same session because of their unsuccessful attempts to complete full ROM during shoulder flexion and abduction. These participants completed more repetitions than other participants, potentially causing fatigue. A recording of a researcher counting from one to five throughout the performance of the SDT should be completed before data collection so that participants perform the SDT consistently. Providing a film of a researcher completing the SDT for participants to follow, would improve precision and accuracy in the performance of SDT. In order to ensure video quality is clear for viewing, researchers should make sure lighting is adequate and consistent throughout recordings. If multiple researchers perform the SDT, interrater reliability should be established prior to participants completing the SDT. If students are rating, it is suggested that students should receive additional training from an experienced clinician to ensure accuracy of ratings and the potential to achieve moderate or better interrater reliability. 23 Providing a scale for participants to weigh themselves privately prior to documenting weight and selecting a dumbbell, would verify accurate selection of weight for the SDT. Researchers who study healthy college students should recruit a more diverse sample. Conclusion Scapulohumeral rhythm has an important role in how one functions and participates in daily tasks and occupations. Shoulder kinematics are crucial to ADLs and instrumental activities of daily living that involve crossing midline to reach the opposite extremity or reaching overhead (Rundquist et al., 2009). The SDT can be a useful tool to identify healthy college students who exhibit scapular dyskinesis and would benefit from further assessment and intervention to restore normal scapular motion. Our study found that 40% of healthy college students had either subtle or obvious scapular dyskinesis in one or both of their scapulae, indicating the necessity to include the SDT in clinical screenings. The percentage may under represent those who have subtle or obvious scapular dyskinesis due to how the ratings are finalized. It is suggested that any abnormalities should be documented, even if the finalized SDT ratings are normal, as a part of the evaluation. Abnormalities in scapulohumeral rhythm can be asymptomatic, indirectly related to poor posture or sedentary lifestyle, and can result from muscle imbalance leading to development of MSD. Measurements of physical activity level and time spent sitting in college students are necessary to determine the influence of posture and sedentary lifestyle that could impact scapulohumeral rhythm. OT practitioners should consider the potential impact of scapular dyskinesis on occupational performance in asymptomatic student populations. 24 References Akodu, A. K., Akinbo, S. R., & Young, Q. O. (2018). Correlation among smartphone addiction, craniovertebral angle, scapular dyskinesis, and selected anthropometric variables in physiotherapy undergraduates. Journal of Taibah University Medical Sciences, 13(6), 528-534. doi:10.1016/j.jtumed.2018.09.001 Andersen, C. 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Electromyographic activity of scapular muscle control in free-motion exercise. Journal of Athletic Training, 51, 195-204. doi:10.4085/1062-6050-51.4.10 Osborn, J., Naquin, M., Gillan, W., & Bowers, A. (2016). The impact of weight perception on the health behaviors of college students. American Journal of Health Education, 47(5), 287-298. doi:10.1080/19325037.2016.1204966 Office of Disease Prevention and Health Promotion. (2014). Physical activity. Retrieved from https://www.healthypeople.gov/ Pate, R. R., Pratt, M., Blair, S. N., Haskell, W. L., Macera, C. A., Bouchard, C., ... & Kriska, A. (1995). A recommendation from the Centers for Disease Control and Prevention and the American College of Sports Medicine. Jama, 273(5), 402-7. doi: 10.1001/jama.273.5.402 Peterson, S. M., Domino, N. A., & Cook, C. E. (2016). Scapulothoracic muscle strength in individuals with neck pain. Journal of Back and Musculoskeletal Rehabilitation, 29, 549-555. doi:10.3233/BMR-160656 Portney, L. G., & Watkins, M. P. (2009). Foundations of clinical research: Applications to practice. Upper Saddle River, NJ: Pearson/Prentice Hall. Plummer, H. A., Sum, J. C., Pozzi, F., Varghese, R., & Michener, L. A. (2017). Observational 30 scapular dyskinesis: Known-groups validity in patients with and without shoulder pain. Journal of Orthopaedic & Sports Physical Therapy, 47(8), 530-537. doi:10.2519/jospt.2017.7268 Rundquist, P. J., Obrecht, C., & Woodruff, L. (2009). Three-dimensional shoulder kinematics to complete activities of daily living. American Journal of Physical Medicine & Rehabilitation, 88(8), 623-629. doi:10.1097/PHM.0b013e3181ae0733. Sedentary Behavior Research Network. (2012). Letter to the editor: Standardized use of the terms sedentary and sedentary behaviours. Applied Physiology, Nutrition & Metabolism, 37, 540-542. doi:10.1139/H2012-024 Sheard, B., Elliott, J., Cagnie, B., & O'Leary, S. (2012). Evaluating serratus anterior muscle function in neck pain using muscle functional magnetic resonance imaging. Journal of Manipulative and Physiological Therapeutics, 35(8), 629-635. doi:10.1016/j.jmpt.2012.09.008 Smith, A. (2015). U. S. smartphone use in 2015. Pew Research Center: Internet and Technology. Retrieved from http://www.pewresearch.org/ Tate, A. R., McClure, P., Kareha, S., Irwin, D., & Barbe, M. F. (2009). A clinical method for identifying scapular dyskinesis, part 2: Validity. Journal Of Athletic Training, 44(2), 165-173. doi:10.4085/1062-6050-44.2.165 Uhl, T., Kibler, B., Gecewich, B., & Tripp, B. (2009). Evaluation of clinical assessment methods for scapular dyskinesis. Arthroscopy: The Journal of Arthoscopic & Related Surgery, 25(11), 1240-1248. doi: 10.1016/j.arthro.2009.06.007 U.S. Department of Health and Human Services. (2018). Physical Activity Guidelines for Americans (2nd ed.). Retrieved from https://health.gov/paguidelines/second-edition/pdf/ 31 Zabihhosseinian, M., Holmes, M. W. R., Howarth, S., Ferguson, B., & Murphy, B. (2017). Neck muscle fatigue differentially alters scapular and humeral kinematics during humeral elevation in subclinical neck pain participants versus healthy controls. Journal of Electromyography and Kinesiology, 33, 73-82. doi:10.1016/j.jelekin.2017.02.002 32 Table 1 Participants Demographics Frequency (%) Gender Male Female n=54 n=4 (7%) n=50 (93%) College Major Occupational Therapy Physical Therapy Other n=54 36 (67%) 13 (24%) 5 (9%) College Year Graduate Undergraduate n=54 49 (91%) 5 (9%) Employed Yes No n=54 38 (70%) 16 (30%) Median Age n=53 23 Mean BMI n=53 23.531 SD: (+/- 2.698) Note. SD = standard deviation. 33 Table 2 Primary Investigator Scapular Dyskinesis Test Ratings Left SDT(%) Right SDT(%) Normal 29 (54%) 30 (56%) Subtle 13 (24%) 13 (24%) Obvious 12 (22%) 11 (20%) 54 54 Category: Total 34 Table 3 Student Investigator Scapular Dyskinesis Test Ratings Left SDT(%) Right SDT(%) Normal 36 (67%) 46 (85%) Subtle 10 (18%) 2 (4%) Obvious 8 (15%) 6 (11%) 54 54 Category: Total 35 Figure 1 36 Table 4 International Physical Activity Questionnaire Results Mean SD Range Weekly Sitting (minutes) Daily Sitting (minutes) 2926.67 410.16 +/-1005.39 +/-147.11 1080 - 46.20 137.14 - 651.43 IPAQ Categories (%) Low 4 (7%) Moderate 15 (28%) High 35 (65%) IPAQ Total MET Score Median Note. SD = standard deviation. 4329  ...

... Running Head: WORK & SOCIAL SKILLS GROUP 1 Young Adults with Disabilities Work and Social Skills Program Development at Kids Abilities: A Doctoral Capstone Experience Megan Chapman, OTS May, 2019 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 A Capstone Project Entitled Young Adults with Disabilities Work and Social Skills Program Development at Kids Abilities: A Doctoral Capstone Experience Submitted to the School of Occupational Therapy at University of Indianapolis in partial fulfillment for the requirements of the Doctor of Occupational Therapy degree. By: Megan Chapman 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 3 Abstract Young adults with disabilities are more likely to be unemployed compared to individuals without a disability due to the limited amount of employment opportunities for these individuals. The effect of this epidemic impacts these young adults occupational performance and social skills necessary to sustain employment. Young adults with disabilities are isolated from social interaction with peers and not given the same opportunities to build work-related skills required to sustain a career. The purpose of this Doctoral Capstone Experience (DCE) was to create a program that incorporated aspects of work-related skills and social skills with peers in a group setting to maximize effectiveness in the clients ability to perform desired occupations. Interventions in the group sessions focused on offering adaptive solutions to increase the clients occupational performance, engage in newly developed occupations and roles that required social interaction with peers, and work-related skills. Home dcor items were created during each intervention session with the group and required social interaction to complete the desired items. Each item that was created within the group was sold at a boutique that sells items made by individuals with disabilities. Each group member demonstrated an observable increase in sustained attention, willingness to complete the work-related skills, and an increase in communication with peers during the implementation sessions. 4 Introduction Employment in our society today defines success as an adult. Employment allows individuals to be self-sufficient and expands ones self-esteem and personal satisfaction (Symanski, Enright Hershenson, & Ettinger, 2003). Overall unemployment rates for individuals with disabilities goes largely unrecognized and continues to fall behind those without disabilities (Lindstorm, Doren, & Miesch, 2011). The reality of employment for young adults with a disability is that employment is limited in the number of opportunities. A relatively small portion of adults with severe intellectual disabilities, autism, or multiple disabilities are exposed to paid work experiences. When and if these work experiences do occur, the individuals with disabilities work for low wages, are provided only a few weekly hours, and take place in segregated settings with little social interaction (Carter, Austin, & Trainer, 2012). Background Information Kids Abilities Indiana, is a pediatric outpatient therapy clinic that specializes in occupational, physical, and speech and language therapies. At Kids Abilities, the therapists believe that therapy should change the life of the child and their family. Therapy should challenge the childs abilities, encourage his or her progress, and celebrate all of their achievements (Kids Abilities Pediatric Therapy, 2017). At Kids Abilities, the therapists focus on understanding the child as a whole and thoughtfully coordinate care with the parents and other disciplines treating the same client. The environment at Kids Abilities is geared toward the childs growth and individual learning needs. A primary concern at Kids Abilities is that many of their clients are becoming young adults and are starting to graduate from high school. These young adults will not be attending college and are not entering the workforce after high school due to their disability or diagnosis. 5 As a result, the caregivers of these young adults are having to find an alternative plan of care for their young adults since their young adult is no longer attending school during the day time hours. When receiving school-based therapy, all goals must be driven by school needs; therefore, these young adults may not be receiving the education on work and social skills needed when graduating high school. Occupational therapy practitioners can use their expertise to address social communication and quality work skills within young adults with disabilities. They also support the development of characteristics that are needed to increase independence within the workplace and other instrumental activities of daily living (IADL). This occupational therapy Doctoral Capstone Experience (DCE) project aims to bridge the gap between school, work, and social skills independence. Literature Review Transitioning into Adulthood The period of adolescence into adulthood is a time of change and transitions. Young adults begin to form their identities, gain independence from their caregivers, acquire relationships, and develop work-related skills (Donkervoort, Wiegerink, Meeteren, Stam, & Roebroeck, 2008). For young adults with disabilities, the transition can be difficult and far from easy due to their impairments and social isolation they may endure (Weaver, 2015). Problems that are consistently seen during this transition for young adults with disabilities include: increased limitations in activities of daily living and mobility; social problems related to occupations, education, and work; social integration; maintaining relationships; sexuality; and a limited ability to communicate (Hirst, 1983; Stevenson, Pharoah, & Stevenson, 1997; Thomas, Bax, Coombes, Goldson, Smyth, & Whitmore, 1985). These problems rise to the surface due to little to no continuity of care in post-school age and into early adulthood (Dussen, Nieuwstraten, 6 Roebroeck, & Stam, 2001). During childhood, children with disabilities are receiving intense rehabilitation and psychosocial treatment, but once adolescence and adulthood occur, structured treatment sessions are usually discontinued (Donkervoort et al., 2008). During this time of transition, changes in both personal and environmental adjustments are needed but are often not given the opportunity to experience environmental adjustments (Donkervoort et al., 2008). Post-School Employment Young adults transitioning from the school system to postsecondary activities are at a pivotal time within their lives. For young adults with developmental disabilities (e.g., autism spectrum disorder, cerebral palsy, and Down syndrome), the transition from the school system to post-secondary activities or career decisions may not occur due to intellectual abilities, social and communication impairments, or other restrictive conditions. Due to these circumstances, many young adults with autism spectrum disorder (ASD), cerebral palsy (CP), and Down syndrome (DS) face underemployment or unemployment (Bennett & Dukes, 2013). Research is limited within the focus of post-school employment outcomes for young adults with severe intellectual disabilities. Most research focuses on students with high-incidence disabilities including but not limited to attention deficit disorder (ADD), attention deficit hyperactivity disorder (ADHD), and speech issues (Benz, Lindstrom, & Yovanoff, 2000; Shandra & Hogan, 2008). Young adults with ASD, ADD, and ADHD do not outgrow their social skill deficits, but continually persist throughout adulthood years (Rao, Beidel, & Murray, 2007). This directly affects these individuals social and occupational daily function, causing these young adults to be dissatisfied with their social relationships and much more likely than the general population to be unemployed (Szatmari, Bartolucci, & Bremmer, 1989; Venter, Lord, & Schopler, 1992). 7 The Relationship between Community Involvement and Work Exposure to community activities for youth with ASD can help these individuals gain functional skills needed for employment (Weaver, 2015). Individuals with disabilities are at a risk of limited activity participation and show less variety in activity participation than typically developing individuals (LeVesser & Berg, 2011; Rodger & Umaibalan, 2011). Due to the complexity and multifaceted services needed for the young adults with disabilities, additional or intensive support and social groups are needed to impact the employment prospects for these young adults. Research has indicated that participation in activities in the home and community that focus on meal preparation, attending groups or clubs, or visiting neighbors that expand social interaction promotes development and learning (Dunst, Bruder, Trivette, Raab, & Mclean, 2001; Humphry & Wakeford, 2006). When individuals are given the opportunities to develop skills in IADL (such as meal preparation, shopping, home maintenance, health management, communication management), the individual has increased autonomy and self-efficacy (Weaver, 2015). This can also lead to increased independent living and community engagement for these young individuals (Weaver, 2015). Foundational skills in activities of daily living (ADL) and IADL allow people to participate and develop the skills needed to engage in work-related skills (Weaver, 2015). For individuals with disabilities, it is important to have specialized support to facilitate meaningful and effective growth in work-related skills. Due to the lack of participation in work-related skills and social integration within the community in young adults with disabilities, I will be developing a work and social skills group program for young adults with disabilities to increase their independent living skills, social interaction skills with peers, and develop career-building skills to increase their quality of life. Model of Human Occupation (MOHO) 8 Occupational therapists use models and theories to guide their thinking and reasoning. These models and theories are used to find the strengths and meaningful occupations within the clients, as well as potential barriers that are causing dissatisfaction in occupational performance. The Model of Human Occupation (MOHO) is an appropriate model to help guide the process of implementing a work and social skills group for young adults with disabilities. The MOHO focuses on the importance of the mind to body connection and how internal motivation and performance of external occupations are interconnected (Cole & Tufano, 2008). Within the work and social skills group, there is a strong focus on keeping each client internally motivated to participate in the occupations that will be completed during group sessions. The MOHO describes how the person develops and modifies their occupations and how the individual interacts with environment (Cole & Tufano, 2008). This is also known as a dynamic open cycle system of human actions. The human occupation is the action of performing work, activities, or play within the temporal, physical, and social contexts (Cole & Tufano, 2008). For the case of the work and social skills group, the human occupation will be the activities that are being completed during the intervention sessions within the physical location of Kids Abilities and the social context of being in a group with peers. The open cycle system gathers information from the environment and the feedback given based on their performance (Kielhofner, 2008). This process is known as input. The input then goes through the person. The person is made up of three subsystems: volition, habituation, and mind-brain-body subsystem. The volition subsystem is the source of motivation that guides what each person does and their feelings about their occupations (Kielhofner, 2008). By giving each client positive feedback during participation in occupations within the group, the client will be more motivated due to positive reinforcement that will drive their volition subsystem. The habituation subsystem focuses on behaviors and 9 roles that each person has within their daily lives (Kielhofner, 2008). Each clients specific behaviors and roles within their daily lives will be taken into consideration to keep them engaged and find meaning within the group activities. The mind-brain-body subsystem is made up of the persons capacity for occupational performance (Kielhofner, 2008). Each clients capacity for occupational performance varies, and it is important to take that into consideration when planning for each group session in advance. The whole system makes adjustments based on the feedback and adapts their actions. After interaction between the input and the three subsystems, the system develops output, which provides feedback to the system and develops new input (Kielhofner, 2008). By adapting each activity to best fit the clients needs, each client will get the most out of the sessions, and this will help develop a positive input associated with the work and social skills group. For the purpose of my DCE, the MOHO will be used to help promote change and motivation for each client that participates within the work and social skills group. During the evaluation process, the assessment tool that will be utilized looks at personal factors including the habituation, volition, and body-mind-brain (Kramer, Valden, Kafkes, Basu, Federico, & Kielhofner, 2014). By having the MOHO incorporated into the evaluation process, the therapist will develop a more holistic occupational profile and gather information to develop an intervention plan for implementation that is client-centered with the clients personal factors, environment, and context as a main focus (Kramer et al., 2014). By remaining client-centered, the clients will be more engaged and motivated to participate in the group sessions. During the group, the leader will aim to develop a shift in each participants open system cycle to cause change in their overall dynamic. By causing change to each clients overall dynamic, the clients will become more independent within their daily living, gain responsibility 10 in their IADL, and improve their social interaction skills with their peers. This in turn will develop each clients sense of occupational competence (Cole & Tufano, 2008). Also, motivation is key. Each client will express their interests, values, and their self-efficacy. Based on volitional findings, group interventions will be developed to best fit each clients needs. Occupational Adaptation Frame of Reference The occupational adaptation frame of reference (FOR) is appropriate to guide the process of implementing a work and social skills group for young adults with disabilities. The occupational adaptation FOR focuses on the adaptation process when an individual is faced with occupational challenges (Schkade & Schultz, 1992). This FOR is comprised of three essential elements: the person, the occupational environment, and the interaction between the two. The person includes sensorimotor, cognitive, and psychosocial systems. The occupational environment includes work, play and leisure, and self-maintenance. Each of these key elements are influenced by a constant. The constants to this FOR include a persons desire for mastery in occupational situations and the environmental demands for mastery from the person in these occupational situations. These two constants continually interact and result in the constant for the interaction element, also known as a press for mastery. The nature of occupational adaptation begins when the individual is faced with occupational challenges. Then the occupational challenges are influenced by the individuals perception of the internal and external expectations for occupational performance. The person makes an occupational response based upon the occupational challenges, evaluation of the possible outcomes, and lastly integrates feedback from the response. Also during this time, the individual is evaluating and integrating feedback given to them within the occupational environment. As more occupational challenges emerge, the same process is repeated (Cole & Tufano, 2008). 11 This FOR also has generation subprocesses. The adaptive response generation subprocess is the generation of a response developed from occupational challenges and perceived role expectations. The adaptive response generation subprocess has two parts. The first component is an adaptive response mechanism that decides the energy levels and methods. The second component is an adaptation gestalt in which the person prepares their sensorimotor, cognitive, and psychosocial system to carry out the plan of action that they have developed through adaptive response. The evaluation subprocess starts when the individual is assessing their personal quality of occupational response generated. The individual evaluates their experience of mastery by looking at their efficiency, effectiveness, and satisfaction of their self. There is little to no need to further adapt the individuals occupation response when the person finds the evaluation positive. On the other hand, if the individual has an overall negative occupation response, then the integration subprocess tells the individual to begin the process of adaptation (Cole & Tufano, 2008). For my DCE, a main goal for the group members are that they will be able to adapt their abilities to maximize effectiveness in their ability to perform desired occupations. Each client will participate in choosing occupational roles to help guide each group treatment session. A focus for each treatment session is to see the clients ability to adapt correctly towards the three subprocesses. To help improve the clients ability to adapt, the interventions will focus on improving the clients internal adaptive response. Also, the leader and volunteers helping to lead the group will manage the environment where the group is completing their activities; this will promote the clients ability to adapt. Each treatment session should be geared toward meaningful activities that the client finds enjoyable. Interventions in the group sessions will be focused on 12 offering adaptive solutions to increase the clients occupational performance and engaging in newly developed occupations and roles. Purpose of the DCE Project The purpose of the DCE project is to enhance the level of independence and social participation with peers in an interactive work and social skills group for young adults with disabilities. Screening and Evaluation Initial Screening with Kids Abilities Site Mentor The initial screening for this doctoral capstone project (DCE) included exploration of the site at Kids Abilities through discussion with the site mentor, other staff therapist members, identification of barriers and resources, and research of current literature regarding work and social skills with individuals with disabilities. Exploration is a key part of the pre-planning phase when developing a program (Scaffa & Reitz, 2014). The exploration is similar to the chart review process a therapist completes to gather background information about their client before evaluating in an outpatient or inpatient setting (Scaffa & Reitz, 2014). During the initial screening, the lead occupational therapist discussed the needs for occupational therapy techniques to help develop and create a work and social skills group through the use of crafts, workshop building skills, and homeware objects (J. Ray, personal communication, January 9th, 2019). Many informal conversations throughout the first four weeks of the DCE were done involving the need for social and work skills groups for young adults with disabilities. Involving and collaborating with all therapy team members is essential to provide exceptional care (Morley & Cashell, 2017), and for that reason I collaborated with other disciplines (including speech therapy, physical therapy, and cranio-sacral therapy) about what 13 they would like to see within the work and social skills group. Collaborating with other disciplines has shown to improve the patients outcomes including behavioral changes, improving decision-making, and participation in self-care (Morley & Cashell, 2017). Other informal conversations took place with the occupational therapist and caregivers when observing OT intervention sessions with the young adults that will be a part of the group. By observing these clients, I developed a clearer understanding of the individuals current level of function, cognitive abilities, and social interaction skills. There is a large range of abilities noted based on each young adults performance during OT sessions. After observing possible clients that will be participating within the group, it was noted that the group interventions would need to be simplified and adaptable for each clients functioning level. The young adults abilities varied from non-verbal hand-over-hand assistance to minimal-moderate assistance required for physical tasks. Also, formal and informal discussions occurred about selling the crafts made within the work and social skills group at a local non-for-profit organization that supports individuals with disabilities (J. Ray, personal communication, January 22nd, 2019). The organization and store are called The Alex and Ali Foundation and The Hope Gallery. The Alex and Ali Foundation is a local foundation that empowers and enhances the lives of young adults with autism and other disabilities by providing opportunities for job skills development, vocational activities, and meaningful community involvement (The Alex and Ali Foundation, 2018). The Alex and Ali Foundation has a unique boutique called The Hope Gallery, that is run by individuals with disabilities (The Alex and Ali Foundation, 2018). The items that the individuals within the work and social skills group created during intervention sessions will be sold at The Hope Gallery (J. Ray, personal communication, February 6th, 2019). 14 Initial Screening of Clients The screening process at my DCE initially began with families reaching out by phone or email stating that their young adult would like to be involved in the program. The individuals that were interested in joining the group that were not current clients at Kids Abilities received information about the work and social skills group by a flyer that was distributed to local foundations including United Cerebral Palsy Association of Greater Indiana, The Jackson Center for Conductive Education, Johnson County Community Foundation, Autism Society of Indiana, Down Syndrome Indiana, and Morgan County Autism Foundation. Most of the clients that are interested in the group will not be able to participate in the group until summer time due to their current school schedules. The young adult and guardian filled out a client registration form to answer questions regarding: date of birth, diagnosis, address, phone number, emergency contact, allergies, medication, interests, and behaviors (Appendix A). After completion of the client registration form, the caregiver and client completed the initial screening. The initial screening was developed by the occupational therapy student with guidance from the lead occupational therapist. The initial screening was a survey that focused on communication, daily living and self-care, and social relationships. Each section had corresponding questions that are answered based on a three-point Likert scale ranging from 1) not like me, 2) somewhat like me, and 3) very much like me (Appendix B). The survey was compiled of questions that were simple and easy to comprehend for answering purposes. The OTR reviewed the survey questions and confirmed each question was geared toward asking age-appropriate basic life skills. At the end of screening, there was a corresponding open-ended question regarding what the participant would like to learn and develop during their participation within the work and social skills group. By 15 completing this screening process, it provided the group leader a clearer understanding of each clients strengths, weaknesses, and baseline level of the skills to be focused on during activities within group sessions. Also, this helped the therapists paint a holistic picture of the client prior to beginning the program. Initial Evaluation with Clients The initial evaluation process was completed with the client and caregiver after completion of the initial screening. The Child Occupational Self-Assessment (COSA) was the assessment tool used to complete the initial evaluation. The COSA is a client-centered assessment tool that is used to measure the individuals perceptions on their occupational competence and the importance of each activity they participate in on a daily basis (Keller, Kafkers, Basu, Federico, & Kielhofner, 2005). The COSA self-reported questionnaire is based on the MOHO (Kielhofner, 2008), which is the model being used to guide this project. Researchers have found that occupational therapists that use the COSA and the MOHO to guide the intervention process have shown to have a better understanding of the clients occupational competence and value for everyday activities (Kramer, Kielhofner, & Smith, 2010). Also, research indicates that using the MOHO theory to guide the evaluation process enhances the practitioners ability to accurately interpret most clients responses to the COSA (Kramer, Kielhofner, & Smith, 2010). The COSA Youth Rating Form with Symbols was used to collect data for the group participants. The prompt was read by the occupational therapy student or the guardian with the occupational therapy student present. The client answered the questions independently or the parent assisted the client with answering the questions based on the clients functional level. The Youth Rating Form with Symbols was used because the symbols were helpful for clients to be able to point at the symbol that symbolizes their expression and keeps 16 the client engaged throughout the evaluation process. By having the participant complete the COSA, the occupational therapist student gained a better understanding of each clients perception of their abilities. After reviewing the completed screenings and COSAs, I noticed some overarching themes. One theme that was noted was a lack of safety awareness and how safety is an area of concern for most parents. Another theme that was noted was that many young adults said they have a problem making others understand their ideas, and this was very important to them. This indicates that the young adults within the group have difficulty effectively communicating their needs to others and would like to improve their communication skills. The intent of the COSA for the purpose of this project was to get to know the young adults perceptions of their abilities and to find overarching themes that can be focused on within the group. In other areas of practice, such as school-based therapy or early intervention the practitioner could solely focus on individual treatment rather than group treatment. In an individualized treatment, the practitioner may have a stronger focus on the scoring of the COSA to get a baseline level for their client. For the participants within the work and social skills group, it is still important to get a baseline for each client, but it is also important to find areas of concern and areas of interests that are overlapping with other participants in the group. Understanding each clients perspective is helpful for developing interventions that best fit each clients needs within the group based on the activities that the client identified as important within their daily life. Implementation Group Craft Approval Since the work and social skills group was partnered with The Hope Gallery, the items being designed during the group interventions had to be approved by the owner of The Hope 17 Gallery before creating. This process was done to ensure that the items will sell at the boutique. I consulted with group members, my site mentor, the owner of The Hope Gallery, and other employees about possible crafts and home dcor that could be completed during the work and social skills group intervention sessions. The items that we chose were based on our group members level of function and their ability to sustain attention to a task. We came to an agreement and decided on the following items: marble tile coasters, rustic wood home signs, rustic wood paw prints, and rustic wood quote signs. Appendix C has pictures of each item that were created by group members. Work and Social Skills Group Sequence and Leadership Style The data collection indicated that the group participants would like to develop workrelated skills and enhance their communication skills with peers, which was supported by literature and the initial screening with my site mentor. Mosey (1970) described a group sequence according to the skills of interaction that are demonstrated or needed within the group. The skills of interaction that are needed within the group sequence are parallel, project, egocentric cooperative, cooperative, and mature (Mosey, 1970). The parallel phase is when the participants are completing the tasks side by side with very little or no interaction with other group members (Mosey, 1970). Project is next in the sequence. The project phase is demonstrated when group members attention is on the task but there is some interaction between the participants within the group (Mosey, 1970). Egocentric-cooperative phase follows the project phase within the sequence and is when all participants are expected to interact with each other. Next, the cooperative phase occurs when each participant is attempting to take care of other participants needs within the group. Mature is the last stage of the sequence. The 18 mature phase is demonstrated when participants assume leadership roles and address one anothers needs (Mosey, 1970). The parallel phase was demonstrated within the work and social skills group for the first three weeks of implementation. The group members solely communicated with the group leader and interaction amongst members only occurred when prompted by the group leader. The young adults in the group focused heavily on the completion of their task of designing a marble tile coaster. Interaction amongst the group members was not required to successfully complete the craft activity. Even though there was little interaction amongst the group members, I was extremely pleased as a group leader. For the group members, it was beneficial for them to get comfortable with one another and complete the task within a group setting rather than an individualized setting. The parallel phase was setting a strong foundation for the group and was continually encouraging social peer interaction. During this phase we were developing a basic level of awareness, trust, and comfort with the other members of the group. During the parallel phase, the group leadership role was to provide unconditional positive feedback to develop trust amongst the group members and the leader. This also helped each participant feel encouraged and want to engage in the task. As a group leader, I reinforced each group members behaviors appropriately. Structure to the group was provided and interaction was facilitated amongst the group leader and the members. The project phase was demonstrated throughout week four and continued throughout the length of the DCE. The project phase was encouraged by having the members complete crafts that required more peer interaction and working as a group to complete the task at hand. During the project phase, the group members designed a rustic wood home sign, rustic wood paw print sign, and rustic wood quote signs. (Refer to Appendix C for picture of items.) Each of these 19 crafts required participation of two or more people working as a cohesive group. Group interaction was emphasized, and the group project was only completed when each team worked together as a unit. The group leader had to encourage peer interaction and socialization within the group, but with consistency, the members started to form interactions beyond those that the activity required. As the group continued to progress, the members started to give each other feedback and seek assistance from one another. During the project phase, the group leadership role shifted to reinforcing cooperation, sharing, and interaction amongst the group members. Also, the leader strategically selected crafts that required more structure and had to be shared by two or more members to complete the craft. Due to the limited time frame of the DCE, the group participants did not reach the egocentric cooperative, cooperative, and mature phases of the sequence. As the group continues, the participants will hopefully continue to grow into these phases. During the completion of the implementation phase, the group leader demonstrated a directive leadership style. The OTS was responsible for the planning and structuring of the group and activities. The directive leadership style is needed when cognition, social, and verbal skills are limited in the group (Cole, 2012). This coincides with the parallel and project level within the sequence. The group leader provided clear verbal directions and demonstrated instructions to complete each task. Each member of the group received a visual outline or task analysis of the steps to complete the activity with pictures to demonstrate each step. An example of the task analysis is in Appendix D. Before completing each step of the task, the leader would point to the visual picture of which step the group member was going to complete next. Then the group leader would ask the group members questions to confirm they understood what was being asked of them and what was to be expected. 20 Also, during this time of my DCE, I continued to work on my leadership skills by demonstrating my strengths of positivity, empathy, strategic planning, and being a strong developer. With my positive attributes, I am quick to give positive reinforcement and also identify the positive aspects in each situation. Within my leadership role for the group, I celebrated every achievement and allowed for work to be fun by making the environment light and upbeat. My empathic sense of self allows me to strongly feel the emotions around me. With the work and social skills group, this helped me understand the non-verbal communication skills of the group members and helped me show empathy when someone was feeling discouraged or anticipating the need to help others before they asked. My strategic planning skills allows for me to see patterns where others solely see complexity. This allows for me to strategically adapt interventions to decrease potential obstacles that may arise. Having a developer mindset as a strength of mine has helped me see the potential in others. For that reason, I want each of the group members to experience success and help them grow. Implementation Staff Development Phase Promotion of staff development was demonstrated throughout the implementation process by training staff members on how to carry out the group interventions after the completion of the DCE. The staff member that will be taking the leadership role after completion of the DCE is the receptionist. Kids Abilities will be hiring a new receptionist and the current receptionist will be solely working with the work and social skills group with supervision and guidance from the lead OT. The completion of the training initially started with having the staff member observe the environment, each group members level of function, leadership style, peer interaction, and assistance required for each member. After observing, the staff member started to slowly be incorporated into the group and became a co-leader. By incorporating the staff 21 member as a co-leader, the staff member became competent and confident in her leadership style and understood the group dynamic. Also, to encourage staff development, I completed a craft guideline booklet for continuation of the implementation phase. The craft guideline booklet has an outline of supplies needed, space demands, and activity analysis with pictures. An example of the craft guideline booklet is in Appendix E. Discontinuation The main focus of this DCE and project was to develop a program that promotes work and social skills for young adults with disabilities through group interventions. Interventions in the group sessions focused on offering adaptive solutions to increase the clients occupational performance and engage in newly developed occupations and roles that are geared toward social interaction with peers and work-related skills. A long-term goal that I established is that the group will continue to expand, the group members will continue to enhance their work related skills, social interaction skills, and continually ensure quality group interventions once my DCE is completed. After determining the needs of the organization and completing a literature review to assess needs in regards to young adults with disabilities and their social and work performance, it was determined that creation of a work and social skills group for young adults with disabilities was necessary for this population. As the DCE has ended, it was necessary to plan accordingly for the future of the work and social skills group and include continuous quality improvement (CQI). CQI is an ongoing effort to address and document outcomes to improve the health of the community (Bonnel and Smith, 2018, p. 46). There are multiple components that are essential for CQI such as reflecting, evaluating, receiving feedback, teamwork, and responding to changing needs (Bonnel and Smith, 2018). 22 To incorporate CQI the student discussed with the site mentor recommendations and analysis outcomes within the group. It was important to review outcomes and discuss recommendations in preparation for the future of the group. The site mentor and owner of the facility provided recommendations to increase effectiveness and sustainability for the group after completion of the DCE project, while also incorporating new craft activities that can be completed as interventions with the group. This promotes the importance of remaining clientcentered and increasing carryover for the group members in other community settings. Project outcomes were collected over the last several weeks of implementation. One outcome noted throughout the implementation phase was an increase in peer interaction both verbally and non-verbally. The first intervention session, no verbal or non-verbal communication amongst peers was voluntarily demonstrated unless prompted by the leader. As the intervention sessions continued, group members started to communicate voluntarily both verbally and nonverbally. The amount of social interaction cues from the group leader drastically changed as the weeks of implementation continued. During the first week of implementation, maximal assistance for verbal communication amongst peers was needed and at the end, minimal cueing from the leader was required to encourage engagement with peers. This has been a vital part of the program because the members of the group are rarely encouraged to participate in peer interaction or participate in a community or group setting. Social interaction is important to participate in during each session because it is required to collectively make the home dcor craft during the interventions. Another outcome that was noted throughout the implementation phase was a decrease in redirecting attention to remain engaged with the task being completed during the interventions. Each group member showed an increase in sustained attention to task and willingness to complete the work-related skills during each group implementation session. By 23 willingly engaging in each work-related task, carryover to other work-related skills should be noted in other environments. The student also completed a cost analysis spreadsheet and presented the findings to the owner of Kids Abilities. The cost analysis was a requirement added at the end of the DCE but was important for the continuation of the work and social skills group. Due to the building of Kids Abilities being small in size, the owner was trying to decide on whether or not she should invest in a small cabin that can be solely for the purpose of work and social skills groups. The cost analysis spreadsheet broke down the cost of each craft that the work group has designed, comparative day program cost, and how much money the work group must make or charge to break even. The cost analysis spreadsheet gave the owner a clear understanding of how much the crafts cost to make, how much each participant should be charged per group session, how much a small cabin will cost monthly, and how many group members must be a part of the group to break even. After reviewing the presented cost analysis spreadsheet, the owner of Kids Abilities is preparing to invest in a small cabin for the work and social skills group. Appendix F provides an outline of the cost analysis. Another incorporation of CQI is the craft guideline booklet. The craft guideline booklet will be used to educate the new group leader as well as give each group member instructions to follow for each desired craft. An example handout of the craft guideline booklet is in Appendix E. Responding to Societys Needs The program development of this DCE has addressed the societal needs of a work and social skills group for young adults with disabilities. Overall unemployment rates for individuals with disabilities go largely unrecognized and continue to fall behind those without disabilities 24 (Lindstorm, Doren, & Miesch, 2011). The reality of employment for young adults with a disability is that employment is limited in the number of opportunities. A relatively small portion of adults with severe intellectual disabilities, autism, or multiple disabilities are exposed to paid work experiences. When and if these work experiences do occur, the individuals with disabilities work for low wages, are provided only a few weekly hours, and take place in segregated settings with little social interaction (Carter, Austin, & Trainer, 2012). By being a member of this group, Kids Abilities is addressing societal needs by allowing these young adults to build the performance skills that may be necessary for the desired occupational performance to sustain a job or career. Each group intervention required the group members to collaboratively make pieces of home dcor that required social interaction to engage with other group members. Also the interventions required building work-related skills such as sequencing, following directions, sustaining attention to the task, memory, and processing skills. Overall Learning The program development through my DCE has helped me grow in a personal manner and professional manner. I have improved my communication skills, confidence, leadership skills, knowledge, professionalism, and enhanced my occupational therapy practitioner skills in a group setting. Communication is essential for a business or program to succeed especially in the healthcare field. During my DCE, I was provided with the opportunity to improve my oral, nonverbal, and written communication skills in a multitude of ways. A few examples of how I improved my communication skills are social interaction with parents, advocating for the group, recruiting group members, presenting my findings to staff members and owner, and training the new group leader. A few examples of written communications that I utilized in a professional manner during my DCE was sending emails and flyers. Verbal communication was 25 demonstrated in a professional manner by advocating for the continuation of group services by presenting a cost analysis to the owner of Kids Abilities and collaboratively speaking with other disciplines in preparation for the group. Because of this experience, I feel I am more confident in my abilities to be an occupational therapist. By taking on this leadership role with little guidance throughout the process, it has given me a better understanding of what my career will be like transitioning from the student role to an occupational therapist role in the near future. Growing as a leader has been a vital part throughout this DCE and has helped me become more confident in applying the skills and clinical reasoning that I have learned during my time as an occupational therapy student. Working directly with these individuals during my DCE has helped me increased my confidence in effectively adapting each intervention plan to accommodate individual group member needs while maintaining client-entered and occupational-based services. Not only have my leadership skills as a new practitioner evolved, but also I developed into a leader that takes the initiative to go above and beyond. I have done this by not looking to or asking my site mentor for constant guidance but rather come to her with my findings or ideas. Initiation is something I have always struggled with in my personal and professional life. Another weakness of mine has been being assertive in a leadership role. During this DCE, I have enhanced my initiation skills and ability to be assertive when needed. Finally, another area of leadership that I have enhanced during this time is being a directive leader. In the work and social skills group, I have used a directive leadership style with the group members during each intervention session. Overall, from this DCE I have learned many valuable skills that not only will be beneficial for my future as an occupational therapist but also have been beneficial for the clients within the work and social skills group and Kids Abilities. I have excelled in communication 26 skills with clients, caregivers, and other disciplines and gained vital experience that has helped me with my professionalism as a practitioner. I am thankful for this experience and Kids Abilities for their willingness to help me succeed. 27 References Bennett, K. D., & Dukes, C. (2013). Employment instruction for secondary students with autism spectrum disorder: A systematic review of the literature. Education and Training in Autism and Developmental Disabilities, 48, 6775. Benz, M. R., Lindstrom, L., & Yovanoff, P. (2000). Improving graduation and employment outcomes of students with disabilities: Predictive factors and student perspectives. Exceptional Children, 66, 509529. Bonnel, W. & Smith, K.V. (2018) Proposal writing for clinical nursing and DNP projects, Second edition. New York: Springer Publishing Company. Bureau of Labor Statistics. (2019, February 26). Persons with a disability: Labor force characteristics 2018. Retrieved from https://www.bls.gov/news.release/pdf/disabl.pdf Carter, E., Austin, D., & Trainer, A. (2012). Predictors of postschool employment outcomes for young adults with severe disabilities. Journal of Disability Policy Studies, 23 (1), 50-63. doi: 10.1177/1044207311414680 Cole, M.B., & Tufano, R. (2008). Applied theories in occupational therapy: A practical approach. Thorofare, NJ: SLACK, Inc. Cole, M. (2012). Group dynamics in occupational therapy: The theoretical basis and practice application group intervention (4th ed.). Thorofare, NJ: Slack. Donkervoort, M., Wiegerink, D., Meeteren, J., Stam, H., & Roebroeck, M. (2008). Transition to adulthood: Validation of the Rotterdam transition profile for young adults with cerebral palsy and normal intelligence. Developmental Medicine & Child Neurology, 51, 53-62. Dunst, C. J., Bruder, M. B., Trivette, C. M., Raab, M., & Mclean, M. (2001). Characteristics and consequences of everyday natural learning opportunities. Topics in Early Childhood 28 Special Education, 21, 6892. doi: 10.1177/027112140102100202 Dussen, L., Nieuwstraten, W., Roebroeck, M., & Stam, H. (2001). Functional level of young adults with cerebral palsy. Clinical Rehabilitation, 15, 84-91. Hirst, H. (1983). Young people with disabilities: What happens after 16? Child, 9, 273284. Humphry, R., & Wakeford, L. (2006). An occupation-centered discussion of development and implications for practice. American Journal of Occupational Therapy, 60, 258267. doi: 10.5014/ajot.60.3.258 Kids Abilities Pediatric Therapy. (2017). Retrieved from https://www.kidsabilitiesindiana.com/ Kielhofner, G. (2008). Model of Human Occupation Theory and Application. (4th Ed.). Baltimore: Lippincott Williams & Wilkins. Keller, J., Kafkers, A., Basu, S., Federico, J., & Kielhofner, G. (2005). Child Occupational Self Assessment (COSA) Version 2.1. Chicago: University of Illinois at Chicago. Kramer, J., Kielhofner, G., & Smith, E. (2010). Validity evidence for the Child Occupational Self Assessment. American Journal of Occupational Therapy, 64, 621-632. doi: 10.5014/ajot.2010.08142 LeVesser, P., & Berg, C. (2011). Participation pattern in preschool children with autism spectrum disorder. OTJR: Occupation, Participation and Health, 31, 3339. doi: 10.3928/15394492-20100823-01 Lindstorm, L., Doren, B., & Miesch, J. (2011). Waging a living: Career development and longterm employment outcomes for young adults with disabilities. Council for Exceptional Children 77, 423-434. Morley, L., & Cashell, A. (2017). Continuing medical education collaboration in health care. Journal of Medical Imaging and Radiation Sciences 48, 207-216. 29 Mosey, A. (1970). The concept and use of developmental groups. American Journal of Occupational Therapy, 24, 272-275. Orsmond, G. I., Krauss, M. W., & Seltzer, M. M. (2004). Peer relationships and social and recreational activities among adolescents and adults with autism. Journal of Autism and Developmental Disorders, 34, 245256. doi: 10.1023/B:JADD.0000029547.96610.df Rao, P., Beidel, D., & Murray, M. (2007). Social skills interventions for children with Aspergers syndrome or high-functioning autism: A review and recommendations. Journal of Autism and Developmental Disorder, 38, 353-361. doi: 10.1007/s10803-0070402-4 Rodger, S., & Umaibalan, V. (2011). The routines and rituals of families of typically developing children compared with families of children with autism spectrum disorder: An exploratory study. British Journal of Occupational Therapy, 74, 2026. doi: 10.4276/030802211X12947686093567 Scaffa, M. E. & Reitz, S.M. (2014). Occupational therapy in community based practice settings (2nd ed.). Philadelphia: F.A.Davis. Schkade, J. K., & Schultz, S. (1992). Occupational adaptation: Toward a holistic approach for contemporary practice, Part 1. American Journal of Occupational Therapy, 46, 829-837. Shandra, C., & Hogan, D. (2008). School-to-work program participation and the post-high school employment of young adults with disabilities. Journal of Vocational Rehabilitation, 29, 117130. Stevenson, C., Pharoah, P., & Stevenson, R. (1997). Cerebral palsy the transition from youth to adulthood. Developmental Medicine and Child Neurology, 39, 33642. Szatmari, P., Bartolucci, G., & Bremmer, R. (1989). Aspergers syndrome and autism: 30 Comparison of early history and outcome. Developmental Medicine and Child Neurology, 31, 709720. Symanski, E., Enright, M., Hershenson, D., & Ettinger, J. (2003). Career development theories, constructs and research: Implications for people with disabilities. Work and disability: Issues and strategies in career development and job placement, 87132. The Alex and Ali Foundation. (2018). Retrieved from https://www.thealexandalifoundation.com/ Thomas, A., Bax, M., Coombes, K., Goldson, E., Smyth, D., Whitmore, K. (1985). The health and social needs of physically handicapped young adults: Are they being met by the statutory services? Developmental Medicine and Child Neurology, 50, 1-20. Venter, A., Lord, C., & Schopler, E. (1992). A follow-up study of high-functioning autistic children. Journal of Child Psychology & Psychiatry & Allied Disciplines, 33(3), 489 507. Weaver, L. L. (2015). Effectiveness of work, activities of daily living, education, and sleep interventions for people with autism spectrum disorder: A systematic review. American Journal of Occupational Therapy, 69, 6905180020. doi: 10.5014/ajot.2015.017962 31 Appendix A Work and Social Skills Group Date: _____________ Name: _________________________________ DOB: _________________ Diagnosis (if any): ______________________________________________________________ Address: ______________________________________________________________________ Phone #: _________________________________ Parents Name: ________________________________________________________________ Emergency Contact: _____________________ Relation: _______________________________ Parents Address (if different from above): ___________________________________________ ______________________________________________________________________________ Email: ________________________________________________________________________ Allergies: _____________________________________________________________________ Medications (if necessary): _______________________________________________________ Any Additional Information (Interests, Behaviors, etc.): 32 Appendix B Screening Knowledge and Behavior: Please circle the number (1, 2, or 3) that describes you best: Not like me Somewhat like me Very much like me Communication: 1. I can explain how I am feeling (angry, happy, worried, or depressed) 1 2 3 2. I ask for help when I need it 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 3. I talk over problems with friends 4. I clearly state my ideas to others 5. I show good listening skills 33 Daily Living & Self-Care: Not like me Somewhat like me Very much like me 1. I am able to use things in the kitchen, like the microwave, electric mixer, or oven 1 2 3 2. I can feed myself using a fork and spoon 1 2 3 3. I am able to clean my living space 1 2 3 4. I can bathe or shower by myself 1 2 3 5. I am able to do my own laundry 1 2 3 6. I can follow basic fire prevention and safety rules 1 2 3 1 2 3 1 2 3 7. I am able to dress myself 34 Social Relationship: 1. I am polite to others 2. I respect other peoples things 3. I show appreciation for things others do for me 4. I can safely interact with others on the internet 5. I deal with anger without using violence 6. I have friends that I spend time with weekly Write a few skills that you would like to learn and develop during your participation within our work and social skills group. __________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ 35 Appendix C 36 Appendix D Sharpie Watercolor Tiles 1. Put cork sticker on back of tile 2. Color tile with sharpies 3. Drop alcohol on tile 37 4. Let dry 38 Appendix E PAW Print Sign Supplies: 8x6 pine wood Cricut cut out paw print (4 height) Wood stain Paint brushes (2 1.5) Old t-shirts or rags White paint Transfer tape Teeth Hangers Hammer Gloves Velcro Space Demands: Table Chairs Adequate lighting Electric fan (for ventilation) Non-carpet floors Large room (at least 10x12 space) 39 1. Put on gloves 2. Stain wood with paint brush (including sides) 2. Rub stain in with rag 4. Let wood dry 40 5. Place Paw print on wood 6. Paint white on board 7. Rub with rag before white paint is dry 41 8. Lightly sand board 9. Use nails and hammer for teeth hanger on back of board 10. Peel off paw print 42 Appendix F Cost Analysis for Kids Abilities Work and Social Skills Group Tile Coaster Items: Self-Adhesive Cork Squares 50 count 4x4 white ceramic subway tiles 100 count Sharpie Permanent Markers 24 count Rubbing alcohol Pipette Dropper Price: $9.99 Link to buy: amazon link $49.99 (Set of 10 roughly $15 on amazon) amazon link $13.39 amazon link $2.50 $.50 Total coast to make 100 tiles: $86.39 (tax not included; sharpies, alcohol, and dropper included in cost) Retail price: $3 per tile coaster = $300 for all tile coasters Profit per 100 tile coasters = $213.61 (this profit could increase based on if supplies are already bought or donated) Average time to make one tile coaster: 20 minutes 43 HOME Dcor Sign Items: 1 piece of pine wood 7.58x24 Paint brush 2 Wood Stain pint White primer or paint Sand paper Sawtooth hangers O wood seasonal pieces Colored acrylic paint set of 18 Cricut Vinyl 12x15 Velcro 1x32 Price: $7.50 for 3 24 boards $2.50 $1 Prices vary, average cost $7 Sample size $1 Varies in prices, $11 for 24 pack 120 pcs, $7.88 Jens husband J free, Hobby lobby cost varies .44 -$1.50 $18.36 Going to use what we have before buying more $11.65 $12.99 Link to buy: Lowes Michaels Lowes Lowes Lowes amazon link amazon link Hobby Lobby, JoAnn Fabrics, Michaels amazon link amazon link amazon link Total cost to make 1 HOME dcor sign: $10 (this includes 5 wood seasonal pieces) Retail price for 1 HOME sign dcor: $35 (including 5 wood seasonal pieces) Profit per home sign = $25 Average time to make each sign: 2-day process; 2 hours. 44 Comparative Cost & Reimbursement Average cost per day for adult day care is $70 Medicaid Waiver: - Does it have to be led by registered therapist? - Can this be covered by insurance? Average for rent-to-own cabin per month is $250 Need to have 5 total participants weekly in group at the cost of $12.50 for two hours to break even. (This is if we are continuing only one time a week on Thursdays for 2 hours) Say in theory, Kids Abilities is paying group leader $12 an hour, you will need seven participants in group weekly at the same rate of $12.50 for 2 hours to break even. (This price does not include extra time to pay the group leader for set-up and clean-up.) If the work group meets three days a week for four hours a day at the rate of $25 per person = $75 a week per person $75 x 5 people = $375 $375 x 4 weeks (1 month) = $1500 Group leader is being paid $12 an hour for 6 hours a day (1 hour extra for set-up and 1 hour extra for clean-up) 3 days a week $12 x 18 weekly hours = $216 $216 x 4 weeks (1 month) = $864 $1500 (participant monthly profit) $864 (group leaders monthly paycheck) = $636 $250 (rent-to-own monthly cost for cabin) = $386 profit per month for profit and material cost. TO BREAK EVEN: 4 participants for 4 hours 3 days a week profit = $1200 Group leader cost for 18 hours paid time per week = $864 Rent-to-own month cost = $250 $1200-864-250=$86 Must have 4 participants in group consistently to break even 45 Rentals Rent to own Cabins: http://www.tristateminibarns.com/miller-barns/cabins/ - Cost for a 10x20 per month is $180.75 for 48 months Rent to own cabin http://www.tristateminibarns.com/miller-barns/rustic-country-cabin/ - Cost for a 12x16 is $187.50 per month or 12x20 is $218.00 per month for 48 months 46 Cabin for sale does not say if they offer a rent to own program on website. http://www.sherenesfivestarbarns.com/Storage-Sheds-Pricing-Indianapolis-IN.html - 10x16x11.6 cottage $2749.00 http://www.built-riteexpressllc.com 47  ...

... Running head: THE IMPORTANCE OF UPDATED PATIENT EDUCATION MATERIALS 1 The Importance of Updated Patient Education Materials and Subsequent Influence on Home Exercise Programs Alyson M. Barnes May 2019 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: Erin Peterson DHSc, OTR, CHT THE IMPORTANCE OF UPDATED EDUCATION MATERIALS A Capstone Project Entitled The Importance of Updated Patient Education Materials and Subsequent Influence on Home Exercise Programs 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 Alyson M. Barnes, OTS Approved by: Faculty Capstone Advisor Date Doctoral Capstone Coordinator Date Accepted on this date by the Chair of the School of Occupational Therapy: Chair, School of Occupational Therapy Date 2 THE IMPORTANCE OF UPDATED EDUCATION MATERIALS 3 Abstract The current project was completed within a Doctoral Capstone Experience at a Community Health Network outpatient clinic that specializes in upper extremity rehabilitation. The objective of this project was to further develop a home exercise program while implementing quality improvement strategies. The needs of the site were assessed via survey which was sent to ten occupational therapists within Community Health Network with a 50% response rate. Based on the needs assessment, the home exercise program system (HEP2GO) required updating to include more hand-specific, diagnosis-specific, and occupation-based exercises, as well as additions that supported health literacy. Using relevant databases, current protocols, and expertise from veteran occupational therapists, the most effective exercises were added to the system as photos and/or videos. Diagnosis-specific programs were created for the following conditions: lateral epicondylitis, medial epicondylitis, carpal tunnel syndrome, carpometacarpal osteoarthritis, and DeQuervains tenosynovitis. In addition to these diagnosisspecific programs, several other exercise programs were created to target cervical stretching, proximal strengthening, as well as active range of motion, passive range of motion, and strengthening protocols for the upper extremity. Occupational therapists at this site verbalized an overall positive response. Additionally, patients stated that they found the exercises easy to understand and benefitted from the video representations. The updated home exercise programs created within this project are now implemented and utilized at several Community Health Network locations. THE IMPORTANCE OF UPDATED EDUCATION MATERIALS 4 The Importance of Updated Patient Education Materials and Subsequent Influence on Home Exercise Programs The primary program evaluator and developer is an Occupational Therapy Doctoral student from the University of Indianapolis, working in conjunction with faculty mentor Dr. Erin Peterson, DHSc, OTR, CHT and site mentor Valerie Goodwin, OTR. The current study was completed as a Doctoral Capstone Project at an outpatient clinic with Community Health Network. This outpatient location specializes in upper extremity rehabilitation. The objective of this project was to further develop a home exercise program while implementing quality improvement strategies. At this site, the current home exercise program system (HEP2GO) required updating to include more hand and occupation-based exercises. While there is substantial client improvement within the clinic, there are also findings to support the idea that home exercise programs can be just as impactful (Sen, 2014; Valdes, 2015). These findings validate the need for excellent home exercise programs. Theoretical Background When examining this issue, the Person-Environment-Occupational-Performance (PEOP) model was used as an overarching guide to inquiry. This model was chosen based on its emphasis on occupation and occupational performance. Within the PEOP model, a person shows function when he or she expresses a level of competency in his or her ability to perform and master occupations (Cole & Tufano, 2008). Intervention strategies for the PEOP include the following: increase occupational performance competency and overall well-being, understand the role of the environment as it affects a person's participation in meaningful activities, improve occupational performance by managing occupations for meaningful participation and mastery, adapt or modify occupations to match the abilities of the client, and teach compensatory THE IMPORTANCE OF UPDATED EDUCATION MATERIALS techniques (Cole & Tufano, 2008). All of these interventions have an occupational element that could be beneficial in a hand clinic, and this model could guide service delivery in a more occupation-based direction. To guide the everyday progress and analysis, a biomechanical frame of reference was used. The biomechanical frame of reference is utilized frequently in hand clinics due to the nature of the most commonly seen diagnoses. Many assessments and determination of progress are documented via biomechanical measures. Within this frame of reference, function involves maintaining strength, endurance, and ROM within normal limits (Cole & Tufano, 2008). Function can also include knowledge and use of good body mechanics within occupations to prevent further injuries (Cole & Tufano, 2008). The biomechanical frame of reference plays a vital role in hand therapy. Literature Review Several factors must be considered when analyzing the current HEP2GO. At present, the home exercise programs being used by the site are outdated. They are currently using handouts of two-dimensional drawings to meet this need. The site occasionally uses HEP2GO, but this system often lacks current, hand and occupation-based exercises. The lack of appropriate and updated patient education materials may be due to several factors, including the following: high productivity standards have taken precedence over program enhancement, lack of task designation within job descriptions, and/or desire to maintain routine and comfort levels with existing program. The American Occupational Therapy Association (AOTA) Code of Ethics states that occupational therapy practitioners must diligently maintain high standards and competency within all practice and research (AOTA, 2015), including patient education. Patient 5 THE IMPORTANCE OF UPDATED EDUCATION MATERIALS 6 educational materials should be updated regularly to promote beneficence and procedural justice within practice (AOTA, 2015). Occupation-Based The current system and outpatient rehabilitation process lacks the use of occupation. Colaianni and Provident (2010) found that 97% of participating practitioners believed that occupation-based interventions were valuable to hand therapy clients, but only 41-50% used occupation-based activities within practice. In another study, Earley and Shannon (2006), found that occupation-based treatment provided immediately to an acute upper extremity condition resulted in decreased pain and improved functional range of motion. The use of occupation is crucial to client recovery and engagement and acts as a fundamental aspect of the occupational therapy profession. Need for Inclusivity The current HEP2GO system must also be inclusive to all populations, utilizing concepts of health literacy. Researchers have analyzed health-related materials in relation to the intended audience. It was found that 89% of patient education materials were at or above a 9 th grade reading level, whereas, most participants receiving these materials were at a 7 th grade reading level or below (Cotugna, Vickery, & Carpenter-Haefele, 2005). Health literacy can be a major barrier to patient compliance, progress within therapy, and can even have psychological effects such as poor self-esteem (U.S Department of Health and Human Services, 2010). Valdes (2018) found that patients actually preferred videos demonstrating home exercises as opposed to written materials. Medline Plus provides a helpful format when creating easy-to-read materials (U.S. National Library of Medicine, 2017). When the following factors are considered, it can result in greater health literacy: knowing the audience, analyzing language used, incorporating the use of THE IMPORTANCE OF UPDATED EDUCATION MATERIALS 7 visual representation, and evaluating and re-evaluating materials until deemed appropriate (U.S. National Library of Medicine, 2017). In general, the current home exercise program must be restructured and must promote health literacy strategies to ensure social justice for all recipients. Lack of Variety The current system also lacks variety and contains only a limited selection of hand exercises. Studies have shown that stretching, conservative management, concentric strengthening, and eccentric strengthening all have positive effects on clinical outcomes for certain diagnoses (Martinez-Silvestrini et al., 2005). A variety of exercises have been shown to benefit functional performance (Martinez-Silvestrini et al., 2005). This emphasizes the need for a diverse inventory of home exercises so that programs can be individually tailored to each clients needs and abilities. Diagnosis-Specific Programs Along with the concept of having a more diverse inventory, the current HEP2GO would benefit from diagnosis specific programs. This would enable therapists to easily access the most effective exercises for that specific diagnosis. Hand clinics often encounter the following diagnoses: fractures, carpal tunnel syndrome (CTS) or other peripheral nerve injuries, lateral epicondylitis, rheumatoid arthritis (RA), osteoarthritis (OA), DeQuervains tenosynovitis, trigger finger, and other tendon injuries/transfers. When updating the HEP2GO, the common diagnoses and most effective exercises must be analyzed. Fractures. A distal radial fracture is one of the most common injuries seen in upper extremity clinics. This most often occurs during a fall on an outstretched hand (Meena et al., 2014). This type of injury can result in pain, range of motion deficits, and residual scar tissue (Meena et al., 2014). Krischak et al. (2009) found that patients with distal radial or boxers THE IMPORTANCE OF UPDATED EDUCATION MATERIALS 8 fractures benefited from contralateral strengthening during the immobilization phase. This exercise correlated with a quicker recovery of grip strength of the involved hand (Krischak et al., 2009; Roll & Hardison, 2017). Additionally, Gulke et al. (2018)found that the following implementations and exercises had a positive impact on metacarpal fracture rehabilitation: scar massage, Chamomile baths, decongestive exercises, composite flexion/extension, close and open safe positioning of hand, shoulder flexion with elbow, wrist, and finger extension with transition to arm at side with wrist flexed, rolling up a pen into a hook fist, pinching a clothespin, and exercises using a squeeze ball. Carpal Tunnel Syndrome. As inflammation occurs within the carpal tunnel, pressure can develop on the median nerve (American Society for Surgery of the Hand, 2015). This condition is often caused by overuse, lack of properly used ergonomic principles, and/or swelling from another upper extremity injury or even from pregnancy (American Society for Surgery of the Hand, 2015). CTS can cause numbness and tingling within the radial side of the hand. Patients with CTS may experience a decrease in symptoms when neural glides are incorporated into therapy programs (Peters et al., 2013; Roll & Hardison, 2017). Sensory symptoms related to CTS can also be relieved via self-massage techniques (Goransson & Cederlund, 2011; Roll & Hardison, 2017). Lateral Epicondylitis. Lateral epicondylitis involves inflammation at the origin of the wrist extensors due to overuse and repetitive movements of the forearm. Lateral epicondylitis can result in pain and decreased functional performance. Smidt et al. (2002) compared patients with lateral epicondylitis by analyzing a group who received corticosteroid injections, a group that received therapy, and a control group. The study found that patients who completed therapy exercises had better functional outcomes (Smidt et al., 2002). These exercises included slow but THE IMPORTANCE OF UPDATED EDUCATION MATERIALS 9 progressive wrist and forearm stretching, muscle conditioning, and occupational exercises (Smidt et al., 2002). Arthritis. OA is the most common form of arthritis. This condition involves the everyday wearing away of the cartilage surrounding the bone (Mayo Foundation for Medical Education and Research, 2019). RA is different in that it is a systemic condition that causes inflammation within synovial membranes. These synovial membranes help lubricate joint movement (Mayo Foundation for Medical Education and Research, 2019). Both OA and RA can cause pain, deformities, and range of motion deficits. Patients with RA demonstrated improved functional performance when provided with a home exercise program that included strengthening and stretching, as opposed to stretching alone (O'Brien, Jones, Mullis, Mulherin, & Dziedzic, 2005; Roll & Hardison, 2017). Cima et al. (2013) compared a group of patients with RA. One group completed hand exercises at home and at the clinic. The control group completed hand exercises only in the clinic. These exercises included the following: motor-coordination exercise with finger extension, flexion-extension of the wrist, pronation-supination, flexionextension of the thumb interphalangeal joint, radial and ulnar deviation, Digi-flex hand exerciser, flexed fingers squeezing exercise putty, exercises for intrinsic muscles with exercise putty, tip pinch performed with all fingers pulling an elastic, and exercises for hand intrinsic muscles with elastic (Cima et al., 2013). When comparing the two groups, the group completing the set of exercises at home had significantly better outcomes than the control group (Cima et al., 2013; Lamb et al., 2017). Stenosing Tenosynovitis. DeQuervains tenosynovitis is a result of inflamed tendons within the first dorsal compartment of the hand. This condition is often caused by repetitive radial abduction of the thumb and ulnar to radial deviation of the wrist (Statteson & Tannan, THE IMPORTANCE OF UPDATED EDUCATION MATERIALS 10 2017). Trigger finger is similar in that it also involves the inflamed tendons within the hand, but at the site of the A1 pulley, typically affecting the third or fourth digit (Mayo Foundation for Medical Education and Research, 2019). Papa (2013) conducted a study using the following exercises to treat DeQuervains tenosynovitis: thenar muscle group stretches, forearm extensor/flexor stretches, eccentric unweighted hammer curls, eccentric weighted hammer curls, eccentric thumb extension and abduction exercises with elastic band, eccentric wrist extension/flexion with dumbbell, and eccentric forearm pronation/supination with Theraband (Papa, 2013). When these exercises were done routinely, they provided positive results, including decreased pain in the radial hand (Papa, 2013). Tendon Repairs. Tendon injuries are often a result of various types of trauma to either the flexors or extensors and are typically repaired surgically. Tendon repairs can cause stiffness and decreased mobility. Within the healing process, scar tissue may develop near the repaired tendons, resulting in tendon adhesions. Patients with tendon injuries/transfers often have positive outcomes when early motion protocols are incorporated into therapy programs (Chesney, Chauhan, Kattan, Farrokhyar, & Thoma, 2011; Roll & Hardison, 2017; Sultana, MacDermid, Grewal, and Rath, 2013). Additionally, after a zone-II flexor tendon repair, active motion therapy resulted in greater outcomes compared to passive motion therapy (Trumble et al., 2010). Rostami, Arefi, and Tabatabei (2013) found that mirror-based home exercise programs can be beneficial to patient outcomes when addressing diagnoses involving range of motion deficits in the upper extremity. Overall, it is imperative that the literature be considered when updating the current HEP2GO at this site. Each upper extremity condition varies in etiology, symptoms, deficits, and course of treatment. Therefore, a wide array of literature must be explored when updating the THE IMPORTANCE OF UPDATED EDUCATION MATERIALS 11 system. The literature will act as a guide so that the most effective exercises for each upper extremity condition will be added to the HEP2GO system. Screening and Evaluation In order to identify the specific needs of the facility, all occupational therapy clinicians were given an online survey via work email. This survey included a variety of multiple choice, checklist, and open-ended questions to further explore the needs of the clinicians regarding the current HEP2GO system. Due to demanding work schedules, only 50% of occupational therapists were able to return the survey, posing a limitation to this project. Nonetheless, significant and meaningful data were collected and analyzed. When rating the current HEP2GO system, 40% of the clinicians reported fair satisfaction and 60% reported good satisfaction. Frequency of use varied between less than once a month, once a month, and several times a week. When asked what they like least about the current system, the clinicians stated that HEP2GO is very physical therapy focused and lacks handspecific exercises. Often, there is not an image that correctly displays the desired exercise, or if there is an image, the quality and angle may be questionable. Additionally, some of the exercise descriptions can be confusing for patients. The clinicians agreed that they desire a more timeefficient and diagnosis-specific database. When the clinicians were asked what they liked most about the current system, they stated that it is easy to edit, organize, print, text, or email programs to patients. They also stated that it is helpful to have actual images of people performing the exercises as opposed to stick figures or drawings. The clinicians reported that patient adherence to home exercise programs was also an issue. As far as patient barriers, the clinicians identified time management as the biggest barrier, along with language, culture, health literacy, pain, and discomfort. According to clinician report, THE IMPORTANCE OF UPDATED EDUCATION MATERIALS 12 this site encountered several different ethnicities, with the majority of patients being Caucasian, African American, Hispanic or Latino. This site occasionally encountered Burmese, Native American, or Asian ethnicities. When discussing education, the clinicians believed the average education level of most patients ranged from high school education to some college. According to the clinicians, patients typically had access to exercise bands and exercise putty, but fewer had access to dumbbells or wrist weights. However, one clinician noted that patients are often willing to buy dumbbells. When asked what type of exercises they would like to see added to the database, the clinicians replied with the following: diagnosis-specific exercises, nerve glides, tendon glides, thumb carpometacarpal (CMC) exercises within confines of splint, strengthening programs with progressions, reverse blocks, digital range of motion, weight-bearing and strengthening with exercise putty, progression of thumb and wrist deviation exercises, edema control techniques, intrinsic strengthening, and self-manual therapy such as scar massage, retrograde massage, and passive range of motion. In addition to these suggestions, 100% of the clinicians agreed that the current system would benefit from more occupation-based exercises. When asked to identify the most common diagnoses seen, 100% of the clinicians reported treating distal radial/ulnar fracture and DeQuervains tenosynovitis; additionally, 80% reported often treating carpal tunnel syndrome, lateral epicondylitis, medial epicondylitis, and cubital tunnel syndrome. Furthermore, 60% of clinicians reported that they often treat trigger finger, osteoarthritis, Dupuytrens contracture, and scaphoid fracture. During review and analysis of the clinician responses, four areas of improvement were defined. The clinicians desired the HEP2GO system to include: 1.) exercises that are handspecific, 2.) organized by diagnosis, 3.) occupation-based, and 4.) be clear and inclusive to all THE IMPORTANCE OF UPDATED EDUCATION MATERIALS 13 populations served. A variety of exercises have been shown to benefit functional performance, however, the success of these exercises depends on the diagnosis being treated (MartinezSilvestrini et al., 2005). Therefore, hand and diagnosis-specific exercises were necessary to include in the HEP2GO system. It was also critical that the HEP2GO system include more occupation-based exercises. Occupation is a fundamental concept within the occupational therapy profession (AOTA, 2014). Furthermore, Colaianni and Provident (2010) stated that whereas some exercises can mimic occupation, only functional task completion can provide the precise movements required for occupational performance. When discussing inclusivity and clarity of patient home exercise programs, the clinicians believed that health literacy and language can be barriers for patients. Cotugna, Vickery, and Carpenter-Haefele (2005) found that most patient education materials are at a higher reading level than a patients level of comprehension. Not only can this impact patient compliance and progress within therapy, but it can even cause poor self-esteem (U.S Department of Health and Human Services [HHS], 2010). These findings demonstrate the need to restructure the current system to include clear and inclusive home exercise programs. The screening and evaluation process within this project may vary from other occupational therapy settings. Typically, the screening and evaluation process primarily involves recipients of occupational therapy. Within this project, the primary clients are the occupational therapy clinicians. The occupational therapy recipients, or patients, are the secondary clients within this project. The essential occupation of the occupational therapy clinicians is patientcare. In order to optimize patient-care at this facility, it was evident that the clinicians desired a better HEP2GO system. This request was to not only provide convenience for themselves, but above all, benefit their patients. The plan for this project encompassed a create/promote THE IMPORTANCE OF UPDATED EDUCATION MATERIALS 14 approach. This approach is different from other settings, as traditional settings tend to favor restoration and modification approaches. An updated home exercise programs must be created to address the needs of the facility as well as promote occupation, health literacy, and evidencebased practice. Additionally, the project utilized a Person-Environment-OccupationalPerformance perspective and was highly influenced by the biomechanical frame of reference. While the biomechanical lens is occasionally used in other occupational therapy settings, it acts as a fundamental feature of evaluation and re-evaluation within hand clinics. Implementation Based on the current literature and needs assessment, it was determined that the site required updated home exercise programs within the HEP2GO system. Throughout my time at this site, I was able to collaboratively create with my site mentor an updated home exercise program for the conditions of lateral epicondylitis, medial epicondylitis, carpal tunnel syndrome, carpometacarpal (CMC) osteoarthritis, and DeQuervains tenosynovitis (Appendix A). In addition to these diagnosis-specific programs, I also created exercise programs to target cervical stretching, proximal strengthening, wrist passive range of motion (PROM), wrist active range of motion (AROM), hand AROM, thumb AROM, thumb PROM, thumb isometrics, elbow AROM, elbow PROM, elbow strengthening, strengthening with exercise putty, and fine motor control (Appendix B). Within each of these programs, clarity of instructions was examined and edited by multiple occupational therapy clinicians throughout Community Health Network to promote health literacy. These exercise programs were analyzed based on Medline Plus guidelines and strategies (U.S. National Library of Medicine, 2017). Medline Plus delineates several strategies that can be used to promote health literacy (U.S. National Library of Medicine, 2017). The following were the specific strategies implemented within this project: limiting content to only THE IMPORTANCE OF UPDATED EDUCATION MATERIALS 15 necessary information, presenting information in a logical order, using language that is at an eighth grade reading level, reviewing the information several times before finalization, avoiding abstract language, and being consistent with word usage (U.S. National Library of Medicine, 2017). These strategies were implemented using the Medline Plus guide and also by comparing our written directions to other health-related sources that promote health literacy. In conjunction with my site mentor, we compiled current literature from relevant databases, the most recent protocol books, discussed exercises that have been most efficient for clients in the past, and incorporated data collected in the needs assessment before selecting exercises for each program. The duration and frequency of each exercise was not assigned as this is to be determined by individual therapists preference. Some of these exercises included cross-friction massage at medial or lateral epicondyle, weight-bearing through exercise putty, lateral and three-point pinch with exercise putty, gross opposition with exercise putty, CMC joint distraction and stabilization, thumb pronation on ball, thenar and webspace release, first dorsal interossei strengthening, finger to palm and palm to finger translation, first dorsal compartment stretch progression, and graded stretching for wrist flexors and extensors. This was accomplished by my site mentor taking photos of me completing the exercises and uploading them to the system. For complex exercises, such as first dorsal interossei strengthening, CMC stabilization, and thumb pronation, videos were recorded and uploaded to provide a clearer representation of the desired movements. I was also able to add some exercises that incorporate occupation, such as wringing out washcloths, handling coins, and weight-bearing through a sponge when washing dishes. Leadership Skills. Throughout this process, my leadership skills have allowed me to collaborate with other occupational therapists and assess the needs of the facility. For example, I was able to send out a survey to gather information from occupational therapists within several THE IMPORTANCE OF UPDATED EDUCATION MATERIALS 16 different Community Health Network clinics. Collaboration among numerous clinics can be difficult, but with my initiative and strategic platform of electronic survey, this difficult task became possible. With my background in research and evidence-based practice, I was able to lead the way in adding exercises that were supported by current evidence. This allowed for more credible and effective home exercise programs. Additionally, I led the facility in initiating the continuous quality improvement of patient education materials, more specifically, the improvement of home exercise programs. With my leadership skills, I was able to organize ongoing monthly meetings to discuss quality improvement strategies, making it easier for the occupational therapists to collaborate and maintain quality of resources. Staff Development. This project has allowed me and other staff members to become more aware of health literacy and the importance of updating patient education materials based on supported evidence. While the staff was most likely aware of these considerations, this project brought them to the forefront, allowing me and the team to further address these issues. Additionally, this project has raised the level of competency for occupational therapists at this site and has allowed for easier access to home exercise programs. These exercise programs are easily adaptable and can be tailored to each patient in a short amount of time. This is beneficial for staff development as this will save time and allow for more hands-on treatment. Discontinuation and Outcome Phase When speaking with all of the occupational therapists impacted by this project, there was an overall positive response regarding the success of this project. Additionally, patients stated that they find the exercises easy to understand and benefitted from the video representations. Based on informal feedback from the occupational therapists, some changes were made to the programs including word usage and chronological order of exercises. However, the updated THE IMPORTANCE OF UPDATED EDUCATION MATERIALS 17 home exercise programs created within this project are currently being implemented and used at both Hillsdale and Noblesville Community Health Network locations. Continuous Quality Improvement. For the ongoing process of continuing quality improvement for this project, I met with each occupational therapist individually to assist them in navigating the updated system as well as inform them of all new additions. Additionally, a monthly focus group will be implemented. The occupational therapists at this site already conduct a monthly journal club meeting. During these meetings, the occupational therapists will conduct a brief focus group to touch on the topic of updating patient education materials. This focus group will discuss necessary updates and delegation of tasks. Also, as this site often hosts students, fieldwork students may also be delegated tasks related to patient education materials. It was determined that incorporating a focus group into an already existing meeting time would promote greater compliance to quality improvement strategies. Future focus groups will be conducted as an open-discussion that promotes all occupational therapists to state ideas, concerns, and thoughts related to patient education materials. Meeting a Societal Need. Within this project, the societal need addressed is the need for updated patient education materials; more specifically, the need for improved home exercise programs within HEP2GO. When analyzing the literature and needs assessment, it was found that the home exercise programs needed to be more occupation-based, inclusive, understandable, and more diverse. Colaianni and Provident (2010) found that most practitioners believed that occupation-based interventions were beneficial to clients, but less than half actually used occupation within practice. To combat this issue, exercises were added to the existing program to include everyday occupation such as weight-bearing through a sponge while washing dishes and managing coins for improved fine motor control. THE IMPORTANCE OF UPDATED EDUCATION MATERIALS 18 The current HEP2GO system also lacked inclusivity and concepts of health literacy. When analyzing health-related materials in relation to the intended audience, researchers have found that most patient education materials are at a higher reading level than the reading level understood by most patients (Cotugna, Vickery, & Carpenter-Haefele, 2005). Health literacy can be a major barrier to patient compliance, and the current home exercise programs were restructured to ensure social justice and health literacy for all recipients. Within my project, each set of exercise instructions were analyzed to include only necessary information, use language that is at an eighth-grade reading level, avoid abstract language, and be consistent with word usage as recommended by Medline Plus guidelines (U.S. National Library of Medicine, 2017). Lastly, the system lacked variety and contained only a limited selection of hand exercises. Studies have shown that stretching, conservative management, concentric strengthening, and eccentric strengthening can all have beneficial effects on clinical outcomes for certain diagnoses (Martinez-Silvestrini et al., 2005). This emphasized the need for a diverse inventory of home exercises. Through the combining of information found in the relevant databases, current protocol books, and in conjunction with my site mentors expertise, the most effective exercises were added to the system. Additionally, for ease of use, many of these exercises were organized by diagnosis. This was done so that the occupational therapists can easily find the most appropriate home exercise program and alter as needed to fit the clients needs and abilities. Overall Learning Communication. Throughout this project, I interacted with occupational therapists with various levels of experience within Community Health Network from both Noblesville and Hillsdale locations. Initially, communication occurred through a face-to-face meeting between THE IMPORTANCE OF UPDATED EDUCATION MATERIALS 19 me and my site mentor. This meeting acted as a brief needs assessment that allowed me to formulate a survey that would better analyze the sites needs. Then, I was able to email the survey to all of the occupational therapists working for Community Health Network at nearby clinics. Once I received feedback, I used those findings to initiate my project. Throughout the implementation of the project, I communicated verbally with my site mentor and also via email with other occupational therapists to clarify their needs regarding HEP2GO. Lastly, for sustainability and quality improvement, I met with all of the occupational therapists face-to-face to assist them in navigating the updated program while also informing them of the updates. When communicating with the occupational therapists, it was critical that I maintained professionalism, clarity, and directiveness with my communications. Throughout this process, I feel as if I developed more effective and refined communication skills. Leadership and Advocacy. I utilized various aspects of leadership to carry out this project. Initially, I had to use investigative aspects of leadership to explore the sites current procedures and identify a need. Then, I had to take initiative in researching and finding a solution to meet that need. Throughout this project, I was also able to demonstrate leadership through advocacy. It was my goal to advocate for health literacy and bring more awareness to the need for understandable patient education materials. I also strived to advocate for evidence-based practice. I did this by initiating home exercise programs that are thoroughly supported by current evidence. Future Practice. Throughout this experience, I learned the importance of updating patient education materials. Along with this, I learned the practicalities that make this task difficult. As the need for high productivity standards skyrockets, it leaves little time for practitioners to update materials. However, this is a necessary task that should be discussed with THE IMPORTANCE OF UPDATED EDUCATION MATERIALS 20 employers so that time can be allotted to updating education materials. Additionally, I learned that it is important to stay immersed in current literature regarding our profession. Often practitioners create a routine treatment and have difficulty straying from that regimen. This highlights the need for continual education and evidence-driven practice. I aim to always include evidence-based literature into my practice. Overall, this experience taught me the importance of communication, leadership, advocacy, and how those skills can be best utilized in future practice. THE IMPORTANCE OF UPDATED EDUCATION MATERIALS 21 References American Occupational Therapy Association [AOTA]. (2014). Occupational therapy practice framework: Domain and process, (3rd ed.) American Journal of Occupational Therapy, 68(Supplement_1): S1-S48. doi: 10.5014/ajot.2014.682006. AOTA. (2015). Occupational therapy code of ethics. American Journal of Occupational Therapy,69(Supplement_3). doi:10.5014/ajot.2015.696s03 American Society for Surgery of the Hand. (2015). Carpal tunnel syndrome. Retrieved from http://www.assh.org/handcare/hand-arm-conditions/carpal-tunnel/ Chesney, A., Chauhan, A., Kattan, A., Farrokhyar, F., & Thoma, A. (2011). Systematic review of flexor tendon rehabilitation protocols in zone II of the hand. Plastic and Reconstructive Surgery, 127(4), 1583-1592. Cima, S. R., Barone, A., Porto, J. M., & de Abreu, D. C. C. (2013). Strengthening exercises to improve hand strength and functionality in rheumatoid arthritis with hand deformities: A randomized, controlled trial. Rheumatology International, 33(3), 725-732. Colaianni, D., & Provident, I. (2010). The benefits of and challenges to the use of occupation in hand therapy. Occupational Therapy in Health Care, 24(2), 130-146. doi:10.3109/07380570903349378 Cole, M. B., & Tufano, R. (2008). Applied theories in occupational therapy: A practical approach. Hamden, Conn: SLACK Inc. Cotugna, N., Vickery, C. E., & Carpenter-Haefele, K. M. (2005). Evaluation of literacy level of patient education pages in health-related journals. Journal of Community Health, 30(3), 213-219. doi:10.1007/s10900-004-1959-x Earley, D., & Shannon, M. (2006). The use of occupation-based treatment with a person who THE IMPORTANCE OF UPDATED EDUCATION MATERIALS 22 has shoulder adhesive capsulitis: A case report. American Journal of Occupational Therapy, 60(4), 397-403. doi:10.5014/ajot.60.4.397 Gransson, I., & Cederlund, R. (2011). A study of the effect of desensitization on hyperaesthesia in the hand and upper extremity after injury or surgery. Hand Therapy, 16(1), 12-18. Glke, J., Leopold, B., Grzinger, D., Drews, B., Paschke, S., & Wachter, N. J. (2018). Postoperative treatment of metacarpal fractures: Classical physical therapy compared with a home exercise program. Journal of Hand Therapy, 31(1), 20-28. Krischak, G. D., Krasteva, A., Schneider, F., Gulkin, D., Gebhard, F., & Kramer, M. (2009). Physiotherapy after volar plating of wrist fractures is effective using a home exercise program. Archives of Physical Medicine and Rehabilitation, 90(4), 537-544. Lamb, S. E., Williamson, E. M., Heine, P. J., Adams, J., Dosanjh, S., Dritsaki, M., & Rahman, A. (2015). Exercises to improve function of the rheumatoid hand (SARAH): A randomized controlled trial. The Lancet, 385(9966), 421-429. Martinez-Silvestrini, J., Newcomer, K. L., Gay, R. E., Schaefer, M. P., & al, e. (2005). Chronic lateral epicondylitis: Comparative effectiveness of a home exercise program including stretching alone versus stretching supplemented with eccentric or concentric strengthening. Journal of Hand Therapy, 18(4), 411-9, quiz 420. Mayo Foundation for Medical Education and Research. (2019). Rheumatoid arthritis vs. osteoarthritis. Retrieved from https://www.mayoclinic.org/diseasesconditions/arthritis/ multimedia/osteoarthritis-vs-rheumatoid-arthritis/img-20008728 Meena, S., Sharma, P., Sambharia, A. K., & Dawar, A. (2014). Fractures of distal radius: An overview. Journal of Family Medicine and Primary Care, 3(4), 325-32. O'Brien, A. V., Jones, P., Mullis, R., Mulherin, D., & Dziedzic, K. (2005). Conservative hand THE IMPORTANCE OF UPDATED EDUCATION MATERIALS 23 therapy treatments in rheumatoid arthritis: A randomized controlled trial. Rheumatology, 45(5), 577-583. Peters, S., Page, M. J., Coppieters, M. W., Ross, M., & Johnston, V. (2013). Rehabilitation following carpal tunnel release. Cochrane Database of Systematic Reviews, (6). Retrieved from https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858. CD004158.pub2/full# Roll, S. C., & Hardison, M. E. (2017). Effectiveness of occupational therapy interventions for adults with musculoskeletal conditions of the forearm, wrist, and hand: A systematic review. American Journal of Occupational Therapy, 71(1), 7101180010p17101180010p12. Rostami, H. R., Arefi, A., & Tabatabaei, S. (2013). Effect of mirror therapy on hand function in patients with hand orthopedic injuries: A randomized controlled trial. Disability and Rehabilitation, 35(19), 1647-1651. Satteson, E., & Tannan, S. C. (2017). DeQuervains tenosynovitis. Treasure Island (FL): StatPearls Publishing. Sen, R. (2014). Home-based exercise program (HEP) vs. institution-based occupational therapy (IOT) in improving hand skills in post Colles fractures: A comparative study. Indian Journal of Occupational Therapy, 46(3), 9097. Smidt, N., Van Der Windt, D. A., Assendelft, W. J., Devill, W. L., Korthals-de Bos, I. B., & Bouter, L. M. (2002). Corticosteroid injections, physiotherapy, or a wait-and-see policy for lateral epicondylitis: A randomized controlled trial. The Lancet, 359(9307), 657-662. Sultana, S. S., MacDermid, J. C., Grewal, R., & Rath, S. (2013). The effectiveness of early mobilization after tendon transfers in the hand: A systematic review. Journal of Hand THE IMPORTANCE OF UPDATED EDUCATION MATERIALS 24 Therapy, 26(1), 1-21. Trumble, T. E., Vedder, N. B., Seiler III, J. G., Hanel, D. P., Diao, E., & Pettrone, S. (2010). Zone-II flexor tendon repair: A randomized prospective trial of active place-and-hold therapy compared with passive motion therapy. The Journal of Bone and Joint Surgery, 92(6), 1381-1389. U.S. Department of Health and Human Services. (2010). Health Literacy and Health Outcomes. Retrieved from https://health.gov/communication/literacy/quickguide/factsliteracy.htm U.S. National Library of Medicine. (2017). How to write easy-to-read health materials. Retrieved from https://medlineplus.gov/etr.html Valdes, K., Naughton, N., & Burke, C. J. (2015). Therapist-supervised hand therapy versus home therapy with therapist instruction following distal radius fracture. Journal of Hand Surgery, 40(6), 1110-1116. Valdes, K., & Campbell, A. (2018). Patient preference for home exercise program provision: A patient survey. Journal of Hand Therapy, 31(1), 148-149. doi:http://dx.doi.org.ezproxy.uindy.edu/10.1016/j.jht.2017.11.012 THE IMPORTANCE OF UPDATED EDUCATION MATERIALS Appendix A Figure 1. Carpal Tunnel Syndrome Figure 2. Carpometacarpal Osteoarthritis 25 THE IMPORTANCE OF UPDATED EDUCATION MATERIALS Figure 3. DeQuervains Tenosynovitis 26 THE IMPORTANCE OF UPDATED EDUCATION MATERIALS Figure 4. Lateral Epicondylitis 27 THE IMPORTANCE OF UPDATED EDUCATION MATERIALS Figure 5. Medial Epicondylitis 28 THE IMPORTANCE OF UPDATED EDUCATION MATERIALS Appendix B Figure 1. Hand Active Range of Motion Figure 2. Thumb Active Range of Motion 29 THE IMPORTANCE OF UPDATED EDUCATION MATERIALS Figure 3. Thumb Isometric Figure 4. Thumb Passive Range of Motion 30 THE IMPORTANCE OF UPDATED EDUCATION MATERIALS Figure 5. Wrist Active Range of Motion Figure 6. Wrist Passive Range of Motion 31 THE IMPORTANCE OF UPDATED EDUCATION MATERIALS Figure 7. Elbow Range of Motion and Strengthening 32 THE IMPORTANCE OF UPDATED EDUCATION MATERIALS Figure 8. Proximal Strengthening Figure 9. Cervical Stretching 33 THE IMPORTANCE OF UPDATED EDUCATION MATERIALS Figure 10. Fine Motor Control Figure 11. Exercise Putty Strengthening 34  ...

... A Retrospective Study of Factors Associated with the Successful Completion of a New Driver Training Program Savanah Wagner, Elizabeth Erb, Mindy Delph, Megan Kraft, and Hannah Patton December 13, 2019 A research project submitted in partial fulfillment for the requirements of the Doctor of Occupational Therapy degree from the University of Indianapolis, School of Occupational Therapy. Under the direction of the research advisor: Lori Breeden, EdD, OTR Running Header: NEW DRIVER TRAINING PROGRAM 1 A Research Project Entitled A Retrospective Study of Factors Associated with the Successful Completion of a New Driver Training Program Submitted to the School of Occupational Therapy at University of Indianapolis in partial fulfillment for the requirements of the Doctor of Occupational Therapy degree. By Savanah Wagner, OTS, Elizabeth Erb, OTS, Mindy Delph, OTS, Megan Kraft, OTS and Hannah Patton, OTS Approved by: Research Advisor (1st Reader) Date 2nd Reader Date Accepted on this date by the Chair of the School of Occupational Therapy: Kate E. DeCleene Huber, OTR, MS, OTD Chair, School of Occupational Therapy Date NEW DRIVER TRAINING PROGRAM 3 A Retrospective Study of Factors Associated with the Successful Completion of a New Driver Training Program Savanah Wagner, Elizabeth Erb, Mindy Delph, Megan Kraft, and Hannah Patton University of Indianapolis NEW DRIVER TRAINING PROGRAM 4 Abstract Background: Researchers examined existing new driver training records to determine factors associated with successful completion of a driver training program. Method: Forty-one de-identified driving evaluation and discharge records were examined retrospectively. Data included demographic information, in-clinic assessments (Trails Making Test (TMT) Parts A and B, Useful Field of View(UFOV), life-skills questionnaire) on-road skills, and intervention units. Mixed method analysis included Mann-Whitney U to compare successful and unsuccessful groups and a qualitative examination of therapists and parents narrative. Results: Individuals in the successful group were more likely to have adequate on-road driving skills of braking/acceleration, four way stop, lining the vehicle, following distance, and traffic gaps than the unsuccessful group (p< .05). Statistical significance was not detected for TMT Part A (p=.551) and B (p=.996) between groups. Qualitative results indicated that successful drivers demonstrated independence in activities of daily living (ADL), instrumental activities of daily living (IADL), and communication skills prior to participating in the new driver program. Also, adequate on-road skills, emotional maturity, and practical levels of anxiety seem to support success for new drivers. Conclusion: Important considerations when evaluating new drivers success are on-road skills, independence in IADL and ADL, communication skills, emotional maturity, and practical levels of anxiety. However, OT/Certified Driving Rehabilitation Specialist (CDRS) should further investigate the use of other executive function assessments for new drivers rather than TMT Part A and B. NEW DRIVER TRAINING PROGRAM 5 A Retrospective Study of Factors Associated with the Successful Completion of a New Driver Training Program In 2016, the Federal Highway Administration reported that there were over 218 million drivers on the road; 8,590,649 were new drivers nineteen years or younger (Distribution of licensed drivers, 2016). Driving is pivotal to ones independence because it allows for social participation and a sense of life satisfaction (McNamara, George, Ratcliffe, & Walker, 2015). However, motor vehicle crashes are the leading cause of death for teens (age 16-19 years) in the United States (CDC, 2019). With 5.4 million children diagnosed with AttentionDeficit/Hyperactive Disorder (ADHD) and 1 in 88 diagnosed with Autism Spectrum Disorder (ASD), there is an increased number of new drivers with these conditions operating a vehicle (Classen, Monahan, & Wang, 2013). Those with ADHD and ASD often have characteristics which compromise driving such as dysfunctions in planning, organizing, attention to detail, executive skills, and motor skills, and those with Generalized Anxiety Disorder have excessive anxiety about ordinary, day-today situations that can be intrusive and cause distress or functional impairment (Classen & Monahan, 2012; Er 2015). The purpose of this study is to determine the factors associated with a new drivers successful completion of a driver training program facilitated by occupational therapists who are CDRS. Literature Review Occupations are various kinds of life activities in which individuals, groups, or populations engage, including activities of daily living (ADL), instrumental activities of daily living (IADL), rest and sleep, education, work, play, leisure, and social participation (AOTA, 2014, p. S19). ADLs are activities oriented toward taking care of ones own body such as dressing, bathing, toileting, personal hygiene, and feeding (AOTA, 2014, p. S19). IADLs are NEW DRIVER TRAINING PROGRAM 6 activities to support daily life within the home and community that often require more complex interactions than those used in ADLs such as driving and community mobility, child rearing, and financial management (AOTA, 2014, p. S19). The IADL of driving is a symbol of entrance into independence and a valued occupation for many individuals (AOTA, 2014). Individual IADLs and ADLs have been shown to relate to the overall functional performance of a person in their everyday lives (Weaver, 2015). Occupational therapists are skilled in the assessment of functional performance in individuals (Dickerson, Reistetter, Davis, & Monahan, 2011). When a client demonstrates fundamental abilities in ADL and IADL, the client is then able to engage in more activities that further enhance overall functioning (Weaver, 2015). Young Adults with ASD, ADHD, and GAD Young adults with ADHD or ASD exhibit behaviors that compromise safe driving performance (Classen & Monahan, 2012). Young adults with ADHD tend to be easily distracted, forgetful, impulsive, and require additional time to process information than peers without ADHD process (ADHD: The Basics, 2016). These characteristics found in young adults with ADHD can negatively impact their driving performance. ASD is also a common disorder seen in young adults characterized with repetitive behaviors, fixated interests, and motor coordination deficits (National Institute of Mental Health, 2011). New drivers with ASD tend to have a higher heart rate, gaze pattern to low stimulus areas rather than high stimulus areas, and slower response speed (Cox et al., 2015; Reimer et al., 2013). Cox et al. found that when adding working memory demands to an already difficult driving task, young adults with ASD are hindered by an increase in steering and braking errors indicating an overall lower working memory performance (2015). Brooks et al. (2016) concluded that young adults with ASD had more difficulty with NEW DRIVER TRAINING PROGRAM 7 psychomotor speed (movement in conscious mental activity), reaction time, cognitive flexibility, and executive function than the control group when using a driving simulator. Studies indicate that drivers with ADHD and ASD, are more likely to get into car accidents when compared to their typically developing peers (Cox et al., 2015). Classen, Mohanon, and Wang (2013) discovered young adults with ADHD and ASD compared to typically developing peers, displayed decreased ability with planning, attention, set shifting, motor performance, and sequencing. Additionally, these young adults had poorer right-eye visual acuity, selective attention, visual-motor integration, cognitive abilities, processing language symbols, integration of verbal and nonverbal mental processes, and motor performance compared to healthy controls (Classen, Monahan, & Wang, 2013). When further evaluated by a CDRS, the individuals made more driving errors related to visual scanning, speed regulation, lane maintenance, and adjustment-to-stimuli compared to healthy controls (Classen, Monahan, & Wang, 2013). While young adults with ASD and ADHD have an increase in hazardous driving skills and safety, many are able to obtain and maintain their license after going through a driver training program. Generalized anxiety disorder (GAD) is one of the common mental disorders in the United States that can negatively impact an individuals quality of life and ADL (Er, 2015). The excessive anxiety about ordinary, day-today situations that is often intrusive and functional impairment impacts those with GAD (Er, 2015). Higher levels of anxiety while driving lead to a variety of dangerous driving behaviors such as increased amount of crashes (Dula, Adams, Miesner, & Leonard, 2010). NEW DRIVER TRAINING PROGRAM 8 Certified Driving Rehabilitation Specialist and Driver Training Programs To optimize community mobility, individuals at risk for impaired driving due to developmental challenges or medical diagnoses are referred to a CDRS before they are able to take the standardized driver assessment for their respective state (DMV.org, 2017). A comprehensive driving evaluation is administered from an occupational therapist who is a CDRS (AOTA, 2016). To comprehensively evaluate drivers, a CDRS plans, develops, coordinates and implements driver training programs for clients of varying ages and needs (AOTA, 2016; Association for Driver Rehabilitation Specialists, 2016). Driver training programs may include strategies, car modifications, adaptive equipment, or interventions (Dickerson, Reistetter, Schold Davis, & Monahan, 2011). The CDRS title, established in 1995, is achieved after extensive experience and a passing score on the exam given by the Association for Driver Rehabilitation Specialists (ADRS) (ADRS, 2016; Dickerson et al., 2011; Yuen, Brooks, Azuero, & Burik, 2012). The credentials indicate experience educating and training drivers, adapting vehicles, and building a network with the ADRS (Dickerson et al., 2011). Educational pre-driving interventions may be helpful to those who have not experienced on-road driving such as young adults with ADHD or ASD. Poulter and Mckenna (2010) used an educational pre-driving assessment to examine if educational tools were beneficial in changing the attitudes of teenagers who scored high on a risk-taking questionnaire (2010). They found that educational interventions made a statistically significant impact on young adult drivers change in attitudes. Frequency and Duration of Driver Training Programs Driver training programs are imperative for young drivers with varying diagnoses such as ASD and ADHD because driving includes many complex skills that impact overall independence NEW DRIVER TRAINING PROGRAM 9 (AOTA, 2014). The duration of a training program needed to successfully complete a program is unknown, but it can be understood that the focus of these programs is to prepare and equip an individual for the complex nature of driving (Mazer, Gelinas, & Benoit, 2004). In addition to determining which client factors were influential in determining a clients readiness to drive this study will include information on the frequency and duration of driver training. Trail Making Tests Many assessments for individuals who have disabilities are not supported by research in predicting ability to safely drive (Adler, Rottunda, Christensen, Kuskowski, & Thuras, 2006; Classen, Wang, Crizzle, Winter, & Lanford, 2013). However, the Trail Making Test (TMT) Part A and B are promising. The TMT are standardized neuropsychological tests administered to individuals ages 11-74 to assess scanning capabilities, visual searching, speed of processing, mental flexibility, divided attention, and executive function (Classen, Wang et al., 2013; Tombaugh, 2004; Reynolds, 2002). TMT Part A and B are administered to individuals who have been referred to a CDRS (Classen, Wang et al., 2013). The goal of the assessment is to connect a series of letters and/or numbers in an ascending order making a trail as quickly as possible (Reynolds, 2002). Low scores on the TMT Part B have been a valid predictor of failing a behind the wheel on-road assessment in many driving studies for populations other than young adults with ADHD and ASD (Classen, Wang et al., 2013; Classen et al., 2011; Uc et al., 2006; Mullen, Weaver, Riendeau, Morrison, & Bedard, 2010). In a study of older drivers who completed TMT Part B and an assessment called Useful Field of View (UFOV), researchers found both tests to be comparable and accurate in predicting behind the wheel on-road performance having a comparison p-value of .02 indicating a correlation between the two assessment (Classen, Wang NEW DRIVER TRAINING PROGRAM 10 et al., 2013). Researchers have found Trails B to be a valid predictor of on-road performance amongst community-dwelling older licensed drivers, people with Parkinsons disease, and patients with brain injury (Classen, Wang, et al., 2013; Classen et al., 2011; Uc et al., 2006; Mullen, Weaver, Riendeau, Morrison, & Bedard, 2010). Gibbons et al. (2017) determined TMT Part B to have the best sensitivity and specificity compared to four other cognitive tests including Trails A to screen for fitness to drive. Marshall et al. found TMT Part A and B to be one of three assessments to be the most useful screening tests to assess cognitive abilities relevant to predicting fitness to drive in patients with strokes (2007). Dawson, Anderson, Datrup, Uc, and Rizzo (2009) examined participants with Alzheimers Disease and found poorer scores on TMT Part A related to significant increases in driving safety errors. With the same purpose and set up as TMT Part A and B, the Comprehensive TrailMaking Test (CTMT) includes five subtests and was made to overcome the limitation of Part A and B being too brief and general (Reynolds, 2002). Reynolds (2002) reports that individuals with a learning disability or cerebrovascular accident (CVA) perform below the standardization sample. When compared to their normal peers, adolescents with a Traumatic Brain Injury (TBI) performed significantly worse on the CTMT, nearly 2 standard deviations below the control group mean (Armstrong, Allen, Donohue, & Mayfield, 2008). Armstrong et al. (2008) found that the CTMT was sensitive in detecting cognitive impairments in individuals with TBI. Overall, research referenced above displays CTMTs sensitivity to the presence of learning disabilities and cognitive impairments that affect skilled driving ability. However, research based specifically on driving performance and the CTMT is limited. For individuals with ADHD and ASD, those that performed poorer in cognition (assessed with the CTMT), visual function, NEW DRIVER TRAINING PROGRAM 11 visual-motor integration, and motor performance made more driving errors than their peers when using driving simulator (Classen, Monahan, Brown, & Hernandez, 2013). There is limited research on the TMT Part A and B and CTMT associated with young adults driving performance. However, researchers of one study found no relationship between the performance-based executive function measures (TMT Part A and B) and driving performance of young adults (Pope, Ross, & Stavrinos, 2016). This current researchers hope to add to research in this area to determine if the TMT Part A and B scores are associated for new drivers with various diagnoses successful completion of a driver training program. Dickerson, Meuel, Ridenour, & Cooper found that older adults driving performance can be predicted by the interaction of physical, visual, and cognitive factors rather than one isolated factor supporting the idea that many factors need to be evaluated by an occupational therapist to determine driving performance (2014). Older drivers performance can be predicted by the interaction of physical, visual, and cognitive factors rather than one isolated factor (Dickerson et al., 2014; Tarawneh, McCoy, Bishu, & Ballard, 1993). Similar to the Dickerson et al. (2014) study, this study will examine the following question: what are the factors associated with a new drivers successful completion of a driver training program? Researchers will be analyzing factors such as an individuals performance in occupations, assessment scores of TMT Parts A and B, and frequency and duration of a new driver training program. Researchers of the study hypothesize that factors associated with successful completion would include higher scores on TMT Parts A and B, independence with ADL and IADL, and increase duration of the driver training program. NEW DRIVER TRAINING PROGRAM 12 Methods Research Design Researchers conducted a retrospective review of de-identified new driver client records from a Midwestern driving rehabilitation center. No identifiable information was collected, thus the study was determined to be exempt by the institutional review board at University of Indianapolis. Participants No human subjects participated in this study; all data were collected from 41 deidentified client records of young adults who participated in a Midwestern new driver training program. Inclusion criteria for client records were as follows: did not possess a state driver's license, evaluated by one of two occupational therapists with the CDRS certifications, participated in the Midwestern new driver training program, and had a referral signed by a physician. This study did not include information from client records who did not participate in the driver training program due to choice or severity of impairments identified during evaluation. Data Collection Prior to data collection, the client records were reviewed by two OT/CDRS to de-identify occupational therapy driving evaluation and discharge summaries as well as give each record an ID number. Data collection took place onsite of the Midwestern driving rehabilitation center for 5 weeks. The evaluation and discharge summaries were transcribed into a Microsoft Excel spreadsheet that was stored on a password protected computer in a locked office at the University of Indianapolis. The evaluation and discharge summaries included in clinic evaluation, on the road evaluation information, and the total number of intervention billing units. NEW DRIVER TRAINING PROGRAM 13 No identifiable health information was collected as a part of this study. All electronic data will be destroyed three years after the completion of the research project. In clinic evaluation. Abundant data were collected from the OT/CDRS in clinic evaluations. Factors included levels of independence in occupational tasks from a Life Skills Checklist, identification of road signs, and lower and upper extremity strength, range of motion, and coordination. Narratives from childrens parents were collected regarding their childs level of independence in life skills. Information was also collected regarding the therapist and parents perception of clients driving potential during the in clinic evaluation. Additional information collected during the in clinic evaluation included age, diagnoses, living situation, employment, school involvement, participation in leisure activities, and driving history. Cognition and executive function were measured using the TMT Part A and B. Vision was assessed with visual acuity, peripheral vision, and the Useful Field of View (UFOV) assessment. Assessment tool reliability and validity. TMT Part A and B were found to be valid tests to measure executive function in adolescents with traumatic brain injuries (Allen, Thaler, Ringdahl, Barney, & Mayfield, 2012) and adolescents with brain dysfunction (Allen, Thaler, Barchard, Vertinski, & Mayfield, 2012). The UFOV is a cognitive assessment used to measure an individuals processing speed that has been reported to predict driving performance. The computer version of the UFOV was reliable and valid with 66 older adults (Edwards et al., 2005). With young adults, McManus et al. (2015) found the UFOV subtest 3 to significantly predict simulated driving collisions. Other researchers found both the TMT Part A and B and UFOV to be comparable and accurate in predicting older drivers on-road performance having a comparison p-value of .02 (Classen, Wang et al., 2013). NEW DRIVER TRAINING PROGRAM 14 On the road evaluation and discharge summary. The on-road evaluation consisted of completing common car functions (apply seat belt, adjust mirror), driving performance with speed modulation, braking and acceleration, and lining a vehicle, decision making skills based on driving scenarios (following distance, 4 way stops), and behavioral observations while driving. The discharge summaries completed by the OT/CDRS included their recommendation for discharge, total number of intervention billing units (1 unit = 8 to 22 minutes) during the new driver training program, and if the client was successful or unsuccessful in completing the new driver training program. When a client was successful in the new driver training program, the OT/CRDS determined the client to be fit to drive and appropriate to take the state drivers test. When a client was unsuccessful in the new driver training program, the OT/CDRS determined the client to be not fit to drive and advised not to take the state drivers test. Data analysis Quantitative. Quantitative data analysis was carried out with Statistical Package for the Social Sciences (SPSS) version 25 using Spearman Rho and Mann-Whitney U. Spearman Rho was used to determine relationships of variables for clients who were successful or unsuccessful in the completion of the driver training program. After statistically significant relationships were identified, and continuous data failed to be normally distributed, variables across groups were compared using Mann-Whitney U-test. Qualitative. Qualitative data were analyzed using a thematic approach to organize, identify, and record patterns in the data (Braun & Clarke, 2006). First, researchers became familiar with the data. Data was organized by successful and unsuccessful drivers and analyzed within like categories. These included: behavioral observations, parents perception and therapists summary of clients driving potential. Next, researcher divided into 2 teams to begin NEW DRIVER TRAINING PROGRAM 15 initial coding data. After key words were identified of 10 client records within each category, researchers came together to insure consistency. Third, themes were identified with corresponding quotes among successful and unsuccessful groups. A table was developed to organize quotes into their thematic category. Themes were then reviewed to insure trustworthiness; member checking was used to validate themes with one of the evaluating CDRS. Lastly, themes and quotes were refined and analyzed in each category between successful and unsuccessful groups to determine conclusions. Results The client records reviewed were between the ages of 17 and 29 with diagnoses of ASD, ADHD, Generalized Anxiety Disorder (GAD), and other specified pervasive developmental disorders. The average age of the drivers was 20.1. These clients lived with various other individuals including but not limited to parent(s), step-parent(s), sibling(s), and grandparent(s), within their home in the Midwest. Quantitative Of the 41 individuals, 24 were successful in completing the new drivers training program, and 17 were unsuccessful. Successful individuals completed new drivers training program for a mean of 64.08 intervention units while unsuccessful new drivers completed the program for a mean of 42.25 intervention units (1 unit= 8-22 minutes). Individuals who successfully completed the driver training program were more likely to have adequate decision making skills for 4 way stops and recognizing an appropriate following distance as a passenger with statistical significance (p <.04) (see Table 1). While behind the wheel, successful individuals in the program were more likely to have adequate skills in maintaining appropriate traffic gaps, braking and accelerating, and lining the vehicle than unsuccessful drivers with statistical significance (p< NEW DRIVER TRAINING PROGRAM 16 .05) (see Table 1). Lining the vehicle is the proper positioning of the vehicle in a lined parking spot. As seen in Table 2, statistical significance was not detected for the scores on TMT Part A (p=.551) and B (p=.996) between the success and unsuccessful group in the new drivers training program. No other between group data for successful completion of the driver training program were found. Table 1 On-Road Assessment Results Between Groups Category Mann-Whitney U Z p<.05 N r 4 way stops 57.5 -2.83 .004 34 -.485 Following Distance 6 -2.073 .038 12 -.598 Traffic Gaps 78 -1.973 .049 33 -.343 Braking and Acceleration 97.5 -2.499 .012 39 -.400 Lining Vehicle 96 -2.075 .038 36 -.346 Passenger Ride Behind the wheel Note. Significant at the p<0.05 level. Table 2 Clinical Assessment Results Between Groups Category Mann-Whitney U Z p>.05 N r TMT Part A 161 -.596 .551 40 -.094 TMT Part B 180.5 -.043 .996 40 -.007 Note. Significant at the p<0.05 level. NEW DRIVER TRAINING PROGRAM 17 Qualitative A qualitative analysis of the life skills, behavioral observations, and therapists perception narratives indicated common characteristics of successful new drivers. The common characteristics were analyzed into six themes: independence in ADL, independence in IADL, emotional maturity, practical levels of anxiety, communication skills, and adequate on-road driving skills. Themes common of life skills. Two themes were common in the successful group: (1) independence in ADL and (2) independence in IADL. Researchers found through parent report and therapists summaries, success in new driver training program was consistently paired with reported independence, with basic self-care tasks. Additional narratives included, client is independent with self-care with minimal reminding and gets himself ready each day. Continued independence and increased responsibility in basic self-care tasks allowed a therapist to report that a client can, complete many higher level ADLs independently. Compared to the parents of the successful clients, the parents of the unsuccessful drivers reported, client requires assistance with high level ADLs and that client has, anxiety completing all self-management. The second theme is independence in IADL tasks. Parents of the clients who were successful reported clients to have independence with meal preparation, clients were able to cook for himself, complete light meal prep independently for quite some time, and regular responsibilities [of].. doing the dishes. Clients were also responsible for their medication management, he takes his medications regularly and he manages his own medication. Taking care of pets was a third IADL clients were responsible for such as taking care of the dog, taking care of the family pets and taking care of the cat. Clients had independence with other IADL such as, manages his own bank account and mowing the lawn. Clients who NEW DRIVER TRAINING PROGRAM 18 were unsuccessful in the training program required assistance with medication management as reported, his parents do a fair amount in terms of managing clients medication routine and, he needs reminding to take his medication. Themes common of behavioral observations. Three themes were common to the successful group: (1) emotional maturity, (2) practical levels of anxiety, and (3) communication skills. Emotional maturity can be depicted through the following therapist narratives. One therapist described a client to have significant emotional maturity, and... [it] impacts his ability to take on the task of becoming an independent driver". Another client demonstrated some insight as he is aware of his overly cautious nature and his fear of driving that may interfere with his goal. These represent the emotional maturity displayed in successful drivers. Of the unsuccessful group the theme of emotional immaturity was revealed when a client raised his t shirt at one point to scratch an itch or access something on his stomach and his mother had to cue him that it was not appropriate. Another client appears to have issues with emotional maturity, this may be a barrier to a successful outcome". The second theme is related to anxiety. Therapists noted the successful clients showed practical levels of anxiety compared to overwhelming, debilitating levels associated with unsuccessful drivers. The therapist recognized that a practical level of anxiety was a positive trait as it indicates the client has a heightened state of alertness and attention to address the diverse driving environments. The therapist reported that one individual in the successful group, stated she was very nervous, however; she offered insight into her anxiety and smiled appropriately throughout. Another successful client had, worked hard to learn to express herself verbally and manage her anxiety. Comparatively, the therapist noted, client's inability to manage his stress NEW DRIVER TRAINING PROGRAM 19 and anxiety behind the wheel of a car could lead to serious, life/death consequences which led to unsuccessful completion of new driver program. The last behavioral observation theme is communication skills. The following quotes describe how the evaluating therapist recognized communication skills that stood out to her. A therapist reported an individual who was successful to have, answered questions thoughtfully in the clinic. He demonstrated some insight into his challenges. Another successful client showed communication skills as, he would thoughtfully ask for a greater explanation if he did not understand a concept or word. In contrast, one therapist documented an unsuccessful client, demonstrated a tendency to be concrete in thinking and when giving answers... [he] was not able to abstract further... his answers were at times tangential from original line of question. Lastly, another unsuccessful client had, difficulty articulating his thoughts in a clear and coherent managing care of the family pets." Theme common of therapists perception. A theme common to the successful group was adequate on-road skills which are the basic skills required to drive a car through a low complex level environment. For example, a drivers skills were described as He physically handled the car well. His turns were smooth and accurate. His lane position was good in the neighborhood. He demonstrated smooth and adequate braking and acceleration. Additionally, descriptions of performance in the vehicle was above average overall with good understanding of road rules and applies them correctly while maintaining adequate physical handling of the vehicle were reported. Unsuccessful clients showed less than adequate skills as described by, he needed cueing on many occasions when approaching intersections, when other vehicles were present, and in "putting it all together"... he had a few critical errors (hitting a curb, missing a stop sign, and attempting to pull in front of a moving vehicle that he should yield to). An NEW DRIVER TRAINING PROGRAM 20 unsuccessful client described as not having adequate on-road skills made errors at several traffic lights and was not able to consistently navigate two and four way stops. This is indicative of a combination of a lack of consistency and poor understanding of the road rules. Discussion Quantitative On-road driving skills such as braking/accelerating, lining up the vehicle and judging traffic gaps were associated with successful completion of a new driver training program. Walshe, McIntosh, Romer, & Winston (2017) found poor lane positioning and poor braking performance to be more common for young adult drivers with ASD as compared to typically developing young adult drivers. The results from this study suggest the importance of on-road evaluations when considering young adults driving potential. Researchers also indicated the need for young adult drivers with ASD to be able to practice these skills (Walshe et al., 2017). While they suggested practicing skills using a simulator to ensure a safe environment, our experience with a CDRS suggests their clinical judgment is sufficient to decide the resources used to practice on-road skills. Additional skills associated with successful completion include adequate decision making for 4 way stops and recognizing an appropriate following distance within the car as a passenger. For this population of new drivers, the TMT Part A and B were not found to be connected to successful completion of a new driver training program. Similarly, Pope et al. (2016) found executive function measure TMT Part A and B did not show association with young adults driving performance. Although our results suggest TMT Part A and B are not representative of new drivers with ASD, ADHD and GAD, driving programs should further investigate the use of TMT with this population. While TMT Part A and B assesses executive function as a whole, NEW DRIVER TRAINING PROGRAM 21 previous research by Walshe et al., (2017) identifies the need to assess one executive function skill at a time. However, with other populations researchers found TMT Part B to be a valid predictor of on-road performance amongst community-dwelling older drivers, patients with Parkinsons disease, and patients with brain injury (Classen, Wang, et al., 2013; Classen et al., 2011; Uc et al., 2006; Mullen et al., 2010). Additionally, Marshall et al. (2007) found TMT Part A and B to be one of three assessments to be the most useful screening tests to assess cognitive abilities relevant to predicting fitness to drive in stroke patients. Therefore, future research is necessary to determine if TMT Part A and B are valid predictors of on-road performance of new drivers. Unsuccessful drivers received less intervention units in the new driver training program than successful drivers. The OT/CDRS reported that within the first 10 hours of training it often becomes clear if individuals will be successful in the program based on clients improvements in driving skills. OT/CDRS whose clients are showing little improvement in driving skills in the first 10 hours of training should consider discharging patients to eliminate unnecessary use of intervention units and resources. Qualitative Life skill. In the current study, parents of clients who were successful in the new driver training program frequently reported the clients independence to complete ADL and IADL tasks. Previous studies in this area have similar findings. In order to properly perform self-care activities, an individual needs to be able to maintain attention, have an understanding of the ADL, motivation to perform the ADL, and proper motor functioning (Guidetti & Tham, 2002). Self-care ADL and IADL such as: home establishment and management, meal preparation and cleanup, safety and emergency, shopping and self-care have been shown to relate to overall NEW DRIVER TRAINING PROGRAM 22 functional performance in individuals (Mann et al., 2005; Arbesman & Logsdon, 2011; Goverover, Chiaravalloti, & DeLuca, 2008; McNulty & Fisher et al., 2001; Brown, Rempfer, & Hamera, 2002). Researchers found a relationship between IADL performance and performance on a behind-the-wheel driving assessment in older adults, suggesting that observation of IADL performance can predict driving ability (Dickerson et al. 2011). The research above supports this studys findings in the importance of assessing independence with ADL and IADL during a driving evaluation. Behaviors. Researchers found that therapists frequently reported emotional maturity, communication skills, and practical levels of anxiety of successful clients in the new driver training program. Based on qualitative themes, researchers concluded that new drivers who demonstrated emphasized behaviors listed above were more likely to succeed in a new driver training program. Similar studies identified that high levels of anxiety correlated with dangerous driving, and that individuals who demonstrated impulsive-sensation seeking or emotional immaturity, and anxiety demonstrated poor driving performance (Po & Ledesma, 2013; Wang , Qu, Ge, Sun, and Zhang, 2018). Observing the behaviors of new drivers can help CDRS occupational therapists determine pre-driving skills and the likelihood of these individuals on their success rate of a driving program. Perception. As discussed by Classen, Mohoanon, and Wang (2013), individuals with ADHD and ASD have decreased performance in planning, attention, motor performance, and sequencing which affects driving performance. In the current study, adequate skills in basic driving were highlighted by therapists for those who were successful. The mentioned characteristics by Classen, Mohoanon, and Wang (2013) are basic skills needed for driving. Therapists perception of clients having adequate skills for basic driving tasks is supported by the NEW DRIVER TRAINING PROGRAM 23 quantitative results that the performance with on-road skills was statistically significant in the groups who were successful. Limitations The limitations of this study include sample size, decreased generalizability, and lack of objective life-skill measures. There was a small sample size with 41 charts reviewed. Additionally, the sample was a small group of individuals who were all located in the Midwest. These individuals had access to this particular clinic, which is not representative of the general population of new drivers with ASD, ADHD, GAD, and other specified pervasive developmental disorders. Implication for practice and recommendations for future research The findings of this study have the following implications for occupational therapy practice. Important considerations when evaluating young drivers success are on-road skills, independence in IADL and ADL, communication skills, emotional maturity, and practical levels of anxiety. OT/CDRS should investigate the use of other executive function assessments for new drivers rather than TMT Part A and B. Future research should be completed to determine on-road skills that predict success in a new driver training program. Additionally, further research needs to be conducted to determine if TMT Parts A and B are predictors of driving performance in young adults. Acknowledgements The researchers would like to thank Suzanne Pritchard, MS, OTR, CDRS and Easterseals Crossroads for their collaboration, guidance, and expertise in this study. 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